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Chapter 18

Contents

CHAPTER XVIII

Japan and Korea

Thomas B. Turner, M.D.

For the United States, the occupation of Japan came as the great culminating phase of 4 years of global war. From the standpoint of military government and, particularly, its public health aspects, this operation was also a culminating experience; the function represented by the terms "civil affairs" and "military government" had finally been recognized at all levels of command as an essential feature of military operations. In both planning and executing the military government program, the experiences of other theaters of operation were liberally called upon, and command support reached a high level of effectiveness.

It will be instructive, therefore, to consider the health aspects of military government for Japan from two standpoints: first, with reference to plans for the invasion of Japan, an operation which fortunately was made unnecessary by Japan's surrender; and second, the occupational phases of military government health activities as they evolved in Japan.

By way of contrast, it will be of interest, too, to consider the analogous operation in Korea which took the form of civil affairs rather than military government, in which local officials enjoyed, at least in principle, a large degree of autonomy.

Section I. Japan

PLANS FOR INVASION OF JAPAN

In chapter XVI, brief reference was made to the ground strategy which had as its objective invasion of the Japanese homeland. The great pincers that were to seize the main islands of Japan had already extended out from Australia by way of New Guinea and the Philippines, the southern prong; and from Hawaii by way of the Marshall and the Marianas Islands and Okinawa to form the eastern prong. With superbombers flying from Okinawa and the bases in the Marianas, and fighters from Iwo Jima and aircraft carriers of the Third Fleet, the Japanese home islands were subjected to heavy bombing as well as bombardment by the guns of heavy naval units during July and early August 1945.

The original plans called for two invasions of Japan. The first, designated Operation OLYMPIC, provided for a three-pronged assault on south-


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ern Kyushu in the fall of 1945 by the Sixth U.S. Army, consisting of the I and XI Army Corps and the V Marine Amphibious Corps. Their mission was to land on the beaches, isolate the southernmost Japanese island, and destroy the defending forces there.

The second phase of the Japanese invasion, Operation CORONET, was to be carried out in the early spring of 1946. The Eighth and Tenth U.S. Armies consisting of nine infantry divisions, two armored divisions, and three Marine divisions were to assault the Tokyo Plain of eastern Honshu; the First Army, redeployed from Europe, was to follow with 10 infantry divisions. The three armies were to occupy the Tokyo-Yokohama area, destroy the Japanese home army, and fan out to occupy the whole of Honshu and Hokkaido.

These plans were shelved when Japan offered to surrender on 10 August 1945, following the atomic bombings of Hiroshima, on 6 August, and Nagasaki, on 9 August.1

Military Government Planning

Planning for the invasion of Japan was begun by the CAD (Civil Affairs Division) of the War Department in August 1943, when Maj. Charles C. Hilliard was designated group leader for planning for Japan at the School of Military Government in Charlottesville, Va. Planning was intensified in January 1944, and Col. David Marcus, JAGC, was designated chief planner for Japan in the Civil Affairs Division.

On 13 April 1944, a staff study by Col. William A. Boekel, which was presented to the Joint Chiefs of Staff, recommended that "Planning for civil affairs (for Japan) be a U.S. responsibility pending determination of other U.N. interests." Apparently, however, certain key decisions were not made at this time and actual planning seems to have proceeded slowly for the remainder of 1944.

In January 1945, the tempo of planning again increased, coincident with the establishment of a State-War-Navy Coordinating Committee which provided a degree of policy guidance. Six topics were outlined for study as follows:

1. Fixing responsibility for military government in Japan.
2. Formulating civilian supply policy and advanced procurement.
3. Formulating surrender policy for Japan.
4. Preparing directives for military government in Japan.
5. Formulating U.S. views on the composition of forces for the occupation.
6. Determining the U.S. position on intergovernmental consultation on problems of the occupation of Japan.

Evidently, little planning for health and medical affairs could be accomplished until some of those basic decisions were made. Out of the fore-

1Marshall, Gen. George C.: Biennial Report of the Chief of Staff of the United States Army, July 1, 1943 to June 30, 1945: The Winning of the War in Europe and the Pacific, p. 86.


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going studies, however, came the decisions that (a) the Commander in Chief, Army Forces, Pacific (Gen. Douglas MacArthur) would be charged with the responsibility of military government in Japan; (b) the Chief of Staff of the U.S. Army would be the executive agency for the Joint Chiefs of Staff regarding military government; (c) the War Department would procure and train military government personnel and would also procure, ship, and distribute military government supplies.

In the meantime, however, supply problems in the Far East were being considered by the International Division of the Army Service Forces. Planning began in the summer of 1944. Supplies and equipment were estimated as the minimum necessary to facilitate military operations by the prevention of disease and civil disturbance. Such supplies were to include minimum quantities of food, fuel, clothing, materials for refugee or internee camps, and medical and sanitary supplies. Maximum use was to be made of indigenous supplies and stockpiles. No attempt at economic rehabilitation was to be made. Insofar as practicable, supplies were to be limited to standard Army items. The target for food requirements was set at 1,500 calories of an average balanced diet per person which would be supplemented for heavy workers employed on military projects.

The basic assumption for logistical planning was that Japanese resistance would have collapsed at least 30 days before occupation by U.S. forces.

The Civil Affairs Division decided that military government was to be exercised through the Emperor and his administrative machinery. Should imposition of direct military government be necessary, General MacArthur was immediately to advise the Joint Chiefs of Staff. Institution of a policy of nonfraternization was left to General MacArthur's discretion. There was to be no "de-Nazification" program similar to that carried out in Germany, but members of certain supernationalist and aggressive organizations would be excluded from office. Educational institutions were to be reopened as soon as possible.

Planning in the Office of the Surgeon General

Training activities were started as early as the spring of 1943 by the Provost Marshal General's Office, with the assistance of Col. Ira V. Hiscock, SnC, and personnel of the Preventive Medicine Service of the Surgeon General's Office.

At least 10 Civil Affairs schools in addition to the one at Charlottesville, were established in July 1943, and a number of these prepared various categories of officers for service in Japan.

In September 1944, further plans for campaigns in the Far East were made by the Preventive Medicine Service in the Surgeon General's Office. Among these were position papers relating to civil affairs and military government. Several principles were enunciated at that time, among which were the following:


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The health program of civil affairs was to be developed under the Civil Affairs Section of any given headquarters rather than as a part of the Chief Surgeon's Office. On the basis of experience in the North African and European theaters, it was strongly proposed that public health should be a major subdivision of civil affairs and so represented in the organizational plan. It was further urged that the chief of the public health branch for a major theater be selected early and assigned to the staff during the operational planning phase. In this connection, it should be noted that Col. (later Brig. Gen.) Crawford F. Sams, MC, selected by The Surgeon General to head civil affairs (medical and public health activities) in Japan, assumed these duties on 22 July 1945.

In the initial sketch of The Surgeon General's civil affairs plan for the Far East, the importance of close liaison in both the planning and operational phases between the Chief Civil Public Health Officer and the surgeons was stressed to assure effective coordination of the civil affairs medical plan with the military medical plan. Again the cardinal objectives of the civil affairs public health program were restated to be, "1. To re-establish and supervise the existing health organization of occupied and liberated countries and 2. To provide minimum facilities for medical care."

Standards of performance were to be based substantially on those existing before military occupation unless higher standards were required to prevent epidemics or civil unrest of an extent that might be prejudicial to the military effort.2

It was recognized that nutritional problems among the civilian population might well pose difficulties for the invading armies since a high incidence of deficiency diseases was present throughout the area even before the war, and this situation was thought to have worsened. Recommendations were made, therefore, (1) to assign specialists in nutrition to civil affairs public health headquarters of theaters and major task forces, and (2) to provide for epidemiologic studies to determine the incidence of deficiency disease of an occupied area since such data would serve as a guide to determining the basic food requirements of a civilian population.3

PERSONNEL PLANNING

Expanded concept of military government health activities.-Until the spring of 1945, civil affairs personnel planning for Japan had been based on the use of a comparatively few highly qualified Medical Department officers, who would be assigned to key positions from which they could direct civilian public health and medical matters with the aid of Japanese medical personnel. While this plan was believed to be adequate for the post-combat phase, reports from Guam, Tinian, Saipan, and other invaded is-

2Memorandum, Col. Thomas B. Turner, MC, for Chief, Preventive Medicine Service, Office of the Surgeon General, 18 Sept. 1944, subject: Civil Affairs Medical Plan for the Pacific Area. [Official record.]
3Memorandum, Col. John B. Youmans, MC, to Chief, Preventive Medicine Service, Office of the Surgeon General, 18 Sept. 1944. [Official record.]


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lands indicated that additional medical personnel should be earmarked to care for civilian casualties during the combat phase to assure that facilities intended for the care of military casualties would not also be burdened with the care of civilians. From experiences on these islands, civilian casualties were expected to be high, with little help initially from native medical resources.

In a memorandum dated 20 March 1945,4 The Surgeon General had outlined the plan for the Okinawa campaign, listing the number and type of medical department personnel his office proposed for the A, B, C, and D teams (later redesignated Teams CE, CF, CG, and CH). In addition, The Surgeon General proposed that one field hospital (Table of Organization 8-510, less nurse personnel) be attached to each corps for the care of civilian casualties, and that this organization as outlined be used as a basis for future logistic planning. This was approved by the Civil Affairs Division.

Estimation, procurement, and assignment.-Having obtained CAD approval, the Civil Public Health Division, with the assistance of Special Planning Division and Military Personnel Division, Surgeon General's Office, proceeded to estimate the number and type of Medical Department personnel required for military government for the Japan operation using the above basis. This estimate was forwarded to the Director, Planning Division, ASF (Army Service Forces), on 21 April 1945, with a recommendation that the War Department troop basis for this operation be augmented to provide for these personnel. This recommendation was studied in various ASF divisions until the early part of June 1945.

In the meantime, Brig. Gen. William E. Crist had been chosen by General MacArthur as his chief military government officer and assigned to the Office of the Chief of Staff for CAD duty. This division was requested by General MacArthur to make plans for military government in the Far East area.

On the advice of The Surgeon General, Public Health was organized as a major function of General Crist's staff, and Colonel Sams was designated as his chief medical officer. Colonel Sams was assigned to the Civil Affairs Division to work under General Crist in planning the medical program. The Surgeon General's Office assisted him in the selection of his staff, and numerous conferences were held concerning all medical phases of military government planning. Personnel needs in the event of either invasion or collapse were discussed. The estimate of 21 April 1945, having been referred by Army Service Forces to the Civil Affairs Division for comment, was reviewed by General Crist and Colonel Sams. Upon reviewing the SGO recommendation and later estimates based upon theater plans, a study for the inclusion in the troops basis of all military government personnel requirements was forwarded by the Civil Affairs Division through channels. While this study was under consideration but before final action was taken, events

4Memorandum, The Surgeon General to Civil Affairs Division of the War Department, 20 Mar. 1945.


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transpired which caused the Commander in Chief, U.S. Pacific Ocean Areas, to authorize the diversion of personnel and troop basis to meet the requirements for military government personnel. In view of this, the CAD study was returned without action.

Colonel Sams left for the theater about 15 August 1945. In a cable on 19 August 1945,5 activation was requested in the Civil Affairs Staging Area of 18 Headquarters and Headquarters Detachments, Military Government Groups and 56 Military Government Headquarters and Headquarters Companies.6 The Surgeon General's Office was asked to procure the needed medical officer personnel to fill these requirements, which were estimated as 74 Medical Corps officers and 56 Sanitary Corps officers (sanitary engineers). The table of organization for Headquarters and Headquarters Detachment, Military Government Groups, included one Medical Corps officer with the rank of lieutenant colonel. The Military Government Headquarters and Headquarters Companies included one Medical Corps officer with the rank of major and one Sanitary Engineer with the rank of captain. Available at the Civil Affairs Staging Area, Presidio of Monterey, were 23 Medical Corps officers and 10 Sanitary Engineers who had been trained at the School of Military Government at Charlottesville and the Yale University Civil Affairs Training School. In addition to these, the Surgeon General's Office requested 46 Sanitary Engineers and 35 Medical Corps officers to report to the Civil Affairs Staging Area to fulfill the requisition for officers. Information obtained from the theater indicated that the additional Medical Corps officers to complete the needs could be furnished from theater sources.

THE UNOPPOSED OCCUPATION OF JAPAN-
MILITARY GOVERNMENT ASPECTS

The unexpected announcement by the Japanese Government on 10 August 1945 of its desire to surrender brought a new and sudden change in plans by those charged with future assault operations. What must be regarded as one of the great strokes of diplomatic history was the decision that the Japanese Government, under the moral leadership of the Emperor, and its armed forces be required to shoulder the chief administrative and operational burdens of disarmament and demobilization, under policy directives from General MacArthur's headquarters.

