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Chapter 8

Contents

CHAPTER VIII

French North Africa (1942-44)

First Lieutenant Raymond E. Finocchiaro, MSC

THE CIVIL AFFAIRS PROBLEM

Decision to invade French North Africa-To relieve the hard-pressed Russians, to deny the oil-rich Middle East to the Germans and preclude their linking up with the Japanese, as well as to reopen the Mediterranean to Allied shipping, Prime Minister Winston Churchill, President Franklin D. Roosevelt, and the Combined Chiefs of Staff decided on 24 July 1942 that French North Africa would be the target of a major Allied invasion. In addition, President Roosevelt was very anxious for American ground forces to be committed to action against the Germans during 1942. An invasion of French North Africa might well enable comparatively small forces to achieve significant results without being forced to engage battle-hardened German troops in the initial stages. It appeared probable also that sizable French forces would rejoin the Allies if Operation TORCH, as the invasion was code-named, were successful.

In early August 1942, by a Combined Chiefs of Staff directive, Lt. Gen. (later General of the Army) Dwight D. Eisenhower was appointed Commander in Chief of the Allied Expeditionary Force that would invade French Morocco, Algeria, and Tunisia (map 7). Although the directive was approved 3 weeks after the decision to invade North Africa had been made, General Eisenhower had already assumed leadership on a provisional basis. The actual plans were developed by Maj. Gen. Mark W. Clark, Eisenhower's deputy commander who had landed in North Africa from a submarine and conferred secretly with sympathetic French officers in October 1942. The objective of Operation TORCH was to gain complete control of North Africa from French Morocco to Tunisia. Thus, by joining with the British Eighth Army, then fighting in Egypt and Libya, the Allies would control Africa from the Atlantic Ocean to the Red Sea.

Both the United States and British Governments had agreed that, although British troops would complement the American forces, the invasion should have a predominantly American tone since the French, whose military and civilian population in North Africa numbered more than a million, were still decidedly hostile toward the British after their naval clashes at Oran and Dakar in September 1940 and the military campaign in Syria in June 1941.

President Roosevelt and, to a lesser extent, Prime Minister Churchill hoped and believed that the French would receive the invaders with only


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MAP 7.-French North Africa areas.

token resistance if the invasion was advertised as a purely American operation. This hope prevailed despite the fact that the Eastern Task Force, which was mainly British, was to be used in the capture of Algiers.

The general policy was that the French inhabitants were to be regarded as friendly and as allies to be gained in the fight against Germany. To achieve this end, enough troops would have to be provided so that local French officials and military leaders could logically use the excuse of unavoidable surrender to "an overwhelming force" when explaining their actions to the Nazi-controlled Vichy Government under which they ruled.

While the invasion plans included provisions to meet and overcome any French resistance, the prevailing idea was that the Allied Forces were not to act as if they were conquering a hostile territory unless continued French resistance was encountered.1

These attitudes determined the character of civil affairs public health activities in these areas. There would be no imposition of military government. This would be not only the first American blow against Germany on

1(1) Komer, R. W.: Civil Affairs and Military Government in the Mediterranean Theater. On file, Office of the Chief of Military History, Department of the Army, undated, ch. 1. (2) Wiltse, Charles M.: United States Army in World War II. The Technical Services. The Medical Department: Medical Service in the Mediterranean and Minor Theaters. Washington: U.S. Government Printing Office, 1965.


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the ground but also one of the earliest American experiences with civil affairs public health activities in an occupied country with a liberated population. The British, who had already gained civil affairs experience in Libya and Italian East Africa, could be of little aid because of their unpopularity with the French. It was, therefore, agreed that the United States would assume complete civil affairs responsibility in the occupied area. This included the provision of the necessary staff personnel and the establishment of the actual government.

It is important to note that certain conclusions concerning American civil affairs policy, which were arrived at following the TORCH operation, affected all later civil affairs planning. Although the ordinary administration of civil affairs in French North Africa was left to the Government of Adm. Jean Francois Darlan, the senior Vichy French official, the Allies were responsible for the economic and political support of the regime which, in turn, involved many problems best characterized as civil affairs. The Allies encountered great difficulties not only in meshing the activities of the many civilian agencies concerned but also in integrating civilian and military efforts in such a manner that the principle of the ultimate responsibility of the theater commander was not violated.


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It is true that the North African experience, although not specifically designated civil affairs/military government, resulted in conclusions which affected all later civil affairs planning. On the other hand, by tradition and practices of the U.S. Army, activities of preventive medicine and public health carried out when troops were in intimate contact with civilian populations, contained the chief elements of civil affairs.

Medical and military organizations-With respect to civil affairs public health activities in the U.S. forces in French North Africa, two organizations were directly concerned. The first was composed of the units and officers of the Medical Department of the U.S. Army attached to the task forces at the beginning and later to the theater forces after the establishment of NATOUSA (North African Theater of Operations, U.S. Army) on 4 February 1943. More will be said about them later. The second organization was AFHQ (Allied Force Headquarters) with its Medical Section headed by British Brigadier (later Maj. Gen.) Ernest M. Cowell, RAMC, Director of Medical Services. His deputy was Col. John F. Corby, MC, USA, and the executive officer was Lt. Col. (later Col.) Earle G. G. Standlee, MC, USA.

Allied Force Headquarters was officially activated in London on 12 August 1942. Its Civil Affairs Section, which was organized 3 days later, was concerned with political, diplomatic, and economic matters, as well as with public health. About 11 September 1942, its staff was increased by the arrival of a group of officers from the United States, graduates of the first class of the School of Military Government of Charlottesville, Va.

The Civil Affairs Section, AFHQ, included, among other branches, a Public Health Subsection. However, no medical officer was assigned to this subsection before the invasion of French North Africa, and medical planning of the assault Task Forces was conducted almost completely independently of AFHQ, and, indeed, independently of each other. Allied Force Headquarters did not accompany the landing forces but arrived in Algiers 2 weeks after the invasion; its Medical Subsection personnel reached the city in late December 1942 and January 1943.2

The invasion.-In the predawn hours of 8 November 1942, U.S. shock troops lowered themselves from amphibious assault boats into the cold Mediterranean waters on either side of Algiers and began wading ashore. At Casablanca and Oran, American and British forces were also moving to seize their objectives. The invasion of Vichy-controlled French North Africa had begun.

2(1) Letter, Col. Thomas B. Turner, MC, Director, Civil Public Health Division, Preventive Medicine Service, Headquarters, North African Theater of Operations, Office of the Surgeon, to The Surgeon General, 21 Feb. 1944, subject: Report of Civil Affairs Public Health Activities in the North African Theater of Operations. Additional general sources for this chapter are: (2) Howe, George F.: United States Army in World War II. The Mediterranean Theater of Operations. Northwest Africa: Seizing the Initiative in the West. Washington: U.S. Government Printing Office, 1957. (3) Meyer, Leo J.: The Decision to Invade North Africa (TORCH). In Command Decisions, Kent Roberts Greenfield, editor. Washington: U.S. Government Printing Office, 1960. Number 7, pp. 173-198. (4) In Medical Department, United States Army. Organization and Administration in World War II. Washington: U.S. Government Printing Office, 1963.


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The Western Task Force, composed of approximately 34,000 troops under the command of Maj. Gen. (later Gen.) George S. Patton, Jr., landed in the Safi-Casablanca-Rabat-Port Lyautey area of the Atlantic coast. The Task Force Surgeon was Col. (later Maj. Gen.) Albert W. Kenner, MC. When the Atlantic Base Section was activated on 30 December 1942, General Kenner was relieved by Col. Daniel Franklin, MC, and assumed the position of Medical Inspector of AFHQ.

The Center Task Force, composed of 40,000 American troops of the II Corps under command of Maj. Gen. Lloyd R. Fredendall, USA, was assembled in the United Kingdom with Col. Richard T. Arnest, MC, the II Corps Surgeon, as its Surgeon. The Eastern Task Force, which consisted of 23,000 British and 10,000 U.S. troops commanded by Lt. Gen. K. A. N. Anderson of the British First Army, landed in the Algerian area, with Tunis as its ultimate objective.

French resistance and attitude.-Although the Allies achieved strategic surprise, the French in every instance but one fought back at the invasion beaches. The effectiveness of their defense, however, was reduced by dissidence among the officers and enlisted men. On 11 November 1942, an armistice agreement was signed and, 2 days later, Admiral Darlan was recognized as de facto head of the French Government in North Africa.

In the weeks and months that followed, American and British forces advanced eastward toward Tunisia, forming the western half of a gigantic vise designed to crush the Axis Afrika Korps. To the east was the British Eighth Army, commanded by Lt. Gen. (later Field Marshal) Bernard L. Montgomery, which was moving westward after its important victory at El Alamein.

In Tunisia, German Field Marshal Erwin Rommel occupied strong defenses, the supposedly impenetrable Mareth Line, which Montgomery succeeded in breaking, and by 13 May 1943, Allied Forces had seized Tunis, Mateur, and the port of Bizerte. The Afrika Korps had collapsed and the Axis powers were squeezed out of North Africa.

THE ROLE OF CIVIL PUBLIC HEALTH

The problem in North Africa-Except for outright military occupation, civil public health is predicated on an interrelationship between armed forces operating in a friendly country and the civil population and government of that country. In North America and Northern Europe, these relationships presented few extraordinary medical problems; in Africa, as in other underdeveloped areas, the problem was monumental. Poverty, disease, and vice were rife throughout the areas through which Allied troops marched. The situation was complicated further by the breakdown of French control and the anomalous position of the Vichy Government regarding the European and native populations of French North Africa. The defeat of France in 1940, followed by the German occupation, had greatly


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FIGURE 30.-An Arab hut for sorting tobacco in the Algiers area, 1943.

weakened French colonial authority. The French Resident-Generals had been reduced to mere puppets.

