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Chapter 1

Table of Contents

Chapter 1


Colonel O'Neill Barrett, Jr., MC, USA (Ret)

Vietnam, one of the smaller nations of Asia, has for 2,000 years enjoyed a prominence in history far out of proportion to its size or economic resources. American military assistance there began in 1950 when the United States decided to give military and economic aid to the French and Vietnamese to assist in the fight against the Vietminh. The defeat of the French forces at Dien Bien Phu in May 1954 and the subsequent Geneva agreement of July 1954 marked the end of colonialism and the establishment of independence and nationalism for the countries of Laos, Cambodia, and Vietnam. Vietnam was divided into areas, North and South, with the 17th parallel as the provisional Demarcation Line. General elections were to be held in July 1956 throughout the country to decide its future. However, such elections were never held.

In South Vietnam in July 1954, Emperor Bao Dai directed the formation of a new government under the leadership of Ngo Dinh Diem. In 1955, Prime Minister Diem called a national referendum to decide if the country should become a republic under his leadership. Diem, with 98 percent of the votes, replaced Bao Dai and proclaimed South Vietnam a republic and himself its first president. In support of the Republic of Vietnam, and especially because of increasing pressure of the Vietcong (Vietnamese Communists), the United States government established several military missions in South Vietnam, the largest and most permanent of which was the MAAGV (Military Assistance Advisory Group, Vietnam). Subsequent buildup of American forces resulted in a total of more than 2½ million U.S. troops having served there by March 1973.* Medical support was established and grew with this effort. This volume tells the story of internal medicine in the United States Army as it evolved and describes the lessons learned and relearned and the advances made in the recognition and treatment of disease.


Despite its small size and its location completely within the Tropics, South Vietnam has three well-defined geographic areas, each of which presents dif-

* Department of Defense Statistics Service. Inquiry, 20 Feb. 1975.


FIGURE 1.- Can Tho, a principal city of the Vietnam Delta, astride the Hau Giang River. Note the fields in cultivation in the outlying part of the city.

ferent environmental, military, and medical problems. The Mekong Delta occupies the southern two-fifths of the country, has heavy rainfall, and is an excellent rice-producing area. The delta, approximately 26,000 square miles, was built up by five branches of the Mekong River, one of the 12 great rivers in the world. Deposition of sediment advances the coastline to the south at a rate of 250 feet per year. Of the total area, 9,000 square miles are under rice cultivation. An extensive series of levees and dikes has been developed for flood control, but during the flood periods, the only dry land is that which forms the banks of canals and rivers (figs. 1 and 2). The high humidity in this area and the necessity for long periods of exposure in rice paddies contributed to the development of the serious dermatologic conditions in American troops described in the volume on skin diseases in the Internal Medicine in Vietnam series (MD-IM1).

The Chaine Annamitique, with several high plateaus, dominates the area extending from the delta north to and beyond the Demarcation Line. One of these plateau areas, known as the Central Highlands, covers an area of 20,000 square miles. This area is composed primarily of bamboo and tropical broadleaf forests interspersed with rubber plantations and farms (fig.3). In this area, troops developed malaria and scrub typhus.

The Central Lowlands consists of a fertile but quite narrow coastal strip lying to the east of the Chaine Annamitique. Rice and sugarcane are the major


FIGURE 2.- Aerial view of flooded rice paddies in the Mekong Delta.

crops. Fishing is an important industry along the coast, and small fishing villages are scattered throughout the coastal plain (fig.4). Several of the large cities of Vietnam-Cam Ranh, Nha Trang (fig.5), Da Nang, and Hue-are located along the coast.

The population of South Vietnam in the mid-1960's was estimated at 16 million. The majority, perhaps as many as 10 million, lived in the delta area where Saigon is located, 5 million lived in the Central Lowlands, and approximately 600,000 lived in the Central Highlands. At least 2 million people were refugees, half of whom arrived in South Vietnam soon after the end of the Indochina War. Another million had fled from areas controlled by the Vietcong. Because of the striking differences in geography, the population was unevenly distributed. Involuntary mobility because of the war compounded this problem. The majority of the population either was rural or lived in small urban centers; only 10 percent of the population lived in the major cities (fig.6).

