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Part I



Problems of Civilian Health Under War Conditions-General Concepts and Origins

Thomas B. Turner, M.D., and Ira V. Hiscock, M.P.H., M.D.

Section I. Concept and Development

Thomas B. Turner, M.D.

The complexities of modern war made it necessary for the U.S. Army in World War II to engage in many new and expanding activities to meet a demonstrated military need. Some of the measures appeared to be remote from military operations at the outset of the war, and many of them were developed with increasing experience and were adapted to changing and widely varying conditions. Civil affairs and military government activities may be placed in this category.

The development and practice of civil affairs and military government by the U.S. Army may be traced from George Washington in the Revolutionary War to World War II and beyond. Washington, interested in both logistics and rudimentary preventive medicine, was concerned with the mutual effects of relations between troops and civilians. One example of his administrative action in this field was his appointment of Gen. Benedict Arnold as military governor of Philadelphia in 1778 after the British, under Sir Henry Clinton, withdrew from the city.

In a more practical way, the U.S. Army had been acquiring experience in military government and civil affairs, including public health and preventive medicine, for nearly a century before World War II. The history of this subject has been recounted by Gabriel and by Holborn, and set forth in great detail in an unpublished study by Daugherty and Andrews of the Operations Research Office (later known as the Research Analysis Corp.).1 

For the United States, the earliest large-scale venture in the field of preventive medicine and public health occurred during and after the Mexican War (1846-48), with the occupation of New Mexico by Gen. Stephen W. Kearny and of Mexico City, Mexico, by Maj. Gen. Winfield Scott. In New Mexico, military government was not highly successful, principally because the occupying authorities failed to consider the customs

1(1) Gabriel, R. H.: American Experience With Military Government. Am. Political Sc. Rev. 37: 417, 1943. (2) Holborn, Hajo: American Military Government: Its Organization and Policies. Washington, D.C.: Infantry Journal Press, 1947. (3) Technical Paper (ORO-TP-29), A Review of U.S. Historical Experience With Civil Affairs, 1776-1954. Prepared by W. E. Daugherty and M. Andrews, Operations Research Office, Bethesda, Md., 1961.


and problems of the inhabitants. In Mexico, on the other hand, General Scott's administration of military government and public relations was conducted with intelligence, with liberality coupled with firmness, and with fairness and understanding. It was responsible for the Mexican people's opposition to General Santa Anna. In his scholarly article on this subject, Gabriel has expressed the opinion that the friendly behavior of the population of Jalapa "is one of the outstanding civil affairs victories in American military history," and that General Scott's plans, orders, and operations put "into effect the principles which have subsequently been fundamental to the American practice of military government and civil affairs."2

In 1918, the Third U.S. Army was called upon to institute military government in the Rhineland with less than 3 weeks of preparation for this responsibility. Because time did not permit the formulation of detailed plans and the preparation of personnel, incoherence of policy and vacillation of purpose were observed especially in the early days of this occupation. Fortunately for the success of the mission, no destruction had preceded the occupation, civil officials could be kept at their tasks, hostilities had ceased, and there was no serious shortage of essential civilian supplies.

Although these and other provisions had been made in the past for the administration of civil affairs in connection with military government, there was little concept, in 1939, of the potential scope and importance of these activities. The vastness and complexity of civil affairs and military government operations that developed in World War II were only partly envisioned in the early planning of the American effort.

By 1940, however, the civil affairs function began to be recognized as something more than military government, and the intelligent and inspiring influence of Lt. Col. (later Brig. Gen.) James S. Simmons, MC, newly appointed chief of preventive medicine in the Surgeon General's Office, resulted in many important new developments. In these developments, the elements of cultures, sociology, economics, and public health came into prominence.

On 30 July 1940, FM 27-5, the first basic Field Manual on military government, was issued by the War Department,3 and discussions then in progress led finally to the establishment, in March 1942, of the School of Military Government at Charlottesville, Va.

The invasion of North Africa on 8 November 1942 brought a host of complicated problems of civil affairs, demonstrating that the military organizations rather than the State Department were the inevitable and best primary agencies to deal with these matters. The problems increased in such volume and difficulty that the existing organization and staff of the

2Gabriel, R. H.: American Experience With Military Government. The Am. Hist. Rev. 49: 633, 637, July 1944.
3By the end of the war, Civil Affairs and Military Government came to be regarded as a grouping of terms employed for convenience to refer to either civil affairs or military government, depending upon the context. See Department of the Army Field Manual 41-10, Civil Affairs Military Government Operations, 2 May 1957.


higher command in Washington could not cope with them effectively. Therefore, on 1 March 1943, the Secretary of War created a Civil Affairs Division as a part of the War Department Special Staff. The first director of this division was Maj. Gen. John H. Hilldring, GS, who took office on 7 April 1943. The Civil Affairs Division acquired extensive responsibilities and became an influential section of the military staff as well as a center of worldwide management of economic, social, public health, and governmental affairs in all countries liberated or occupied as the result of Allied military operations. Additionally, both before and after the establishment of the Civil Affairs Division, an officer in the Operations Division of the War Department General Staff assisted with many civil affairs and military government matters. There was, however, no G-5 (or civil affairs) section for this function in the General Staff in Washington. In May 1944, first in the headquarters of SHAEF (Supreme Headquarters, Allied Expeditionary Force), a "fifth staff officer"4 was appointed with the designation "Assistant Chief of Staff, G-5" and assumed command of the G-5 section. Similar arrangements were made in most of the overseas theaters of operations and in some of the armies.