In these countries where venereal diseases were endemic and others, such as malaria and typhus fever, were constant dangers, the efforts of both French physicians and Allied medical officers to enforce public health measures were often frustrated by the incoherent and disorganized government systems.

Before the war, the Governments of Morocco, Algeria, and Tunisia had made great strides in safeguarding the health of the European populations. Despite their efforts, however intense, to do likewise for the indigenous inhabitants, the native populations continued to live amid indescribable filth. The French found it impossible to alter the ingrained habits of the predominantly Moslem population. Generally, the Moslems were too poor to change their living conditions, unwilling to develop habits of personal cleanliness and community sanitation, or untutored in the advantages of a sanitary environment (fig. 30). Poverty and filth, together with the native population's suspicions of French motives, prevented any real progress. Low moral standards, combined with the unsanitary surroundings, pre-


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sented a serious threat to the health of the American troops that arrived in the invasion.3

The Pasteur Institute of Algeria-The foremost research institute in North Africa was the internationally important Pasteur Institute of Algeria. Subsidized by the Algerian Government, it functioned closely with the Direction de la Santé Publique et de la Famille, systematically attacking all the principal problems of contagious disease rampant throughout Algeria. Its director was Dr. Edmond Sergent who was assisted by six chiefs of service, seven laboratory chiefs, and others. One of the most important activities carried on there was the constant fight against malaria and, more specifically, the actual planning for control of the disease.

The Institute also carried on research in bacteriology, parasitology, mycology, immunology, and entomology. Public health surveys were frequently undertaken and routine bacteriologic analyses were performed. Postgraduate instruction was also a function of the Institute staff.

One of the Institute's major efforts was a program to combat tuberculosis in Algeria. After extensive investigations by means of the von Pirquet test, Institute members found that tuberculosis was more prevalent in the larger centers with European inhabitants, and concluded that much of the tuberculosis resulted from contact with natives who had returned to Algeria after contracting the disease in France. The Pasteur Institute then successfully vaccinated large numbers of natives, especially children, with the BCG (bacille Calmette Guérin) live vaccine. A 50-percent reduction in the infant mortality rate was soon evident, and this was attributed to the Institute's vaccination program.4

The Institute's main laboratories were in Algiers and its facilities were frequently used by U.S. medical personnel while the Allied Forces were in North Africa.

Plans for Public Health

Since U.S. forces had had relatively little experience with civil affairs at the time of the North African invasion in November 1942, plans for a public health program in the French protectorates were sketchy. Many U.S. medical officers arriving in North Africa were not fully aware of the health problems that American troops would face there and, consequently, many emergencies and problems that arose were solved by improvisation.

As was later proved in French North Africa, public health is a major component of civil affairs because of certain considerations, the most obvious of which is that widespread disease among the civilians of an area can seriously affect military operations, whether by direct troop infection or by disruption of activities in support of military operations.

3Simmons, James Stevens, Whayne, Tom F., Anderson, Gaylord W., Horack, Harold Machlachlan, Thomas, Ruth Alida, and collaborators: Global Epidemiology: A Geography of Disease and Sanitation. Philadelphia: J. B. Lippincott Co., 1951. Volume II. Africa and the Adjacent Islands, pp. 530-547, 558-594.
4War Department Technical Bulletin (TB MED) 90, 6 Sept. 1944, subject: Medical and Sanitary Data on Algeria.


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As a result, the governing authority of an area-be it civilian or military-must assume responsibility for the public health of that area, and must include programs for disease prevention and facilities for general medical care.

The AFHQ Medical Section-Although the Eastern Task Force's landings in the Algiers area were accomplished initially by U.S. and British troops, the British First Army landed as soon as hostilities ceased and began to proceed eastward toward Tunisia. Algiers remained a British responsibility and, consequently, no U.S. base section was initially established in the area. Unfortunately, the U.S. public health planning for the invasion was hurried and incomplete. When the U.S. component of the AFHQ Medical Section arrived in Africa in December 1942, the U.S. officers immediately realized that their previous expectations of merely a planning role had been inaccurate and that the section would have to become involved in operations from the standpoint of hospitalization and evacuation, as their British counterparts already were.

As plans were instituted for the activation of base sections, it soon became apparent that a certain amount of administrative and operational supervision would be required of the AFHQ Medical Section.

The Medical Section was maintained at theater level, giving its Surgeon direct access to the theater commander, the chief of staff, and the chiefs of the general and special staff sections. This also facilitated the Surgeon's entry into all subordinate theater commands. Had the Medical Section been placed at communications zone or services of supply level, coordination of the professional aspects of medicine and surgery by the Consultants Division throughout the various echelons of command would have been increasingly difficult. As it was, since advice on all technical matters came from the highest theater level, it was accepted in subordinate echelons without much difficulty. The coordination and correlation of technical subjects between various commands were also simplified.  

The Medical Section originally was a completely integrated staff section since early Anglo-American interests in the North African campaign were closely interrelated in both tactics and logistics. The Chief Surgeon, AFHQ, was British, with an American Deputy Surgeon. Within the Medical Section were separate British and American branches within the theater.5

Upon arrival in Algiers 2 days before Christmas 1942, the American component had been authorized only five officers and five enlisted men, but additional officer personnel had been assigned as overstrength. Colonel Corby, the senior American officer, took command of the U.S. personnel.

Four subsections were quickly established for Hospitalization and Evacuation, Medical Records, Dental, and Veterinary activities. Lt. Col.

5A more detailed study of the organization of Allied Force Headquarters at its inception can be found in Medical Department, United States Army. Internal Medicine in World War II. Volume I. Activities of Medical Consultants. Washington: U.S. Government Printing Office, 1961, pp. 150-154.


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(later Col.) Perrin H. Long, MC, the AFHQ Medical Consultant, also served as adviser on preventive medicine and neuropsychiatry.

Since centralized administrative control over the base sections had not been provided for in the preliminary planning, the base sections proceeded somewhat in accordance with their own desires, and a divergence of development and activity soon resulted. It became increasingly apparent that some form of centralized control was essential and that an augmentation of personnel would also be necessary.

Therefore, on 26 April 1943, a new table of organization for the base section, providing for 22 officers and 30 enlisted men, was approved. The assignment of additional personnel to the medical sections necessitated a change of location to a larger building, which, although somewhat removed from the other section staffs, still provided working space for both the British and American staffs. Before the move, both staffs had worked side by side in the same office although separate files had been maintained. In the new location, the British and American officers were completely separated, occupying different floors, but close liaison was constantly maintained and regular weekly joint conferences were held.

The creation of NATOUSA-On 4 February 1943, the North African Theater of Operations was established. With its creation, the control of all troops, material, and installations in the newly defined NATOUSA area passed from the commanding general of the European Theater of Operations to the NATOUSA commander, General Eisenhower.

The headquarters was similar to the usual communications zone setup, with general and special staff sections. However, as a personnel economy measure, NATOUSA's sections were to be staffed with the corresponding U.S. Army personnel in AFHQ general and special staff sections, and the senior American officer in each would become chief of the section. The NATOUSA Medical Section officers, therefore, served in dual capacities. When dealing with strictly American operations within the theater, they acted as NATOUSA staff officers. All joint operations with the British, however, were carried out in their capacities as AFHQ members.

Thus, NATOUSA and Allied Force Headquarters were operated with the same personnel, although AFHQ, as the combined Allied command, retained operational and tactical control. The NATOUSA Surgeon was given administrative and operational supervision over the U.S. base sections but no direct control of the subordinate commands. This diffuse overall medical organization directly contrasted with the British system, in which operational control reached from the highest to the lowest echelon throughout the British Army. Of the two systems, the British method was producing better medical results and creating fewer problems.

On the day NATOUSA was activated, Colonel Corby, AFHQ Deputy Surgeon, was relieved from duty and returned to the United States. General Kenner then became NATOUSA Surgeon with Colonel Standlee, AFHQ


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Executive Officer, as Deputy Surgeon. General Kenner also acted as AFHQ Medical Inspector until April 1943, when he returned to the United States. Brig. Gen. Frederick A. Blessé, MC, former Fifth Army Surgeon, was officially assigned as his successor on 16 April, although he had been on temporary duty at NATOUSA Headquarters since March.6

Lt. Col. (later Col.) William S. Stone, MC (fig. 31), who was assigned to the NATOUSA Surgeon's office as Theater Preventive Medicine Officer in July 1943, arrived in Algiers on 5 August 1943. He remained in that role until 1 November 1944, when NATOUSA became MTOUSA (Mediterranean Theater of Operations, U.S. Army), at which time he assumed the same functions for MTOUSA. From February 1944 to September 1945, he also served as Chief of AFHQ's Preventive Medicine Division.

The Base Sections

Atlantic Base Section.-The Medical Section, Headquarters, ABS (Atlantic Base Section), was activated in Casablanca on 30 December 1942, with Col. (later Maj. Gen.) Guy B. Denit, MC, as its Surgeon.

Before the arrival of the base section, all medical activities in the area had been carried on by the Western Task Force. The ABS Medical Section conducted immediate surveys and inspections of the area which revealed a deplorable native situation with poor public health supervision. The water was nonpotable and plumbing was inadequate. Malaria control was but a gesture. Time-consuming alterations would be necessary to transform the existing facilities into adequate hospital and housing installations. Furniture, communications, transportation, and space seemed to be eternal problems. In short, the tremendous problems of safe troop sanitation, eradication of health hazards, and proper public health control became the primary tasks of the ABS medical personnel.7

The Surgeon's Office operated primarily as an administrative unit, although a few medical officers performed some professional duties before the arrival of the Fifth General Dispensary. Thereafter, the Medical Section devoted itself entirely to administrative supervision, plans and training, and other duties pursuant to the administration of subordinate units.

