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Chapter 9

Contents

CHAPTER IX

Sicily and Italy

Thomas B. Turner, M.D.

Section I. The Italian Campaign

BACKGROUND

Within the worldwide scope of Army operations in liberated and occupied territory, the Mediterranean Theater has a special significance. It was in this theater that the U.S. Army first encountered major problems of civil affairs in military government (CA/MG); here it tested traditional doctrine against the realities of total warfare, made necessary modifications, and developed policies and techniques which were later applied in other areas.1

In July 1942, the Combined Chiefs of Staff decided to launch an invasion of French North Africa as a prelude to an attack on "the soft underbelly of Europe." An Anglo-American AFHQ (Allied Force Headquarters) was soon thereafter established in London under the command of Lt. Gen. Dwight D. Eisenhower to plan the invasion. On 11 September, a group of officers, graduates of the first class of the School of Military Government at Charlottesville, Va., reported for duty at AFHQ, and the Civil Affairs Section of that headquarters was activated under the direction of Col. Charles W. Booth.

As originally planned, this section included, among others, a specialist division designated "Public Health." It should be noted, however, that no medical officer was ever actually assigned to this duty before the invasion of North Africa on 8 November 1942.

While the invasion touched off a succession of highly complex political questions, the French territories, after a few critical weeks in which the relations between the invading forces and the local governments were in an exceedingly fluid state, remained essentially self-governing units. General Eisenhower was confronted with many problems of a high level political nature. Mr. Robert D. Murphy, the senior American State Department officer then in the theater, assisted him in making decisions to cope with them. However, problems pertaining to medicine and public health were more specific in nature, and were not considered to any significant extent at this time because primary consideration had to be given to resolving the many broad problems necessary to the successful prosecution of the war.

1Komer, R. W.: Civil Affairs, and Military Government in the Mediterranean Theater, undated. [On file in the Office of the Chief of Military History, Department of the Army.]


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The absence of a medical officer in the Civil Affairs Section, AFHQ, was not, therefore, a matter for concern at this period. The original branches of the Civil Affairs Section were replaced by three Subsections designated "Military," "Political," and "Economic," respectively. Most of the civil affairs personnel during this period were civilians, functioning through the North African Economic Board and the OFRRO (Office of Foreign Relief and Rehabilitation Operation) Field Mission; several physicians, officers of the U.S. Public Health Service were assigned to North Africa by attachment to the OFRRO Field Mission.

Tactical Situation

The initial move in the campaign against Sicily and Italy was the invasion of the Island of Pantelleria, east of Cap Bon, Tunisia, by Allied troops on 11 June 1943. On 10 July, assault forces of the 15th Army Group, which consisted of elements of the Seventh U.S. Army and the British Eighth Army, landed on Sicily. The landings were made on the southern and eastern shores from Syracuse to west of Licata. British troops were on the right and U.S. troops on the left.

As the British Eighth Army moved northward along the eastern portion of the island and encircled Mount Etna, the Seventh U.S. Army swept through the center to the western tip of the island, then moved eastward along the north coast, joined the British Eighth Army at Messina, and thus completed the conquest of Sicily on 17 August 1943. The Eighth Army crossed the Strait of Messina onto the beaches of the Italian mainland at Reggio, Calabria, on 3 September, and steadily moved eastward and northward. The British 1st Airborne Division landed unopposed at Taranto and Brindisi following the unconditional surrender of Italy on 8 September. The next day, the Allied Fifth Army invaded the beaches at Salerno, south of Naples.

The Pattern of Civil Affairs in Sicily and Italy

The initial planning for civil affairs activities in Sicily was carried out by Force 141, the forerunner of the 15th Army Group, but, as the date for the invasion of Italy approached, a Military Government Section was established at AFHQ to serve as the staff section for civil affairs for General Eisenhower. Col. (later Brig. Gen.) Julius C. Holmes, an American, was appointed as the chief of this section, with Lt. Col. (later Col.) Arthur T. Maxwell, a British officer, as the deputy chief. Although this group was not established in time to contribute much to the planning for the invasion of Sicily, its role in policy formulation and in the higher direction of operations continually increased once the invasion was launched.

As will be pointed out later, this staff section never included a medical officer, nor was responsibility ever clearly fixed on any one AFHQ medical officer to concern himself with civil affairs.


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In point of time, the group designated "AMGOT" (Allied Military Government of Occupied Territories), which was organized as a component of Headquarters, 15th Army Group, antedated the Military Government Section, AFHQ. This group carried out the first civil affairs operations along the lines we know today.

AMGOT officers went ashore with assault troops in Sicily on D-day (10 July 1943) and, again, with the invasion of the Italian mainland on 3 September 1943. Effective civil government was reestablished locally, and the administration of military government was placed on a territorial basis as quickly as possible. The original plans provided for the division of Italy into seven Regions, as follows: I-Sicily; II-Calabria, Lucania, and Apulia; III-Campania; IV-Abruzzi-Lazio; V-Umbria-Marche; VI-Sardinia; and VII-Rome (see maps 8 and 9). Later, regions were sometimes reidentified or consolidated as areas reverted to the Italian Government. Umbria was rejoined to Marche in Region V.2

The fall of Mussolini on 25 July 1943 immediately altered the relationship of the Allied Powers to the Italian Government and people, and this change was accentuated further by the opening of armistice negotiations a month later. This led to the concept of two instruments through which Allied direction of Italian civil affairs would be accomplished: one, limited largely to the combat zone, would be carried out through the existing AMGOT organization of the 15th Army Group; the other, to exercise jurisdiction over the rear areas, would be in the form of an ACC (Allied Control Commission).

Creation of what in effect were two control bodies led to jurisdictional disputes which, while perhaps not of transcending importance, were at times acrimonious and involved medical personnel as well as other officers. Although the limits of authority and responsibilities of these two civil affairs organizations were often not clearly defined, an idea of how each functioned will be gleaned from the following accounts.

PLANNING FOR THE OCCUPATION OF ITALY

Policy Questions

In planning the invasion of Sicily, two policy questions which had far-reaching effects on subsequent civil affairs operations were warmly debated. The first was whether civil affairs was to be a joint Anglo-American responsibility or if each country was to administer separate parts of Sicily; as is well known, the decision was to make this a joint undertaking.

The second major question was whether civil affairs should be or-

2(1) Munden, 1st Lt. Kenneth W., AGD, dated 26 Mar. 1948, subject: Analytical Guide to the Combined British-American Records of the Mediterranean Theater of Operations in World War II, p. 285. (2) Harris, C. R. S.: Allied Military Administration of Italy 1943-1945. History of the Second World War. United Kingdom Military Series. London: Her Majesty's Stationery Office, 1957, pp. 94, 124, 270 (map 12), and 456-457.


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MAP 8.-Original division of Italy into Allied Military Government of Occupied Territories Regions, 1943.

ganized primarily on a civilian basis as in North Africa or should be an integral part of military operations. The decision was to follow the latter pattern although satisfactory integration between civil affairs and more traditional military activities was achieved only after several major campaigns, and involved many months of trial and error.

Civil affairs planning for the invasion of Sicily began with the assignment of Lt. Col. (later Brig. Gen.) Charles M. Spofford, GSC, as the senior American officer to Force 141. He was joined later by his opposite number, Maj. Gen., The Lord Rennel of Rodd, who, because of his rank, became the senior civil affairs officer. By April 1943, preliminary plans had been formulated and approved in broad outline in both London and Washington. On 2 June, Brig. Gen. Frank J. McSherry succeeded Colonel Spofford.


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MAP 9.-Allied Control Commission regional organization, Italy, 1 April 1944.


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The plan as formulated called for a single combined military administration, the Allied Military Government of Occupied Territory. The method of administration envisioned was to use both direct and indirect controls over the civilian population. The commander of the occupying forces would also be the military governor of Sicily and would carry out his responsibilities through AMGOT. A Chief Civil Affairs Officer would be appointed to the commander's staff to serve as his principal civil affairs adviser as the administrative head of AMGOT. This officer would be assisted by a deputy chief and six specialist divisions-Legal, Finance and Accounting, Civilian Supply, Public Health, Enemy Property, and Public Safety.

Military government personnel in the field would be under two Senior Civil Affairs Officers on the staffs of the two task forces slated for invasion, the Seventh U.S. and the British Eighth Armies. Below them would be the actual operating units headed by Civil Affairs Officers. It was decided that civil affairs officers would not be provided for communities below 12,000-15,000 population except when special problems existed. The total personnel for Sicily was estimated to be 390 officers and 469 enlisted men; if the number available was much smaller, civil affairs officers were to serve as staff officers to tactical commanders who were to have final responsibility and authority for civil affairs during military occupation. As soon as possible, the tactical basis of civil affairs was to be changed to a provincial organization under a senior civil affairs officer in each province.

Planning for Public Health Operations

A small nucleus of British and American planning officers, including medical officers, was assembled at Chréa, Algeria, by the Military Government Section, AFHQ, in Algiers. The first officers arrived in early May 1943. Early in June, several hundred additional officers, including more medical officers, began to arrive. These men were placed in the training and holding center until they were used as military government officers in Sicilian and Italian mainland operations. The planning and training groups, known as Headquarters, AMGOT, were a part of the combined General Staff of Force 141. After the Italian surrender on 8 September, the words, "Occupied Territory," were omitted, and the organization became known as Headquarters, AMG (Allied Military Government), 15th Army Group.3

No medical personnel were on the Military Government Section's staff, AFHQ, and officers of Headquarters, AMGOT, dealt directly with the Director of Medical Services, AFHQ, Maj. Gen. Sir Ernest Cowell (British) during the planning period.

Medical and welfare functions were combined in HQ, AMGOT, and initially were under Col. D. Gordon Cheyne, RAMC, assisted by Col. (later

3This section is based in part on material submitted by Lt. Col. Leonard A. Scheele, U.S. Public Health Service, formerly assigned to HQ, AMGOT, 15th Army Group, and, later, to the Allied Control Commission, Italy. [On file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]


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Brig. Gen.) Edgar E. Hume, MC, Lt. Col. James A. Tobey, SnC, and Maj. Leonard A. Scheele, USPHS. Later, Lt. Col. Donald C. MacDonald, RAMC, Maj. Gordon M. Frizelle, RAMC, and Lt. (later Maj.) Manlio A. Manzelli, SnC, served on this staff. Lt. (later Capt.) Henry S. Price, MC, was responsible for medical care of officers and troops of HQ, AMG. Welfare personnel were under Maj. (later Lt. Col.) Ernest F. Witte, GSC. All were subsequently transferred to the Allied Control Commission except Colonels Cheyne and Tobey.

Sections were planned for public health administration, regional health services, medical education, maternity, infant and school hygiene, communicable disease control, sanitation, laboratory services, and control of biologicals, but this organization was not accomplished during the AMGOT or AMG phases because of the shortage of public health officers. The number of officers assigned to headquarters never exceeded eight, and was usually less than this; in fact, it later fell to two when the Allied Control Commission was activated and HQ, AMG, 15th Army Group, gave up responsibility for rear areas.

Planning was based on the policy that Italian public health laws and regulations in force at the time of the invasion would be continued and that existing Italian public health personnel and organization would be used to the maximum extent possible, except in those instances when officials were found to be objectionable Fascists. At first, the plan was to deploy Military Government public health personnel with tactical units, and then to deploy them along territorial lines at the earliest possible opportunity after fighting had ceased.

Planning at Chréa included the writing of an AMGOT handbook. Instructions were prepared on refugee camp health problems and their solution, the medical aspects of air raid precautions, surveys of housing, instructions for medical responsibilities and activities of regional, provincial, and local military government-civil affairs officers and public health officers.

American public health officers who came to Chréa had all been trained either at the Charlottesville School of Military Government or in one of the Civil Affairs Training Centers at Yale or elsewhere. Upon arrival at Chréa, they attended classes covering general military subjects and had a small amount of specialized [instruction in] malaria control, typhus control, water sanitation, and related subjects. Following lectures on these subjects, roundtable discussions were held.

Initial planning for medical supplies for civilian use was done in Chréa. Lists of essential drugs and dressings, prepared by the Technical Advisory Committee on Medical Supplies and Services of the ARB (Allied Postwar Requirements Bureau), were provided to HQ, AMGOT, by the Director of Medical Services, AFHQ. These were lists of minimum essential drugs required to sustain a population of 100,000 persons for 1 month. Based on an estimate that seven-eighteenths of the population would re-


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quire supplies, 21 drug units and 21 dressing units were requested for delivery in Sicily. These units were to be made up from U.S. Army medical supplies from the United States. In addition, quantities of typhoid and smallpox vaccine were to be shipped from the Pasteur Institute in Algiers.

In midsummer, so-called CAD (Civil Affairs Division) Unit Lists were received, which replaced the former ARB Unit Lists. Planning for later Sicilian and Italian mainland operations was made on the basis of the new CAD Unit Lists, 150 U.S. drug and dressing units and 750,000 cubic centimeters of antitetanus, antityphus, and smallpox vaccines being requested.

In late August 1943, a new group of officers, who were to become the nucleus of the Allied Control Commission, arrived at Tizi Ouzou. This group did independent planning and later followed AMG to operate in occupied areas behind the combat zone.