Operations Instructions No. 7 materially altered the mission assigned to the Army commanders. Instead of actually instituting military government, Army commanders were to supervise the execution of the policies concerning government functions assigned to the Japanese Government by GHQ, AFPAC (General Headquarters, U.S. Army Forces, Pacific).7

5Cablegram (IN 18292), Army Service Forces in the Pacific to the War Department, 19 Aug. 1945.
6Memorandum, Acting Director, Civil Affairs Division, to The Surgeon General, 22 Aug. 1945.
7Reports of General MacArthur. Vol. I (Supplement): MacArthur in Japan: The Occupation: Military Phase. Washington: U.S. Government Printing Office, 1966, p. 194.


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New plans had to be promulgated quickly for the occupation; troops, materials, supplies, and transportation had to be procured on the basis of their availability rather than on that of fulfilling prime requirements. The Eighth U.S. Army was assigned the task of occupying northern Honshu and Hokkaido. Its mission was to occupy critical areas in those islands and to establish control over the armed forces of the enemy and the civilian population within the prescribed terms of the surrender.

Headquarters of the Eighth U.S. Army had moved from Leyte to Okinawa on 26 August. On 28 August, an advance group landed at Tokyo airfield (Atsugi), preceded by fighter planes overhead. The leading plane, bearing Col. Charles P. Tench of G-3 Section GHQ, commanding the advance party, was followed by 15 others-150 officers and enlisted men in all. Within 45 minutes after the lead plane landed, the field had been invested and communications with Okinawa established. The main airborne force arrived on 30 August.

Under the supervision of Japanese Maj. Gen. Seizo Arisue, the field was put in order by dawn the next day for the accommodation of large planes which were to bring the 11th Airborne Division. Meanwhile, elements of the Third Fleet anchored in Sagami Bay. A "correct" attitude was the keynote of individual relationships. By October, all of the Eighth and Sixth Armies were in Japan-a total of more than 460,000 men.

The Sixth Army occupied roughly the area south of Tokyo; and the Eighth Army, the area north of a line running across Japan just south of Tokyo and Sagami Bay (map 22).

Organization of Military Government

The occupation of Japan was theoretically under the Far Eastern Commission, comprising representatives of the several Allied Powers, with the Joint Chiefs of Staff being the top military policymaking group. Reporting to the Joint Chiefs was SCAP (Supreme Commander for the Allied Powers), General MacArthur, who was in operational control of the occupation and with whom originated most of the important policymaking decisions regarding Japan.

The Public Health and Welfare Section was one of 14 principal staff sections under GHQ, SCAP; Colonel Sams (fig. 87), chief of this section, was responsible for all military government health activities of the occupation. The Eighth Army was the operational unit.

As noted previously, a Military Government section had been established in GHQ, AFPAC, to administer occupied Japan. Military government teams were available to take over the government of Japan in every phase of activity, but those teams assigned to the Sixth and Eighth U.S. Armies were now used in the major cities of Japan to assure compliance with SCAP's policy directives.

By a directive dated 28 August 1945,8 military government activities

8See page 75 of footnote 7, p. 664.


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MAP 22.-Occupation of Japan by the Sixth and Eighth U.S. Armies, fall 1945.

of Army and Corps commanders were limited to a few specified functions, and the following policies were set forth:

1. SCAP will issue all necessary instructions directly to the Japanese Government.

2. Every opportunity will be given the Government and people of Japan to carry out such instructions without further compulsion.

3. The Occupation Forces will act principally as an agency upon which SCAP can call, if necessary, to secure compliance with instructions issued to the Japanese Government and will observe and report on compliance.


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FIGURE 87.-Brig. Gen. Crawford F. Sams, MC.

On 6 September, a directive9 stated that SCAP would exercise authority through Japanese governmental machinery and agencies, including the Emperor, to the extent that this satisfactorily furthered United States objectives. A new Economic Section and Scientific and Civil information, and Education sections were created in GHQ, AFPAC.

On 26 September, a directive10stated that there would be no direct military government in Japan; that a number of special staff sections would be established by GHQ, SCAP, to advise the Supreme Commander on nonmilitary matters in relation to the occupation of Japan, and that the Military Government Section, GHQ, AFPAC, would be discontinued.

On 2 October, GHQ, SCAP, was established with general and special staff sections of which Public Health and Welfare was one. These corresponded in general with the main technical branches of the Japanese Government.

The Public Health and Welfare Section was required to initiate policies

9See page 75 of footnote 7, p. 664.
10See page 75 of footnote 7, p. 664.


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relating to public health and welfare problems. The primary aim was to achieve a level of health and welfare among the civil population which would prevent widespread disease and unrest likely to interfere with the occupation. The major problem was the lack of trained and experienced Japanese personnel to conduct those programs at national, prefectural, and local levels.

The Eighth U.S. Army Military Government System

Military government in the Eight U.S. Army was organized at three principal levels: a staff section at Army Headquarters, a staff section at each of two Corps headquarters, and military government units stationed throughout Japan.11

Initially, military government was established in the Eighth Army as a Civil Affairs section under G-1 in the Philippines. Immediately after surrender, four Military Government companies were organized with personnel provided by GHQ and civil affairs units in the Philippines. In anticipation of any emergency that might arise, selected members of tactical units were organized in military government staff sections at divisional and regimental levels. In October, as trained military government units arrived in Japan, tactical units were relieved of this responsibility.

At Army level, military government continued under the Civil Affairs Section until 21 September, when this section was redesignated Military Government subsection, G-1, but shortly thereafter, it was reorganized as a Special Staff section.

Military government units were formed into groups and subordinate companies, each of which contained medical personnel. By mid-November, seven groups and eight companies had been assigned to the Eighth Army; three groups and two companies were directly under Army, and the others were attached to Corps and U.S. Army Service Command which operated at corps level in Kanagawa Prefecture. A special detachment was set up for military government in Tokyo.

On 1 January 1946, all occupation duties in Japan were assumed by the Eighth Army, to which were assigned at that time six groups, 24 companies, and 28 detachments. Later, a new unit, designated a "team," was formed to provide better use of specialist personnel. These teams were identified with each prefecture which, in turn, were grouped in seven regional groups. Three types of teams were created-a major, intermediate, and minor-to correspond to the importance of the prefecture.

Status of Public Health in Japan

Although Japan's introduction to Western culture began only as recently as 1853, the evolution, in theory at least, of Japanese health measures followed fairly closely that of the Western World and their level of medical

11Unpublished manuscript, R. W. Komer: Civil Affairs and Military Government in the Mediterranean Theater, Office of the Chief of Military History, Department of the Army. [Official record.]


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and scientific sophistication approached that of the more advanced countries of the West.

In 1873, a medical bureau, which dealt with matters of public health as well as medical education, was established in their Department of Education; and the following year, statutory authority was contained in a "Medical Code." In 1875, this bureau was transferred to the Ministry of Home Affairs, renamed the "Sanitary Bureau," and, from then on, dealt largely with sanitation and epidemic diseases.

Fundamental weaknesses in the system, however, were the lack of authority at the national level and the absence of an analogous organization at the prefectural and local levels for, here, health matters were customarily under the authority of the police, with the national bureau having advisory powers only. Faced with growing problems induced by rapid industrialization and a high incidence of malnutrition and tuberculosis, the Japanese Government in 1938 created the Ministry of Health and Social Affairs (later called the Ministry of Welfare) which became responsible for the health and welfare of the civilian population, including labor administration and social insurance. An attempt was made to reorganize the health services at the prefectural and local levels as well; however, under the impact of war and the consequent domination of civilian affairs by the Japanese military, these changes scarcely came into being as functional entities and, for all practical purposes, local health matters remained under the jurisdiction of the police. Moreover, there was tampering with medical, dental, and nursing education and major diversion of professional personnel and supply activities to military needs so that, by the end of the war, the Japanese civil health program had largely collapsed.

At the local level, such health and sanitation activities as existed were carried out by the police and the neighborhood associations which were influential in all phases of Japanese life. The health centers, established in 1932, were primarily advisory clinics for tuberculosis or maternal and child health activities and were not directed to the supervision of broader health programs in the more modern sense.

BROAD HEALTH PROGRAMS DEVELOPED
UNDER SCAP DIRECTION

Colonel Sams arrived in Tokyo on 30 August 1945. On 22 September, SCAP issued a directive to the Imperial Japanese Government as follows:12

The Supreme Commander for the Allied Powers directs that the Imperial Japanese Government take the following action:

1. An immediate survey by agencies of the Japanese Ministry of Health and Welfare to determine:

a. Disease prevalence in each prefecture.

12SCAP Directive to the Imperial Japanese Government, 22 Sept. 1945, subject: Public Health Measures.


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b. Medical, dental, veterinary and public health personnel available in each prefecture.
c. Hospital facilities, medical, veterinary and sanitary supplies present in each area with a comment in each instance as to its adequacy.
d. The adequacy of laws and regulations of the indigenous Japanese Public Health and Welfare authorities to meet current requirements.

2. Immediately inaugurate such measures as:

a. Weekly reports of communicable diseases by prefecture.
b. Examination, detention or hospitalization of cases or suspected cases of communicable disease.
c. Immunization, disinfestation and control of any disease which would be likely to seriously affect civilian health.

3. Restore all public water supply, sewerage systems and other human waste disposal means to the maximum civilian capacity with the least practicable delay through the use of civilian resources and labor.

4. Reopen or continue in operation civilian hospitals, sanatoria, leprosaria and clinics for use of indigenous population as rapidly as conditions permit or require. Where civilian hospital space is inadequate, a survey of schools or other buildings will be made to locate facilities which are suitable to be used as emergency hospitals and these buildings so designated.

5. All civilian (wholesale) and Japanese Military and Naval medical, dental, veterinary, sanitation supplies and military foodstuffs will be distributed through indigenous Japanese agencies in accordance with Military Occupational control plans on recommendation of the Supreme Commander for the Allied Powers for their conservation and distribution.

6. Inaugurate port quarantine control in cooperation with United States Naval Forces. Port quarantine will be established by Japanese civilian control.

7. Reopen or continue in operation civilian laboratory facilities for public health work, for clinical diagnosis, and for the manufacture of sera and vaccines.

8. Expedite the reporting and analysis of vital statistics data in accordance with policies established by the Supreme Commander for the Allied Powers.

9. Place special emphasis on adequate measures for the control of all venereal diseases occurring in indigenous Japanese personnel. This will be accomplished by using existing Japanese agencies.

On 2 October, General Orders No. 7 establishing the Public Health and Welfare Section was issued by the Commander in Chief. Since this document set the stage for the program developed during the Allied Occupation, it is quoted in its entirety.

1. The Public Health and Welfare Section is established as a Special Staff Section to advise the Supreme Commander for the Allied Powers on policies relating to Public Health and Welfare problems in Japan and Korea.

2. The functions of the Section are:

a. Make recommendations to:

(1) Prevent disease and unrest in the civilian population in accordance with objectives of the Allied Powers.

(2) Expedite the establishment or reestablishment of normal civil health control procedures, in order to prevent the spread of any disease likely to interfere with the success of the occupation mission.

(3) Provide for the early establishment of the essential public health and welfare activities to meet the minimum humanitarian requirements of the civil population and to protect the health and welfare and to further the accomplishment of the mission of the Occupation Forces.


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(4) Require the various interested governments to establish such standards of health, sanitation and quarantine in connection with repatriation of displaced persons as will prevent danger to Occupation Forces.

b. Make recommendations for the disposal of existing stocks and for the control of production and traffic in narcotics in Japan and Korea.

c. Make recommendations relative to, and to direct the conduct of such surveys of public health and welfare activities as are essential:

(1) To keep the Supreme Commander for the Allied Powers factually informed on public health and welfare conditions in Japan and Korea.

(2) To insure a factual and dependable basis for progressive formulation and modification of policies and plans pertaining to public health and welfare requirements and activities.

d. Prepare instructions for the initiation, coordination and development of such plans and programs as are required to meet the public health and welfare objective of the Supreme Commander in preventing serious diseases and distress in the civil population.

e. Coordinate such reports on the public health and welfare situation and activities in Japan and Korea as are required.

f. Conduct all liaison with and coordinate the activities of all non-military missions, commissions, or agencies concerned with public health and welfare problems in Japan and Korea.

3. Liaison will be maintained with:

a. The Japanese Ministry of Health and Social Affairs (Welfare).
b. International Red Cross.
c. American Red Cross.
d. Japanese Red Cross.
e. Chief Surgeon.
f. The Economic and Scientific Section for the purpose of coordinating matters pertaining to the production and distribution of Japanese and Korean medical, dental, veterinary and sanitary supplies and equipment.

Under Colonel Sams' leadership, a modern health program was instituted in Japan within a relatively few months after the occupation began. This program was directed from SCAP but was implemented largely by the Japanese. The organization of public health activities at national and local levels conformed to the general reorganization of the Japanese Government in accordance with the new constitution adopted after the end of the war.

The Ministry of Health and Welfare, which was one of the cabinet ministries in the Japanese Government, was reorganized to integrate four fundamental aspects of health and welfare: Preventive Medicine, Medical Care, Welfare, and Social Security. Labor activities formerly in the ministry were transferred to a new Ministry of Labor.

