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Chapter 7

Contents

Part III

THE MEDITERRANEAN


CHAPTER VII

The Middle East Countries

Brigadier General Crawford F. Sams, MC, USA (Ret.)

HISTORICAL NOTE

Prewar Planning

President Franklin D. Roosevelt signed a memorandum to Secretary of War Henry L. Stimson on 13 September 1941, requesting that arrangements be made as soon as possible for the establishment and operation of supply and maintenance depots in the Middle East. The facilities were to service American aircraft and all types of ordnance furnished to the British in that area. The President also directed that British authorities be consulted on all details as to location, size, and character of the depot and transport facilities.

Since the United States, at that time, was officially a nonbelligerent, the War Department was required to contract with civilian companies to construct these depots. Planning and supervision of all activities were the responsibility of the Army.

The U.S. Military North African Mission, headed by Maj. Gen. Russell L. Maxwell, USA, was established immediately by the Secretary of War to make plans to execute the presidential directive. The original plans called for projects to include ordnance shops with tank and other heavy equipment repair shops, quartermaster motor repair, engineer repair, and locomotive repair shops, and signal repair installations-all to be located in Egypt. Similar activities on a smaller scale were planned for Palestine. An Army Air Forces repair depot, ordnance repair shops, a naval base, and port facilities were to be established in Eritrea and at Port Sudan. All of these activities were to be carried out under the principle of Lend-Lease. All construction was to be of theater-of-operations type, which would permit use by military units should subsequent events require it. If existing corporations could not be induced to construct and operate these activities, new corporations were to be established for this purpose (map 6).

A special staff and a general staff were assembled to prepare detailed plans before the departure of the Mission for the Middle East. The initial plans provided for 12,940 U.S. civilians and 8,300 natives. The overall plans of the Mission provided tentatively for the rough grouping of the installations into a standard theater of operations-communications zone organization. An advance section was to be located near Cairo, Egypt; a second advance section, in the Palestine area. Within the Intermediate Zone,


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MAP 6.-Service Command, U.S. Army Forces in the Middle East, 15 May 1943.

installations were to be located at Port Sudan and Asmara. The base section was to be at Port Elizabeth, Union of South Africa.

Since poor sanitation was a detriment to the successful operation of such a mission, and medical facilities for many thousand American civilian employees were considered to be either unavailable or inadequate, the chief of the Mission decided that a separate medical service would be required to support these installations.

The Surgeon, Maj. (later Brig. Gen.) Crawford F. Sams, MC, reported to the chief of the Mission in Washington on 16 October 1941 in compliance with War Department orders.

The original medical plan as approved by The Surgeon General and the Secretary of War, based upon the overall mission plan, provided for dispensary or ambulatory patient treatment and essential hospitalization for American civilian personnel.

To provide this medical service, it was estimated that 1,942 doctors,


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dentists, nurses, and other civilian personnel would be required to staff the dispensaries and station hospitals to be located tentatively as indicated:

Area

Number of beds

Cairo

300

Palestine

250

Port Sudan (Anglo-Egyptian Sudan)

900

Asmara-Gura area (Eritrea)

600

Port Elizabeth (Union of South Africa)

100


The estimate was based upon (1) a probable hospital admission rate for disease and injuries selected from available data for civilians in a tropical zone under unfavorable conditions as four per 1,000 per day, and (2) a plan of evacuation to the Zone of Interior, established as 120 days as the maximum period for retention of white patients in the area.1

Medical supplies were to be procured at a level of 120 days to allow time for shipping. Supplies were to be sent to Port Sudan, subject to confirmation after the arrival of the Theater Surgeon in the theater.

Not much information was available in Washington, D.C., concerning the medical and public health situation in the countries of the Middle East. One report of the Rockefeller Foundation indicated that typhus and cholera, as well as the usual gastrointestinal diseases, were endemic in these countries. Therefore, the Surgeon planned to make sanitary surveys of the area as soon as possible after his arrival in the Middle East; then, he would issue specific instructions as to essential sanitary measures to be undertaken by contractors to preserve the health of the civilian personnel in the designated areas. However, it was believed justified at this stage of the planning to require the usual immunizations against smallpox, typhoid, paratyphoid, tetanus, and yellow fever since the existence of yellow fever in the area was considered probable, at least in the Eritrea-Ethiopia area. After consultation with Col. (later Brig. Gen.) James S. Simmons, MC, Chief of the Preventive Medicine Division of the Surgeon General's Office, and a special committee of the National Research Council assembled for the purpose, the new Cox method typhus vaccine and cholera vaccine were considered of sufficient value to require immunization of all personnel before they departed for the Middle East.

In the overall planning, the Army Air Forces was to establish an air route across Central Africa to ferry aircraft from Accra to the Middle East under contract with Pan-American Airways. Under the directive from the Secretary of War to the chief of the Mission, General Maxwell was to assume responsibility for all American personnel, both civilian and military, within the Middle East theater of operations. This would necessitate the subsequent development of a plan for provision of medical service for personnel of the refueling and repair installations to be established along the Trans-African Air Route into the Middle East.

1Annual Report, Medical Department, U.S. Army Forces in the Middle East, 1942.


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After the Army Air Forces Surgeon, Col. (later Maj. Gen.) David N. W. Grant, MC, was asked for assistance, an informal agreement was reached, providing that three flight surgeons would be sent to the Middle East, on request of the Mission Surgeon, for assignment to selected bases on the Trans-African Air Route.

At the direction of General Maxwell, the Surgeon negotiated with British representatives in Washington concerning Lend-Lease requirements of medical supplies for the Middle East area. An agreement was signed, and subsequently approved, between Mr. Booth of the British Purchasing Commission and the Surgeon, U.S. Military North African Mission, under which requirements for Lend-Lease supplies, specifically medical supplies and equipment for the Middle East, would be prepared jointly by the British Middle East representatives in Cairo and the Surgeon of the U.S. Military North African Mission. These requirements would then be accepted by the British Purchasing Commission in Washington for procurement, a timesaving procedure.

Mission Organization

The U.S. Military North African Mission was divided into two groups. One group, which included the Surgeon, was to proceed to the Middle East theater. The second group was to establish a home office in Washington, through which communications could be sent and followup action taken with representatives in the General Staff and Technical Services of the War Department. Col. Howard T. Wickert, MC, was designated by the Surgeon General of the Army as the individual to be contacted by the Mission home office concerning any medical communications and requirements.

Selection and Training of Personnel

The Mission Surgeon was authorized one first lieutenant and one enlisted man to accompany him to the Middle East; 1st Lt. (later Col.) Dan Crozier, MC, and S. Sgt. (later Capt.) Charles L. Tackett were selected. Additional military medical personnel were to be furnished, as required, by the Surgeon General of the Army upon request of the Surgeon of U.S. Military North African Mission through the home office.

The home office was to negotiate contracts with General Motors Corp., Douglas Aircraft Corp., and various construction companies to procure civilian doctors, male nurses, and other medical personnel required to staff and operate the dispensaries, hospitals, and other medical units included in the original plan.

The Surgeon of the Mission was designated as the first officer to depart from Washington for the Middle East via the Pacific. After he was joined in Hawaii by the Chief of the Mission, his aides, the Mission Signal Officer, and a Navy representative, the group proceeded via commercial air trans-


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portation across the Pacific and India to the Middle East, arriving in Cairo on 22 November 1941. En route, the chief of the Mission informed the Surgeon of a conference he had in Washington with Mr. Harry Hopkins, the assistant to the President. Mr. Hopkins had indicated that, since the Axis powers had overrun Europe and penetrated deeply into Russia, the United States likely would be brought actively into the war early in the spring of 1942. Fighting at that time was limited to the operations in Russia and to the Western Desert in North Africa. The initial military activities of the United States against Germany and Italy probably would begin in the Middle East. To prepare for such contingency as soon as possible, the movement of some military units into the Middle East theater was considered desirable. The considerable controversy in the United States concerning our active intervention in the war in Europe might increase should combat units be moved to the Middle East at this stage. However, the President and Mr. Hopkins believed that there would be little or no opposition to sending military medical units to staff hospitals to this area before any formal intervention in military operations. The chief of the Mission received verbal instructions from the White House to have the Surgeon dispatch a message to the War Department when he arrived in Egypt. The message was to request that theater-of-operations military units replace the civilian teams programmed in the medical plan to operate dispensaries and hospitals for medical care of the American civilians.

Sanitary Surveys and Supply

The first concern of the initial group of five individuals who arrived in Cairo, Egypt (fig. 21), on 22 November 1941 was to meet with the authorities at British Middle East Headquarters to revise the initial plans agreed to at numerous conferences with British officials and to select sites for the establishment of the bases.

The Surgeon made sanitary surveys of Egypt, Eritrea, the Anglo-Egyptian Sudan, and Palestine. These surveys included information concerning the prevalence of diseases and the availability of medical facilities for the civilian population since it was contemplated in the revised plans that many thousands of natives would be employed in both the construction and the operation of bases. In each area, first aid was to be provided for injuries incurred by natives on the job and their subsequent hospitalization in existing native medical facilities, to relieve the burden on American medical installations. Health officials in each area were contacted to determine the local legal regulations and the United States obligation under those requirements to provide medical service to any of their nationals who might be employed by our contractors.

These medical surveys were invaluable to the Surgeon in subsequent developments. The firsthand knowledge obtained during the personal visits and contacts served as a background for decisions to be made as the


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FIGURE 21.-Cairo, Egypt, November 1941.

American representative on the Medical Advisory Council of the Middle East Supply Center. The countries of the Middle East were found to be almost entirely dependent on imports of drugs and medical supplies for their civilian populations. Since the Axis powers had overrun Europe, the only sources of such supplies were the United Kingdom and the United States. Although the Lend-Lease agreement applied initially only to active belligerents against the Axis, it was later extended to include the non-belligerent countries of the Middle East. Shipping was in short supply because of German submarine activities. Therefore, a British Middle East Supply Center had been established in April 1941 to procure all imports, to coordinate requirements, and to insure equitable distribution and use of the supplies.2

For drugs and medical supplies, health officials of the various countries prepared their requirements for the civilian populations. These data were presented to the British Medical Advisory Council, where they were screened, and hearings were held with the officials of these countries when possible. The consolidated requirements were recommended for approval and subsequent procurement and shipment to the Middle East. This rigid control system for the civil public health and medical care supplies for

2Motter, T. H. Vail: The Persian Corridor and Aid to Russia. United States Army in World War II. The Middle East Theater. Washington: U.S. Government Printing Office, 1952.


215

some 10 nations, embracing approximately 200 million people, continued throughout the war. Despite its magnitude, the system proved very successful.

Wartime Developments

Initial planning had been based on supporting two lines of communications: one in support of combat forces through Egypt to the Western Desert; the other based on a buildup of a line of communications through Palestine and Syria into Turkey in support of the Australian, New Zealand, and other Allied troops stationed in Syria and Lebanon, where they formed a reserve for a possible invasion of the Balkans should Turkey enter the war on our side.

