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Chapter 10
CHAPTER X
Venereal Diseases
Thomas H. Sternberg, M.D., Ernest B. Howard, M.D., Leonard A. Dewey, M.D., and Paul Padget, M.D.
Part I. Zone of Interior
SIGNIFICANT POLICIES IN PREVENTION AND CONTROL
On 31 May 1912, the War Department published General Orders No. 17 containing specific measures for venereal disease control. This directive was based on evidence and data collected between 1900 and 1912, particularly during the last 4 years of the period. Among the measures ordered were those providing for compulsory prophylaxis, disciplinary measures, physical inspections, education, and early treatment. The introduction of these practices was followed by a decline in venereal disease rates which continued, except for the period of World War I, until the eve of World War II.
The advent of World War II saw the expansion of existing measures, the elimination of some, and the introduction of important new policies and practices. These changes were predicated by the monumental expansion of the Army and its wide dispersion throughout all parts of the world. Many of the most difficult problems were geographic in nature, due to differences in mores, cultures, and public health consciousness of the various countries
1This chapter attempts to present the Army's experience in the prevention and control of venereal diseases from the beginning of mobilization in 1940 to the termination of World War II and during the immediate postwar period. The task of compilation has been extremely difficult because of the immensity of the Army venereal disease program, concerned as it was with 8 million or more men and women in service scattered over most of the areas of the world. Details of the treatment of venereal diseases, venereal disease education, and venereal disease activities in civil affairs and occupied areas are not fully discussed. As it was apparent, however, that none of these subjects could be completely divorced from prevention and control activities, they have been mentioned within the framework of the chapter. A detailed account of the treatment of venereal diseases during World War II will appear in volume II, Internal Medicine in World War II [in preparation]. The account of venereal disease education will be integrated into the chapter on health education in preventive medicine, in volume IX of the series Preventive Medicine in World War II [in preparation], and the handling of venereal disease problems in connection with civil affairs and in the occupation of liberated countries will be specifically considered in volume VIII of the same series [also in preparation].
Every effort was made to document this history. However, since the authors were either directly concerned with the making of policy and with operational procedures in the Office of the Surgeon General or were in charge of venereal disease control activities in the theaters of operations concerning which they have written, parts of this chapter were based on personal knowledge of methods and results. Some portions of the chapter dealing with problems in oversea areas were written by officers not directly connected with activities in the areas concerned. In such instances, the material was prepared from reports of those who had taken part in the activities recorded.
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which the Armed Forces of the United States entered. Changes in the basic philosophy governing control measures manifested themselves in corresponding changes of policy such as the elimination of punishment for those acquiring a venereal disease, an increased emphasis on informing and educating the soldier on the venereal diseases, and an extensive contact-tracing program which was designed to cure and rehabilitate. Enlightened public opinion and ever-increasing interest in the venereal diseases by the population at large contributed to the firm and unequivocal stand which the Army took with respect to prostitution-that of suppression. The all-out nature of World War II required, more than ever, close cooperation and collaboration among the Army, civilian agencies and organizations, and the community in order to effect complete control. Finally, of utmost importance in bringing about changes in policies and practices was the discovery of new drugs and the innovation of new methods of treatment.
The Basis for Civil-Military Cooperation
It was recognized in World War I that a successful venereal disease control program required a joint effort by numerous agencies. In that war, the U.S. Public Health Service and the American Social Hygiene Association played particularly prominent roles in the control of venereal diseases. Civilian communities, especially in the extracantonment areas, launched extensive programs including the suppression of prostitution, venereal disease education, and improvement of epidemiological and treatment facilities. Unfortunately, with the close of the war interest lagged and the entire civilian program lapsed into a long period of relative quiescence which did not end until 1937, when Dr. Thomas Parran, Surgeon General, U.S. Public Health Service, published "Shadow on the Land : Syphilis." This book provided the impetus for the reestablishment of a vigorous venereal disease control program in most of the States. With the allocation of Federal funds through the La Follette-Bulwinkle Act of 1938, the State health departments organized venereal disease control programs. As the growth of the Nazi power forecast World War II, the military services, the U.S. Public Health Service, and the American Social Hygiene Association, recalling their joint action in World War I, met to establish plans for another collaborative effort. Out of these conferences emerged a joint resolution formally titled "An Agreement by the War and Navy Departments, the Federal Security Agency, and State Health Departments on Measures for the Control of the Venereal Diseases in Areas Where Armed Forces or National Defense Employees are Concentrated" (appendix B). The resolution was more commonly known as the Eight-Point Agreement. The agreement was adopted by the Conference of State and Territorial Health Officers, 7-13 May 1940. It was promulgated to the Army by The Adjutant General in a letter dated 19 September 1940.
Throughout the war, with minor exceptions, the close liaison and cooperative relationship established by this agreement between the Army, the U.S.
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Public Health Service, the American Social Hygiene Association, and, later, the Social Protection Division of the Federal Security Agency operated effectively to produce an integrated civilian venereal disease program.
War Department policy.-The policy of the War Department throughout the war was the repression of commercialized prostitution. The aforementioned letter, published by the War Department on 19 September 1940, called the attention of commanding officers to this policy and directed their adherence to it. On 16 December 1940, another letter was issued by The Adjutant General enjoining commanding generals of all armies, corps areas, and departments to declare areas off limits for members of their command whenever local authorities failed to cooperate by eliminating conditions inimical to the health and welfare of the troops. Upon receiving information that certain medical officers were examining inmates of houses of prostitution as a protective measure in safeguarding enlisted personnel against venereal disease, Maj. Gen. James C. Magee, The Surgeon General, directed that a letter be addressed to surgeons of major headquarters to correct any misunderstanding or ignorance of War Department policy on the part of medical officers and their commanders.2 This letter stated that because of these actions the War Department had been misrepresented as condoning the commercialization of prostitution. Attention was directed to the two aforementioned letters, and The Surgeon General's policy was made clear and explicit in the following statement: "It is recognized by those interested in public health that the attempted segregation and regulation of prostitution is of no public health value. Also, those interested in public health appreciate that in any attempt to control venereal disease unrelenting war must be waged on prostitution and the criminal exploiters of prostitutes."
Despite these early, vigorous, and clear-cut directives by the War Department, a few line officers still seemed to misunderstand the attitude of the War Department and passively or actively supported commercialized prostitution activities in many civilian communities. In an effort to correct the attitude of these officers and to forestall adverse public opinion, a very strong Armywide directive3 was published. This referred to the lack of uniformity with respect to the enforcement of War Department policies governing the improvement of moral conditions in the vicinity of camps and stations. Reference was made in this directive to the letters that had been published previously on the subject of prostitution, and commanding officers were again forcefully directed to take every measure in support of local civilian agencies to suppress prostitution activities. This directive further stated: "* * * Local officials will not be encouraged in any respect either directly or indirectly in
2Letter, Col. Larry B. McAfee, MC, Executive Officer, Office of the Surgeon General, to the Surgeons of all Corps Areas, Departments, and Independent Stations, 13 Jan. 1941, subject : Cooperation With the U.S. Public Health Service in the Control of Venereal Diseases.
3Letter, The Adjutant General to Commanding Generals of all Corps Areas, Departments, Armies, GHQ Air Force, Armored Force ; the Chiefs of all Arms and Services, and the Commanding Officers of Exempted Stations, 22 Mar. 1941, subject : Improvement of Moral Conditions in the Vicinity of Camps and Stations.
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non-enforcement of these laws and regulations and under no circumstances will military personnel or civilian personnel under military control be permitted to make inspections of any character of houses of prostitution."
In addition to this formal directive, the Chief of Staff sent a personal letter to all corps areas and Army commanders in which he said:
The Adjutant General is sending to all appropriate commanders a formal letter on the subject of moral conditions in the vicinity of Army camps and stations in which he summarizes the War Department's policy. Recently these policies have frequently been misquoted. A few weeks ago, for example, an ill-advised statement resulted in the impression becoming current that the War Department advocated segregated districts in the vicinity of Army camps. We were immediately subjected to a barrage of protests.
It will be extremely serious if our attitude on such questions is misunderstood, or if we lay ourselves liable to criticism either for lack of tact or lack of firmness in our dealing with civil health officers. The entire subject is too important to be treated as routine and it demands a uniform adherence to War Department policy. For this reason I am bringing The Adjutant General's letter informally to your personal attention and to that of the other commanders who will receive it.
The May Act.-By late 1940, it was becoming increasingly evident that local law-enforcement facilities for the repression of prostitution were inadequate in many communities. Recommendations, suggestions, and even exhortations by members of the Army and the Navy, the U.S. Public Health Service, and other organizations concerned with the problem were, in many cases, to no avail. There was no way to put teeth into their suggestions. These agencies, civil and military, were most ineffective in areas where the conditions were most deplorable. It was at this juncture that Congressman Andrew J. May, chairman of the House Committee on Military Affairs, on 20 January 1941, introduced in the House of Representatives a bill designed to suppress prostitution in extracantonment communities through Federal agencies, when local law-enforcement agencies were unable to achieve such suppression. This bill, H.R. 2475, was supported by the Army, Navy, and American Social Hygiene Association and was also the result of spontaneous congressional sentiment. On 3 March 1941, Congressman May wrote to Maj. Gen. James C. Magee, The Surgeon General, requesting his presence as a witness in support of the bill, if he favored it. Congressman May went on to say that if General Magee found it impossible to attend in person, he would be happy to accept a written statement from The Surgeon General which could be incorporated into the record. The Surgeon General replied to Congressman May by letter on 7 March 1941, agreeing with the purpose of H.R. 2475. Among the reasons given for agreeing with the bill were the following: Statistically, venereal disease was at that time the greatest single cause of noneffectiveness in the Army; disability and loss of efficiency resulting from this cause were completely preventable by means available; the source was at the time always to be found in the civilian population and lay without military jurisdiction; three-fourths of all venereal infections among Army personnel could be traced to infected prostitutes; and, during recent months, the
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control of prostitution in extracantonment areas had appeared as a major problem confronting camp and station commanders.
The bill was officially titled "The May Act" (appendix C) and became law on 11 July 1941. Described as an act to prohibit prostitution within such reasonable distance of military and/or naval establishments as the Secretary of War or the Secretary of the Navy or both should determine to be needful to the efficiency, health, and welfare of the Army and/or Navy, it became more than the policy of the armed services: it was national policy.
Removal of Punishment for Acquiring Venereal Disease
The most important change in basic policy in connection with venereal disease control within the Army during World War II was the removal of punishment for acquiring a venereal disease. On 18 January 1943, The Surgeon General recommended to The Adjutant General that the law prescribing loss of pay or time for acquiring a venereal disease be repealed. The change recommended by this letter was revolutionary. It ran directly counter to established Army policy and conflicted with the opinion of numerous Army officers, particularly line officers. On no other issue revolving around the venereal diseases was opinion within the Office of the Surgeon General so divided. Those having experience with these diseases in civilian life were generally in favor of the change, while many of the more experienced medical officers remained unconvinced of its desirability. The question still occasionally enters the realm of controversy.
The basis for this punishment of individuals who contracted venereal disease lay in the act of the 69th Congress, first session, chapter 302, section 2, 17 May 1926 (44 Stat. 557; 10 U.S.C. 847b; ML 1939, sec. 1442) and was founded on the premise that disciplinary measures and loss of pay were deterrents to exposure on the part of military personnel to venereal diseases. It was becoming increasingly clear, however, that this act was not achieving the objectives for which it was designed.
Brig. Gen. David N. W. Grant, Air Surgeon, Army Air Forces, wrote to The Surgeon General on 19 November 1942 stating that the application of this act was of particular concern to the Air Forces. It had led to the development of situations more dangerous than the venereal diseases themselves. Flying personnel were concealing the fact that they had contracted a venereal disease and, in spite of directions to the contrary, were flying while receiving clandestine treatment involving the extensive use of sulfa drugs. The Air Forces had reason to believe that sulfa drugs affected the skills involved in flying and no one receiving arsenical drugs was permitted to fly. The Air Surgeon cited the case of a flying officer whose death could reliably be attributed to anoxemia caused by the presence of methemoglobin resulting from the promiscuous use of sulfanilamide. The Air Surgeon mentioned that a survey of private physicians in the vicinity of Hunter Field, Savannah, Ga., revealed that they were treating more cases of venereal disease than the
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station surgeon. He strongly recommended that the Army regulations enforcing the act be rescinded in order to save the cost of concealed infections to the Air Forces in men, planes, time, and disruption of training and tactical service, and in order to improve the health, efficiency, and safety of personnel.
On 13 January 1943, Brig. J. C. Meakins, Department of National Defense, Canada, writing to Lt. Col. (later Col.) Thomas B. Turner,4 Chief, Venereal Disease Control Branch, Office of the Surgeon General, noted that the Canadian Armed Forces had discontinued hospital stoppages (loss of pay) for venereal disease since 15 May 1942. This action had been taken, continued Brigadier Meakins, to prevent the concealment of infection, and because of the considerable and increasing proportion of cases of nonspecific urethritis admitted to hospitals (particularly overseas), for which hospital stoppages could not have been made as a diagnosis of gonorrhea had not been readily possible. Brigadier Meakins attributed these findings largely to the increasing use of sulfa drugs with the object of concealment, and he maintained that punishment of only certain confirmed cases amounted to unfair discrimination.
The Subcommittee on Venereal Diseases of the National Research Council had on two occasions recommended repeal of the law. The minutes of its eighth meeting, held on 20 September 1940, contained the following statement:
In order to further the control of the venereal diseases, all provisions relating to forfeiture of pay and/or loss of time in the U.S. Army, Navy, Coast Guard and Public Health Service personnel infected with any venereal disease, whether or not such personnel is therefore absent from duty, and whether such disease was contracted at any time before or after entry into the services, should be forthwith repealed.
This statement was reiterated in recommendations made at the 16th meeting of the subcommittee held on 24 July 1942. Since the abolition of the act of 17 May 1926 would require an act of Congress, the subcommittee had also recommended at its seventh meeting on 6 September 1940 that the American Social Hygiene Association be requested to draw up a bill embodying provisions for repeal of the law and to discuss it with the Surgeons General of the Army, the Navy, and the U.S. Public Health Service, as well as with the Secretaries of War and the Navy and with the Federal Security Administrator, preliminary to its submission for congressional action.
On 10 August 1942, Dr. Joseph E. Moore,5 Chairman of the Subcommit-
4Colonel Turner was director of the Venereal Disease Control Division, Preventive Medicine Service, early in the war and was directly responsible for most of the policies adopted. His keen knowledge of public health methods and his untiring efforts and tactfulness made many things possible which might otherwise have failed.-T. H. S.
5Dr. Moore served as chairman of the Subcommittee on Venereal Diseases, National Research Council, throughout the war and as consultant to the Venereal Disease Control Division, Preventive Medicine Service, and The Surgeon General. Dr. Moore and the Subcommittee on Venereal Diseases never failed to respond to the call for help in all matters concerning venereal disease control and treatment. In addition, Dr. Moore was always available, day or night, for special consultation and made several trips to oversea theaters during the course of the war in response to special needs for his services. At the conclusion of the war, the President of the United States awarded Dr. Moore the highest civilian decoration, the Medal for Merit, for his great and unselfish patriotism and service.-T. H. S.
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tee on Venereal Diseases of the National Research Council, gave his personal views on the topic in a letter to Col. (later Brig. Gen.) Hugh Morgan, MC, Division of Professional Services, Office of the Surgeon General, in answer to a request by Colonel Morgan for more information on which to base a recommendation for the abolishing of penalties for venereal diseases. Dr. Moore also stressed the fact that fear of future punishment did not prevent exposure to venereal diseases and actual punishment following their acquisition succeeded only in promoting their concealment and spread. He commented on the fallacy of classifying venereal disease as due to misconduct. It appeared to him that the soldier who acquired a venereal disease was no more guilty of misconduct than his more fortunate brother who, by sheer good luck or the use of prophylaxis, escaped. This matter of good and bad luck was also mentioned in connection with the loss of pay. The more fortunate man whose course was uncomplicated was treated on a full-duty status and lost no pay, whereas the more unlucky fellow, who through no fault of his own was incapacitated by the disease or by reaction to the treatment, was penalized. The effect of this law which was of primary concern to Dr. Moore was the fact that concealment of disease fostered spread of disease. A soldier who attempted self-treatment of venereal disease or received inadequate treatment from untrained civilian physicians was much more likely to infect other civilian women who in turn would infect additional soldiers. Dr. Moore stated that any public health measure which promoted the concealment of disease and thereby fostered the spread of that disease resulted in the ultimate disadvantage of both the civilian community and the Army. Dr. Moore also apprised Colonel Morgan of many specific instances found by members of his Subcommittee on Venereal Diseases wherein the venereal disease control program was adversely affected by the law in question.
The memorable letter of 18 January 1943, in which The Surgeon General recommended to The Adjutant General repeal of the act of 1926, was prepared by Colonel Turner with the close collaboration of Colonel Morgan. The writers used freely the advice and opinions of those mentioned above and, in addition, set forth at length the results of the Army's experience with the law. The highlights of the argument for its repeal are summarized in the following paragraphs:
1. With respect to the concealment of disease, self-treatment, and treatment by nonmilitary personnel, these practices usually mean inadequate and ineffective treatment, more frequent resistant cases and relapses, unnecessary loss of manpower, and a resultant increase in the spread of the disease.
2. The law is obviously unjust in that individuals differ in their reaction to treatment. Diagnosis is difficult and often impossible when just a few doses of sulfa drugs are taken. Furthermore, unlucky persons are branded with the stigma of being diseased due to misconduct, while others who escape are not. It is particularly unjust when an individual is liable to be punished if he fails to report the contracting of a venereal disease, is also absolutely
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certain of receiving punishment if he does report, and is removed from duty while being treated. In addition to being unjust, the law also places the Army in a most incongruous position concerning inductees entering the service with a venereal disease. The Army accepts an inductee as qualified for military duty and then immediately hospitalizes him and under law deprives him of his pay. Moreover, in such instances, it is impossible to determine whether or not the infection is the result of misconduct inasmuch as the disease was contracted at a time when the inductee was not under military control.
3. The presence of this law influences the attitude taken on this whole subject, with undesirable side effects. For example, in some organizations, reduction in grade is made mandatory for noncommissioned officers who acquire venereal disease. The Army can ill afford to penalize itself by restricting the usefulness of men whose training may represent large investments in time and money and whose services are greatly needed.
4. When men are taken from the relative safety of their home environment and placed in situations where the risk of venereal infection is many times as great, the Government should be ready to assume a share of the responsibility, just as it has always done in the case of other diseases.
The advent of new drugs for the treatment of gonorrhea has materially shortened the course of the disease. Therefore, the monthly venereal disease inspection provided in Army Regulations No. 615-250 is inadequate to prevent concealment since the only cases of gonorrhea that are likely to be discovered are those which have recently developed or those which have not responded to treatment from unauthorized sources.
On 27 September 1944, Congress enacted a bill repealing the provision included in the act of 17 May 1926 which provided for loss of pay for acquiring a venereal disease. War Department Circular No. 458, 2 December 1944, effected this change within the Army.