INVASION OF SICILY-REGION I

Personnel

Initially, two American medical officers (Maj. Edgar B. Johnwick, USPHS, and Capt. (later Maj.) Anthony Pino, MC), one British medical officer (Maj. Leslie G. Norman, RAMC), and one Canadian sanitary engineer (Capt. (later Maj.) Alexander S. O'Hara) accompanied the assault forces which landed on Sicily on D-day and on D+1. In addition, another American medical officer, Maj. (later Lt. Col.) Orpheus J. Bizzozero, MC, accompanied the Military Government team with Seventh U.S. Army Headquarters.

The officers with Seventh U.S. Army Headquarters stayed with that group until it established itself in Palermo; then, a Military Government team was formed for that city and province, and Major Bizzozero became the Public Health Officer of the team.

Major Johnwick was pressed into service in the very early days as the general administrative officer for three communes in Agrigento Province because of the small number of military government officers who landed on Sicily in the initial combat phase. His work was so "efficient" that it required several months to secure his return to public health work. Captain Pino accompanied the 45th Division as a member of its Military Government detachment. When this division entered Messina and the Military Government detachment began to operate territorially, he became the Military Government Public Health Officer for the City and Province of Messina.

Major Norman and Captain O'Hara, who accompanied the British Army, were responsible for Military Government Public Health in the areas occupied by British troops in the initial period; namely, Syracuse and Ragusa Provinces. Later, Captain O'Hara was moved to Caltanissetta to become Provincial Public Health Officer there.

Advance elements of HQ, AMGOT, 15th Army Group, including the Public Health Division, moved to Syracuse, Sicily, during the period 18-25


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July 1943. When Palermo fell, the Headquarters moved there and began functioning on 2 August.

Beginning in August, Military Government Public Health was operated on a territorial basis in Sicily. The province was selected as the best level at which to place officers; at first, one medical officer and, in most instances, one sanitary engineer officer were placed in each of the nine provinces in Sicily. Whenever a sanitary engineer was not on full-time duty in a province, one was always available part time from an adjoining province. No Military Government Public Health Officers were with armies or divisions in Sicily after mid-August 1943.

When the time arrived for the invasion of the mainland, it became necessary to consolidate provinces in Sicily and reduce public health personnel to obtain additional officers to send with the assault forces and to man the new areas to be occupied.

Problems Encountered in Sicily

For Military Government, the campaign in Sicily was a new venture; plans had been made but had never been tested. What happened to one civil affairs medical officer who landed with elements of the British Eighth Army in Sicily on D-day4 is described below:

Mission-The mission of this [Civil Affairs] team was to land with the reinforcements on D-Day, 10 July 1943, at Licata, Sicily, and establish military government there, extending the scope of its activities inland as the Division advanced.

Use of Intelligence-The team received instructions concerning its target from a collection of publications issued by the Office of Strategic Services and the Ministry of Economic Warfare [Br.]. G-2, Third Division, furnished recent air reconnaissance photos and tactical information concerning the target. The publications contained names and location of important medical installations and gave the names and titles of physicians and health authorities in Agrigento Province where Licata was located. A brief resume of the medical administration of Sicily and a short historical review of health conditions were also covered. This information was found to be out of date in many respects since changes had taken place by the time the landings had occurred. Medical officers had been discharged, or had fled from their posts, one hospital in Licata had been abandoned because of damage (which was not visible in air reconnaissance photos), and some civilian public health activities were being carried out by organizations not named in the intelligence surveys. However, the basic information obtained was very useful in the sense that it served as a starting point for interviews with civilian authorities. In some details, particularly knowledge of the higher administrative channels in Italian government, the AMGOT officers proved to be better informed than the Sicilian public servants who were questioned. This was a particularly useful and impressive administrative advantage.

Plan of Operation-The original plan was, briefly, to have each AMGOT officer seek out his civilian opposite number in Licata and establish the normal function of that particular public office for the benefit of the civilians in order to keep civilian demands on the resources and time of the task force to a minimum. In this plan, the public health officer had the following immediate tasks:

4Report, Maj. Edgar B. Johnwick, USPHS, subject: Notes on AMGOT Public Health Activities in Sicily (Period covered: 10 July to 3 September 1943). [On file at The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]


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1. Locate the city health officer, the head of each hospital, the head of the local Red Cross, the leading physicians and the head of the Air Raid Protective Organization for the purpose of giving these men authority to continue their work under the Military Government, and to issue such orders from time to time, as were required to accomplish the task of the occupation.

2. Visit and inspect all local hospitals and medical installations in the company of the Italian administrative head of the institution to ensure that staffs realized that they were to continue their duties and recognized that AMGOT has delegated responsibility to one specific individual.

3. Search for medical supplies and ensure that such supplies as were available were equally distributed.

4. Investigate the food situation and ensure that food supplies continued to be delivered to the people, particularly to hospitals.

5. Investigate the water supply to the city and ensure that this remained adequate. (Licata was furnished with an inadequate number of public fountains, supplemented by a small aqueduct ending in a storage tank from which distribution was effected by water carts.)

6. Insure that the mayor maintained in operation the city refuse disposal system (which was primitive and unsatisfactory even in peace), and that he supplemented this with clean-up details for removing rubble and debris from the streets.

During the three days that the writer remained in Licata (to 13 July 43), the above activities were undertaken and some progress was made toward accomplishment of the mission. Many difficulties were encountered and most of them were surmounted through the ingenuity of officers and enlisted men and the cooperative attitude of other members of the task force not attached to AMGOT. During the first three days following the invasion, frequent surprise raids by single German fighter planes careening over housetops kept the civilian population in a constant state of alarm and confusion.

Later, in a comprehensive report of Headquarters, 15th Army Group, on 11 October 1943, Colonel Cheyne summarized the experiences in Sicily up to that time.5 The following excerpts are taken from that report:

A considerable amount of detailed information has now been coordinated and the machinery of health administration is working more smoothly than could ever have been thought possible in the short time concerned.

The organisation of the Public Health Division has continued on the lines indicated in the planning programme an organisation which has now stood the test of actual working conditions for nearly three months. The various sections of the Division are now working much more as a team, and any tendency to a diversion into water-tight sub division has been rigorously discountenanced.

As regards the policy of the future, this is at present wrapt up in some degree of mystery especially with the advent of an Armistice Control Commission in which Public Health is strongly represented.

An effort has been made to reestablish reporting of communicable diseases as previously done under Italian health regulations. The disruption of communications between individual physicians and communal health officers * * * led to a complete breakdown of the reporting system. Communications are improving gradually, and weekly and monthly reports are beginning to flow to Provincial Health Officers and this Headquarters.

Reports from about one-third of the communes in Sicily for approximately a 3-week period listed 571 cases of typhoid fever, 404 cases of

5Report, Col. D. Gordon Cheyne, RAMC, to Chief Civil Affairs Officer, AMGOT HQ, Sicily, 11 Oct. 1943, subject: Report on Health Conditions Prevailing in the Territories Administered by AMGOT.


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pulmonary tuberculosis, and 535 cases of malaria. Even these fragmentary data served to focus attention on typhoid fever, tuberculosis, and malaria as the most important communicable diseases. The total population of Sicily at this time was roughly 3.5 million. Colonel Cheyne's report continues:

The structural condition of Sicilian hospitals is dependent upon their position as regards centres of most intense military operations. * * * It is the policy of AMGOT to provide the funds necessary for re-building. * * * In the days immediately after the occupation, lack of electricity hampered the work of many hospitals and laboratories, but as soon as electric power became available it was put at the disposal of the hospitals by the military authorities.

The health of the people has been good beyond expectation. * * * Typhoid fever alone has caused concern, * * * malaria is much more common than statistics indicate.

Medical stores are obtained from two sources-(1) Captured Italian material, (2) Drugs and dressings imported from the United States. Essential medical supplies are first distributed to hospitals and later to selected pharmacies. A central medical store has been set up at Caltanissetta * * * from which all the Provinces draw their requirements. * * * A system of accounting is being prepared, by which each province draws its medical stores upon repayment. Each province has received initially a 20 ton brick containing such essentials as wool, gauze, iodine, bandages, anaesthetics, suture material, sera and vaccines, sulphanilamides, denatured alcohol, insulin and antiseptics.

INVASION OF THE MAINLAND-REGION II

On 3 September 1943, the British Eighth Army crossed the Strait of Messina to Reggio and moved steadily eastward and northward, eventually joining the British X Corps, which had landed with the Fifth U.S. Army at Salerno. Following the Italian surrender on 8 September, a British airborne division landed unopposed at Brindisi, and within a short period, the whole of Region II, comprising the compartments of Calabria, Lucania, and most of Apulia, was firmly in Allied hands.

Major Johnwick and Capt. (later Maj.) William H. Ball, MC, accompanied the assault troops that captured Reggio di Calabria, and the former became the first Military Government Public Health Officer for Region II. These two medical officers subsequently were joined by four others. The headquarters of this region was moved later to Matera. In November 1943, most of Region II was transferred (along with Region I-Sicily) from the control of Military Government, 15th Army Group, to the Allied Control Commission, and Capt. (later Maj.) Everett E. Carrier, MC, became the Regional Director of Public Health.

With the exception of the initial attack on Reggio, there was very little heavy fighting in Region II, which embraced all the extreme southern portion of Italy. On the whole, the public health problems were essentially those likely to have been encountered in that portion of Italy during peacetime and consisted, for the most part, of endemic malaria, outbreaks of smallpox, and recurring small outbreaks of typhoid fever and other intestinal diseases. Some shortages of medical supplies and soap occurred,


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but, again, this situation was scarcely more than an aggravation of previously existing conditions.

NAPLES AND REGION III

An epidemic of typhus fever served to focus attention on civil public health in Naples and Region III and emphasized the developing administrative confusion. As so often happens, from this near-crisis came a new understanding of the potential and the importance of an adequate public health program in civil affairs.

Troops of the Fifth U.S. Army stormed ashore at Salerno on 9 September 1943. The situation was critical for a fortnight, but eventually the U.S. VI Corps and British X Corps broke out of the beachhead and captured Naples on 1 October. Operating under Military Government, 15th Army Group, Colonel Hume, a medical officer then serving as Senior Civil Affairs Officer for Region III, took over the direction of civil affairs in Naples City and Naples Province with Col. Emeric I. Dobos, USPHS, as chief of Public Health and Welfare. Colonel Dobos was replaced in December 1943 by a British officer, Col. Walter H. Crichton, formerly with the Indian Medical Service.

The early health problems encountered in Naples are described by Colonel Dobos:6

With the Headquarters Staff of AMG Region III, we arrived in Naples on October first and established headquarters at the Municipio. The capital city of Southern Italy, with a population of over 1 million, was found in a state of utter confusion. All public services were out of commission. The Sereno Aqueduct, which provided the water supply of Naples, was blown up in several places, and the source in the hills of Benevento was still in the hands of the enemy. Potable water was obtainable only from the sixty shallow and deep wells scattered near the port area of the city. None of the wells were provided with pumps; the water had to be dipped by buckets. Thousands of people crowded the streets, congregating around the water points, carrying home water in bottles, jugs, crocks and small barrels. The inhabitants of the most populous residential district, the Vomero, situated up on the hill, had to walk several miles to fetch water from the wells which were located near the water front. Water for drinking purposes was obtainable in sufficient quantities to satisfy minimum needs, but the most serious trouble was the lack of water for flushing toilets. * * * The water supply of Naples was reestablished on 22 October, three weeks after our occupation of the city. The Corps of Engineers [did] an outstanding job in the quick and efficient repair of the 55 mile long aqueduct.

* * * The lack of electricity created a number of inconveniences, but from the public health standpoint the chief danger was in its effect on the sewer system [which required electrically operated pumps to maintain the flow]. * * * The hospitals suffered much inconvenience as the result of lack of electric power particularly since all the sterilizing units were operated by electric current, but that was only one of the many important factors that well-nigh paralyzed these institutions.

The food situation during the first weeks of our occupation was critical, * * * The hardest hit were the inmates of institutions who didn't have funds, nor access to

6Report, Lt. Col. Emeric I. Dobos, USPHS, undated, subject: Allied Military Government. Italy, Region III; Allied Control Commission, Sardinia, Region VI. [On file at The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]


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the surreptitious means of transport, of which the individual citizen could take advantage when it came to securing foodstuffs for himself and his family. Claims of death from starvation were frequently exaggerated by the hospital authorities * * * As the supply organization improved we were able to establish priorities for inmates of institutions, which led to considerable amelioration of the situation. * * *

One of the many urgent problems was the disposal of the dead. Upon our arrival there was a back-log of 500 cadavers decomposing in the homes, hospital morgues, and air raid shelters. For that the lack of transportation facilities was one of the main reasons. * * * The population revolted against the idea of burying the dead without caskets, but neither wood, nor manufacturing facilities were available to provide them. * * *

On our arrival we were confronted with a two weeks' accumulation of garbage * * * with the heaps getting bigger and more numerous daily. * * * Hundreds of pushcarts were also mobilized in an endeavor to improve conditions.

Excerpts from the monthly report for December 1943, prepared by Colonel Crichton, summarize the situation in Naples and Region III toward the end of its second month of military government.7

The weather in the Region had been exceptionally severe, with low temperatures and unusually heavy rains. Lack of transport and communication facilities made it extremely difficult to obtain reliable data on vital statistics. The outbreak of typhus had been the main preoccupation of the civil public health staff. (This will be described in more detail later.) Other important diseases affecting the Region were typhoid, venereal disease, and malnutrition.