At least 85 percent of the population in the mid-1960's were ethnic Vietnamese who had settled in the Mekong Delta or the river valleys and coastal portions of the Central Lowlands (fig.7). Culturally and ethnically they are related closely to the Chinese, the largest minority group. The Chinese numbered approximately 1 million, living primarily in the Cho Lon area of Saigon (fig.8). They retained a cultural distinctness and had a tremendous economic impact on the country, despite an attempt at government-directed assimilation. The next largest minority group, the Montagnards (mountain people), lives in the highlands. This group included more than 30 tribes, probably numbering 700,000 to 1 million people (fig.9). Referred to as Moi - a derogatory term meaning


FIGURE 3.- Grazing cattle on the open plains near Pleiku in the Central Highlands, an ideal farming area.

"savage"-by the Vietnamese, they suffered most from racial discrimination in Vietnam. In the late 1960's, at least the official attitude toward the Montagnards began to change in order to counter the efforts of the Vietcong to infiltrate and win over rural populations. Despite some attempts at improved economic standards and living conditions, this group represented a serious political, economic, and medical problem to the central government. Other prominent minorities included the Khmers and the Chams.


Had they been actively sought, some data, although admittedly sketchy, were available to American physicians which could have served as background information for the medical experience which was to develop. In fact, however, almost no information was presented to those first medical units to arrive in Vietnam. The advance party of the 8th Field Hospital, the first medical unit assigned to Vietnam, was briefed by the office of the USARPAC (U.S. Army, Pacific) surgeon and by the commander of the U.S. Army Hospital, USARYIS (U.S. Army, Ryukyu Islands). Available information was vague and consisted of an awareness of malaria, some concern about the high incidence of tuberculosis in the civilian population, and a knowledge that there were large numbers of poisonous snakes in the country. On the other hand, the potential scope of the


FIGURE 4.- Small fishing village near Nha Trang, nestled to the east of the Chaȋne Annamitique.

malaria problem was not anticipated, and although both scrub typhus and leptospirosis were under active study at the U.S. Army Research Unit, Kuala Lumpur, Malaya, the presence of these diseases in Vietnam was not reported. Cholera, though anticipated, never became a problem in American troops. Bubonic plague, endemic and epidemic in the civilian population, also did not seriously affect U.S. personnel.

In this review, the more important diseases, by comparison and contrast, are discussed together from the Vietnamese and French points of view. The data gathered on diseases in the Vietnamese population and French forces reflect experience remarkably similar to that later recorded by American medical personnel and would have been useful background information. The preciseness and validity of the Vietnamese data are admittedly questionable because of the difficulty in gathering data in that country, unavailability of data from ARVN (Army, Republic of Vietnam) sources, and lack of trained personnel and diagnostic facilities to confirm suspected diagnoses. The problem was compounded by the negative Vietnamese attitude toward autopsy based on both custom and religious belief. In the Buddhist faith, with its concept of reincarnation, corporal mutilation is forbidden. Therefore, except in rare legal cases, autopsy was not performed.

Civilian medical services in Vietnam were poor, even though support was provided by official and unofficial groups from outside the country. This support


FIGURE 5.- Nha Trang, situated along the east coast of the fertile lowlands, commands an ideal harbor.

included Project Vietnam, sponsored by the American Medical Association; Project HOPE (Health Opportunity for People Everywhere); MEDICO (Medical International Cooperation Organization); the MILPHAP Program (Military Provincial Health Assistance Program); and the MEDCAP (Medical Civic Action Program) teams of the U.S. Army Medical Corps. A department of public health had been in existence since independence, ostensibly operating through provincial medical officers, responsible for all governmental health facilities and programs in each province. In many instances, however, facilities and personnel existed only on paper; in others, facilities were so understaffed and personnel so poorly trained that their impact was negligible. Although Western-style medicine first was introduced into Vietnam before 1800 by medical missionaries, and despite French activities in establishing hospitals and clinics, the majority of Vietnamese received care via traditional oriental medicine.

