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Chapter 3



Medical Supplies for Civil Health Programs

Thomas B. Turner, M.D.


The average civilian physician in the United States takes medical supply largely for granted; pharmaceutical houses are usually able and eager to supply all needs and the shelves of the corner drugstore are abundantly stocked. In a war-devastated country, however, even the finest program for the rehabilitation of health services cannot succeed if certain basic medical supplies are not available.

During World War II, there was a steady depletion of medical supplies in enemy and enemy-occupied countries, especially in Italy and in the Philippines and, to a lesser extent, in Germany. To this were added the destruction of hospitals, the treatment of military and civilian casualties, and the difficulties of distribution caused by the breakdown in transportation. While the War Department was aware of the situation, the necessities of logistical planning and a lack of appreciation of the importance of medical supply on the part of civil affairs health officers often combined to render the civilian medical supply system less effective than it might have been.

Moreover, in the earlier operations, particularly in Italy, the importance of stockpiling medical, sanitary, and other supplies for civil affairs and military government purposes was only partially recognized. The great value of specialists in medical supply to the civil affairs program was not appreciated so that supplies, both those locally available and those imported, were not handled and distributed in the most efficient manner.

As in other aspects of the civil public health program, valuable lessons were learned during the initial Italian operations, and deficiencies were quickly corrected.



The Inter-Allied Committee on Post-War Requirements was constituted under a resolution adopted by the Allied Governments at a meeting held at St. James's Palace in London on 24 September 1941.1

1Report to Allied Governments by Inter-Allied Committee on Post-War Requirements, London, England, June 1943.


According to the terms of this resolution, the common aim was to insure that supplies of food, raw materials, and articles of prime necessity would be made available for the postwar needs of the countries liberated from Nazi oppression. While each of the Allied Governments was to provide for the economic needs of its own people, their respective plans were to be coordinated for the successful achievement of the common goal. They would prepare estimates of their requirements and indicate the order of priority in which they desired supplies to be delivered.

As a first step toward planning for the reprovisioning of Europe after the war, the committee resolved that a bureau should be established by His Majesty's Government in the United Kingdom with which the Allied Governments and authorities would collaborate in preparing estimates of their requirements. After collating and coordinating these estimates, the bureau would then present proposals to a committee of Allied representatives under the chairmanship of Sir Frederick Leith-Ross.

The Soviet Government, while accepting most of the resolution, made a reservation as to the bureau's constitution and suggested a further meeting of the Allied Governments to settle the arrangement definitely. Further discussions might have cleared this point, but the Soviet Government did not appoint a representative to the committee nor did they submit any estimate of Soviet requirements.

The other European Allied Governments and authorities appointed representatives to the committee, and the U.S. Government, which had at first appointed only an observer, accepted full membership in January 1942. The governments of all the British Dominions and of India were also represented. The Chinese Government, although not formally associated with the St. James's Palace resolution, showed continuous interest in the work of the Inter-Allied Committee, and was represented by an observer at the committee's meetings. The Brazilian Government requested that it be more closely associated with the committee's work and was also represented by an observer. In addition, the International Labour Office was invited to appoint an observer, and all the committee's papers were made available to that office.

Another committee involved in this early planning was the one on medical supplies and services, under the chairmanship of Dr. Melvile Mackenzie of the United Kingdom; Dr. Hugh H. Smith, of the Rockefeller Foundation, and Dr. Kenneth B. Turner, of the Office of Scientific Research and Development, were the United States representatives. This committee, basing their estimates on the requirements for 100,000 people for 1 month,2 determined that in Western Europe alone 37,000 metric tons of drugs and 52,000 metric tons of hospital supplies would be required in the first 6 months after liberation. Special attention was given to supplies for ma-

2Medical Department, United States Army. Medical Supply in World War II. Washington: U.S. Government Printing Office, 1968, p. 375.


ternity and infant welfare, typhus fever control, malaria, and tuberculosis; and to biologicals for the control of epidemics of enteric infections, including dysentery, cholera, and diphtheria. These requirements, with modification, were used as the basis for all subsequent planning for civil populations.