Typhoid fever was known to have been endemic and, because of the similarity of names, was probably responsible for the initial delay in recognizing the presence of an incipient epidemic of typhus. A severe epidemic of typhoid occurred in Montesarchio, a suburb of Naples.

The food situation throughout December was grave. While no cases of avitaminosis had been recognized, undernutrition was rife, particularly among inmates of civil hospitals, where the lack of transport had severely curtailed food supplies. The shortage of food was believed to be a contributing factor in the high incidence of both typhus and the venereal diseases, presumably through the attendant social disruption. Olive oil, an important item of the Italian dietary, was not available through food control sources and was available in the black market at the exorbitant price of 200 lire per liter; yet it was reliably reported that oil was abundant in all of southern Italy. The humble bean, which for generations had been scorned by all but the lowest classes, became a delicacy which could be afforded only by the rich. The milk collecting and distributing system had collapsed. In brief, the food situation was serious largely because of transportation problems.

Hospital facilities had been greatly reduced by destruction from air attacks, looting, and, finally, requisitioning for military use. Glass for

7Monthly report, Col. W. H. Crichton, Director of Public Health and Welfare Department, AMG Region III, 30 Jan. 1944.


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rehabilitation of damaged structures was virtually unobtainable and beds, bed linen, and certain essential equipment were exceedingly scarce.

Transport-In a city in which every means of public conveyance, except a few decrepit taxis and some flea infested horse drawn vehicles, is out of action, it is literally impossible for any efficient work to be done by this staff * * * unless adequate transport is made available. * * * Trucks for the haulage of important A.M.G. like medical stores and clothing are also extremely difficult to get. * * * The need for transport however should not extend to the private cars of civilians who are fulfilling a useful function-to requisition doctor's cars for instance is merely a case of robbing Peter to pay Paul. Doctors should be specially privileged in this respect and should be furnished with markings which will protect them from depredations carried out by officers from the many formations established in this city.

Medical Stores-Naples has been made the receiving and distributing center for all A.M.G. medical stores. Lt. Light, R.A.M.C., has been appointed in charge of the stores. Here again the greatest difficulty was experienced in providing Lt. Light with a means of conveyance to enable him to carry out his duties.

Venereal Disease-Next to typhus this disease provides the most serious problem affecting the health of the troops in this Region. Major Lewis [Maj. John A. Lewis, USPHS] has been appointed as Adviser on Venereal Diseases and several important steps have been taken to combat the disease.

Among these steps to combat venereal diseases were the following:

1. All houses of prostitution were placed out of bounds (31 December).

2. The bed capacity of Pace Hospital (venereal disease, for women) was increased by 139 beds to 268.

3. The standard of inspection of prostitutes arrested by the police was improved.

4. Civilian venereal disease clinics were advertised in the press and by posters in lavatories.

5. Steps were taken to provide the venereal disease hospitals with more effective drugs than they had had in stock.

6. Italian standards of treatment and cure were reviewed and suggestions for improvement made.

7. It was recommended that an edict be published prohibiting civilian doctors from treating infected soldiers.

8. An effort was made to increase the stock of antivenereal drugs in pharmacies in the hope of effecting a reduction in the exorbitant price then being charged for these drugs.

9. The campaign against pimps was intensified by the police.

Early in 1944, cases of smallpox began to occur in excessive numbers in both the City and Province of Naples; the incidence continued high throughout the year despite an active vaccination program in which more than 300,000 persons, mostly children, in Naples City alone, were vaccinated by the end of June. The disease was mild in character and did not serve as a serious threat to the military forces in and around Naples.


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Typhus Fever

The outbreak of typhus fever in Naples was the most dramatic and the most widely publicized one of the war. Detailed accounts will be found in another volume in this Preventive Medicine series8 and in a monograph by Soper, Davis, Markham, and Riehl.9

Two facts, one administrative, the other scientific, must be noted as background material for the events to be described. The essential administrative fact was that responsibility for military government operations in Naples was shared in some undefined way by the AMG 15th Army Group and the Senior Civil Affairs Officer and his deputies in Naples. While a number of medical officers of the military forces stationed in Naples were aware generally of the situation in the civilian population, they had no direct responsibility for civil affairs activities in this area. Likewise, a number of medical officers attached to the forward headquarters of ACC in Naples could only advise and exhort for they had, at that time, no direct operational responsibility in the Naples area.

The scientific fact to be noted is that MYL powder, which was then a standard delousing agent for the Armed Forces, was in abundant supply in Naples. This agent differed from DDT in that the latter had residual killing potential for lice while MYL did not. In any event, it was the use of MYL, not DDT, initially in the dusting program which effectively brought the typhus epidemic under control.

A seeding of typhus cases was known to have occurred during the German occupation. Frequent air raids before and after the liberation of Naples by the Allied Armies on 1 October 1943 had led to great overcrowding in the deep tunnels and cellars under the city, the ricoveros which served as makeshift air raid shelters. Naples had a semipermanent air raid shelter population estimated at 12,000, caused in part by fear of air raids and in part by destruction of housing. This situation was aggravated by the influx of large numbers of refugees from the north. Prisoners released when the Germans evacuated Naples were known to have been exposed to typhus while in prison and, most likely, were the major source of spreading and seeding the disease throughout Naples.

In October, 25 typhus cases among civilians were reported; in November, 46 cases. Col. William S. Stone, MC, Chief of Preventive Medicine of the North African theater, called attention to this situation on 18 October, 9 November, and 3 December 1943. By the first week of December, the incidence of typhus cases had increased sharply.

The chief of the Public Health and Welfare Section of the civil affairs group in Naples, Lt. Col. (later Col.) W. Carter Williams, MC, submitted

8Medical 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, ch. X.
9Soper, F. L., Davis, W. A., Markham, F. S., and Riehl, L. A.: Typhus Fever in Italy, 1943-45, and Its Control With Louse Powder. Am. J. Hyg. 45: 305-334, May 1947.


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recommendations for a program to meet the threat imposed by the rising attack rate. However, definitive steps were not taken, either through lack of appreciation of its potential seriousness or through delay in implementing control measures. An interesting commentary on military security is that, at this time, civil affairs medical officers and, indeed, most of the U.S. and British medical officers in Naples were not aware of the existence of DDT, probably because of the classified nature of the information. Military government officers had been briefed on the use of MYL and DDT powders during their training period at Tizi Ouzou. In retrospect, probably the early use of DDT in the ricoveros would have cut short this epidemic before it was well under way. There was also initially too little appreciation of the effectiveness of the standard delousing powder (army MYL).

A cable request for diagnostic antigens on 3 December 1943 from Colonel Hume to the Cairo office of the United States of America Typhus Commission alerted that organization to the occurrence of typhus in Naples; but when the services of the Commission were offered, they were declined by both the 15th Army Group and the Senior Civil Affairs officer for the Naples area. Large quantities of DDT, nevertheless, were shipped by air to Naples, where the civil public health group assisted by Dr. Fred L. Soper and other civilian staff members of the International Health Division of the Rockefeller Foundation initiated a control program. This program was carried out under great handicaps, particularly the almost total lack of transportation facilities, and a shortage of personnel.

Adequate transport and other facilities were made available toward the end of December as a result of the forceful representation of Brig. Gen. Leon A. Fox, Field Director of the Typhus Commission (fig. 39), to Brig. Gen. Arthur W. Pence, CE, Commanding Officer of the Peninsular Base Section, and to Gen. Everett S. Hughes, Deputy Theater Commander of the North African theater. Without these facilities, the control program could not have been implemented. This was done in accordance with the authorizations embodied in Executive Order No. 9285, which established the Typhus Commission. On 1 January 1944, responsibility for the control program was formally transferred from the civil affairs group to the Typhus Commission.

In January 1944, the peak month, more than 1,000 new typhus cases were reported. The epidemic was quickly brought under control, however, and only 39 new cases were reported during the last week of February. Few cases occurred among U.S. military personnel operating in this area while a somewhat larger number occurred among British troops; the difference was attributed primarily to the fact that all U.S. military personnel had received typhus vaccine while the British troops had not.

The actual organization and supervision of Italian civilian teams of doctors, nurses, and various technicians by Dr. Soper and the Rockefeller Foundation staff formed the backbone of this epoch-the first time in con-


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FIGURE 39.-Brig. Gen. Leon A. Fox, MC.

temporary history that a full-blown typhus epidemic was brought promptly and completely under control.

The principal features of the typhus control program as carried out in Naples were as follows:

1. Protection of key personnel by immunization and frequent DDT dusting of all medical personnel engaged in the program, including civilian personnel in hospitals likely to receive typhus cases.

2. Establishment of DDT dusting stations at strategic points in the city, with particular coverage of the main air raid shelters and refugee camps. More than 1.5 million civilians were dusted with hand dusters using 5-percent DDT in talcum powder during a 6-week period in December and January. Since the objective was to dust each person once weekly, undoubtedly this figure includes many repeat dustings; nevertheless, it is evident that a substantial proportion of the population of Naples had the benefit of this important control measure.

3. Large scale immunization of civilian population. Immunization teams likewise were established at strategic points throughout the city, and thousands of injections of typhus vaccine were given. Opinion differs concerning the effectiveness of this control measure, but it probably did not play a major role. The effort involved in securing even limited coverage of


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the general population was probably out of proportion to the beneficial results.

4. "Flying sparks" control. Since the normal movements of populations may carry infected persons to outlying districts, all physicians and health authorities in adjacent communities were alerted for the occurrence of typhus cases, and highly mobile teams ("Flying Squadrons") were organized to carry DDT dusting powder and vaccine to the vicinity of any such reported cases. Not only the patient but also his family and immediate neighbors were dusted, and the members of his family were given typhus vaccine. This was the so-called block-dusting program, first used in Naples.

Administrative Perplexities

By mid-December 1943, Military Government personnel had been through the fire of three major military operations. Individually, the work of the civil public health officers had been of a high order and these men were accepted as important components of Military Government operations. Administratively, however, the situation was becoming complex and, to put it mildly, somewhat confused, especially in the realm of public health activities. This became apparent when serious trouble threatened in Naples.

In mid-November 1943, the HQ, AMG, 15th Army Group moved to Bari and relinquished control of Sicily and most of Region II to the Allied Control Commission, which began operating officially on 10 November. This commission was directly responsible to AFHQ, as was HQ, AMG (through the Commanding General, 15th Army Group). As a result of this separation, there was relatively little official public health liaison between HQ, AMG, and ACC during the period November-December 1943. There was no medical officer on the Military Government Section staff of AFHQ to provide the coordination required between the two major headquarters described. The situation was complicated further by the fact that the AFHQ staff was at Algiers although, by mid-December, one nonmedical officer was present in Naples representing the Military Government Section of AFHQ at advanced HQ, AFHQ.

At the time of activation of the ACC, its headquarters was in Palermo, Sicily. Its public health functions were moved to Naples between 15 and 25 December 1943. At that time, Naples was part of Region III, which was under the direction of HQ, AMG, 15th Army Group. The situation with respect to military echelons present and having responsibility in and about Naples was extremely complicated in December 1943 and early January 1944. HQ, AMG, 15th Army Group, and HQ, AMG, Fifth U.S. Army, controlled the area with respect to Military Government; yet ACC had its Forward HQ there. The main Headquarters of ACC operated from Salerno. An American base section (Peninsular Base Section) and a Metropolitan District both had Headquarters in Naples at this time. A British Line of


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Communications (equivalent of an American base section) had its Headquarters in Naples. In addition, AFHQ had an advanced Headquarters there with the Director, Medical Services, and Surgeon's representatives, and both the British and American Navies had District Headquarters in Naples. The reasons for this vast array of headquarters were logical since the Fifth U.S. Army front was stalled north of Caserta at the time, which gave that Army a real interest in maintaining security in its immediate rear area, including Naples. It became imperative for the Base Section organizations to move in early to land and store the supplies needed for the late winter drive because Naples was the first sizable port on the west coast of the Italian mainland.

This multiplicity of commands in Naples is mentioned because undoubtedly it was one of the causes of the initial confusion in dealing with the Naples typhus epidemic. The confusion was complicated further by the lack of specific directives as to areas of administrative and geographic responsibilities. Appropriate liaison between officers at AFHQ, Army Group, and Army levels, combined with the issuance of simple directives delineating administrative and functional responsibilities, would have reduced confusion considerably. Lack of specialist liaison personnel at all these levels posed more problems. That the United States and the United Kingdom were engaged in a joint operation, each with its own and often different conception of what controls should be used, further aggravated the situation.

When, therefore, the growing typhus epidemic posed a serious threat to military operations through the Port of Naples, it was virtually impossible to determine what military organization, and therefore what medical officer, had primary responsibility for control measures among civilians. Fortunately, General Fox assumed the initiative and took responsibility for preventive measures after Dr. Soper's team had done some extremely effective block dusting.

Toward the end of January 1944, when the epidemic was clearly subsiding, there began the acrimonious but largely off-the-record debate as to which group really had controlled typhus in Naples. The writer, who was in Naples at the time as a representative of the Surgeon General's Office, was appointed a year and a half later to a high level joint British-American Commission to adjudicate the issue, but fortunately, the war's end brought the realization that all concerned could properly share the credit for a job well done. Special note should be made of the exemplary action of the American Navy medical components in Naples at the time of the epidemic, who, staying above the tempest, took the opportunity to make a documentary film of the typhus epidemic and the control measures initiated. The work of Dr. Soper and his staff was of inestimable value. Considerable credit must also be given to Colonel Stone, MC, the Preventive Medicine Officer of AFHQ, who anticipated many of the problems and made excellent recommendations to superior officers on ways to handle them.