Changes in the military situation brought about several major revisions in the original plan. Port Sudan was entirely eliminated from consideration; its projects were moved to the Asmara-Massawa area in Eritrea and combined with the proposed installations there. The proposed base section in Port Elizabeth was moved to Bombay, out of jurisdiction of the Mission. Under the revised civilian plan for health and medical care of the civilian-operated installations, it was considered necessary to take over and operate a 100-bed hospital at Massawa, to operate a dispensary at Asmara, a 250-bed station hospital at Ghinda, and a 250-bed station hospital at Gura for support of the civilian-operated air depot to be established there. In Egypt, a 150-bed station hospital was planned for the depot to be established at Heliopolis, near Cairo. A 150-bed station hospital was to be built at the base selected at Tel Litwinsky in Palestine. After the operation of the medical units by civilians was changed to operation by military medical units, arrangements were made to hospitalize U.S. civilians and military personnel in British military hospitals until U.S. Army hospitals were completed.

The Japanese attack on Pearl Harbor changed the outlook of all U.S. Army activities in the Middle East. Considerable confusion occurred because of uncertainty as to the status and the future of numerous projects which were ready to be started. Nevertheless, civilians employed by contractors began to arrive, and construction commenced. The 250-bed station hospital at Gura, for the air depot to be operated by the Douglas Aircraft Corp., was one of the early units completed.3

Aircraft ferrying activities, then in operation by Pan-American Airways, had medical problems. No organized medical service existed for the African portion of the route, which was extended subsequently to Malaya and Australia. Many members of the aircrews and the civilians flying with them arrived in Cairo ill with dysentery and malaria acquired along the way. These patients were cared for at the headquarters dispensary in Cairo and hospitalized in nearby British military hospitals. A plan to establish a

3Vickery, Maj. E. L., MC: History of the Medical Section, Africa-Middle East Theater, September 1941 to September 1945, Volumes I and II.


216

medical service along the African ferry routes was prepared by the Mission Surgeon after consultation with the chief medical officer of Pan-American Airways. This plan was in accordance with previous tentative arrangements made with the Air Surgeon, Colonel Grant, before his departure from Washington.

Militarization of all Mission projects subsequently was directed by the War Department in an order dated 15 February 1942.4 Although 6 months were allowed for the conversion, militarization was completed after only 2 months.

Arrangements were made with the British General Headquarters, Middle East Forces, to turn over the captured Italian 500-bed hospital at Mai Habar, between Asmara and Gura in Eritrea, for use in place of the proposed 500-bed station hospital in Asmara.

In July 1942, directives were received from the War Department to plan for an alternative line of communications across Central Africa, to be known as the Trans-African Road. This road was to replace the long sea supply route around South Africa up to Suez, and was to be used if the Allied Armies in the Middle East were driven out of Egypt. Capt. (later Lt. Col.) Thomas G. Ward, MC, who reported on 2 June 1942 for duty as Medical Inspector and Chief of Preventive Medicine, was assigned to the reconnaissance party which left Khartoum on 14 June 1942 and arrived 6 weeks later in Lagos, Nigeria, on the west coast of Africa. The usual sanitary and medical intelligence information was obtained. Malaria, venereal diseases, sleeping sickness, filariasis, yellow fever, and gastrointestinal diseases were determined to be the major health hazards along the proposed line of communications. Because civilian medical facilities were lacking for either American military personnel or native construction workers needed to build the intermediate bases for operating such a trans-African supply route, the success or failure of the route would depend on a carefully planned and executed medical service. However, the change in the tactical situation after the battle of El Alamein in October 1942 made implementation of this plan unnecessary. Military medical units subsequently arrived in the theater and provided medical services extending over this tremendous area, from the border of India on the east to Tunis on the west, and from the Turkish border on the north to Kenya on the south.5 All of these military hospitals did provide medical service and medical care for the several thousand civilian American personnel in the theater throughout the war.

During the course of operations in the Libyan campaign across the Western Desert, British military hospitals in Eritrea had to be moved to Egypt to support their forces in this campaign. By agreement with the

4Memorandum, Maj. Gen. B. Somervell for The Adjutant General, 15 Feb. 1942, subject: Closing Out of Overseas Contracts and Militarization of Contract Activities.
5The locations and changes of locations of these units are discussed in Wiltse, Charles M.: The Medical Department: Medical Service in the Mediterranean and Minor Theaters. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1965.


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Director of Medical Service, Middle East theater, the American hospitals in Eritrea took over the medical support of remaining British military units and American and British civil personnel in that area; they also provided emergency service for the care of natives and many thousand Italian prisoners of war who were working voluntarily for the Allied forces in Eritrea. However, after the surrender in Tunis in May 1943, the American military units were transferred from Eritrea, and responsibility again was gradually turned over to the British.

The year 1943 witnessed the successful achievement of the major Allied military objectives in Africa and the Middle East.6 The mission of the U. S. Army Forces in the Middle East, which had changed to the concentrated support of the fighting in the Western Desert toward Tunisia, contributed to the surrender of the Axis there on 13 May

Theater Organization

Between 10 April and 19 June 1942, militarization of the North African Mission was accomplished. Three area commands were established: Eritrea, Heliopolis, and Palestine. Approximately 10,000 U. S. civilian and military personnel were stationed in Eritrea. The size of the Heliopolis depot was greatly expanded, and provision was made for approximately 10,000 U. S. personnel there. In Palestine, the planning figure was set at 5,000, to be housed in the depot at Tel Litwinsky; this number was later reduced. Surgeons were selected for the staffs of the three area commands. The Theater Surgeon, in addition to his other duties, was the Acting Executive Officer for the Mission and Acting Personnel and Supply Officer.

On 19 June 1942, orders received from the War Department designated the militarized mission as a theater of operations, USAFIME (U. S. Army Forces in the Middle East), under the command of Maj. Gen. Lewis H. Brereton, USA.

The Iranian Mission had been a separate enterprise, with the mission of establishing a line of communications from the Persian Gulf to Russia to supply Lend-Lease military supplies to that ally. In 1942, this mission was placed under USAFIME command and was reorganized as the Iran-Iraq Service Command.

The U. S. Army Middle East Air Force, established on 28 June 1942, was placed under the jurisdiction of the theater commander. The four service commands-subsequently designated the Eritrea, Delta, Levant, and Persian Gulf Service Commands-together with the Army Ground Forces and U.S. Army Middle East Air Force, operated directly under USAFIME. On 12 November 1942, the U.S. Army Middle East Air Force was redesignated the Ninth Air Force, with the mission of supporting the British

6Annual Report, Medical Department, U.S. Army Forces in the Middle East, 1943.


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and Allied Armies on the offensive across the Western Desert.7 In a later reorganization, Headquarters, SOS (Services of Supply), USAFIME, was established and all of the service commands were placed under it. The surgeon was the Theater Headquarters Surgeon and the SOS Command Surgeon.

On 7 December 1942, the Libyan Service Command with headquarters at Bengasi was established. This included all of Libya, exclusive of territory still occupied by the enemy.

The command of the theater was transferred on 10 September 1943 from General Brereton to Maj. Gen. Ralph Royce, USA. On 12 September 1943, the SOS Headquarters was disbanded by General Order 63, Headquarters USAFIME. The same directive also brought the U.S. Army Forces in Central Africa under USAFIME jurisdiction and established the West African Service Command, to include all former activities of U.S. Army Forces in Central Africa except those in Liberia. The West African Service Command Headquarters was at Accra, Gold Coast.

The U.S. Army Forces in Liberia retained its name and activities but was under jurisdiction of USAFIME Headquarters. The Tripoli Base Command was disbanded on 25 September 1943; the Bengasi Base Command, on 21 November 1943. They had been formed from the Libyan Service Command. The Delta Service Command took over all of their activities in addition to the Tripolitania activity.

Suez Canal Ports Command, which had operated separately since March 1943, was discontinued and reabsorbed into the Delta Service Command on 10 October 1943. Persian Gulf Service Command was reorganized as the Persian Gulf Command on 10 December 1943, made independent of USAFIME, and remained so until the end of the war.

The Chief Surgeon in the Middle East theater, Colonel Sams, who had served in Sicily for the brief campaign there, returned to the Medical Field Service School in the United States, where he directed the Department of Military Art. Colonel Sams was replaced in the Middle East by Col. Eugene W. Billick, MC.

The number of Army personnel assigned to the theater reached its peak in July 1943 when 66,203 troops were assigned, plus 6,984 air transport command personnel for whose medical service the Theater Surgeon was responsible. U.S. civilian personnel reached a peak of approximately 10,000 and gradually decreased to 4,000. Their medical service and the preventive medicine activities provided for them were carried out by the military medical installations.

RELATIONSHIPS WITH HEALTH AGENCIES

Relationships were first established with the various Ministries of Health of the Middle East countries during the course of the sanitary

7Craven, Wesley Frank, and Cate, James Lea: The Army Air Forces in World War II. Volume II. Europe: Torch to Pointblank. Chicago: The University of Chicago Press, 1949.


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FIGURE 22.-Air view of the 2748th Station Hospital, Iran, 1943.

surveys. Contacts were maintained through the Medical Advisory Council of the Middle East Supply Center in reviewing the requirements presented by various ministries of health or their counterparts in such areas as Palestine, which was under British control.

Relationships with the Egyptian Government pertaining to activities undertaken by the typhus commission in that country, and activities concerning the control of malaria moving northward into the Delta from the Anglo-Egyptian Sudan, are discussed in detail later in this chapter (p. 235).

Relationships with the Free French Military Forces and with the Egyptian Military Forces for the procurement of military medical supplies and equipment are properly a part of the history pertaining to military and medical operations, rather than civilian health activities.

SPECIAL PROBLEMS AND THEIR MANAGEMENT

Although the American personnel were largely concentrated on the military bases and field installations (fig. 22) in the Western Desert and did not exceed some 75,000 men, the major preventive medicine problem in the Middle East was created by the employment of an estimated 400,000 natives from the various countries included in this vast area. An accurate figure on the number of natives employed could not be obtained because of the continuous fluctuation in the numbers engaged, either in construction or in operation and maintenance in all types of activities on bases and other installations. These civilians included not only natives of West Africa,


220

Egypt, Eritrea, Palestine, Syria, Sudan, Persia, and Iraq, but also many thousands of European derivation, such as Jewish people in Palestine, Poles in Iran, and Italian prisoners voluntarily working for the American forces in Eritrea and in the Delta and Western Desert areas. These thousands of individuals, in close contact with U.S. military and civilian personnel during working hours and frequently living near or even on the bases, created the special problems inherent in the preventive medicine activities in the Middle East.

Personnel

European and native personnel were employed not only by all of the other technical and combat services but also by the Medical Department. They were of great value in making it possible for a comparative handful of American military and civilian personnel to construct and operate such extensive military and supply installations. Wherever possible, from clerks to technical personnel in laboratories, or as cooks or maintenance personnel, they replaced military personnel and saved on shipping and maintaining American personnel.

Medical Intelligence

Attempts made in Washington to collect information about the medical situation in the Middle East before the departure of the Surgeon were practically fruitless. This area had been considered a sphere of British influence, and the U.S. intelligence agencies had almost no information or interest in collecting information about this vast area. Only after the arrival of the Surgeon in the Middle East and subsequent personal contacts with Allied representatives in the military services, and contacts with the civilian officials in the health organizations of the various countries, could a clearer picture of the health situation be obtained. This included the incidence of disease, the availability and quality of the doctors, nurses, and paramedical personnel, and medical installations to serve this vast civil population. Continuing information was obtained both from the British and, after the arrival of additional medical personnel, by personal reconnaissance of the small staff of the Theater Surgeon's office and that of the Service Command Surgeons and subordinate post surgeons.