Personnel problems were particularly acute, especially in the beginning. Extensive efforts were made to secure and develop men competent to do the required work. Civil affairs officers, especially selected on the basis of civilian experience in public administration, were trained in the language, history, governmental structure, and customs of the country to be occupied.

The pressure of events contributed to a steadily expanding role for civil affairs in the various theaters of operations. World War II was total war in the most literal sense. Complex political questions had to be decided quickly by the military commander. At the lower levels, the conduct of military government influenced the health and welfare of the individual civilian and, in turn, determined the cooperation and assistance which the Allied armies received from the civil population. Moreover, events demonstrated again that decisions made during a campaign, largely on the basis of military considerations, may affect profoundly the foreign policy in the postwar period. To every extent possible, therefore, such considerations should be foreseen at the time and balanced against military necessities.


Military government may be defined as the supreme authority exercised by an armed force over the lands, property, and inhabitants of enemy territory, or Allied or domestic territory recovered from enemy occupation. It is exercised when an armed force has occupied such territory, whether

4Mrazek, J. E.: The Fifth Staff Officer. Military Review, U.S. Army Command and General Staff College, Fort Leavenworth, Kans. 36: 48, March 1957.

by force or agreement, and has substituted its authority for that of the sovereign or previous government.

Situations frequently arise, however, in which an armed force exercises control over civilians to a lesser degree than under military government, or a friendly nation may govern the territory in which the military force is located, or a military force may be operating in areas controlled by its own nationals. To cover all of these relationships, the term "civil affairs" is commonly used in referring to those manifold and complex activities involving the government and the civilian inhabitants of such areas.


The field of responsibility broadly known as public health was a major component of civil affairs activities. Its importance rested on the following considerations:

1. Widespread disease in the civil populations can seriously impede military operations, either through the spread of disease to the military forces or through disruption of community activities supporting military operations.

2. Since public health is an integral part of government, the governing authority must assume responsibility for health programs directed to the prevention of epidemics and to the provision of facilities for medical care. Standards were those existing before the war and were to be restored as far as possible through the use of local personnel and facilities.

3. The character of World War II, with its aerial bombardment, rapid movement of ground troops, and bitter defense of cities, increased the danger to the civil population, which frequently sustained heavy casualties. Humanitarianism and the desire to secure the good will and cooperation of the civil population impelled the Allied military forces under such circumstances to render assistance in providing medical care for civilians who came under their control.

The basis of the Medical Department's responsibility towards civilians under Army control was specified in Army Regulations No. 40-5, dated 15 January 1926, which stated that among the general functions of the Medical Department would be "the preservation of health and the prevention of disease among personnel subject to military control, including the direction and execution of measures of public health among the inhabitants of occupied territory."




Beginning as little more than an idea in the minds of a few men in the spring of 1940, the civil affairs activities by the end of 1945, as an integral part of the operations of the victorious Allied armies, had en-


compassed the Italian peninsula, most of Western Europe, the Philippines, Japan, Korea, the Chinese mainland to a limited extent, certain territories and possessions of the United States, and numerous other areas. They were indeed global in scope. As with the master strategic plan for the war as a whole, it is instructive to look back to the genesis of the civil affairs program and to respect the vision of those officers of the Regular Army and of the Reserves who laid the groundwork for this major undertaking.

The fall of France to the German Army, in June 1940, brought a greater realization of things to come, with increasing perception that the U.S. Army, if involved in the war, would have heavy responsibilities for the health of both military and civilian personnel in liberated and occupied countries overseas. At this early date, Colonel Simmons began to formulate a plan for civil public health activities in relation to military government.5 To assist in this work, he arranged, during May and June 1940, to call to active duty Lt. Col. (later Col.) Ira V. Hiscock, SnC, and Lt. Col. (later Col.) Albert W. Sweet, SnC, from civilian health positions. They were joined later by Lt. Col. (later Col.) William A. Hardenbergh, SnC, who, even in the 1930's, at the Medical Field Service School at Carlisle Barracks, Pa., had formulated and taught in the military sanitation class a scheme of surveys, analysis, and recommendations for the health phases of military government in Mexico. This plan comprised elements of what became known later, from 1940 onward, as medical intelligence and civil public health affairs of military government.6 On 26 June 1940, Colonels Hiscock and Sweet submitted to The Surgeon General a plan for public health administration in occupied countries, which formed the basis of the program subsequently developed.7

In preparing this plan, health conditions were surveyed in a number of countries of the Western Hemisphere. As an outgrowth of these studies, what subsequently became the Medical Intelligence Division, Preventive Medicine Service, was organized in April 1941. As one of its services, this division provided essential medical and sanitary data on foreign countries for use in civil affairs training and planning.8

During 1940, advice was also given by Preventive Medicine Service of the Surgeon General's Office on the public health sections of a manual on military government then being drafted in the Office of the Chief of Staff (p. 4). This manual outlined the fundamental principles and scope of