In 1965, there were approximately 800 Western-trained physicians in the country, 500 serving in ARVN and 150 civilian physicians in private practice in Saigon, with the remainder of the country having a total of 150 doctors, or one for each 100,000 persons. Inadequate supplies, facilities, and training further limited the effectiveness of this potential reservoir for sound medical care. Two medical schools, one in Saigon and one in Hue, were the only continuous source of physicians. The school in Saigon, however, graduated only 50 students per year, nowhere near the number needed to meet the requirements of the country.


FIGURE 6.- Aerial views of Saigon. Top: Natural access to the sea along the Saigon River. Bottom: An example of congestion in major cities.


FIGURE 7.- Canals were used for commercial and public transportation, as well as a source of water for the people. Top: Typical dwelling on a levee in the Mekong Delta. Bottom: Sampans.


FIGURE 8.- Commercial activity on crowded Cho Lon street.

The three branches of  l'Institut Pasteur, located in Saigon, Da Lat, and Nha Trang, offered some degree of medical sophistication, especially in microbiology and the production of vaccines and serums. In addition to the meager supply of physicians, there were 3,100 nurses, 1,213 midwives, and 5,000 other paramedical workers, including health workers, sanitary agents, and dispensary personnel (Smith et al. 1967, p.131). Despite the French and later the American influence in the country, the prestige and acceptance of Western medicine had developed slowly throughout most of the country.

By contrast, the country had at least 4,600 practitioners of traditional oriental medicine (ong lang) (Smith et al.1967, p.133). These doctors retained great prestige, especially since they represented deep-rooted cultural values and social traditions. Their techniques included acupuncture, cupping, moxibustion, and the use of a large pharmacopoeia of herbs, many of which have therapeutic value.

For the French forces in Vietnam, the incidence* of the 10 most common causes for hospital admissions from 1945 to 1954 was as follows (MI-OTSG, p.3):

Skin diseases - 42

Digestive disorders (except amebiasis)- 36

Respiratory disorders (except tuberculosis) - 28

Venereal diseases - 21

Diseases of the sense organs - 21

Malaria - 19

* The incidence is expressed as a 9-year average of the number of cases per 1,000 troops and corresponds to the ratio between the average monthly number of troops and the average monthly number of patients.



FIGURE 9.- Typical Montagnard tribesman seen in Central Highlands village.

Amebiasis - 11

Neuropsychiatric disorders - 2

Contagious diseases - 3

Beriberi - 1

Skin diseases, gastrointestinal problems, and respiratory infections (excluding tuberculosis) were the most frequent problems, a pattern similar to that seen in American troops in later years.


As was true for Americans, most of the skin disorders among French troops resulted from inadequate personal hygiene and especially the inability to obtain clean and dry underclothes and socks. The official French files (MI-OTSG, p.22) stated that mechanical washing installations, though not attaining the perfection of washing equipment in the American Army, would have made it possible to boil linen and thus kill germs which would otherwise not be destroyed through washing.



The most common digestive disorders affecting French troops, aside from amebiasis, were salmonellosis and shigellosis. Shigellosis was never a serious problem; only a few minor epidemics were reported and only two deaths occurred in a 9-year period. On the other hand, salmonellosis was an important infectious disease among the expeditionary forces. Epidemiologically, Salmonella typhosa was the predominant organism, isolated in 89 percent of all positive cultures. Its seriousness was emphasized by an 11-percent mortality rate. The disease was generally sporadic in nature and not seasonal in occurrence. One major epidemic of typhoid fever occurred in 1954 during resettlement of a tribe of Nungs. This group of natives had not been vaccinated, and the mortality rate was approximately 25 percent (MI-OTSG, pp.12-13). In the Vietnamese, the incidence of typhoid fever and of salmonellosis was considered high, but reliable figures are lacking. When culture data were available, S. typhosa again was the prevalent organism isolated. Possible sources of infection were pigs and the gecko (Gecko verticillatus), a reptile whose meat is eaten and in whom the carrier rate is as high as 50 percent. On the other hand, poultry sources, including duck eggs, played an insignificant role in the dissemination of salmonellosis in Vietnam.

In contrast to the American experience, amebiasis was considered the most serious endemic disease encountered in Indochina. During the 1945-54 period, 193,308 cases were diagnosed, resulting in 192 deaths (mostly among prisoners captured at Dien Bien Phu) and 4,953 medical discharges (MI-OTSG, p.9).