Medical Care and Hospitalization

The initial plan proposed in Washington was to provide American hospitalization for U.S. civil personnel who were brought from the United States to build and operate the various bases. The number of civil personnel operating bases was reduced by approximately 50 percent from the original planning figure, as shown by actual arrival of civil personnel and the almost immediate militarization of the installations. Nevertheless, throughout the


221

period of the war, several thousand American civilians remained, for whose medical care and hospitalization the military medical services were responsible. Early in the activities of the theater, particularly in the U.S. Military North African Mission phase, the civil contractors and the engineers exerted continuous pressure on the surgeon to include hospitalization of native personnel. This was successfully resisted although the contractors, under the supervision of the engineers, desired to offer medical care to natives as an incentive for employment.

In general, throughout the Middle East theater and, later, throughout the Africa-Middle East theater, the principle was followed that medical care and hospitalization of the hundreds of thousands of natives employed at Army and Army Air Forces installations would not be provided in U.S. Army hospitals. To protect the military personnel, preventive measures-such as immunization, delousing, and malaria control-would be taken among the natives, who were the greatest hazard to Army personnel from a medical standpoint. Medical care for injuries incurred on the job or for illnesses usually was provided by dispensary service. Dispensaries, whenever possible, were staffed with medical personnel recruited from the country in which the installation was located. Local medical personnel served as civil employees of the Army Medical Department. The dispensaries were supervised as part of the overall medical activities of the installation by the responsible U.S. Army Medical Department personnel. With the exception of Liberia, where hospitalization was provided for native personnel in a U.S. Army hospital, hospitalization for both injuries and illnesses, occurring among the civil population employed by the Army for either construction or operation of installations, was provided in native hospitals operated by the government of the host country. This was accomplished by arrangement with the civil health authorities of the various governments, depending upon the laws of the respective country regarding liability for hospitalization for injuries or illnesses on the job. Financial reimbursement also depended on the laws of the country concerned.

Eritrea.-Hostilities in Eritrea between the Italian and the British forces terminated on 30 November 1941 with the surrender at Gondar, Ethiopia. A small British Imperial Force of approximately 20,000 troops was in occupation. These troops were transferred elsewhere, principally to the Delta area in Egypt. The country was administered by the Occupied Enemy Territory Administration, which consisted of a skeleton British staff with an Italian subordinate staff of personnel taken over from the Italian Colonial Administration. The British were experienced and adept in administering behind the scenes a large native country, using only a few British personnel. Two types of hospitals were available for the civil population. There were six provinces, divided into regions, and each province had a provincial medical officer. Medical officers had been assigned to the two principal cities of Asmara and Massawa. Two laboratories were located in


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Asmara: a diagnostic laboratory, and a serovaccine institute in which both medical and veterinary serum and vaccines were prepared. The Italian doctors practicing in Asmara and Massawa were augmented later by Italian naval and army officers. The British Royal Army Medical Corps and the Indian Army Medical Corps provided medical care for the army of occupation. However, by agreement with the British Middle East Headquarters, these remaining garrison troops were hospitalized in the U.S. Army hospitals subsequently established. The native civilian hospitals throughout the entire country of Eritrea contained approximately 1,500 beds. Two radically different systems and standards of hospitalization and medical care existed in the area: one was found in Italian-operated hospitals for Italian civil and military personnel; the second was found in either the native wards of these hospitals or separate native hospitals. Food, the amenities, and standards of medical care for natives were far below those provided for Europeans. Dispensaries were established at military installations at Gura, Decamere, Asmara, Mai Habar, Ghinda, and Massawa for the civilian population other than American civilian personnel. These dispensaries, for the most part, were staffed by Italian doctors either former civilian or military personnel, under the supervision of American medical officers. Dispensary service was provided for Italians and, in separate sections, for native personnel working for the American civil contractors and, subsequently, for American military units. Italians and native personnel requiring hospitalization for either injury or illness incurred on the job were hospitalized at the Prince Umberto Hospital in Massawa, at the Ospedal Civile Regina Ellen in Asmara, or the Decamere Hospital in Decamere; the latter also provided hospitalization for natives and Italians sent from Gura, approximately 5 miles south of Decamere.8

Egypt.-The Ministry of Public Health of Egypt was responsible not only for preventive medicine activities but also for the operation of the government-owned hospital system. The hospitals were controlled directly by the hospital section of that ministry. The hospital beds in Egypt, exclusive of British military hospitals, were 95 percent government owned and operated; the remaining 5 percent constituted a few private hospitals in the large cities. There were several types of hospitals: general hospitals, ophthalmic hospitals, and skin and venereal disease hospitals. The Endemic Disease Section of the ministry had its own hospitals which treated schistosomiasis, malaria, ancylostomiasis, and leprosy. The Infectious Disease Section of the ministry also had its own hospitals which treated enteric diseases, typhus, plague, smallpox, erysipelas, and other infectious diseases. The one exception to the above hospital system was a 2,500-bed hospital in Cairo, operated by the faculty of medicine of the university, which accepted all types of cases for teaching purposes. The provincial hospital establishment, also operated by the Ministry of Public Health,

8Report, Surgeon, USMNA Mission, 15 Dec. 1941, subject: Sanitary and Medical Survey, Massawa-Asmara-Decamere-Gura, Eritrea.


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provided a hospital in each provincial capital. In some provinces, there was a separate ophthalmologic hospital. In those capitals which did not have such a separate hospital, special wards were established for ophthalmologic diseases, which were prevalent. The provincial hospitals usually contained about 200 beds. In the larger towns exclusive of the capitals, 48 smaller hospitals were caring for all types of cases. They averaged about 50 beds each. In the larger villages, there were 62 hospitals of a still smaller size. Each hospital had an outpatient department through which most of the native population received ambulant medical care. Initially, the American civilian and military personnel were hospitalized in British military hospitals in the Cairo area, principally the British 63d, 9th, and 15th General Hospitals. After the establishment of the U.S. Army 38th General Hospital and military hospitals at Ataka, Devesoir, and Fayid which were serving American personnel in the Ninth Air Force bases and at the Port of Ataka, American civil personnel were also hospitalized in these military medical units. At dispensaries for native personnel maintained in accordance with an agreement with the Egyptian Government, the thousands of natives employed in these areas were given first aid for injuries or illnesses incurred on the job. Those who required hospitalization for injury or disease were sent to Egyptian hospitals at Heliopolis, Ismailia, Port Said, or Suez. Before the war, the Anglo-American Hospital in Cairo and the Anglo-Swiss Hospital in Alexandria were used by foreign nationals, principally American, Greek, Swiss, and British. However, after the United States entered the war, these hospitals were not used for American civil personnel in view of the agreement reached with the Director of Medical Service, British Middle East Forces, that our personnel would be hospitalized in British military hospitals until our own were in operation.9

Palestine.-The Government of Palestine was headed by a High Commissioner appointed by Great Britain since Palestine was administered as a mandate by the British Government. Under the High Commissioner, the Secretariat included a Department of Health headed by a British medical officer, Col. G. W. Harron, assisted by Dr. J. MacQueen. Palestine was divided into 17 districts, each headed by a commissioner and a British senior medical officer. A Government hospital was located in each district. The British Medical Section Headquarters, Line of Communication, was located in Jerusalem. The hospitalization situation for civilians in Palestine was unique. Because of the antagonism between Jews and Arabs, placing both groups in the same hospital was obviously impractical. The charity cases were practically all Arabs because of the difference in economic status. Therefore, throughout Palestine, Government hospitals were established for the care of the Arabs. The Jews cared for themselves in voluntary hospitals, which corresponded to private or endowed hospitals in the United States. There were 1,255 beds maintained in Government hospitals at

9Letter, Surgeon, USMNA Mission, to The Surgeon General, 2 Jan. 1941, subject: Sanitary and Medical Survey, Cairo-Heliopolis, Egypt.


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Haifa, in which a 220-bed hospital for natives was located and another at Tel Aviv, where a 234-bed hospital was located. For Jewish personnel in the same areas, three voluntary hospitals at Haifa had a combined total of 153 beds. At Jaffa, there were four hospitals with 207 beds. There were 20 Government and 39 voluntary clinics distributed in all large communities. Military activities of the U.S. Forces were near Tel Aviv (fig. 23). A site at Tel Litwinsky had been selected for the base, about 5 miles west of Tel Aviv. Since civilian employees at Tel Litwinsky consisted of both Jewish and Arab personnel, in addition to American civilians, arrangements were made to provide dispensary service for those injured on the job. Hospitalization for the Jewish personnel was in the nearest private hospital for Jews. The Arab personnel were sent to the nearest Government-owned hospitals at Tel Aviv and Jaffa. The Jewish philanthropic organization, Hadassah, operated and maintained an excellent university hospital in Jerusalem. This hospital was used for a few Americans before the establishment of the U.S. hospital at Tel Litwinsky. During the short time that U.S. heavy bomber groups were maintained at airbases in Palestine and Syria, arrangements were made to hospitalize U.S. military and civilian personnel in nearby British military hospitals or in the French hospital in Damascus. Native personnel were hospitalized as previously stated. The dispensaries were staffed by Jewish doctors, of whom there were many because the refugee situation had caused hundreds of Jewish doctors to leave Europe for Palestine. These were under the supervision of American medical officers, and provided dispensary service to Jewish and Arab civilian employees.10

Iran-The Iranian Mission, as a separate mission, was to establish a line of communications from the Persian Gulf to the Russians, who had moved into and occupied northern Iran, including the terminus of the mountain road at Kazvin. Brig. Gen. Raymond A. Wheeler, USA, had been relieved from command of the Iranian Mission and was succeeded, on 4 April 1942, by Col. Don G. Shingler. Lt. Col. (later Col.) Hall G. Van Vlack, MC, a Medical Reserve officer who had worked in missionary hospitals in Iran, had arrived in Basra, Iraq, on 4 March 1942; his mission was to supply medical service to the civilian personnel of the Iranian Engineer District. A provisional 50-bed hospital was to be established for this purpose. The Iranian Mission, originally located in Basra, was moved to Umm Qasr, 54 miles northeast of Basra in Iran. The mission subsequently moved to Ahwaz at the head of the navigable water of the Karun River, and a 50-bed hospital unit was established there.

In June 1942, when the Iranian Mission was taken over and reorganized as the Iran-Iraq Service Command of the Middle East theater,11 the Theater Surgeon made a staff visit to this area. Plans were made for the

10Letter, Surgeon, USMNA Mission, to The Surgeon General, 14 Jan. 1942, subject: Sanitary and Medical Survey, Palestine.
11See footnote 2, p. 214.