At the same time, health and welfare departments were established in all prefectural (state) governments on an equal status with other major departments of the prefectural governments. The same subdivisions were created in the prefectural departments as at the national level.

Within each prefecture, health center districts were established, with one district for approximately each 100,000 population. Each district contained at least one organized and staffed health center, which might have one or more branches according to population distribution. In cities with


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more than one health district, a city health department was organized to supervise and coordinate the activities of the district health officers.

Under a new health center law, districts were to include the following principal functions: public health nursing, maternal and child hygiene, public health statistics, diagnostic laboratory services, dental hygiene, nutrition, sanitation and hygiene, health education, medical social service, communicable disease control, venereal disease control, and tuberculosis control.

The sections that follow contain sufficient detail to convey some idea of the magnitude of the problems of the health field that confronted the occupation forces and the people of Japan, and some of the steps taken to meet those problems. It must be borne in mind that, during the period covered by this account, Japanese currency was not permitted as a medium of exchange outside Japan, and that virtually all the materials needed to implement a program of public health and medical care could be obtained only from Japanese sources-from industrial and pharmaceutical plants that were, in many instances, badly damaged or antiquated.

SPECIFIC HEALTH PROBLEMS

General Measures

Japan, with a population of 80 million, was a truly nationally governed country with residual legislative power vested in the Japanese Diet. One of the first measures, therefore, was to provide the appropriate national executive group-in this instance, the Ministry of Health and Welfare-with the authority and the executive mechanisms to fulfill its responsibilities.13

In turn, appropriate authority was vested in the Prefectural Health Department, the Health Center Districts, and, in metropolitan areas, the City Health Department.14

The successive steps in establishing this program on a firm legal basis in Japan were, first, to develop a basic plan which had the approval of the Supreme Commander and the concurrence of competent Japanese officials. This plan was then incorporated into a national health act which provided an adequate legal basis to administer and procure personnel, equipment, and funds.

A second step was to establish a model health center in one area (Suginami-Ku) of Tokyo to demonstrate to the Japanese the intent of the law.

13Most of the statistical data for this section are taken from the following sources: (1) Report, Lt. Col. Wilson C. Williams, Chief of Preventive Medicine Subsection, SCAP, to Chief Public Health Officer, Public Health and Welfare Section, SCAP, 9 Oct. 1945, subject: Report on Preventive Medicine Organization and Activities in Japanese Ministry of Public Health and Social Affairs (Welfare), (Through September 1945). [Official record.] (2) Report, Brig. Gen. Crawford A. Sams, subject: Public Health and Welfare Organization and the Preventive Medicine Aspects of Public Health and Welfare in Japan, 1948. [Official record.] (3) Report, General Headquarters, SCAP, Public Health and Welfare Section, December 1949, subject: Mission and Accomplishments of the Occupation in the Public Health and Welfare Fields. [Official record.] (4) Report, General Headquarters, SCAP, Public Health and Welfare Section, subject: Public Health and Welfare in Japan. With provisional summary of health statistics for years 1945-48. [Official record.]
14See footnote 13 (2).


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This center also provided training opportunities for military government health officers who were to be responsible for overseeing the health program in Japan, and for Japanese professional personnel who were to head the prefectural and local health department activities.

A third step was to establish a similar model in each of the 46 prefectures of Japan and to inaugurate similar demonstration courses for local personnel. Continuing courses were offered also in specialized fields of public health.

The first phase of this ambitious program was completed by 1948, less than 3 years after the occupation, a truly remarkable accomplishment.

The fulfillment of this program was contingent upon the subsequent activation of health centers in the remaining 780 districts, which was virtually accomplished before the end of the occupation.

To convey some idea of the acute shortage of trained personnel, at the end of the war Japan had only two trained sanitary engineers, both from foreign schools, and no medical social workers. Moreover, there had been no formal public health training in Japan; and only through the fellowship program of the Rockefeller Foundation had a small nucleus of public health officers been trained abroad, mostly in the United States, before the outbreak of the war. This small group was, as might be expected, enormously helpful in implementing the rejuvenated health program.

An Institute of Public Health had been built in 1939 with funds from the Rockefeller Foundation, but its teaching program had scarcely begun before its activities were curtailed by the war. Plans were quickly made under the Military Government Program to reopen the institute and to reorient its program to provide greater educational opportunities in the field of public health. This was accomplished in 1947. Indeed, because of the severe shortage of trained public health personnel, stress was placed on teaching preventive medicine and related subjects in many of the Japanese medical institutions.

Included in this massive educational effort were successful attempts to bolster educational facilities and opportunities in the fields of medicine, pharmacy, and sanitary engineering.

It is interesting to note that, by the end of the war, virtually all key positions in the various bureaus of the national and prefectural governments, including public health, were held by persons with a law degree. As a part of the occupation program, these individuals were gradually transferred-in the Ministry of Public Health and the Prefectural health departments, to posts more commensurate with their training-and were replaced as rapidly as possible with professionally qualified personnel.

Within the relatively few months after the occupation, a major revolution had been wrought in the national attitude toward public health and in the means for giving expression to it. For a country so thickly populated, where subsistence can be at a precarious level and where there is potential


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for disaster in epidemic diseases, this new orientation must indeed be regarded as a significant event in the life of the Japanese nation.

Health Statistics

While vital statistics, births and deaths, had for many years been reliably reported through police channels, the mechanisms for securing good health statistics were defective and, during the last years of the war, had deteriorated further. One of the first steps of the Military Government health program was to establish health reporting on a weekly basis throughout the nation.

The average mean crude annual death rate for the period 1938 to 1945 was 18.3 per 1,000, with a high of 29.2 for 1945; this rate was reduced to 14.6 in 1947. A substantial proportion of these reductions was accounted for by a striking decline in infant mortality. The average mean annual rate per 1,000 live births for 1938 to 1943 was 94.9 infant deaths; for 1947, it was 76.2. In both adults and infants, the major reduction occurred in deaths from enteric diseases and pneumonia.

Sanitation

Despite Japan's industrial and military sophistication, its standards of sanitation were far below those of most Western nations. Public water and sewerage systems existed only in the larger cities and, for the most part, sewage disposal was through the antiquated system of "honey buckets" in which disposal was from individual privy, to collecting cart, to gardens.

At the time of capitulation, while the water systems of some cities had been disrupted by bombing, the Tokyo water supply was largely intact, and token chlorination was in effect. This was promptly bolstered by supplies of chlorine from the occupation forces and, throughout the nation, water supplies were fairly rapidly put back into satisfactory operation.

Likewise, even the primitive sewage disposal systems common in all but the largest cities had deteriorated because of the labor shortage due to military demands. Again, the rehabilitation of these facilities to prewar standards was accomplished fairly quickly. Modernization was accepted as a long range objective.

Little attention had been given to insect or rodent control except as it pertained to malaria control. A vast rat population was supported on the comparatively meager diet of the Japanese people, and the number of flies in a kitchen was regarded as a subtle tribute to the prowess of the cook. The incidence of louse infestation had increased and foci of typhus fever cases were being brought to light (see p. 676).

Coal was practically nonexistent by the end of the war; this, together with crowding, water shortages, inadequate sewage disposal, and fuel shortages, led to a repitition of conditions encountered in Italy, Germany, and elsewhere under the impact of war, in which the incidence of skin diseases,


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notably scabies, dysentery, and many other infectious diseases markedly increased.

The Public Health and Welfare Section assigned a high priority to this problem. An intensive campaign of public education was inaugurated, and strenuous efforts were made to rehabilitate whatever water systems had been in existence. In addition, early in 1946, six-man sanitary teams were organized, initially to deal with an outbreak of typhus. They were trained in elementary fashion and equipped with minimum facilities to deal with environmental sanitation, including insect and rodent control. By the spring of 1946, 9,000 such teams were in operation. Even assuming some inefficiency, vacillation of purpose, and waste, the impact of these teams, while impossible to measure, must have been enormous.

With the passage of time, too, the economy began to improve, the labor force increased; food, water, and fuel became more abundant-factors which, together with the specific health programs, brought fairly prompt improvement in the health of the nation.

Communicable Diseases

Only a few diseases were legally notifiable before the occupation, and, by the end of the war, even these few were no longer being reported. One of the first actions of Lt. Col. Wilson C. Williams on reaching Japan in late September 1945 was to assemble the available information concerning the prevalence of infectious diseases throughout Japan.

It was clear from these data that enteric diseases, including typhoid, had a high incidence throughout Japan, probably substantially higher than the prewar level although valid statistical comparison could not be made. The data were qualitatively useful, however, in indicating foci of unusual incidence. Similar reports indicate that smallpox was present in the country at a high endemic level, that typhus outbreaks were occurring in Hokkaido, the northernmost large island of Japan, and that tuberculosis and venereal disease were health problems of major importance.

The situation immediately after the surrender was complicated further by the mass movement of people in and out of cities in search of food, by the return of thousands of Korean laborers to their native country, and by the anticipated return of Japanese soldiers from all over the Far East and the Pacific Archipelago.

The enteric diseases.-The incidence of dysentery is commonly regarded as a good index of the sanitary level of a community although reliable data on incidence are not readily obtainable in many countries. A few figures for Japan will be cited as broadly indicative of the sanitary level.

In the period 1938-45, the reported average annual incidence of dysentery, presumably both amebic and bacillary, was 101.6 per 100,000 population, with peak rates of 138 in 1939 and 1945. The rate for 1946 was 116.8. In 1947, the mean morbidity rate per 100,000 population had declined to 50.5, and in 1949, to 18.3, the lowest in the history of Japan to that time.


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Typhoid and paratyphoid fever cases reached a peak in 1945, the greatest number occurring in the months immediately preceding and following surrender. The incidence remained high during the early months of 1946 and then sharply declined. Actual fatality rates per 100,000 for typhoid and paratyphoid fever combined were 12.2 in 1945, 7.8 in 1946, 4.2 in 1947, and 2.0 in 1948. During 1946, approximately 20 million persons received vaccinations against these diseases (fig. 88); and in 1948, these immunizations and reimmunizations were made obligatory for certain age groups, a more questionable health procedure. Production of the large quantities of vaccine needed for this program was accomplished largely through Japanese facilities.

Smallpox.-An old Japanese law required immunization against smallpox, and the disease had been reasonably well controlled in the past. However, enforcement had become progressively lax and, since 1938, a higher endemic level had been noted. In the initial review by military government health authorities, vigorous steps were taken to rehabilitate facilities for the production, assay, and distribution of smallpox vaccine; and a widespread immunization program was pressed.

By the end of January 1946, 60 million persons, three-fourths of the population of Japan, had been vaccinated, which should have broken the epidemic. To the alarm of health authorities, the number of smallpox cases continued to mount in the later months of 1945, reaching a peak of 6,304 in March 1946, with 17,800 cases, or a rate of 23.7 per 100,000 population, being reported for 1946. It was discovered that, by the old regulation, alcohol or phenol was required to be used as an antiseptic; in actual practice, the vaccinia virus was place on the arm still wet with antiseptic, so that successful immunization was the exception rather the rule. When this situation was discovered, a decision was made to revaccinate the entire population of Japan by proper methods. This was accomplished in a few months-some 75.3 million immunizations in all-surely one of the most stupendous health operations in the history of the world. Cases of smallpox progressively declined to 3,850 in April, 1,746 in May, 1,057 in June, 114 in July, 41 in August, and nine in September. In the following year, 391 smallpox cases were reported, and in 1948, 29 cases, giving annual rates of 0.5 and less than 0.1 per 100,000 respectively. The smallpox rate remained at this low level to the end of the occupation.

Typhus.-Early in the occupation, a conference of representatives of the Public Health and Welfare Section, the United States of America Typhus Commission, and Japanese authorities was held to discuss the typhus situation. This group concluded that the winter of 1945-46 promised to be the most serious one for typhus in Japan and Korea, and also in China and Manchuria, since 1942.

Based on recommendations of the Typhus Commission, the Chief, Public Health and Welfare Section, GHQ, SCAP, arranged to import the following essential typhus control supplies for civilian use: DDT insecticide pow-


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FIGURE 88.-A Japanese civilian receives typhoid inoculation, Tokyo, 1946.

der and dusters, gasoline engine driven delousing outfits, and typhus vaccine.

A vigorous control program was outlined; for military personnel, this was to consist of (1) a stimulating dose of typhus vaccine for all troops on 1 November and 1 February, (2) monthly issue to each man of one can of louse powder, and (3) a training program for military typhus control teams.

A program directed to the civilian population was to consist of (1) immunization and monthly delousing in coal mines, labor camps, and six of the major cities of Hokkaido which were the main typhus foci; (2) delousing all persons crossing Tsugaru Strait between Hokkaido and Honshu; (3) delousing all Japanese repatriates from the Asiatic mainland and Korea; and (4) appropriate control measures in the event of an epidemic.