Two striking statistical observations were made concerning the occurrence of amebiasis. The first was that the rate of occurrence was as high among medical corps units as among combat troops. Further, the incidence was quite high (8 to 10 percent) in European and North African troops, lower (5 percent) in African troops, and quite low (4 percent) among Indochinese troops of the "French Union." These data are shown in table 1. There is no information to suggest whether or not this difference represented partial immunity to the disease in native troops in the French forces. Hepatic amebic abscess was a serious complication, and in 1954 alone, 50 such abscesses were surgically drained (MIOTSG, p.11). Epidemiologically, the disease was noted to be seasonal, most cases occurring during the hot season. In contrast to the French experience, amebiasis was a serious cause of morbidity in the Vietnamese population, was listed as the third most common communicable disease in the country, and

TABLE 1.- Incidence of amebiasis by race and combat status, French forces, 1945-54


occurred four times as often as bacillary dysentery. The seasonal variation noted in the French statistics is not reflected in the Vietnamese data.

Venereal disease was one of the principal problems encountered by the French Army Health Service during the Indochina War. A total of 207,893 cases were reported from 1946 to 1954, including gonorrhea, syphilis, granuloma in guinale, and lymphogranuloma venereum (MI-OTSG, pp.21-22). Numbers of cases and incidence rates are shown in table 2. These data differ from the American experience in at least two ways. The relative number of cases of syphilis was high in the French experience and extremely low in the American data. On the other hand, chancroid was relatively common in American troops and is not even listed as a cause of disease in the French data. Definitive data on the occurrence of venereal disease in the Vietnamese population were lacking.

TABLE 2.- Venereal diseases in French troops in Vietnam, 1946-54

In the Tropics, malaria is ever present. In combat, it often has produced more ineffectiveness than all battle and nonbattle injuries. Col. C. H. Melville (1910) wrote: "The history of malaria in war might almost be taken to be the history of war itself, certainly the history of war in the Christian era." In German East Africa in 1918, there were 72,000 hospitalizations among 50,000 troops, or an occurrence rate of 1,440 cases per 1,000 troops per year. For the 1946-54 period, a total of 293,814 cases of malaria were recorded among the French forces. During 1946, the incidence was 40 per 1,000 troops per year; it decreased dramatically by 1954 to 8.6 per 1,000. The death total for the entire period was 620. In contrast to that of amebiasis, the incidence of malaria among medical troops was far lower than in combat units (MI-OTSG, pp.6-7).

The striking reduction in incidence of malaria by 1954 was attributed to two factors, chemoprophylaxis and preventive measures. During the 1946-48 period, chemoprophylaxis was provided through use of quinine and quinacrine. The incidence during this period was quite high. By 1949, paludrine was the prophylactic agent used, and the decline in incidence began at that point. Of equal importance, however, was the institution of stringent preventive measures including the use of mosquito nets, long sleeves and pants, and insect repellent. At all cantonments, DDT was regularly sprayed, either in suspension or dissolved in petroleum. Although it was a serious problem, malaria did not play the tragic role in the Indochina War that it had in earlier campaigns in the Tropics.


Malaria has always been one of the most important causes of morbidity and mortality among the Vietnamese. The government, through the Malaria Eradication General Administration and the World Health Organization teams, had made significant strides toward the control of malaria in Vietnam during the late 1950's. Increasing hostilities after 1960 made the task of malaria eradication impossible.

In South Vietnam, malaria is primarily a disease of the mountain areas. A hyperendemic area exists in the southern Central Highlands, a region extending broadly in the north and east toward the mountainous part of the provinces of Binh Tuy, Long Khanh, Phuoc Long, Binh Long and the northern parts of the provinces of Bien Hoa, Binh Duong, and Tay Ninh. There is no good evidence for endemic malaria in the coastal plains, and cases seen in urban areas are believed to have been imported by persons migrating or traveling extensively in endemic areas (Smith et al. 1967, p.126).