Responsibility for Treatment of Venereal Disease
Transfer of responsibility within the Office of the Surgeon General.-During the early administration of the venereal disease control program, the treatment of venereal disease was a responsibility of the Medical Consultants Division. However, because of the desirability of centralizing the responsibility for all phases of venereal disease control, Brig. Gen. Charles C. Hillman, Chief, Professional Services, recommended to The Surgeon General on 3 November 1942 that the treatment phase of venereal disease control be transferred to the Venereal Disease Control Branch of the Preventive Medicine Division. It was believed that such a change would serve to bring about a desirable unification of the venereal disease control program. The prevailing divided responsibility often resulted in uncertainty as to which office should initiate action or make decision on proposals reaching the Office of the Surgeon General. The situation thus created lent itself to inattention to or
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delay in the proper handling of matters of policy. It was suggested that the proposed change would in no way disturb the excellent working relationship between the Venereal Disease Control Branch and the Medical Practice Division, nor render any less readily available the help and advice of members of the latter Division. General Hillman further stated that the treatment of venereal disease was now highly routinized and that a majority of the problems presented were those concerned with administrative procedures incident to the handling of large numbers of venereal disease patients rather than with the more complex aspects of professional care. It was also proposed that a treatment section be added to the Venereal Disease Control Branch. These recommendations were favorably considered, and the Treatment Section, Venereal Disease Control Branch, was established on 12 November 1942 by Office Order No. 466. Maj. (later Col.) Thomas H. Sternberg, formerly Venereal Disease Control Officer, First Service Command, was assigned as the first chief of this section.
Determination of treatment responsibilities in the field.-The responsibility of venereal disease control officers in the field had never been clear with respect to the treatment of venereal disease. Conflict occasionally occurred between the medical consultant assigned to service command headquarters and the venereal disease control officers. In an effort to clarify this jurisdictional problem, the War Department published a memorandum6 directing that the service command venereal disease control officer serve as principal advisor to the chief of the medical branch in all matters relating to venereal disease, including treatment as well as prevention. The memorandum further directed that full utilization be made of such added advice and assistance as might be rendered by the consultant in medicine in problems pertaining to the professional care of patients with venereal disease. Following the announcement of this policy, the problem was resolved satisfactorily in most instances by the establishment of joint inspectorial and consultative duties. The venereal disease control officer directed his surveys toward treatment procedures with particular emphasis upon duty-status treatment and the followup of syphilitic patients. The medical consultant directed his study to therapeutic practices in the hospital.
Induction of Individuals With Venereal Disease
In the early period of mobilization, persons known to have venereal disease were rejected for military service mainly because the facilities and personnel then available were inadequate to cope with the problems resulting from their induction. This policy resulted in the accumulation of a large backlog of rejected syphilitics, recognized by all concerned as a potential manpower reservoir which could be drawn upon at the earliest practical moment to fill Selective Service quotas. A similar situation did not develop
6Memorandum, The Surgeon General for Commanding Generals of each Service Command, attention : Chief, Medical Branch, 19 Nov. 1942, subject : Venereal Disease Control Officer.
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in individuals suffering from gonorrhea or chancroid since Selective Service Boards classified them as 1A until asymptomatic and then referred them for induction. Early in 1942, the Army training program appeared sufficiently advanced and the administrative and professional procedures well enough organized to provide diagnostic and treatment facilities necessary for the induction of men currently infected with, as well as men previously deferred because of, venereal disease. Accordingly, the Office of the Surgeon General initiated and developed the necessary plans, and The Adjutant General issued two radiograms to all service commands. The first of these, dated 7 December 1942, authorized the induction of registrants with uncomplicated venereal disease. The second, dated 10 December 1942, defined the types of venereal disease with which men could be inducted and provided regulations for the rate of induction of these individuals so that existing facilities for their management would not be overtaxed.
Mobilization regulations were revised to include authorization to induct all selectees with uncomplicated gonorrhea, syphilis (except cardiovascular syphilis, neurosyphilis, or other forms of visceral syphilis), and chancroid. Individuals with active lesions of granuloma inguinale or lymphogranuloma venereum were rejected. To assure the preinduction rejection of registrants with an abnormal spinal fluid, The Adjutant General, on 9 June 1943, authorized the commanding generals of all service commands to hospitalize for spinal-fluid examination all registrants with a positive serologic test for syphilis. Previously, registrants with a positive serologic test for syphilis had been inducted before a spinal-fluid examination had been made. As a result, individuals with an abnormal spinal fluid had to be put through the lengthy, time-consuming procedure involved in obtaining a certificate of disability discharge. The economy of this move was tremendous, considering the fact that from 15 to 20 percent of apparently latent syphilitic registrants were found to have abnormal spinal fluid.
An immediate effect of the Army's induction of syphilitic registrants was to relieve civilian health departments of a large part of their syphilis treatment load. The Army benefited by obtaining a large number of individuals suitable for military service at a time when the manpower situation was acute.
ORGANIZATION AND PROGRAMS, OFFICE OF THE SURGEON GENERAL
In 1940, the venereal disease program was still administered by the Subdivision of Preventive Medicine, and no specific officer was assigned to carry out venereal disease control duties. The activities consisted primarily of maintaining the syphilis registers of the Army and conducting the voluminous correspondence connected with them. However, the increase in active participation by The Surgeon General in the national program for the control of the venereal diseases required increasingly greater amounts of correspondence and necessitated many time-consuming conferences with venereal disease con-
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trol offices of the U.S. Public Health Service, the National Research Council Advisory Committee, the American Social Hygiene Association, and other organizations. Consequently, when the Subdivision of Preventive Medicine, Office of the Surgeon General, became the Preventive Medicine Division by Office Order No. 87 of 18 April 1941, the Venereal Disease Control Subdivision was created as a part of this new division. The functions of the new Venereal Disease Control Subdivision included developing Army policies in matters pertaining to the control of venereal disease, analyzing and recording venereal disease reports, collecting and filing syphilis registers of all cases in the Army and the Civilian Conservation Corps, effecting a periodic followup on "cured" cases of syphilis, preparing recommendations as to the management of individual problem cases, and maintaining liaison with other governmental and civilian venereal disease control agencies. Capt. (later Col.) James H. Gordon, MC, was assigned as the first chief of this new subdivision.
Toward the end of 1941, it was apparent that the Venereal Disease Control Subdivision could not carry out its functions successfully without the assignment of additional trained personnel. On 29 December 1941, in a memorandum to Col. (later Brig. Gen.) James S. Simmons, MC,7 Chief, Preventive Medicine Service, Office of the Surgeon General, Captain Gordon recommended the addition of one field grade officer trained and experienced in the clinical and public health aspects of venereal disease control, a trained statistician (officer or civilian) with experience in venereal disease statistics, and an appropriate increase in the number of civilian clerks. In addition, he recommended that additional facilities be provided for statistical studies, informational service, and research.
The Venereal Disease Control Division.-The Office of the Surgeon General was reorganized in March 1942. At this time, the Preventive Medicine Division became the Preventive Medicine Service, thus elevating the Venereal Disease Control Subdivision to a division. The internal organization and functions of the Venereal Disease Control Division established at the time of this reorganization prevailed to a substantial degree through the remainder of the war years. From time to time the division changed status, alternating between division and branch status as changes took place in the organization of the Office of the Surgeon General, but these changes affected little the internal organization of the Venereal Disease Control Division.
The Venereal Disease Control Division was primarily a policymaking and planning group with very few administrative or supply functions. In carrying out its mission, liaison with other divisions and services of the Office of the Surgeon General, other branches of the Army, and other governmental and civilian agencies constituted a major portion of its activities. Members of the division were in frequent contact with the various staff sec-
7General Simmons (deceased), Chief, Preventive Medicine Service, Office of the Surgeon General, made many original and effective contributions to the development and carrying out of the venereal disease control program and in connection therewith bore heavy responsibilities.-T. H. S.
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tions of the Services of Supply, the Army Ground Forces, and the Army Air Forces, as well as with the General Staff, itself. Representatives of the division were in almost daily contact with the U.S. Public Health Service, the Division of Social Protection of The Office for Emergency Management (later of the Federal Security Agency), the American Social Hygiene Association, and the National Research Council. A member of the division represented The Surgeon General on the Interdepartmental Committee on Venereal Disease Control. Colonel Turner, who had been assigned on 29 January 1942 to the Preventive Medicine Division, was designated to head the expanding Venereal Disease Control Subdivision and to develop the new Army venereal disease control program as expeditiously as possible. The Venereal Disease Control Division, as it was reorganized in March 1942, was able also to place into effect and supervise a new venereal disease control program which was to be carried out throughout the Army.
By mid-1942, the essential work of the division was being carried out by three Medical Corps officers, one Sanitary Corps officer, and three clerk-stenographers. (In 1918 the analogous branch had included seven officers and four enlisted men.) The internal organization was dictated by functional considerations into three branches-Preventive Measures, Civilian Collaboration, and Education. Colonel Turner was in charge of the division and also the Preventive Measures Branch. As chief of the division, he was immediately responsible for the work of the entire division and represented The Surgeon General and the Army on various committees and boards dealing with the problem of venereal disease. His primary concern as the officer in charge of preventive measures was the collection and analysis of reliable data on the occurrence of venereal disease, the study of rates, the evaluation of different forms of prophylaxis, and the procurement and assignment of specially trained personnel. The 85 or more venereal disease control officers in the field at this time were personally selected by Colonel Turner. The statistician, 1st Lt. (later Capt.) Stanley B. Russell, MAC, was also assigned to the Preventive Measures Branch. He assisted the chief of the branch and was personally responsible for the processing of syphilis registers, the analysis of raw data on venereal disease, and the carrying out of routine office procedures of the division. Maj. (later Col.) William A. Brumfield, Jr., MC, was in charge of the Civilian Collaboration Branch and, as the title of the branch suggests, maintained liaison with and assisted the division chief in coordinating the activities of various national, State, local, and private organizations which were participating in the effort to reduce sources of infection within the civil population. Additionally, he maintained liaison with the Navy Department. The officer in charge of the Education Branch was Maj. (later Lt. Col.) Gaylord W. Anderson, MC. His functions primarily concerned the study and development of various methods relating to the education of the soldier in venereal disease prevention and the preparation of material for this program. In many respects, these functions were on the
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order of a widespread advertising and selling campaign rather than strictly educational.
Later developments and changes.-Colonel Turner became director of the Civil Public Health Division of the Preventive Medicine Service on 1 January 1944 and was replaced as the director of the Venereal Disease Control Division by Major Sternberg. In November 1942, the Preventive Medicine Division, Professional Services, was given responsibility for the treatment of venereal disease (p. 147) and the Treatment Section was formed, replacing the Preventive Measures Branch. On 19 September 1944, the Civilian Collaboration Branch was eliminated and its duties were assigned to the director of the Venereal Disease Control Division. At the same time, the Preventive Measures Branch was reinstituted and the Education Branch discontinued. When, on 6 January 1944, Capt. (later Maj.) Granville W. Larimore, MC, then chief of the defunct Education Branch, was made chief of the Health Education Unit, Preventive Medicine Service, the educational functions of the Venereal Disease Control Division were transferred to the Health Education Unit.
Consultant functions of staff.-One of the most important functions of the Venereal Disease Control Division staff during the war was that of consultant to various field installations and oversea theaters. Staff members made frequent field trips in the Zone of Interior and overseas for the purposes of analyzing problems encountered at the various installations and of observing firsthand the venereal disease program in operation. This was particularly important in determining defects in the program and needs for changes or improvements. It also served to cement personal relationships with the men in the field-relations which proved to be of considerable value. In addition, special problems encountered in various theaters overseas were of sufficient importance that requests were sent to the Office of the Surgeon General for assistance from the Venereal Disease Division staff. A number of oversea trips were made in this connection including trips to Africa, the Middle East, India, the South Atlantic Command, and the Pacific.
Venereal disease control for WAAC.-In response to a strong recommendation by a committee of the National Research Council pertaining to a provision for venereal disease control among female components of the Army, approval was granted in early May 1943 for the establishment of a WAAC (Women's Army Auxiliary Corps) Liaison Section in the Venereal Disease Control Branch. On 28 May 1943, Maj. (later Lt. Col.) Margaret D. Craighill, MC, was assigned to the branch as chief of the WAAC Liaison Section. Since Major Craighill's responsibilities with respect to medical problems of the WAAC soon came to extend beyond the field of venereal disease, which never in fact constituted a serious problem among this group of service personnel, she was transferred on 15 July 1943 to the Operations Service, Office of the Surgeon General, and the WAAC Liaison Section was discontinued.
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ORGANIZATION AND PROGRAMS IN THE FIELD
Establishment of control officers.-Shortly after the outbreak of war, the chief and various subdivisions of the Preventive Medicine Division drew up plans for a reorientation of activities toward lines specifically designed to meet the needs of war. In his 29 December 1941 memorandum to Colonel Simmons, Captain Gordon included the following recommendations with respect to the control of venereal disease: "It is believed that the plan proposed by you of establishing a venereal disease control officer in the GHQ of any expeditionary force, the Staff of the Surgeon of each Army, Division, Corps Area (and Department), and each camp of 20,000 or more is fundamental to the success of the venereal disease control effort. This, along with the equally important and concurrent problems of finding the best qualified individual for each position and insuring that their services be used to the fullest possible advantage, represents in my opinion the greatest contribution that the office can make to the control efforts."
The proposed plan to establish venereal disease control officers in various commands had been submitted to The Surgeon General by Colonel Simmons earlier in December 1941. Both the Training and Personnel Divisions of the Office of the Surgeon General had approved the plan, and it was submitted essentially unchanged by The Surgeon General to The Adjutant General on 5 January 1942. In giving the background of the situation, The Surgeon General wrote:
The recent declaration of war has made it necessary to reconsider the Army's program for the control of venereal diseases in order to make such changes as may be required to augment and strengthen this program. The control measures employed during recent years have produced a very satisfactory decline in the disease rates and have been adequate for the peacetime conditions which existed; however, the change to a wartime status introduces many new conditions requiring additional facilities for the effective control of these diseases. For example, there will be an increase in the hazard of infection due to the development of a greater reservoir of infected civilians in contact with the expanding Army. Also the increased responsibilities and duties of the surgeons and medical inspectors of large organizations and units will further limit the time available for the important duties required in connection with the prevention of venereal diseases.
Anticipating this situation, tentative plans were considered several months ago with a view to augmenting the medical staffs of such organizations by the assignment to them of additional medical officers who are specially trained in control of venereal diseases. Such an arrangement has been actually tried in one location, namely, at Fort Bragg, North Carolina, where Major Paul Padget, a reserve officer from The Johns Hopkins Medical School with special training in venereal disease control, was placed in charge of all diagnosis, treatment, and control activities. This arrangement has worked out in a most satisfactory manner and has resulted in a definite improvement in the venereal disease control program at Fort Bragg.
The Surgeon General then went on to inform The Adjutant General of a list of qualified civilian physicians which his office had compiled to facilitate the selection and procurement of the required number of officers. Stressing the
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urgency of the situation because of the time it would take to commission these physicians, he continued:
According to the plan a "venereal disease control officer" should be assigned as an additional member of the staff of the surgeon of each of the following organizations: (a) Headquarters, each corps area and department; (b) Headquarters, each camp of 20,000 or more troops; (c) General Headquarters; (d) Headquarters, Communication Zone; (e) Headquarters, each field army; (f) Headquarters, each division.
The "venereal disease control officer," as assistant to the surgeon, should be utilized to supervise and coordinate the entire program of venereal disease control. This includes the planning, initiation, and coordination of pertinent and timely measures to bring about a satisfactory reduction in venereal disease in troops.
In addition, The Surgeon General specified the duties which these venereal disease control officers would perform.
The plan was approved by The Adjutant General and promulgated in a command letter to the Army in February 1942.8 Specifically, The Adjutant General authorized the assignment of a venereal disease control officer as assistant to the surgeon of each division, army, communications zone, general headquarters, corps area, department, and station complement serving 20,000 or more troops. General functions of these new venereal disease control officers were also mentioned, but, as for specific details, the letter stated: "From time to time The Surgeon General will publish such additional instructions as may be necessary for the guidance of venereal disease control officers." With the publication of this letter, the position of venereal disease control officer was first established in the Army during World War II. It was a singular landmark in venereal disease control activities.
To effect the provisions of the letter of 6 February authorizing the assignment of venereal disease control officers to posts and command headquarters, medical officers with training or experience in venereal disease control and public health were selected, and many civilian physicians with venereal disease control experience were invited to accept commissions and assignments to key positions. In addition, arrangements were made for the training of medical officers at the Johns Hopkins School of Hygiene and Public Health under the direction of Dr. Moore. Plans were made for the training of 100 officers for a period of 8 weeks and a refresher course of 2 weeks for certain officers already assigned to venereal disease control duties. On 21 February 1942, in a letter to surgeons of major headquarters, The Surgeon General stated (1) that selection of venereal disease control officers should be on the basis of established proficiency in this field and (2) that formal training in epidemiology and public health in recognized schools and experience in conducting a venereal disease control program in a city, county, State, or national public health agency were considered basic requirements.
8Letter, The Adjutant General to Commanding Generals, all Armies, Corps Areas, Departments, Divisions, and Communication Zones; Commanding General, Field Forces; Chief, Army Air Forces; Chief, Armored Force, 6 Feb. 1942, subject: Venereal Disease Control Officers.
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Requests from the field for venereal disease control officers exceeded their availability, and therefore, through more informal procedures, additional medical officers were assigned to selected installations for venereal disease control training. It soon became evident that sufficient medical officers trained in venereal disease could not be recruited to enable the assignment of a venereal disease control officer to each division. This provision was accordingly rescinded, by War Department Memorandum No. W40-6-42, dated 10 September 1942, and the duties were assigned to the division medical inspector.
Duties and functions of control officers.-The functions and duties of a venereal disease control officer were specified in a previously cited letter from The Surgeon General to surgeons of major headquarters. These functions involved the prevention of venereal disease through a comprehensive educational program; adequate prophylaxis facilities-individual and dispensary; cooperation with civilian agencies in the elimination of civilian sources of infection; early detection, segregation, and adequate treatment of cases to break the chain of contact; the collection and the detailed analysis of data concerning the incidence of syphilis, gonorrhea, and other venereal diseases acquired by men in the units of the command; and continuous study of problems peculiar to the command with a view to recommending new measures. The venereal disease control officer was also instructed to reduce time lost per case through improvement of treatment methods.
Redefinition of control program.-Toward the close of 1942, The Surgeon General considered it advisable to publish a directive redefining the functions of the venereal disease control officer and the basic measures of the venereal disease control program. On 14 November 1942, a memorandum was therefore transmitted to The Adjutant General recommending the publication of a War Department circular summarizing the different phases of the program. Only a portion of this memorandum was finally published in War Department Circular No. 53 on 17 February 1943. Nevertheless, this circular was significant in many ways. For the first time, the service command venereal disease control officer was clearly designated as the officer chiefly responsible for the integration of the civilian and Army programs. The responsibility for the provision of inspectorial and consultant services to staging areas, ports of embarkation, and exempted stations-activities not otherwise provided with such a service heretofore-was also delegated to the service command venereal disease control officer. The Army Air Forces had developed a relatively autonomous venereal disease control program which had frequently led to duplication of effort.9 This directive was designed to eliminate partially the conflicting and overlapping duties of venereal disease control officers assigned to service commands and those assigned to Air Force commands and stations.
9Personal observations of Maj. Ernest B. Howard, MC, Headquarters, 4th Service Command, 18 May 1942-19 April 1944.