There was no DDT or typhus vaccine in Japan, the sole source being the CAD supplies earmarked for Japan, or available in regular Army supply channels, although the situation was such that it seemed unwise to divert these latter supplies to civilian use.

A dusting and vaccination barrier was planned for the ferry points between Hokkaido and the main island of Honshu; but this action was ineffective because the Korean miners in Hokkaido had revolted 2 weeks before the arrival of occupation forces and had dispersed widely through Japan in an effort to return to Korea. In other words, typhus-infected lice had been seeded throughout Honshu, and outbreaks occurred in some of the major cities, including Osaka, Kobe, Nagoya, and Tokyo, beginning in December


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1945. From 1 January to 1 July 1946, 29,939 cases were reported, with a total of 31,141 cases being reported for the whole of 1946.

Problems were experienced in obtaining shipping space for DDT powder. When Japan capitulated, some 11 ships were being loaded in New Orleans and West Coast ports with relief supplies, including medical supplies and clothing, for Japan. The AFPAC headquarters then announced that Japan could not expect aid from the United States, and canceled dispatch of the 11 ships by AFPAC. This information, incidentally, first reached the War Department through the public press. The director of the Typhus Commission, Brig. Gen. Stanhope Bayne-Jones, MC, alert to the implication of the cancellation, immediately arranged through Maj. Gen. (later Lt. Gen.) LeRoy Lutes, USA, to have the 75 CAD antityphus units earmarked for Japan, and possibly Korea, forwarded to Japan since he regarded such action as essential to the protection of U.S. troops in those areas.15

The shipment authorized by Gen. Brehon B. Somervell, Commanding General of the Army Service Forces, included 10-percent DDT powder and dusters in addition to the regular antityphus units. Shipping orders for those supplies were issued on 8 October, and the shipment reached Japan in December 1945.

With the assistance of Col. Joseph F. Sadusk, Jr., MC, executive officer of the Typhus Commission Field Headquarters in Tokyo, an extensive program of DDT dusting and immunization was carried out during January 1946 in most of the trouble areas. The program followed much the same pattern that had been successful in Italy and Northwest Europe. The monthly buildup and defervescence of the epidemic on a national basis, from September 1945 through September 1946, were as follows: 

 

Number of cases

1945:

September 

117

October 

44

November 

285

December 

153

1946:

January 

272

February 

2,036

March 

10,435

April 

8,486

May 

5,298

June 

3,412

July 

507

August 

213

September 

67


Source: Report, General Headquarters, SCAP, Public Health and Welfare Section, subject: Public Health and Welfare in Japan, 1948. Statistical annex, table 25, p. 19. [Official record.]

During the winter of 1946-47, the number of cases increased but scarcely reached previous endemic levels (1,064 cases in 1947), and only 429 cases were reported in 1948.16

15Memo for file, Brig. Gen. Stanhope Bayne-Jones, MC, Headquarters, United States of America Typhus Commission, 28 Sept. 1943, subject: Cancellation of Medical and Other Civilian Supplies for Japan. [Official record.]
16Medical Department, United States Army. Preventive Medicine in World War II. Volume VII. Communicable Diseases. Arthropodborne Diseases Other Than Malaria. Washington: U.S. Government Printing Office, 1964, p. 260.


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Tuberculosis.-Pulmonary tuberculosis had long been a leading cause of death in Japan. For several years, the death rate for all forms of the disease rose steadily, reaching 280 per 100,000 population in 1945, one of the highest rates in the world.

Considered a shameful disease by the Japanese, cases all too rarely came under medical care until the late stages. Shortages of food and fuel, overcrowding, and the generally poor economic conditions during the later stages of the war had contributed to the increasing prevalence. At the time of occupation, many patients had left the tuberculosis sanatoriums to seek food, and thus contributed to a further spread of the infection.

Japanese scientists had been conducting research on BCG vaccine since 1927; in 1943, the National Research Council of Japan had recommended that the use of this control measure should be encouraged. In 1944, more than 5 million individuals between the ages of 10 and 19 who were tuberculin-negative were given BCG; and in 1945, more than 3 million persons between the ages of 15 and 24 were inoculated. Some doubt exists concerning the potency of the vaccine used.17

Because of preoccupation with more acute health problems, the Public Health and Welfare Section did not tighten up the control measures for tuberculosis until the fall of 1946, at which time a major effort aimed at the eventual control of the disease was inaugurated. The essential elements of this program were:

1. To encourage the return of patients with active tuberculosis to sanatoriums through public education and provision of adequate food, fuel, and facilities to these hospitals.
2. A program of professional education in diagnosis and treatment for the medical and nursing professions.
3. Inauguration of a school lunch program for children.
4. Mass casefinding examinations in schools, factories, and among contacts of active cases.
5. A stepped-up program of BCG vaccination.18

Beginning in 1947, compulsory notification of tuberculosis was required for the first time in Japan. Relying on the specific mortality rates as an index of the trend of the disease, it should be noted that the rate per 100,000 population for 1946 was 264.2; for 1947, 187.5; and for 1948, 181.1. It is difficult, of course, to determine those elements of the program which were most effective in reversing the trend of tuberculosis in Japan, or to what extent the improvement in the general economy and sanitary level of the country was responsible.

Venereal diseases.-Fraternization of Allied soldiers with the Japanese was not forbidden and the venereal diseases were inevitably of concern to the occupying forces. The Japanese, on the other hand, had long regarded this problem as one limited to prostitutes and, in general, the medical profession

17See page 8 of footnote 13 (3), p. 672.
18See page 8 of footnote 13 (3), p. 672.


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was ill-informed regarding clinical manifestations and epidemiologic patterns; methods of treatment were archaic. Licensed prostitution was legal and flourished widely since geographic limitations of brothels had broken down during the war years.

In October 1945, syphilis, gonorrhea, and chancroid were declared reportable diseases; and in January 1946, the Japanese Government was directed to annul laws pertaining to the legalization of prostitution. A program designed to revolutionize the psychological, epidemiologic, clinical, and legal approaches to these diseases was vigorously implemented, but with uncertain success. In 1946, approximately 436,000 cases of syphilis, 556,000 cases of gonorrhea, and 108,000 cases of chancroid were reported.

Treatment facilities were established, largely through the health centers referred to previously, and penicillin and the sulfonamides were made increasingly available as the pharmaceutical industry swung into production. A new venereal disease prevention law passed by the Diet in 1948 included provision for premarital examination, prenatal examination, and examination of all contacts and suspects for evidences of venereal disease.19

Diphtheria.-The incidence of diphtheria rose during the war years, with 94,274 cases reported in 1944; 90 percent of the deaths occurred in children under 10 years of age. Diphtheria toxoid had never been used as a control measure although antitoxin was available for treatment and temporary prophylaxis.

The necessity of a nationwide immunization program was recognized immediately, but no toxoid was available. While waiting for the production of this biological by the pharmaceutical industry, other control measures such as quarantine and focal passive immunization were instituted. The number of cases reported in 1946 was 66,000.

During the latter part of 1946, a large-scale active immunization program was begun, and 16 million children were inoculated. Deficiencies were discovered, however, because of frequent confusion between toxoid and antitoxin, and it is not known what proportion of this number was properly immunized. A second large-scale immunization program was mounted in 1947. Case rates, per 100,000, were as follows: 1945, 122.8; 1946, 65.5; 1947, 36.4; and 1948, 20.3.20

Cholera.-Only an occasional case of cholera had been reported in Japan during the preceding two decades, and none was recognized during the early months of the occupation. Anticipating problems in this respect from the repatriation program, stringent quarantine measures were initiated in September 1945. In the spring of 1946, cases began to appear among repatriates on ships from China and other areas of the Far East, and a few cases filtered into Japan through the smuggling in of non-Japanese. Cholera cases continued to increase, and a peak was reached in July and August; 1,229 cases were reported for 1946. Stringent control measures-isolation,

19See page 11 of footnote 13 (3), p. 672.
20See pages 24 and 26, and tables 23 and 24 of footnote 13 (4), p. 672.


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quarantine, disinfection, and focal immunization-which were applied to the areas where cholera cases occurred were probably responsible for limiting the epidemic. Approximately 34.5 million persons received cholera vaccine. No cases were reported after December 1946.21 Control measures were less successfully applied in southern Korea (see p. 696), where an epidemic of 15,642 cases occurred.

Other infectious diseases.-The early development of facilities for penicillin production in Japan was responsible for a sharp reduction in the mortality from pneumonia. No cases of plague were reported during the occupation years or, indeed, in any year since 1926.

No large outbreaks of Japanese B encephalitis occurred since 1935; sporadic cases were not uncommon, but the disease was not made officially notifiable until 1946. In the last 6 months of 1946, 259 cases were reported, but in 1948, coincident with the delayed inauguration of the mosquito control program, an outbreak of 7,208 cases occurred.22

Malaria, which had been endemic in Japan for many years, was not made a notifiable disease until 1946. In 1947, reported cases numbered 11,841; and in 1948, 4,940. It was determined, however, that most of these cases were recurrent attacks among repatriated Japanese.23

In the 52 years between 1895 and 1947, life expectancy in Japan increased only from 42.8 to 50 years for men and from 44.3 to 53.9 years for women. However, during the 3-year period under Allied Military Government, 1947-50, the life expectancy for men increased from 50 to 58 years, and for women from 53.9 to 61.5 years.24

MEDICAL CARE PROBLEMS

Medical Education

Before the war, Japan had 18 medical schools of university caliber and 10 second-class schools. For the most part, all of these schools followed the older German pattern of reliance principally on didactic lectures, with little practical experience in the clinic or laboratory being required. While only 10 second-class medical schools existed before the war, under the pressure of necessity, 41 others had been started. The degree granted by these poorer schools differed somewhat from that of the university schools, but the opportunity for such graduates to practice medicine was not limited. Approximately 60 percent of all medical graduates of 1945 were from these second-rate schools. Understandably, therefore, the general level of medical practice in Japan was low despite the presence of some physicians trained in scientific medicine. A small group of physicians in Japan had graduated from European, chiefly German, or American medical schools.

21See page 27 and table 25 of footnote 13 (4), p. 672.
22See page 34 of footnote 13 (4), p. 672.
23See table 23 of footnote 13 (4), p. 672.
24Professional paper, Brig. Gen. Crawford F. Sams, dated 1 Nov. 1951, subject: American Public Health Administration Meets the Problems of the Orient in Japan.


682

Under the impetus provided by the Public Health and Welfare Section, a Japanese Council on Medical Education, comprising physicians representing the better medical schools, was formed in early 1946 to consider the reform of their medical education system. In 1947, the nonuniversity "technical" medical colleges were classified in A or B categories; members of the latter group were either closed or put on probation, pending radical improvement. At the same time, changes in the curriculum were introduced, placing greater reliance upon practical work in the laboratory and the clinic.

As a part of these reforms, the Japanese Medical Association was reorganized to exclude direct governmental influence; new leadership was recognized; and a new constitution was formulated, dedicating the association to the promotion of quality medical education, higher ethical standards, and the advancement of public health. Prefectural and local medical societies were likewise formed.

At the same time, SCAP inaugurated national examinations for medical licensure. The first examinations were held in 1947, under the auspices of the Council of Examinations for Medical Licensure of the Japanese Ministry of Welfare. One year of internship after graduation from medical school was required for licensure.

The Medical Examiner System

Exaggerated Japanese press and radio reports on the number of deaths attributed to starvation in persons found on Tokyo streets resulted in the Tokyo Metropolitan Health Bureau's being instructed to conduct an autopsy at the Tokyo University Medical School on each body subsequently found. The system, first placed in effect on 24 November 1945, showed that these deaths, in fact, were caused by disease. In April 1946, this provision was enlarged to cover all deaths believed to have public health importance. This activity proved of such value that it was extended to include all the large metropolitan areas in Japan, and legal authority for the system was established by direction in December 1946. This law also created authority for turning over to the medical school all unclaimed bodies for use in instruction in anatomy. Up to this time, the use of cadavers for such teaching was actually illegal.

Medical Literature

The international exchange of medical literature had virtually ceased upon the outbreak of war. Early in the occupation, the great need for modern medical literature was recognized, but currency restrictions curtailed the purchase of such material. The situation was alleviated partially by loans and donations from the Surgeon General's Office in Washington and by textbooks and journals made available to each military government team. The demand, however, far exceeded these meager resources.

After 2 years of effort and with the assistance of the Civil Information


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and Education Section of SCAP, the Public Health and Welfare Section succeeded in arranging for the republication of certain American journals and textbooks in Japan. The Japanese Medical Association began publication of its journal in November 1948.

Hospital Care in the Early Occupation Period

Civilian hospitals deteriorated during the war because of the removal of equipment for other uses and because of the effects of bombing; 1,027 hospitals with a total bed capacity of 53,000 were destroyed. Medical supplies had been diverted from civilian and military use, and there was an overall shortage of drugs, X-ray films, and dressings.

At the time of surrender, 320 Army and Navy hospitals with a bed capacity of 78,000 were in operation. These institutions were rapidly turned over to the Ministry of Welfare and gradually reoriented to civilian purposes.