The Base Section Surgeon was responsible for prescribing and controlling the policies established by the Medical Department to safeguard the health of the troops and the indigenous population. Since this responsibility had many implications and ramifications, it was essential that the Surgeon be assisted by specially qualified subordinates whose individual efforts could be channeled into a highly efficient, well-coordinated unit.

To achieve this goal in the Atlantic Base Section, Colonel Denit acted as the deciding authority in all matters of policy and procedure while the Deputy Surgeon and Executive Officer supervised the routine affairs of all

6For a description of the organization of NATOUSA, see footnotes 2 (4), p. 256 and 5, p. 260.
7Annual Report, Atlantic Base Section, 1943.


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FIGURE 31.-Col. William S. Stone, MC, Preventive Medicine Officer, North African theater, inspects a louse-infested native in Algeria in 1943. Colonel Stone found more than 50,000 lice and eggs in the folds of these rags, enough to keep this native chronically anemic. Thousands of tiny bites and almost constant scratching made his body one large area of irritated, broken skin, with the ever-present danger of serious infection.

subsections, Matters which also concerned nonmedical specialties, such as the Transportation Corps' role in evacuation and the Engineer's cooperation in malaria control activities, were also a responsibility of the Surgeon's Office, which collaborated with other Section Staffs whenever such action was necessary.

In general, although the overall medical policy for the entire area was set by the Theater Surgeon, routine matters were handled directly between the Surgeons of the various base sections.

Mediterranean Base Section.-The advance echelon of the MBS (Mediterranean Base Section) medical unit arrived in Oran on 11 November 1942 as part of TORCH's G-3 Section. The Medical Section remained attached to the Center Task Force Surgeon for duty until the activation of the base section in Oran on 8 December, a month after the invasion began. Most of the section's personnel had arrived on convoys by that date, and the final contingent was expected shortly. Col. Howard J. Hutter, MC (fig. 32), became the first MBS Surgeon.


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FIGURE 32.-Col. Howard J. Hutter, MC, Surgeon, Mediterranean Base Section, at his desk in Oran, Algeria, in 1943.

Operating in the Mediterranean Base Section were the medical services for the port of Oran and the replacement depots, a medical supply depot with many widespread warehouses, a general dispensary, an Army medical laboratory, a sanitary company, a medical battalion for evacuation, dispensaries and minor hospitalization, and malaria control and survey units. Also in operation was a French civilian malaria control agency.

French and Arab civilian employees, both men and women, professional and laborers, were hired for specific tasks in medical installations from time to time. These civilians were used in addition to many thousands of U.S. medical personnel who were rotated through the base section and were utilized wherever possible as rotation relief and medical inspectors.8

The MBS Medical Inspector, noting that cooperation with the French civil and military population was necessary if adequate disease control among U.S. personnel was to be achieved, arranged for a weekly meeting with French officials. Sanitation, venereal disease, and epidemiology were discussed at these meetings and great strides were made toward prophylactic measures for the control of certain endemic communicable diseases. Other subjects included preventive measures for typhus and malaria, which were prevalent in the area. The result of these discussions was that conferences on malaria, typhus, and venereal diseases were arranged later for area medical officers.

8Hutter, H. J.: Medical Service of the Mediterranean Base Section. Mil. Surgeon 96: 41-51, 1945.


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Eastern Base Section-The last of the three sections to be established was EBS (Eastern Base Section), which was activated in Constantine, on the northeastern coast of Algeria (in MBS territory) on 21 February 1943, by its own order.

One officer and seven enlisted men from the Mediterranean Base Section and four ABS officers comprised the EBS Surgeon's staff which gathered at MBS Headquarters in Oran on 22 February. From there, an advance echelon, consisting of the Surgeon, another officer, and three enlisted men, left for Constantine, arriving 4 days later and establishing the EBS Medical Section. The remainder of the section arrived on 5 March. Lt. Col. (later Col.) William L. Spaulding, MC, was the first Surgeon, although he was succeeded on 21 July by Col. Myron P. Rudolph, MC. Colonel Spaulding was then reassigned as the EBS Medical Inspector.

Originally organized with a strength of five officers and seven enlisted men, the EBS Medical Section was by necessity augmented by the attachment of officers from other units under the Surgeon's control and from higher headquarters. A veterinarian, venereal disease control officer, dental surgeon, and medical and surgical consultants were obtained in that way.

The immediate missions of the EBS Medical Section were supply and the hospitalization and evacuation of battle and local casualties. Only one hospital was operating at the time and no other medical installations or facilities were available.9

Various diseases were prevalent among the civil inhabitants of the area, endemic malaria and typhus being the most widespread. Smallpox was found mainly among the native population in rural areas where successful vaccination programs were difficult. The incidence of other diseases, including dysentery, plague, and rickets, was also widespread and threatened to affect the U.S. troops in the base section.

Civil Affairs Division, War Department Special Staff

The medical supervision of the civil health programs was to become more and more dependent on the base sections since most of the liaison on public health matters in North Africa was carried on by medical officers on the staffs of the Chief Surgeon, NATOUSA, and Surgeons of the base sections.

Not until 1 March 1943, almost 4 months after the invasion and more than 15 months after the attack on Pearl Harbor, was a Civil Affairs Division created and added to the War Department's Special Staff in Washington. Maj. Gen. John H. Hilldring, GS, became the first director on 7 April 1943. By the time this new division (which originally was created to handle the mounting civil affairs problems in North Africa) had actually established any definite policies, most of the major problems in NATOUSA had been met and resolved by trial and error.

9Annual Report, Eastern Base Section, 1943.


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PUBLIC HEALTH AND SANITATION

Of the three base sections established, the Mediterranean Base Section assumed the most important role since it eventually became the staging area for the Sicilian and Italian campaigns and the subsequent invasion of Southern France. Although the problems that confronted the MBS Surgeon and his staff were essentially the same as those that arose in the other two base sections, they were magnified many times. This section of the history, therefore, will deal primarily with the public health efforts of the Mediterranean Base Section, which can be considered as representative of the North African theater.

The situation in Algeria-Before the fall of France in 1940, Algeria had been by far the most advanced protectorate in public health. Overall administration of the program, as pointed out earlier, rested with the Central Service of Public Hygiene and Preventive Medicine, headed by an Inspector General of Hygiene. Nominally, this organization was responsible for all public health activities, which included the battle against disease, the control of epidemic outbreaks, the management of serums and vaccines, and port sanitation. The Inspector General was assisted by a colonial physician and the Director of the Anti-Malaria Service. Assistant medical hygienists, who were designated by the Governor General to take charge of special hygienic and epidemiologic missions, also provided some assistance.

For the purposes of local public health administration, Algeria was divided into 112 zones or "circumscriptions," each of which was supervised by an overworked French physician whose duties included visits to native communities, consultations, vaccinations, and supervision of local hospitals and dispensaries. U.S. military commanders and medical officers, confronted with problems of public health and sanitation, usually had to work through these harried doctors. Liaison was often poor and led to less than optimum results.

The colonial physicians were assisted by "native technical adjuncts" who were trained in a 3-year course and accompanied the physician on his visits, applying bandages, giving injections, and even acting as interpreters. Colonial visiting nurses often were on hand to carry out the duties for which the native adjuncts were unsuited, such as care of female patients. In 1940, there were 108 technical adjuncts, 80 colonial visiting nurses, and an undetermined number of native visiting nurses in Algeria.10

The German occupation and subsequent Allied military actions severely crippled the comprehensive and generally progressive sanitary organization that France had established in her North African protectorates. In addition, centuries of living in filth made it difficult for the natives to adjust to requirements of cleanliness. All this was complicated by the natives' suspicion and distrust of their French rulers, which was transferred to the British and American forces allied with France.

10See footnote 4, p. 259.


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FIGURE 33.-An Arab family sit on the doorstep of their home near Algiers, 1943.

Sanitary problems in the MBS.-Although the sewage disposal facilities in the larger cities of North Africa had been adequate before the invading Anglo-American armies arrived, they were overloaded by the waste products of the influx of troops.

Sanitation was virtually nonexistent in the smaller towns throughout the protectorates (fig. 33). It was common to see the streets and sidewalks littered with human and animal feces; sewage was thrown onto the streets and left to rot. In addition, the natives were not averse to urinating publicly in the streets.

The natives rarely bothered to remove dead animals from the roads, preferring instead to let them decompose where they lay. The task of notifying the local French authorities upon discovery of a decaying animal usually fell to U.S. Army personnel, who in turn instructed their subordinate units to report all such discoveries so that the local civilian authorities, once notified, would be forced to act.

Even in the larger cities, such as Oran, empty lots became collecting stations for piles of garbage which, left in the sun, soon became major breeding grounds for swarms of flies and mosquitoes, thus creating one of the major health problems.


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The task of remedying the sanitary ills that afflicted the natives in Algeria fell to the medical personnel of the Mediterranean Base Section. Work began immediately. Upon his arrival in Oran, the MBS Medical Inspector, realizing that French cooperation was necessary for the adequate control of disease for the protection of American personnel, consulted with the French public health and city administrative officials and arranged a series of weekly meetings on sanitation which began in December 1942 and continued until 15 November 1943.

A wide range of problems was discussed: the incidence of communicable diseases among the civilian population; sanitary projects for the city of Oran, which served as a gathering place for swarms of breeding mosquitoes and unbathed natives; methods for the control of prostitutes who openly roamed the streets; and sanitary procedures for disposal of garbage and fecal wastes.