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Dual functions of control officers.-In many posts with a strength of over 20,000, where a full-time control officer was authorized, the post surgeon appointed the same individual as medical inspector and venereal disease control officer. To prevent this practice, The Surgeon General10 recommended that the combining of the positions of medical inspector and venereal disease control officer should be discontinued. As the need, however, for medical inspectors became more acute, the practice of assigning the venereal disease control officer to other duties-usually medical inspector or chief of the venereal treatment section-spread, and by 1944 few full-time venereal disease control officers were assigned to posts.
Problems at ports of embarkation.-Early in the war when large numbers of troops were being shipped to the European theater, numerous protests were sent to the War Department from the command in the European theater with respect to the large number of troops arriving at the theater's port of debarkation with venereal disease. Major Sternberg went to the New York port of embarkation and to the numerous installations and camps used for staging areas to make a study of this problem. He discovered that soldiers to be shipped overseas were given 24- to 48-hour furloughs a day or two prior to their actual shipment. Many of these soldiers spent that time in one of the large cities on the eastern seaboard and in many instances were exposed to venereal disease. The ports of embarkation were doing careful inspections just before shipment, and soldiers found to have venereal disease at that time were held for treatment. However, since the incubation period in most of the venereal disease is from 3 to 21 days, many of the soldiers developed their venereal disease on shipboard or after arrival at the port of debarkation. The only solution to this problem would have been to give the final leave 2 or 3 weeks before shipment, but this was not considered fair or feasible. Nevertheless, the ports of embarkation were requested to carry out intensive venereal disease educational programs in an effort to reduce to a minimum the number of exposures and infections. At the end of the war, when troops were returning to this country from oversea theaters, this same situation occurred in reverse.
COLLABORATION WITH CIVILIAN AGENCIES
U.S. Public Health Service
Early cooperative efforts.-On 16 January 1940, The Surgeon General suggested to The Adjutant General that the U.S. Public Health Service be requested to cooperate with the Army in safeguarding the health of military personnel by suitable measures of extramilitary area sanitation in connection with the concentration of maneuvering troops in the Southern United States. He noted that such cooperation would be directed particularly to
10Letter, The Surgeon General to Commanding Generals each Service Command, Department, and Port of Embarkation, 2 Oct. 1942, subject: Venereal Disease Control Officers.
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the control of venereal disease, but that other problems of environmental sanitation requiring liaison between the Army and civilian agencies would also be considered. On 30 January 1940, the Secretary of War wrote to Mr. Paul V. McNutt, Federal Security Administrator, requesting such assistance. The Secretary reflected on the fine support that had been given to the Army by the U.S. Public Health Service during World War I and continued:
It is desired that the U.S. Public Health Service, operating under the authority of existing laws and using its own resources, cooperate with the Army in safeguarding the health of military personnel by suitable measures of extra-military area sanitation in connection with the present concentration of troops in the South. This cooperation is particularly desired at this time in regard to the increase in venereal disease which has been traced directly to organized vice in adjacent municipalities. Other matters of environmental sanitation will arise during the course of the coming maneuvers in which the U.S. Public Health Service can be of great assistance to the Army.
I would appreciate hearing from you as to the extent and character of assistance the U.S. Public Health Service will be prepared to give the Army.
On 12 February 1940, the Federal Security Administrator replied to the Secretary of War indicating that the cooperation and assistance requested would be "extended gladly." He suggested that representatives of the two agencies confer with a view to determining the exact needs and the extent of the assistance required. On 23 February 1940, The Adjutant General directed The Surgeon General to arrange with the Surgeon General, U.S. Public Health Service, for a conference of representatives of the two agencies to plan for joint action. Such a conference involving Army and U.S. Public Health Service representatives was held, and on 18 March 1940, a letter was sent to the Commanding General, Eighth Corps Area, Fort Sam Houston, Tex., informing him of the consent of the Public Health Service to cooperate with the Army in safeguarding the health of military personnel and directing him to furnish the fullest possible assistance to the Public Health Service representatives.
On 5 April 1940, Dr. Raymond A. Vonderlehr, Assistant Surgeon General, Division of Venereal Diseases, U.S. Public Health Service, wrote to Col. (later Brig. Gen.) Albert G. Love, MC, in the Office of the Surgeon General with reference to the forthcoming May 1940 Conference of State and Territorial Health Officers at which plans were to be formulated for the provision of U.S. Public Health Service aid throughout the country for the fiscal year beginning 1 July 1940. In this letter, Dr. Vonderlehr suggested that it might be desirable for the Army to obtain commitments from State and local health departments with reference to the development of better health services in the civilian areas under consideration for future troop concentrations and maneuvers.
Meanwhile, the U.S. Public Health Service sent its representatives into the Louisiana maneuver area in accordance with the request of the Secretary of War. The work accomplished by these representatives was so satisfactory
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that, on 11 April 1940, The Surgeon General recommended to The Adjutant General that the arrangements made in the Louisiana maneuver area be extended to all other maneuver areas and that similar arrangements be established for extracantonment sanitation at all regular Army posts throughout the country. This request was favorably considered by the War Department, and on 29 April 1940 Dr. Parran was notified that The Surgeon General was authorized to make arrangements with the Public Health Service for further cooperation in extracantonment sanitation, provided the measure met with the approval of the Public Health Service. It was further suggested that detailed arrangements be made at informal conferences as was done in the Third Army maneuver area. To effect this extended collaborative program, The Adjutant General sent letters to the commanding generals of the First, Second, Third, and Fourth Armies and to the commanding general of each corps area, informing them of the proposed project and outlining the general plan agreed upon by the Public Health Service and the War Department.
On 20 May 1940, Dr. Vonderlehr wrote to The Surgeon General making certain recommendations which portended the establishment of the extensive contact-reporting program. In this letter, he stated : "Since the incubation period for syphilis is so long that relatively few cases acquired in the Louisiana-Texas area will develop during the maneuvers, it is apparent that the reporting of contacts suspected of being infected in Louisiana and Texas will do much to discover such contacts and bring them under treatment and control before the second maneuvers are held in this area in August. I feel sure that the State and local health authorities will be glad to cooperate on this basis if you are able to furnish the necessary information."
On 22 May 1940, The Surgeon General recommended that The Adjutant General direct corps area commanders to report to the State boards of health of Louisiana and Texas the source of infection of venereal diseases developing among soldiers after the return of their organizations from the maneuver areas. On 31 May 1940,11 a letter was published incorporating these recommendations, and the contact-reporting program had its inception.
Liaison officers assigned to all corps areas.-The early improvised relationship between the U.S. Public Health Service and the Army was formalized in May 1940 by the adoption at the Conference of State and Territorial Health Officers of the Eight-Point Agreement (appendix B). In order to facilitate the operation of this agreement and to provide close liaison in all matters pertaining to public health, an agreement was reached by the Army and the U.S. Public Health Service to detail a Public Health Service officer to each corps area headquarters. On 28 October 1940, the corps area commanders were informed by The Adjutant General of these assignments and were directed to provide suitable office space and equipment and to cooperate
11Letter, The Adjutant General to Commanding Generals of all Corps Areas, 31 May 1940, subject: Extension of Present Utilization of U.S. Public Health Service.
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with the U.S. Public Health Service and its representatives to the fullest extent.
Attacks on Army venereal disease policies.-This well-established working relationship was temporarily shaken by publication in 1941 of a book by Dr. Parran and Dr. Vonderlehr entitled "Plain Words About Venereal Disease." This book criticized the Army for what the authors considered its failure to take sufficiently drastic action against prostitution in extracantonment areas. Charges and countercharges were made, and eventually, on 27 November 1941, Mr. McNutt wrote to the President about the matter. Shortly afterwards, however, the attack on Pearl Harbor occurred. With the American declaration of war, what had threatened to precipitate a serious break in mutual confidence between the Army and the U.S. Public Health Service faded into insignificance in the face of the new responsibilities and problems facing both services.
Summary of U.S. Public Health Service-Army collaboration.-With the exception of this temporary schism, the relationship between the U.S. Public Health Service and the Army from 1940 to 1945 was highly satisfactory and mutually advantageous. To a varying extent, every activity of the Venereal Disease Control Division of the Public Health Service during World War II affected the Army's program. Only the history of that division's activities (in the files of the U.S. Public Health Service) can tell the complete story of that collaboration and assistance. The success of the Army venereal disease control program in the Zone of Interior was due in no small measure to the active support and cooperation provided by the Public Health Service. The program of the Public Health Service constituted one of the most valuable contributions to venereal disease control during World War II. Important phases of this program were liaison activities at service command headquarters; cooperation in the contact and separation programs; support of State and local control programs by allocation of funds and assignment of personnel; distribution of educational literature, films, and posters; analysis of statistical data; support of legislation; establishment of rapid treatment centers; organization of public meetings; and extensive research activities (fig. 13). Some of these activities are discussed elsewhere in this chapter.
American Social Hygiene Association
The Venereal Disease Control Division of the Army and the American Social Hygiene Association maintained a close collaborative relationship in both World War I and World War II. As the only nongovernmental, private agency continuously active for many years in venereal disease control, the American Social Hygiene Association occupied a key position in civilian control efforts and through its educational, legal, and other activities provided invaluable support and assistance to the Army. The moving spirits of the American Social Hygiene Association, Dr. William F. Snow and
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FIGURE 13.-U.S. Public Health Service bus clinic. A U.S. Public Health Service physician demonstrates how blood test specimens are taken in these mobile clinics operated primarily in the South. (Photo courtesy U.S. Public Health Service.)
Dr. Walter Clarke had cooperated with the U.S. Public Health Service, the Army, and the Navy in World War I and were therefore able to bring their experience to bear on the problems of World War II. From the standpoint of the Army, the major contributions of the American Social Hygiene Association during World War II included the organization of local social hygiene societies and their sponsorship of public meetings to stimulate citizen interest; the improvement of State antiprostitution laws; the investigation of prostitution activities by undercover methods and the submission of reports of these investigations to the Army and other interested agencies; and the provision of extensive educational material in the form of posters, pamphlets, and films for use in Army installations (fig. 14).
Role of the Association.-The role of the American Social Hygiene Association was formally recognized in Point Eight of the Eight-Point Agreement. As stated elsewhere (p. 140), the full text of the Eight-Point Agreement was published as a directive to the Army. On 16 December 1940, the attention of commanding generals of all armies, corps areas, and departments was again directed to the American Social Hygiene Association's activities by a War Department letter concerning control of the use of intoxi-
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FIGURE 14.-Scene from the American Social Hygiene Association film "With These Weapons," produced for the war effort. (Photo courtesy of American Social Hygiene Association.)
cating beverages and the improvement of moral conditions near camps and stations. The American Social Hygiene Association maintained a central headquarters in New York City and assigned field representatives to each service command to provide liaison with service command headquarters. Thus, by the end of 1940, collaboration between the American Social Hygiene Association and the Army had been firmly established through the publication of directives and the assignment of American Social Hygiene Association field representatives (fig. 15).
Antiprostitution activity of the Association.-One of the most important activities of the American Social Hygiene Association was its undercover studies of prostitution in all the larger cities and towns. The association conducted recurring surveys of communities and reported its findings to different Army command levels for information or action. In numerous instances, prostitution activities were first detected by these surveys, and action was initiated resulting in their elimination. Without the incontrovertible evidence provided by these surveys, the effort to repress prostitution and enforce antiprostitution laws would have failed in many cities because of resistance and obstructionism by prostitution interests, the apathy of police and citizens, and the difficulty of proving in court the existence of prostitution.
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FIGURE 15.-President or American Social Hygiene Association confers with the three Surgeons General. Dr. Ray Lyman Wilbur (center) discusses venereal disease control measures with (left to right) Comdr. C. L. Andrus, USN, representing the Surgeon General, U.S. Navy; Maj. Gen. James C. Magee, Surgeon General, U.S. Army; Dr. Thomas Parran, Surgeon General, U.S. Public Health Service; and Dr. William F. Snow, chairman of the Executive Committee, American Social Hygiene Association, Washington, November 1940.
The Army's venereal disease control program was also facilitated by widespread improvements in State and local antiprostitution laws that were brought about mainly through efforts of the legal section of the American Social Hygiene Association. Many States strengthened their existing laws, and others, with no previous legislation, passed "model" laws suggested by the American Social Hygiene Association. The association published an exhaustive study entitled "Digest of State and Federal Laws Dealing With Prostitutions and Other Sex Offenses," Publication A-422. One hundred copies of this study were distributed within the Army to venereal disease control officers. The association also supported the May Act in 1941 and several other bills involving venereal disease control.
Stimulation of interest by the Association.-Venereal disease control programs, like other public health efforts, to an important degree depend for their success upon the maintenance of a high level of professional and
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lay interest. The American Social Hygiene Association significantly contributed to this phase of the educational program by conducting well-publicized (fig. 16) Social Hygiene Day meetings each year in cities throughout
FIGURE 16.-Social Hygiene Day, 2 February 1944. These and similar posters were distributed to and displayed in pharmacies throughout the country to publicize Social Hygiene Day and to get educational and informational material to the public. (Photo courtesy of American Social Hygiene Association.)
the country to which the Army, the Navy, and the U.S. Public Health Service, as well as local groups, were asked to send representatives (fig. 17). These meetings served to prevent inertia and apathy and often injected new enthusiasm into local control efforts.
Division of Social Protection
Development of the Division of Social Protection and its objectives.-Following adoption of the Eight-Point Agreement and the increasing evidence in early 1941 of commercialized prostitution in civilian communities surrounding Army installations, a new agency was established in the Office of The Coordinator of Health, Welfare, and Related Defense Activities, Office for Emergency Management, to implement Point Six of the Eight-Point Agreement which referred to the repression of commercialized and clandestine prostitution. This agency was the Division of Social Protection, formally established in early 1941. On 3 September 1941, the Division of
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FIGURE 17.-Participants in Social Hygiene Day meeting in Boston, 1944. Left to right, Capt. Edward M. Cohart, MC, Venereal Disease Control Officer, First Service Command ; Dr. C. Walker Clarke, American Social Hygiene Association ; Lt. John L. Ward (MC), USNR, Venereal Disease Control Officer, 1st Naval District ; and Dr. George Gilbert Smith, president of the Massachusetts Society for Social Hygiene. (Photo courtesy of American Social Hygiene Association.)
Social Protection was made a subdivision of the Division of Health and Welfare, Office of Defense Health and Welfare Services, Office for Emergency Management, and remained in that status until 29 April 1943. On the later date, the functions of the Office of Defense Health and Welfare Services were transferred to the Federal Security Agency where the Office of Community War Services was established as an integral part of the Office of the Administrator. The Social Protection Division functioned within the Office of Community War Services until 30 June 1946.
The broad objectives of the Social Protection Division were the safeguarding of the Armed Forces and the civilian population from the hazards of prostitution, sex delinquency, and venereal diseases. To accomplish these objectives, the section was instructed to gather and evaluate information with respect to: Prostitution and related conditions in cities and counties adjacent to military establishments, the statutory and administrative mea-
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ures designed to combat such conditions, the extent to which these measures were enforced, and the results being achieved. The section was also given the mission to implement community activities directed toward the protection of women from sexual exploitation and the social rehabilitation of prostitutes and other sexually delinquent women. By September 1941, the program of this division had begun to take shape, and regional and State representatives had been assigned to the field. On 2 October 1941, the War Department advised the field of the establishment of this new agency and outlined the program of the division.
National program of the Division.-The program by which the Social Protection Division attempted to achieve these broad objectives included the promulgation of policies in cooperation with such national law-enforcement societies as the International Association of Police Chiefs and the National Sheriff's Association, the preparation and distribution of educational material, the organization of coordinating committees (The Interdepartmental Committee on Venereal Disease Control and the National Advisory Venereal Disease Committee), the arranging of local public meetings, and the application in each local community of the policies and programs developed by these national deliberative committees. The field staff of the Social Protection Division, including 12 regional offices and their associated suboffices, had the responsibility of transmitting these policies to, and effecting their application in, local communities.
Field operations of the Division.-The translation into community action of policies and programs laid down from the Washington office of the Social Protection Division was the responsibility of field, regional, and State social protection representatives. Theirs was a complex and difficult operational assignment. It was necessary for them to coordinate their activities with the U.S. Public Health Service and the American Social Hygiene Association whose activities in the field of venereal disease control long antedated those of the Social Protection Division. In addition, they had to integrate their programs with that of the armed services whose venereal disease control officers also carried out control functions in the civilian communities surrounding Army installations. Furthermore, the already difficult functions of these field representatives was made more complex when the Social Protection Section was given the responsibility for the preparation of special reports in connection with the May Act. The conduct of investigations and the preparation of reports in conjunction with this added responsibility became largely an added function of these field representatives. It was not surprising that, in many instances, efforts of these diverse agencies conflicted instead of supporting one another.
Sometime after Mr. Eliot Ness became director of the Social Protection Division, a National Advisory Police Committee on Social Protection was organized as an advisory body to the division. This committee, made up of eminent police chiefs and sheriffs, made recommendations that were sent to
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every police chief and sheriff in the country. The judiciary and the legal profession were brought into the program on a national level through the American Bar Association which appointed a National Committee on Courts and Wartime Social Protection to work with that division. This committee included many of the leading law experts in the country. It completed a study embracing recommendations for adequate health and prostitution laws which was submitted to the States and endorsed by the Council of State Governments. Mayors and city managers were reached from the national level by articles which appeared in the publications of the American Municipal Association, the National Conference of Mayors, and the Inter-National City Managers Association. The American Municipal Association made the social protection program one of the principal subjects of its annual meeting in 1942. To influence liquor vendors, the help of the American Brewing Foundation, the Distilled Spirits Institute, and State liquor control boards was enlisted.
The National Hotel Association in cooperation with the Social Protection Division set up standards for good hotel operations, and educational material incorporating these recommendations was distributed to hotels throughout the country. To counteract pimping by taxicab drivers, which had become flagrant in many communities, the Social Protection Division and the Office of Defense Transportation completed a joint agreement for the revocation of Certificates of War Necessity when voluntary cooperation could not be obtained. The National Cab Association embarked upon an educational program in which drivers' unions also participated. Activities directed toward the prevention of prostitution and the rehabilitation and redirection of prostitutes were also initiated in cooperation with committees appointed by various national social agencies such as the Conference of Women Superintendents. These and many other policymaking and coordinating activities of the Social Protection Division were energetically carried out by Mr. Ness, who, as director of public safety for Cleveland, Ohio, had already completed a successful antiprostitution and general law-enforcement program and had established working relations with many of the agencies with which he now so effectively strove to develop and promulgate overall law-enforcement policies. In these efforts, Mr. Ness repeatedly sought and received the support and advice of the Office of the Surgeon General. Most of the directives that were distributed by the Social Protection Division were coordinated with the Army before publication. Meetings arranged by the Social Protection Division almost invariably included an Army representative, and many conferences and committees convened in which both the Army and the Social Protection Division participated. Mr. Ness was succeeded, as director of the Division, in 1944 by Mr. Thomas Devine who continued the same close and cooperative relationship with the Army that had been established by Mr. Ness.