Early in the occupation, a weekly reporting system was established, which showed the bed occupancy of the hospitals of Japan. Initially, this report included all hospitals of more than 10-bed capacity, other than tuberculosis and mental hospitals and leprosariums. With the passage of the Medical Service Law in July 1948, an institution was required to have a capacity of 20 beds before being classified as a hospital; and the reports were made monthly.

At the same time, a program directed to the improvement of hospitals was inaugurated, but these changes were intimately related to medical and nursing education, and to age-old customs, so that progress was inevitably slow. The First National Hospital in Tokyo was selected for development into a model institution. There were about 244,000 hospital beds in Japan, or one bed for each 328 persons in the population.

Model hospitals were established subsequently in each prefecture following the pattern of the Health Center program for expansion. The First National Hospital became the site of the first School of Hospital Administration in Japan.25

Atomic Bomb Casualties

Although one of the greatest military disasters of all time to befall a civilian population occurred in Japan-the atomic bombing of Hiroshima and Nagasaki-the Allied occupation of these cities did not occur for about a month so that military government was not importantly involved, except indirectly. The bomb was dropped on Hiroshima on 6 August 1945, and on Nagasaki on 9 August; some 64,000 deaths occurred immediately or within several weeks in the former city and 39,000 in the latter. Many thousands more were severely wounded. It is noteworthy that Japanese scientists quickly deduced the essential nature of this new powerful destructive force and demonstrated the presence of excess redioactivity in the soil within a few days after the initial explosion.

25See footnote 13 (4), p. 672.


684

Since the first group of U.S. investigators did not arrive in the bombed areas until 8 September, the bulk of the rescue work fell upon the Japanese themselves. Working parties reached Nagasaki on 19 September and, because of the intervention of a typhoon, they reached Hiroshima on 12 October.26These working parties, consisting of U.S. Armed Forces medical personnel, directed their energies primarily to investigation of the many different medical effects of the bombing although, in the process, much good medical care was rendered to Japanese civilian victims.

Two stimuli for the scientific and medical evaluation of these extraordinary events came from Washington: one, a request to AFPAC from Maj. Gen. Norman T. Kirk, The Surgeon General, and Lt. Gen. Leslie R. Groves, director of the Manhattan Project, that Col. Ashley W. Oughterson, MC, and Lt. Col. Averill A. Liebow, MC, be detailed to make an immediate survey of the situation. The other stimulus was the formation of a group by the Manhattan Project under the command of Brig. Gen. Thomas Farrell, with the medical component under Col. Stafford L. Warren, MC; this group arrived in Japan in early September. These two groups were integrated before proceeding to the destroyed cities.

Access to the bombed areas was difficult because of the disruption of rail and air travel. Nagasaki was accessible by sea; Hiroshima was not, because of the presence of large minefields. Three naval medical units organized under the supervision of Cdr. Shields Warren, MC, USN, were dispatched to Japan from the United States. On 12 October 1945, a Joint Commission for the Investigation of the Effects of the Atomic Bomb in Japan was established, with Col. Elbert DeCoursey, MC, as the senior medical officer. This Commission was composed of the following three groups: the Manhattan Project Group, under General Farrell; the GHQ group under Colonel Oughterson, representing the Chief Surgeon's Office; and a Japanese Government group, under Dr. Masao Tsuzuki of the Imperial University of Tokyo. Responsibility for longtime followup was eventually assumed by the National Research Council. Studies carried out under the auspices of these groups have been published by the U.S. Atomic Energy Commission in a monumental work of five volumes under the general title of Medical Effects of the Atomic Bomb in Japan.27

Nutrition

Historically, Japan has always had a food deficit, and food imports amounted to about 15 percent of her requirements. The diet basically was composed of rice, fish, and fresh seasonal vegetables. During the war, the Japanese were on a restricted ration which became more severe as the war progressed and imports were curtailed. For example, the usual military daily allowance of 3,400 calories had fallen to 2,900 by the end of the war. The

26Oughterson, Ashley W., and Warren, Shields: Medical Effects of the Atomic Bomb in Japan. National Nuclear Energy Series, Manhattan Project Technical Sec. Division VIlI-Volume 8. New York: McGraw-Hill Co., Inc. 1956, pp. 3 and 7.
27For summary volume of this work, see footnote 26.


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average civilian allowance was only 1,300 calories daily, but most people averaged 1,600; and, while the nutrition of the civilian population had suffered, no serious problem in this respect existed.28

Desiring more data on the nutritional status of the civilian population, SCAP directed that a nutrition survey be made in Tokyo in December 1945 since rumors then were rampant that deaths were occurring from starvation. Similar surveys were made early in 1946 in Nagoya, Osaka, Kure, Fukuoka, Sapporo, Sendai, Kanazawa, and Matsuyama. In addition, an equal number of people were surveyed in the rural areas immediately adjacent to these urban areas. The surveys were repeated at 3-month intervals, about 150,000 persons being surveyed each time.

The surveys consisted of studies of representative households in each area, data being obtained on the physical condition of the individual and his estimated daily caloric intake. As might be expected, the food intake varied according to season, being highest in the fall and winter after the harvest of the rice and sweet potato crops, and these variations were most pronounced in the large urban centers. During the late summer periods of 1946 and 1947, the average caloric intake fell to 1,300 calories in some of the larger cities. This decline was accompanied by an increase in the proportion of persons with one or more deficiency symptoms, such as inadequate lactation, delayed menstruation, hyperkeratosis, glossitis, and anemia. Large stocks of canned meat held by the military forces were particularly helpful in meeting hospital requirements during the food shortage in the summer of 1946.

One of the most important programs begun by military government was the school lunch program which, in particular, added protein and calcium to Japan's school population. Powdered skim milk was the basis of this diet change, which resulted in increased stature and weight for the new generation of Japanese. This change in the dietary pattern, which included new emphasis on meat eating, has probably had a lasting effect on Japanese health according to subsequent reports.

Nevertheless, a shortage of food persisted during the entire occupation. An effort was made to supply some of the deficiencies through imports. This was not a simple problem for not only were many imported foods, such as wheat, unfamiliar to the Japanese, but also their preparation called for increased fuel which was also in short supply.

Dental Affairs

During the war, civilian dental practice virtually disappeared because of the shortage of personnel and materials. Eight dental schools remained after the war and served as the nucleus for improving dental education in Japan.

The Council on Dental Education was established early in the occupa-

28Memorandum, Col. Bruce P. Webster, MC, 12 Sept. 1945, regarding conference with Japanese Minister of Health concerning "Current Health Problems in Japan."


686

tion to recommend educational reforms. Three years were added to preliminary schooling as a requirement for entry into dental college, and the dental school curriculum was substantially changed. A National Board of Dental Examiners was established for the first time, and the Japanese Dental Association was reorganized as a nongovernmental society.

Plans were made to provide dental service in each of the 800 health centers in Japan.

Nursing Activities

In prewar Japan, nursing had never received professional recognition, and in only a few hospitals did nurses, in fact, achieve professional standing. Standards of education fell during the war.

Under SCAP guidance, a Nursing Education Council was formed and was very active in the inauguration of a modern nationwide nursing program. Based on the council's recommendations and with supervision and assistance from American nursing personnel, refresher and full-time training courses were started, educational standards were raised, and registration and licensure requirements were placed into law.

On 1 June 1946, a model demonstration school of nursing was opened in the Central Red Cross Hospital in Tokyo. The student body from St. Luke's College of Nursing, hitherto about the only modern nursing school in Japan, was merged with that from the Central Red Cross Hospital, and the faculties of both schools were used to instruct the combined total of 420 trainees. Other demonstration schools of nursing were planned.

Shortly after the occupation, the existing government-controlled nursing societies were dissolved; in their place, the National Nurses Association was established as an independent professional organization.

Veterinary Affairs

Under the Department of Agriculture, the prewar veterinary program was concerned mainly with the eradication of certain diseases, notably infectious osteomalacia and tuberculosis. During the war, civilian activities were sharply curtailed, and the program concentrated on the care of military horses. Although monthly inspections of dairy plants continued, there was virtually no meat inspection.

In 1946, a Council on Veterinary Affairs was established under the guidance of SCAP, and this group reorganized the Japan Veterinary Medical Association along democratic lines. Veterinary education was improved, and a new program for the control of animal diseases was promulgated. Steps were also taken to increase the production of biologicals used in the control of these diseases. The eradication of bovine tuberculosis was accepted as a long range objective. An expanded immunization program to control canine rabies was also begun.


687

Medical Supply Problems

Some insight into medical supply problems may already have been gained from the foregoing sections. Much of the shortage was in materials which, while essential for health, were not commonly regarded as medical supply items; for example, fuel, clothing, hot water, soap, and bedding. However, there were also real shortages in strictly medical supplies.

Before the war, the Japanese pharmaceutical and allied industries had expanded to develop a large export business throughout the Orient. Generally, these supplies were produced in relatively small factories; and at the time of surrender, about half of these factories had been destroyed or diverted to the production of war materials. The capacity of the remaining plants was only about 20 percent of prewar requirements, and about two-thirds of the output went to the Japanese Army and Navy.

Immediately after the arrival of the occupation forces, surveys were made to determine the medical supply situation. It was found that considerable potential for production of pharmaceuticals and hospital supplies existed and that management was eager to reestablish production.

The decision was made, therefore, (1) to attempt to rehabilitate indigenous production rather than to rely on extensive and expensive imports, and (2) to supplement this production by importing only those materials which could not be produced in Japan. Through SCAP directives, the Ministry of Welfare was required to develop procedures to fulfill its supply responsibilities. Ministry officials were given guidance and training to enable them to increase production and to establish effective distribution.

Japanese and U.S. military medical supplies.-At the time of surrender, all Japanese military supplies and equipment were taken over by the occupation forces. Upon completion of an inventory, nonwar materials, such as food, clothing, and medical supplies, were returned to the Japanese Government for civilian use. Distribution of medical supplies to normal civilian channels was delayed, however, because most of these supplies were concentrated in large depots and dumps often in remote areas.

Essential medicines and biologicals were imported in the months following surrender while indigenous production was being established. Also of great value were U.S. Army surplus medical supplies which were made available to relieve this critical shortage.

Production.-An overall production plan was developed in the early months of the occupation. The most essential and critical items were to be produced first. The whole operation required sweeping changes in the system of production, control, and allocation of raw materials. Responsibility for medical supply items was firmly placed on the Ministry of Welfare. In addition, an Economic Stabilization Board was established to allocate raw materials to various industrial groups.

At the beginning of the occupation, acceptable biologic products of various types were desperately needed to prevent and control infectious diseas-


688

es. One of the first major projects undertaken which had a high priority was the production of vaccines for typhoid, typhus, cholera, and diphtheria, and tetanus toxoid. Facilities for standardization and quality control were lacking and many biologicals produced in the early phases of the occupation were of dubious efficacy.

In 1946, a Laboratory Control Section was established in the Japanese Ministry of Welfare and a national laboratory control program was inauguarated. Official minimum standards for the various biologicals were promulgated for the guidance of the production laboratories. Supplies of laboratory animals were developed and the production of penicillin, sulfonamides, DDT, and BCG was later brought under surveillance.

During the early stages of the occupation, X-ray machines, X-ray films, and the chemicals necessary for their development were unobtainable. By the end of 1946, production of these items was increasing rapidly, with priority being given to the requirements of the antituberculosis campaign.

Initially, the Ministry of Welfare strictly controlled the distribution of some 365 medical supply items, notably drugs, surgical dressings, and infant foods. By the end of 1948, only 79 items were controlled. The distribution system was altered radically to place primary responsibility on local health departments for distribution to hospitals, physicians, clinics, and pharmacies rather than to leave this responsibility with the manufacturers themselves.

A program designed to raise the level of pharmacy education and practice was also begun by the Ministry of Welfare, under the guidance of SCAP.

Narcotics Control

No control over narcotics existed in Japan before the occupation, in disregard of her obligation to international bodies charged with regulating the supply and distribution of narcotics throughout the world.

Upon occupation, the Japanese Government was directed immediately to prohibit the cultivation of narcotic plants as well as the manufacture and exportation of narcotics, to enact laws establishing strict centralized control over narcotics, to establish a narcotics enforcement agency, and to destroy all heroin supplies.29

CONCLUSIONS REGARDING JAPAN

It is beyond the scope of this chapter to describe in detail the renaissance of the Japanese health services. Moreover, one can only speculate to what extent the American occupation was responsible for the vast rebuilding of these modern and essential functions which contribute so much to the human welfare-a development that went beyond anything previously known in Japan. When General MacArthur and his staff entered Japan, not only had the military forces been completely defeated, but also the civilian

29See footnote 13 (4), p. 672.


689

economy and social structure had almost disintegrated. The U.S. occupation forces began the immense task of reconstruction.