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Also, in his capacity as Medical Supply Officer, AFHQ, he prepared and submitted requisitions for the vitally needed supplies and equipment.

The dissimilarity between U.S. and British policies on staff assignments in the Allied Control Commission created unusual and difficult situations; for example, if a British lieutenant were assigned to a position calling for a lieutenant colonel, he immediately would be promoted to, and receive the pay and allowances of, that grade. Of course, the reverse was also true. Most U.S. officers, including qualified Public Health specialists, were assigned to, and retained indefinitely in, positions calling for grades higher than the ones they actually held, but, because of the U.S. promotion policy, they could not be promoted. Obviously, considerable maneuvering occurred as British officers sought to fill higher grade positions which actually called for a U.S. officer. That these situations did not become overwhelming is a tribute to Brigadier George S. Parkinson, RAMC, Director of the Public Health Subcommission of ACC and former Dean of the London School of Tropical Medicine, whose sincerity and understanding inspired both the United States and British components. He took a positive stand against favoritism which was most commendable.

These difficulties, magnified unduly at the time, reflect in part the growing pains of a new venture, civil public health, as an integral part of military operations. But it was clear then, as it is now, that the primary difficulty arose from a failure at theater level to provide for centralized technical responsibility for civil public health affairs. A contemporary report made by a representative of the Surgeon General's Office pointed out some of the difficulties, and recommended corrective measures in part as follows:10

While theoretically the responsibility of each organization may have been clearly defined, in actual operation confusion resulted. * * * Policies regarding technical matters and the utilization of medical personnel were being determined by two individuals instead of one, with no unifying influence at the top.

An attempt has been made to correct this situation by the centralization of authority for both AMG and ACC in one individual, Lt. Gen. Mason MacFarlane, who is directly responsible to Gen. Alexander [Commanding General, 15th Army Group]. At the present writing responsibility for the technical aspects of civil public health as administered by both AMG and ACC seems to have been placed on the Director of the Public Health and Welfare Subcommission of ACC, Brigadier Parkinson, who is very well qualified to assume that responsibility. Because of diverging chains of command, however, this too may fail to resolve certain civil public health difficulties unless the technical leadership of Brig. Parkinson is recognized by all concerned.

* * * Too little attention has been paid throughout to the relative importance of a civil public health program in the whole picture of military government. The most obvious defect in this respect is the lack of any one medical officer at Allied Force Headquarters whose primary concern is with civil public health problems. An effort has been made to utilize the resources available in the Medical Section of British headquarters

10Letter, 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. [On file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]


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and in the office of the Surgeon, NATOUSA, but this can be only a hit or miss proposition unless there is at least one qualified medical officer thoroughly familiar with AMG problems and projected operations who can maintain close liaison with the British and American medical sections. This individual should be responsible for obtaining the best available advice on matters pertaining to public health objectives, medical supplies and personnel.

Although this and other recommendations were concurred in and some were implemented by AFHQ, this one was not, possibly because the beginning of the end of the Italian campaign was at hand.

THE ANZIO BEACHHEAD

The landings at Anzio just south of Rome took place on 22 January 1944, and for several weeks, elements of the U.S. VI Corps were engaged in one of the bitterest actions of the Italian campaign in an area that stretched for approximately 18 miles along the coast and 7 miles inland.11 Military Government personnel accompanied the landing forces, but no medical officer was among them.

Even in the severest engagements, however, civil health problems arise and must be handled by someone, which, in this instance, was the medical service of the combat forces. The following account is quoted from the annual report of the Fifth Army Medical Service for 1944:12

Though the medical care of civilians on the beachhead was the responsibility of the Allied Military Government, representatives of the Fifth Army Surgeon were obliged through force of circumstances to take a hand in this matter. [It should be noted that the Chief, 15th Army Group, AMGOT, had issued orders forbidding ACC medical personnel from going into the beachhead.] The existing civilian hospital was a misnomer. It was inadequately staffed and miserably equipped. Supplies were at once made available to this hospital from Fifth Army medical depots on the beachhead. But supplies alone would not eliminate the handicap under which the civilian hospital operated. Many of its patients had sustained wounds which required extensive treatment and long periods of convalescence.

Beginning with the early days of the beachhead, these cases were evacuated along with combat troops to base installations. In the case of the civilian hospital humanitarian reasons alone dictated this action. The same action was taken in the case of civilians who were brought direct to the evacuation hospitals operated by the Fifth Army for its troops. Bed space urgently needed for combat troops was being utilized for civilian wounded. To free this space, the principle governing the evacuation of combat troops was extended to cover civilians as well.

In both instances, if the course of recovery required fourteen days or less, the casualty remained in the evacuation hospital and would not be removed from the beachhead. If the course of recovery required more than fourteen days, the casualties-soldier and civilian alike-were evacuated to base installations the moment they were strong enough for the movement. When the greater number of civilians living in the Anzio area were evacuated from the beachhead to protect them against German artillery fire and bombing attacks, the medical care of civilians ceased to constitute a major concern of the medical department. There were a number of casualties which occurred

11United States Army in World War II. Special Studies. Chronology, 1941-1945. Washington: U.S. Government Printing Office, 1960, pp. 164-174.
12Annual Report, Surgeon, Fifth Army Medical Service, 1944, ch. III, p. 30.


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from day to day among civilians left behind on the beachhead to guard property, but these were accommodated without strain on the medical resources assigned specifically for troops.

From 6 to 10 February, the beachhead was visited by Mr. Donald E. Hagaman, Field Supervisor of War Relief for the American National Red Cross, from whose report the following is extracted:13

Health conditions in the Campana region are reported to be good, and there are no appearances of epidemics or serious concentrations of illness. However, since the region is so close to the military operations-it does seem logical to believe that more and more wounded will appear unless the military operations move forward.

At the present time there is one civilian hospital, of 35 beds, in Nettuno which is handled by a Dr. Donati and his brother. * * * The hospital is presently established in the home of Dr. Donati, and supplies have been given him by the Army Medical Corps and AMG. All beds are filled and there are many walking wounded who are kept at this hospital.

Shortly thereafter, Major Norman, RAMC, was assigned as the medical officer with AMG and, on 28 February, reported that about 7 tons of AMG supplies had been sent to the bridgehead 3 weeks previously.14 These supplies were adequate for about another month.

The beachhead reached a degree of stability until the breakout in the May offensive. In April, it was decided to evacuate compulsorily most of the civilians in the area (fig. 40), with the exception of essential farmers and their families. This decision was made partly to reduce the incidence of malaria and other infectious diseases among troops. By 15 April, 733 civilians had been evacuated by sea to Naples, with approximately 1,000 persons remaining as permanent residents of the beachhead. All refugees were dusted with DDT and given medical attention, if needed, before embarkation.

FOGGIA AND REGION IV

Situation Under British Eighth Army Control

Region IV, which originally comprised the Compartments of Abruzzi and Lazio, excluding Rome, when first activated was limited to the Foggia area in the northern part of Apulia. Foggia was captured by the British Eighth Army in October 1943 and served also as a base for the Twelfth Air Force.

A report from the AMG medical officer assigned to the British Eighth Army, Lt. Col. (later Col.) Charles J. Farinacci, MC, on 19 October 1943 indicated that considerable damage had been done in the city.15 Housing was a serious problem since most of the few remaining habitable houses

13Report, Field Supervisor, American Red Cross War Relief, 9 Feb. 1944, subject: Visit to Beachhead Sector, Anzio, Nettuno and Campana Region, App. B.
14See footnote 13.
15Telegraphic report, Lt. Col. Charles J. Farinacci, MC, to Captain Benson, AMGOT, Eighth Army, Italy, 19 Oct. 1943, subject: Report of the Health and Sanitation of City of Foggia.


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FIGURE 40.-A civilian girl, shot by Germans while trying to warn Americans of German positions, is taken from an aid station and carried to an ambulance for further evacuation to the rear.

had been requisitioned by the military. Probably 30,000 people were homeless. The main sewer was broken in 15 or 20 places. There was no civilian hospital in the city, and no one knew what diseases were occurring. Essential drugs, such as alcohol, iodine, sulfonamides, and insulin, were almost unobtainable. Soap was badly needed to contend with outbreaks of scabies and impetigo.

Colonel Farinacci recommended the following program:

a. Anti-louse campaign by use of posters, public baths, routine examination by the panel doctors.16

16One may observe here that DDT, a month before its use in Naples, was not generally known, or available, to medical officers. The first DDT arrived in the Mediterranean theater in December 1943.


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b. Immediate supply of drugs and sera to the province for issue to the various hospitals and public health institutions.

c. Immediate establishment of both a surgical and medical hospital for civilians of Foggia.

d. Return of all antimalarial clinics to the provincial authorities * * *

e. Establishment of a refugee camp or camps in the vicinity of Foggia to care for the homeless.

Display of the public health posters that Colonel Farinacci mentioned began in 1944. Written in Italian, the posters were designed to encourage civilians to help the military combat disease vectors. Many of the posters were seasonal in character; for example, in the spring of 1944, posters warned the populace about the fly and mosquito dangers, and in the fall, posters depicted the dangers of typhus and warned the people to stamp out the body louse. Huge posters called attention to the three common enemies: the mosquito, the fly, and the Nazi soldier. Bold black letters spelled out "Unite in a common cause-Destroy your enemies." These posters awakened in the people a consciousness for disease preventive measures and supplemented the disease control program effectively.

By 26 October, Colonel Cheyne noted in a visit to Foggia17 that "* * * general sanitation of town improving. Medical supplies discussed. I consider strong representations should be made to Army to liberate some of the hospital buildings taken over. Called on A.D.M..S. 86 Sub Area who promised active cooperation."

On 8 November 1943, Colonel Cheyne notes, "Large numbers of refugees are returning to Foggia, a much bombed and damaged town. In addition large numbers of persons are coming through the lines. The responsibility of redistribution is a joint Military and Civil one, the collection in the forward area is clearly a military one, the redistribution in back areas is clearly an Italian responsibility. This is accepted by all concerned."

Colonel Farinacci writes further on 19 Nov. 1943:18

Medical supplies for the Forward Areas are rapidly being furnished as quickly as transportation becomes available. Up to this date, both the Provinces of Foggia and Campobasso have each been given approximately 10 tons of Emergency Medical Supplies. The C.A.O.S. in the Forward Areas have been cooperating by taking back with them in their vehicles the Medical supplies needed for the communes they serve. * * * The supplies received thus far are adequate in quantity for the next several months but unfortunately, the variety is too limited; for example there is great need for Sulphur Ointment for the Scabies which is very prevalent in both Campobasso and Foggia; Insulin is non-existent in either of the two provinces and none has been received. The same deficiency exists with regards to Smallpox Vaccine and Diphtheria Antitoxin. Can there be a special request made of the 15th Army Group, AMGOT for the above items, as well as for a supply of X-ray Films and Sodium Hyposulphite for the X-ray Laboratory of the Campobasso Civilian Hospital? * * * The greatest obstacle to im-

17Tour notes, Col. D. Gordon Cheyne, MC, Director of Public Health, AMGOT, 15th Army Group, 26 Oct. 1943.
18Report, Lt. Col. Charles J. Farinacci, MC, Division of Public Health, AMGOT, to Group Capt. Benson, Commanding AMGOT, Eighth Army, Italy, 19 Nov. 1943, subject: Public Health.


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provement in Medical Care of the civilian population has been the lack of communication and transportation. * * *

In connection with the distribution of Medical Supplies I have given the Medico Provinciali permission to sell the medical supplies wholesale to Drug-houses and Pharmacies at the wholesale price established by the Italian Minister of Interior and also have given permission to allow the same Drug-houses and Pharmacies to sell retail at the same price standards. * * * These established prices are contained in [a Bulletin published in 1935] with its amendments latest of which is dated 1939.

Reversion to Allied Control Commission

Foggia passed from AMG to ACC control in November 1943. Lt. Col. (later Col.) Thomas N. Page, MC, became the director of the Public Health and Welfare Division of the newly created Region IV. While the situation in Foggia City was improving, difficulties were still being encountered in sewage disposal, civilian hospitalization, and the handling of refugees.

Refugees from the North were averaging about 800 a day. These were collected at railheads and transported to the south of Italy. No medical screening was possible because of a lack of trained personnel.

By February 1944, the major breaks in the sewage system had been repaired, garbage and trash collection services had been reestablished, and one of the two medical laboratories in the city had been rehabilitated. Medical supplies were arriving in satisfactory quantities from Naples. DDT dusting of refugees had begun, the AMG, British Eighth Army, being responsible for those coming through the lines; the health authorities of Foggia City, then under the direction of Lt. Col. Ewen G. Dalziel, RAMC, were responsible for other refugees including those landing from Yugoslavia. One free soup kitchen feeding about 1,160 persons per day was operating in Foggia, but hunger was not an acute problem. Infectious diseases did not seem to be unusually prevalent although reports were inadequate.