Planning in the Surgeon General's Office

European area.-Supply planning for the European Theater of Operations, U.S. Army, began early in 1943. On 2 February, Col. (later Brig. Gen.) James S. Simmons, MC, and Col. Ira V. Hiscock, SnC, discussed with the Director, Supply Service, Surgeon General's Office, the Army's responsibility for providing medical and sanitary supplies for civilian use during the early stages of military occupations. This was the beginning of a series of conferences and interviews which led to the establishment, on 28 June 1943, of a board, known as the CAD (Civil Affairs Division) Board (p. 15), "to prepare, develop, and implement the medical portion of the War Department's program for aid to civilian populations in liberated countries."3

In response to a request from the International Division, Army Service Forces, on 2 July 1943, as modified by a memorandum of 11 September 1943, the CAD Board drew up an estimate of the amount and variety of medical and sanitary supplies necessary to provide for civilian populations during the initial period of military occupation in the Netherlands, Belgium, France, Corsica, Italy, Sardinia, Yugoslavia, Albania, Greece, Bulgaria, Norway, Denmark, Finland, Romania, Czechoslovakia, Poland, Austria, and Germany.

The CAD Board estimate was submitted to the International Division on 30 September 1943. The list of recommended supplies included basic medical units, supplementary tropical units, obstetrical bags, biologicals, quartermaster sanitary and antimalarial supplies, and engineer sanitary and antimalarial supplies. The number of each unit allotted to any country was based on the amount of destruction expected, the state of depletion of medical supplies, and the prewar standard of medical care in the country in question. It was not War Department policy to attempt to provide a level of medical care above the country's previous standard.

About 1 November 1943, the International Division requested the board to meet with representatives of the British Supply Mission to bring the U.S. and British supply programs into agreement. A detailed comparison of the two programs was made during several conferences over a period of approximately 6 weeks. The estimate of 30 September 1943 was revised and resubmitted to the International Division on 23 December 1943.4 Several minor changes had been made and some new units had been added

3Office Order No. 419, Office of the Surgeon General, U.S. Army, 28 June 1943. 
4Memorandum, Brig. Gen. R. W. Bliss, Chief, Operations Service, Office of the Surgeon General, for The Director, International Division, Headquarters, ASF, 23 Dec. 1943, subject: Civilian Supplies in Occupied Territories-Medical Supplies, with 18 enclosures: lists of "CAD Medical and Sanitation Units."


The revised list contained the following units: (1) Basic Medical Unit, consisting of drugs, dressings, surgical accessories, and confinement supplies; (2) Supplemental Tropical Unit; (3) Supplemental Biological Unit; (4) Obstetrical Bag; (5) Tracheotomy Set; (6) Hospital Units; (7) Basic Laboratory Unit; (8) Malaria Survey Laboratory Unit; (9) Sanitation Supply and Equipment Units; (10) Antimalaria Supply and Equipment Units; and (11) Typhus Unit (including items suggested by the United States of America Typhus Commission).

In February 1944, in response to a request from the International Division, an estimate of veterinary requirements was submitted, adding to the civilian supply program the Basic Veterinary Unit, consisting of drugs and dressings, and veterinary surgical, laboratory, and biological units.

In a memorandum of 26 January 1944, the International Division requested a breakdown of requirements by departments in France and by provinces in the Netherlands. This breakdown was submitted on 20 February 1944. In attempting to forecast the requirements for medical supplies for the various areas, the following basis of calculation was used:

Basic Medical Unit: The distribution of this unit was based on four factors: (1) the number of hospital beds per 1,000 population in the area to be cared for, as compared with the number of hospital beds per 1,000 population for Norway, which was 8.5, the highest medical standard in Europe; (2) depletion, which depended upon the estimated depletion of expendable medical supplies; (3) the estimated segment of population in need of and accessible to medical care, expressed in numbers per 100,000 persons to receive medical care (one basic medical unit was equipped to furnish medical care to 100,000 medically destitute persons); and (4) situation, which depended on the anticipated conditions under which a territory would be liberated. In a "no scorch" situation, the factor was one; in a "limited scorch" situation, the factor was two; in an "operational" situation, the factor was three.