5(1) Unpublished diary, Col. James S. Simmons, MC. Entry dated 20 May 1940. (2) Simmons, James S., Whayne, Tom F., Anderson, Gaylord W., Horack, Harold M., and collaborators: Global Epidemiology: A Geography of Disease and Sanitation. Volume I. Philadelphia: J. B. Lippincott Co., 1944, pp. vii, x.
6Letter, W. A. Hardenbergh to Dr. Douglass W. Walker, 5 June 1951, enclosing memorandum covering some early developments in Army civil affairs (by W. A. Hardenbergh), dated 5 June 1951.
7Report, Lt. Col. Ira V. Hiscock, SnC, and Lt. Col. A. W. Sweet, SnC, to The Surgeon General, 26 June 1940, subject: A Plan for the Military Administration of Public Health in Occupied Territory.
8(1) Office Order No. 87, War Department, Office of the Surgeon General, 18 Apr. 1941, subject: Further Reorganization of Professional Service Division and Designation of New Divisions. (2) Anderson, Gaylord W.: Medical Intelligence. In Medical Department, United States Army. Preventive Medicine in World War II. Volume IX. Special Fields. Washington: U.S. Government Printing Office, 1969. pp. 251-340.


public health. In 1943, on the basis of first experiences in North Africa, to expound a more rigid attitude toward the enemy, and to indicate new concepts, the original field manual was superseded by a joint Army and Navy publication.9



Geographically, Army civil public health activities were almost as farflung as the war itself. Whereas the varied terrain in different theaters of operations affected military tactics and thus brought about modifications in the operations of the fighting forces and of the attached medical components, civil affairs activities were less influenced by geographic features than by the differing cultural patterns of the peoples with whom they were concerned.

Differing languages, customs, and forms of government presented varied problems to civil affairs officers, necessitated the development of different plans of operation for various countries, and required frequent improvisation to cope with peculiarly local problems. On the other hand, a pattern of disease phenomena which recognizes no language barriers and a continuing thread of humanitarianism provided common denominators for civil affairs health activities throughout the many regions of the world in which the program functioned.

The civil affairs program inherently served two functions: a primary one in furthering strictly military operations, and a secondary one in laying the basis for subsequent policies beyond the military phase. This dual function, from which stems the importance of civil affairs, created a dichotomy of objective which caused many of the difficulties and the conflicts that plagued the civil affairs program throughout the war. These difficulties came to the surface principally in regard to organizational and administrative questions at higher echelons, but their effect was perceptible even at the lowest operational level. These same conflicts were encountered in the civil public health programs and constituted one of the major problems of civil public health in World War II.

In the chapters that follow, an account will be given of the health activities carried out by the U.S. Army, at times in collaboration with the British Army, at other times in conjunction with the U.S. Navy, and sometimes with the participation of the American National Red Cross, the U.S. Office of Foreign Relief and Rehabilitation Operations (later United Nations Relief and Rehabilitation Administration), or with other appropriate organizations. An effort will be made to evaluate the results of these activities in terms of the degree of success that attended the program instituted to meet the principal problems. However, an ironic characteristic of civilian and military public health and preventive medicine is that only its

9War Department Field Manual 27-5 and Navy Department OpNav 50E-3, Army-Navy Manual of Military Government and Civil Affairs, 22 Dec. 1943.


failures are spectacular, while its successes so often can be gauged only by the things that do not happen.


The civil health program, together with the military government and civil affairs program as a whole, may be divided into three principal phases: planning, combat, and occupation. A fourth phase, missions to friendly countries, may be recognized.

In addition, in several instances, as during maneuvers in the United States, during martial law in Hawaii, and in connection with the evacuation of the Japanese from California, civil affairs and public health activities were carried on by U.S. Army Forces that were operating in areas or possessions of their own country. These episodes are described in chapter IV.

Planning phase .-Careful and farsighted planning to meet anticipated situations is necessary for all military operations. However, in laying the plans for the early military government operations in Italy, and later in the Philippines, little attention was given to the medical and public health aspects of the problem. The emergencies that arose were met by improvisation; only heavy reliance on Medical Department personnel and some reliance on supplies earmarked for the fighting troops saved the civil public health program in these areas from ineffectiveness. On the other hand, the careful planning which preceded the invasions of Northwest Europe and Japan was reflected in the more satisfactory manner in which the civil health program functioned.

Combat phase .-The combat phase is limited to the period during and immediately following combat, and is territorially limited largely to the actual area of military operations. In this period, the medical program was stripped to its bare essentials-for example, medical care for wounded civilians, the exposed, the seriously ill, and parturient women; provision of a few basic lifesaving medical items, such as morphine, ether, surgical dressings, antibiotics, tetanus antitoxin, and insulin; the conservation of locally available medical items; and the provision of a relatively unpolluted water supply.

In Italy and Western Europe, the medical problems of this phase of the civil affairs operations were not excessive. Either the Army moved slowly and the civilians had time to evacuate the actual combat zone, or progress was rapid and cities and towns were not badly damaged. The cellars and subterranean passages, so common a feature of European buildings and towns, afforded good protection against shellfire. By contrast, in certain other areas, particularly the smaller islands of the Pacific, the flimsy houses offered little protection against naval gunfire and aerial bombing, and civilian casualties were high.


Occupation phase.-The occupation phase can be divided into stages: the first, which may be designated as the organization stage, extends from the combat stage to the period when authority is turned over to its original government, or until it is succeeded by the military government stage.

No sharp line can be drawn between the combat and the occupation phases of the civil health program for, in the early stages, the situation is likely to be changing rapidly. In some operations, particularly in Southern Italy, inaugurating the organization stages of the health program was delayed. This may be attributed to a combination of inadequate planning at lower echelons, shortage of personnel, and some confusion arising from an uncertainty as to relationship to more or less friendly peoples. When Germany and Northern Italy were reached, the results of superior planning and experience were evident in the rapidity with which the civil health program was converted from the combat to the organization stage.