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Evaluation of Division activities.-The contribution of the Social Protection Division to the venereal disease control program during World War II will long remain controversial because the methods of approach utilized by different agencies involved in the program during the war were often conflicting. There is no question that in many communities the Social Protection Division succeeded in bringing about suppression of prostitution and improvement of the overall venereal disease control program. There is also no question, however, that in many communities and in many instances the Social Protection Division field representative did not clearly understand his role in the overall program and, instead of securing coordination and improved control procedures, caused confusion and personal enmity. Many of these difficulties were due to the failure of the Division of Social Protection representative to perceive clearly the different responsibilities of the Division and the U.S. Public Health Service. In many instances, the Social Protection Division representative made public health recommendations to State and local health authorities which conflicted with previous recommendations by U.S. Public Health Service representatives. In other instances, the approach to Army officers was so belligerent that conflict and personal enmity resulted. By contrast, at the national level the Social Protection Division worked most successfully with the military services and other agencies involved in venereal disease control.
Interdepartmental Committee on Venereal Disease Control
Establishment and organization.-Publication of the book "Plain Words About Venereal Disease" by Parran and Vonderlehr was the impetus for the establishment of the Interdepartmental Committee on Venereal Disease Control. Soon after publication of the book, Mr. McNutt conferred with the Secretary of War, Henry L. Stimson, in order to establish closer liaison between the various departments on the matter of venereal disease control. Mr. McNutt wrote to Secretary Stimson on 6 December 1941 recommending specifically that the Secretary of War, the Secretary of the Navy, and the Federal Security Administrator "* * * join quite informally as a top committee to confer perhaps once a month * * * to consider condensed overall reports from our several competent advisors * * *."
On 26 December 1941, Mr. McNutt again wrote to the Secretary of War recommending a program of collaboration for the Secretary of War, the Secretary of Navy, and the Federal Security Administrator in connection with venereal disease control. This program included nine points, point eight of which recommended the establishment of a committee of six composed of two representatives each from the War Department, the Navy Department, and the Federal Security Agency. Mr. McNutt also recommended that this committee consider as advisers to be frequently consulted appropriate representatives of the Department of Justice and recognized private agencies. On 6 January 1942, the Secretary of War wrote to the
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Federal Security Administrator stating that the War Department was in accord with the general principles outlined in the proposed program and would cooperate in every feasible manner in the control of venereal disease in communities adjacent to military reservations. Two representatives, one from the Office of the Surgeon General and the other from the General Staff, were designated as representatives of the War Department to serve on the proposed Interdepartmental Committee. Colonel Simmons, Director, Preventive Medicine Division, was appointed representative for The Surgeon General.
Meetings of the Committee.-The first meeting of the Interdepartmental Committee on Venereal Disease Control was held in the Office of the Surgeon General on 23 December 1941 in response to a verbal request of Mr. Charles P. Taft, Assistant Coordinator, Health, Welfare and Related Defense Activities, Office for Emergency Management. This initial meeting was attended by representatives of the Army, the Navy, the Federal Security Agency, and the U.S. Public Health Service. It was concerned primarily with the problem of venereal disease control in Panama and Cuba. The second meeting of the Interdepartmental Committee on Venereal Disease Control was held on Friday, 2 January 1942, in the Office of the Surgeon General. At this meeting, in addition to the Army, the Navy, and the Federal Security Agency, representatives were also present from the American Social Hygiene Association and the Panama Canal Health Department. The minutes of the second meeting recorded that discussion touching upon venereal disease control problems in many areas, including the Caribbean, resulted in no definitive action. Although liaison had now been established between the different national agencies concerned with venereal disease control, it was not yet clear at the conclusion of this second meeting of the Interdepartmental Committee exactly what its function or method of action should be.
On 22 January 1942, the third meeting of the Interdepartmental Committee was held in the Office of the Federal Security Administrator. The committee now included a representative from the Federal Bureau of Investigation. A brief summary of this meeting was prepared for the Army Chief of Staff.12 The representative of the Social Protection Division reported that favorable results were being accomplished throughout the country by cooperative action between the Social Protection Division, military services, and local officials. In connection with the May Act, discussion brought out that considerable differences of opinion concerning its invocation were expressed by representatives of the Public Health Service and the American Social Hygiene Association on the one hand, and the military services and the Federal Security Agency on the other. It was the opinion of Dr. Parran of the U.S. Public Health Service and Dr. Snow of the American Social Hygiene Association that invocation of the May Act in
12Memorandum, Brig. Gen. J. H. Hilldring to Chief of Staff, 26 Jan. 1942, subject : Conference, Inter-Departmental Committee on Venereal Disease Control.
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certain localities as test cases should be considered in order to impress the underworld. Representatives of the military services on the other hand opposed indiscriminate invoking of the act, holding that the bill should be invoked only when local services could not or would not satisfactorily handle the situation. The representative of the Federal Bureau of Investigation informed the committee that it would be necessary that the Bureau be given advance notice of approximately 14 weeks in order that competent personnel could be trained to administer the act.
On 7 February 1942, Colonel Turner, chief of the Subdivision of Venereal Disease, was appointed a member of the Interdepartmental Committee to replace Colonel Simmons. The committee met again on 18 March 1942. The major portion of the agenda concerned problems of venereal disease and prostitution in Puerto Rico. After consideration of a report from Mr. Taft, the committee drafted a resolution condemning the attempt of the Caribbean authorities to regulate prostitution and transmitted the resolution on 18 March to the department surgeon. On 2 June 1942, another meeting was held at which subjects of general interest were considered, but no important action was taken. The initial results of the invocation of the May Act in the Tennessee area were discussed and it was noted that, although a good deal of publicity had occurred locally, very little note was taken of the invocation in other parts of the country. At this meeting, the Social Protection Division representative suggested that, in order to achieve better cooperation from State and local police authorities, it might be advisable to call a meeting of representatives of police chiefs in Washington. This recommendation was approved and such a meeting was later convened.
On 26 August 1942, Major Brumfield, The Surgeon General's representative to the committee, wrote a memorandum to Colonel Turner, chief of the Venereal Disease Control Branch, in which he stated: "The programs for venereal disease control in areas adjacent to military establishments are suffering because of lack of understanding between the local representatives of the agencies concerned. The principal offenders are the field representatives of the Social Protection Section who apparently do not understand exactly where they fit into the picture." This conflict existed principally between the Social Protection Division representatives and those of the Public Health Service. In order to clarify the situation, Major Brumfield had discussed the objectives of the nationwide program with the Assistant Surgeon General, Venereal Disease Division, U.S. Public Health Service; the director of the Social Protection Section; the executive director of the American Social Hygiene Association; and the Surgeon General of the Navy. At their suggestion, he had prepared an outline of the duties and responsibilities of the various groups which he now submitted with the memorandum. In a letter to Mr. Taft on 8 September 1942, Major Brumfield suggested that the outline be submitted to the Interdepartmental Committee on Venereal Disease Control for consideration at its next meeting. At the 18
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September 1942 meeting of the Interdepartmental Committee, this draft was favorably considered and the committee recommended its issue as soon as possible to all staff members of the agencies concerned so that each agency would be better informed of its functions in relation to the other agencies. On 12 October 1942, the statement entitled "Relationships of the Army, Navy, United States Public Health Service, Social Protection Section, and the American Social Hygiene Association in Venereal Disease Control" was submitted by Mr. Taft to The Surgeon General for his comment and indorsement. On 2 November 1942, The Surgeon General acknowledged receipt of this statement and concurred in its publication. It was officially released for publication on 15 January 1943 by the Office of Defense Health and Welfare Services, Office for Emergency Management.
At the meeting of 18 September 1942, several other subjects received considerable study. The Federal Bureau of Investigation representative reported on the progress of the May Act in the Camp Forrest area. He reported indications that an attempt would be made by local individuals to contest the constitutionality of the act, but that it was expected that this challenge would be successfully met. The question of the use of Civilian Conservation Corps camps as venereal disease hospitals was also discussed, and consideration was also given to the request submitted by the Anglo-American Caribbean Commission for the assignment of a U.S. Public Health Service officer to this area.
At the next meeting of the Interdepartmental Committee on 17 November 1942, the venereal disease problem in the Caribbean and the operation of the May Act continued to command the attention of the committee. As a result of the discussion at this meeting regarding the venereal disease problem in the Caribbean, the chief of the Venereal Disease Control Division, Office of the Surgeon General, took action to strengthen the Army venereal disease control program in this area by securing and assigning Maj. (later Col.) Daniel Bergsma, MC, an officer specially trained in venereal disease control, to that command.
General satisfaction was expressed in connection with the operation of the May Act. It was the opinion of those present that the operation of the act had been effective in the two areas in which it was invoked but that the mechanism of invoking the act through War Department Circular No. 170, 16 August 1941, was cumbersome. The changes effected as a result of this observation were discussed elsewhere (p. 174).
In late 1943, some members of the Interdepartmental Committee were apparently convinced that further meetings would not result in sufficiently useful action to warrant them. For example, Dr. Snow, Chairman, Executive Committee, American Social Hygiene Association, wrote to Colonel Turner on 3 December 1943 saying, "* * * it [the committee] ought to be more active and useful or else some other device should be tried for accomplishing the
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fullest measure of cooperation and exchange of current views between governmental and voluntary agencies * * *."
During 1944, the committee was inactive. In 1945, a meeting was convened at the request of the Social Protection Division on 12 September. Particular attention was paid by the conferees to the rising Army venereal disease rates and to the question of continuing the May Act. The minutes of the Committee meeting of 30 November 1945 stated that when Commander Ferree, the Navy representative raised the question of the importance of continuing the Interdepartmental Committee, it was the unanimous opinion of all those present that the committee should not only be continued, but that it should be an active functioning organization. At this meeting, the functions and responsibilities of the committee were restated; Mr. Watson B. Miller, Federal Security Administrator, was elected to serve as chairman; and the committee continued to function during the immediate postwar period.
Miscellaneous Agencies
The high proportion of venereal diseases acquired by military personnel in bars and taverns led the War Department to enlist the cooperation of the Brewing Industry Foundation and other liquor industries (fig. 18). War Department Memorandum No. W850-35-43, dated 18 July 1943, referred to the desire of the Brewing Industry Foundation, New York, N.Y., to assist the Armed Forces in maintaining satisfactory conditions in and around retail beer establishments near military posts. The memorandum authorized commanding officers to solicit the assistance of this foundation. On 30 August 1943, War Department Memorandum No. W850-43-43 further defined the nature of the assistance available from the Allied Liquor Industries, Inc., New York, N.Y., the Distilled Spirits Institute, Inc., National Press Building, Washington, D.C., and the Conference of Alcoholic Beverage Industries, New York, N.Y.
Numerous other organizations were at one time or another cooperating with the Office of the Surgeon General in its venereal disease control program. Among these were church organizations, State and local health departments (fig. 19), officials of States and cities, Negro organizations, the National Federation of Women's Clubs, and other groups. In addition, the Venereal Disease Control Division carried on an extensive correspondence with civilian doctors, nurses, and nonprofessional people regarding problems of venereal disease treatment and control.
One of the chief activities of the Venereal Disease Control Division of the Office of the Surgeon General during World War II was the civilian collaboration program. Because of the fact that the venereal diseases, unlike most other communicable diseases, were acquired by military personnel from civilian sources outside military jurisdiction, it was necessary to depend upon civilian agencies to a much greater degree than was true in other
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FIGURE 18.-Bars and taverns played a part in the spread of venereal disease. An investigator of the Chicago Health Department checks, with a Chicago bartender, information supplied in a contact report.
Medical Department programs. In this program of collaboration with the military services, the Social Protection Division of the Office for Emergency Management (later, of the Federal Security Agency), the U.S. Public Health Service, and the American Social Hygiene Association played the most important roles. By February 1943 it was possible to say: "* * * the past year was a period during which collaboration between military and civil authorities reached a highly effective level. Venereal disease control officers of the Army were in almost daily contact with officers of the United States Public Health Service, with State and local health department officials, and with representatives of other civilian agencies."13 Without these joint efforts the success achieved during World War II in the control of venereal disease among military personnel would never have been possible.
13Turner, T. B.: The Suppression of Prostitution in Relation to Venereal Disease Control in the Army. Federal Probation 7 (2) : 8-11, April-June 1943.
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FIGURE 19.-Local health department efforts. The Chicago Health Department enters a float urging the fight against venereal disease in the annual Chicago Defender parade, 1943.
SPECIAL PROGRAMS AND ACTIVITIES
Control of Prostitution
Definitive action to eradicate commercialized prostitution was the responsibility of civilian law-enforcement agencies, but the degree to which these agencies carried out the provisions of the law depended very often upon the sincerity and persistence with which local commanding officers supported repressive measures. For this reason, the War Department issued a series of directives clearly stating its position with respect to prostitution and designed to impress upon line and medical officers the need for repression. The perennial struggle between those who advocated segregated areas of prostitution rather than suppression of prostitution as a venereal disease control measure was not eliminated by the many directives published by the War Department. In July 1943, it was still evident that at least a few commanding officers disagreed with the established policy of the War Depart-
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ment. For this reason, another directive reiterating War Department policy was published in July 1943.14
Enlistment of support of State governors and industry.-To secure full support of the Army's control efforts, the Secretary of War, in March 1942, addressed letters to the governors of all States calling their attention to the danger which prostitution and venereal disease presented to the war effort unless prompt and effective suppressive measures were enforced. He asked the governors to assume responsibility for stimulating State and local law-enforcement agencies in carrying out the venereal disease control program and for the initiation of a program of public education. On 25 May 1942 , the President sent a letter to Mr. McNutt commending the Interdepartmental Committee on Venereal Disease Control for its efforts and referring to the need for continued venereal disease control measures. This letter was transmitted by Mr. McNutt to some 8,500 key executives of war production plants. He called for their active encouragement of physical and moral fitness and referred specifically to the Eight-Point Agreement and to the need for the cooperation of these plants in repressing prostitution and controlling venereal disease locally.
Prostitution overseas.-The problem of prostitution in oversea theaters is discussed separately in the individual oversea theater reports. It is of interest to note at this point, however, that in 1945 evidence was becoming increasingly available that prostitution not only existed but in some oversea areas was being actively supported by U.S. Army commanding officers. On the basis of a report submitted by Dr. Joseph E. Moore, a letter from The Adjutant General to all oversea theaters was dispatched on 24 April 1945 . This letter called the attention of commanding generals of oversea theaters to War Department policy with respect to the suppression of prostitution and strongly urged that measures effective in the continental United States also be applied in oversea commands. Use of off-limits authority when cooperation of civilian law-enforcement agencies could not be obtained was directed.
Results of antiprostitution program.-The results of the wartime anti-prostitution program-a program which, it should be emphasized, was a joint enterprise entered into by many agencies of which the military services constituted only one-were evident in practically every city and community throughout the Nation. In over 600 cities and towns, segregated areas of prostitution activities were eliminated. In other communities, efforts to initiate new prostitution undertakings were frustrated by aroused and public spirited local citizens.
Evaluation of antiprostitution program.-Certain lessons were learned
14Letter, The Adjutant General to Commanding Generals, Army Ground Forces, Army Air Forces, Army Service Force; Commanding Generals, Defense Commands, Service Commands, Military District of Washington, Ports of Embarkation; Commanding Officers, Posts, Camps, and Stations, including exempted Stations, 31 July 1943, subject: Improvement of Moral Conditions in the Vicinity of Camps and Stations.
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in the Army's wartime program that should be useful in any future repression program. It was early observed that the mere arresting of girls who were fined or even convicted of prostitution was inadequate to eliminate clandestine or commercialized prostitution. It was only when cities and communities emphasized the role of middlemen-facilitators, bellhops, cab drivers, and other individuals who procured customers for prostitutes-that any repression program could succeed. In addition, many communities which wished to cooperate with the Army and other agencies were handicapped by the lack of detention facilities. It was only after the provision in 1943 and 1944 of treatment centers and, in some instances, of enlarged jail facilities that these communities were able to conduct successful programs.
Operation of May Act
Procedures for invocation.-The May Act made prostitution in areas designated by the Secretaries of War and of the Navy a Federal offense. To establish a procedure for the invocation of the act, the War Department published on 16 August 1941 Circular No. 170 which described in detail the steps to be taken by each commanding officer before the actual invocation of the act by the Secretary of War. The Social Protection Division was intimately connected with the procedure for invoking the act, since each local commanding officer was required to submit a request to the regional representative of the Division for a special survey of the area to determine the extent of prostitution activities before invocation could be recommended. A report of this survey was transmitted to the commanding officer who then proceeded to take action in accordance with the recommendations made by the Division representative. Thus, the invocation of the act depended to an important extent upon the findings of the Social Protection Division. However, the Interdepartmental Committee on Venereal Disease Control found the procedures described in this circular to be exceedingly complicated due to the problem of conflicting jurisdictions. The committee favored centralizing the initiation of the act in a single general officer in each area in order to overcome this difficulty. Accepting these recommendations, The Surgeon General advised the War Department that the commanding general of each service command should be made responsible for initiating procedures and recommending to the War Department the invocation of the act. The change, as recommended, as effected by War Department Circular No. 12, 7 January 1943.
Invocation of May Act.-In only two areas was the May Act invoked during the war. The first occurred in an area surrounding Camp Forrest, Tenn., on 20 May 1942. For many months in the fall of 1941, Camp Forrest had attempted to secure adequate law enforcement in repressing prostitution in communities surrounding the camp. These efforts met with failure. After many conferences with State and local health departments, and with
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their concurrence, the camp commander finally decided to request that the May Act be invoked (fig. 20).
FIGURE 20.-Opening of sports center at Camp Forrest. At about the same time the May Act was invoked in areas surrounding Camp Forrest, intensive efforts were made to provide adequate recreational activities on post, May 1942.
The second invocation of the act took place in and around Fort Bragg, N.C. Brig. Gen. E. P. Parker, Jr., Commanding General, Fort Bragg, had taken initial steps to secure repression of prostitution by local communities but, as in the case of Camp Forrest, had had no success. In October 1941, General Parker, through the Commanding General, Fourth Corps Area, requested the regional representative of the Social Protection Division to conduct the initial survey required by Circular No. 170. On the basis of the unfavorable findings reported by the Social Protection Division survey, General Parker requested Governor Broughton of North Carolina to convene a meeting of responsible health and law-enforcement officials to consider the contents of the report. This meeting was held, the findings were discussed, and the civil officials were given until 31 December 1941 to repress prostitution activities in the counties surrounding Fort Bragg. It
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was apparent at the conclusion of this period that the efforts of the local authorities had failed, and further steps were therefore taken by the commanding general to invoke the May Act. Actual invocation of the act became effective at midnight on 31 July 1942.
In many other areas, initial steps were taken to invoke the May Act but actual invocation did not occur because local communities succeeded in eliminating prostitution without Federal intervention. By the end of 1942, it had become clear that a threat to invoke the act was almost as effective as invocation itself. Extreme foresight had been demonstrated as early as 1941 in the clear statement, in the program of the Social Protection Division, of this policy of depending upon local communities until every resource had been exhausted. This program stated in part:
It is, therefore, the responsibility of this Division to attempt to bring about a voluntary adoption of its program [for the repression of prostitution] by local authorities as a permanent policy. The establishment by military authorities of areas as out of bounds for men in uniform, or the invocation of the May Act, are measures to be taken only as a last resort. Experience in the last war, and the attitude of the Federal and local authorities to date in this emergency, all point to the likelihood that our program can be established in most defense areas on a voluntary basis.
The May Act was never invoked again after its two early invocations in Tennessee and North Carolina, for it was not believed necessary by local commanding officers, the Social Protection Division, and other agencies involved. In almost every instance, local communities succeeded in solving their own problems without Federal intervention, although it was no doubt true that, without the existence of the May Act and the ever-present possibility of invocation, the same local communities might have been more reluctant to take positive action.