On 15 June 1944, the City of Rome passed from the control of the Fifth U.S. Army Allied Military Government and became a separate Allied Military Government Region under ACC. A month later, Rome and the Provinces of Littoria and Frosinone were added to the expanding Italian Government territory.19 These provinces, particularly Littoria, had borne the brunt of the stalemate between the two opposing forces during the winter months up to and following the offensive of 11 May 1944. Considerable destruction to building and water and sewage facilities had occurred, but some balance had been reestablished. There had been widespread disruption of civilian activities. The ditch system of the Pontine marshes had been completely disrupted by the Germans. Weed cutting barges had been sunk, motors of water pumps destroyed, and false connections between ditches made.

Nevertheless, the general health of the population seemed to be good.

19See page 171 of footnote 2 (2), p. 295.


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Malaria was on the increase, but supplies of Atabrine were adequate and an active malaria control program was in progress.20 Hospitalization for civilians was, in general, adequate, but much equipment had been looted or destroyed. Most of the medical practitioners were at their posts, but a shortage of gasoline restricted their activities. Medical supplies were short but not dangerously so, and civilian supplies had been supplemented by captured German military stocks as well as by CAD units from Naples.

Mine fields proved to be a serious handicap to the inauguration of malaria control programs as well as to ordinary agricultural pursuits. The shortage of transportation influenced every phase of health activities.

On 1 August 1944, Rome Region combined with Region IV. This region, which originally included Abruzzi and Lazio, was reconstituted as the Lazio-Umbria Region, comprising the Provinces of Rome, Frosinone, Littoria, Viterbo, and Rieti in Lazio and the two Umbrian Provinces of Terni and Perugia. "Region IV thus became a 'mixed' region, since in three of its provinces, Rome, Frosinone and Littoria, Military Government no longer prevailed, as they had been transferred to Italian Government territory, whereas the four provinces to the north of Rome were still subject to Allied Military Government."21 The staff of the Rome Region, whom General Hume had brought to Rome, took over administration of the combined region. The former Commissioner for Region IV and his chiefs of sections were detached to organize Region XII which was eventually to encompass the northern Provinces of Venezia, Tridentina, and Veneto.

SARDINIA-REGION VI

The Germans spontaneously evacuated Sardinia and shortly afterwards, on 4 November 1943, Company F of the 2675th Regiment arrived on the island and established military government.22 No military engagements took place on the island preceding our occupation, with the exception of a few heavy bombing raids on the important seaports during May 1943, in which the City of Cagliari was severely damaged.

The AMG unit was under the command of Brigadier M. Carr (British), who served first as Senior Civil Affairs Officer and, later, as Regional Commissioner. Because of the housing shortage in Cagliari, the unit headquarters was originally established in Sassari, an inland town of 60,000 population. Besides the AMG unit, approximately 15,000 U.S. troops, consisting principally of the 42d Wing, Twelfth Air Force, operated bomber bases and other airfields throughout the island.

In addition to the normal population of about 1 million, approximately 300,000 Italian troops were interned in Sardinia, thus adding greatly to the

20Medical Department, United States Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government Printing Office, 1963.
21See page 172 of footnote 2 (2), p. 295.
22This section is taken mainly from an account prepared by Col. Emeric I. Dobos, USPHS; see footnote 6, p. 304.


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problem of supplying food, which had to come mostly from the mainland. No medical officer was assigned to the staff of Region VI until 1 April 1944.

The most important public health problem was malaria, which had been made more acute by the suspension of virtually all preventive measures during the war and by the depletion of medical personnel by calls to duty with the Italian Army. The chief medical officer of Region VI, Colonel Dobos, with the advice of Col. Paul F. Russell, MC, Consultant in Malariology for ACC, instituted a malaria control program in the areas adjacent to Army bases.

NORTHERN ITALY

After the offensive in May 1944 and the occupation of Rome on 4 June, the German forces retreated rapidly through central Italy, and fought only delaying actions for time to prepare a new stand on the Pisa-Rimini line.

The City of Rome was governed by AMG, Fifth U. S. Army, from 4 to 15 June when it came under the jurisdiction of ACC as Rome Region. On 1 August, it, together with the provinces of Frosinone and Littoria, was added to Italian Government territory. During this brief period, signs of jurisdictional conflict developed between General Hume, the director of AMG, Fifth U.S. Army, and Brigadier Parkinson, the chief medical officer of the ACC. The swift advance of Allied troops to the Arno brought province after province under AMG. The liberated areas were damaged only slightly, and no serious civil health problems were encountered.

Portions of Region V (Umbria and Marches) were taken over by ACC from the British Eighth Army, and portions of Region VIII (Tuscany) from the Fifth U.S. Army.

After the establishment of the Bonomi Government on 6 July 1944 in Rome, progressively fewer supervisory functions were performed by the ACC, and sharp reductions were made in personnel. A new policy was then adopted to return to Italian control territory no longer in the operational area. Indeed, by the fall of 1944, a major reorientation of policy toward the Italians had evolved, bringing with it an acceptance of the idea of long term objectives including reconstruction and rehabilitation.

On 20 October 1944, the Italian Government assumed responsibility for distribution of all civilian medical supplies in all of liberated Italy through an organization named ENDIMEA (Ente Nazionale Distribuzione Medicinali degli Alleati). All payments were to be made centrally rather than at regional level. AMG Fifth and Eighth Armies could use this agency in territories under their jurisdiction if they so desired. Civilian medical supplies produced in Italy were to remain in the owners' hands for sale to the public, with only excess production going to regions other than the one in which they were produced.


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FIGURE 41.-Four Italians carry a civilian refugee wounded during the battle for Cassino to a nearby hospital.

Health Activities of AMG Fifth and Eighth Armies

The Allied Forces in Italy spent the winter and early spring of 1944 in arduous combat before Cassino (fig. 41) and on the Anzio beachhead. There followed the rapid advances of May, June, and July to the Arno, where there was intense fighting during the last 2 weeks of August and the first 2 weeks of September. The front was stabilized along the Gothic Line during the succeeding winter. Finally, in the great forward movement of Allied troops in April and May 1945, the rout of the Germans was so complete that the remainder of northern Italy was occupied within a few days.

With the reevaluation of the AMG-ACC relationship had come a clearer delineation of functions between the two organizations having to do with the Italian civil population. In the area under Army control, AMG activities were to be primarily of an emergency nature and territory was to be turned over to ACC jurisdiction at the earliest possible moment. For example, during the rapid advance northward, AMG medical and sanitary officers were attached to the Armies for the emergency phase, then dropped off for permanent assignment as predesignated areas were captured and came


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under ACC control. Consequently, most of the AMG-ACC health personnel acquired valuable field experience under combat conditions before taking over their more prosaic duties as area officials.

In December 1943, Headquarters, AMG, 15th Army Group, tried to create a permanent tactical public health organization with officers at each Corps G-5 Section. It was never possible, however, to obtain the personnel to meet these requirements; for the remainder of the Italian campaign, only two medical officers were at Headquarters, AMG, 15th Army Group (Colonel Cheyne and Maj. (later Lt. Col.) Lendon Snedecker, MC) and one medical officer each at Headquarters, Fifth U.S. Army, and Headquarters, British Eighth Army, respectively. Lt. Col. Thomas Parr, RAMC, the Senior Public Health Officer with AMG, Fifth U.S. Army, and Colonel Farinacci, who held a similar post with the British Eighth Army, had little more than a skeleton organization to deal with health problems in the Army areas.

From the reports for the period23 when the Fifth U.S. and British Eighth Armies were making their major advances of May, June, and July 1944, it seems evident that AMG personnel were becoming more proficient in using existing local governmental officials to the fullest extent. Furthermore, lessons had been learned concerning the vital importance of transportation and communications. The medical supply situation was, on the whole, immeasurably better than that encountered in southern Italy in respect to both civil affairs medical supplies and those available in the newly occupied territory. Finally, it is evident that the American Red Cross personnel were being used in Army areas to a greater and greater extent.

Pisa, Florence, and other cities and towns, which were caught in the heavy fighting along the Arno, had been heavily damaged, and in addition had been subjected to a long siege (fig. 42). The pattern of events in Naples, Foggia, and other cities of southern Italy was being repeated. Hospitals were found to be in bad condition, both from the standpoint of physical destruction and from that of pillaged equipment and supplies. In addition, the heavy rains of September and October had aggravated the destruction of buildings and equipment exposed by shell-damaged roofs and walls. A major effort, in which the Red Cross took a leading role, was directed toward getting the remaining hospital, first aid, and social welfare facilities and equipment under cover. In some forward areas, especially in the mountain communities along the Gothic Line, winter weather forced Allied troops into covered billets which, in a few places, included hospital space, thereby increasing the problem of reestablishing ambulatories and hospitals for civilian casualties.24

23Public Health Reports, Fifth U.S. Army. Allied Military Government, City of Florence, 1944, with appendixes.
24Report, George H. Bickel, Supervisor, Red Cross War Relief, 5th Army, AMG, to Lt. Col. T. Parr, RAMC, Senior Public Health Officer, AMG, 5th Army, and Mason H. Dobson, Director, Civilian War Relief ARC, subject: Red Cross War Relief Operation Report, 5th Army Combat Team, September 1 to November 1, App. D.


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FIGURE 42.-An Italian child, wounded in a forward war area, is treated at a Fifth U.S. Army Refugee Center aid station in the Florence area.

In Florence, particularly, the main aqueducts had been damaged and the water supply remained crippled for weeks. The AMG sanitation officer, on starting work there on 1 September 1944, described it succinctly: "The chief problems that constituted serious public health hazards were: (a) No water. (b) Broken sewers and heavy collection in the sewers of solid material resulting from unsufficient water to properly flush them. (c) An accumulation of over 2000 cu. meters of garbage on the streets with practically no transportation to move it."25

The report for October showed that the sanitary situation had improved considerably although, in November, the two main aqueducts were still not functioning.

Despite the disruption of sanitary services, no disease outbreaks of importance occurred. The incidence of typhoid fever was high, but it had been rather high in this area even in normal times so that the situation seemed to be only slightly worse because of the war damage.

25Monthly Report, Capt. Edmond A. Turner, SnC, Allied Military Government, City of Florence, to SPHO, Florence City, 19 Oct. 1944, subject: Monthly Report for September, App. G.


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Closing Phases of the Italian Campaign

With the rapid surrender of the Germans in the north during May 1945, large sections of northern Italy came under the jurisdiction of the Fifth and Eighth Armies, quickly passed to the ACC, and, in turn, reverted to the regularly constituted Italian Government.

Damage within the Po Valley was generally limited to large city communications centers and to the Alpine areas along the Brenner Pass railroad line. In addition, limited but intense destruction in certain Alpine villages had been done during reprisal raids on partisan forces.

Although few hospitals had been destroyed in the rout of the Germans, virtually all bed space was filled by German sick and wounded to the exclusion of the civilian population, a condition which had existed during the past year. In Verona, for example, 1,000 general hospital beds and 800 beds for tuberculous patients had been in German hands. Despite damage to the two main hospitals of the city during the last stand of the Germans along the Adige River at Verona, 1,800 beds were returned to civilian use by 1 June 1945 through the efforts of AMG, Fifth Army, and cooperating American Red Cross personnel.26

Liberation of northern Italy also brought the problem of handling large numbers of refugees and displaced persons who poured through the Brenner Pass from Austria. Typhoid fever, tuberculosis, and malnutrition were the principal health problems encountered; an antityphus program was instituted and this disease presented no problem.

Section II. Problems and Lessons of the Italian Campaign

Military Government problems in the health field were more numerous and extensive in the earlier months of the Italian campaign, when the Allied armies were successively invading and occupying Sicily and southern Italy, than they were in the latter half of the campaign when the area involved was mostly that part of Italy north of Rome.

Not only were health problems normally greater in southern Italy but also, at all levels, personnel concerned with civil public health were much less experienced than later in the course of the campaign.

In addition to the administrative difficulties to which reference has already been made, the problem of transport, or rather the lack of it, loomed larger than any other. Likewise, problems of medical supply and medical and health personnel presented difficulties which, in turn, affected the manner in which other civil health problems were met.

26Memorandum, George L. Bickel, Supervisor, Civilian War Relief, ARC, Fifth Army, AMG, to Col. Thomas Parr, SPHO, AMG, Fifth Army, and S. John Crawley, Director, CWR-ARC Mediterranean Theatre, 7 June 1945, subject: Civilian War Relief Operations May 1, 1945 to June 1, 1945.


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TRANSPORTATION

In report after report covering military government health activities in Sicily and Naples, mention is made of the lack of transportation facilities for Allied Military Government personnel, for Italian physicians and others engaged in health activities, and for essential medical supplies. A contemporary report states:27

(Deficiencies in the civil health program may be attributed largely to) inadequate transportation facilities for key public health personnel and medical supplies. In the Italian operation AMG medical personnel were repeatedly sent into an area to organize and direct a civil health program without any means of transportation whatsoever. This is extremely wasteful of medical manpower. In the early days of occupation it is not possible to mobilize civilian physicians, organize hospitals, provide essential medical supplies, and obtain additional transportation facilities without the means of getting around the community. While existing Tables of Equipment appear to be adequate, actual transportation frequently is still not available for transport of directing medical personnel and supplies.

It is scarcely possible to overemphasize the effects of the deficiencies in transportation facilities and in medical supplies. This situation became particularly acute when Military Government officials in Naples were confronted with a rising rate of typhus fever cases. With the assistance of the team of experts headed by Dr. Soper of the Rockefeller Foundation, a program of typhus control was developed, but this program could be only partially implemented until army vehicles were made available through the Peninsula Base Command.