In the early months of 1943, little cooperation was forthcoming from the French civilian authorities who, being elected officials, were often not trained medical personnel. As a result, many recommendations made to them were given lipservice and then ignored. The mayor of Oran, in particular, had been generally indifferent to public health problems, but his successor tried in every way possible to help the Army's medical personnel in promoting new sanitary procedures among the civilian population. The new mayor regularly visited the MBS Surgeon's office, thereby improving liaison and coordination between military and civilian officials. Since a lack of materials, transportation, and labor often hampered his efforts, Army supplies were turned over to civilian health agencies in Oran whenever possible.11

To get the job done, U.S. medical officers and sanitarians often made unofficial surveys and tried to work as closely as possible with French medical personnel. These medical officers were restricted by the prevailing policy that nothing could be done without the approval of the French officials, and great care was taken not to offend the French population who, it must be remembered, were regarded as allies and not as a conquered people.

Some progress on minor matters was made in Oran, but vital projects, such as the extension of sewers and the covering of hitherto open sewage ditches, were unsuccessful because of a lack of such supplies as cement and steel. Medical Section representatives consulted with the MBS Engineer on the problem of open drainage, but the situation was never satisfactorily resolved although laborers did clean out the drainage ditches on occasion. For a brief time, Colonel Hutter was able to hire a crew of approximately 60 Arab laborers who, supervised by an Army sergeant and operating with two 2½-ton trucks, were dispatched to clean some of the debris and open sewers around the town.

11Annual Report, North African Theater of Operations, U.S. Army, Medical Section, 1943.


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Farms and piggeries on the outskirts of Oran were often inspected and the owners of those found to be filthy, which was the great majority, were offered the services of the Arab work force to clean the farms and bring them up to U.S. standards. Some accepted and others refused. No direct action was possible against those who refused to clean their property since the medical inspectors could only solicit the cooperation of local farmers and had no means of compelling them to accept the proffered services. Most farmers, however, quickly consented to the suggestion that their piggeries be cleaned. 

Local civilian health officials were virtually powerless to enforce their own regulations concerning sanitation, such as they were, because they lacked money and manpower. Consequently, they were seldom consulted in the latter stages of the Army's cleanup campaign, as the U.S. medical officers carried their program directly to the people.12

A lack of funds forced the disbanding of the native labor force in mid-1943. Medical personnel were then faced with the nearly impossible problem of getting the native population to clean their own living areas and public places. Individuals who consistently refused to clean fly-breeding areas were reported to the civil authorities which, by yearend, had begun to reestablish their control and were thus able to enforce public health measures more effectively. Although much of the filth was removed, the natives still had little appreciation of sanitation, and only a prolonged educational program at all levels of their society would really solve the problem.

In general, there was little rapport between U.S. military personnel and French military and civilian authorities on matters of sanitation. There was no official French agency within the Mediterranean Base Section with the responsibility of disseminating to the civilian population information on communicable diseases, water pollution, areas of endemic diseases, and the like. As a result, most of the efforts to protect the U.S. forces had to be channeled into a program of educating the U.S. troops on what places to avoid and what general sanitary measures to practice.

Water problems-Water presented a twofold problem in French North Africa. Obtaining an adequate amount of water for the U.S. personnel stationed throughout the base sections caused enough difficulty, but, once obtained, the water was found to be nonpotable. This was surprising since many North African cities had adequate, and fairly modern, water supply systems.

In Algeria, water was usually found to be contaminated, even in the large cities. Bacteriologic and chemical examinations were made regularly in the public health laboratories and the Pasteur Institute of Algeria, but these tests failed to remedy the situation. In general, the French and native

12Interview, Lt. Col. Douglas Hesford, MSC, with Dr. (formerly Major, MC) Louis B. Simard, 26 Aug. 1962.


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populations showed little concern over the purity of their water since their main beverage was wine. Whatever water they purchased for drinking was bottled and rarely contaminated. The American troops, however, whose daily consumption of water was great, were faced with problems.

Oran's civilian water supply, which also serviced the hotels and apartments housing U.S. officers, came from a hilltop reservoir that overlooked the city. Here, too, the water was nonpotable, mainly because it was unchlorinated. This, explained the French city officials, was caused by their inability to buy the necessary chlorinating materials. They pointed to a chlorination plant that had been built but was lying idle. To solve the problem, the MBS Staff Engineer agreed to supply the needed chlorine.13 Once chlorinated, the water had to be checked constantly to maintain its potability standard; however, French laboratories in Oran were inadequate to perform the necessary analyses and, once again, help was provided by the MBS laboratories. As a result, a close check was kept on the city water supply for both civilians and military personnel.

Water also proved to be a problem for troop recreational activity in Algeria. American troops were not permitted to swim in fresh water because of the presence of schistosome-carrying snails. Swimming was permitted, however, at the beach of Ain-el-Turk, 10 miles west of Oran, where a large number of Army installations had been established. A water analysis showed that the Mediterranean was polluted for a radius of almost 1 mile from a sewage outlet in the vicinity, but that, past this restricted area, the water was uncontaminated and, therefore, safe for swimming.

Civilian establishments-By American standards, most of the civilian establishments frequented by U.S. troops in French North Africa, from bars to barbershops, were unsuitable for use because their cleaning methods were unsanitary.

Restaurants proved to be a particular problem. Except for the Hotel Continental, which the Army immediately occupied after the landings in Oran, the city's restaurants were particularly filthy. Initially, all restaurants were placed "off limits" for U.S. military personnel because the water used for washing dishes, glassware, and eating utensils was cold untreated tap-water. Screening was virtually nonexistent in these restaurants and flies swarmed throughout their kitchens. The bars, too, were put off limits because of the fear that diseases would be contracted from drinking glasses rinsed with unchlorinated water. At first, the restaurant and bar owners resisted any suggestions that their sanitary conditions be improved, disregarding such requests as "crazy" demands. When the Army began to take action by declaring their establishments off limits, the protests began. The typical complaints that necessary chlorine and screening materials were unavailable soon followed.

13See footnote 12, p. 269.


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To alleviate the problems and answer the complaints, the Army distributed chlorinating materials in sufficient quantities to restaurant and bar owners on an individual basis so that all eating and drinking apparatus could be sterilized. Screening materials, always scarce, were obtained in limited quantities with the assistance of the Staff Quartermaster and were given to the restaurant owners.

Restaurants were not placed "on limits" again until their owners complied with Army regulations and used chlorine in their wash water. Those not meeting acceptable standards retained their undesirable off limits status. Needless to say, owners were quick to respond, and most of the restaurants were on limits by the end of 1943. Periodic checks were made on the cooks, food handlers, and eating facilities to insure that some sort of sanitary standards were being maintained. Stool cultures of the food handlers of some restaurants were taken to see if they were carriers of disease, and these cultures were examined in hospital laboratories and in the 15th Medical Laboratory in Oran.

The French civilian authorities did relatively little to aid the restaurant inspection program, remaining apathetic towards the project and leaving most of the work to the U.S. Army. After a time, the Army, finally realizing that the civil officials would do nothing, no longer bothered to contact them and just did the work themselves.14

As with the restaurants, sanitation in the civilian barbershops was poor. As a rule, barbers did not sterilize their instruments and used feather dusters to brush away hair after cutting. U.S. Army medical inspectors were especially critical of these practices and tried to persuade the barbers to discontinue use of the dusters and begin sterilization of their instruments. Once again, resistance was met. Establishments owned by uncooperative barbers were placed off limits, but even this measure proved somewhat unsuccessful. American troops, especially combat troops in the base sections for rehabilitation leave, ignored the restrictions. Consequently, the number of Military Police had to be increased to keep the U.S. soldiers out of the barbershops designated as unsanitary. Finally convinced that the U.S. Army meant to enforce its regulations, most of the barbers began to comply with the Army's demands, and their shops were again placed on limits.

Sanitary training of troops.-Despite the continuing efforts to improve the sanitary environment for American troops, the same problems of sanitation remained throughout the war. But it was not only the French and native civilians who opposed the medical protective measures. Lack of cooperation among the American troops themselves contributed significantly to the problem. The troops continually managed to ignore the directives designed to protect their health. It was especially difficult to indoctrinate them in the perils they faced if they ate certain foods or frequented unsanitary hotels and restaurants.

14See footnote 12, p. 269.


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FIGURE 34.-An Arab laborer distributes fertilizer on a potato crop on a farm near Algiers, in November 1943.

An example of how the troops were told to do one thing but did another occurred in 1943 and concerned the raw vegetables that grew in the gardens around Oran. Because of the North Africans' habit of using human excrement for fertilizer (fig. 34), amebiasis was quite prevalent among the native population. French reports indicated that 3,000 to 4,000 cases were treated each month. As a consequence, American troops were instructed not to eat fresh fruit and vegetables, especially lettuce, since chlorine did not kill the infecting amebae. Many soldiers, however, ignored all directives and ate the proscribed fruit and vegetables, and suffered the inevitable results.

The situation deteriorated to such a degree that even the MBS Surgeon's office had little influence upon troops directly under its advisory control in matters of enforcing sanitation. The Surgeon had little or no authority over the combat troops and even the Communications Zone soldiers, with whom his office dealt primarily, paid little heed to his warn-


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ings. The few public health measures that had any effect whatsoever were usually instituted at lower echelons by the battalion surgeons who had direct contact with the troops.15

In many instances, Command did not give sufficient support to the sanitation program and, at other times, training in health and sanitation was too infrequent to be of any real value. This spirit of noncooperation was not limited solely to U.S. troops; French and British soldiers were also characterized by a similar nonchalance in matters of sanitation and personal hygiene.