General Sams and his competent staff were able to mobilize the health and medical resources of Japan to benefit the people. With the steadfast support of the Supreme Commander, General Sams and his group moved quickly and decisively to encourage and direct the Japanese to establish a health system and a health service capable of dealing with the manifold problems of first a defeated people and then a reconstituted industrial nation. The Japanese people without the occupation forces eventually would have achieved a degree of stabilization of its public health situation, but it is unlikely that this could have been accomplished so quickly or reached so high a level without the grand pattern imposed by the occupation forces within a period of a few months. Nor could it have been accomplished without the willing cooperation, hard work, and professional competence of the medical and allied professions of Japan. After all, the whole purpose was to help Japan return to the community of democratic nations where respect for human rights and human welfare was a guiding principle.

Section II. Korea

CIVIL PUBLIC HEALTH

Organization of Military Government Health Activities

Korea was regarded by the Allied Powers as a friendly country rather than as a defeated enemy like Japan. However, since Korea had long been under the domination of Japan, there was no local government with which the Allied Powers could work. Hence, the immediate pattern of Allied occupation was in the form of a benevolent military government.30

When hostilities ceased on 14 August 1945, the XXIV Corps, which had been heavily engaged in Okinawa and was reequipping and retraining for the assault on Japan, was designated as the force to occupy Korea. Advance elements arrived in Korea on 8 September. Included in the party was Lt. Col. Joseph Auerbach, MC, who served as acting surgeon in the absence of Col. Laurence A. Potter, MC, the Corps Surgeon, who was on leave. Also included in the advance party was Capt. Virgil H. F. Boeck, MC, whose first mission was to survey American prisoners, determine health and sanitary conditions in Korea, and locate sites for hospitals and other medical installations. The main components of the XXIV Corps, including the 6th, 7th, and 40th Infantry Divisions and ASCOM 24 (Army Service Command-24), began to arrive in Korea on 15 September.

On 15 August, the 38th parallel was designated as the line dividing the

30Material for this section is taken from (1) Historical Summation, Headquarters, U.S. Army Military Government in Korea, undated, subject: History of the Department of Public Health and Welfare, September 1945-May 1947, and (2) a paper by Col. James P. Pappas, MC, subject: Civil Assistance to the Republic of Korea, Public Health, 1950 Through 1954. [Official record.]


690

Soviet and U.S. zones of occupation in Korea. The area north of this line consists of approximately 46,500 square miles while the southern section has a land area of about 38,000 square miles. Beginning in August 1945, Russian troops entered Korea and accepted the surrender of Japanese occupation forces above the 38th parallel; U.S. forces accepted the surrender of Japanese forces below this line. A joint commission from the two occupying powers was formed to develop a four-power trusteeship through which the United States, the Soviet Union, the United Kingdom, and China would oversee a provisional government until the Koreans were able to govern themselves. However, the Soviets blocked all efforts by the Koreans to unite their country and, in May 1948, the North Koreans established the People's Democratic Republic of Korea, followed by the formation by the South Koreans of the Republic of Korea. This account describes civil affairs/military government public health activities in South Korea.31

U.S. Military Government in Korea operated under Lt. Gen. John R. Hodge, Commanding General, XXIV Corps, until August 1948. Headquarters, U.S. Army Military Government in Korea, was established in September 1945 and continued until August 1948. By June 1949, the last U.S. troops, with the exception of military advisers, were withdrawn from South Korea. The chief medical officer for Military Government health affairs was Dr. William R. Willard of the U.S. Public Health Service, serving in the grade of colonel, MC, with the Armed Forces in Korea.

Under the Japanese organization of the Korean Government, public health activities were under the direction of the national police and consisted largely of inspection and licensing. Welfare activities were carried on as a function of the Department of Education.

By Ordinance No. 1, signed on 24 September 1945 by General Hodge, the Military Governor of Korea, the Public Health Section of the Bureau of Police was abolished and a Bureau of Public Health was established. On 27 October, welfare activities were added, and the name was changed to the Bureau of Public Health and Welfare. Shortly thereafter, an ordinance was issued, establishing a Department of Public Health and Welfare in each province.

At the national level, the Bureau was administered by a director and consisted of two principal branches, Public Health and Welfare, each under a deputy director. The Public Health Branch included the following sections: Medical Services, Preventive Medicine, Vital Statistics, Sanitation, Laboratories, Dental Affairs, Veterinary Affairs, Nursing Affairs, and Pharmaceutical Affairs. The Welfare Branch consisted of seven sections:Administration and Policy, General Relief, Research and Analysis, Welfare Training, Institutions and Agencies, Bureau Housing, and Bureau Employee Welfare.

At the end of 1945, approximately 50 officers and 30 enlisted men had

31ROTC Manual No. 145-200. American Military History, 1607-1958. Washington: U.S. Government Printing Office, 17 July 1959, p. 492.


691

been assigned to the Bureau of Public Health and Welfare, of whom about two-thirds were a part of the Public Health Branch.

The activities of the provincial Bureau of Public Health and Welfare were predominantly in the field of health, and the following sections were organized: Medical Services, Preventive Medicine and Vital Statistics, Sanitation, Veterinary Affairs, Pharmaceutical Affairs, and Welfare.

By an ordinance promulgated in October 1946, the national Bureau was designated a Department with its various sections being designated Bureaus. Concurrently, the provincial health organizations were renamed Bureaus.32

Medical Influences in Prewar Korea

Korea, over the years, had been subjected to three major influences in the field of medicine and public health: Chinese, American, and Japanese. Since ancient times, treatment of the sick in Korea had been based largely on Chinese herb medicines and Chinese philosophy of "positive" and "negative" influences-the Yang and Yin theory. Herbs were prescribed chiefly to restore the balance between Yang and Yin, surgery was primitive, and modern medicine as brought in by the Americans and Japanese made slow headway against this long heritage of the past; presumably today it is still a potent influence.

Western medicine was introduced first into Korea by American medical missionaries in the last two decades of the 19th century. While the main purpose was propagation of the Christian faith, good medical care was a powerful component of the missionary effort.

With the advent of the Japanese who established a protectorate over Korea in 1905 and annexed the country in 1910, the American missionaries gradually were suppressed. From then on, the principal medical influence was Japanese which, on the whole, represented the then current Western point of view. Fifty hospitals were erected, five medical schools were started, modern waterworks were constructed, and quarantine stations were established.

However, not only did the organization of public health follow the traditional Japanese pattern of subservience to the police, but also opportunities for Korean nationals to become proficient in administration were exceedingly limited. Thus, at the time of Korea's occupation by the American Army, there were virtually no experienced public health personnel.

Health Situation at the Time of Occupation

There had been no fighting in Korea and, consequently, no destruction of medical and sanitary facilities although, during the war years, the facilities deteriorated as did the quality of medical services. Vital statistics pertaining to births, deaths, and marriages were collected routinely by the Department of Justice. Statistics on the occurrence of disease, however, were

32See footnote 30 (1), p. 689.


692

meager. Malaria was endemic, tuberculosis was prevalent, typhoid and dysentery were common, and the infant mortality rate was high.

The repatriation of large numbers of Koreans from Japan and China, with attendant crowding in port cities, presented unusual opportunities for the spread of epidemic diseases. While quarantine stations (map 23) were maintained at the principal South Korean ports-Pusan, Inchon, Mokpo, and Kunsan-the enforcement of regulations at times was lax. At other times, the services were inadequate to cope with the workload.33

HEALTH PROBLEMS AND PROGRAMS

Vital statistics.-The reports of births, deaths, marriages, and divorces obtained through the Justice Department were continued, but an early step in the health program was to devise and inaugurate modern health statistics reporting as an integral part of health services. This program met with doubtful success because of the dual system. At the same time, an effort was made to begin a system of communicable disease reporting, a program which was limited by the paucity of physicians in many areas of the country, by the lack of laboratories where definitive diagnoses could be made, and by the generally inadequate state of communications.

Reports of communicable disease were made first by the doctor to the local administrative office. These reports were then forwarded to the Provincial Health Department where they were consolidated and submitted to the national office, usually with a delay of 2 to 4 weeks. As might be expected, there was believed to be substantial underreporting of many diseases, confusion of terms such as typhus and typhoid, and designation of dysentery as cholera during epidemics of the latter disease.

Medical services.-While there was no destruction of hospitals and sanatoriums, virtually all the key personnel of these institutions were Japanese; with their departure, services largely collapsed. Before the war, there were 795 Japanese doctors in South Korea and an unknown number of Korean "regular" doctors (as contrasted to folk-medicine doctors). By 1947, there were 2,317 Korean "regular" doctors, giving a ratio of 1 to 8,300 population, but more than 30 percent of these were practicing in Seoul which had only 5 percent of the population of South Korea.

The 46 government-owned and -managed general hospitals had a total bed capacity of 4,128. These were formerly used principally by the Japanese; and after the war, the bed occupancy varied from 60 percent to a low of 5 percent during the cold weather because of inadequate heating facilities. However, nearly every practicing physician had his own private hospital which varied in capacity from 1 to 100 beds; these facilities provided most of the general hospitalization. The military government health officer often found himself trying to resolve conflicting claims of Koreans for the right to operate the many private hospitals previously owned and operated by Japanese physicians before repatriation.

33See footnotes 30 (1) and (2), p. 689.


693

MAP 23.-Quarantine stations at principal South Korean ports, fall 1945.

By the end of November 1945, the larger provincial and municipal hospitals and private hospitals in and near Seoul surveyed by military government officials were found to have adequate medical supplies by Korean standards although coal and food supplies were inadequate. Problems of price, procurement, distribution, and transportation still remained acute. However, the outpatient departments were very active, and the first health center in Seoul had been officially opened.

In addition, there were two mental hospitals of 50- and 30-bed capacity, three tuberculosis hospitals with a total bed capacity of 300, and four leprosariums with a total capacity of 29,000 to care for an estimated 40,000 lepers in South Korea.

Infant and child mortality.-Infant mortality was about 300 per 1,000 live births, and approximately one-half of all children born died before the age of 5 years. Infant nutrition was far below Western standards.

Pediatric clinics were established in the provincial capitals, but the work of these clinics was limited by inadequate supplies and personnel and seemingly by the general apathy of the people.

Port quarantine.-Four major ports were used by foreign commerce


694

-Pusan, Inchon, Mokpo, and Kunsan. Quarantine stations in each of these ports were under the direction of an American quarantine officer. All incoming ships were inspected routinely; all crew members and passengers were vaccinated for smallpox, cholera, and typhoid before coming ashore; and any ship found to be carrying patients with communicable diseases was quarantined. Nevertheless, cholera was introduced through Pusan in 1946.

Nutrition.-A nutrition section in the Bureau of Preventive Medicine was established during the early months of the occupation; but after abortive attempts at nutrition surveys among the Korean populace, the section was discontinued because of a lack of experienced personnel and funds.

Public health education.-Efforts were made through radio, newspapers, town meetings, and posters to disseminate information concerning the control of communicable diseases, especially those epidemic at the time. An educational film on cholera control was produced in Korea and widely shown throughout the provinces by a portable unit. As usual, accomplishments of this program were difficult to evaluate.

Medical education.-One of the first governmental acts after occupation was to establish the Korean Board of Medical Licensure, composed of prominent Korean physicians and representing the National Korean Medical Society, the Korean Board of Medical Education, and the Department of Public Health and Welfare. It was decided early to discontinue licensing of "limited" doctors (those trained by apprenticeship to regular doctors) and herb doctors, and to permit only those previously licensed by the Japanese to practice. By August 1945, most of the medical practitioners in South Korea had registered with the National Board. Graduate courses for physicians were organized in Seoul in October 1946, about 1 year after the end of Japanese control, and 5-day graduate courses by visiting lecturers were arranged in each of the provincial capitals.

In the seven recognized medical schools in South Korea, administration was delegated by military government to the Medical Education Section of the Education Bureau. At the same time, a Board of Medical Education was organized to establish standards and define policies for these schools.

In August 1946, Seoul National University was established in an attempt to bring the existing university up to standards approximating those of universities elsewhere. Merged into the national university were various Seoul colleges including the medical college. By September 1946, official recognition had been given to the College of Medicine of Seoul National University, Severance Union Medical College, Seoul Women's Medical College, Taegu Medical College, and Kwangju Medical College.

A 6-week course in public health was organized at Seoul University in November 1945. The first class was comprised of 22 Korean physicians.

Preventive medicine.-One of the largest and most diverse health programs was developed under the Bureau of Preventive Medicine. Trained native health personnel were in critically short supply, and few Korean physicians had experience in administrative health activities. Moreover, commu-


695

nication was poor, the social and political situations were confused, and black marketing of medical supplies was widespread.

Communicable Diseases

Smallpox.-At the time of occupation, a number of minor smallpox epidemics were reported, and the disease appeared to be on the increase. During the winter of 1945-46, a nationwide epidemic of smallpox occurred, the epidemic peak being reached in April, during which a total of 19,809 cases were reported.