The second stage, military government, is that level in which a relatively stable occupational government is established. Professionally, the problems differ little from those of the preceding stage except that longer range plans may be inaugurated. As will be noted later, the establishment of a commission form of government, in both Italy and Germany, was accompanied by some organizational changes, by important changes in personnel, and by a partial reorientation of the overall civil affairs program. In Italy, the activation of the Allied Control Commission (later Allied Commission), while most of the country had yet to be taken from the Nazis, resulted in conflicts in questions of authority and responsibility between representatives of the Allied Control Commission on the one hand, and those of Allied Force Headquarters on the other. This situation was particularly true in several episodes involving the civil health program. In Germany, the transfer of authority from SHAEF to the U.S. Group Control Council was completed without a break in the continuity of the civil health program; and the same was largely true in Austria. In Japan and in Korea, the entire civil affairs operation was confined to the military government phase.

Missions .-With the liberation of territory belonging to U.S. Allies, the governments of these countries immediately took over their rightful function. Since most of these countries had suffered damage both from military operations and from deprivation of food and medical supplies, the United States and Great Britain wanted to assist in providing an initial impetus toward rehabilitation. This was accomplished in Western Europe through the dispatch of missions, one to each country, which functioned under the policy direction of G-5 SHAEF. Each of these missions, which were numerically small, had one or more medical officers who were responsible for the health aspects of the missions' activities. Missions were sent to France, Belgium, the Netherlands, Denmark, Luxembourg, Romania, Bulgaria, and Greece. In the Far East, there was a mission to China.



The basic problems encountered in the Army civilian health program in liberated and occupied areas during World War II were essentially those normally present in those areas but which had been magnified and intensified by destruction, civilian casualties, disorganization, and shortages of medical personnel and supplies. In some instances, these problems occurred in areas, as in Northwestern Europe, where the level of sanitation and medical care had been high; while in other areas, as on Okinawa, the general level of public health had always been low.

Although the civil affairs health problems differed quantitatively rather than qualitatively from peacetime health problems, the responsibility of civil affairs health personnel was peculiarly one of organization, administration, and supply. In addition, complex problems such as the control of narcotic drugs and the control of typhus fever, where lack of control could be devastating for both civilians and troops, required the special attention of all concerned.

To restore local health services following occupation of an area, it was necessary frequently to go beyond what had existed before the war to provide adequate protection for military personnel. For instance, in a number of areas, no satisfactory system for reporting infectious diseases had ever existed, yet reliable statistical data on where and how much disease is occurring are an elemental requirement for any health program.

The entire civil affairs health program in World War II was supervised by a small number of Medical Department officers, and necessarily so, because of the severe shortage of such officers available to meet the demands of both the Armed Forces and the homefront. Consequently, local health personnel had to be relied upon almost entirely to implement the civilian health program in a particular area. Still, the Army civil public health officer provided a focal point around which local resources could be organized.

Depending upon the size of the area under control, the civil affairs health officer served a function analogous to that of the chief medical officer of a ministry of health, or a State or city health officer. In this capacity, he had both a staff function, as the principal medical adviser to the chief civil affairs officer, and a supervisory function, as the ranking professional in the organized health services of that area.

The responsibility of each civil public health officer within his sphere of activity was to appraise a given situation, outline a few clear and practical objectives, organize and direct local health and medical personnel, and assist in obtaining supplies and facilities essential to the program. Except in unusual circumstances, it can be regarded as a misdirection of energy for the civil public health officer to attempt to treat patients or to operate a clinic.


Section II. Development and Organization of Civil Public
Health at War Department Level

Thomas B. Turner, M.D., and Ira V. Hiscock, M.P.H., M.D.

The civil affairs program was a comparatively new development, and those phases pertaining to civilian health underwent a natural growth process of organization. In retrospect, this organizational evolution seems at times to have had little rationale. The net result, however, was the development, within the Army, of a group which did the job required in a creditable manner. Since so many of the problems encountered were administrative, the pattern will be described in some detail (chart 1).


The initial responsibility for development of a program and for recruitment of personnel for civil affairs and military government was assigned to Maj. Gen. Allen W. Gullion, The Provost Marshal General. In March 1942, the School of Military Government, under The Provost Marshal General, was established at the University of Virginia at Charlottesville, Va. Colonel Hiscock (fig. 1), as a member of the preventive medicine staff in the Surgeon General's Office, had been working since 1940 on plans for the administration of public health in occupied and liberated countries. In January 1943, he was placed on duty with the Provost Marshal General's Office as a representative of the Medical Department.

In addition to helping select professional personnel for the School of Military Government at Virginia, of which he was a graduate, and for several newly developed civil affairs training schools elsewhere, Colonel Hiscock served as liaison officer with 15 or more Government agencies then engaged in studying problems related to public health in the war effort, including especially the Health Committee of the Office of Foreign Relief and Rehabilitation Operations. This committee was comprised of The Surgeon General of the U.S. Public Health Service as chairman, representatives of The Surgeons General of the Army and the Navy, and other persons internationally prominent in public health.


When the Civil Affairs Division of the War Department Special Staff was organized on 1 March 1943, provision was made for a medical section in its Civilian Relief Branch. The Civil Affairs Division operated without a public health officer until 28 April 1943, when Colonel Hiscock was transferred to assume charge of what subsequently was designated the Public Health Section, which embraced health and medical services, hospitals, sanitation, and medical supplies.


CHART 1.-Organization of U.S. Army responsibility for Civil Public Health, 1943


FIGURE 1.-Col. Ira Vaughan Hiscock, SnC.

The following memorandum, prepared by Colonel Hiscock on 24 July 1943, indicated the magnitude of the public health problem in occupied territories, as visualized at the time:


Subject: Planning for Public Health in Occupied Territory.