Recognizing these obstacles to public health, Colonel Hutter arranged for an international symposium on public health for American, British, and French participants. This symposium was held in Oran on 6 November 1943, almost a year after the North African invasion.

An outcome of the meeting was the establishment of sanitary displays in various large cities and in centers of troop population. Although these displays were intended primarily for the training of the troops of the three nations, civilians were permitted, and actually encouraged, to see them. Among the exhibits were field sanitary devices, many of which could have been used to good advantage by the indigenous population had they been able to secure them or the materials to construct them. But, as was the situation throughout North Africa, these devices were casually ignored.

Supplies for civilian public health.-It is unlikely that much preinvasion planning was done to determine how essential medical supplies for the civilian population would be obtained and dispensed by the various base sections once ashore. Originally, medical supplies were expected to reach the operational areas in prepacked supply units directly from the Zone of Interior or from the base of operations. This never fully materialized, and, consequently, the burden fell largely on AFHQ.16

A major supply system, which was established in December 1942 and revised in early 1943 with Allied membership, was the NAEB (North African Economic Board) which eventually became the North African Joint Economic Mission on 1 June 1944. The board was responsible for importing all supplies that were deemed necessary for civilian use by the French Provisional Government. The NAEB also initiated, formulated, and established policies, plans, and programs for civilian economic matters in North Africa. Later, the board's duties were expanded to include the actual purchase and distribution of necessary commodities for civilian use in matters of public health and relief under Lend-Lease.

On 26 February 1943, Drs. Dudley A. Reekie, Dorland J. Davis, and Michael L. Furculow (officers of the U.S. Public Health Service with the grade of colonel) were assigned to serve as medical officers with the Military

15lnterview, Lt. Col. Douglas Hesford, MSC, with Dr. (formerly Major, MC) Mortimer M. Cohn, 6 May 1962.
16Medical Department, United States Army. Medical Supply in World War II. Washington: U.S. Government Printing Office, 1968.


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North African Mission. Their duties included assistance in the procurement and distribution of medical supplies for the civilian population and service as medical advisers in relief and rehabilitation activities.

These officers arrived in Algiers in late March and were assigned as the medical section for the NAEB's Division of Public Welfare and Relief under Allied Force Headquarters. Dr. Davis immediately began a preliminary survey of the need for medical supplies among Morocco's civilian population, and later conducted a similar survey of Oran upon request of city officials.17

In the Mediterranean Base Section, the Medical Section's operating instructions specifically stated that civil authorities would be assisted "wherever possible by directing their efforts through the proper channels to secure allotted funds and materials from the NAEB."18

In 1944, the MBS Supply Section became extremely active, assuming the responsibility of maintaining the theater reserve while actively participating in the collection of medical supplies for operations in Italy and southern France. During the year, more than $300,000 worth of supplies were issued to the French while the equivalent of little more than $52,000 in supplies and service was received in return.19

COMMUNICABLE DISEASES

The planning for the preventive medicine program to be undertaken by the AFHQ and NATOUSA Medical Section concentrated on four major areas: respiratory diseases, intestinal diseases, malaria, and venereal diseases. Also considered was the possibility that serious outbreaks of typhus, epidemic hepatitis, plague, and cholera might arise to threaten the health of the Allied troops in the area, consequently impairing the Allied war effort in North Africa.

With these general considerations in mind, policies and programs were formulated to obtain the necessary personnel and equipment to combat these conditions, with emphasis being given to the training of medical personnel at all levels.

From 1943 to 1945, five outbreaks of epidemic proportions were experienced, all of which produced high noneffective rates. Intestinal diseases and malaria were prevalent in the summer of 1943. These were followed by epidemics of infectious hepatitis and trenchfoot in the winter of 1943-44 with a recurrence of hepatitis during the following winter. Venereal disease, which became prevalent almost as soon as the troops arrived, remained a problem throughout the campaign.20

17Williams, Ralph Chester: The United States Public Health Service, 1798-1950. Washington: Commissioned Officers Association of the United States Public Health Service, 1951, pp. 695-697.
18Standing Operating Procedures, Medical Section, Headquarters, Mediterranean Base Section, Office of the Surgeon, dated 19 May 1943.
19Medical History of the Medical Section, Headquarters, Mediterranean Base Section, 1944.
20Report, Preventive Medicine Officer, Office of the Surgeon, MTOUSA, 1945.


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Of the communicable diseases in the theater, malaria proved to be the most serious although hepatitis was not far behind. Their importance resulted not only from the number of days lost but also from the fact that, when key personnel were afflicted, the resulting long periods of disability frequently disrupted organization and operations.

Respiratory, intestinal, and venereal diseases were less important. However, from 1943 to 1945, the incidence of venereal disease still created a problem of major proportions.

Intestinal Diseases

Dysentery and diarrhea.-The North African theater comprised an area in which the filth diseases of man had been prevalent for generations. The poor sanitary habits of the local population combined with inadequate, and sometimes nonexistent, sanitary facilities to make outbreaks of dysentery and diarrhea commonplace. Waste disposal was seldom practiced, flies abounded, and screening was scarce in even the most modern buildings. These conditions were complicated by the fact that unit and individual troop training in sanitation was usually deficient. As a consequence, serious outbreaks of these intestinal diseases occurred in 1943 from May to July, particularly among the newly arrived units and in the replacement depots. In the more seasoned units, the letdown following the Tunisian campaign and the onset of the fly-breeding season were undoubtedly responsible for some outbreaks.

Initially, the local French health authorities, both civil and military, did not consider that bacillary dysentery would constitute a threat to the U.S. troops in North Africa. However, when Colonel Long, U.S. Consultant in Medicine (fig. 35), and the British consulting physician and surgeon inspected British hospitals in January 1943, numerous bacillary dysentery cases involving American patients were noted. In general, the disease was found to be a direct result of highly unsanitary practices. Colonel Long recommended to the Deputy Surgeon of the Allied Force that rigid sanitary discipline be maintained in all units. This could be done, he noted, by making every effort to prevent officers and enlisted men from purchasing raw vegetables and certain fruit from unauthorized sources. He further suggested that all civilian mess attendants, cooks, food handlers, and other food service personnel be subjected to three bacteriologic and urine examinations to rule out the possibility that they could be carriers of typhoid, paratyphoid, or bacillary dysentery.21

From 24 to 26 March 1943, the prevalence of bacillary dysentery was discussed by the Committee on Hygiene and Epidemiology of the Technical Section for Public Health in the French High Commissioner's Office.

21Long, Col. Perrin H., MC: A Historical Survey of the Activities of the Section of Preventive Medicine, Office of the Surgeon, MTOUSA, 3 January to 15 August 1943.


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FIGURE 35.-Col. Perrin H. Long, MC, Consultant in Medicine, Allied Force Headquarters. (Photograph, courtesy of National Library of Medicine.)

Dr. Gaud, the Commissioner for Health in Morocco, commented that bacillary dysentery did not seem to be very common in the civil population in Morocco, with but 10 to 106 cases being reported per month, the low being in February and the peak in October. Colonel Jame, the departmental surgeon of Morocco, concurred with Dr. Gaud, reporting that the disease was similarly uncommon in French troops and occurred mainly in new recruits.

Dr. J. Grenoilleau, Director of Public Health in Algeria, noted that there appeared to be little amebic or bacillary dysentery in Algeria. General Gauthier, 19th French Corps Surgeon, stated that his corps had not been troubled much with dysentery for 4 years. Chef de Médecin Chitron of the French Navy noted that "dysentery was practically nonexistent in naval personnel."22

Despite such reassuring statements from the French health officials, Colonel Long believed that bacillary dysentery would become a problem as soon as fly breeding commenced since the sanitation throughout the area was so inadequate. Preventive measures were taken wherever possible, but be-

22See footnote 21, p. 275.


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cause of equipment shortages, outbreaks of bacillary dysentery among U.S. troops occurred simultaneously throughout North Africa in early May when the flies multiplied. Diarrhea and dysentery became prevalent in the Eastern Base Section on 17 May, 2 days later in the Atlantic Base Section, and by 24 May in the Mediterranean Base Section. In all, 57,000 cases were reported throughout French North Africa in 1943.

In Oran, an attempt to locate all possible sources of flies among the civilians or within the city itself was started with the 60-man Arab work force that had been assembled by the MBS Surgeon. However, this attempt soon failed because of lack of funds. All street cleaning and washing stopped although an MBS engineer inspected any reported areas of fly breeding.

An attempt to persuade the civilian population to clean their own areas was once again unsuccessful although some of the uncooperative individuals were reported to civilian authorities who tried to aid the U.S. health officials.23

Typhoid and paratyphoid fevers-During 1943, the 62 typhoid cases and 45 paratyphoid cases which occurred among NATOUSA military personnel were traceable to food handlers or to unapproved water sources.

Because typhoid fever was prevalent in the indigenous population of North Africa and there were many suspected carriers of the disease, it was considered advisable to give stimulating doses of 0.5 cubic centimeter of typhoid-paratyphoid vaccine every 6 months to the U.S. forces in North Africa.24

In the Mediterranean Base Section, the incidence of typhoid fever among the civilian population was reduced gradually from 747 cases in 1942 to 641 in 1943, and to 520 by November 1944. In October 1944, typhoid fever threatened to assume epidemic proportions, with 242 reported cases. However, the flurry was short-lived.25 U.S. troops were completely protected by extraordinary precautions, such as declaring all bars and restaurants off limits, prohibiting eating in private homes, and close surveillance of all civilian employees. Few typhoid vaccinations were given to civilians by local health agencies throughout 1944, but all U.S. civilian employees were immunized against the disease, as well as against typhus and smallpox.