Effect of the Act.-In general, the May Act produced a definite decline in commercialized prostitution in the areas in which it was invoked. It was also apparent, however, that its enforcement met with difficulties in certain localities because of lack of local cooperation or the rigid requirements of the Federal court in defining the admissibility of evidence.15 In eastern Tennessee and North Carolina, the act was particularly effective at the beginning of its enforcement. However, as commercialized prostitution activities were gradually suppressed and eliminated, "amateurs" and promiscuous girls became the primary factor in spreading venereal disease. When the Federal Bureau of Investigation was forced to direct its efforts against them, the operation of the act became less satisfactory and was subjected to certain criticism. An article entitled "In May Act Areas" by Kathryn Close, which appeared in the March 1943 issue of Survey Mid-Monthly,
15(1) Letter, Lt. Col. Roy C. Tatum to The Surgeon General, 1 Apr. 1943, subject : Report on Operation of the May Act, inclosure thereto. (2) Letter, Maj. Paul S. Parrino, Venereal Disease Control Officer, Camp Forrest, Tenn., to Capt. Myron T. Nailling, Assistant Chief, Litigation Section, Judge Advocate General Department, Headquarters, 4th Service Command, 14 Sept. 1943, subject : Enforcement of the May Act in Tennessee.
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discussed many of the difficulties encountered by the Federal Bureau of Investigation in its efforts to enforce the May Act. In one area, the Nashville-Western Tennessee area, there was general dissatisfaction with the act both in the Army and among the Federal Bureau of Investigation agents who operated in this area. Soon after the act was invoked, a case was presented before the Federal court covering the Nashville area but was thrown out on the basis of the type of evidence presented. This initial court failure discredited the May Act in this area and made subsequent enforcement efforts more difficult. It was because of the unsatisfactory situation in Nashville that an inspector general's report16 on the operation of the May Act in Tennessee contained the following conclusions:
1. Nashville has made less progress under the May Act than has been reported elsewhere where invoked, although some improvement in the general situation is noted (fig. 21).
FIGURE 21.-Soldiers' and Sailors' Room at Union Station, Nashville, Tenn. Well-meaning citizens of Nashville provided this facility which in its first year of operation entertained over 85,000 men.
16Report, Lt. Col. Warren D. Leary, Inspector General Department, to Commanding General, 4th Service Command, Atlanta, Ga., 30 Mar. 1943, subject: Special Inspection on Operation of the May Act-Vicinity of Camp Forrest, Tennessee.
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2. The Federal Bureau of Investigation field division at Memphis was not able to put into effect the system of direct investigation and seizure employed by the Knoxville agency.
3. A vigorous enforcement of the new State legislation would make the May Act unnecessary.
4. The venereal rate at Camp Forrest has a more direct relationship with the education program in effect there by the venereal disease control officer than with the enforcement of the May Act.
Concerning the North Carolina area, the same inspector general recommended17 that consideration be given to obtain more Federal Bureau of Investigation agents with May Act experience to work in the area; that consideration be given by Fort Bragg authorities to continue to exert pressure and stimulate city and county authorities and civic groups to be unrelenting in their efforts against prostitution; and that continued study be made by Fort Bragg authorities to determine the advisability of curfew regulations for Fort Bragg personnel and off-limits procedure for cab companies and other violators.
The opinion of The Surgeon General concerning the May Act was fully stated in the ninth endorsement to a letter pertaining to the operation of the May Act in counties surrounding Fort Bragg, which was initiated by the Judge Advocate General.18 In this correspondence, The Surgeon General's opinions were, substantially, as follows:
1. The invocation of the May Act in the two areas mentioned has been followed by a substantial decrease in prostitution activities, and this has had a favorable effect on the venereal disease control program in those areas.
2. In general, the Federal Bureau of Investigation has done an effective job in providing leadership for enforcement activities in those areas. In the final analysis, the effectiveness of the May Act depends upon public opinion in the areas concerned, the cooperation of local law-enforcement officials, and the attitude and decisions of the Federal courts in those areas. The attitude of the various courts concerned in the two areas under discussion has by no means been uniform.
3. The threat of invocation of the May Act has had a salutary effect on law-enforcement activities by local officials in many areas in which the May Act has not been invoked.
In concluding his comments, The Surgeon General stated: "* * * this office is actively supporting a program designed to obtain effective law enforcement without resorting to invocation of the May Act. It is believed that much has been accomplished by such a program and invocation of the May Act in other areas is not recommended except in those communities which repeatedly fail to cooperate in this program."
17Report, Lt. Col. Warren D. Leary, Inspector General Department, to Commanding General, 4th Service Command, Atlanta, Ga., 23 June 1943, subject: Report of Special Survey of the Operation of the May Act about Fort Bragg, N.C.
18Memorandum, Judge Advocate General to Director, Control Division, Army Service Forces, 24 Sept. 1943, subject: Operation of May Act in Countries Surrounding Fort Bragg, North Carolina, 9th endorsement thereto.
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This statement reflected a gradual change in policy that had been developing during 1942 and 1943 subsequent to invocation of the act in Tennessee and North Carolina. It coincided with the statement that had been enunciated by the Social Protection Division in 1941.
Contact-Tracing program
Development of reporting form.-The importance of securing adequate contact information from infected military personnel was recognized at the outset and was included in the Eight-Point Agreement (appendix B). Paragraph 6, AR 40-1080, 31 December 1934, had already required the reporting of communicable diseases to civilian health departments, but instructions for the routine transmittal of venereal disease contact information were not furnished until the publication of Circular Letter No. 50 on 28 May 1941.19 Under the provisions of this circular letter, contact information was obtained by a medical officer and transmitted on a form provided for this purpose by the local State health departments. Although AR 40-1080 and the Eight-Point Agreement required the reporting of venereal disease information in accordance with local civil requirements or regulations, the actual transmittal of the form to State or local health departments was left to the discretion of the reporting medical officer, who weighed the usefulness and authenticity of the information. This system resulted in confusion because of the multiplicity of forms and channels of transmittal. On 11 May 1942, Dr. Vonderlehr, U.S. Public Health Service, wrote to Colonel Turner suggesting that a standard form be devised for reporting contacts to civil health authorities. Colonel Turner accepted the suggested and offered to collaborate with the Public Health Service in the preparation of such a form. A tentative form was devised and submitted to service command venereal disease control officers and Public Health Service liaison officers for their comments. A final form was developed by Major Brumfield and sent informally to each service command for local reproduction and distribution in late July 1942. Unfortunately, no uniform procedures for the transmittal of the form were directed, and, because of the informal distribution of the suggested form, many changes were made in the field.
In October 1942, the Venereal Disease Control Division recommended to the Executive Officer, Office of the Surgeon General, the adoption of a standard contact form for distribution throughout the Army, and by January 1943 the initial printing was under way. The distribution of this form (MD Form 140) established a uniform system of reporting contact information. In May 1945, minor revisions were made and the form was reprinted as WD AGO Form 8-148.
Operation of program.-The method of securing information from infected soldiers varied in the different commands. At some posts medical
19Circular Letter No. 50, Office of The Surgeon General, U.S. Army, 28 May 1941, subject: Cooperation With State Health Departments in Reporting of Venereal Disease.
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officers assumed sole responsibility, while in others responsibility was delegated to enlisted men or to civilian public health nurses. Opinion differed as to the relative efficacy of the different methods, but it was clear that the more persuasive and persistent the questioning the more useful was the information obtained (fig. 22).
FIGURE 22.-Contact-tracing interview. Privacy, persuasiveness, persistence, and visual aids were of utmost importance in gaining useful information. (From TB MED 243. Photo courtesy of Bureau of Medicine and Surgery, Dept. of Navy.)
Evaluation of program.-The value of this contact-tracing program can hardly be overestimated. Thousands of infected girls were located and brought under treatment by civil health departments, and places of assignation were identified and eliminated by law-enforcement agencies (fig. 23). The nature of the epidemiological problem was clearly presented by analyses of the material made available through this program, and control efforts were concentrated and directed accordingly. These contact reports provided source data for papers appearing in the medical literature,20 and the Social Protection Division charged with the responsibility of stimulating and coordinating local prostitution suppression programs, relied to a large extent
20(1) Norris, E. W., Doyle, A. F., and Iskrant, A. P.: Venereal Disease Epidemiology, Third Service Command: An Analysis of 4,641 Contact Reports. Am. J. Pub. Health 33: 1065-1072, September 1943. (2) Norris, E. W., Doyle, A. F., and Iskrant, A. P.: Venereal Disease Epidemiology in the Army Third Service Command: Progress Report for Period January Through June 1943. Ven. Dis. Inform. 24: 283-289, October 1943.
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FIGURE 23.-Contact-tracing program results. Places of assignation were identified and thousands of infected girls were located and brought under treatment. (From TB MED 243. Photo courtesy of Bureau of Medicine and Surgery, Dept. of Navy.)
upon the contact information derived from these reports to develop and evaluate their local programs.
One fact that became particularly clear from a study of these reports was the interdependence of the control programs among all military establishments and civilian communities. As a result of greatly increased movement within the wartime civilian population, wide dispersion of contacts occurred. Each community provided infectious contacts for military personnel stationed in distant areas. It was early apparent that successful control programs influenced rates not only in posts contiguous to any given area but also in far distant installations. The effects of local failures were felt in distant commands.
In an article entitled "Epidemiology of Venereal Disease" published in the June 1946 issue of the American Journal of Public Health, Colonel Sternberg analyzed a collection of epidemiological information obtained from 71,156 Army personnel who had acquired venereal disease in the United States during the period from 1 January 1945 to 30 June 1945. A study of
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these data revealed that, of all Army venereal infections which were diagnosed and treated in service commands, 32 percent occurred in service commands other than those in which exposure took place. During the period of this study, 9,641 venereal infections in Army personnel were diagnosed and treated in 1 of the 8 States comprising the Ninth Service Command. Of these, 4,540, or 47 percent, were acquired in 1 of the other 40 States. Colonel Sternberg pointed out that these data demonstrated most forcibly that no single State by its own efforts could hope to control venereal disease since a large percentage of the sources of venereal disease cases diagnosed in one State were traceable to another. He considered these facts ample justification for New York, Ohio, or any other State to have a legitimate interest in the effectiveness of the venereal disease control programs carried on by Illinois, Texas, California, or any other distant State and to be critical should these programs fail to meet acceptable standards.
Inducting Individuals With Venereal Disease
Development of program.-To facilitate the initial management of inductees with venereal disease, 34 barracks-type hospitals with a total of 6,510 beds were constructed at various reception centers and staffed by specially qualified medical officers. All these officers received a short intensive course in the diagnosis and treatment of venereal disease at the Institute for the Control of Syphilis, University of Pennsylvania, before their assignment. The first of these hospitals began to function in September 1942, and all were in operation by March 1943.
Operation and results of program.-Following induction, individuals with venereal disease were sent to the special hospitals where observation and treatment of high quality were accomplished without stigmatization. Patients were confined to the hospital area while under treatment but, for the most part, were ambulatory, were afforded regular recreation and exercise, and in addition were assigned light duties. Regular post exchange items such as cigarettes, candy, and toilet articles were available for purchase. The hospitals were neither marked nor inclosed in such a manner as to make them conspicuous or to identify their character. The average patient remained in the hospital for 10 days and was then referred through the reception center to a normal training assignment where further necessary treatment was administered by unit medical officers. Those with gonorrhea or chancroid were not discharged from the hospital until cured. All selectees with presumed latent syphilis were given a complete spinal fluid examination before induction and were rejected if any significant abnormalities were found.
Administrative problems encountered in the program, although complex, were overcome by a series of directives which appeared in early 1943. The function of the venereal disease facilities was outlined in detail in War Department Memorandum No. W40-1-43, dated 15 Jan. 1943. On the same
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date, a letter was published21 detailing the administrative and professional care of recent inductees with venereal disease. With the publication of this letter, problems involved in the induction of registrants with venereal disease were resolved, and the induction of such individuals proceeded at a rapidly increasing rate. Approximately 100,000 such registrants were processed during 1943. Because of the enormous backlog of inductable registrants with syphilis, further efforts were made late in 1943 to speed their induction. In August 1943, a letter22 was published emphasizing the importance of the venereal disease induction program and authorizing the utilization whenever necessary of available Medical Department installations, other than venereal disease facilities at reception centers, for the processing of such individuals.
As a result of this program, 200,000 individuals with venereal disease were inducted through December 1945. Of these, approximately 170,000 were individuals with syphilis.23
Separation of Military Personnel With Venereal Disease
Development of program.-The importance of protecting the public from the spread of venereal disease by infected individuals discharged from the service was appreciated throughout the war. The basic Army regulations pertaining to the control of communicable diseases provided for the retention and treatment, before discharge, of individuals in an infectious state of venereal disease. AR 40-210, dated 15 Sept. 1942, also provided for the transmittal to the health department of the State of intended residence a summary of pertinent data, so as to enable civilian physicians to continue observation and treatment. It was apparent that the demobilization of the Army of World War II required a much more ambitious and detailed program than that envisioned in the Army regulations, and, accordingly, conferences with the U.S. Public Health Service were arranged to develop the plans for what later became a smoothly operating venereal disease separation program.
During January and February 1944, Colonel Sternberg met with Dr. John R. Heller of the U.S. Public Health Service to develop specific plans for the separation program. At these conferences, it was decided that the Army would draw blood for serologic tests for syphilis and transmit the blood specimen to a laboratory designated by the Public Health Service for examination, treat individuals with infectious venereal disease before discharge, and make syphilis registers available to the Public Health Service
21Letter, The Surgeon General to Commanding Generals, Army Ground Forces, Army Air Forces, Services of Supply, Service Commands, Departments; Commanding Officers, All Posts and Camps Having Reception Centers, 15 Jan. 1943, subject: Treatment of Recently Inducted Individuals With Venereal Disease.
22Letter, The Adjutant General to Commanding General, 1st Service Command, Army Service Forces, 5 Aug. 1943, subject: Acceptance of Men With Venereal Diseases.
23Karpinos, B. D.: Venereal Disease Among Inductees. Bull. U.S. Army Dept. No. 10, vol. VIII, October 1948.
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for the abstracting of information. Syphilis cases were to receive 10 Mapharsen and 5 bismuth injections, and all other venereal disease cases were to be held until cured or until optimum treatment had been administered. The Public Health Service, on the other hand, agreed to examine the blood specimens through State and local serologic laboratories and insure the proper followup and necessary treatment of separatees with syphilis.
This program was recommended by Mr. McNutt, in a letter to Secretary Stimson on 19 February 1944. Secretary Stimson replied favorably on 28 February 1944. Dr. Parran also wrote to Secretary Stimson on 6 March 1944 and to Maj. Gen. Norman T. Kirk, The Surgeon General, on 9 March 1944. Dr. Parran expressed his hopes that the integrated approach, as planned, could be adopted.
The Secretary of War replied to Dr. Parran on 16 March 1944 as follows:
The development of adequate plans for the management of individuals with venereal disease at the time of demobilization is of great interest to the Army. We are particularly anxious that procedures be effected at that time which will assure uninterrupted medical care for those individuals needing it and will prevent the return to civilian communities of soldiers with an infectious venereal disease. The preliminary plans to cope with this problem, as outlined in your letter, are considered most satisfactory, and you may be assured that the Army will exert every effort to carry out its share of the program.
Special problems.-The decision to undertake a mass blood testing survey of separatees was based upon the following considerations: The knowledge that a definite, but unknown, number of syphilitic infections had occurred among military personnel without detection and treatment; the desirability of providing a final serologic test for syphilis in order to determine the adequacy of the treatment given for the disease in the Army; and the importance of establishing seronegativity at separation in connection with veterans' pensions, et cetera. A program to provide treatment before discharge for individuals with positive blood tests but with no previous history of treatment was carefully considered. This program was not adopted for the following reasons :
1. A minimum period of 3 months was necessary to establish or exclude syphilitic infection.
2. Specialized diagnostic and treatment facilities with trained personnel would have to be organized.
3. The Public Health Service not only had its rapid treatment centers and State and local medical facilities adequate to handle the load but was anxious to assume the responsibility.
4. Separatees would resent delay of the separation process and would probably prefer treatment, when indicated, after separation.
5. The majority of individuals with a positive serologic test for syphilis at separation would have syphilis in a stage not likely to be communicable.
Revision of separation program.-The program developed by the Army-Public Health Service conferees and accepted by the Federal Security Ad-
185
ministrator and the Secretary of War was established experimentally at the Pilot Separation Center at Fort Dix, N.J., on 30 March 1944.24
During the next 2 months, several important changes were made in the program to remedy defects that had become evident at Fort Dix. A standard form, the "Army Separation Serology Report and Laboratory Slips" (WD AGO Form 38-1), was developed. The examination of the blood was carried out by the nearest Army laboratory rather than by State laboratories, thereby saving time, breakage, and expense. The syphilis register and the new serology report form were sent by the Army directly to the nearest regional U.S. Public Health Service unit. The regional units, in turn, prepared from Army serologic reports their own syphilis epidemiological report forms. For cases having a history of incomplete treatment, abstracts of Army syphilis registers were made on this form. The epidemiological information was then transmitted to State health departments by regional public health units, thus facilitating followup. These changes were established by distributing to separation centers a tentative outline of final physical examination regulations.
A further important revision of the venereal disease separation program was proposed in August 1945. The system of referring information from regional U.S. Public Health Service units to State health departments resulted in an inescapable delay between separation and initiation of followup treatment. To circumvent this difficulty, the Public Health Service proposed that its representatives be assigned to all separation centers to interview before discharge individuals with a positive or doubtful blood test. In September 1945, the Army accepted this proposal25 and agreed to let the Public Health Service place its representatives in all separation centers and in many of the larger separation points. Separatees showing positive serologic tests were given the option of either being treated in a rapid treatment center before returning to their homes or being provided with transportation to a rapid treatment center of their choice. As for the other separatees with only doubtful test results or just a history of syphilis, copies of the Army serologic tests were forwarded to the Public Health Service regional units. In some cases of separatees not interviewed by the Public Health Service representative in the separation centers and points, the Army syphilis register was abstracted onto a single-sheet form, "Abstract of Army Syphilis Register" (VM 1296), and attached to serology reports. The data from these reports were then transcribed by the Public Health Service to their syphilis epidemiological reports. In August 1946, the Public Health Service withdrew its representatives, and the Army took over preparation of these syphilis epidemiological reports.
24Letter, The Surgeon General to Commanding General, 2d Service Command, 30 Mar. 1944, subject: Final Physical Examination To Be Performed at Separation Center.
25War Department Technical Manual 8-255. Terminal Physical Examination on Separation From Military Service, 10 Sept. 1945.
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Analysis of program.-Whatever the procedures at separation, a separation epidemiological report was eventually prepared for each separatee with a positive or doubtful serologic test reaction or with a history of syphilis. Only those whose treatment or observation had been completed while they were in the Army were exempted. From these separation epidemiological reports and from followup studies made by the Public Health Service, tables 15 through 17 were prepared.
As may be seen from table 15, covering the period November 1944 through October 1946, the serologic tests for syphilis revealed that 6.5 per 1,000 Army persons separated during this period had a positive test for syphilis without previous history; 10.9 per 1,000 separatees had a positive or doubtful serologic reaction without previous history of syphilis; and 9.1 per 1,000 separatees had a positive or doubtful reaction with history of syphilis. In round numbers, about 145,000 soldiers-2 percent of all those separated during this period-had a positive or doubtful reaction to serologic tests. Of these 145,000, 79,000 had no previous history of syphilis insofar as Army records were concerned-47,000 with positive reactions and 32,000 with doubtful reactions.