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FIGURE 23.-Tel Aviv, Palestine, a modern Jewish city near the U. S. base at Tel Litwinsky.

medical service of military medical units to support some 27,000 service troops who were to operate two ports, the Iranian railroad to Teheran, the truck and air assembly plants, and the road for truck transport to Kazvin. The thousands of natives who were to be employed were to be provided only with first aid for injuries or illnesses incurred on the job, by dispensaries under supervision of American medical officers. The natives were hospitalized in the nearest Iranian Government hospital. The Ministry of Health operated all Iranian civil hospitals other than military and missionary hospitals. Of 76 hospitals in Iran, 44 were Government operated, eight were for the military, and eight were small quarantine station hospitals. Five American missionary hospitals were located in the northern part of the country, and four British missionary hospitals were in the southwest section. Three hospitals were operated by the Anglo-Iranian Oil Co. Only about 5,251 beds were available for the entire population of 15 million. A "Pasteur Institute" was located in Teheran which manufactured various kinds of serums, antitoxins, and vaccines. Of the 1,500 medical practitioners in Teheran (fig. 24), approximately 200 had received formal training in European or American medical schools or at the Teheran Government medical school. The Iranian Government-operated hospitals at Teheran, Khorramshahr, Ahwaz, Bandar-e Shāhpūr, and Hamadan were used for the medical care of the thousands of civilian natives employed by the U.S. Army units.12

12Medical Report, Intelligence Branch, Preventive Medicine Division, Office of the Surgeon General, 3 June 1943, subject: Medical and Sanitary Data on Iran.


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FIGURE 24.-A street scene in Teheran, Iran, 1943.

West Africa.-A report on the bubonic plague epidemic indicates that the natives suffering from this disease were hospitalized in both a French military hospital and a native hospital in Dakar.

Liberia-In this area, information is lacking as to available civilian hospitals for the care of natives employed by the U.S. Army. However, a free clinic was established at Roberts Field and operated by an Army medical officer to treat native women with venereal disease. From May 1942 to March 1943, an advance detachment of the 25th Station Hospital provided medical care for military personnel and natives employed by the Army at Roberts Field.13

13(1) See footnote 3, p. 215. (2) Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956.


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Anglo-Egyptian Sudan-The native civilians employed at the airfield and base, including the U.S. Army hospital, at Wadi Seidna on the Nile River north of Khartoum, were provided dispensary service at the installation for injuries incurred. Hospitalization was provided in Khartoum in native hospitals under control of the Anglo-Egyptian Government.

Psychological Problems

Psychological problems encountered in dealing with the civil population in the countries of the Middle East and Africa can be grouped into two major categories. The first type was that presented by the Middle East or African "old hand," represented by the European who had lived most, if not all, of his adult life in the Middle East or Africa. He may have served as a civil servant of the colonial powers, such as the British, French, or Belgian; as a European adviser to a native government, formerly a colony of one of these European nations; as a member of the armed forces of the colonial power stationed there; or as a European commander or adviser to native military forces. These "old hands" were a valuable source of information. In many instances, it was through them-particularly when they held special advisory positions in governmental medical services-that contact was made to undertake joint measures to prevent disease and provide medical care for the thousands of natives employed on, and frequently living either on, or adjacent to, U.S. military installations. These Europeans had an attitude, developed as a protective mechanism, which permitted their mental survival through many years of service in these unfavorable environments. The attitude was manifested by an almost complete detachment from the health problem of the natives who surrounded them and who carried out the work in the countries. The diseases in the country were talked about in abstract terms as native diseases. The fact that the European was exposed also to enteric, insectborne, or contact diseases was considered one of the hazards of living in that part of the world. An occasional bout with malaria or dysentery was looked upon as of no particular consequence. Standards of sanitation among the native populations in producing, distributing, and preparing food, for example, were of little concern to the European (fig. 25).

In discussing the enteric disease hazard, particularly the bacillary dysentery problem, with a senior European medical officer while having dinner in the beautifully appointed dining room of the elegant Shepheard's Hotel in Cairo, this officer expressed, perhaps for all of the European population, the psychological attitude which made mental survival possible for them in these countries. He said that, "So long as the linen is of fine quality and clean, and the servants are trained well in the proper serving of the meal, one does not dare to think beyond the kitchen door as to how the cooks prepare the food or as to the condition of the native markets from which they procure the food."


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FIGURE 25.-Egyptian lemonade peddler or "sherbulli" in Cairo, 1943, illustrates the unsanitary methods of food handling encountered by the Allies.

The second type of psychological problem was that presented by native populations who were the adult survivors of the enteric, insectborne, or contact diseases which they had all acquired early in childhood. The adults represented that small portion of infants born who survived these diseases since, in many of these countries, 50 to 90 percent of the children died before reaching the age of 5 years.14 The natives, on the whole, were illiterate

14See page 21 of footnote 12, p. 225.


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and were living in filthy surroundings. These conditions made the problem of health education among these hundreds of thousands of natives more complex than that of the explanation and illustration of the relationship of cause and effect in the control of communicable diseases.

The author's experience with the problem may best be illustrated by a situation at Heliopolis. As a member of the site selection board, the Chief Surgeon had selected a site for this base 15 kilometers from the nearest native community. This was done specifically to try to minimize the hazards of the diseases which might be transmitted from native populations to American personnel who would be stationed there. The area was free from flies and mosquitoes-a somewhat isolated piece of desert. When construction was undertaken, thousands of native laborers moved in to live in temporary camps. Pit latrines were constructed and efforts were made through illustrations, lectures, and demonstrations to teach these people to use them. Although squat-type latrines were used, each morning human feces were deposited on the ground outside the latrines. The flies swarmed. Then, sweepers were employed to clean the ground each morning. However, they, in turn, contaminated the ground which they had just cleaned. Finally, another gang was employed whose sole mission was, through the exercise of a long pole, to "elevate" any other native, including the sweepers, found to be squatting on the desert. Even this was only partially successful.

If no other lesson is learned from this entire chapter on civil public health, it should be this: that the problem of improving the health standards of underdeveloped nations is not so simple that it can be solved by sending a few teachers on the assumption that all people, if given the same educational opportunities, are equally capable of understanding or absorbing that education.

Communicable Diseases

Yellow fever and quarantine.-The Trans-African Air Route across Central Africa ferried not only personnel and supplies but also all types of combat aircraft, including fighter planes for use in the Western Desert west of Egypt. The route was extended to India, from Khartoum through Gura, Eritrea, and along the southeast coast of Saudi Arabia. A serious problem was created in the enforcement of quarantine regulations, particularly in reference to the possible spread of yellow fever. The route traversed by the air transport refueling stations was within the yellow fever belt. Within the Middle East theater, portions of the Anglo-Egyptian Sudan and Eritrea were also in the endemic area. Combat aircraft arriving in the Middle East landed at airfields to which they were to be assigned. These airfields extended from Ryak in Syria, and Ramat David and Lydda in Palestine, to Ismailia, Devesoir, and Heliopolis in Egypt. There was no central location at which quarantine procedures could be carried out. The transportation in these aircraft of infected insect vectors, as well as crews


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or passengers who might have become infected during stopovers in the yellow fever belt, made possible the introduction of yellow fever into any of the Middle East countries and also into India, where the British reported a large reservoir of potential insect vectors.

For reasons of military security, civil authorities were not permitted to exercise their normal quarantine prerogatives under international agreement in inspecting or certifying either personnel or aircraft in the military services during the war. After numerous conferences, it was agreed: (1) that the British Middle East Theater Headquarters and their subordinate command medical services would carry out strict inspection of British aircraft with their military medical personnel; and (2) the Medical Department, USAFIME, would undertake similar responsibilities for American aircraft arriving in, or in transit through, the Middle East theater to India or the China-Burma-India Theater. By agreement, these quarantine procedures involved the checking of immunization certificates for smallpox, typhus, cholera, and yellow fever. Immunization for yellow fever was to be completed at least 9 days before entry into the yellow fever belt. Physical inspections were carried out and, if necessary, passengers were detained for observation by the military medical services. Of particular importance was the spraying of aircraft for insect vectors immediately upon arrival within the theater boundaries, at the first airfield at which the aircraft landed after transit of the yellow fever zone. Technical instructions were issued through subordinate commands, particularly the Ninth Air Force, placing responsibility for carrying out these quarantine regulations on our medical officers at the various airfields.

On 19 June 1944, the Egyptian Government reopened the question of their resumption of the enforcement of quarantine regulations, particularly for aircraft entering Egypt; they suggested the establishment of a quarantine station at Payne Air Field adjacent to the Heliopolis base, and on the Upper Nile at Luxor. The second communication, received from the Egyptian Government on 28 July 1944, listed infected areas, including Casablanca on the west coast of Africa, where a bubonic plague epidemic had occurred. This communication required immunization against plague for passengers in planes arriving in Egypt from Casablanca in Morocco, Haifa and Jaffa in Palestine, and Nairobi and Mombasa in Kenya.

On 22 August 1944, conferences were held by Colonel Billick, Chief Surgeon, USAFIME, with Dr. M. Khalil Bey, Undersecretary of State for Health in Egypt, and with Allied military and naval authorities, to prevent certain communicable diseases and disease vectors from entering Egypt through U.S. civilian personnel. Agreements were reached for continuation of the procedures pertaining to military, naval, and civilian personnel of the United States arriving in Egypt by air. The exercise of quarantine procedures was to be continued by Egyptian quarantine officers on U.S. merchant marine vessels docking at Port Said, Suez, or Alexandria; U.S.


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civilian personnel found to be ill were to be hospitalized or examined at the U.S. military general hospital at Camp Huckstep at Heliopolis.

Smallpox.-Among the native populations in the Middle East, protection of U.S. military and civilian personnel against smallpox was carried out through repeated booster doses of vaccine. Native civilian populations living or working on bases were given smallpox immunization. An epidemic of smallpox in northern Iraq, Syria, and southeastern Turkey, which had been in progress at the end of 1943, was a health hazard. Three deaths occurred from smallpox among U.S. personnel in the Persian Gulf Service Command in the summer of 1943. The vaccination of contacts, all other military and civil personnel in the areas who had not been vaccinated within a year, was required to control the threat to U.S. personnel.

Cholera.-The Middle East was historically an area in which explosive epidemics of cholera had spread from the endemic areas of India. The movement of ships from ports in India and the projected establishment of the air transport route through the Middle East to India provided the possibility of reintroduction of cholera from India into the Middle East. This hazard was the basis for the requirement that all military and civilian personnel being sent from the United States to the Middle East theater should be immunized against cholera. A cholera epidemic was reported in May 1942 to have begun at Khorramshahr, a port on the Persian Gulf which was enlarged and rebuilt for use in the line of communications running north into Russia by civil contractors under supervision of military engineers. However, personal investigation of this epidemic by the Surgeon revealed that cholera vibrio had not been isolated in the feces of the supposed cholera victims. No cases of cholera occurred among American personnel in the theater during the war.

Malaria.-Initial sanitary surveys conducted by the Surgeon in Eritrea, Egypt, Palestine, and Syria had indicated that malaria would constitute one of the major health hazards to U.S. civilian personnel and to native personnel employed on bases in these countries. In Eritrea, the British had malaria control units in operation on, and immediately around, their installations at Massawa, Gura, and Asmara. Malaria was endemic in Egypt in the irrigated areas in the delta and extending southward along the Nile. In Palestine, the Jordan Valley was historically a highly malarious area, and on the western slopes of the mountain range parallel to the coast in Palestine, malaria was prevalent along the streams draining this area into the sea. Irrigation in the coastal plain increased the problem of mosquito vector control. Extensive activities had been carried out under the British Mandate for control of malaria in this area, particularly in the cities and communities inhabited by the Jewish population.