In general, intestinal disease declined sharply after intensive sanitary training and discipline were imposed. Training in proper sanitary methods was included in all unit training programs and in reception depots. New units arriving in the theater were contacted soon after landing and were advised on the disease situation and the importance of instituting preventive measures.

As screening became available, it became possible to enclose all kitchens, latrines, most messhalls, and contagious wards of hospitals throughout the

23See footnote 12, p. 269.
24NATOUSA Circular No. 59, dated 13 Apr. 1943, Section II.
25See page 13 of footnote 19, p. 274.


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theater. In 1944 and 1945, screening and other supplies became more readily available, and the rates of intestinal disorders sharply declined.

Circumstances often forced U.S. units to bivouac near civilian centers or French military installations with native colonial troops whose sanitary standards were extremely low. Allied Military Government personnel (and later the Allied Military Control Commission) in coordination with French officials were able to get cooperation from the civil population. Eventually, a semblance of proper sanitary disposal was developed in most areas where U.S. troops were operating. Direct liaison with commanders and medical personnel in foreign military units then resulted in a general uplifting of sanitary standards among their soldiers.

Insectborne Diseases

Malaria.-Although malaria was prevalent in French North Africa, the seasonal distribution was not the same throughout the North African theater. Generally, probably as a result of relapsing cases, the clinical incidence began to increase slightly in April 1943. The upswing from new infections appeared in May and continued to rise steeply in June and July, reaching a peak in late July or in August. The rate usually declined in September-in some areas, there was a modest secondary peak in October-and dropped abruptly to its lowest point in March.26

The malaria control program was one of the largest undertakings of the NATOUSA Medical Section. From the beginning of 1943 to late spring, malaria control progressed through various stages of planning, liaison, and general development which necessarily preceded the physical organization phase.27

A Malaria Advisory Board was established in 1943 by Brigadier (later Maj. Gen.) Ernest M. Cowell, RAMC, Director of Medical Services, AFHQ, under Brigadier E. R. Boland, the British consulting physician. American, British, and French malariologists and major combat command representatives comprised the board. The U.S. representative was Colonel Long, the NATOUSA Medical Consultant and, later, NATOUSA Preventive Medicine Officer and Malariologist.

Colonel Long laid the groundwork for the malaria control program by arranging conferences with British and French malaria control representatives. These representatives agreed on an arrangement with civilian health agencies whereby the local agencies would assume responsibility for the bulk of the environmental malaria sanitation in extra-military areas.

On 9 June 1943, Col. Loren D. Moore, MC, commander of the 2655th Malaria Control Detachment, was attached to NATOUSA's Medical Section Headquarters for duty as theater malariologist. However, he was soon in-

26Russell, P. F.: A Note on the Epidemiology of Malaria in NATOUSA. M. Bull. North African Theater of Operations 1: 29-30, 1944.
27Medical Department, United States Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government Printing Office, 1963, pp. 249-302.


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capacitated through illness and was replaced on 24 July by Col. Louis L. Williams, Jr., of the U.S. Public Health Service. A week later, Colonel Williams was stricken with coronary disease. On 21 September, Col. Paul F. Russell, MC, became theater malariologist, a post he held until 4 March 1944, when he left to become chief of the Malaria Control Branch of the Allied Control Commission. His replacement was Lt. Col. Justin M. Andrews, also of the U.S. Public Health Service, who originally had been appointed assistant malariologist to Colonel Moore on 9 June 1943.

On 23 February 1943, the Deputy Theater Commander requested a joint conference of British and American military and French military and civil malaria authorities so that the needs of the French could be ascertained while, at the same time, obtaining their cooperation in malaria control. After considerable discussion, which accomplished little, a small committee was appointed to determine what supplies the French actually needed.

A letter was issued by the NATOUSA Surgeon on 7 May 1943, which authorized certain U.S. commanders to issue supplies to the French Director of Public Health and to expend up to 500,000 francs (approximately $11,400) per month for malaria control work. This policy was dictated by the presence of large numbers of troops, many under bivouac conditions, scattered throughout the country, and by the offer from civilian health agencies, who were acquainted with the terrain and the malaria problem, to assist in malaria control if provided with the necessary measures and equipment. The responsibility of the local civilian agencies was to encompass all anopheline breeding areas outside the limits of U.S. military installations. In most areas, excellent results, benefiting both civilian and military personnel, were achieved by the arrangement.

A French antimalaria program was launched in Oran in April 1943, with Dr. Georges Rehm as its director. This civilian agency had been authorized a maximum monthly expenditure of $500,000, but actual expenses never exceeded $70,000 in a single month. Nevertheless, problems were omnipresent. Dr. Rehm was rarely able to resolve mounting labor troubles and was able to employ an adequate work force in relatively few areas. A satisfactory drug supply for the treatment of malaria was difficult to arrange, and drugs for suppressive medication were never available. The NAEB supplied the only available drugs. In several localities, mosquito control projects were either seriously impeded or stubbornly opposed by municipal officials or certain influential colonials. As a result, the Army was forced to assume full responsibility for such operations in and around areas where American troops were stationed.

A shortage of military malaria control vehicles added to the difficulties. Even in some places where ample labor was available, there was no transportation to the job site. The civilian health agencies, faced with difficulties in labor procurement, found themselves with a lack of sufficiently trained personnel to supervise work operations. Some of the agencies were


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plagued by indirect and time-consuming methods of operation. In other instances, military malaria control groups had to take over civilian control work to protect the troops.

Committees composed of representatives from various interested agencies met regularly in the base sections for a mutual exchange of information on antidisease activities, with particular emphasis on malaria, and to coordinate plans for future work.

A lack of trained malariologists in the theater during much of 1943 hampered the effectiveness of the antimalaria program. This deficiency also contributed to a disabling lack of cooperation and unification of purpose between special antimalaria units, between military and civil organizations and programs, and between Allied Forces agencies.

Experience indicated that, had a trained malariologist been assigned to each base section who was permitted to devote his entire time to the supervision of the malaria control program and who could establish and maintain liaison between all agencies involved in the program, many of the difficulties encountered would have been minimized and more effective results would have been achieved.

Casual native labor, recruited through either civil health agencies or military active labor organizations, performed most of the physical labor in North Africa. Italian POW's (prisoners of war) were also used in the theater (fig. 36), except in the Atlantic Base Section. Soldier labor from a sanitary company was used in the Mediterranean Base Section. Of all labor sources, POW's were found to be most satisfactory.

As the danger to the Mediterranean lifeline diminished in the summer and fall of 1943, emphasis shifted northward and the Mediterranean Base Section became the major staging area for the invasion of Sicily and the Italian campaign. Several ABS malaria control and survey units were soon transferred to the Mediterranean and Eastern Base Sections and, later, to the newly activated Peninsula Base Section in Italy.

Therefore, by agreement with French authorities, on 27 August 1943, all control work previously done by U.S. Army units was assumed by the French Malaria Control Service, with particular emphasis being placed on the work in areas where U.S. personnel were still stationed. These areas were the cities of Casablanca and Fedala and the airports at Marrakech, Ras E. Mar (Fès), and Salé.

On 1 November 1943, all American subsidies for French malaria control work were discontinued, and the difficult and apparently never-ending task of malaria control was left in the hands of the French civilian health agencies. Thereafter, all malaria supplies needed by the agencies were obtained through Lend-Lease channels.

Typhus fever.-The months of planning and preparation that preceded Operation TORCH included the consideration that French North Africa would be the first typhus-infected area invaded by U.S. troops in World


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FIGURE 36.-A work party of Italian prisoners of war digs a drainage ditch for malaria control in the Mediterranean Base Section, 1943.

War II. The lack of adequate medical intelligence on typhus fever in North Africa was, in part, responsible for the establishment of the United States of America Typhus Commission by Executive order of President Franklin D. Roosevelt on 24 December 1942.28

Unfortunately, the medical intelligence information received by AFHQ's Medical Section concerning the occurrence of typhus fever was soon found to be incomplete. Based on a report of only 4,000 typhus fever cases during the winter of 1941-42, when in reality there had been more than 64,000 cases by the end of 1942, the British decided not to vaccinate their troops against the disease. This decision was to become a source of great anxiety. AFHQ's American component, on the other hand, had been immunized before going overseas.29

28Medical Department, United States Army. Preventive Medicine in World War II. Volume VII. Communicable Diseases: Arthropodborne Diseases Other Than Malaria. Washington: U.S. Government Printing Office, 1964.
29See page 24 of footnote 21, p. 275.


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Upon the arrival of Allied Forces in North Africa in November 1942, the typhus situation did not seem too disturbing. A few hundred cases existed in Morocco and a somewhat larger number in Algeria; but, because of a lack of medical liaison between the Allied Forces and a partial disruption of liaison between the various French health facilities as a result of the invasion, indications that a major epidemic of typhus fever among the civilian population was mounting in North Africa escaped attention until January 1943.30 At that time, the correlation of reports from Morocco, Algeria, and Western Tunisia clearly showed that the incidence of typhus fever was rapidly rising. At the same time, reports of typhus fever breaking out among the unvaccinated British troops began to reach AFHQ's Medical Section.

The local situation was disturbing. The native population was riddled with typhus as were native troops serving in the French Army. These soldiers were in isolated wards in French military hospitals. Their high rate of incidence was attributable in part to their custom of carrying their wives, family, and livestock with them as they traveled, thereby creating unusually close and congested living conditions which consequently permitted the easy transmission of lice.