TABLE 15.-Results of serologic tests for syphilis of U.S. Army personnel at time of separation, November 1944 through October 1946
Type of serologic reaction
Number of reactions1
Rate2
Separatees without history of syphilis:
Positive
47,029
6.5
Doubtful
31,819
4.4
Total
78,848
10.9
Separatees with history of syphillis:
Positive or doubtful
65,608
9.1
Negative
94,137
13.1
Total
159,745
22.2
All separatees:
Positive or doubtful
144,456
20.0
Negative
94,137
13.1
Grand total
238,593
33.1
1The number of serologic reactions and their distribution by type were obtained from data supplied by the U.S. Public Health Service on the basis of Separation Epidemiologic Reports (FSA -USPHS Form 9576-B).
2The rates were computed on the basis of the total number of Army personnel separated during this period (7,207,478 persons), based on monthly reports submitted to The Surgeon General (SGO Form 916, before June 1945, and WD AGO Form 8-196, after June 1945).
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It would be misleading, however, to interpret these results of the serologic tests as prevalence of syphilis among separatees. Followup studies made by the Public Health Service on separatees of all services referred for treatment indicated that slightly over one-third were not infected-the tests were biologically false positive; about one-third needed no treatment; and one-third required treatment. The data are presented in table 16.26
TABLE 16.-Results of followup examinations by the U.S. Public Health Service of Armed Forces separatees with positive or doubtful serologic reactions for syphilis1
Findings
Number of separatees
Percent
Separatees without history of syphillis:
No infection
41,614
66.4
Infection under treatment before investigation
4,578
7.3
Untreated infection
16,427
26.3
Total
62,619
100.0
Separatees with history of syphillis:
No infection requiring treatment
36,155
69.3
Infection under treatment before investigation
6,359
12.2
Untreated infection
9,666
18.5
Total
52,180
100.0
Total examined:
No infection
41,614
36.3
No infection requiring treatment
36,155
31.5
Infection under treatment before investigation
10,937
9.5
Untreated infection
26,093
22.7
Grand total
114,799
100.0
1Data based on tabulations prepared by the State and regional tabulating units of the U.S. Public Health Service. The data relate to followup cases reported through December 1946, except for the State of Mississippi after December 1945 and the States of California, Florida, Kentucky, and Louisiana and the City of New York after June 1946.
Although the number of biologically false positive tests, when presented in this context, appears excessive, it is within the range of biologic false positive and laboratory errors. The U.S. Public Health Service estimated that 6.24 per 1,000 of serologic tests performed on all separatees of the Armed Forces were false positives. Other data available to the Public Health Service indicate that this figure ranges between 4 and 7 per 1,000 depending on the
26The data relate to only about 58 percent of total reported cases with positive or doubtful serologic reactions. For various reasons, final data were unavailable for the other 42 percent. Furthermore, data for some States and New York City did not cover the full period.
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test used, the proficiency of the laboratory, and the prevalence of intercurrent infections. Insofar as the separatees were concerned, malaria was one of the more common causes of nonsyphilitic reactions to the serologic test. Since the proportion of separatees exposed to malaria was greater than the proportion of the general population of the United States, this probably tended to inflate the proportion of so-called false positives among the reactors screened out by the serologic test.
A diagnostic breakdown of the treated cases is shown in table 17. The majority of the cases, about 42 percent, were diagnosed as early latent syphilis, and syphilis of unknown stage, about 31 percent, was the next most prevalent.
TABLE 17.-Distribution of followup cases of syphilis in Armed Forces separatees, brought to treatment, by diagnosis1
Diagnosis
Total
Without history
With history
Number
Percent
Number
Percent
Number
Percent
Primary syphilis
864
3.3
559
3.4
305
3.2
Secondary syphilis
1,430
5.5
1,222
7.4
208
2.2
Early latent syphilis
10,882
41.8
7,841
47.7
3,041
31.5
Neurosyphilis
508
1.9
341
2.1
167
1.7
Late syphilis (excluding neurosyphilis)
4,526
17.3
2,414
14.7
2,112
21.8
Unknown stage
7,883
30.2
4,050
24.7
3,833
39.6
Total
26,093
100.0
16,427
100.0
9,666
100.0
1Data based on tabulations prepared by the State and regional tabulating units of the U.S. Public Health Service. The data relate to followup cases reported through December 1946, except for the State of Mississippi after December 1945 and the States of California, Florida, Kentucky, and Louisiana and the City of New York after June 1946.
SPECIAL PROBLEMS OF CONTROL AMONG NEGRO TROOPS
The venereal disease rate of Negro soldiers was consistently 8 to 12 times higher than the rate among white soldiers. It became evident early in the course of the war that venereal disease control measures and educational methods directed mainly toward white troops had little effect upon Negro troops. Various expedients were tried or recommended in early 1943 with singular lack of success.
Conference on Control
In an effort to develop an effective program specifically directed toward the Negro, The Surgeon General convened a conference of key medical officers and representatives of civilian agencies in Washington, D.C., on 5 October 1943. Present at this meeting, in addition to white and Negro medical officers from key installations and commands, were representatives from the Venereal Disease Control Branch, Office of the Surgeon General; the Training Division,
189
Office of the Surgeon General; the Special Services Division, Army Service Forces; the Office of the Air Surgeon; the Office of the Secretary of War; the U.S. Public Health Service; the Social Protection Division, Office of Community War Services, Federal Security Agency; and the American Social Hygiene Association.
Observations
The following observations were made by the conferees with respect to the extent of the problem, underlying factors in the civilian and military population, and possible methods of attack:27
The problem.-The seriousness of the venereal disease problem among Negro troops is evident from the fact that the Negro venereal disease rate varies from 8 to 10 times the white rate and has steadily increased, reaching a maximum of 152 per 1,000 per annum in August 1943. This rate is so high that it may result in material interference with the full military utilization of Negro troops. The syphilis rate of 30 per 1,000 per annum during the past 6 months is a rate 15 times that for white troops. This is a particularly unfortunate situation in view of the time lost due to lengthy treatment required and the possibility of serious complications. This rate creates an estimated requirement of 750,000 hospital bed-days for the treatment of Negro venereal disease cases in 1943, thereby throwing a very considerable additional burden on the Medical Department. This represents an approximate total of 60,000 cases of venereal disease in Negro soldiers in 1943, 15,000 of which will be cases of syphilis (based on prevailing rates). Eventually, this will result in an inestimable financial burden upon the Government for the care and compensation of conditions arising from this vast number of venereal infections. (These data relate only to Negro troops stationed in the continental United States and, further, do not include those infections acquired before induction.)
Underlying factors involved.-It is generally recognized that the causes for high incidence of venereal disease among Negroes are basically socioeconomic. Because of the interdependence of the underlying factors affecting both the military and civilian population, both are given consideration.
Some of the factors which influence the venereal disease rate in the civilian population are the following: (1) Low educational level, as evidenced by degree of illiteracy among Negro selectees, and general lack of knowledge about health matters, (2) inadequate law enforcement in Negro communities with respect to the increasing prostitution conditions brought on by the war, and (3) lack of recognition of the seriousness of the problem, together with reluctance to face the facts.
Some of the factors directly influencing the high venereal disease rate
27Memorandum, Lt. Col. Thomas B. Turner, MC, for Director, Preventive Medicine Division, 13 Oct. 1943, subject: Report of Conference on Venereal Disease Control Problems Among Colored Troops, with enclosure thereto.
190
among Negro military personnel are: (1) The factors noted for the civilian population which contribute to a high degree of infection in troops who come in contact with them, (2) insufficient recreational facilities to offset adverse conditions often encountered by Negro soldiers in extracantoment communities, (3) a venereal disease education program generally inadequate to meet the specific needs of Negro soldiers, and (4) the presence of a defeatist attitude on the part of many commanding officers with respect to venereal disease prevention among Negro troops.
Methods of attack.-The control of venereal disease among white troops is effected through measures aimed at reducing the sex-exposure rate, increasing the use of prophylaxis, and minimizing the risk of infection from the adjacent civilian community. These same general principles are no less valid when applied to Negro personnel, but their application presents many problems in addition to those encountered with white troops. However, the venereal disease incidence among Negro soldiers can be reduced and rates more nearly approximating those of white personnel can be achieved. This is evidenced by the experience in certain posts and commands where venereal disease control programs have been developed embodying good recreational facilities, improved educational techniques, good prophylaxis facilities, proper command support, and effective extracantonment cooperation.
Among these commands is the Eastern Flying Training Command with 30 stations having Negro personnel, located for the most part in the Southeastern United States, which has reduced its Negro venereal disease rate from 220 to 65 over the past 15 months. One of the major factors reported as contributing to this reduction is the use of Negro noncommissioned venereal disease control officers, specially trained in a short course at Tuskegee Army Air Field, Ala. These men, upon their return from the course, were utilized in promoting especially adapted venereal disease education for Negro troops, and in other phases of the venereal disease control program. Another important factor was the exceptionally strong command support given to the program.
The important role that recreation plays in the overall venereal disease control picture arises from the need for wholesome activity to occupy off-duty time as a substitute for the often undesirable recreation offered by the Negro civilian community, frequently in an environment conducive to the spread of venereal disease. The other role of recreation is its contribution to the improvement and maintenance of morale.
It is recognized that effective venereal disease education of Negro personnel offers many more problems and difficulties of accomplishment than does that of white troops. Some of these problems have their basis in the extreme lack of correct health knowledge among Negro soldiers. An educational approach, based on the fullest possible utilization of Negro officers and noncommissioned officers, will be the most effective, because Negro commissioned and noncommissioned officer personnel can better understand the mores,
191
folkways, and race psychology of the Negro soldier than similar white personnel, and can thus be used more advantageously. Furthermore, extensive use should be made of those psychological appeals for the avoidance of venereal disease which have proved to be effective in certain commands. Among these are appeals to racial pride, competitive spirit, and patriotism. The present training aids used in conjunction with venereal disease education lack maximum value because they are aimed primarily at the white soldier.
With respect to the repression of prostitution, the prevalence of commercialized Negro prostitution activity around many Army camps is a prolific source of venereal disease at the present time. This Negro prostitution problem, which is a recent development, requires a concerted attack by military and civilian agencies.
Because of the exposure of the Negro soldier to a more highly infected civilian population, the provision of the most effective prophylactic measures is essential. Where easily accessible station prophylactic facilities have been made available, a beneficial effect on the venereal disease rate has been universally observed. Individual chemical and mechanical prophylactic kits have been found to be useful adjuncts but not as effective at the present time as station prophylaxis. This can be accounted for by the reluctance of the men to use mechanical prophylactic materials, and the complexity involved in the use of the present two-tube chemical kit. A newly developed prophylactic measure against gonorrhea and chancroid is the use of sulfathiazole by mouth, the effectiveness of which, when properly administered, has been demonstrated in many installations. It is believed that its effective administration would be enhanced by the noncommissioned venereal disease control officer program referred to above.
Recommendations
The Surgeon General's conference on special problems relating to the control of venereal disease among Negro troops made the following recommendations:
Recreation.-The Special Services Division should give particular attention to the provision of recreation facilities for Negro troops so that the adverse environmental influences affecting the Negro soldier may be counterbalanced. Recreational activities for small units should be intensified. Better coordination of Special Services activities with sudden changes in training or assignments, which adversely affect troop morale, is desired. More effective liaison between Special Services officers and venereal disease control officers at all levels is needed, and it is recommended that appropriate directives covering this point be published.
Specialized personnel.-Negro medical officers with the proper qualifications should be selected to act as venereal disease control officers for Negro troops. The primary duty of these officers will be to develop and coordinate
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venereal disease control activities among Negro troops of the command. A school for the training of Negro noncommissioned venereal disease control officers should be established at Tuskegee Army Air Field, Alabama, and the use of graduates should be similar to that in the Eastern Flying Training Command.
Education.-Training aids specifically directed at Negro troops are urgently needed and should be developed by the Training Division of the Surgeon General's Office in cooperation with the Venereal Disease Control Branch.
Repression of prostitution.-A suitable directive should be published reiterating the Army policy with respect to the suppression of prostitution and the use of off-limits action. The directive should remind unit commanders that this policy refers not only to white but also to Negro prostitution activities. The Army should give its fullest support to those civilian agencies engaged in a Negro prostitution-suppression program.
Prophylaxis.-Station prophylactic facilities, both on and off the post, for Negro personnel should be generally improved with respect to more suitable locations, better appearance, and the use of Negro attendants wherever feasible. Prophylactic stations for Negro troops should not be located in proximity to police stations or military police stations. Furthermore, efforts should be intensified to develop a single-tube chemical prophylactic kit effective against both syphilis and gonorrhea to replace the present two-tube kit which has been found to be too complex for maximum use.
War Department Circular on Control
One concrete result of the conference was the preparation and publication of War Department Circular No. 88, Venereal Disease Control Among Negro Troops, dated 28 February 1944, embodying in principle the recommendations made. This circular prescribed a complete program including assignment of Negro medical officers trained in venereal disease control techniques, improvement of recreational facilities, repression of commercialized prostitution, and provision of adequate prophylactic facilities.
During the 6 months following publication of this circular, the Negro venereal disease rate reached a high of nearly 160 per 1,000 men per year, and it was apparent that the circular had failed to achieve its purpose. Failure was attributed to the scarcity of trained Negro medical officers capable of carrying out this work, the wide dispersal of Negro troops, and in some instances a lack of satisfactory command interest or support. A notable exception to the overall failure of the program, a marked reduction in rate, effected at Tuskegee and Fort Huachuca, Ariz. (fig. 24),28 demonstrated that successful venereal disease control programs in Negro troops were possible on a local level. The programs at these two posts were organized and carried out by
28Maj. (later Lt. Col.) George McDonald, MC, was outstanding in his work-T. H. S.
193
FIGURE 24.-WAAC personnel arrive at Fort Huachuca, Ariz. The arrival of Negro WAAC personnel at Fort Huachuca provided opportunities for wholesome on-post recreational activities for the Negro men stationed there, December 1942.
superior Negro medical officers, backed by strong command support and utilizing all available control procedures including educational media, religious appeals, competitions, and the development of venereal disease control officers among noncommissioned officers.29
Other Control Efforts
Concurrently with the Army's efforts to control venereal disease among Negro troops, civilian agencies were conducting campaigns directed toward the elimination of adverse influences in Negro communities (fig. 25). As a part of this campaign, the American Social Hygiene Association held a conference in New York City on 22 and 23 November 1943 on wartime problems in venereal disease control. One of the purposes of the conference was to consider practical measures whereby Negro voluntary organizations could best join in united action at Federal, State, and local levels to reduce the
29Memorandum, Lt. Col. Thomas H. Sternberg for Truman K. Gibson, Jr., Civilian Aide for Negro Affairs to The Secretary of War, 29 Sept. 1944, subject: Venereal Disease Control in Negro Troops.
194
FIGURE 25.-Learning the facts of venereal disease. This group of predominantly Negro patients at a rapid treatment center receive instruction through films, filmstrips, and lectures as a part of their rehabilitation.
venereal disease among the Negro population. Plans were developed for the initiation of an intensive venereal disease information program to be continued on a sustained, consistent basis for an indefinite period. A continuing action committee functioning under the American Social Hygiene Association was appointed. The committee included a representative from the Army.
In January 1944, the Military Training Division, Army Service Forces, decided to introduce a course on the leadership of Negro troops in all officer candidate schools and requested that a section on venereal disease be submitted for inclusion in this course. On 28 January 1944, this material was submitted and became part of the basic course of instruction at officer candidate schools.
After a preliminary conference with the Assistant Chief of Staff, War Department, G-1 (personnel and administration), and the Office of the Secretary of War concerning the material to be included in a motion picture designed to be viewed by Negro troops, the Venereal Disease Control Division and the Signal Corps cooperated in the preparation of the film, "Easy to Get." This was considered one of the best training films of the war.
195
In late September 1944, the Director, Venereal Disease Control Division, in an effort to establish a more effective approach to the problem of venereal disease among Negro troops-a problem which was no nearer solution in 1944 than in 1942-joined Mr. Truman K. Gibson, Jr., Civilian Aide on Negro Affairs to the Secretary of War, in recommending the establishment of a special Secretary of War commission to control venereal disease in Negro troops. This proposed commission was to have a central advisory staff directly under the control of the Secretary of War and a field staff of specially trained Negro officers to operate as "trouble shooters," but the recommendations were never placed into effect.
Summary and Evaluation of Control Program
The Negro venereal disease rate for the year 1943 for troops in the continental United States was 136 per 1,000 per annum; the rate in 1944 was 159 and that in August 1945, 309. Results of serologic tests for syphilis of white and Negro Army personnel at time of separation are presented in table 18 for the period May 1945 to September 1945 (a much shorter period than that covered by the data of table 15). During this period, slightly more than 400,000 persons were separated, distributed by race as follows: 374,161 white separatees and 26,785 Negro separatees. These figures illustrate better than words the failure of the effort made to control venereal disease in Negro
TABLE 18.-Results of serologic tests for syphilis of U.S. Army personnel at time of separation, by race, May-September 1945
Serologic reaction
White separatees
Negro separatees
Total
Reactions
Rate
Reactions
Rate
Reactions
Rate
Number
Number
Number
Without history of syphilis:
Positive
2,011
5.4
1,075
40.1
3,086
7.7
Doubtful
1,505
4.0
313
11.7
1,818
4.5
Total
3,516
9.4
1,388
51.8
4,904
12.2
With history of syphilis:
Positive or doubtful
613
1.6
890
33.2
1,503
3.7
Negative
2,579
6.9
1,529
57.1
4,108
10.3
Total
3,192
8.5
2,419
90.3
5,611
14.0
Total, positive or doubtful
4,129
11.0
2,278
85.0
6,407
15.9
Total, negative with history of syphilis
2,579
6.9
1,529
57.1
4,108
10.3
Grand total
6,708
17.9
3,807
142.1
10,515
26.2
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troops during World War II. Except for isolated instances of success, the history of venereal disease control in Negro troops was one of frustration and failure. It was apparent throughout the war that the high Negro venereal disease rate was only one facet in a complex social and economic problem and that, without a solution of the fundamental underlying factors, efforts to control venereal disease in Negro troops by films, directives, schools for noncommissioned officers, disciplinary action, and other measures could not be successful. These measures could only influence the fringe of an enormous problem. The failure to control venereal disease among Negroes in the Army was, at least in part, a reflection of the failure of society through individual and governmental efforts to develop a satisfactory race relationship between the white and Negro populations.
PROPHYLAXIS
Early Developments
The provision of prophylaxis against venereal disease through prophylactic stations and the sale of prophylactic materials at post exchanges had been accepted Army control procedure for many years before World War II. AR 40-235, 11 October 1939, directed commanding officers to establish prophylactic stations at suitable locations within each command and, when facilities permitted and necessity therefor existed, to establish such stations in adjacent civilian communities. The regulations also directed that post exchanges make available suitable materials for individual prophylaxis, the composition and quality of the material to be prescribed by the commanding officer upon the recommendation of the surgeon. Two manuals, War Department Field Manual 8-40, Field Sanitation, 15 August 1940, and War Department Technical Manual 8-220, Medical Department Soldier's Handbook, 5 March 1941, described in further detail the operation of prophylactic stations and the method of applying prophylaxis. The basic drugs employed were 2 percent Protargol, and 30 percent calomel, supplemented by 1:1,000 solution of mercury bichloride and soap and water.