In the American malaria experience discussed later (Part III), the species difference, especially after the recognition of chloroquine-resistant falciparum malaria, was an important consideration in the evaluation of the malaria prob lem. Available data, including French and Vietnamese records, contained no comments about the species encountered, and certainly no evidence suggested that the falciparum species would present the problem it did in terms of drug resistance.

Three other common infectious diseases in the Vietnamese population-tuberculosis, leprosy, and trachoma-deserve comment, although they were of no significance in either French or American troops. Tuberculosis has always been a serious problem in Vietnam. Following independence, the central government established an antituberculosis program. Best available data suggest that as many as 500,000 cases of active disease existed in 1960. Of the almost 23,000 new cases reported in 1955, approximately 9 percent had involvement of bones or joints. If all extrapulmonary forms are considered, 32 percent of all new cases were nonpulmonary forms of the disease (Zeville 1961, pp.75-77).

Leprosy was another serious infectious disease common in the Vietnamese civilian population (fig.10) but not reported in either French or American troops. An assessment of the disease in Vietnam by "The Anti Leprosy Struggle National Plan" indicated approximately 50,000 cases in the country, with 9,000 cases in Saigon. The disease occurred predominantly in inhabitants of the highlands; endemic rates here were among the highest in the world. Some statistical evidence suggests that the frequency of new cases was declining during the 1948-59 period (Zeville 1961, pp.37-39).

Trachoma was one of the great social and medical problems in Vietnam, ranking second only to malaria in the list of the most common infectious diseases in the country (excluding acute respiratory infections). While most of the cases were mild and chronic in nature, an estimated 30 percent of those affected suffered partial loss of vision. There was a striking geographic difference in incidence of the disease within the country. It was common in the coastal districts of central Vietnam, especially in the provinces of Quang Ngai and Quang Tri, and


FIGURE 10.- Leprosy patients were treated in the hospital in Qui Nhon. Top: Characteristic leonine facies. Bottom: Deformed hands of lepromatous leprosy.


the areas of Phan Thiet and Phan Rang. Rates were significantly lower in the highlands and the delta areas. The disease apparently is contracted early in childhood; in some endemic areas, 60 percent of children tested were found to have the disease. Vigorous efforts by the central government and USOM (U.S. Operations Mission), using trachoma-prevention teams and aureomycin ophthalmic ointment, seemed to have had some effect in decreasing the incidence of the disease (Zeville 1961, pp. 93-95).

Scrub typhus was first suspected in Vietnam in 1935 and was confirmed by 1'Institut Pasteur in 1937. Scant data are available from Vietnamese sources since it was not a reportable disease in the country. Occasional cases were known to occur, and at least two minor epidemics have been described. In 1942, 22 cases occurred in North Vietnam; in 1950 an "epidemic" was reported among troops in Chau Doc, but details are not available. No information is available concerning the species or vector of the disease (Zeville 1961, p.63).

Despite knowledge of scrub typhus in Vietnam, the disease was not considered important at the beginning of the Indochina campaign. Only 4 cases were reported in 1949, and 19 more in 1950. As French troops entered the Chaine Annamitique, the endemic area for scrub typhus, they experienced violent outbreaks. By the end of the campaign, a total of 5,708 cases and 158 deaths had been recorded (MI-OTSG, pp.19-20).

An uncommon disease, which has nevertheless generated much interest, is melioidosis. It was first identified in Vietnam in 1925, both in human cases and in epizootic form. Vietnamese epidemiological data suggested that human infection developed by exposure to contaminated mud or water by way of the skin or respiratory tract. Evidence also suggested that arthropods might be involved in transmission of the disease. Among French troops sporadic cases were noted, although the incidence was probably higher than recognized since the pulmonary form resembles tuberculosis. Again, epidemiological data suggested that soil from rice fields and irrigation canals was the primary source, explaining why accident victims and troops with open wounds who fell in rice fields developed the disease. During the 1953-54 period, 21 cases among French troops were reported (MI-OTSG, p.15).

Intestinal parasitism is widespread in Vietnam and is especially common among children. Infection rates are unknown, but one Vietnamese physician commented (Zeville 1961, p. 45): "Everybody is infected." In fact, surveys of schoolchildren in some areas showed a 100-percent infection rate. The parasites most commonly seen included Ascaris lumbricoides, Ancylostoma duodenale, Trichuris trichiura, Giardia lamblia, and Strongyloides stercoralis. Multiple organisms in the same patient were not uncommon.