1. Policy and planning are so closely inter-related that the Civilian Relief Branch, Public Health Section, regards consideration of forward planning as essential.

2. The prevention of epidemics and the provision of emergency medical services are primary functions of military government for which detailed coordinated plans are essential. The first task in each area set free from the invader presents the greatest challenge ever faced by medical and public officers, even with maximum use of local facilities.

a. As to epidemic disease, malaria is of first importance in Italy, the Balkans and the Pacific; dysentery and typhoid fever have a high incidence in many areas occupied or to be occupied; gonorrhea and syphilis increase under stress of war; all types of communicable disease increase in an undernourished and economically handicapped population. Typhus, which decimated the troops of Napoleon, is not an isolated phenomenon, witness the experience following the last war in the Soviet Union, and rumors indicate an increase in various countries during the last two winters.

b. Other problems include loss of physicians killed or driven into exile; systematic looting and destruction of hospitals; destruction of water supplies as in the Ruhr and at Bizerte and at Pantelleria; destruction by deliberate sabotage.

c. Of all tragedies of war and devastation, those related to mounting rates of mortality in maternity and infancy, affecting the health and strength of future generations, are of appealing urgency. Infant mortality rates in the Low Countries are soaring, and diseases of childhood will leave their mark on physique and morale.


d. Detailed plans are necessary for providing medical relief, sera and vaccines and other medical and sanitary supplies immediately on occupation of an area.

3. Progress in planning to date has included the following:

a. Recruitment and training of public health personnel selected from the Army, the U.S. Public Health Service, and civil life, coupled with the establishment of a Specialist Pool. This has given a list of about half of the number of such technical personnel as may be required on a global basis. These steps were taken by the Office of the Provost Marshal General in cooperation with the Office of the Surgeon General and with assistance from the Civil Affairs Division.

b. Preparation, under the auspices of the International Aid Division, ASF, with the participation of CAD, of basic lists of food, medical and sanitation supplies for use during the initial period of military operations.

c. Preparation, by CAD in cooperation with representatives of the Office of the Surgeon General, of a brief memorandum outlining basic features of a program for occupied territory.

d. Participation, in a liaison capacity, of CAD officers in the planning by OFRRO of public health programs to be undertaken in foreign areas when responsibility is turned over by the military to the civilian authorities.

e. Conferences, regarding public health plans and programs, of CAD officers with representatives of the Inter-Allied Post-War Requirements Committee (London) and of the British army.

4. Following the pattern which worked successfully in the preparation of lists of supplies, the Office of the Surgeon General proposes to enlarge the scope of the activities of the small Board which was constituted on the basis of the Directive of ASF, International Aid Division, to prepare lists of supplies in order to assist, as needed, in preliminary planning for the public health program and personnel required for effective functioning of military government.

5. If approved, the Public Health Section will maintain close and direct liaison with the above-mentioned Board of the Office of the Surgeon General. Furthermore, this Board should prove useful to CAD in consideration of technical questions of policy, program and supply in the public health field, and should be utilized as needs arise.

Colonel, SnC

Close liaison was maintained with the Surgeon General's Office, particularly the Preventive Medicine Service; the Special Planning Division, Operations Service; Personnel Service; and the Supply Service.


Beginning on 2 February 1943, Colonels Simmons and Hiscock discussed with the director of the Supply Division, Surgeon General's Office, the Army's responsibility for providing medical and sanitary supplies for civilian use during early stages of military operations. A series of conferences and interviews were held on the entire question of the Army's program of essential medical supply for civilians. On 18 May 1943, in an informal memorandum, the public health officer, Civil Affairs Division, recommended to the liaison officer, International Division, Army Service Forces, that "necessary plans be instituted to insure that adequate medical and sanitary supplies and such other items as may be required to meet


essential civilian health needs available for emergency use in occupied territory during the initial period of military operations." On 5 June 1943, in response to a 31 May 1943 request from the International Division, The Surgeon General nominated Col. Howard T. Wickert, MC, director of Plans Division, Operations Service, as the officer to be contacted by the International Division on matters pertaining to medical supplies for civilian populations. Finally, on 28 June 1943, under Office Order No. 419, The Surgeon General appointed a board of officers "to prepare, develop, and implement the medical portion of the War Department's program for aid to civilian populations in liberated countries." This board was later commonly referred to as the CAD Board, and consisted of representatives of Supply Service, Operations Service, and the various professional services. On 15 July 1943, Colonel Wickert was succeeded as president of this board by Col. Arthur B. Welsh, MC, who in turn was succeeded by Col. George M. Powell, MC, on 13 October 1943.



Definitive plans for a public health program in occupied and liberated territory were initiated in the fall of 1942 at the School of Military Government, and were developed further with the organization of the Civil Affairs Division, War Department Special Staff. This program was based largely on the original plan written in the Preventive Medicine Division, in June 1940, by Colonels Hiscock and Sweet under the direction of Colonel Simmons.10 Although constant informal contact was maintained between the Public Health Section of the Civil Affairs Division, War Department Special Staff, and the Preventive Medicine Division, Office of the Surgeon General, it became evident in the fall of 1943 that the responsibilities of The Surgeon General had increased to a point where it was necessary for his office to participate even more actively in the Civil Affairs Division public health program. On 6 November 1943, a letter from the public health officer, with concurrence of the Chief, Civil Affairs Division, stated:

* * * it is understood that the function of the Civil Affairs Division is related primarily to policy. Furthermore, while it is essential that there be a public health officer on a regular basis in the Civil Affairs Division, it is also believed that the Office of The Surgeon General is the logical agency for carrying forward plans for health organization and service. An officer on duty in the Civil Affairs Division is in a key position to participate in these activities in a liaison capacity.