This episode not only dramatically showed the potentialities of preventive medicine, but also contributed to an understanding on the part of Army authorities of the importance of transportation in the civil health program.

PERSONNEL

In general, the policy was to maintain to the maximum extent a numerical balance between American and British personnel in the public health program.28 However, at no time were the British able to provide their full share of personnel (see pp. 34, 454).

A fact which led to a considerable disturbance of the morale of the officers was that many of them lost their opportunities for promotion assignments when they were transferred to Military Government and assigned to Civil Affairs training centers in the United States. Many of these men had excellent public health specialist qualifications, yet they were serving overseas as lieutenants and captains because tables of organization were not sufficiently liberal. Because promotion policies were quite rigid, it was not possible to promote them during this campaign

27See footnote 10, p. 312.
28Starr, Lt. Col. Chester G.: From Salerno to the Alps, 1943-1945: A History of the Fifth Army. Washington: Infantry Journal Press, 1948, p. 486.


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although their training and experience in the United States and the positions of great responsibility which the average officer held in Sicily and Italy warranted promotion for most of them.

The combined operation in Italy showed the excellent ability of public health officers of Great Britain and the United States to work in the closest harmony and fellowship.

While relationships at the personal level were usually excellent, jurisdictional disputes plagued the early months of AMG-ACC operations in Italy. This perhaps was largely due to the historical rigidity of command patterns in which personnel assigned to one command pass from the control of the assigning command. For example, medical and sanitary officers, held in the officers' pool of Tizi Ouzou, were eager to move into operational areas under the control of AMG, 15th Army Group, for field experience. The 15th Army Group, however, would accept these officers only on permanent assignment. Despite the need for such personnel on the one hand and the desire of the officers on the other, AMG would not agree to accept the temporary assignment of medical personnel who later would be needed in the area operations under ACC.

One of the principal problems of the 15th Army Group was the inability to obtain sufficient officers, particularly specialists, to fill the table of organization. This meant that Headquarters, AMG, was unable to give the various provincial region public health officers enough supervision and coordination. The chief reason for this was the inability of the British to furnish their quota.

The absence of trained nutrition officers on the staff of Headquarters, 15th Army Group, made it difficult to furnish the best advice to the supply division regarding the nutritional status of the Italian people in the conquered areas, during the period from 10 July to mid-November 1943, before ACC was activated.

Civilian Casualties

The initial problem during the beach assaults and the push inland was one of providing medical care and hospitalization for civilian casualties. Modern warfare is extremely mobile and, frequently, the moving front exposes large numbers of civilians to the hazards of bombing, strafing, and artillery and small arms fire. Italian air raid precautionary services were poorly organized. Large underground, concrete shelters had been provided in many communities, especially in the larger cities, and the rocky terrain in parts of Sicily and southern Italy provided shelter in the form of caves, but all too often raids came without adequate warning and large numbers of people were killed or injured.

As our troops moved forward, the sick and injured frequently became a severe burden on forward military hospitals. Military Government public health officers were helpful in transferring these patients to undamaged


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Italian hospitals which could care for them, but this activity was hampered by a shortage of civilian and military ambulances and gasoline.

In December, Headquarters, AMG, 15th Army Group, developed a plan to alleviate the forward medical problems. This consisted of establishing a small pool of Italian doctors, usually three, at Army level, who could be deployed as required when special problems arose in forward areas. As the small pool was depleted, it was refilled. Subsequently, ACC "drafted" Italian doctors for assignment where civilian medical care and the services of physicians were required.

Local Health Administration

One of the first problems faced by the Military Government public health officer was the reestablishment of local health administration, including the use of existing public health personnel when they appeared to be competent. In some instances, it was necessary to replace them with new personnel who were often untrained and without previous public health experience. These Italian health officers were instructed in their duties verbally and by written directives. The larger health departments in cities like Palermo, Messina, Catania, and Naples were all understaffed. Transport was vital, particularly for the provincial officials and the heads of health departments of larger towns and cities, but at first, there were almost no vehicles. However, 1 to 2 months after an area was occupied, it was usually possible to requisition cars for these higher officials.

Hospitals

Contrary to expectations, relatively little damage was done to most hospitals in Sicily and southern Italy although, when time permitted, the Germans methodically removed or destroyed all medical supplies and equipment. In most instances, patients with chronic diseases had left the hospitals because of the war, and, on many occasions, weekly bed occupancy reports in Sicily showed a high percentage of unoccupied beds. It should not be inferred from this that the number of beds per capita was ideal, but ordinarily there were enough to satisfy demands.

A contemporary report of the situation in the Civil Hospital of Campobasso, when it came under the supervision of AMG on 3 November 1943, illustrated some of the problems encountered in southern Italy. There were 73 patients in a hospital with a capacity of 50 beds. There were no dressings and most important drugs were in short supply. There was no method of working autoclaves and no major surgery was being performed. Most of the patients in the hospital were battle casualties from mine or grenade accidents and phosphorus or petrol burns; many of them were children. The only way to obtain food was for the Mother Superior of the hospital to forage around the community each morning, but these efforts yielded progressively less as food became scarcer. Within 3 days after the


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hospital came under AMG jurisdiction, essential drugs, dressings, and plaster for fractures had been made available, corpsmen had been assigned to various administrative duties, and a surgical team from one of the tactical medical units had cleaned up the backlog of surgical cases. Supplementary rations were provided from military supplies.

The most frequent type of damage to hospitals was loss of roof tiles and glass as the result of blast rather than from direct hits by bombs. Replacing the glass was virtually impossible and the tiles were replaced with considerable difficulty. Hospitals were generally poorly equipped, fuel and other utility services were frequently badly disrupted, and often they either were understaffed or were staffed with nurses and others whose work would be considered substandard in the United States. A shortage of hospital facilities in Palermo and Syracuse, Sicily, was brought about primarily by the occupancy of buildings by military medical services. For example, many buildings of the Palermo University Hospital which had not been destroyed by our bombing were occupied by one, and later by two, American evacuation hospitals. In December 1943 when it became apparent that this was preventing the reopening of the University of Palermo Medical School, upon representation by Colonel Williams of ACC, the Commanding Officer of the 59th Evacuation Hospital, Col. Oral B. Bolibaugh, MC, agreed to move it to another location.

In Syracuse, one of the few large mental hospitals on the island was taken over progressively by British Eighth Army hospitals. It became necessary to double up already crowded patients and, later, to move a thousand to other places. Several provinces which had no facilities for hospitalization of mental patients sent their cases to Syracuse on a contract basis. The only other institution available at the time to which Syracuse cases could be evacuated was in Agrigento, several provinces away. When movement was attempted by train, great difficulty was encountered. Because the train was very slow, many patients died en route and some escaped. A deficiency in the whole Military Government program was the failure to allocate early those civilian medical facilities not required by Allied medical units and which would be available for civilian use.

Many hospitals had splendid facilities for isolating patients with communicable diseases, but all too frequently little effort was made to use them. A very definite shortage of beds for tuberculosis existed in both Sicily and southern Italy.

Civilian Medical Personnel and Medical Schools

Although most physicians were well trained and of high caliber, many of the older ones were quite primitive in their knowledge and methods. There was relatively little specialization except in some of the larger cities. The Italian Government had made some effort to improve medical care and had stimulated the training of specialists. Dentists and technicians were


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sparsely scattered in the area, and the incidence of dental caries was high. Nursing standards generally were low in southern Italy and Sicily. Midwives were used extensively although, despite the relatively rigid training required under the Italian public health code, many of them were poorly trained.

In general, professional problems were considered to be Italian problems. Our forces were not in Sicily and Italy to improve the quality of Italian medical care except when this helped to protect the health of our troops by preventing the spread of communicable diseases, or when improvement was necessary in preventing civilian unrest, which might have interfered with the total Allied military effort.

It must be said to the credit of the Italian medical and related professions that they cooperated wholeheartedly in carrying out the AMG and ACC-AC programs during this period.

A prominent defect in the professional program was the lack of a directive from AFHQ defining the status of captured Italian doctors and nurses. A timetable for their release should have been set up, but as it was, these doctors and nurses frequently sat in prisoner-of-war camps when they could have been used profitably in caring for civilians. Had such a program been in effect, American and British medical personnel would have been relieved of much of the burden of caring for civilians and could have devoted more time to the care of Allied casualties and to other necessary duties.

COMMUNICABLE DISEASES

The most prevalent communicable diseases were malaria, venereal diseases, and tuberculosis. The first two were extremely important because of the danger of their spreading to our troops. Tuberculosis undoubtedly was important, too, in view of the extensive fraternization of our troops with Italian civilians, but its effect on the troops was not immediately apparent. Typhoid fever was a grave local problem, but the sanitary discipline of our troops was sufficiently good to prevent its becoming a serious cause of illness. Louseborne typhus fever first became a threat in the Naples area in the late fall of 1943, and by the end of the year, a considerable epidemic was raging in that city. The effectiveness of immunization and louse control methods was evident since troops were practically free from typhus. Sandfly fever and acute catarrhal jaundice did not appear to be special problems in the civilian population although they did cause trouble to our soldiers in Sicily.

Malaria

The greatest concentration of malaria in Italy was found in Sicily and Calabria. In the early days after battle, getting accurate reports of the current incidence was difficult. In one commune, Teresa de Riva, at the east


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base of Mount Etna, 1,072 cases were reported in the month of August 1943. Of this number, 342 were primary and 730 were recurrent; 1,000 were tertian, 37 were quartan, and 35 were estivo-autumnal malaria. The population of this community had been 8,300 and was estimated to have increased in August to 11,000 with the influx of refugees.29

The terrain of the south, especially in coastal areas, and the climate were especially conducive to mosquito breeding. Several narrow coastal plains contained many irrigation ditches and much brackish water. In addition, our bombing and shelling had made many craters which were water filled, and these had frequently dammed up ditches which were part of irrigation and malaria drainage projects. In one instance, Army Engineers prepared an emergency landing strip on the north coast of Sicily, filling in several important drainage channels. When the rains occurred, serious mosquito breeding problems were created.

In prewar times and until 1943, tree quinine, furnished by the Italian Government, was obtainable in tobacco shops. Most provinces of Sicily and Calabria had provincial malaria laboratories, but lack of personnel had greatly reduced activities during the war. The Italian Red Cross ran a number of ambulatory clinics, and many other agencies were involved in the overall field control program. Unfortunately, the programs of the individual agencies lacked adequate coordination.

Provincial antimalaria committees did a measure of coordination by advising some of the malaria control agencies on the technical aspects of control. However, they gave advice only when requested, and the actual control remained with the individual organization. Furthermore, lack of central coordination for the whole of Sicily led to many undesirable situations. The Provincial Genio Civile did some ditching and dusting but frequently farmed out the antimalaria work to private contractors. This practice produced very poor results in many areas for the amount of money spent. The organization for the colonization of Sicily also did malaria control work as did the Consorzio di Bonifica. The latter received some funds from the Ministry of Agriculture; however, practically all of the other organizations received the bulk of their funds from the Ministry of Interior.

A beginning was made by Military Government in 1943 toward the creation of centralized control of malaria projects for the 1944 malaria season in Sicily. This centralized control was vested in the Provincial Antimalaria Committee. An Island antimalaria committee was planned to coordinate the Provincial work.

By the end of 1943, more than 2,000 men were employed on various malaria control projects. During the fall of 1943, the greatest effort was directed toward areas near our troop concentrations and airfields.

Large stocks of Atabrine were found in captured Italian medical

29See page 19 of footnote 3, p. 298.


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FIGURE 43.-Col. Paul F. Russell, MC.

supplies, and an effort was made to start free distribution of this drug. However, its use for civilians was usually restricted to those already suffering from malaria. Stocks of quinine which were found were kept by our military supply authorities. Adequate quantities of paris green were on hand in a few limited areas, and requisitions were prepared for oil and additional paris green to be used in early 1944. DDT was not available for mosquito control until that summer. Paris green was favored because officials and workers had been trained in its use and were more familiar with it than they were with the use of oil. However, oil was more generally available for civilian programs.

Malaria control was considerably handicapped by the shortage of transportation for control workers and their required supplies. All malaria control activities during this early period were the responsibility of Lieutenant Manzelli. In view of the size of the problem and despite his excellent work, this was inadequate staffing.

In line with earlier recommendations30 and upon request of ACC, the expert malariologist, Colonel Russell (fig. 43) was sent from the SGO and placed in charge of the Malaria Control Branch of the Public Health Sub-

30See footnote 10, p. 312.


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Commission, ACC, in April 1944. He had the assistance of three officers, including Lieutenant Manzelli as entomologist. Direct communication on malaria control matters was authorized between the Chief of this branch and regional and Army civil public health officers; monthly reports covering malaria surveys and control activities were required; and highest priority was given to control measures in the vicinity of Allied military establishments. An extensive control program based on drainage, filling, oiling, and the proper treatment of civilian cases was inaugurated. This program was timely since the onset of warm weather foreshadowed a tremendous increase in the malaria problem.31

Venereal Diseases

No reliable statistics were available on the various venereal diseases for Italy as a whole. However, the experience of individual venereal diseases treatment clinics indicated that syphilis, gonorrhea, and chancroid incidence was high. The activities of detection and treatment clinics had decreased during, and toward the end of, the war; hence, vigorous efforts by Military Government were required to stimulate the reopening and expansion of the clinic program.