Cholera has occurred in epidemic proportions in Indochina since the second half of the nineteenth century. In 1850, an epidemic involving 2 million people was reported. In 1908, an attack occurred in Hue affecting half the population of the city, with a mortality rate of 70 percent. The highest incidence of disease was noted in the south, especially in the delta region where control of coastal traffic was difficult. Cholera, however, was not a problem for the French expeditionary


forces during the 9 years of the Indochina War. A total of only 110 cases, leading to 55 deaths, was seen (MI-OTSG, p. 5). Although two minor epidemics occurred in the civilian population in 1946-47, the spread of disease was prevented, in large part, by the use of repeated vaccination, enforcement of hygienic measures, and the use of fresh water supplies. In the spring of 1964, a cholera epidemic occurred throughout South Vietnam. More than 15,000 cases but only 700 deaths were recorded. This relatively low death rate was the result of massive United States aid. More than $1.8 million worth of intravenous fluids were provided and administered by United States and Vietnamese personnel. Immunization activities were undertaken in several provinces, but effectiveness was hampered by Vietcong propaganda which convinced the local population that "the needle" would kill them (Smith et al. 1967, pp. 127-28).

Plague has been a persistent problem for the Vietnamese. The first reported epidemic in South Vietnam occurred in 1906. Rats transported to Saigon in material brought from Canton and Hong Kong were apparently responsible. The epidemic spread to Cho Lon, Gia Dinh, and Soc Trang. Serotherapy was attempted at this time but was unsuccessful. Mortality in untreated patients was 86 percent; in those treated, it was 72 percent. In 1914, during an outbreak at Can Tho which spread to Vinh Long, a 100-percent mortality rate was observed in cases of pneumonic plague. Before the onset of the Indochina War, some sporadic cases were noted, although none were reported from 1937 to 1941. As judged by more recent experience, this information probably does not represent a true decline in the disease but rather imprecise reporting, as was seen in 1962 when the central government refused to acknowledge proven cases in Nha Trang. In 1948, 355 cases were reported from Indochina, although only 80 were recorded in South Vietnam. Between 1952 and 1960, sporadic cases were reported, especially from coastal areas in South Vietnam (Zeville 1961, pp. 54-55). Like cholera, plague was not a problem for French troops in Indochina. Of a total of 17 cases recorded throughout the entire war, 14 were among Indochinese troops. Two of these patients died. Because of the presence of murine agents in camp areas, French authorities always enforced vigorous control measures, including control of the rat population and close supervision of food and garbage disposal (MI-OTSG, p.5).

A final comment concerning alcohol and drug abuse is appropriate, especially in view of the drug problem which developed in American troops. Alcoholism was a serious problem throughout the Indochina War, almost ex clusively involving troops of the "French Union," primarily European troops. A contributing factor, in addition to whisky, was the availability of beers with a high alcoholic content. In 1953, there were 1,438 admissions for alcoholism, or 0.05 percent of all hospital admissions. Of all medical discharges in 1953, 10 percent were for chronic alcoholism. The true impact of alcoholism is underemphasized by these figures since they reflect only the direct effects of alcohol. The consulting physician for the Armed Forces of the Far East estimated that alcoholism was the indirect cause of 50 percent of medical deaths in 1947 (MI-OTSG, p.24).


Regarding the use of drugs by French forces during the Indochina War, the experience is tersely summarized by the statement, "Health problems caused by drug abuse were practically non-existent during the Indochinese campaign" (MI-OTSG, p.27). This is in dramatic contrast to the tragic story concerning American troops told in the forthcoming volume on drug abuse in the Internal Medicine in Vietnam series (MD-IM3).

The final medical results of the Indochina War, 1945-54, as listed below, were tabulated by Surgeon-General Blanc and Surgeon-Captain Armengaud of France and graphically relate the problems of the medical service of the Expeditionary Corps (Black):

Men serving tours in Indochina,1945-54 - 1,609,989
Hospitalized for medical reasons - 694,123
Died of disease - 5,154

Evacuated for medical reasons - 33,913


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