From the foregoing, it is evident that between early 1940 and late 1943 detailed plans had been made for large portions of a program for the administration of civil affairs in connection with military government in occupied and liberated countries, and that several highly important organizational steps had been taken by the General Staff; the Civil Affairs

10See footnote 7, p. 7.


Division of the Special Staff; the Provost Marshal General's Office; and the Surgeon General's Office and several of its divisions, notably the Preventive Medicine Division. During this time, President Roosevelt and certain members of his cabinet were keenly concerned with these matters. Although experience, which took time, was needed to delineate clearly the essential role that the Army would play in civil affairs and military government, the Army's responsibilities and authority were definitely enunciated by President Roosevelt in a letter to the Secretary of War on 10 November 1943, which follows:


November 10, 1943

Dear Mr. Secretary:

Although other agencies of the Government are preparing themselves for the work that must be done in connection with the relief and rehabilitation of liberated areas, it is quite apparent if prompt results are to be obtained the Army will have to assume the initial burden of shipping and distributing relief supplies. This will not only be the case in the event that active military operations are under way, but also in the event of a German collapse. I envisage that in the event of a German collapse, the need for the Army to undertake this work will be all the more apparent.

Therefore, I direct that you have the Army undertake the planning necessary to enable it to carry out this task to the end that it shall be prepared to perform this function, pending such time as civilian agencies must be prepared to carry out the longer range program of relief.

You may take this letter as my authority to you to call upon all other agencies of the Government for such plans and assistance as you may need. For all matters of policy that have to be determined in connection with this work you will consult with the State Department for any political advice; and upon the Treasury for such economic and fiscal direction as you may need.

        Very sincerely yours,
Franklin  D. Roosevelt.

The Honorable
    The Secretary of War
    Washington, D.C.

On 14 November 1943, before the President's letter reached the Surgeon General's Office, General Simmons, in a letter to The Surgeon General, recommended that a branch designated as the "Civil Affairs Public Health Branch" be established in the Preventive Medicine Division and that the purpose of this branch be to coordinate and handle for The Surgeon General all matters pertaining to the development of the public health program for occupied territories subject to policy directives of the Civil Affairs Division of the Special Staff.11

The necessity for such an organization within the Surgeon General's Office became clearer upon the receipt from the International Division of a memorandum, dated 7 December 1943, subject: Civilian Relief Require-

11Letter, Brig. Gen. James S. Simmons, USA, Director, Preventive Medicine Division, Office of the Surgeon General, to The Surgeon General, 14 Nov. 1943, subject: Recommendation of the Establishment of a "Civil Affairs Public Health Branch."


FIGURE 2.-Thomas B. Turner, M.D., formerly Colonel, Medical Corps.

ments for Europe in the Event of Collapse. This memorandum enclosed a copy of the letter from President Roosevelt to the Secretary of War.

In response to General Simmons' recommendation, the Civil Public Health Division was established as part of the Preventive Medicine Service on 1 January 1944.12 Lt. Col. (later Col.) Thomas B. Turner, MC, was appointed as its first director (fig. 2).

Civil Affairs Branch, Special Planning Division, Operations Service,
Surgeon General's Office

As noted previously, The Surgeon General established, on 28 June 1943, the Civil Affairs Division Board, which made extensive studies of civilian requirements for medical supplies. On 23 December 1943, a memorandum from the Commanding General, Army Service Forces, to the various technical services, directed the establishment of a full-time civilian supply unit. This memorandum stated:

1. It is becoming increasingly apparent that the supply of civilian populations in combat areas, zones of communications, and in liberated areas vitally affects operations and operational plans.

12Office Order No. 4, Army Service Forces, Office of the Surgeon General, 1 Jan. 1944.


2. Estimating requirements for civilian populations under various operational plans and in the event of a collapse of Germany, pursuant to the President's directive dated 10 November 1943 calls for special knowledge of conditions within the various countries and a special technique of research in order that estimated requirements can be made reasonably firm.

* * * * * * * *

4. There is a need for the preparation of proper estimates of requirements on a country by country basis and proper plans for handling civilian relief supplies both in connection with operations and in the event of collapse. The problems involve study of the internal economy of each country, its industries and its distribution system. Study of proper export and import relationships with other countries is also required. The need for solutions of many of the problems raised is pressing. Experience has shown that, while it may be desirable to utilize personnel engaged in current requirement and procurement activities, in the development of such plans, at least the supervision and direction of the estimates of requirements and preparation of plans requires the undivided attention of competent personnel.

5. It is therefore directed that a civilian supply unit be established on the staff of each Chief of Technical Service mentioned above, unless such action has already been taken. It is desired that each such unit have initially assigned to it at least one qualified officer for full time duty with the unit. * * *.

In response to this memorandum, a Civil Affairs Branch was established in the Special Planning Division of the Operations Service on 5 February 1944.

Assignment of Responsibility

According to the Manual of Organization and Standard Practices, dated 15 March 1944, the functions of the Civil Affairs Branch, Special Planning Division, Operations Service, and of the Civil Public Health Division, Preventive Medicine Service, both of the Surgeon General's Office, were:

Civil Affairs Branch. Operationally directs and coordinates under the Chief of the Operations Service all activities within the Office of The Surgeon General which relate to medical relief, including supplies, sanitation, training, personnel, and medical and veterinary service in occupied countries during the period of military responsibility. Maintains liaison with War Department offices and other agencies outside the Office of The Surgeon General on civil affairs matters.