A program of compulsory vaccination had been in operation under the Japanese, the custom being to vaccinate children at 1 year, again at 6 years, and a third time at 10 years. However, the results of vaccination were not checked routinely, vaccination technique was often poor, and doubtlessly the vaccine deteriorated because of improper handling. At any rate, there were obviously many nonimmune individuals in Korea at the time of the epidemic.

A nationwide program of vaccination was inaugurated in October 1946 under the auspices of military government. Approximately 18 million doses were distributed in South Korea during the next 3 months. This vaccine was produced in the National Veterinary Laboratory at Pusan. By May 1947, only 113 cases of smallpox had been reported. Most of the cases had been traced to a visitor to North Korea and occurred in one of the more isolated regions of South Korea (Kangnung area of Kangwon-Do).

Japanese B encephalitis.-Late in the summer of 1946, three cases of Japanese B encephalitis occurred in U.S. troops in the Kunsan area of Cholla-Pukto Province. No cases were found among the civilian population at the time, but the mosquito vectors of the disease were found. Random survey of blood samples from Koreans showed a high frequency of antibodies to this virus.

Typhus fever.-At the time of the Allied occupation, the United States of America Typhus Commission had begun a survey of typhus in South Korea and predicted that the incidence would probably be considerably higher than it was the preceding year. By November, a dusting program had already been started in Kyonggi Province, at the border stations along the 38th parallel, and at the Seoul Railroad Station. Casefinding and insect control teams likewise were being trained in all provinces. Despite these steps, during the winter of 1945-46, a typhus epidemic occurred in South Korea, with a total of 5,869 cases being reported. The highest incidence for any month was 1,064 cases reported in April. Delousing measures and vaccination programs were begun, but these measures seemed to have little effect on the course of the epidemic which ended in June.

During the winter of 1946-47, typhus recurred with 1,183 cases being reported by 1 May. The picture was somewhat confused by the presence of relapsing fever, which tended to be endemic with low mortality.

Typhoid fever.-This disease had a high endemic incidence in Korea throughout the early occupation period, 9,319 cases being reported during


696

the first half of 1946. The disease was believed to have been transmitted by carriers since no explosive outbreak attributable to contaminated water was encountered. Vaccination programs were conducted in areas of high concentration of the disease, but no nationwide program was initiated because of the shortage of laboratory supplies needed to produce vaccine.

Cholera.-An alarming epidemic of cholera occurred as the Koreans were being repatriated from China. The disease was introduced into the province of Kyongsang-Namdo and spread to the whole of South Korea. The first case occurred in May 1946 and the peak incidence was observed in July, the epidemic being assisted by widespread floods in June. Altogether, 15,642 cases of cholera were reported with 10,191 deaths; the actual number was believed to have been much higher since concealment of cases by families was common. No cases occurred in U.S. military or civilian personnel or their dependents.

A nationwide anticholera vaccination program was begun in June 1946, and by late August, almost all persons south of the 38th parallel had received cholera vaccine. The National Vaccine Laboratory in Seoul produced approximately 30 million cc., and 10 million cc. were received from Japan. Quarantine measures and restriction of travel were invoked but were believed to have had only a limited effect. Most cholera patients received little or no treatment because hospital facilities were lacking in many of the areas involved. Where it was possible to obtain and use intravenous fluids, the case fatality rate was greatly reduced.

Epidemiologic and bacteriologic studies indicated that the principal means of spread was through contaminated surface drinking water and through infected food consumed at large funerals, a common practice in Korea. The shortage of doctors in the provinces made prompt detection and isolation of cases difficult. Eventually, teams of physicians and medical students were dispatched to the provinces where they assisted in early case-finding, vaccination, and isolation of contacts, and in obtaining stool cultures on all suspected cases and immediate contacts. The police and constabulary worked in coordination with public health officials in enforcing quarantine restrictions, establishing roadblocks, and restricting civilian traffic by rail and water. The highest incidence of cholera occurred in the provinces of Kyongsang-Pukto and Kyongsang-Namdo. A severe epidemic of cholera is believed to have occurred in North Korea at the same time, but no facts are available.

Diphtheria.-Diphtheria was a major cause of childhood morbidity in Korea during the years under discussion. In 1946, 864 cases were reported; and 457 cases were reported from 1 January to 1 May 1947. Toxoid immunization had not been used in Korea, and facilities for its production were not available. Diphtheria antitoxin was readily available from the National Laboratory in Seoul.

Malaria.-The occupation troops had a high incidence of malaria. Although the disease was not a major cause of disability among Korean civil-


697

ians, the spleen and parasite index was high, indicating its endemic occurrence. Malaria control measures were conducted principally by the Armed Forces (fig. 89).

Tuberculosis.-Tuberculosis was probably the most widespread and, in the long run, the most disastrous of all diseases in Korea although its occurrence was less spectacular than the epidemics of smallpox, typhus, and cholera. Tuberculosis was estimated to cause approximately 45,000 deaths annually. By May, little progress had been made in instituting a civilian health program directed to the control of this disease. Lack of progress was attributable to the shortage of sanatorium beds and X-ray facilities. A Korean Antituberculosis Association, formed in the fall of 1945, was not effective because of lack of supplies. Construction of the Mason Tuberculosis Sanatorium, in Kyongsang-Namdo, was begun under the military government; the sanatorium opened in June 1946. By December, 116 beds were occupied, but months elapsed before the hospital was functioning effectively. Deficiencies in tuberculosis control must be counted as one of the more serious gaps in the civil public health program in Korea

Venereal diseases.-The accurate incidence of venereal diseases was not known although the high rate among occupation troops was clear evidence of high frequency in the civilian population. Prostitution had been legal in Korea for many years. There were no public clinics and diagnostic and treatment facilities were inadequate. At the insistence of the occupation forces, a program of venereal disease control was inaugurated by military government personnel in November 1946. Free clinics were established in all the provincial capitals, diagnostic facilities were provided, and adequate supplies of penicillin were made available. By May 1947, however, there was little tangible evidence of effective control among civilians.

Laboratory Program

When the State laboratories of Korea passed from Japanese to Korean hands, they constituted a rundown physical plant which had never adequately produced the volume or variety of biologicals needed for the human or animal population of Korea Moreover, essential phases of the relatively small-scale production had been entirely dependent upon skilled Japanese personnel since the few Koreans employed had occupied only positions demanding less skill.

During 1946, the following were produced: vaccines for cholera, pertussis, rabies, smallpox, typhoid, and typhus; also diphtheria and meningococcus antiserums, diagnostic antigens for cholera, dysentery, typhoid, paratyphoid A and B, typhus, and tuberculin, as well as diagnostic antiserums for cholera, dysentery, typhoid, and paratyphoid A and B.

Since many of these biologicals were produced in small quantities, the local supply was augmented through imports. In addition, various biologicals were produced for use in animals. Comparative costs of local production and importation of the same biologicals showed that substantial sav-


698

FIGURE 89.-American military personnel of the 601st Malaria Control Unit search for signs of mosquitoes in rice paddies just outside Seoul, Korea.

ings would result from increasing production capabilities in Korean laboratories.

Under military government, a National Chemistry Laboratory was established as a part of the governmental laboratory system. This facility carried out synthesis and preparation of organic compounds required by other laboratories, such as purification of glycerin and phenol; synthesis of trichloracetic acid and preparation of peptone; toxicological studies; certain nutritional studies on selected population groups; preparation of certain drugs such as chaulmoogra oil; and the chemical analysis of water.

Sanitation Problems

Before military government took over the management of internal affairs in Korea, most of the sanitary work was under the Bureau of Police. Japanese personnel were responsible for water and sewage facilities. When military government was established, sanitation problems became a responsibility of the National Health Services Bureau of Sanitation.

While the larger cities had reasonably efficient water supply systems,


699

most of the smaller towns and villages were supplied by wells, an estimated 240,000 in all. Sewage systems in the larger cities functioned fairly well; garbage collections, however, were never satisfactory, largely because of the shortage of trucks and gasoline.

During the period of military government, an effort was made to develop programs of sanitary inspection of restaurants, hotels, and markets, and to establish some control over public toilets, burial grounds, and the housing of animals and fowls in relation to public wells. These programs developed slowly and were only partially effective.

Nursing Services

Under the Japanese, Korean nurses had been little more than servants. Most of the professionally trained personnel were Japanese, and these held all the key posts in the hospitals and schools of nursing. There was no public health nursing program, and midwifery was uncontrolled. When most of the Japanese nurses were removed during the war, training activities ceased.

Under military government, a Nurses' Educational Committee was formed to survey available personnel, curriculums of schools of nursing, laws relating to nurses and midwives, and methods of examination and licensure.

The 20 schools of nursing in Korea varied in quality from the high standards of Severance Union Hospital School of Nursing to very low standards in some of the provincial hospitals. From the deliberations of the Nurses' Educational Committee, a smaller study group consisting of three doctors and five nurses was formed; and on the recommendations of this group, a program was begun to improve the nursing profession in Korea. Among the accomplishments under this program were the following: On 15 January 1946, a Nurse and Midwife Licensure Board was established whose function was to prescribe curriculums and standards for nursing and midwifery education and licensure. The board also proposed the establishment of a National Korean Nurses' Association and provincial nursing associations. Four refresher courses of 2 months each for graduate nurses were organized, and 186 students graduated from them; four refresher courses in midwifery were also completed with a total of 50 students in attendance; and four courses of 3 months each in public health nursing were completed by 69 graduates. A 3-month course for training instructors and chief nurses was begun on 1 April 1947, with 22 graduate nurses enrolled. As of 1 June 1947, Korea had 746 recognized graduate nurses, 774 student nurses, 227 nurses aides, and 1,200 midwives.34

Textbooks on pediatrics, nursing arts, and nursing ethics were translated and printed. Course outlines were prepared by the Korean staff for use in advanced nursing courses and in schools of nursing. Plans were also laid for a small-scale visiting nurse program. Four nurses were selected for

34See page 11 of footnote 30 (1), p. 689.


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inservice training in the United States, under the auspices of the Rockefeller Foundation, and an expansion of that program was envisioned. Plans were laid for the publication of a Korean journal of nursing.

Dental Services

The only dental college in Korea at the time of the American occupation had been operated as a privately owned school by a group of Japanese; at the end of the war, it was taken over by a group of Korean dentists. Responding to political pressure, the school subsequently was turned over to the Government and became a part of Seoul National University. Its curriculum was converted gradually to the American pattern of dental education.

No dental materials or equipment was produced in Korea; all came from Japan or the United States. At the time of American occupation, about 400 Korean and 900 Japanese dentists were practicing in Korea. When the Japanese dentists were repatriated, their offices and equipment were turned over to the Government for leasing to Korean dentists, especially those coming from North Korea.

Professional standards were low. No graduate of the Korean Dental College was required to pass a licensing examination although such examinations were required of graduates of foreign schools. A school dental program which had been in operation before the war lapsed because of a shortage of dentists.

With the organization of the Department of Public Health and Welfare, a Bureau of Dental Affairs was established, with both American and Korean directors. National laws pertaining to dental affairs were revised to conform more nearly to the U.S. Code in these matters. A Board of Qualification and Examination was set up and all dentists were subjected to relicense procedures. Authority was obtained from the Department of Finance for dentists to purchase gold for professional use and, subsequently, about 135,000 grams were released annually for this purpose.

Other dental materials and supplies, obtained from Army surplus stores, were distributed to the dental college and to practicing dentists through the Seoul Dental Supply Co., which was privately operated. This company was also licensed to import dental materials and equipment.

Because of the extreme shortage of dentists, a plan was evolved whereby experienced dental apprentices could take a course of lectures in the dental school, followed by an examination, and be issued a limited license to practice in the provinces for a period of 5 years.

As military government drew to an end, progress was being made slowly toward establishing school dental hygiene programs, organizing low-cost dental clinics in hospitals and health centers, and improving the educational standards and equipment of the dental college.


701

Veterinary Affairs

Before the establishment of military government in Korea, veterinary services, as such, did not exist as a governmental function. The relatively few Korean veterinarians practicing under the Japanese supervision were not well trained by modern standards. At the time of the occupation, an epizootic of rinderpest in North Korea threatened to decimate the livestock population of the whole of Korea. Supplies and equipment for veterinary purposes were limited to a small quantity of Japanese stocks.

A Bureau of Veterinary Affairs was established within the Department of Public Health and Welfare soon after the inauguration of military government. During the Japanese control, animal treatment and related activities had been regarded as an agricultural function while meat inspection and other sanitary functions were under the supervision of the police. A combination of these two activities into a single governmental bureau was believed desirable, in part to make better use of scarce personnel.

The most urgent problem was to establish effective control of the spread of rinderpest from North Korea. This involved securing laboratory animals, producing rinderpest vaccine, and sending teams into the fields to immunize all cattle in a zone 15 miles wide along the 38th parallel. Presumably this immune zone, which was rigidly maintained, created an effective barrier.

Rabies, which is enzootic throughout Korea, reached epizootic proportions on the island of Cheju-Do during the winter of 1946. A program of restraint and vaccination of the canine population was instituted, and the outbreak was completely controlled within 3 months.