The west coast of Africa and intermediate stations along the Central African air transport route were in the most highly malarious areas in the entire theater. The first death from malaria among U.S. civilians in the


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Middle East resulted from an infection by a civilian who had stopped over at Accra before arrival at an airfield at Devesoir. The only symptoms presented had been a mild gastrointestinal complaint for which the dispensary surgeon had given symptomatic treatment. The patient was found dead the following morning. The autopsy revealed engorgement of all cerebral vessels with malaria plasmodia.

Conferences were held with British medical authorities of the British Middle East theater. Fortunately, one of the foremost authorities in malariology, Col. J. A. Sinton, RAMC, on the staff of the British medical directorate, was a valuable consultant to the Surgeon, U.S. Military North Africa Mission, and subsequently to USAFIME. After evaluating the situation, the Chief Surgeon in the Middle East theater adopted a policy to control malaria by organizing malaria control units and exercising malaria control discipline by both military and civilian personnel of U.S. Forces. Suppressive quinine or Atabrine was to be used only by troops or civil personnel in areas in which activities to control malaria vectors and human reservoirs among the civil native population were unsuccessful, or in which the military situation required that troops carry out combat operations in situations in which antimalaria control could not, for operational reasons, be undertaken. This policy for malaria control at U.S. installations paralleled that which was in effect for all Allied forces under British control throughout the Middle East.

The policy was the subject of numerous conferences in the spring of 1943 when the British Eighth Army, supported by the Ninth Air Force and U.S. Army service units, having successfully fought the Axis forces across the desert to Tunisia, advanced northward into southern Tunisia and established liaison with the Allied North African Forces who had invaded Tunisia from the west. The North African Forces had been on routine suppressive Atabrine; the Middle East Forces were not. Although Ninth Air Force units were placed for operational control under the Allied Force Headquarters in North Africa, the supply, including medical services, remained the responsibility of U.S. Army Forces in the Middle East. The medical authorities of the Allied North African Forces desired that all British, Free French, Polish, and American Forces in Tunisia should conform to their regulations for the routine use of suppressive Atabrine.

Conferences were held first at Tripoli, and subsequently at Cairo, with representatives of the Allied Forces in North Africa Headquarters and the Director General of the British Medical Services from the United Kingdom on one side, and the British Director of Medical Services of Middle East Forces and the Chief Surgeon, USAFIME, on the other side. Antimalaria units (p. 234) had accompanied British and American Forces in their long trek across the southern coast of the Mediterranean into Tunisia and had successfully controlled malaria among those forces. It was finally agreed that the policy of the Middle East Forces would remain in effect so far as


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their personnel in Tunisia were concerned. Malaria did not develop there. However, agreement was reached that, for the projected operations in Sicily, which was known to be highly malarious, suppressive Atabrine would be used by both invading forces-those from the Allied Force Headquarters based in Tunisia striking the southern coast of Sicily; and the Middle East Forces, including the Ninth Air Force, who would invade the east coast of Sicily from bases in Tripolitania.

Carrying out the policy originally adopted, of relying on malaria control through means other than suppressive quinine or Atabrine, involved extensive work with the native civilians living near, or employed on, U.S. military installations. This was also true for the never-ending and arduous task of attempting to indoctrinate and enforce malaria discipline through command and medical channels at all installations where U.S. military and civilian personnel were stationed. Where possible, base sites were selected, such as Heliopolis and Tel Litwinsky, as far removed as possible from the human reservoir of native civilian populated areas but which, at the same time, would permit the satisfactory operation of the bases. However, in many instances such as at ports and near major cities, military installations had to be located in densely inhabited native areas. At Heliopolis and Tel Litwinsky, the initial selection of a relatively isolated site was nullified partially by moving native personnel into temporary habitations close to the military installations where they were employed.

The attempt to eradicate the human reservoir among these thousands of native civilian laborers by extensive therapy was impracticable. The supply of quinine in the hands of Allied Forces was extremely limited and Atabrine production was still too low to permit such an effort. Even had adequate supplies of drugs been available for such an extensive therapeutic program among the civil population, it was recognized that, although the reservoir of carriers could be reduced, it could not be completely eliminated. This had been shown by the Gorgas Memorial Laboratory in Panama during a 10-year study before the war in some five isolated native villages by the use of Atabrine or quinine. Therefore, control activities (other than health education activities of U.S. personnel pertaining to the use of screening, avoiding exposure after nightfall where possible, and routine spraying of quarters on installations) emphasized attack on the insect vector in the adult stage by using sprays in adjacent native communities. An attack was also made on the larvae through draining and oiling anopheline breeding areas within 1- to 2-mile perimeters of the inhabited areas of the military installations. This measure also was only partially successful since only pyrethrum was used.

Pyrethrum was available in adequate quantities from Kenya Colony for spraying adult mosquitoes, and paris green and oil were available for attacking the larvae. Not until early 1944, however, were adequate supplies of DDT available in the Middle East theater for the control of insect vectors.


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To implement the policies as far as insect vector control was concerned, antimalaria units were organized in the Eritrea, Levant, Delta, and Persian Gulf Service Commands in accordance with General Order No. 19, Headquarters, USAFIME, dated 17 October 1942. Each organization consisted of one officer and five enlisted men, supplemented by a force of civilian laborers which varied in strength as the work required. Lt. Col. (later Col.) Daniel E. Wright, U.S. Public Health Service, who had many years of experience in malaria control in Sicily, Crete, and the Balkans, was attached to the Chief Surgeon's Office as Malariologist and was given technical supervision over the malaria control program in the theater. As the malaria rate among troops in the Persian Gulf Service Command increased, two more units were sent to that area in July 1943.

The Chief Surgeon was informed of the organization and training of standard antimalaria units by the Surgeon General's Office in the United States late in 1942. As soon as this information was received, these organized table-of-organization units were requested. Nevertheless, they did not arrive until a year later. Additional units were requested and moved into the Central African and Liberian Commands when those areas were incorporated in the theater. By 1944, all antimalaria units were placed under centralized control of the theater headquarters, largely as the result of a visit of the Theater Medical Inspector and a Malaria Control Commission sent by the Surgeon General's Office to West Africa late in 1943.

Eritrea.-The British had antimalaria control units in operation when U.S. personnel first arrived in Eritrea. As their forces were moved to the combat areas, and the U.S. forces began to operate at the naval base at Massawa, at Ghinda, Mihabar, Decamere, Gura, and Asmara, U.S. anti-malaria control units gradually took over the work in the immediate vicinity of U.S. Army installations. They were comparatively successful, and malaria did not become a major problem, as far as a noneffective rate is concerned, among American civil or military personnel in Eritrea.

Delta Service Command.-Although malaria was a potentially serious threat, against which much effort was expended by the malaria control units in the areas immediately adjacent to U.S. military installations in Egypt including airfields occupied by the Ninth Air Force, the disease did not become a major cause of noneffectiveness among U.S. troops or U.S. civilians in the Delta area. Most hospitalized cases had become infected while en route over the Trans-African Air Route. As military operations in the Western Desert advanced toward Tunisia, malaria control units accompanied the Ninth Air Force and carried out survey and control work at airfields and SOS installations as far west and north as Sfax in Tunisia.

However, in January 1943, malaria among the civil population in Egypt became a major concern of the Director General, British Middle East Forces, and the Chief Surgeon, USAFIME. This concern pertained to the movement northward from the Sudan of the highly effective vector,


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Anopheles gambiae. Egyptian health authorities reported many deaths from malaria among the native population living in the irrigated areas along the Nile River, and that A. gambiae had reached Luxor. They maintained that the spread was being caused by the use of the air, water, and rail supply routes by British and U.S. Forces from the Sudan into the Delta area of Egypt. Should this movement continue and gain access into the Delta where the majority of Egypt's civil population lived, there would be grave danger of a real epidemic of malaria with high mortality caused by the comparatively domestic breeding habits of A. gambiae.

The United States of America Typhus Commission Field Headquarters under the directorship of Rear Adm. Charles S. Stephenson, MC, USN, had arrived in Cairo in January 1943 and was attached to the Theater Surgeon's Office for administrative purposes. An outstanding member of this commission was Dr. Fred L. Soper of the International Health Division of the Rockefeller Foundation. He had demonstrated the possibility of eradicating A. gambiae from a vast river valley in Brazil after the species had been introduced and had spread widely from the west coast of Africa in the 1930's.

Conferences were held with the Egyptian Minister of Health and with the Director of the Medical Services of British Middle East Headquarters. It was agreed that the movement of A. gambiae northward into Egypt posed a serious threat to military operations based in Egypt. Negotiations took place with the Egyptian Government, the Rockefeller Foundation, and the Typhus Commission for Dr. Soper to survey the Anopheles invasion and make recommendations for its control. Since the Egyptian Government lacked the technical personnel, insecticides, and transportation for carrying out control measures, these were to be supplied jointly by British and U.S. Army Forces. Initially, some British malariologists opposed this arrangement as an infringement on their prerogatives in Egypt and the Sudan by U.S. forces and the Rockefeller Foundation. The surveys by Dr. Soper confirmed the existence of the problem. Equipment was furnished to the Egyptian Ministry of Health and technical advice and supervision were offered. However, the Egyptian Government, having appropriated 250,000 Egyptian pounds for this program, desired as a matter of national pride to undertake the control program without such technical supervision. Unfortunately, some dissension arose between Dr. Soper and Col. (later Brig. Gen.) Leon A. Fox, the new director of the Typhus Commission. Colonel Fox arrived in Cairo in March 1943 to replace Admiral Stephenson, who was relieved because of illness. Dr. Soper was subsequently reassigned to Algiers.

The failure of the Egyptian Government to control the northward progress of the A. gambiae after the first year resulted in an ultimatum presented jointly by the Medical Director of the British Middle East Forces and the Chief Surgeon, USAFIME, that this continuing threat to military


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operations could not be tolerated, and more active supervision and greater effort would be required. Technical advice and supervision by representatives of the International Health Division, Rockefeller Foundation (chiefly Dr. Soper at the start) were then accepted; and the A. gambiae was not only stopped, but also in the next 2 years was forced back south of the Sudan-Egyptian border. This program was so successful that periodic dusting with paris green and DDT, when available, was finally suspended on 30 August 1945.

By the end of 1943, three malaria survey units and five malaria control units were operating in the theater, in addition to those in the Persian Gulf Service Command, which had been made into an independent command outside of theater control. Units were stationed in Liberia, Accra, Dakar, the Delta, and Eritrea Service Command.

Malaria was the principal health problem at the stations of the Air Transport Command at Accra and across Central Africa. The African population was shown in a survey to be positive for plasmodia in the first blood samples drawn in 68 percent of the native children.15 The most important mosquito vector in that area was A. gambiae.