The result of the multiplication of the above factors was the number of basic medical units required by the area for 1 month. For example, a country of more than 12 million total population, of which 3 million might be inaccessible, would contain 9 million persons to be supplied. If the country had 1.2 hospital beds per 1,000 population before the war, was to be liberated under "limited scorch" conditions, and was to be considered 80 percent depleted as far as medical supplies were concerned, the calculation of the required number of basic medical units would be 20 per month or 120 for 6 months.

Obstetrical Bag: four bags per 100,000 population to be cared for (four bags per basic medical unit).

Malaria Survey Laboratory Unit: one laboratory per 20,000 cases of treatable malaria.

Sanitation Equipment Unit: sufficient quantity to furnish 1 gallon of water per day per person of urban populations having prewar public water supplies.

Sanitation Supply Unit: one per month for each equipment unit.

Antimalaria Equipment Unit: one per 6,000 cases of malaria.

Typhus Unit: for distribution and content of this unit, The Surgeon General relied on the advice of the Typhus Commission as to where epidemic typhus might occur.

For the other units, calculation was based on the most recent information available to The Surgeon General concerning the existing and anticipated destruction of medical equipment in the areas concerned.

The composition of each supply unit was established only after long and elaborate planning which began in London in 1941. Revisions were made as experience suggested, but the final composition of each unit remained essentially as issued in December 1943.

Pacific area.-Civil health planning for the Pacific area did not begin until early 1944. The nucleus of a plan which also included supplies for civil health was discussed at a conference held on 18 March 1944 between members of the Civil Affairs Division, War Department Special Staff, and the Civil Public Health Division of the Preventive Medicine Service, Surgeon General's Office.

The situation regarding civilian populations in most of the Far Eastern countries differed substantially from that in Europe. The level of medical care was much lower and diseases were more prevalent and more varied. Since the strategic and tactical projections were not firm in the early stages of planning, a number of countries which were never invaded by Allied Forces were included in the estimates. Although the same civil affairs units were to be used, calculation of needs for each unit was based on the most recent information then available to The Surgeon General. Because the area of the Far East included in the planning was so vast and the need could be so urgent but limited geographically, it was decided to establish a reserve pool of biologicals such as vaccines, immune serums, and diagnostic antigens.


As in so many other aspects of civil affairs activities, the pattern of distribution of medical supplies was largely formed in the Italian campaign, slowly, haltingly, in the hard school of experience.5

As originally planned, medical supplies were supposed to reach the operational area in preassembled supply units directly from the Zone of Interior or from the base of operations. In actual operations in Sicily, the plan failed and the burden of medical supply and supply planning for

5Letter, 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, U.S. Army, 21 Feb. 1944, subject: Report of Civil Affairs Public Health Activities in the North African Theater of Operations, enclosure 3 thereto.


civil public health fell largely upon Allied Force Headquarters, at whose insistence a well-qualified medical supply officer eventually was assigned to the Allied Control Commission (later Allied Commission). Working with the medical supply section of North African Theater of Operations, U.S. Army, this officer developed a supply system, the principal features of which were: (1) assignment of a well-qualified medical supply officer to the top operating staff level to maintain close liaison with the medical supply officer of theater headquarters, establish a central stock control agency, screen all requisitions for medical supplies for Allied Control Commission and Allied Military Government, and establish a central depot, under his direct control, and subdepots as required; (2) routing of requisitions for medical supplies, and the supplies themselves, through military government medical supply channels rather than through general civil affairs or Army supply channels; (3) obtaining emergency supplies from Army supply depots in the Communications Zone, when approved by theater headquarters; (4) experienced personnel for key positions in central and sub-depots to be supplied by military governments, and all other personnel were to be procured locally; (5) using medical supply units, such as civil affairs units, only in the initial phases of an operation; (6) early inauguration of an item supply requisition supply system; (7) preparing an inventory of local medical supplies and facilities for production of medical items to integrate them with supplies to be furnished by military government; and (8) using the central stock control agency to insure maximum use of local resources, equitable distribution of imported supplies, and editing of requisitions to eliminate items which were either produced locally or available in adequate quantities in another area.