Attention was given concurrently to other veterinary programs which included inspection and licensing of slaughterhouses, pasteurizing plants, fish and meat markets, and tanneries. Most important were measures designed to increase the number of veterinarians and improve the quality of their education. Formerly, veterinary education, such as it was, was at the equivalent of American high school level and was under schools of agriculture. Under military government, minimum requirements were raised to include 4 years of college work, and plans were laid to establish a College of Veterinary Medicine in Seoul. In the interim, plans were made to send students to veterinary colleges in America.

Census figures, even though only approximate, indicate the serious decline in the animal population in South Korea from 1938 to 1947 (table 5).

A national ordinance, designed to control the slaughter of animals and preserve the remaining livestock, was enacted; breeding of animals was encouraged; and production goals were established.

In September 1946, a new curriculum was introduced in the College of Agriculture and Forestry, which established a School of Veterinary Medicine in Seoul National University.


702

Medical and Related Supplies

Most of the 72 major drug manufacturing plants in Korea under the Japanese were in the vicinity of Seoul. Immediately upon occupation, these plants were put under guard and their funds were frozen; after an audit, military government officials invited bids for their operation. Successful Korean bidders were required to furnish cash bond covering 30 percent of the appraised value of each concern. Considerable difficulty was experienced in finding the personnel required to operate these plants; by the end of November, only 20 plants were in operation, with production ranging from 5 to 60 percent of normal. Raw materials were available, but essential fuel was in short supply.

TABLE 5.-Estimated animal population in South Korea, 1938, 1943, and 1947
 

Animal

1938

1943

19471

Cattle, draft

1,717,000

1,062,000

661,141

Cattle, dairy

---

2,000

1,124

Horses

51,200

35,000

34,142

Sheep

27,000

48,000

3,546

Goats

44,000

---

25,663

Swine

1,507,000

636,000

181,331

Poultry

7,165,000

2,983,000

1,516,364

1As of 1 January 1947.
Source: Historical Summation, Headquarters, U.S. Army Military Government in Korea, undated, subject: History of the Department of Public Health and Welfare, September 1945-May 1947, p. 14.

No appreciable quantity of surgical instruments or of laboratory, X-ray, dental, or veterinary supplies had ever been manufactured in Korea. Upon occupation, estimates for a 6-month period called for delivery of 360 basic medical units at the rate of 20 every 10 days, starting as soon as possible. By the end of March, some units had been received through the Port of Inchon. Each medical unit was designed to provide for 100,000 persons for 30 days.

Before the American occupation, the Bureau of Pharmaceutical Affairs was controlled by the Bureau of Police, with three-fourths of its personnel being Japanese. Under the direction of an American military government officer, three Koreans, remaining in the Bureau after discharge of the Japanese, inventoried Japanese medical supplies in the hands of drug wholesalers. Supplies uncovered amounted to approximately 664 items, plus 150 items of herb medicines.35

Shortly after occupation, the Korean Medical Supply Co. was named as the agent for the Department of Public Health and Welfare to inventory, receive, and distribute all recovered Japanese supplies and all medical supplies received from the United States. Distribution quotas for each prov-

35See page 16 of footnote 30 (1), p. 689.


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ince were determined by the Bureau of Pharmaceutical Affairs, which was transferred to the Department of Public Health and Welfare. Provincial health departments controlled the allocation of supplies to hospitals and doctors in their areas. To expedite distribution, one or more drug wholesalers were designated in each province as distributing agents for the health department.

In January 1946, a Pharmaceutical Affairs Committee was organized to study existing laws and regulations pertaining to drugs and the drug business. In March, a new ordinance36 was published which, among other provisions, prohibited the sale of drugs by street peddlers, which had been the practice under Japanese rule. In May, a further ordinance37 promulgated by military government placed the control of all medical supplies under the Department of Public Health and Welfare; in July, Ordinance No. 96, covering registration and licensing of pharmacists, drug manufacturers, wholesalers and retailers, was published. Immediately, 441 pharmacists were licensed while 105 applications were disapproved.

The first of 360 CAD medical units were received in March 1946, and additional units were delivered through November of that year. Early in 1946, the Korean Pharmaceutical Promoting Co. was organized by the Bureau of Pharmaceutical Affairs to increase the output of locally produced pharmaceutical supplies. This organization, consisting of 70 to 80 drug manufacturers in South Korea, controlled the allocation of raw materials to drug manufacturers. Among locally produced drugs were such items as alcohol, iodine, bismuth nitrate, sodium bromide, sodium chloride, dextrose, and a few insecticides. High-quality cod liver oil was being produced in North Korea and steps were taken to import it into South Korea. The military government attempted to increase the number and types of pharmaceutical items produced in Korea; in April, they published an official price-list establishing ceilings on the retail prices of drugs.

In November 1946, responsibility for production and control of narcotics was given to the Department of Public Health and Welfare. At that time, large quantities of narcotics, including 28 million grams of opium, were turned over to the Bureau of Pharmaceutical Affairs. Another ordinance38forbade the growth or possession of poppy or poppyseeds in any form although its enforcement continued to be a problem throughout the occupation period. Previously, large quantites of opium were processed in Korea; in the Seoul area alone were 10 narcotics manufacturing plants, one of which was reported to be the largest in the world. Data indicated that the Japanese were producing enough opium in Korea to meet world needs.

36U.S. Army Military Government in Korea Ordinance No. 62, 29 Mar. 1946, subject: Regulation of Drugs, Medicines, Pharmaceuticals and Related Articles.
37U.S. Army Military Government in Korea Ordinance No. 90, 28 May 1946, subject: Economic Controls.
38U.S. Army Military Government in Korea Ordinance No. 119, 11 Nov. 1946, subject: Narcotics Control.


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Red Cross

Under the Japanese, the Korean Red Cross was, in effect, a branch of the Japanese Red Cross, and all of its senior personnel were Japanese. Its program was largely medical and its activities included the operation of a large modern hospital near Seoul and a tuberculosis sanatorium at Inchon. Originally, supervision of the Korean Red Cross was placed by military government under the Foreign Affairs Division but, in December 1945, was transferred to the Welfare Division of the Department of Public Health and Welfare. Plans were made to expand its program to include such functions as disaster relief and community organization.

In January 1946, the first American Red Cross civilian relief team arrived in Korea and began to reorganize the local Red Cross service. In July, the Korean Red Cross was recognized officially as a corporation under the civil code although, because of internal frictions, complete autonomy was not gained until March 1947.

The Health of Occupation Troops

A major objective of the civil public health program in Korea-the protection of occupying troops-was accomplished. The XXIV Corps was relatively free of epidemic disease during the last quarter of 1945 and during 1946. Malaria, however, was a major problem; 1,868 new cases were reported in troops in 1946, with 65 definitely established as having been acquired in Korea.

EVALUATION OF PERSONNEL AND
ADMINISTRATIVE PROBLEMS

The key officers in health affairs of military government39were Colonel Potter, surgeon of the XXIV Corps, and Dr. Willard, the U.S. official in charge of the civil health program. In April 1946, Col. William D. Willis, MC, replaced Colonel Potter as the Corps surgeon. A goal of the program was to train Koreans for posts of responsibility as rapidly as possible so that initially, in each major post in the health field, there were both an American officer and a Korean civilian. However, not only were there few trained Koreans in public health, but also the Army rotation policy returned troops rapidly to the United States, so that few of the officers or enlisted men who entered Korea early in the occupation stayed more than a few months. Such rapid turnover made effective work difficult.

The problem was aggravated further by personnel shortages. Numerous officers trained for military government were retained in the United States and separated from the Service; many of those who subsequently were assigned to this duty had no understanding of the purpose of the occupation and little interest in anything except returning home. Of particular

39Much of the material in this section is taken from: Willard, W. R.: Some Problems in Public Health Administration in the U.S. Army Military Government in Korea. Yale J. Biol. & Med. 19: 661-670, March 1947.


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concern was the attitude of medical officers who were assigned as health officers without preparation, some of whom displayed a feeling of resentment and helplessness. Fortunately, some of these officers adjusted well and used common sense and ingenuity in accomplishing their various missions.

The shortage of trained professional personnel for military government health affairs was aggravated also by a scarcity of Service personnel such as administrative assistants and stenographers. The lack of office supplies and motor vehicles was felt as keenly as were shortages of medical supplies. All of this seriously impaired the efficiency of the professional personnel. For example, the officer in charge of laboratories spent much time in scrounging material from other Army units to rehabilitate laboratory equipment or to make culture media; in waiting for a jeep to take him to the laboratory; in making out payrolls for his Korean employees; in negotiating with the finance office of the military government for expense money; and in typing his own reports rather than in directing the manufacture of biological products or in training Koreans to do the laboratory work.

Military Government Ordinance No. 1, and some succeeding ordinances, created confusion among the various governmental agencies as to responsibility for public health administration. It was not realized in how many different police laws public health matters were covered. Venereal disease control among prostitutes, sanitation of eating establishments, public bathhouses, and other matters were retained under police control by virtue of their coverage in the Peace Preservation Section of police laws which were not broken down in the new ordinances with the appropriate transfer of jurisdiction to the Department of Public Health and Welfare. Similar jurisdictional difficulties arose with the Department of Agriculture concerning veterinary problems, with the Department of Justice concerning vital statistics, and with the Department of Commerce concerning drug manufacture. To secure additional legislation or administrative agreements with the departments concerned proved difficult and time consuming. The delays caused dissatisfaction in the field; despite them, some men established local relationships which enabled them to solve pressing local problems.

Bureau Memorandum No. 1, issued in November 1945, directed each province to organize a Bureau of Public Health and Welfare which, for all practical purposes, was a small-scale replica of the National Department. Because personnel were scarce, most provinces were only partially organized, with several consolidated sections, although some had an almost complete organization. The provinces were given wide latitude in organizing their subordinate governmental units. At the same time, other national departments were directing the organization of their counterparts in the provincial governments, but it became apparent that overall direction and coordination were necessary to insure balance in the relative size of different agencies of government and to put a ceiling on the number of employees.

Eventually, a Secretariat of Provincial Affairs was created and directed to draw up a plan of organization for all echelons of Government as well


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as to approve budgets within its limit. This work progressed slowly because of the concept that Korea had always managed with very little health work or organization, and now was no time to make an expensive expansion of the organization, particularly in view of the very limited trained personnel. In contrast, however, was the necessity of capitalizing on this unique opportunity to give Korea an effective public health organization. A skeleton organization at all levels of government was believed necessary. Flesh could be added to the skeleton later, but it might be difficult later to create the skeleton.

The problem was more complicated than this, however. The provincial departments of Public Health and Welfare were already organized more or less according to Bureau Memorandum No. 1. If the Department were reorganized with fewer sections as required, it would result in important resignations because Koreans, more than Americans, will not accept a reorganization which means a compartive loss of position in the administrative chain of command. Personnel were too scarce to risk any loss.

The problem finally was solved, but only after considerable delay, for the provincial personnel believed they could not go ahead with their organization and program until the organizational pattern was fixed.

Dr. Willard, in summary, stated, "A medical officer with no previous experience in Military Government cannot visualize clearly the problems in the early stages of an occupation. Those who had theoretical training in Military Government Schools acquired some familiarity with the nature of the problems, although theory and practice differed widely. The time required for administrative work far overshadowed that devoted to medical work."

Although smallpox and typhus, for example, represented major epidemic control problems, the health officers soon found that their primary job was not vaccinating and dusting with DDT, but in making it possible for others to do this work. This required the recruitment of personnel, not always an easy matter. Delays in defining organization patterns and policies handicapped some health officers in securing authorization to employ the necessary help. Delays in establishing fiscal policies and procedures caused some embarrassing delays in paying salaries. Procurement of supplies required more than requisitions if supplies were to be expected; it required telephone calls in a country where the service was exasperatingly poor when not impossible, or personal trips under difficult conditions. After procurement, the task of arranging for delivery was not easy in a country with little public, and inadequate army, transportation. These were some of the problems of epidemic control for the health officers in the early months of occupation.

The rehabilitation and maintenance of hospitals were much greater tasks than anyone anticipated. The hospitals needed coal, food, drugs, dressings, paint, window glass, soap, and instruments. Considerable scrounging


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was necessary to supply hospitals, and much effort was required to make the Koreans keep the hospitals clean.

Rice became scarce and inflation developed, creating problems for the health officer. Special rationing arrangements had to be worked out for hospitals, and difficult problems of adjusting wages for nurses developed. Strikes by nurses were narrowly avoided in several instances. The strike threat was usually related to the wage problem; occasionally, to political agitation.

These experiences provide lessons from which the United States may profit if the Nation again has to inaugurate military government.

Advance planning for public health administration in Korea was clearly inadequate. The Army did not realize the magnitude, complexity, or technical nature of military government until too late.

Medical officers must have some training in military government, particularly in public health administration. This is more important than special knowledge about disease conditions in a particular area.

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