* * * * * * *

Division. Formulates policies and develops plans for health programs in occupied and liberated territories. Assists in the selection of specialized personnel. Maintains contact with field operations. Integrates programs with those of other agencies operating in this general field.

In view of the conflicting statement of functions in the manual, the director of the Civil Public Health Division forwarded a memorandum, on 13 April 1944, to The Surgeon General, requesting clarification as to which division would assume the primary responsibility for:

(1) Recommendations pertaining to public health policy and practice in occupied countries.

(2) Procurement, selection and assignment of Medical Department personnel for civil affairs in conjunction with Personnel Service and other interested Services.


(3) Training of Medical Department personnel for civil affairs activities in conjunction with Training Division.

(4) Preparation of guides and manuals pertaining to civil affairs in conjunction with Training Division.

(5) Matters pertaining to medical supplies for civil affairs in conjunction with Supply Service and the CAD Supply Board.

The director of the Civil Public Health Division recommended in this memorandum that his division be responsible for the functions listed in paragraph (1), (2), (3), and (4), and that the Special Planning Division be responsible for those listed in paragraph (5).

This matter was referred by the Deputy Surgeon General to Operations Service. On 25 April 1944, in a memorandum for the Deputy Surgeon General, the chief of Operations Service outlined the following division of responsibility:

1. The Operations Service [Civil Affairs Branch of Special Planning Division] will be responsible for:

a. Overall coordination of Civil Affairs Activities for The Surgeon General.

b. Liaison with agencies outside the Office of The Surgeon General, except as covered by paragraph 2e below.

c. Development and implementation of the program for medical and sanitary supplies for the civilians of occupied and liberated areas utilizing the advice and assistance of the C.A.D. Supply Board.

2. The Preventive Medicine Service [Civil Public Health Division] will be primarily responsible for:

a. Recommendations pertaining to public health policy and practice in occupied and liberated areas.

b. Procurement, selection and assignment of Medical Department personnel for Civil Affairs in conjunction with the Operations Service, Personnel Service and the other interested services.

c. Training of Medical Department personnel for Civil Affairs activities in conjunction with the Training Division, Operations Service.

d. Preparation of guides and manuals pertaining to Civil Affairs in conjunction with the Training Division, Operations Service.

e. Liaison with agencies outside the Office of The Surgeon General on matters pertaining to the foregoing functions (Paragraphs 2a, b, c, & d above).

f. Coordination of matters of major importance and those likely to affect overall planning with the Operations Service.

The Manual of Organization and Standard Practices was changed thereupon (1 May 1944) to read-

Civil Affairs Branch. Coordinates for The Surgeon General, under the Chief of the Operations Service, all activities which relate to medical relief, including supplies, sanitation, training, personnel, and medical and veterinary service in occupied countries during the period of military responsibility. Maintains liaison with War Department offices and other agencies outside the Office of The Surgeon General on civil affairs matters, except as are specifically covered by the functions of the Civil Public Health Division, Preventive Medicine Service. Develops and implements the program for medical and sanitary supplies for the civilians of occupied and liberated areas utilizing the advice and assistance of The Surgeon General's C.A.D. Supply Board.

* * * * * * *

Civil Public Health Division [Preventive Medicine Service]-Develops plans per-


taining to public health policy and practice in occupied and liberated territories. Assists in the procurement, selection, assignment and training of Medical Department personnel for Civil Affairs. Assists in the preparation of guides and manuals pertaining to Civil Affairs public health activities. Maintains liaison with agencies outside the Office of The Surgeon General on matters pertaining to the foregoing functions. Coordinates matters of major importance and those likely to affect overall planning with Special Planning Division, Operations Service.

Relationship of the Surgeon General's Office to Civil Affairs Division,
War Department Special Staff

As previously noted, there was a Public Health Section in the Civilian Relief Branch of the Civil Affairs Division. This section consisted of one officer who maintained close liaison with the Surgeon General's Office, principally through the Preventive Medicine Service. On 10 August 1943, in a memorandum for the Chief, Civilian Relief Branch, Civil Affairs Division, subject: Provision for Control of Epidemics in Occupied Territory, this officer stated:

For continuing advice regarding policies, the Office of The Surgeon General of the Army should be extensively utilized by the Civil Affairs Division. To cope with the many problems of infectious diseases and to forecast needs for the future, the Preventive Medicine Division, SGO, maintains a comprehensive program. This serves to safeguard the health of the Army on the one hand, and through the common sharing of scientific knowledge, to protect the public health generally.

Again, in an informal memorandum for the Chief, Economics and Relief Branch, Civil Affairs Division, subject: Planning for Public Health, dated 25 January 1945, Colonel Hiscock proposed:

When a project of planning for public health is initiated or received for action by the public health officer, of CAD, it is discussed with the Director of the Civil Public Health Division, SGO. If extensive research or work in preparation of a report or guide is required, the assistance of the Surgeon General's Office is requested, because of the special staff maintained for such a purpose and of the availability for consultation of specialized personnel. Questions of medical supply planning are coordinated with International Division and cooperation is obtained from the Special Planning Division, SGO. Likewise, questions of personnel are coordinated with Personnel and Training Branch, CAD, and cooperation is obtained from the Personnel Division, SGO, working through the Civil Public Health Division, SGO. In a similar manner, assistance has been obtained from the Nutrition, the Medical Intelligence, and the Sanitary Engineering Divisions of SGO, to give only a partial list. For matters of joint interest with the Navy, excellent cooperation has been developed, in working with the Chief Medical Officer of the Military Government Section, Central Division, OCNO, with whom joint conferences are frequently held, and, when indicated, include representation from the Surgeon General's Office of the Army.