Medical supplies.-In a report for Region IV of the Allied Control Commission for Italy, Col. Thomas N. Page, MC, regional public health officer, described the civil affairs medical supply situation which he said was not good.6 He cited the reason as a breakdown in rail transport between Naples, the location of the civilian medical depot, and Rome, the site of the regional warehouse (fig. 5). Approximately 10 civil affairs units were received: one was brought forward by the transport of Region IV, five were shipped by schooner to Gaeta, and the balance were picked up from Rome Region. An additional 30 civil affairs units, although they had been ordered on 14 July and were due to arrive in Rome about 1 August, actually were not expected to arrive until 31 August because they had been sent by ship to Anzio and by truck from there. Some captured German and Italian supplies, turned over by an American unit moving forward, helped to fill the gap.

Two civil affairs units were delivered to each of the five provinces

6Public Health Report, 1 July 1944-31 July 1944, Region IV, Allied Control Commission. Section I, Public Health, pp. 14-16. Prepared by Col. Thomas N. Page, MC, on 1 August 1944.


FIGURE 5.-Regional medical supply warehouse, Rome, Italy, 1944.

(Rieti, Viterbo, Littoria, Frosinone, and Terni) under the control of Region IV (see map 9) and, while these were not sufficient, they did make it possible to keep medical units operating. Other small amounts were furnished to Rome Region hospitals, displaced persons at Foggia, and to the Fifth U.S. Army and the British Eighth Army.

Food.-Because of the lack of transportation, the amount of food distributed to hospitals was insufficient. Provincial supply officers reported, however, that supplementary rations put at their disposal were made available to hospitals, orphanages, and welfare institutions.

In Rieti Province, a highly agricultural area which had suffered very little damage, the situation was not so serious as in other provinces. Fruits were abundant, the grain harvest was good, the olive harvest assured an ample supply of olive oil, and when the sugar beet factory was repaired, the province had a minimum supply of sugar. The greatest problem was the difficulty in transporting food from one commune to another over damaged roads.

Viterbo Province, too, was remarkably well supplied with food. Their greatest need was sugar and salt, and powdered milk for the child clinics and orphanages.

Pharmacies.-In Littoria Province, many of the drugstores were completely destroyed. Some of them were set up in temporary locations but were badly in need of even the simplest items, such as alcohol, gauze, bandages, and iodine.

Every town in Frosinone Province had one or more drugstores. All druggists were requesting medicines, mostly sulfonamide drugs and Italian specialties, to fill prescriptions.


Many pharmacies in Rome Province were completely destroyed and others were partly damaged. Most of them had reopened, either at new sites or in damaged buildings that had been repaired, and they were functioning even though their supplies were greatly depleted. Some pharmacists purchased medicines independently to augment their stocks; others carried on as well as they could with what stocks they had on hand. The greater part of the two civil affairs units was received and delivered to the Medico Provinciale for distribution, first to hospitals according to the population they served, then to hospital pharmacies, and then to private pharmacies, thus relieving some of the shortages.

In the entire province of Rieti, there were 133 pharmacies of which 70 were located in the larger communes and 63 were dispersed among the other communes. All these pharmacies had limited medical supplies as it had been a long time since their stocks had been replenished.

Pharmacies in Viterbo and Terni Provinces were numerous and, in general, had suffered little damage. Stocks, while not abundant, were sufficient for normal needs for a short period.

Regional Warehouses

General.-Regional warehouses were established, and detailed instructions for their operation were issued. The instructions, similar to those contained in a memorandum from Colonel Page to the provincial commissioners, dated 18 May 1944, stated that regional warehouses, under the direction of the regional public health officer, would receive, store, and distribute to the provinces all supplies coming from the Central Depot.

Items purchased by a province would be distributed throughout the province under the direction of the provincial public health officer, or Medico Provinciale, with the approval of the regional public health officer. The Medico Provinciale was permitted to hire the personnel necessary to operate his own wholesale establishment, operating it on provincial funds without profit.

Responsibilities.-The provincial commissioner was responsible for carrying out the operating instructions and for delegating duties and responsibilities, as indicated, to the regional public health officer or to the provincial public health officer.7

The provincial public health officer was responsible for establishing, staffing, equipping, and operating a provincial storehouse, including the maintenance of accounts and submission of reports as required by the operating instructions.