In the Mediterranean Base Section, which encompassed most of Algeria and was headquartered in Oran, the French Board of Health, from January to March 1943, gave live typhus vaccine to approximately 37,000 Arabs among whom the disease was especially prevalent, with further inoculations starting in December. Live vaccine was used because of the difficulty in giving more than one inoculation. MYL powder, a louse powder consisting of pyrethrins as a toxicant, mixed with a synergist, an ovicide, an antioxidant, and a pyrophyllite powder, was also available for delousing Arab typhus contacts, and the French set up centers for delousing Europeans.

In 1942, 1,064 cases of typhus fever were reported among civilians. This number dropped to 298 the following year, and then fell to a minimum of seven cases for January through November 1944.

Since typhus was endemic to the area, French civilian doctors, working out of the MBS Surgeon's office, inspected bars, restaurants, and barber-shops, resulting in a marked improvement in their general cleanliness and sanitation. However, personal hygiene among the natives had made few, if any, forward strides since the arrival of U.S. troops.

During 1943, six cases of typhus fever were reported in MBS troops. These cases were mild, atypical, and nonfatal. All of the men had been immunized, but two of them had not received booster shots.

In September 1943, a louse survey was made, and louse counts were made in three representative MBS units. No lice were found, but eggs were present on the clothes of one man. During bimonthly inspections, few men

30See page 25 of footnote 21, p. 275.


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were found to be infested. In fact, the problem of louse control among MBS troops was minimal, mainly because of adequate facilities for good personal hygiene.31

It is appropriate to include here a brief account of the development and use of a new method to eliminate louse infestation and the consequent control of epidemic typhus fever by dusting individual members of civilian and military populations with lousicidal powder. The basic method and its variations were devised, tested, and proved effective in North Africa in 1943 largely by American military and civilian personnel, with the support of medical and sanitary establishments of the Allied Forces of the United States and Great Britain. Personnel from the Offices of the Chief Surgeons fostered the necessary relationships and arrangements with military units and native governments, communities, and institutions. Elements related to Civil Affairs and Military Government in Egypt and Algeria also collaborated in the work.

Application of the results was not so much needed in North Africa but was urgently needed in Italy in the winter of 1943-44, when a dangerous epidemic of louseborne typhus in devastated, overcrowded Naples threatened the advance of the U.S. and British Armies in the Italian campaign against the Germans. The prompt eradication of that epidemic was as spectacular as it was protective, and this achievement is regarded as one of the most brilliant and important triumphs of preventive medicine.

The final experimental work in North Africa was done during the period from March to December 1943 by members of the staff of the Typhus Commission in Cairo and by the Typhus Team of the Rockefeller Foundation Health Commission. This work was directed by Dr. Fred L. Soper (formerly attached to the Typhus Commission), with the constant support of Colonel Stone, Chief Preventive Medicine Officer of NATOUSA, in Algeria. In addition, invaluable assistance was given by Dr. Sergent, director of the Pasteur Institute of Algeria.

Both groups showed that the application of the louse powders, MYL and DDT, to the garments and skin of persons fully clothed killed adult lice and all stages of the instar. As the insecticide remained in the fabric of the clothing, it exerted a persistent louse-inhibiting action for more than 2 weeks. The powder was applied by blowing it with garden rose dusters underneath the clothing, upon the skin, into whatever underclothing was worn, and into bedding, hats, and hair (fig. 37).

In Algeria, Dr. Soper's team, which also included Drs. William A. Davis, Floyd S. Markham, and Louis A. Riehl, dusted thousands of louse-infested Arabs in the village and commune of L'Arba, at the Maison Carree, which was a large civil prison near Algiers, and at a prisoner-of-war camp in the vicinity of Algiers. Careful counts of lice in the clothing and on the subjects' bodies were made at various intervals before and after the dusting.

31Annual Report, Office of the Surgeon, Mediterranean Base Section, 1943.


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FIGURE 37.-Medical Section personnel of the Mediterranean Base Section in Algiers treat Arab children with new insecticide powder designed to kill typhus lice.

The results showed that, in a closed population group where everyone is treated and then protected from reinfestation, two treatments of either MYL or DDT (preferably 10-percent DDT, a chlorinated phenolic compound, in pyrophyllite powder) at 2-week intervals could be expected to immediately reduce lousiness and prevent a dangerous degree of infestation during a 3-month period.32

Venereal Disease

There is no indication that much advance theater-level planning for VD (venereal disease) control was considered before the invasion of North Africa. While a preventive medicine officer was included on the AFHQ staff, there is no mention in the official records of any VD control policy.

32(1) Soper, F. L., Davis, W. A., Markham, F. S., Riehl, L. A., and Buck, P.: Louse Powder Studies in North Africa (1943). Arch. Inst. Pasteur d'Algerie. 23: 183-223, September 1945. (2) Soper, F. L., Davis, W. A., Markham, F. S., and Riehl, L. A.: Typhus Fever in Italy, 1943-1945, and Its Control With Louse Powder. Am. J. Hyg. 45: 305-334, May 1947. (3) Wheeler, C. M.: Control of Typhus in Italy 1943-1944 by the Use of DDT. Am. J. Pub. Health. 36: 119-129, February 1946. (4) See footnote 27, p. 278.


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FIGURE 38.-Military Police patrol an "off limits" area of Algiers.

Apparently the only decision made was to make no decision until after the landings. At such time, actual experience would be the guide.33

Once ashore, the various units instituted and carried out their own control measures in their particular areas, a system which continued until January 1943. On 3 January 1943, Colonel Long, AFHQ's Consultant in Medicine, and Lt. Col. John W. R. Norton, MC, Preventive Medicine Officer, began to coordinate the various aspects of the VD control program. At a joint conference with British and American health officers in Algiers in January, local French representatives stated that the incidence of venereal disease in the native population was very great and that clandestine prostitutes, of whom there were many, were almost always infected. The health officials contended that the police and medical surveillance (fig. 38) then in effect rendered most of the "registered" prostitutes, both on the streets and in brothels, relatively free from the disease. This fact, they concluded, should convince the Allied medical officers to support and maintain a system of controlled prostitution.34

33See footnote 11, p. 268.
34Report, Lt. Col. Perrin H. Long, MC, 28 Sept. 1945, subject: Historical Report Upon Activities for the Control of Venereal Disease in the North African Theater of Operations From 3 January to 8 March 1943.


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On 8 March 1943, Lt. Col. (later Col.) Leonard A. Dewey, MC, was assigned as full-time theater VD Control Officer with responsibility for control and treatment. Six additional officers were assigned later that month for duty on the various base section staffs. All major theater organizations and major cities (with the exception of Algiers, which was under British control) were thus provided with the services of a trained and experienced VD control officer. This principle, inaugurated in NATOUSA, was to become an integral part of the Preventive Medicine program through the Sicilian and Italian campaigns.

Control by U.S. authorities.-Because of the high rate of infection among the indigenous population, venereal disease soon became the chief problem among U.S. troops, especially those stationed in the Mediterranean Base Section. Although estimates of the rate of venereal infection among European and native prostitutes varied, this rate reached extraordinary proportions throughout the theater. In Oran, a French physician, who handled the examinations daily, estimated that probably 95 percent of the women he inspected were infected at the time they were examined. Another 3 percent were just recovering from infection, and the remaining 2 percent would probably contract a venereal disease within the week before the next examination. Apparently, the rate of infection remained constant whether the prostitute was a panderer walking the streets or a woman operating in a brothel.

U.S. officials estimated that the average prostitute in a brothel would usually accommodate six soldiers per hour and about 50 or 60 per 8-hour period. This situation made disease control almost impossible. Although prostitutes in the larger cities insisted that U.S. troops wash themselves and use prophylactics, those in smaller towns were not so demanding. Generally, the madams of brothels urged their girls to conduct a cursory visual examination of each customer, looking for chancres, syphilitic lesions, and venereal discharges. If any were found, the man was refused. Of course, the visual examination was useless in the chronic stages of gonorrhea or syphilis so the spread of infection was rampant.

These circumstances cast considerable doubt on the value of the French examination program, which called for a cursory skin inspection at local health centers. A prostitute servicing 50 men a day would have accommodated approximately 350 men between her weekly examinations. Consequently, if she contracted a venereal disease immediately after an examination, she could infect 350 men in the interval before her next examination, at which time hopefully the disease would be discovered.

MBS control measures-Shortly after the activation of Mediterranean Base Section, the VD Control Officer, Capt. (later Maj.) Mortimer M. Cohn, MC, inspected Oran and its surrounding environs. His major recommendation, which he continually repeated in letters to the MBS Surgeon, was to place all brothels off limits because of control difficulties. Cohn reasoned that declaring them off limits would reduce a prostitute's clientele


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from six men to one man an hour since she would have to solicit her trade. Reducing opportunities of contact, Cohn argued, would correspondingly reduce rates of infection.

Invariably, these reports were returned, with the remark that the prohibition could not be put into effect. The common reason given was that, if prostitution was outlawed, the French women in the theater might be molested by U.S. troops, a situation which could adversely affect Franco-American relations. Since France was considered an ally, U.S. military policy dictated against any action which might strain relations or weaken the joint war effort. Nevertheless, some instances of molestation did occur despite the controlled prostitution program.

To reduce contagion among U.S. troops, Colonel Hutter, the MBS Surgeon, had established prophylactic stations throughout his base section. Set up at the entrance to each red light district, these stations were manned by Medical Section aidmen, sometimes with local civilian assistance. However, as troop strength grew, the incidence of venereal disease increased proportionately.