Persian Gulf Service Command.-The principal Anopheles vectors in Iran were found to be Anopheles elutus, stephansi, and superpictus. The work of the antimalaria units in the first malaria control season was handicapped by lack of sufficient personnel and specialized equipment. The work in the second malaria season was increasingly effective as indicated by the reduction in malaria rates among both military and civil personnel.

West African Service Command.-Joint control efforts were made between the U.S. Army, Liberian health authorities, British and-where applicable-French military medical authorities. These activities, over several years, succeeded in reducing the malaria incidence among American personnel to manageable proportions, from the unenviable position of having the highest malaria rate of any of our forces in the world.

Liberia.-In this command, malaria was the principal disease problem, as indicated by the malaria rate of 2,000 cases per thousand per year. The arrival of the malaria control unit in October 1943 resulted in effective reduction in malaria incidence. The use of malaria control in the West African Service Command and the Central African Command was continued under the supervision of the Inter-Allied Malaria Control Group at Accra and the theater malariologists of U.S. Army Forces in the Middle East, until the units were deactivated after the end of the war.16 One of the most important factors in the improvement in this control program was the arrival of adequate DDT powder in 1944, to permit its large-scale use instead of the kerosene, oil, and paris green previously used.

15See page 126 of footnote 3, p. 215.
16Complete detailed reports of malaria and malaria control units are contained in (1) footnote 3, p. 215, and (2) Medical Department, U.S. Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases. Malaria. Washington: U.S. Government Printing Office, 1963.


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Levant Service Command.-After the medium and heavy bomber groups of the Ninth Air Force were moved from bases in Syria and Palestine to the Delta area and, subsequently, into the Western Desert during the late fall of 1942 and early spring of 1943, the activities of the malaria control unit there were confined to control in and about the remaining American military base at Tel Litwinsky, northeast of Tel Aviv.

Typhus.-One of the principal problems in the civil population in the Middle East was typhus. Both endemic fleaborne and epidemic louseborne forms were present. Louse infestation among the native population was common. In 1942, some 26,000 civilian cases of typhus with 3,000 deaths were reported in Egypt alone. Major outbreaks of typhus also occurred during this period in Turkey, Syria, and Iran. How much of the outbreak in Iran could be attributed to the inflow of thousands of released Polish prisoners of war from Russia into the Teheran-Kazvin area, for movement onto bases in Palestine, cannot be determined. These Polish men and women, captured by the Russians in 1939 when eastern Poland was invaded, had been held in concentration camps until agreements had been reached, among the Allied governments concerned, for their release by the Russians and movement into the Middle East. The men were to be organized and equipped as military units at bases in Palestine and Syria. These bases had been occupied previously by Australian divisions recently withdrawn for use against the Japanese, after Japan entered the war. The Polish troops were to augment the single Polish Brigade in the Western Desert. They subsequently served throughout the remainder of the African and Italian campaigns against the Axis. Many Polish women, and some men not qualified for military service, remained in Iran and Palestine, of whom some were employed by either British or American military installations.

From a visit to the staging areas near Teheran, the Surgeon, U.S. Military North African Mission, confirmed reports that these people not only had smallpox and typhoid but also were heavily infected with typhus. Eradication of typhus, particularly among the military personnel who were to be organized and equipped to become an effective fighting force, created a problem for both the British Middle East Forces and U.S. Army Forces there.

Dr. Herald R. Cox had developed a method through the inoculation of chick embryos which, for the first time in medical history, made possible the production of comparatively large quantities of vaccine against typhus. A question of the efficacy of this vaccine was raised in 1941 by a member of the Preventive Medicine Division of the Surgeon General's Office. The Surgeon, U.S. Military North African Mission, recommended that all U.S. military and civilian personnel sent to the Middle East should be inoculated with this new vaccine. This recommendation was sustained upon its concurrence by a committee of the National Research Council. The available stocks, other than those required in the United States to carry out this program,


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were shipped to the Middle East and stored at the Heliopolis depot. Approximately 1 million doses of this vaccine were all that were available in the Middle East. Military operations and political exigencies had to be considered in determining the allocation of this limited stock of vaccine to the various governments urgently demanding that each of them receive all the available vaccine.

The British had doubts as to the efficacy of the vaccine; in conferences with Col. (later Brigadier) John S. K. Boyd, pathology consultant at British Middle East Headquarters, they decided not to use the vaccine for their troops other than on an experimental basis for voluntary inoculation of former Polish prisoners of war in Palestine.

Turkey was being wooed diplomatically in an effort to bring that nation into the war on the Allied side. This factor had to be considered in weighing that Government's request for typhus vaccine. In Egypt, not only were local pressures exerted through official channels, but Government officials also told the Egyptian populace that the vaccine which would protect them against death from typhus was in the hands of the American Forces.

The decision was made (1) to allocate the vaccine on a priority basis; (2) to give some vaccine to each of the requesting countries; and (3), since the quantity was limited, to use it for police, medical personnel, and others actively engaged in caring for typhus cases among the civil population (fig. 26).

In Egypt, some 21,000 doses were allocated for typhus; however, much of it was diverted into black market channels. Certain Government officials publicly implied that the Chief Surgeon was withholding additional stocks of vaccine from the Egyptian civil population. This major political problem was later solved by a public statement, authorized by the Theater Commander, Lt. Gen. Frank M. Andrews, USA, that allocation had been made to the Egyptian Ministry of Health and no more vaccine was available from American stocks. After the Typhus Commission arrived in January 1943, a procedure was set up to submit the Commission's recommendations to the Medical Advisory Committee of the Middle East Supply Center, of which the Theater Surgeon was the American member. Allocations of typhus vaccine for the use of civil populations in the Middle East would be made by the Middle East Supply Center, as were all other imported medical and pharmaceutical supplies and equipment.

It was hoped that laboratory personnel could be trained at the beautiful, but almost unused, vaccine laboratory in Cairo and that additional vaccine could be produced at the Hadassah Hospital Laboratory in Jerusalem, Palestine, and at the American University Medical School at Beirut, Lebanon. These projects were not successful, partly because of the limitations of the untrained native laboratory personnel. Ultimately, some 3 million doses of typhus vaccine imported from the United States were dis-


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FIGURE 26.-U.S. Army medical personnel inoculate Egyptian civilians for typhus.

tributed for the control of typhus in the civil populations in the Middle East.

The work of the Typhus Commission in the Middle East was important in civil health programs in that area, where one of the severest of the known typhus epidemics of World War II occurred.17 The commission members, drawn from the Navy, the U.S. Public Health Service, and the International Health Division of the Rockefeller Foundation, were sent to the Middle East, and were attached to the office of the Theater Surgeon, USAFIME, for administrative purposes. The field unit arrived in Cairo in January 1943. Negotiations were started immediately for use in Egypt of the laboratory at the Serum and Vaccine Institute, and of a clinical ward in the local government-operated fever hospital for clinical cases. Field experiments were undertaken also by agreement with the Egyptian Government. The comparative effectiveness of dusting with the new DDT delousing powder, the use of the typhus vaccine, the use of the old steam disinfestation for

17A detailed report of the activities of the United States of America Typhus Commission in the Middle East may be found in (1) Medical Department, United States Army. Organization and Administration in World War II. Washington: U.S. Government Printing Office, 1963, ch. VI. (2) Medical Department, U.S. Army. Preventive Medicine in World War II. Volume VII. Arthropodborne Diseases Other Than Malaria. Washington: U.S. Government Printing Office, 1964, ch. X.


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delousing clothing, and the use of various combinations of these measures in controlling epidemics were carried out in three Egyptian villages: MÓt Riheina, El-Shimb‚b, and El-Tarf‚ya in the province of GÓza. Long term studies were also made on the epidemiology of typhus. Experimental work was carried out at the Egyptian Fever Hospital on the comparative effectiveness of various forms of treatment, including the use of hyperimmune rabbit serum and para-aminobenzoic acid.

A small outbreak of typhus occurred at Aden at the southwestern tip of the Arabian Peninsula. Yemen natives, who were louse-infected, were employed by the Army to work on the base, a station on the Air Transport Command route. Periodic delousing of the native employees was carried out. Rigid control through reimmunization of American personnel prevented outbreaks of typhus among the American military and civil personnel, as well as the native civil personnel employed by them.

During the late summer and fall of 1945, General Fox made extensive typhus surveys in North Africa, India, the China-Burma-India Theater, Iran, Iraq, and Turkey. The activities of the Commission from its base of operations in the Middle East were extended to assist in controlling an outbreak in Naples, Italy. Extensive dusting of civil populations was carried out in the Middle East as well, and instructions were given for delousing personnel of the United Nations Relief and Rehabilitation Administration, which was planning to carry its activities into the Balkans when military operations permitted. The Surgeons General of the Egyptian and Iranian Armies agreed to a program of vaccination for their troops under the supervision of the Typhus Commission; and in 1943, the entire Egyptian Army and a large part of the Iranian Army were properly vaccinated.

In 1943, 22 mild cases of typhus occurred among American civil and military personnel but fortunately none was fatal.18 During a comparable period, British forces exposed equally to the civil population and to the laborers working at the installations suffered many hundreds of typhus cases, with an appreciable number of deaths. This caused the British medical authorities in the Middle East to change their minds and to request procurement of U.S. typhus vaccine for inoculating their troops.

In August 1943, General Fox asked to be relieved as director of the Commission and was appointed Field Director in Cairo. Col. (later Brig. Gen.) Stanhope Bayne-Jones, MC, was appointed director of the Typhus Commission, with headquarters in Washington, D.C. (fig. 27).

Enteric diseases.-Throughout the area, the lack of potable water by U.S. military standards, the complete lack of hygiene as it pertained to human waste disposal and the handling of native foods, and the universal infection of the native civil population by one or more of the dysentery bacteria, together with the psychological problems previously discussed in relation to this hazard, made the enteric diseases one of the major

18See footnote 5, p. 216.


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FIGURE 27.-Brig. Gen. Stanhope Bayne-Jones in 1944.

medical problems for American military and civilian personnel in the theater. The fly transferred enteric organisms to the food directly from human feces commonly not disposed of. Although, after the first year, the food for American military and civilian personnel was imported from the United States, it was handled and largely prepared by native assistants to the cooks in the messes. It would be difficult to duplicate the magnitude of the fly problem in any other part of the world. The fly swarms were such that, habitually, Europeans and, ultimately also, American military and civilian personnel carried "fly whisks" to prevent masses of these insects from clustering on the face about the eyes, nose, and mouth.

The efficacy of the typhoid and paratyphoid vaccines in the protection of the military and civil personnel of the American forces was well proven in preventing, with the exception of a few mild cases, the occurrence of these diseases even in the presence of environmental conditions favoring universal infection. Approximately 75 mild cases of typhoid and paratyphoid occurred in the theater during the 15 months from July 1942 to October 1943.

However, in the dysenteries, for which no vaccine existed, educational and control measures were carried on continuously. Strict regulations required abstinence from local dairy products, thin-skinned unpeeled fruits,


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uncooked vegetables, and berries which were available. Local restaurants were placed out of bounds. No food which might have been contaminated while being grown, handled, or washed with Nile or canal water was permitted to be eaten without cooking. Nevertheless, every group of newcomers yielded a large percent of its number to the temporary diarrheas or mild dysentery acquired through violating these instructions. The curiosity for tasting native foods and the elegance of some of the dining rooms in major European-operated hotels in Iran, Palestine, Egypt, and Eritrea could not be resisted by the newcomer although the food served was obtained from native sources. There was, therefore, always a major rise in the incidence of enteric diseases among both military and civil personnel until a lesson had been learned, and it was found advisable to adhere to the theater regulations.