This policy of providing prophylaxis against venereal disease for those individuals who exposed themselves was criticized on numerous occasions by church groups and other civilian representatives on the basis that it incited to promiscuity and was inconsistent with the educational program which emphasized continence and the danger of the venereal diseases. Characteristic of these criticisms was a letter from Bishop John F. O'Hara, Military Delegate to the Military Ordinariate of the Roman Catholic Church in the United States, to the War Department criticizing the use of contraceptives. Characteristic also of the War Department's position on the matter was the following proposed reply to Bishop O'Hara, which was prepared by The Surgeon General:30
30Memorandum, The Surgeon General to the Secretary, General Staff, War Department, Washington, D.C., 18 Apr. 1941.
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I have read with interest your thoughtful letter concerning the use of contraceptives for venereal prophylaxis in the Army and the attitude of certain officers regarding prophylaxis and continence among soldiers, and I appreciate fully the motives which moved you to take up this matter.
You may be assured that there is no inclination on the part of the War Department to minimize the importance of the moral aspects of the venereal disease problem. However, in the interest of military efficiency, this problem must also be considered in the same manner as any other disease. The men are in the Service for training, and time lost is a serious matter. Since venereal diseases constitute a most serious cause of lost time, every reasonable means of reducing such infections must be employed. The results obtained over the last twenty-five years indicate that venereal prophylaxis is an effective method.
The measures now in force are the result of continuous study and evolution since the beginning of our Army, and the present program of venereal disease control is generally conceded to be the most effective one yet developed. The present policy follows well established lines including: education (stressing the importance of continence), case-finding, treatment (prophylactic and specific), segregation of infectious individuals, the suppression of prostitution, and the provision of wholesome recreational facilities. The removal of any of these measures would weaken this program which has resulted in such a dramatic reduction of venereal diseases in the Army.
It must be recognized that regardless of what advice is given an unknown proportion of men will expose themselves to the hazard of venereal contagion. For such individuals the Army advocates the use of mechanical and chemical prophylactics, not as contraceptives, but solely as an effective procedure for the prevention of infection. A committee of specialists in the control of venereal disease, appointed by the American Social Hygiene Association and the United States Public Health Service, in September 1940, indorsed the use of the rubber condom as the safest method of venereal prophylaxis.
There is some question as to indiscriminate distribution or open sale of prophylactic kits at post exchanges. Those supplied by the Army are only for the protection of the soldier, and it is insisted that such as are sold at post exchanges must be of good quality. This affords better protection against infection than would otherwise be obtained, as it discourages their purchase in poolrooms, tilling stations, etc., which frequently sell articles of inferior quality.
In conclusion, I assure you that while certain individual officers may have expressed personal views to the contrary, the War Department recognizes that the only perfect method of preventing venereal diseases is continence, and that for moral and physical reasons it is officially in favor of chastity among troops.
An extensive correspondence between members of Congress and the War Department in connection with prophylaxis continued in 1941 following the publication of War Department Field Manual 21-10, Military Sanitation and First Aid. Of particular concern to Congressmen and their constituents was paragraph 80 d of this field manual which follows:
d. Prophylactic measures. (1) Mechanical.-The condom affords the only practical mechanical protection against venereal infection. Post exchanges are required to stock condoms of approved quality. A condom will prevent gonorrheal infection which must enter the urethra. It is not certain protection against syphilis, chancroid, or lymphogranuloma inguinale which may enter the skin and tissues about the genitals. Consequently, chemical prophylaxis must be given even after a condom has been used.
On 27 August 1941, for example, the Honorable Robert R. Reynolds sent to The Surgeon General communications from several individuals with regard
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to the statements found in paragraph 80 d of FM 21-10. The Surgeon General, in his reply on 28 August, made the following statements:
The Army's acceptance of the rubber sheath as the most effective individual prophylactic is a result of years of medical observation. Civilian medical authorities agree in recommending this method. The best recent statement of this opinion may be found in a report of the Special Joint Committee, appointed by the American Social Hygiene Association and the United States Public Health Service, published in the October 1940 issue of Venereal Disease Information * * *.
In the educational material on sex hygiene and venereal disease provided to troops, emphasis is always placed on continence and high moral standards. To insure this Army regulations require that a chaplain take part, with the commanding officer and the medical officer, in the periodic instruction. A certain proportion of soldiers in any group will reject this advice and expose themselves to the possibility of venereal contagion. For these the Army makes available the best prophylactic measures known. No soldier is forced by regulations or orders to use these measures, nor does the Army issue any type of individual prophylactic.
Later Procedures
As the war progressed, the necessity for providing prophylactic measures as one phase of the venereal disease control program became evident to most of the critics, and incoming correspondence protesting the use of prophylaxis was gradually reduced to a minimum. Accepting prophylaxis as a necessary measure, the War Department recognized serious deficiencies in the program as it was established at the beginning of the war and took steps to eliminate them. Thus, by 1945, The Surgeon General had been designated as the officer responsible for determining quality and composition of prophylactic materials, a new single-tube sulfathiazole-calomel individual chemical prophylactic had been developed, and the method of distribution was fundamentally changed-prophylactic materials were made a standard Medical Department item, and provision was made for free issue of these materials through medical supply channels.
Development of individual chemical prophylaxis.-No suitable individual chemical prophylactic kit was available for sale at post exchanges in 1940. Calomel ointment for protection against syphilis had been sold for many years, but this drug had no preventive action against gonorrhea or the other venereal diseases. On 2 January 1942, Mr. E. J. Schabelitz of Schabelitz Research Laboratories wrote to The Surgeon General submitting samples of a product developed by his research laboratories containing, among other drugs, 0.25 percent silver picrate jelly for protection against gonorrhea. Mr. Schabelitz' letter referred to the successful use of the drug at several naval installations, particularly at the Central Prophylactic Station, San Diego, Calif., and his letter recommended its sale throughout Army post exchanges. The material was forwarded to the National Research Council for consideration.31 In a memorandum dated 7 January 1942, Major Gordon advised Colonel
31Letter, Lt. Col. John A. Rogers to Dr. Lewis H. Weed, Division of Medical Sciences, National Research Council, 10 Jan. 1942.
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Simmons concerning the current status of silver picrate as a gonorrhea prophylactic.
According to Major Gordon, silver picrate was included in New and Nonofficial Remedies-1940, and Knight and Shelanski had found silver picrate to be effective in the treatment of gonococcal urethritis.32 Comdr. R. A. Nolan, MC, U.S. Navy, had introduced the use of 0.5 percent silver picrate jelly as a substitute for silver proteinate solution in station prophylaxis at several places on the west coast and had published the results in 1941, calling this new method the V Plan. Further experiences of Commander Marsh indicated that the use of 0.25 percent silver picrate jelly was at least as effective as the standard silver proteinate.33 Commanders Nolan, Marsh, and Boone had recommended the adoption of a supplementary individual chemical prophylaxis in the form of a packet such as those prepared by John Wyeth & Bro., Inc., and the Schabelitz Laboratories, the packet containing soap-impregnated gauze, a tube of silver picrate jelly, and a tube of calomel ointment. Furthermore, the Philadelphia Department of Health was making use of the Wyeth V-Packette in providing prophylaxis through hospital emergency rooms, and this service had been accepted by the Commanding General, Third Corps Area. In conclusion, Major Gordon made the following qualified recommendations:
In view of the recognized and unavoidable hazards of mechanical prophylaxis and the impossibility of scattering station prophylaxis facilities sufficiently to provide this service at a convenient distance from each place of contact, it would appear that this method should have serious consideration as a possible adjunct to the present prophylaxis armamentarium. I do not feel that it is desirable to recommend this method of individual chemical prophylaxis as the sole reliance, supplanting the mechanical prophylaxis, but there appears to be no reasonable objection to the acceptance of additional effective methods which may be available in order to make protection as complete as possible.
By March 1942, the use of the 0.25 percent silver picrate Wyeth's VPackette had been approved in a branch of the Air Corps.34 On 27 March 1942, a communication from The Surgeon General to the Quartermaster General recommended an individual chemical prophylactic packet containing silver picrate for oversea troops. On 31 July 1942, in Circular Letter No. 80, The Surgeon General further recommended a silver picrate prophylactic packet for general distribution in Army post exchanges. In addition to the silver picrate, calomel, a soap-impregnated cloth, and an instruction sheet were recommended for inclusion in the packet. It was noted that existing evidence indicated that no single-tube chemical prophylactic was a satisfactory substitute for the soap-silver-mercury combination. Shortly after the publication of this letter, several pharmaceutical houses produced packets conforming to
32Knight, F., and Shelanski, H. A.: Treatment of Acute Anterior Urethritis With Silver Picrate. Am. J. Syph., Gonor. & Ven. Dis. 23: 201-206, 1939.
33Letter, Lt. Comdr. J. A. Marsh, MC, USN, to Dr. J. F. Mahoney, Director, Venereal Research Laboratories, Marine Hospital, Staten Island, N.Y., 27 Nov. 1941.
34Letter, Maj. James H. Gordon to Lt. Comdr. K. P. A. Taylor, MC, USNR, Office of the Commandant, 15th Naval District, Balboa, Canal Zone, 26 Mar. 1942.
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the specifications of the individual chemical kit prescribed, and post exchanges throughout the Army made them available to military personnel.
A few weeks after the initiation of widespread sale of these kits containing a tube of silver picrate, it became painfully evident that silver picrate was not a satisfactory gonorrhea preventive because its use was attended by irritation, occasionally to the point of nonspecific chemical urethritis. Furthermore, the whole prophylactic procedure was complicated, and the drug stained and was unstable. The development of a suitable single-tube ointment which protected against both gonorrhea and syphilis without producing irritation now became one of the most urgent needs of the control program.
The PRO-KIT combining sulfathiazole and calomel in a nonirritating, nongreasy ointment base was the final product of an intensive, coordinated research effort conducted by the Army, the National Research Council, the Food and Drug Administration, and the Warner Institute for Medical Research. Initially, early in 1943, a combined sulfonamide-calomel ointment of uncertain composition was developed in Liberia by Capt. (later Lt. Col.) Thomas G. Faison, MC, who recommended its adoption in the Army in a letter to The Surgeon General on 19 April 1943 (pp. 273-274). The problem was referred to the Subcommittee on Venereal Diseases of the National Research Council which recommended at its 19th meeting on 10 June 1943 that immediate studies be undertaken to prepare a satisfactory ointment. The resources of the Warner Institute for Medical Research, through Dr. Marvin Thompson, and of the Food and Drug Administration, Federal Security Agency, through Dr. H. O. Calvery, were placed at the disposal of the Army. Within a short time, two ointments had been developed which were submitted to field trials. On 17 February 1944, the National Research Council recommended35 that, if by 4 April the experience gained from the field trials was sufficient to warrant a choice, one of the products be adopted for a standard individual chemical prophylaxis. In a memorandum to General Simmons on 28 March 1944, Colonel Sternberg reviewed the status of the chemical prophylaxis program and recommended adoption of the combined sulfathiazole-calomel ointment. The salient points of Colonel Sternberg's memorandum are summarized below:
1. During the past 8 months, the Venereal Disease Control Branch had accumulated data on the results of field trials of the new calomel-sulfathiazole ointment to be used in preventing venereal diseases. Sufficient information was now available to evaluate the efficacy of the new ointment and to have it considered for adoption as a standard venereal disease prophylactic in the Army.
2. The ointment had been used in widely separated areas and under conditions which provided for careful observation and followup. Particular attention had been directed toward finding any evidence of failure to protect
35Minutes of Conference on Chemical Prophylaxis of Venereal Diseases, National Research Council, Division of Medical Sciences acting for The Committee on Medical Research of the Office of Scientific Research and Development, 9 Feb. 1944.
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and of local and systemic reaction to the drugs used. In addition to field trials, experimental animal and laboratory studies carried out under the supervision of the National Research Council Subcommittee on Venereal Diseases had confirmed the effectiveness of the combination of calomel and sulfathiazole in preventing syphilis and gonorrhea. The Subcommittee on Venereal Diseases would recommend the adoption by the Army of this new prophylactic.
3. Of reports reviewed to date, the total number of prophylactics that had been given was 16,537 among which had been 27 failures-only 0.16 percent of the total.
4. The calomel-sulfathiazole prophylactic ointment enjoyed wide acceptance and approval from men using it. In some areas, a 300-percent increase in prophylactic rates was reported. Besides proving to be an effective preventive for venereal diseases, the new ointment had advantages over the older two-tube chemical prophylactic in that only a single tube was required, it was nonirritating and caused no burning when inserted in the urethra, and it was nonstaining-the vanishing cream base did away with the need for protective clothing. Moreover, it was simple to use and required less time for proper use.
5. In view of the excellent reports from field trials and laboratory work, it was recommended that the new venereal disease prophylactic ointment be adopted as standard for use in the Army and be included in individual chemical prophylactic packets for distribution in all military areas.
On 18 April 1944, Colonel Sternberg advised the Director, Technical Division, Office of the Surgeon General, that the new chemical prophylactics be distributed in a kit with the notation "PRO-KIT" on the outside. Thus, the development of a satisfactory single-ointment prophylactic effective against both gonorrhea and syphillis reached a successful conclusion. The PRO-KIT was the most important venereal disease preventive measure developed during the war.
Mechanical prophylaxis.-No important changes other than method of distribution occurred in the mechanical prophylaxis program. Assistance in providing condoms of the best quality was provided by Circular Letter No. 4, Office of the Surgeon General, dated 8 January 1940, which specified in detail the tests and specifications that condoms must meet before being sold by post exchanges. Subsequently, when the mechanical prophylactic kit was made a standard Medical Department item, approval of the Food and Drug Administration was obtained in advance of distribution.
Station prophylaxis.-Official Army prophylactic stations constituted an integral part of the venereal disease control program in 1940. The procedures followed in the stations were described in technical and field manuals (p. 196). Never entirely satisfactory because of the relatively prolonged procedure and the objection of many individuals to urethral injection of 2 percent Protargol solution because of irritation and pain, the prophylaxis provided at stations was, nevertheless, a useful adjunct. No change was made in the basic prophy‑
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laxis, even after the development of the PRO-KIT. The recognized desirability of replacing the Protargol-calomel regimen with sulfathiazole-calomel was never effected because of the problem of supply presented by the PRO-KIT. Late in 1945, after V-J Day, the supply of PRO-KIT's improved and plans were made to introduce them into prophylactic stations in place of Protargol and calomel.
Centralization of responsibility.-An important advance in the prophylaxis program was the placing of responsibility for furnishing and recommending prophylactic materials upon The Surgeon General by Changes No. 1, AR 40-210, on 8 December 1942. The previous confused situation created by the delegation of responsibility to local commanding officers was eliminated by this change.
Compulsory prophylaxis.-In many posts, commanding officers were resorting to compulsory methods of distributing prophylactic materials, a practice which met severe criticism from civilian sources and was contrary to the policy of The Surgeon General. A letter was therefore submitted on 24 January 1942 by The Surgeon General to The Adjutant General recommending that action be taken to prevent further use of compulsion in the matter of individual prophylaxis. This policy was later included in Changes No. 3, AR 40-210, dated 1 May 1943.
Distribution of prophylactic packets.-Major changes were made in the method of distribution of prophylactic materials. Briefly, prophylactic packets were initially provided through post exchanges. Later, authority was given commanding officers to purchase the kits from the exchanges out of company funds and distribute the kits through company facilities. Finally, the kits were made a standard Medical Department item, and free distribution was made through regular medical supply channels.
Oral sulfathiazole prophylaxis.-The use of sulfathiazole by mouth as prophylaxis against gonorrhea was considered by many investigators, civilian and military, soon after its introduction for the treatment of gonorrhea. Fort Benning, Ga., and the Armored Forces, Fort Knox, Ky., pioneered in the use of the drug as a prophylactic agent against gonorrhea.
On 24 September 1942, Headquarters, Armored Forces, Fort Knox, published Memorandum No. 152 on the overall control of communicable disease. The following paragraph pertaining to sulfaprophylaxis was included:
5.c. It is recommended that all men exposed more than one hour prior to taking prophylaxis be given a two-grant dose of sulfathiazole, followed by two one-gram doses at four-hour intervals. This method of complementing the routine prophylaxis has been tried in several Armored Forces units, and it has been noted that the venereal rates for these units have dropped to an almost irreducible minimum.
This recommendation was not in conflict with any published War Department directive, but neither was it specifically authorized. For this reason, the newly assigned surgeon of the Armored Forces, Col. Alvin L. Gorby, MC, called the Office of the Surgeon General, requesting informally the reaction of The
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Surgeon General to this Armored Forces memorandum. No objection was expressed to the "experimental" use of the drug.
In the field, however, Armored Forces units were meeting obstruction from post surgeons and supply officers who, in some instances, refused to release the drug for prophylactic purposes. Thus, the project was brought to the attention of The Surgeon General who, in an endorsement to the Commanding General, Army Ground Forces, on 4 February 1943, established the following policy:36
1. The oral administration of the sulfonamide drugs for venereal disease prophylaxis is not approved for general use in the Army.
2. Approval may be given for use of the drug for this purpose on a trial basis under conditions which will permit evaluation of the results as regards prophylactic efficacy and toxic effects.
3. Its use should be confined to units which have shown a venereal disease rate of over 30 per 1,000 per year, the total dose of sulfathiazole for one exposure should not exceed 4 grams, and not more than one prophylactic "course" should be given in any one week.
4. Administration before exposure should be avoided.
Concurrently with the Armored Forces prophylaxis project, experiments were being conducted at Fort Benning with two groups of soldiers, one of which received oral sulfathiazole prophylaxis while the other served as a control. The results were encouraging, and the material was submitted to The Surgeon General in the form of a paper which was later published in the Journal of the American Medical Association.37
In the meantime, the Armored Forces submitted a favorable report on their studies and recommended routine adoption.38
Only one adverse report was submitted, a report which delayed authorization of oral sulfa prophylaxis by several weeks. In this case, a study was initiated by the Fourth Service Command medical laboratory at the direction of Headquarters, Fourth Service Command, to determine whether prolonged administration of sulfathiazole in the dosage used at Fort Benning produced blood or kidney pathological changes. The initial report indicated a high percentage of hematuria in the test group and a complete absence of such findings in the control group. This report threatened to cause the immediate discontinuance of the whole project. Fortunately, this unfavorable development was avoided by the submission of a subsequent study by the Fourth Service Command medical laboratory which not only failed to confirm the
36Letter, Capt. William E. Sutton, MC, Battalion Surgeon, Headquarters, 750th Tank Battalion (L), to Commanding Officer, 750th Tank Battalion (L), Fort Lewis, Wash., 7 Oct. 1942, with 10th endorsement The Surgeon General to Commanding General, Headquarters, Army Ground Forces, Army War College, 4 Feb. 1943.
37Loveless, J. A., and Denton, W.: The Oral Use of Sulfathiazole as a Prophylaxis for Gonorrhea. J.A.M.A. 121 : 827-828, 13 Mar. 1943.
38Letter, Commanding General, Headquarters, Armored Forces, to The Surgeon General, 22 Feb. 1943, subject : Report of Use of Sulfathiazole as a Prophylactic Agent, with endorsements thereto.