He submitted requisitions to the regional public health officer by the first of each month for supplies to cover the following month. Long term

7Executive Memorandum No. 34, 1 Mar. 1944, subject: Instructions for Handling Medical Supplies. Published by Allied Control Commission, Italy, in "Instructions for the Guidance of Officers of the Commission, vol. I," pp. 61-64.


requirements were presented semiannually for the periods 1 July to 31 December and 1 January to 30 June; the regional public health officer then consolidated requisitions for the entire region.

The provincial public health officer was also responsible for obtaining supplies at the regional warehouse and distributing them throughout the province, by his own method, but with the approval of the regional public health officer, in the following order of priority: (1) hospitals and clinics, (2) doctors and midwives, and (3) pharmacists and other retailers.

Funds for purchasing the supplies were deposited with the local sub-accountant or in a bank to the credit of the Allied Finance Agency, each region being assigned an Allied Finance Agency account number.

Accounting.-Supplies would be segregated by types and sources, both physically in the storehouse and on all accounting records and documents. The following code letters, combined with U.S. nomenclature and placed after the item number, were used to identify the supplies by types and sources:

Type of source                                                                    Code letter

U.S.A. imports                                                                                  A

U.K. (United Kingdom) imports                                                            B

U.S. Army                                                                                         X

U.K. Army                                                                                         Z

Captured or confiscated, Italian                                                           H

Captured or confiscated, German                                                         G

Purchased (specify source)                                                                  P

Miscellaneous (other Allied Nations)                                                 Specify

Example: 10110-B Acid, Boric, USP, indicated U.K. import.

Requisitions (indents).-Requisitions (indents) for supplies would contain only items shown on the civil affairs list; would be prepared in English, in triplicate, on ordinary stationery; and would give the following information: where and how supplies were to be shipped; basis for the requisition (such as population of province); and item number, nomenclature, unit, and quantity.

The original and one copy were to be forwarded to the regional public health officer; the triplicate copy was to be retained by the originating agency.

Sales.-Records of sales, based on approved requisitions, were to be prepared, in triplicate, on issue voucher F/F 18, showing the item number, nomenclature, unit, quantity, unit and total sales price, and instructions for making payment. To facilitate the preparation of monthly reports, separate issue vouchers would be prepared for sales from each source of supply in instances where a single requisition was filled from more than one source. Each issue voucher was to be paid separately, the payment being made into a bank for the Allied Finance Agency, with a notation that the collection was on the account of Public Health Division. Copies of the bank deposit


slips were attached to the monthly report of sales. The purchaser or his representative was required to present a signed copy of a bank deposit slip and sign the receipt certificate; the warehouse officer signed the issue certificate on the duplicate and triplicate copies. In forward areas where this procedure might not be possible, payment could be made to the nearest finance officer or subaccountant with the manner of payment noted on the duplicate and the triplicate copies of the issue voucher.

For any free issues of supplies in emergency cases, issue voucher F/F 18 contained the following certificate over the signature of the issuing officer: "Emergency free issue-No organized local government unit in vicinity."


As the Italian Government began to assume responsibility for liberated Italy, an organization known as ENDIMEA (Ente Nazionale Distribuzione Medicinali degli Alleati) came into existence for the distribution of medical supplies. The directive establishing this organization included the following instructions.

In conjunction with representatives of Headquarters, Allied Control Commission, a system of payment was established so that the regions would not be required to handle payments when supplies on hand had been distributed.

A new set of prices for imported Allied supplies would be published by ENDIMEA under rules and regulations set by the Italian Government. Prefects of provinces would be notified about the new organization by the Italian Government. Institutions which formerly received supplies free, or at a wholesale price, were to apply to the public health officer of the province concerned, who would make the necessary arrangements for payments.

ENDIMEA would act as the sole distribution agency for medical supplies furnished by the Allies for the civilian population in liberated Italy. In those parts of Allied Military Government territory which the senior civil affairs officers of the Fifth U.S. Army and the British Eighth Army might indicate, this same organization would be responsible for distribution. In those provinces in which the senior civil affairs officers of the Fifth U.S. Army and the British Eighth Army did not desire this organization to function, the provisions of Executive Memorandum No. 348 would remain in force.