The malaria control units initially organized in the theater on a provisional basis were, in fact, insect control units and were used not only to control malaria but also to control flies. Where possible, the units supervised native workers in eradicating fly-breeding areas on or near military installations, by either removing organic waste materials or spraying. This spraying was carried out for both larvae and adult fly control.

Infectious hepatitis.-Infectious hepatitis was known historically to be endemic in the Middle East, particularly in Palestine where it was known as the Levant Disease since most of the immigrants who arrived in that area acquired the disease sooner or later. Although the hepatitis was found also in Egypt, the Western Desert, and Iran, it was not a problem in Eritrea for some unknown reason. An epidemic occurred among British Forces in the El Alamein position in 1942. A similar epidemic appeared among German and Italian troops in North Africa during October and November 1942. During the sixth Libyan campaign, many prisoners who were suffering from jaundice were seen by the Chief Surgeon. A few cases appeared among U.S. Army troops and U.S. Army Air Force personnel; 77 cases occurred among Americans in the Africa-Middle East Theater from July through December 1942. Because of the prolonged noneffective period which results from hepatitis and its possible effect on military operations, the Surgeon, USAFIME, requested that a commission be sent to the theater to study this disease.19

On 26 April 1943, a commission headed by Dr. John R. Paul arrived in Cairo to study infectious hepatitis and sandfly fever. Laboratory space and ward space were made available to the commission at the 38th General Hospital at Heliopolis. Previous experimental work done by a British investigator who inoculated a number of British volunteers with blood from a case of infectious hepatitis had shown that the incubation period of this disease was exceptionally long. None of the British volunteers had come down with clinical symptoms of the disease during a 3-month observation

19See page 37 of footnote 3, p. 215, and footnote 5, p. 216.


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period, but after they were returned to combat units, all of them came down with the disease. Fatigue, emotional strain, and other factors were thought to have some effect in precipitating the clinical syndrome in infected individuals. The method of transmission was unknown, but it was thought it might be an insectborne disease. The almost complete incapacitation of the 2d New Zealand Division at El Alamein before the Battle of El Alamein in October 1942, when they had been subjected to a windborne flight of mosquitoes from the Delta, resulted in efforts to determine whether or not mosquitoes were a possible insect vector. Although infectious hepatitis is now known to be transmitted as an enteric infection, this was not determined by the time the commission ended its activities on 15 December 1943. The subsequent occurrence of hepatitis as one of the major worldwide medical problems among American and other Allied Forces prompted extensive research in many theaters.

Sandfly fever.-Although sandfly, or pappataci, fever was prevalent throughout the Delta area, the Levant, and Iran, its principal importance was in the production of a significant noneffective rate rather than a high mortality rate. Symptoms, although of short duration, were frequently exceedingly severe for a number of days. Therefore, it was one of the problems to be investigated by the virus disease commission. Since the sandflies responsible for the spread of this disease were most prevalent in adobe buildings, or in sandbagged or dug-in emplacements, the control of the sandflies finally became a matter of spraying the areas inhabited by both military and civil personnel. No great effort was made to control sandflies among the native population.

Venereal diseases.-In the Middle East, venereal disease posed a serious problem because legalized prostitution could not be suppressed in sovereign countries by U.S. Army military authorities as was attempted in the United States.20 Another factor was the absence of normal social contacts with white females of good character by both military and civil Americans. Capt. Herbert L. Traenkle, MC, was assigned as Venereal Disease Control Officer for the theater on 24 November 1942. The usual educational methods, warnings, and establishment of prophylactic stations were put into effect in all areas. The high venereal disease rates for U.S. civilians may be explained partly by the fact that the civil personnel were located almost entirely in base installations while approximately 40 percent of the military personnel, assigned principally to the Air Force and to SOS, were in the Western Desert in combat operations where possibilities of exposure were exceedingly limited.

In Eritrea, former Italian brothels were operated by the British military medical authorities. Separate brothels were maintained for white officers, for white other ranks, and for nonwhite other ranks. Similar in-

20Medical Department, U.S. Army. Preventive Medicine in World War II. Volume V. Communicable Diseases Transmitted Through Contact or by Unknown Means. Washington: U.S. Government Printing Office, 1960.


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stallations were in operation in the Sudan. All other brothels were placed off limits to military and civil personnel. In Egypt and Palestine, this approach to the problem was not practicable.

As the Allied Forces, including U.S. Army Air Forces and supply personnel, moved westward through Bengasi and Tripoli to Tunisia, the venereal disease rate among these people increased, particularly as the civil population gradually returned after fighting had ceased.

In Iran, the legal brothels were placed out of bounds, and a controlled house, again under British supervision, was permitted to operate in the town of Basra in adjacent Iraq.

In the Liberian Command, the venereal disease rate among natives appeared to be exceedingly high. The infection rate among Negro troops, who composed the majority of military forces there, was correspondingly high. A free clinic, established to examine and treat women, was run by an Army medical officer. If a woman was found to be free of disease, she was given a tag; if not, she was offered treatment. This did have an effect since, eventually, the soldiers would not accept a woman who did not have the tag. This development appeared to be accompanied by a drop in the venereal disease rates. "Tolerated women's villages" were established in Liberia as a result of cooperative activities of the Liberian health authorities, the medical director of the Firestone plantation, and U.S. Army medical personnel. Compulsory chemical prophylaxis was required of all men who visited the "tolerated women's villages" after 1 May 1943. The very high venereal disease rate decreased markedly following a fourfold increase in the prophylactic rate.21

Although some methods used to control venereal disease among American civilian and military personnel employed in certain areas of the Middle East were unorthodox by U.S. standards, they were effective in reducing the rate where they were employed. No attempt was made to control venereal disease among the vast native population in the area other than to treat infected women.

Schistosomiasis.-While the native population in the Delta area of Egypt was almost universally infected with schistosomiasis, it was not a hazard to American civil or military personnel because bathing in the Nile or in the irrigation canals was prohibited. A few cases occurred in a British Royal Engineers battalion which violated the regulation shortly after arrival, but it was not a hazard otherwise. However, in cooperation with the Director of Medical Services of British Middle East Forces and at the request of the Minister of Health of Egypt, copper sulfate for the control of snails in the Delta area was included in medical supplies procured from the United States, as recommended by the Middle East Supply Center. Schistosomiasis was found to be present along two rivers in the western watershed of Palestine, but since this was not an immediate hazard to

21See footnote 5, p. 216.


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FIGURE 28.-A native youth suffering from right cervical and submental plague, Jaffa, 1943.

American civil or military personnel, it was not a problem for the medical service other than to prohibit bathing and swimming in these rivers.

Dengue.-Dengue, which was endemic in the coastal area of Eritrea, had produced a number of cases among British troops in 1941. However, after U.S. civil and military personnel took over the bases of Massawa, the work of the insect control units resulted apparently in successful control of the mosquito vector of this disease. No outbreak occurred subsequently.

Plague.-In the initial survey in Palestine, the Surgeon, U.S. North African Mission, had seen cases of bubonic plague22 in the native hospitals in Haifa. Additional cases were reported by British medical authorities as having been endemic in the port of Jaffa (fig. 28), which was a native city. Bubonic plague constituted a potential hazard as coastwise shipping, bringing tungsten from Turkey along the coast of the Levant and through the Suez Canal, offered the possibility of spreading plague through rat infestation on the ships which stopped in Haifa.

22For additional information on plague, see (1) footnote 17 (2), p. 239, and (2) Medical Department, U.S. Army. Preventive Medicine in World War II. Volume III. Personal Health Measures and Immunization. Washington: U.S. Government Printing Office, 1955.


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Such an outbreak did occur at Port Said in 1942. This was of concern to the Surgeon, USAFIME, because of the hazard of exposure to U.S. personnel operating ammunition depots which supplied bombers on airfields near Port Said. In the course of this outbreak of bubonic plague, nine cases of pneumonic plague were identified among the civil population of Port Said. Port Said was placed out of bounds to all U.S. military and civilian personnel. Intensive efforts were made to influence the course of the epidemic through rat and flea control. Although pneumonic plague decreased markedly, the Egyptian authorities never completely eradicated the rat population. Additional cases of plague occurred at Port Said in April 1944. Military security required the suppression of all information about the plague epidemic at Port Said lest the Axis know that this dangerous health hazard existed in the base of operations of the Allied Forces in the Middle East.

Sporadic cases of bubonic plague continued to occur and spread, probably through coastwise shipping, to Suez. A major outbreak occurred in Suez in November-December 1943. This was investigated by Colonel Ward, Medical Inspector of USAFIME. His extensive investigation on the epidemiology and measures undertaken by the Ministry of Public Health in Egypt were described in great detail in his report. He conferred repeatedly with Egyptian health officials and urged much more stringent control measures. During this epidemic, primary pneumonic plague was first discovered on 13 January 1944. Before this, the usual bubonic or septicemic forms had been in evidence. Fortunately, the number of cases of primary pneumonic plague declined very rapidly. For this outstanding piece of work, Colonel Ward was awarded the Legion of Merit on 22 February 1944.

An outbreak of plague in Dakar in the West African Service Command in April 1944 was not so extensive as the one in the Suez area. Whether this epidemic occurred from endemic sources or was introduced by ships from the Middle East was never determined. British control of the port insured that rodent control work was being done, but the French authorities preferred to rely on a vaccine prepared in the Pasteur Institutes. In the plague outbreak in Dakar, native huts were treated by spraying with DDT powder for control of fleas and by attempting to reduce the rat population. Disinfestation of natives by dusting with DDT was also carried out. Vaccination of American personnel with American vaccine was an additional protection for American military and civil personnel.

Both bubonic and septicemic plague appeared at Casablanca. A civil employee of the French Government contracted plague and died on 20 July 1945. The French and American authorities quickly collaborated in putting control measures into effect.


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Heat

In the Middle East theater, heat23 presented a problem to all Americans rather than to the native population. This problem was largely confined to the exceedingly high temperature areas of the Port of Massawa, and in the Persian Gulf south of the mountains at Andīmeshk to the ports at Khorramshahr and Bandar-e Shāhpūr. Heat was a health problem in three clinical forms. The importance of the incidence of any one depended on a combination of the variables, temperature and humidity.

The first and most hazardous form, heat stroke, was a problem in the port of Massawa and in the Persian Gulf. Exceedingly high temperatures in these localities were recorded; the maximum of 129į F. in the shade was recorded at Andīmeshk in Iran during one visit of the Chief Surgeon. Heat stroke, with a high mortality, had caused many deaths among British and other civilian personnel working in that area.