The VD control program in the Mediterranean Base Section was intensified in 1944 and received good cooperation from the French civil authorities. A VD clinic operated by civilian doctors employed by the MBS Surgeon continued to function and gradually improved its procedures. All prostitutes picked up by the vice squads were examined, and those found infected were isolated at a French State Board of Health dispensary until cured. Beginning in October 1944, the French police arranged to have infected prostitutes from brothels included in the isolation policy.

Cooperation with civil agencies-Opinion on the type and spirit of cooperation received from local public health agencies in North Africa varies. On one hand are those who feel that the civil agencies did as well as they could with what they had; on the other are those who decry an almost complete lack of cooperation between the local French authorities and U.S. medical units.

Colonel Long reported favorably on the work with civil authorities, noting that the civil police departments had been cooperative in carrying out any program requested by Army authorities, including an effective campaign against clandestine prostitution which aided the enforcement of off limits policies. The civilian health authorities were willing to cooperate, but their efforts actually proved of little value because of their "complete lack of understanding of modern methods." In a few areas, local agencies were willing to adopt some American methods and had instituted the beginnings of scientific VD control programs.35

A dimmer view of civilian-military cooperation was taken by Captain Cohn, who reported, "Rapport and cooperation with the French civilian medical authorities are notable only by their absence." As VD Control

35Annual Report, Preventive Medicine Division, NATOUSA, 1943.


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Officer, he contacted local physicians in towns outside Oran, and this process constituted the total exchange of information between his office and the local French doctors. Cohn reported that he knew of no official Army or civilian agency in any city he visited where there existed a dissemination of information concerning the contagious disease within that very community.36

As can easily be seen, two schools of thought existed in the VD control problem. Those who felt that the prevention of contacts was most important urged the off limits classification of all brothels. The others believed that contacts were unavoidable and that a regulated system of "approved" brothels with adjoining prophylactic facilities was necessary to reduce contacts in less desirable locations.

In November 1943, a survey of VD rates throughout North Africa revealed that organizations maintaining an off limits and repression policy had consistently lower rates by 15 to 40 percent than those units with supervised and regulated prostitution. The survey also indicated that the chief effect of the regulated prostitution was to produce a larger number of sexual contacts within the houses without materially reducing contacts on the outside.

All the blame for the chaos that engulfed the venereal disease control program cannot be placed upon the theater prostitution policies, however. Once again, the incomplete planning that characterized most of the U.S. medical operations in North Africa arose to plague this already complicated situation. As a result, any beneficial medical developments that arose from the North African experience resulted more from trial and error than from prior planning. Many man-hours were lost, especially in the early stages, which could have been saved by comprehensive and detailed planning and immediate implementation upon arrival. While many of the control programs succeeded, too often the problems of little cooperation, no coordination, and inadequate supply doomed many worthwhile efforts that otherwise could have done much to check the venereal disease problem and considerably reduce the casualties it created.

Respiratory Diseases and Tuberculosis

Respiratory diseases never reached epidemic proportions in North Africa. Generally, only mild infections occurred which followed the nonepidemic seasonal trends. Common respiratory diseases accounted for almost 90 percent of the total respiratory diseases in NATOUSA in 1943, but since no true epidemic, even of a localized nature, occurred, they never seriously affected military efficiency.

Tuberculosis had a high morbidity rate among the native inhabitants of Algeria, with glandular and skeletal forms especially common. The highest incidence was among Moslems and the lowest occurred in the

36See footnote 15, p. 273.


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European population. Investigation by the Pasteur Institute indicated that rates were higher in larger centers than in nearby villages inhabited exclusively by natives.

To reduce its spread, the Pasteur Institute began vaccinating large numbers of natives, especially children, with the BCG live vaccine, with great success. The use of the BCG vaccine was credited with a 50-percent reduction in the infant mortality rate in one series of 1,667 vaccinations, and similar results occurred thereafter.37

Use of the BCG vaccine among U.S. troops was also considered, but The Surgeon General decided that, since its value was not fully established, it would be unwise to add an uncertain vaccine to a list of inoculations already in use which had fully demonstrated their value.

Thus, the tuberculosis preventive program in NATOUSA remained basically the same as that in all theaters of operation; namely, early diagnosis of the disease through casefindings and hospitalization for isolation and treatment in known cases.

Plague

Before the invasion of North Africa, plague was classified as a disease of potential military importance, but actual experience later revealed relatively few cases. A total of 373 cases among the native population was reported in March 1943 in Algeria alone, including 17 in Algiers. A rat survey of that city showed that the most common species of flea was the dangerous vector Xenopsylla cheopis, and that the number of fleas per rat varied from two to five. These statistics, though inadequate for a complete picture of the situation, indicated that plague would be a constant threat to MBS armed forces.38

Only a few cases of bubonic and pneumonic plague appeared in the port area of Oran, however. U.S. military authorities were constantly trying to convince the French to enforce rat control policies and to fumigate all incoming ships. This program, generally haphazard at best, proved to be ineffective.

SUMMARY

The concept of civil affairs was still relatively new at the time of the North African invasion in November 1942. As a result, plans for a public health program in the French possessions were sketchy at best. Despite innumerable health studies conducted by the Pasteur Institute of Algeria and extensive reports issued by the Algerian Government before World War II on prevailing health problems, U.S. medical officers were not fully apprised of the health problems that American troops would face in

37See page 11 of footnote 4, p. 259.
38See page 9 of footnote 4, p. 259.


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North Africa. Consequently, they were forced to meet by improvisation the many emergencies and difficulties that soon arose.

Little high-level liaison was ever established with French civil authorities, and civil affairs public health activities could have ended in disaster had it not been for the work of Medical Department officers on the various base section staffs of NATOUSA as well as personnel from local Army medical units and hospitals. Since the headquarters surgeons were limited to broad policymaking and technical supervision, the lack of operational control over subordinate commands left the preventive medicine program in the hands of the lower echelon medical officers.

As can be expected, this situation allowed the program's effectiveness to vary from command to command, and thus much of the early work was haphazard. Often the medical officers of lower commands were not trained in preventive medicine and had to proceed on a trial-and-error basis. In some instances, an unfamiliarity with the French civil and public health systems left the Army officers with no one with whom to effect liaison on health matters.

It was not until 1 March 1943, too late for the North African operation, that the Secretary of War created a Civil Affairs Division as a part of the War Department Special Staff. Before the Civil Affairs Division ever began to establish definite policies, the major problems in North Africa had been met and partially resolved by trial and error.

At the lower levels, the conduct of civil affairs influenced the health and welfare of the individual civilian and, in turn, determined the cooperation and assistance which the Allied Armies received from the civilian population. It must be remembered that the Allied Forces recognized the sovereignty of France in North Africa, exerting less control over the indigenous population than they would under a typical military government setup. The term "civil affairs" better represents the manifold and complex activities involving the Free French Government and the civilian inhabitants in North Africa, and public health remained a major component of civil affairs activities.

Perhaps the most significant point of the North African preventive medicine campaign was that new methods were tried to meet unexpected situations. Despite the difficulties created by poor planning and inadequate supervision, important lessons were learned, and those policies and procedures that proved successful formed the basis of the preventive medicine programs later used in Italy, France, and Germany.

Certain important points stand out:

First, the planning for any campaign must include well-laid preventive medicine plans. Of course, such planning would be wasted unless the importance of these plans could be impressed upon command. All unit commanders, from the highest to the lowest levels, must realize the importance of carrying out the recommended preventive medicine measures if the pro-


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grams are to succeed. Included in such planning should be the provision to secure detailed analyses of the areas into which troops are going and information on control measures.

Second, to carry out preventive medicine measures, supplies must reach troops promptly. These supplies include screening, sprays and sprayers, diesel oil, all current insecticides and rodenticides, and insect repellents. This need was demonstrated by the high diarrhea and malaria rates in 1943, which resulted from the failure to provide troops with fly and mosquito control supplies.

Finally, provision must be made for immediate liaison with local government and local public health officials. Such coordination and cooperation are essential to a successful civil affairs public health program in an occupied area.

Of course, a civil affairs program is as dependent on men as it is on methods and materials. Well-trained medical personnel, acquainted with preventive medicine procedures, are necessary for useful public health activities.

These points were demonstrated and proven in North Africa. Adequate preventive medicine programs were created, many for the first time, often through the ingenuity of the officers and men in overcoming the recurring handicap that plagued their early efforts.

As the date of the Sicilian invasion drew near, planning for civil affairs in Sicily and Italy was stepped up by Allied Force Headquarters. In May 1943, a small group of British and American officers assembled at Chréa, Algeria, to prepare for the coming invasion on 10 July, undergoing training for the Italian campaign. These planning and training groups originally were known as Headquarters, Allied Military Government of Occupied Territory. After the Italian surrender on 8 September, the words "Occupied Territory" were dropped from the name. This group carried out the first civil affairs operations as we know them today.

In late August 1943, a new group of officers arrived at Tizi Ouzou, a mountainous resort near the coast, east of Algiers. These men formed the nucleus of the Allied Control Commission and later followed teams of the Allied Military Government into Italy to operate in occupied areas behind the combat zone. The work of both groups on the Sicilian and Italian mainlands is included in chapter IX of this volume.

As attention shifted northward to Italy and Western Europe, the importance of French North Africa began to wane. With North Africa securely in Allied hands, little more than a holding action was left for the troops who remained behind. On 1 November 1944, NATOUSA itself passed out of existence, becoming the Mediterranean Theater of Operations.

In March 1945, the Mediterranean Base Section, which had absorbed the Atlantic and Eastern Base Sections 5 months before, was itself transferred to the expanded Africa-Middle East Theater, and Headquarters,


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MTOUSA, was relieved of its responsibility in northern Africa. But by that time, the fighting in North Africa was over and the concept of civil affairs public health-which had had its inception there-was at last a workable reality.

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