It is recommended that this plan of referral of matters of policy and planning related to public health to the Surgeon General's Office for discussion and for assistance when needed be continued, inasmuch as such cooperation insures sound technical advice, provides extensive service, facilitates coordination with plans for the military forces, and enables the Civil Affairs Division to function with a minimum public health staff.

In April 1945, when Colonel Hiscock was released from active duty, no other officer was assigned to the Public Health Section, Economics and


Relief Branch (formerly Civilian Relief Branch), to replace him. However, arrangements were made for an officer (Maj. James B. Gillespie, MC) from the Civil Public Health Division, Preventive Medicine Service, to devote part of his time to the Civil Affairs Division to carry on the changing duties. This complied with a request in a memorandum dated 23 March 1945, from the director of the Civil Affairs Division to The Surgeon General, which stated:

Mutual benefit has accrued from cooperative working relationships developed between the Civil Public Health Division of Preventive Medicine Service of The Surgeon General's Office and the Public Health Section of the Economics and Relief Branch of the Civil Affairs Division. In effect, the Director of the Civil Public Health Division acts for the Surgeon General and the Chief of Preventive Medicine Service in a consulting capacity to the Civil Affairs Division which arranges joint conferences, furnishes reports and other information of direct concern to The Surgeon General.

In order to make this service more effective, it is requested that arrangement be made for an officer of the Civil Health Division of Preventive Medicine, SGO, to spend part time in the Civil Affairs Division. This request confirms previous discussions between representatives of The Surgeon General's Office and the Civil Affairs Division.

Necessary office and clerical service to facilitate the work of such officer will be provided by the Civil Affairs Division.

Relationships With Other Services and Staffs

Operations of civil affairs and military government at War Department level included relations with the U.S. Navy, and at the highest military levels with the Joint Chiefs of Staff and the Combined Chiefs of Staff. While it is not necessary to discuss these relationships here, they must be mentioned to make the account complete. An excellent summary of the need for civil affairs and military government, and of the higher staff relationships, was given by Gen. George C. Marshall, USA, as follows:13

Orderly civil administration must be maintained in support of military operations in liberated and occupied territories. In previous wars, the United States had no prepared plan for this purpose. In this war it was necessary to mobilize the full resources of both liberated and occupied countries to aid in defeating the enemy. The security of lines of communication and channels of supply, the prevention of sabotage, the control of epidemics, the restoration of production in order to decrease import needs, the maintenance of good order in general, all were factors involved. It was important to transform the inhabitants of liberated countries into fighting allies.

The Civil Affairs Division was created on 1 March 1943 to establish War Department policies designed to handle these problems. In joint operations, the Division works closely with a similar agency in the Navy Department, as well as with related civilian agencies to determine and to implement United States policies. The Army and Navy are represented on the Joint Civil Affairs Committee under the Joint Chiefs of Staff which is charged with planning for civil affairs in both Europe and the Pacific. In combined operations, United States policies are coordinated with those of the British through the Combined Civil Affairs Committee of the Combined Chiefs of Staff.

13Biennial Report of the Chief of Staff of the United States Army to the Secretary of War, July 1, 1943, to June 30, 1945, p. 90.



Since the civilian health activities involved many different elements in the organizational structure of the Army, it is not surprising that, in the evolution of this essentially new function, delegation of responsibility was not always clear and organizational paradoxes were at times encountered. In an undertaking so vast as that required to wage World War II, confusing situations are probably inevitable; fortunately, intelligent men of good will can usually achieve an efficiently working pattern that transcends an organizational chart.

In reviewing the evolution of the organizational pattern at War Department level, apparently while the initial concepts of the role of civilian health activities in the Army's overall mission were formulated by General Simmons, the early development of this specialized program was along two, often largely independent, lines: (1) Problems pertaining to program, personnel, and training were handled largely by one individual stationed not in the Surgeon General's Office but in the Civil Affairs Division of the War Department Special Staff, led by an understanding general. Liaison between this officer and the chief of the Preventive Medicine Service, Office of the Surgeon General, and the Army Service Forces, and many others was good on an informal basis. (2) Problems pertaining to supply were handled largely by the Special Planning Division of the Operations Service in the Surgeon General's Office; however, much broader functions were assigned to this division.

Only relatively late in the war was any official responsibility delegated to the Preventive Medicine Service and then in a limited and unclear fashion. From the vantage point of this experience, the essential nature of the civilian health activities apparently comprised, in the main, those elements commonly associated with public health and preventive medicine. If this view is correct, it seems logical to place the main responsibility for the civilian health program on individuals who have special knowledge of, and experience in, public health and preventive medicine. Such personnel and points of view will most likely be found within the Preventive Medicine Service.

The experience in World War II also emphasizes another point: the importance of fixing responsibility for the civilian health program long before combat operations are imminent. Much useful early planning can be done, especially with reference to personnel who must be drawn largely from among Reserve forces and civilian groups.

Typical command General Staff and specific medical Civil Affairs functions at various echelons, are delineated in chart 2 for Headquarters, U.S. Army, Europe.


CHART 2.-Medical Civil Affairs relationships and functions European Theater of Operations, U.S. Army, 1944