Italy had a system of licensed prostitution and, in the larger cities, had inadequate programs to control venereal diseases in this group of women. As far as our troops were concerned, this disease problem was considerably expanded with the enormous growth of clandestine prostitution. Italian police services had disintegrated considerably and their efforts to control licensed and unlicensed prostitutes were feeble and ineffective. In Sicily, and for a short time in Italy, some of the existing brothels were taken over for the exclusive use of U.S. troops.32

Shortage of qualified personnel in Military Government public health in the initial period prevented the assignment of an officer to full-time venereal disease control activities before the arrival, in the fall of 1943, of Maj. John A. Lewis, Jr., USPHS, a well-qualified venereal disease control officer. He attacked the problem with great vigor and was influential in causing the Italians to set up improved detection and treatment facilities, and in bringing about a system for examination, detention, and treatment of women in the infectious stage of their disease.33

* * * In every city and large town in Italy the problem was the same; promiscuity and high venereal disease rates. Repeated conferences were held by the Venereal Disease Control Officer of the AC with medical and provost marshal officers of the headquarters of both British and American troops throughout occupied Italy in an effort to

31For full details concerning the evolution of the outstanding control program directed by Colonel Russell, see footnote 20, p. 318.
32Medical Department, United States Army. Preventive Medicine in World War II. Volume V. Communicable Diseases Transmitted Through Contact or by Unknown Means. Washington: U.S. Government Printing Office, 1960.
33Report, Maj. John A. Lewis, Jr., USPHS, Surgeon, District No. 3, 7 Dec. 1945, subject: Report to the War Department-History of Civil Affairs in Italy, pp. 11-14, 22-26. [On file at The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]


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decide on a definite policy directed towards reducing exposures by the suppression of clandestine prostitution. In January of 1944, the Director of the Public Health Sub-Commission agreed that the Allied Commission should take the initiative and coordinate a cooperative program with all headquarters of troops in Italy. The Director of the Legal Sub-Commission agreed to publish the laws on venereal disease as it applied to the control of prostitution and working through Italian government channels to obtain better enforcement of Italian law directed against clandestine prostitution. The program as it pertained to the AC consisted in (1) a repression of clandestine prostitution, and (2) the provision of medical diagnosis and treatment, for clandestine prostitutes suspected of infection. In addition, it was understood that the Venereal Disease Control Officer would request the various headquarters throughout Italy to put all houses of prostitution off-limits to their troops, and to request that they enforce the order using military police. In order to carry out the first part of the program, repression of clandestine prostitution, police action was required and this meant the close cooperation between Military Police, Italian police and AMG Public Safety Officers. It was not possible for the Italian police to do the job alone; very often it would be necessary for an Italian police to arrest a prostitute in the company of an American or British soldier. Unless there was an Allied Military Police along to protect the Italian police, a fight would be started between the soldier and the Italian policeman; this happened on several occasions. For this reason, early in the program it was realized that vice squads should be started consisting of Allied soldiers and Italian police. An Allied Military Policeman would accompany an Italian policeman and be present at the time of each arrest. Early in January, 1944, the Venereal Disease Control Officer of PBS (Peninsula Base Section), the Surgeon of the Metropolitan Area, the ADH of the 55th area of Naples for the British, and the Surgeon of IBS (Island Base Section), arranged with their Provost Marshal to create vice squads. Later on vice squads were formed in other Italian cities. The vice squads consisted of an officer and of several enlisted men. * * * Italian police, or Carabinieri were assigned to work with the vice squad men. The actual arrests were made by the Italian police usually but sometimes by the Military Police and then the girl was turned over to the Italian police. The arrest, charges, and results of examination were all recorded at the Questura (the police station) and made available to the AMG Public Safety Officer. The Public Safety Officers of AMG were repeatedly urged by the Venereal Disease Control Officer of the Allied Commission to keep the number of arrests high in order to discourage clandestine prostitution. In turn, the Public Safety Officers applied pressure on the Italian Police Officials, who in turn ordered the Italian Police to increase their activities in combatting clandestine prostitution. In addition, the Ministry of Interior was induced by the Allied Commission to send to the Prefects, a decree calling for more vigorous enforcement of Italian laws with regard to clandestine prostitution. The net results of these activities were that a great many women were arrested in the larger cities of Italy on suspicion of clandestine prostitution with Allied troops. * * * Following intensive activity to repress clandestine prostitution it appeared that some headway was being made. Both Italian and Military Police reported that there was a decline in clandestine prostitution. * * *

The treatment of venereal diseases was the most profitable of all the specialties of medicine in Italy. One could not but be impressed with the large numbers of signs advertising Specialist in Venereal Diseases. When the AC moved into Naples about the middle of December, it was noted that some of the Italian venereal disease specialists were advertising venereal disease treatments to troops. It was learned that many American soldiers were reporting to Italian physicians for treatment of their venereal diseases instead of reporting their infection to their unit commanders. A determined effort was made by AMG to stop this practice. The Medico Provinciale was told by the Regional Public Health Officer that it was strictly prohibited for any physician to offer or to give treatment for venereal disease to either an American or British soldier. A threat


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was made by the Regional Public Health Officer to suspend the license to practice of any Italian physician who did not comply with the order. In addition, Military Police were instructed by the Venereal Disease Control Officer of PBS to remove these signs wherever found. It was believed that this action was relatively successful in breaking up the practice of [Italian] physicians treating Allied soldiers infected with venereal diseases.

In January and February of 1944 visits were made to all of the larger towns in Italy, Sicily and Sardinia occupied at that time to coordinate activities of AMG-ACC, Italian Health Organization and Troop Activities. These took the Venereal Disease Control Officer to Palermo, Catania, Syracuse, Messina, Trapani, Lecce, Taranto, Brindisi, Cagliari, Sassari, Caserta, and the towns neighboring to Naples as well as Salerno. In all of these places emphasis was placed in getting hospital beds for venereal disease patients, creation by the Military Police of vice squads for the repression of clandestine prostitution, enforcement of the "off-limits" policy of houses of prostitution, and of parts of cities where contacts were most frequent. * * *

When the houses of prostitution were put "off limits," 31 December 1943, there was an immediate fall in the number of prophylaxis given, but at the same time that the houses of prostitution were put "off limits," Naples itself was put "off limits" to visiting troops, because of the typhus epidemic figures. Prophylaxis given by PBS in Naples December 1943, 49,052; January 1944, 14,787. As a result of numerous conferences with the various headquarters, 7th Army, IBS, Sardinia Garrison, PBS, Metropolitan Area, 15th Air Force, 12th Air Force Service Command, British Districts 1, 2 and 3, and their areas and sub areas, it was agreed, that the agreed upon policy should be reduced to writing in the form of a directive and circulated to all concerned and that this policy should contain specific instructions for the Italian physicians as regards diagnosis and treatment. After discussion of the points with various sections of the Allied Commission it was decided to produce a directive addressed to the Regional Commissioners of the Allied Commission relating to this subject. * * *

Prior to the issuance of this directive the Director of the Public Health Sub-Commission arranged a conference with Doctor Vezzoso, the Chief Physician of the Italian Government and his advisors and the Public Health Sub-Commission on the subject of venereal disease control. The program of the Public Health Sub-Commission was explained by the Venereal Disease Control Officer and emphasis was placed on the fact that the Allies considered the venereal disease problem of its troops serious enough to warrant more effective measures for its control by the closest cooperation of all military and civilian authorities was suggested (really ordered!). The outlines of policy was discussed, which called for more strict enforcement of existing laws and the expansion of the hospitalization program. Directives on subjects went out from the Italian Government to the various Provinces explaining that the allies had requested that more effective action be taken and called for strict enforcement of laws against clandestine prostitution and for the hospitalization of infected prostitutes. These directives made negotiation with Italian Provincial Officials much simpler. Venereal disease rates showed a decline in the early months of 1944.

Typhoid and Paratyphoid Fevers

The enteric diseases were endemic among civilians in Sicily and southern Italy. It was not uncommon for a small town of 5,000 to 10,000 people to have 40 to 60 current cases of typhoid and paratyphoid fever during the summer and fall of 1943. Much of the disease was water-spread, although in some coastal areas, seafood infection and infection from vegetables fertilized with night soil were common. Poor home nursing and


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infrequent isolation of cases led to much contact spread. The importance of the innumerable flies in the area in spread of the disease is unknown.

Water was frequently drawn from unprotected wells. Latrines of primitive construction were often placed near wells and, worse still, many persons did not bother to use a latrine and were not particular about where excrement was spread.

Chlorination of water supplies, the collection of sewage in closed systems, and sewage treatment were practically absent in southern Italy and Sicily, except in a few of the larger cities. Even then, only a small portion of the population of these cities was served by piped systems. In many instances, Military Government sanitary engineers assisted communities to build makeshift chlorinating apparatus and supervised the chlorination of local water supplies.

Much effort was made to bring about a better system of isolation of typhoid patients in hospitals since control measures in the average Italian home where typhoid cases existed were usually so primitive that most of the nonimmunes in the same home also contracted the disease.

Vaccine for immunization was made available by Military Government, but extensive immunizations were undertaken in only a few towns which had a continued high incidence of typhoid fever.

Tuberculosis

Tuberculosis was a considerable problem in the civilian population. A number of provincial tuberculosis clinics had been established, and before the start of the war, the Italian Government had begun making tuberculosis surveys. However, this work had lagged during the war, and the work of building facilities for the hospitalization of patients had not moved apace with the casefinding program. The few tuberculosis sanatoriums that were found in southern Italy were crowded with incurable cases while convalescent patients often were released too early.

In general, Military Government was too busy with acute problems which had an obvious bearing on the health of troops, and with the urgent day-to-day health problems of Italian civilians, to do very much about tuberculosis in the early period when specialist personnel were scarce.

Acute Communicable Diseases of Childhood

The incidence of diphtheria and other acute communicable diseases of childhood was high throughout the area, and the Italian provincial health authorities were urged to improve their control. Efforts were made to reestablish immunization programs against smallpox and diphtheria, and the necessary biologicals were furnished.

Because of the destruction of communications, a complete breakdown in reporting communicable diseases occurred. Military Government public


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health officers attempted to reestablish it and, by the end of January 1944, haphazard reporting was in progress.

Trachoma

Trachoma should be mentioned as an important civilian health problem, particularly in Sicily. Infection rates were extremely high and the Italian Government had established trachoma clinics in small provincial capitals and in many of the smaller communes. In addition, an effort had been made in the larger cities to segregate children in special schools for trachoma cases. The antitrachoma work had virtually come to a standstill during the war and was slowly being reestablished in the initial Military Government period.

Scabies and Impetigo

Scabies and impetigo deserve special mention since the incidence of these diseases was extremely high in the population of southern Italy and Sicily, especially in children. An effort was made to supply the material needed for treatment. It was difficult to provide sufficient sulfur ointment for the treatment of scabies in the early period. Actually, Sicily had many large sulfur mines, but the lack of ointment base made it impossible to use the local sulfur adequately; consequently, little progress was made in the control of these two diseases. Overcrowding, the acute shortage of soap, and poor habits of personal hygiene were factors in the continued high incidence.

CIVILIAN HEALTH ACTIVITIES

Laboratory Services

Virtually every province had a small laboratory to which doctors could send specimens for examination. Unfortunately, the lack of laboratory supplies and, in many instances, the destruction, requisitioning, or looting of laboratory equipment, especially microscopes, by civilians or Allied troops, made it almost impossible for many laboratories to function satisfactorily. Military Government public health officers tried to redistribute existing supplies of materials to equalize and provide essential public health laboratory services to all.

Maternal and Child Health

Part of the Fascist plan was to build a healthy, childbearing, and prolific womanhood; hence, an extensive system of maternity and child health clinics had been created. These clinics had ceased to function during the latter part of the war and were reopened very slowly by the Italian


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authorities. In some areas, reestablishment of the program was retarded by the lack of transportation and because this activity had been supervised by the party rather than by local and provincial health officers.

Infant and maternal mortality rates in southern Italy were always high. The rate in Sicily per 1,000 births in 1939 was 127, compared with 97 for Italy as a whole and 48 in the United States.34 During the war, rates are alleged to have gone considerably higher. Enteric diseases were the commonest causes of infant deaths under a year, with respiratory diseases running a close second.

Smallpox vaccination was compulsory within the first 6 months after birth, with revaccination required later. To continue this program, smallpox vaccine was imported from the Pasteur Institute in Algiers.

Diphtheria immunization was made compulsory in 1939. However, when it was discovered that immunization had not been extensively carried out in southern Italy and Sicily, efforts were begun to reestablish and improve this program.

The Fascist Party operated the ONMI (Opera Nazionale per la Protezione della Maternità e dell'Infanzia). This semiofficial agency was extensive and did much work for indigent mothers and young children by supervising foster homes, caring for orphans, and operating prenatal clinics, day nurseries, and child and maternity feeding stations.

The Fascist youth movement organization, GIL (Gioventù Italiana del Littorio), operated a number of dispensaries for children and conducted antituberculosis, malaria, and trachoma programs. These programs were financed by the National Government and by individual taxes and contributions. They were abolished by the Military Government, and their programs ceased to function in Sicily. In cooperation with the welfare officer of HQ, AMG, 15th Army Group, Major Witte, a partially successful effort was made to reestablish many of the activities described. The local and provincial public health and welfare heads were made responsible for these programs and given more responsibility than ever before. Thus, the establishment of an integrated public health program was begun.