Heat stroke had also been responsible for deaths among Italian prisoners of war and some British troops working in Massawa after the capture of that port from the Italians. The previous policy of the Italians had been to rotate personnel from this port up to hill country for recuperation. However, after Massawa was captured by the British, prisoners and others were required to work almost continuously in the port, and heat stroke with its high mortality was the result. In American planning for civil personnel to take over this work, provision was made for a rest area at Ghinda where American personnel, principally civilians, were sent to work on the salvage of some 70 Italian ships scuttled in the harbor and to rehabilitate the naval base. The engineers thought the use of air-conditioning units in living quarters, hospitals, and offices would protect the military and civil personnel from the ravages of heat stroke. Finally, heat stroke centers had to be established in the Persian Gulf desert area and at Massawa. Civil employees of the early contractors were required to call for assistance if they ceased to perspire when working out in the open sun and were immediately placed in the heat stroke centers for the therapeutic procedures which often were responsible for saving their lives.

The second clinical problem, heat exhaustion, was a potential threat throughout most of the Middle East, including the Western Desert. However, the use of salt tablets and adequate consumption of water were sufficient to prevent this from being a major health hazard. The maceration of the skin following heat rash, which occurred particularly in areas of high humidity, was a source of noneffectiveness, particularly among the civil employees. These people frequently had to be rotated from their stations to

23The subject of heat trauma is dealt with in (1) lecture delivered by Col. Tom F. Whayne, MC, formerly Chief, Preventive Medicine Division, Office of the Surgeon General, entitled "History of Heat Trauma As a War Experience" in Military Medicine Notes, Army Medical Service School, Walter Reed Army Medical Center, Volume II, 1951, Section 5, "Problems of Hot and Cold Climates," pp. 1-38; (2) Medical Department, U.S. Army. Preventive Medicine in World War II. Volume IX. Special Fields. Washington: U.S. Government Printing Office, 1969, ch. IV.


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rest areas in Palestine or into the mountains north of the Persian Gulf. In Eritrea, they were sent up into the mountains at Asmara or Ghinda.

The third clinical problem, "heat syndrome," was particularly troublesome among civilian and naval personnel at Massawa as well as among civilians who had stayed too long in the Persian Gulf desert and port areas. The syndrome is the result of combinations of high humidity and moderately high temperatures, or of very high temperatures with moderate humidity. It was insidious. There was a moderate apparent secondary anemia. The clinical manifestations were basically those resulting from a chronic cerebral hypoxia. Forgetfulness, inability to concentrate mentally on the work to be performed, and marked mental depression occurred. The Surgeon had found this syndrome under similar conditions in Panama and was well aware of its implication on the usefulness of key personnel working in the areas mentioned above. This became particularly serious in the Massawa area when civilian employees used in diving and salvaging operations were not permitted rest periods in the hill areas by the officer in charge of this operation; the officer himself subsequently had to be relieved. The recovery from this syndrome is a prolonged one and apparently can be effected only by complete removal from the unfavorable environment.

The high incidence of heat trauma in the deserts of the Persian Gulf Command in 1942 contrasted with the decrease in the yearly admission rates between 1943 and 1944 and was caused by several factors. The consensus of the Command was that, with the experience gained from U.S. troops performing in the hottest theater (Persian Gulf Command) in 1942, certain radical changes had to be made in the living conditions of the troops. Beginning in 1943, the living conditions were improved throughout the Command. Proper working hours were adhered to, and the troops were handled in a way most likely to protect them from heat injury. With these corrective measures instituted, even during the hot summer, heat stroke decreased markedly throughout the Middle East Theater.

Hygiene and Sanitation

The lack of hygiene and sanitation among the native personnel has been adequately discussed. Water was a major problem in Eritrea, where potability and quantity were factors. The limited quantity of available water required strict rationing for bathing and laundry. The Italians had relied on bottled water for drinking; however, an investigation by the Surgeon showed that the source of this bottled water was a highly contaminated surface spring. This was, therefore, prohibited for use by Americans. Although an American water geologist was brought to the theater, he was unable to increase appreciably the availability of water for American installations or for the native population.

In other areas such as the Levant, the Delta, and the Persian Gulf, water supplies were adequate for all purposes. However, since no source


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was found to be potable by military standards, water treatment facilities were built at all U.S. bases.

In the Western Desert, water presented the greatest problem of warfare and was a controlling factor in the speed at which military operations could be undertaken. Water was obtained largely from aqueducts left from long vanished civilizations. When combat operations moved back and forth across the desert during the various Libyan campaigns, the retreating side would carefully salt the aqueducts to deny that water to the advancing enemy. Under conditions of great necessity, water consumption could be reduced to approximately a quart a day, per man, but this was dangerous. Dehydration occurred and urination was often reduced to once daily of 4 or 5 cubic centimeters of highly concentrated fluid.

Waste disposal, as far as the native civil population was concerned, consisted of defecation at any place at any time. Sewage treatment and disposal plants were constructed for the use of U. S. personnel at all bases operated throughout the Middle East theater where semipermanent installations were built. In some areas, bucket latrines were used, and the accumulated feces were collected for fertilizing by the natives.

The problem of insect control has been discussed under malaria and other insectborne diseases.

Nutrition

Initially, the U.S. Military North African Mission had to rely upon local sources for procuring food (fig. 29). Not until late in 1942 did American rations become available. No one suffered from inadequate nutrition during this period.

The American contractors found that giving wheat, and particularly salt, was a greater incentive in terms of payment to native employees than the local currency. The local civil population was usually both undernourished and malnourished.

Veterinary Problems

Maj. Edgerton L. Watson, VC, arrived in the theater on 7 July 1942 as a result of a request by the Surgeon, U. S. Military North African Mission. At that time, both U.S. military and civil personnel were subsisting on locally procured food as American rations imported from the United States were not yet available. Some canned corned beef imported from Argentina by the British was available to U.S. personnel. Other than this, camel, donkey, or water buffalo meats could be obtained from local slaughterhouses. However, an inspection showed that the sanitary standards in these slaughterhouses were not acceptable. After the arrival of Major Watson, an adequate supply of cattle was found in Eritrea, with cold storage plants available for freezing beef in Massawa and Asmara. No abattoir was found


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FIGURE 29.-Native vegetable market stall in Cairo, 1943.

to be acceptable; however, a partially completed building was found on the outskirts of Decamere which, after remodeling, could be converted into a good slaughterhouse. This project was completed and, for the first time in the history of the Middle East, an abattoir was in operation under supervision of U.S. Army veterinary personnel, producing beef under sanitary conditions comparable to those in the United States. This beef was distributed to U.S. personnel in Eritrea and also shipped to the Delta area.

In the Delta Service Command, the Veterinary Service was responsible for establishing and supervising a poultry slaughterhouse operated by a native contractor, from which poultry was made available for military and civilian personnel. A dairy farm at Alexandria, Egypt, was approved as a source of milk for U.S. personnel at the 38th General Hospital on 21 December 1942. The herd was tuberculin tested, and veterinary personnel were to supervise production of milk under an agreement with the dairy operator that he would comply with their sanitary standards for a premium price paid for the milk. This project was discontinued after a short period of operation because the native manager lacked an appreciation of the need for sanitation.

Fresh milk was obtained and pasteurized under the supervision of the Veterinary Service in Palestine under a similar agreement, with the milk being available to Americans in the Tel Litwinsky hospital and rest camp.


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In the Central African Command, sanitary slaughterhouses were built and operated under veterinary supervision at El Geneina, El Fāsher, and Lagos. The bulk of the slaughtering for the Central African area division took place at the slaughterhouse at Lagos, Nigeria. 

In March 1945, Maj. Walter A. Lawrence, VC, investigated diseases of swine in Lebanon at the request of the commercial attachť of the American Legation there. The high disease death rate of animals had seriously affected the meat supply of the Lebanese. In cooperation with the Lebanese Government, Major Lawrence developed a tentative plan for animal disease control in areas where he found hog cholera, hemorrhagic septicemia, and swine erysipelas.

On 3 June 1945, the veterinarian discovered hoof-and-mouth disease in a Cairo municipal abattoir and notified Egyptian officials. Within 48 hours, the disease was identified in 13 other localities in Egypt.

In the course of inspecting locally procured poultry, meat, and eggs, and in training native personnel to assist in the operation of the abattoirs and poultry slaughterhouses, the Veterinary Service created several nuclei among native civil personnel engaged in these activities, from which knowledge might be spread to improve the standards of processing and handling meat, poultry, and dairy products.

Narcotics

Iran was one of the legitimate world sources of narcotics for worldwide medical use. Opium, morphine, and other products of opium could be obtained legally; it was readily procurable in bazaars and teahouses. Hashish, widely used as an aphrodisiac throughout the Middle East, was also freely available. It was feared that U.S. personnel, through the usual American curiosity to try anything once, and particularly through boredom and lack of recreational activities, might be tempted to try the use of narcotics and become addicted. This problem, which theoretically might have become a major health problem, did not materialize. Relatively few cases of addiction were found among American personnel.

SUMMARY

A Presidential directive issued on 13 September 1941 was the basis upon which the U.S. Military North African Mission was organized to provide effective aid to British and Allied Forces fighting in the Middle East.

The initial plan was to provide this assistance through the construction and operation of military installations by U.S. civilian contractors and native labor although these installations were to be located in an active theater of military operations. The entire operation was to be under the control of a military staff-the U.S. Military North African Mission.


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Based on this concept, the initial medical plan provided for preventive medicine and medical care services for U.S. civilian personnel and for limited emergency medical care and preventive medicine services for the native labor to be employed at U.S. operated installations. The medical problem, therefore, was essentially a civil public health and medical care program.

After the formal entry of the United States into the war, the War Department directed the militarization of the entire operation. This was completed by 19 June 1942. The U.S. Army Forces in the Middle East was established as a theater of operations and the planned support for civilian medical personnel was replaced by theater-of-operations type military medical units.

Missions assigned to the USAFIME were changed during the subsequent years of the war. The basic medical mission became that of providing preventive medicine and medical care for U.S. Army personnel. However, the continuing mission was to provide preventive medicine services and medical care for the several thousand American civilian personnel who remained in the theater as employees of the U.S. Army throughout the war.

In addition to this mission, the major civil public health activities increased because of the several hundred thousand natives employed by the U.S. Army throughout the Middle East and Africa. As a policy, only limited emergency medical care for injuries and illnesses acquired on the job was provided, usually through the establishment of dispensaries staffed by locally recruited civilian medical personnel under the supervision of the U.S. Army Medical Corps. The major preventive medicine activities were centered on these native personnel who were in contact with U.S. military and civil personnel, to control the spread of the enteric, insectborne, and contact diseases with which these natives were almost universally infected. The comparative success or failure of these preventive medicine programs is reflected in the noneffective rate among U.S. military and U.S. civil personnel stationed in a most unfavorable environment.

It must be emphasized that in the Middle East theater only Eritrea and Libya were occupied territories captured by Allied Forces from the enemy. Civil affairs/military government activities in these countries were exercised by the British. In all other areas, U.S. Army installations were located in sovereign neutral nations or in areas under the political control of Allied Nations other than the United States. Therefore, civil public health activities carried out by the U.S. Army Medical Department were confined to that portion of the local native population working for, or living on or adjacent to, U.S. military installations. Such activities were carried out in cooperation with native health organizations, if any existed. All preventive medicine was focused on the protection of U.S. military and civilian personnel from health hazards presented by the native populations and the environment in which they were working.

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