So that ENDIMEA might function properly, regional commissioners had to close all regional warehouses within 10 days; sell all supplies on hand to recognized outlets and send in a complete final statement for all supplies by 31 October 1944; assist ENDIMEA representatives by advising them of the dealers that had been set up at provincial level and in obtaining the necessary transport permits for distribution within their regions; and

8See footnote 7, p. 52.


advise all provincial public health officers to submit requisitions either to ENDIMEA representatives or to the Public Health Subcommission, Headquarters, Allied Control Commission, once each month starting with November. These requisitions were to be submitted not later than 31 October. For provinces which were to be taken care of by Allied Military Government of the Fifth U.S. Army and the British Eighth Army, there was no procedural change.

In Allied Military Government territory of the Fifth U.S. Army and the British Eighth Army, stocks on hand as of the date of receipt of the directive would be distributed as indicated in Executive Memorandum No. 34. Stocks received after that date would be shipped on an issue voucher from the Allied Control Commission Medical Depot, and show that these supplies were being issued to an area where "no organized local governmental unit exists."

Civilian supplies of a finished status (that is, completely manufactured and packaged) would not be frozen but would remain in the owner's hands for sale to the public within the region. No civilian medical supplies, except those in excess, would be allowed to leave the region in which located without the approval of the regional commissioner; however, biologicals could be distributed to other provinces.

Raw or unfinished medical supplies would be frozen, and Headquarters, Allied Control Commission, was to be advised of the location and the inventory of such materials.

Regional commissioners in Allied Military Government territory and senior civil affairs officers of the Fifth U.S. Army and the British Eighth Army might still requisition required civilian medical supplies when such action was considered necessary to protect the health of the civilian population or to assure proper distribution within their areas.


Another complex and extensive problem concerned the control of narcotic drugs. The files of the Bureau of Narcotics, U.S. Treasury Department, are replete with correspondence showing the cooperation between that bureau and the War and Navy Departments. Another example of this cooperation is the lecture series given by the Commissioner of the Bureau of Narcotics and other highly trained and experienced officers of the bureau to students in the schools of military government. The purpose of the training was to acquaint the officers and men who would be in charge of military government in occupied countries with the narcotics laws of those countries, to give them general information about narcotic drugs, to acquaint them with existing conditions relative to narcotic drugs, particularly in the Far East, and to teach them how to cope with narcotics addicts.

The War and Navy Departments received the full cooperation of the Bureau of Narcotics also in the enforcement of military government orders


related to narcotics in occupied countries. The bureau advocated, and the military authorities agreed to, the destruction of all factories manufacturing narcotic drugs in previously Japanese-occupied countries, and the seizure of all such drugs. Several narcotics agents who were serving in the Armed Forces were assigned to the Pacific theater specifically to establish proper narcotics control in Japan and Korea. Experts in the enforcement and administration of narcotics laws were assigned from the bureau for limited periods to assist in this work. With the help of these experts, it was possible to locate quantities of opium and of narcotic drugs which had been cached by the Japanese. Records of the Japanese Opium Monopoly were seized, and some Japanese officials cooperated by revealing the locations of drug factories. All narcotic drugs which had no medicinal value, or which had been adulterated, were destroyed.

In addition to approximately 100 former employees of the Bureau of Narcotics who entered military service, many of whom were assigned to narcotics work, the Army requested and received for special duty several highly trained experts to assist in establishing control measures in all countries occupied by U.S. Forces.


On the whole, the general concept of a basic medical unit (or "brick," as the British Forces called it) seems to have been valid; and in actual use, the unit served the purpose for which it was intended. Usually, when these 20-ton units arrived at supply depots in occupied countries, they were rearranged on an item basis for peripheral distribution. This fact, however, does not minimize the usefulness of the unit concept.

One might question the necessity of a dual supply system, military and civilian, operating side by side. But one of the main purposes of civil affairs was to free the combat forces of the burden of the care of the civilian population in the territory in which military operations were in progress. To a considerable extent, military medical supply channels were relieved of this burden through the civil affairs units. In some instances, military supply was called upon for emergency items before the arrival of the units, but these were the exception rather than the rule.

In the operation of civil public health supply channels, the importance of having key personnel who were trained in medical supply became apparent and was soon recognized as essential to the civil affairs supply operation. Also, the importance of medical supplies in the civil public health program cannot be overemphasized. Adequate planning and effective operation are essential. No program, however well conceived, can function without the necessary medical items and the transportation to distribute them.