A plan was made to avoid closing all ONMI and GIL activities on the mainland when these Fascist organizations were abolished. This worked successfully in Naples.

Sanitation

The primitive sanitation in Sicily has been mentioned. At first, because of an expectation of inadequate water in Sicily to supply both civilian and military needs, large quantities of water were taken by the assault forces for use as ballast in the ships. This proved unnecessary because an ample supply of water was found in Sicily. In general, the supply was from wells

34War Department Technical Bulletin (TB MED) 178, July 1945, subject: Medical and Sanitary Data on Italy.


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and springs; and in the average town, the water was dipped from wells in buckets. In the larger cities, there was a piped supply although few people had water piped to their houses. The typical method of collecting water in some larger cities was to open a submerged tap in the sidewalk or in the street and, with a small container, to dip water out of this hole into a larger container.

On the whole, the water was fairly pure at the source although occasional instances of contamination by sewage were found. In Naples and several larger cities, water was piped from the nearby mountains through aqueducts. A number of these were broken in the course of the fighting, but they were repaired by the Italians and Army Engineers with very little difficulty.

In general, little treatment of sewage was carried out in Sicily and southern Italy. A few cities of 50,000 population or over did have pipe sewage from a portion of the city to various inadequate disposal plants. Sewage and water mains often were found side by side, ruptured by bombing or shelling, thus contaminating the water.

Kitchen and other household refuse usually was dumped into the street or road in front of the houses in the various cities because of the breakdown in transportation. Then, the Military Government Public Health officer had to reorganize the disposal of refuse; this was done by arranging for pickup by mule carts and dumping outside the town.

Refugees, Displaced Persons, and Housing

Refugee problems were always acute in the areas through which the moving battlefront passed. The civilians tended to move laterally from the areas of the principal thrusts, and then to return to their homes after the front moved on. Occasionally, as occurred on the east side of the Apennines north of Foggia, tens of thousands of refugees moved back as the German lines withdrew; then, when the fighting became static, they began to move both through the lines and up onto the Apennine ranges lateral to the lines and, finally, south and into the British Eighth Army area. These refugees constituted a difficult problem because often more than 1,000 a day came through the lines, interfering with Allied operations. Arrangements were made to receive them at forward interrogation points, and to move them by truck to entraining points where they began their long journey south on empty supply trains or special passenger trains. A limited number of Italian doctors with kits of medical supplies accompanied them. The Italian Government in Brindisi arranged with the prefects of the various Provinces of southern Italy to absorb the refugees in the southern area by communes. The practice of moving them so far from their homes may be questioned, but this was entirely the responsibility of the Italian Government.


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Bombing of houses had created another serious refugee problem; thousands of people were homeless and were living in caves and air raid shelters. The town of Augusta, Sicily, which was an Italian naval base, was heavily bombed and completely destroyed. Its approximately 20,000 inhabitants were living in a series of caves north of the city. Fewer than 100 civilians, mostly the aged and infirm, remained in the town. The problem of organizing the refugees in the caves and caring for them proved to be difficult. Fortunately, many doctors who had practiced in the community remained with them and worked heroically to provide medical care. Later, many of these people were distributed to other eastern Sicilian communities.

It was always difficult to disperse refugees through any system of billeting in the homes of others for the simple reason that the average Italian household was already overcrowded. Censuses showed the average room in an Italian house already accommodated three to four individuals. Cooking was frequently done out of doors on small wood and charcoal stoves, and both rooms of the average dwelling were used for sleeping.

Few displaced persons were recovered until the Calabria area was occupied, and then a large concentration camp was found at Cosenza. This housed several thousand people of approximately 20 nationalities, including a large number of Italian Jews. Approximately 200 Yugoslavs were found at Palermo. After Cosenza, the next large displaced person population were Yugoslav refugees who were brought by ship to the east coast of the peninsula to escape the fighting and the destruction along the western Yugoslav coast. The Yugoslavs began to arrive in January 1944, and although the numbers which reached Italy during that month were relatively small, their continued influx in ever increasing numbers later became a serious problem.

Housing surveys performed in Sicily revealed that only a few communes presented acute housing problems. Trapani reported 15,000 homeless in an area then having less than half its normal population. Marsala reported 14,000 homeless, but most of the damaged buildings there could be repaired in 1 month if labor and materials were available. Unfortunately, they were not readily available. Messina also had a serious housing shortage, as did Foggia on the mainland. Glass and roofing tiles were in especially short supply, and it was impossible to import building materials to make repairs. Fortunately, the winter of 1943 was relatively mild, and there was little suffering.

It was feared that epidemics might occur on a large scale among the packed dwellers of air raid shelters. These people were dirty, louse-infested, and had little medical care; sanitation in the air raid shelters was poor; and numerous cases of enteric disease developed in them. Shelter dwelling was a considerable factor in the spread of typhus fever in Naples. Whenever there was a reasonable possibility that these people could find other housing, the mayors and police officials of the towns were ordered to close the shelters at all times except during air raids.


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Clothing the population was a problem in southern Italy. Good, serviceable shoes were especially scarce although many people had improvised wooden shoes or leather shoes with wooden soles. Most people were wearing the last of their usable clothing, frequently patched, and obviously they badly needed additional clothing for the winter. Supplies could not be obtained through military channels, but the American National Red Cross agreed to provide surplus clothing from England and the United States. This clothing began to arrive in Naples during the first week of January 1944.

Nutrition

The general state of nutrition of the population of Sicily, which was primarily agricultural, was fairly good. However, it became obvious that the dislocation of distribution and of the trade in grain between Africa, Sicily, and the mainland of Italy were creating a serious situation, requiring that wheat be imported from elsewhere. This problem had been anticipated in planning for Sicily. Unfortunately, no transportation was available to bring in 30,000 tons of grain which had been stored in Algeria for Military Government use in Italy.

"Black Marketing," which had prospered under Fascist auspices during the war, was an extremely important factor in preventing equitable distribution of existing foodstuffs both before and after the arrival of Allied troops.

Because there were no nutrition experts in the Military Government organization during this period, no adequate studies of the nutritional states of the people could be undertaken. In general, nutrition appeared to be less adequate in Naples itself than in the surrounding area, partly because of the inability to bring food in from the surrounding countryside. Fortunately, southern Italy and, particularly, Sicily had good supplies of grapes, olives, pistachios, filberts, and citrus fruits which normally would have been distributed to the whole country or exported. These were available for the occupied area alone and furnished much required food.

The general opinion of the public health authorities of Military Government and the Allied Control Commission was that the state of nutrition in southern Italy and Sicily during the first 6 months was good. A moderate amount of undernutrition probably always existed in the economically depressed groups who formed the bulk of the population of these areas. As usual, the farmers did not fare badly. Hoarding, which was common among them, was found to be extremely difficult, if not impossible, to stop even though vigorous means, such as sneak raids, were used.

Grain production in the area had fallen considerably because of the shortage of manpower and the lack of fertilizer during the war years. All grain reserves had been used up, and living was more or less on a day-to-


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day basis in most communities. Hospitals especially required extra and special foods which were difficult to provide.

Veterinary Medicine

Because Allied Military Government had no veterinary officers, its ability to ascertain and cope with veterinary problems was greatly limited. In some instances, a sanitary engineer dealt with problems of milk supply. In general, only raw milk was sold; it was delivered from door to door. Usually, the herd of cows or goats was milked at the door so that the consumer could see that he was obtaining undiluted milk. In the larger cities were stores selling only milk and, generally, they sold skimmed and watered milk.

The Allied Control Commission included a veterinary medical officer from the beginning of its operations. On Sicily, he reestablished meat inspection. Farmers tended to sell directly to the consumer because of the scarcity of meat and the exorbitantly high prices. Thus, meat bypassed the old slaughterhouses where inspection had been carried on in prewar days. This officer also was able to assist the Zoo-Prophylactic Institute in Palermo to begin production of human biological products, such as smallpox vaccine, diphtheria antitoxin, and other biologicals for human use.

Beginning in early January, fairly comprehensive data on veterinary problems became available. It is clear that the ACC veterinary officer, Major Rushmore, played an influential role in reestablishing Italian meat production.

Medical Supplies

The 21 Allied Post-War Requirements Bureau drugs and 21 Allied Post-War Requirements Bureau dressing units were delivered to Palermo in a series of shipments and were moved to Caltanisetta, where a former Italian military medical supply depot had been taken over by HQ, AMG, 15th Army Group. Initially, the Seventh U.S. Army had captured this depot which contained approximately 125 tons of Italian supplies. These supplies were turned over to HQ, AMG, which distributed them to the provinces (Provincial Health Officers) for redistribution to hospitals within their area in the form of balanced "bricks" or units. Allied Post-War Requirement Bureau unit supplies were then issued on an item requisition basis.

The Allied Military Government made an effort to work out accounting procedures in Sicily and started to develop price lists. This work was continued and finished by the Allied Control Commission in 1944. At first, supplies were issued to the Italians on memo receipt, with the understanding that they would pay later.

Assault parties landing on Sicily carried with them no medical supplies for civilian use. Although they managed without them in Sicily, it developed later that such supplies should be brought in within a few days of an


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assault. At the time of the Salerno landings, small quantities of emergency supplies accompanied the troops. The value of maintaining small dumps of emergency civilian supplies in forward combat areas in Army depots became apparent and such a program was instituted by the Fifth U.S. Army in December 1943.

Colonel Farinacci set up a highly successful program for handling medical supplies in the British Eighth Army area. Captured Italian medical stores, supplemented by some U.S. Army medical supplies, were made up into Spearhead Medical Kits and Spearhead Civilian Hospital Kits. The former consisted of such emergency medical supplies as cotton, bandage rolls, aspirin, sulfathiazole, gauze, alcohol, iodine, ether, sulfanilamide, and adhesive plaster, and were used by Civil Affairs officers when they first entered liberated villages. The latter were used to provide for the basic needs of civilian hospitals after liberation on the basis of one kit per 100 beds. The hospital kits were furnished gratis to the hospital only until the reestablishment of civilian government and the sale of medical supplies (CAD units) had become established in the area. Refugee Medical Kits were also made up, and were issued gratis to the refugee camp dispensaries. This was essentially a Spearhead Medical Kit, supplemented by various drugs.

In November 1943, Region III Military Government Headquarters set up a second central medical supply depot in a Red Cross warehouse in Naples. This was later taken over and operated by ACC under the direct supervision of Col. Martin E. Griffin, MC. Colonel Griffin, assigned by The Surgeon General on request of ACC, succeeded in reorganizing the entire ACC civilian supply program. Because of Colonel Griffin's wide knowledge of Army medical supply problems, the civil affairs supply program was, for the first time, efficiently coordinated with that of the combat forces.

As the Allied troops moved forward, the principal items in critically short supply were cotton, iodine, bandages, anesthetics, suture material, serums, vaccines, sulfanilamide drugs, alcohol, insulin, and antiseptics. There was never a shortage of drugs for the population of Sicily. However, considerable hardship was experienced in Region IX because of the failure both to plan sufficiently far in advance and to accept the initial supply requisitions; as a result, 15th Army Group did not receive instructions changing the method of requisitioning. This was corrected later and emergency supplies were furnished directly from the Naples warehouse.

The period under discussion was hardly long enough to enable one to draw any final conclusions on the adequacy of distribution of items and quantities within the ARB and CAD unit lists. The Italians always wanted more drugs in ampoule form for injection, but this was not considered to be essential. Most Italian physicians were accustomed to using drugs with trade names and were unaccustomed to using drugs marked with drug names as were our supplies. This pointed to a need for a booklet which


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would describe, in the language of the country, the items and indications for their use, and doses, but AMG was too busy and too understaffed to undertake such a project.

During the period under discussion, there was no formal agreement between Military Government public health authorities and the Surgeons at any level regarding the distribution that was to be made of captured medical supplies, and there was no theater directive on this subject. The author considers such a directive to be important.

Volunteer Organizations

The Italian Red Cross was the largest volunteer organization operating in the medical field. In prewar times, many of the Italian Red Cross activities were in the field of service programs and were quite similar to those of the American Red Cross. However, during the war, after the Italian Red Cross was reorganized, they established many hospitals throughout Italy in which civilian air raid casualties were cared for. The personnel of these hospitals wore military uniforms and held grades and ratings similar to those of medical personnel in the Italian Army.

Allied Military Government began the reorganization of the Italian Red Cross on Sicily and appointed a new director with power to carry out the program throughout the entire island. The principal change in the new organization was the elimination of the pseudomilitary aspect of hospital operation and the system of rank and ratings. Hospitals built by the Red Cross were turned over to municipalities for operation under local government auspices. Fascists who were involved in the program were removed, and more stress was laid on service programs for the homeless and needy and those on disaster relief. This reorganization appeared to be highly successful and similar reorganizational measures were begun on the mainland.

Much help was given to AMG authorities by British and American Red Cross personnel serving with the AMG. Another volunteer agency in the field of medicine was the tuberculosis association, which had provincial branches and, in Sicily, had a coordinating organization in Palermo. The work of this group was not interfered with, although it should be stated that they were relatively ineffective. They had derived most of their funds from the Italian Government in the past, and official support was withdrawn when they were separated from Rome by the battleline.

Activities of the many insurance associations, several of which provided medical benefits, ceased. The new welfare program instituted by HQ, AMG, 15th Army Group, provided medical assistance to the indigent by payment of necessary medical and hospital charges for its relief clients.

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