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previous report but strongly suggested that the first investigator was guilty of defective laboratory technique and preconceived notions.
On 28 July 1943, it was recommended that oral sulfathiazole prophylaxis for gonorrhea be authorized, and on 12 August 1943 Circular Letter No. 146, Office of the Surgeon General, U.S. Army, was published, concerning the subject.
Sulfathiazole prophylaxis was used widely throughout the Army during the remainder of the war. Its use was attended by success in many instances, but considerable opposition was also expressed by many officers who preferred to rely upon other preventive measures. The principal defect of the sulfonamide prophylaxis program was the need for carefully supervised and executed local administrative control. The tablets were often used for purposes other than prophylaxis, and other abuses were observed. In general, it may be said that this prophylactic program was a valuable adjunct to the control of venereal disease during World War II but that its successful utilization required painstaking supervision.
THOMAS H. STERNBERG, M.D.
ERNEST B. HOWARD, M.D.
Part II. Mediterranean (Formerly North African) Theater of Operations
ORGANIZATION AND ADMINISTRATION
In the available records of planning before the invasion of North Africa, there is no indication that any consideration was given to the problem of venereal disease control at the theater level. A preventive medicine officer was included on the original staff of Allied Forces Headquarters, but no mention is made of the consideration or adoption of any overall policy regarding venereal disease control. If any thought was given to the problem before the invasion, the decision was apparently made to defer policymaking until such time as it could be guided by actual experience.39
During November and December 1942, venereal disease control policies were developed and carried out by various units in the areas occupied by them. Medical officers in these units were designated as venereal disease control officers, though few of them had any previous training or experience in this line of work. Until January 1943, no attempt was made to coordinate venereal disease control activities in the theater nor to develop overall theater policies. On 3 January 1943, Lt. Col. (later Col.) Perrin H. Long, MC, was assigned to Allied Forces Headquarters as consultant in medicine, and he, with Lt. Col. John R. Norton, Preventive Medicine Officer, took initial steps toward coordination of the program. A brief form for reporting venereal disease contacts was developed and was required to be submitted on each
39Annual Report, Medical Section, North African Theater of Operations, U.S. Army, 1943.
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venereal disease case in order that information might be collected regarding chief sources of venereal disease. Meetings were held with civil authorities, and recommendations were made regarding the prostitution problem in the theater. In February, Colonel Long's recommendation40 that all brothels be placed off limits was unfavorably considered by the command.
In March 1943, Lt. Col. (later Col.) Leonard A. Dewey, MC, was assigned as full-time venereal disease control officer for the theater with responsibility for supervision of venereal disease control and treatment. Late in March 1943, six additional medical officers with special training and experience in venereal disease control arrived in the theater and were assigned to headquarters of major organizations as follows:
Lt. Col. Asa Barnes, Atlantic Base Section, Casablanca.
Maj. James E. Flinn, Mediterranean Base Section, Oran.
Capt. William E. Flood, Twelfth Air Force, Algiers.
Maj. John G. McNiel, Eastern Base Section, Constantine.
Lt. Samuel S. Frank, XI Corps, Tunisia.
Capt. Thomas R. Hood, Fifth U.S. Army, Oujda.
These officers worked on the staffs of the surgeons in the headquarters concerned and supervised venereal disease control activities in areas under the jurisdiction of these headquarters. All major organizations in the theater were thus supplied with the services of a trained and experienced venereal disease control officer, and each major city in the theater with the exception of Algiers, which was under British control, was covered by one of these officers. Changes in assignments were later necessitated by reorganizations and tactical progress, and a specific position vacancy was seldom provided in tables of organization. However, the general principle of maintaining a venereal disease control officer on the staff of each major organization was continued throughout the North African and Italian campaigns.
The Twelfth Air Force Surgeon used his chief of preventive medicine as the venereal disease control officer. The Fifth U.S. Army during the first half of the year had two different officers assigned to venereal disease control. Neither of these officers was trained as a venereal disease control officer, and both moved on to other assignments leaving the venereal disease program to the already heavily burdened chief of the preventive medicine section. The Island Base Section on Sicily, where venereal disease rates were among the highest in the theater, never had a position vacancy on the staff of the base section surgeon for a venereal disease control officer.
To remedy this situation, an effort was made to set up a venereal disease control unit under the theater headquarters to include a definite table of organization with both commissioned and enlisted personnel. The commissioned personnel were to be attached to the staffs of surgeons of armies, base sections, and air forces on temporary duty. The enlisted personnel were to be organized into platoons to provide educational and prophylactic facilities.
40Long, Perrin, H.: Historical Report Upon Activities for the Control of Venereal Disease in the North African Theater of Operations, From 3 January 1943 to 8 March 1943. [Official record.]
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It was agreed in the Office of the Surgeon, NATOUSA (North African Theater of Operations, U.S. Army), that this sort of organization was to be desired for any specialized program, but it was impossible to get approval for the organization within the theater. The enlisted personnel desired were later provided under War Department Table of Organization and Equipment 8-500, dated 26 July 1943, and were attached to the army, base section, and air force in which they were used, under the supervision of the venereal disease control officer, for the operation of prophylactic stations in metropolitan areas.41
PROSTITUTION AND ITS CONTROL
General situation in North Africa.-In all of the countries bordering the Mediterranean, a well-organized system of governmental regulation of prostitution had existed and had been in operation for years before the arrival of U.S. troops. In French North Africa, Sicily, and Italy, prostitutes were registered, given periodic medical inspections, and treated when found infected. These measures, Colonel Long reported, constituted almost the entire venereal disease control program carried on in the civilian population of these countries.
No estimate can be made as to the total number of registered prostitutes in North Africa at the time of the invasion other than that the number was huge. Every community of greater than hamlet size had several registered prostitutes, and the larger cities had hundreds. According to Colonel Long, Algiers, Algeria, had 600 registered prostitutes, and Casablanca, French Morocco, 1,500. Oran, Algeria, had 450 registered prostitutes.
Registered prostitutes were divided into two classes: "Incrites soumises," or those operating in recognized houses of prostitution; and "Incrites insoumises," those registered but operating as free lancers. Either prostitutes were registered at their own request or registration was compulsory if a girl was arrested on a morals charge more than one time. Once registered, a prostitute was not allowed to engage in any other occupation unless registration was officially canceled by the authorities. Registration could be canceled upon recommendation of two citizens of good repute, in which case the girl was allowed to marry or to engage in the occupation of her choice. In either case, it was necessary that all arrangements be completed for the new occupation before registration could be canceled.
All registered prostitutes were handled in the same manner. They were required to report to the local health center twice each week for medical inspection which ordinarily consisted of a cursory inspection of the skin and a speculum examination of the vagina and cervix. According to Colonel Long, these inspections were carried out very rapidly, from 75 to 100 being accomplished in an hour. Standard operating procedure called for a cervical smear to be taken at each visit, to be stained with methylene blue and examined
41Annual Report, Medical Section, Headquarters, Peninsular Base Section, NATOUSA, 1943.
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immediately. A serologic test for syphilis was also to be done every 3 months on each registrant. Observation of the examinations in Algiers and Oran showed that they were not carried out as planned. A smear was made on not more than 1 in 10 individuals examined, and very poor technique was used in taking and examining the smears. No smear was made unless purulent discharge was evident. In Oran, girls waiting in line were observed sponging out their vaginas preparatory to examination. Under such conditions, purulent discharges were seldom seen. A similar laxness existed in the program for the serologic testing of prostitutes. Examination of the records revealed that many prostitutes had received no serologic test for more than 6 months.
Treatment of those found infected ranged from poor to totally ineffective. The best treatment program existed in Algiers where sulfapyridine was used for the treatment of gonorrhea and sulfarsphenamine and bismuth were used for the treatment of syphilis. Gonorrhea patients received 3 days of treatment and were discharged as cured if one negative smear was secured on the day following completion. Colonel Long stated that this practice without doubt caused the discharge of many infectious patients. Among the syphilis patients, none were found who had received adequate therapy according to American standards, even had a more potent arsenical been used. Neoarsphenamine was available in Algiers, but sulfarsphenamine was used almost exclusively because it was considered more effective.
In addition to the registered prostitutes, there were numerous clandestine prostitutes who made prostitution their sole or chief source of income. These operated in hotels and cafes and, to a lesser extent, on the streets in all cities in North Africa. No governmental control was exercised over this class except when they were occasionally apprehended by police and brought into the registered class. According to French civil authorities, clandestine prostitution had always existed in the larger cities but had increased considerably since the fall of France. Refugees had poured in from all countries of Europe, and, for many of these individuals, prostitution was the only available source of livelihood. After the American occupation, the number was further increased as a result of the inflation caused by scarcity of goods and American spending. It was necessary for many domestic servants, earning 800 francs ($16) per month, and typists, earning 2,000 to 3,000 francs ($40 to $60) per month, to supplement their incomes. A girl had no difficulty in earning 500 francs a day as a prostitute, and many of the more attractive made 2,000 francs or more per day. This, according to Colonel Long, was naturally the means chosen by most of the underpaid female workers to supplement their incomes.
When confronted with the widespread prostitution just described, the U.S. authorities considered two possible sources of action. Suppression of prostitution was first considered but was immediately abandoned as impractical because of the magnitude of the problem and because the civil authorities were very unsympathetic to the idea. The second course considered was to
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place certain areas off limits to U.S. troops but to allow them free access to certain of the better houses of prostitution over which close supervision was maintained. This was the course which was adopted immediately after the invasion and was continued for various periods of time in the several areas.
Casablanca.-In Casablanca, French Morocco, the native quarters of Medinas (fig. 26) which contained all of the established houses of prostitution were placed off limits to U.S. troops on the day of occupation and remained so until 10 December 1942. On 10 December 1942, the famous walled city in the New Medina was opened to U.S. troops, and prophylactic facilities were provided for their protection. The walled city occupied an area of approximately four city blocks in the New Medina and was surrounded by a 30-foot wall topped with broken glass. It housed some fifteen hundred registered prostitutes who were strictly confined within the walls. Male patrons were admitted through a single gate at which was located a French prophylaxis station where the men could obtain prophylaxis if they desired. A clinic and hospital were located within the walls at which inmates received the usual inspections and, when deemed necessary, treatment as well. The walled city remained open for 3 days-10, 11, and 12 December 1942-and was again placed off limits on 13 December. Disturbances arising among the troops in the walled city were responsible for this action. The walled city and all other brothels in Casablanca remained off limits from 13 December 1942 throughout the occupation.
Oran.-In Oran, Algeria, the native brothel section was put off limits immediately after the invasion and a number of the better type of European brothels were selected for the use of U.S. troops. Seven brothels in rue d'Aqueduc were set aside for the use of white troops, and a large prophylaxis station was set up in a brothel near the entrance to the street, which was a blind street. Two additional brothels in slightly different sections of the city were selected for white troops, and two were set aside for Negro troops. Prophylaxis stations were established in each of these, and men were required to take a prophylaxis before leaving. An added restriction placed on Negro troops was that they be in the house not longer than 30 minutes. Military police were stationed within the brothels to enforce regulations. Americans were allowed to patronize the houses between 1700 and 2100 hours. At other times the brothels were supposed to be closed under an agreement made between the civil authorities, madams, and U.S. authorities. This agreement was not adhered to, however, and the houses were ordinarily open to civilian trade during other hours of the day and night.
This system was established because it was believed that the prostitutes employed in brothels were freer of infection than those on the outside. This belief was based on the report of the examination of prostitutes in Oran by the civilian health authorities for the third trimester of 1942. This report showed the rate of infection to be 0.61 percent among brothel inmates, 16.4 percent among registered prostitutes operating outside of brothels, and 16.4
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FIGURE 26.-Old Medina, Casablanca. This native section of the city was declared off limits to U.S. Army personnel.
percent among clandestine prostitutes. It was later discovered that, when brothel inmates were reported as sources of venereal disease, they were always found to be free of infection by the civilian examiner, even when a previous examination by a U.S. Army medical officer had shown infection. As a
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result of this finding, arrangements were made with civil authorities in April to hire a refugee physician with good professional background to examine all girls reported as contacts of U.S. Army personnel with venereal disease.
The brothels in Oran operated under this system almost continually until 28 May 1943, and, as prophylactic records indicate, did a flourishing business. In December, 15,265 prophylactic treatments were administered in the stations within the brothels, and, by March 1943, the number had risen to over 46,000. While the houses were in operation, many individuals with venereal disease stated that their infections had been acquired within these houses. This seemed probable because the prophylaxis stations were overloaded and the treatments were very poorly administered. Frequent recommendations were made that the system be discontinued and the houses be placed off limits, but no consideration was given to this proposal until April, when most of the brothels in Oran were closed for 18 days because of a shortage of water. It was noted that an appreciable drop in new venereal disease admissions occurred during and immediately following this period. As a result, an off-limits directive was issued on 28 May 1943, after which a 50-percent drop in venereal disease rates occurred.
Algiers.-A somewhat different system was adopted in Algiers, Algeria. The native quarter, or casbah, was placed off limits at once, not particularly as a venereal disease control measure but because it was regarded as too dangerous a place for U.S. troops to visit. Four large brothels and a large number of small hotels, each housing 1 to 3 prostitutes, operated outside the casbah, and these remained on limits to troops. No attempt was made to provide prophylactic facilities in conjunction with these brothels, but a prophylaxis station was established in the same general section of town. The largest and most ornate of these brothels, the Sphinx, was reserved by the management for Allied officers during the evening hours, but enlisted men and civilians were admitted during the daytime. This system was regarded as unsatisfactory and many cases of venereal diseases were attributed to the brothels by troops in the area, but the system was not changed until late July 1943 when the brothels were officially placed off limits. Enforcement, however, was rather lax.
Eastern Algeria and Tunisia.-In the Eastern Base Section, comprising eastern Algeria and, later, Tunisia as well, the prostitution problem was much less important than in other sections of North Africa.
At the close of the Tunisian campaign, the base sections in North Africa, in general, had established off-limits and repression policies in dealing with the problem of prostitution, while in other areas selected brothels continued to be regulated and supervised. In November, a survey was made of venereal disease rates in the various organizations in North Africa, and a comparison was made between those maintaining a regulation and supervision policy on the one hand and those maintaining an off-limits policy on the other. It was found that rates in organizations with an off-limits and repression policy
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were consistently lower by 15 to 40 percent than those in organizations which supervised and regulated prostitution. The survey indicated that the chief effect of supervision and regulation was to produce a huge number of sexual contacts within the houses without materially reducing contacts on the outside. There was no indication that supervision and regulation of prostitution could be considered a venereal disease control measure by any stretch of the imagination.42 On the basis of this survey, it was recommended to the commanding general that placing of brothels off limits and repression of prostitution be adopted as theater policy, but this recommendation was not approved.
Sicily.-After the conclusion of the Sicilian campaign, conditions similar to those formerly encountered in North Africa but greatly magnified were met. Inflation was more severe, and there had been a much more serious disruption of normal civilian activities (fig. 27). Drugs and medical care had been grossly deficient for several years, and the incidence of venereal diseases among the civilian population was extremely high. In Sicily and Italy, only very limited quantities of sulfanilamide had been available during the 2 years preceding U.S. occupation. No other sulfonamide drugs at all had been available. This resulted in totally inadequate treatment of gonorrhea with an inadequate drug, which in all probability gave rise to sulfonamide-resistant strains of the gonococcus. At any rate, gonorrheal infections contracted in Italy and Sicily by U.S. troops were much less responsive to sulfonamide therapy than the infections contracted in Africa had been. The incidence of sulfonamide resistance in Italy was approximately 60 percent as compared to a resistance of approximately 25 percent in North Africa.43
Prostitution was almost universal among all but the highest class of Sicilian women. Government-regulated brothels also existed in all of the larger towns-brothels which in normal times were operated under a system practically identical with that used in North Africa but which had largely broken down as a result of the stress of war.
Immediately after the cessation of hostilities in Sicily, brothels in the larger communities were taken over for the exclusive use of U.S. troops. In Palermo, the chief center for U.S. troops, six houses of prostitution were selected for U.S. troops and put in operation during the first week in September 1943. Prostitutes were examined twice weekly by a Sicilian physician and less frequently by a U.S. Army medical officer. Prophylactic stations were established within or adjacent to each house, and military police were stationed at each house to maintain order and to insure that each man received prophylaxis before leaving.44 In spite of this program, venereal dis‑
42Dewey, A. L.: Venereal Disease Control-A Survey. M. Bull. Mediterranean (North African) Theat. Op. No. 1, 1: 33-35, January 1944.
43(1) Essential Technical Medical Data, NATOUSA, for December 1943, appendix Q. (2) History of Fifth Army Medical Service, MTOUSA, 1945.
44Letter, Lt. Col. Leonard A. Dewey, MC, to The Surgeon, NATOUSA, 20 Oct. 1943, subject: Report of Inspection of Venereal Disease Control and Treatment in the Palermo Area, October 13 to 17.
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FIGURE 27.-A market street in Palermo, Sicily.
ease rates in the Seventh U.S. Army rose steadily from 31 per 1,000 per annum in August to 119 in November among white troops. Comparable rates prevailed among Island Base Section troops.45 No changes were made in procedures in Sicily before 1 February 1944.
45(1) Statistical Venereal Report, NATOUSA, for August 1943. (2) Statistical Venereal Report, NATOUSA, for November 1943.
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Italy and the problem in Naples.-In the Italian campaign, little contact was made with the civilian population until after the capture of Naples. Civilians were largely evacuated from the area between Salerno and Naples during combat, and very few had been able to return to the area before the fall of Naples. In no area previously occupied had there been such a complete collapse of all civilian functions as in Naples. Monetary inflation was extreme, food was scarce, and a large portion of the population was unemployed. Civilian morale was at a low ebb. Women of all classes turned to prostitution as a means of support for themselves and their families (fig. 28).
FIGURE 28.-Destitute and desperate, many women in Naples turned to the streets.
Small boys, little girls, and old men solicited on every street for their sisters, mothers, and daughters and escorted prospective customers to their homes (fig. 29).
In addition to this widespread clandestine prostitution, there were in Naples an undetermined number of established brothels which had been regulated by the civilian government and had been used by the German and Italian armies (fig. 30). Regulation had largely broken down at the time of the city's fall, and many of the prostitutes had fled to the surrounding country during the Allied attack on the city. These brothels resumed operations, however, within a few days following the Allied occupation but were
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FIGURE 29.-Soliciting in Naples. (From a series of posed educational photographs prepared for the Fifth U.S. Army surgeon.)
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FIGURE 30.-A brothel in Naples. (From a series of educational photographs prepared for the Fifth U.S. Army surgeon.)
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open to Allied troops for only a short time. During the second week in November 1943, the brothels were surveyed by a U.S. Army medical officer who selected certain of the better ones for use by U.S. troops. All others were placed off limits to U.S. personnel.
Prophylaxis stations were established in the brothels selected, and prostitutes were inspected by civilian physicians. Military police were stationed in the houses to keep order and to enforce the regulation that each man receive a prophylaxis before leaving. Each man was inspected by a Medical Department enlisted man for evidence of venereal disease upon entrance to the house and, if such evidence was found, was taken to a dispensary for examination. These houses were well patronized from their initiation, but this fact had no apparent effect upon the volume of contacts outside the brothels. A tremendous increase in venereal disease rates occurred among troops in the area during November, and a further increase occurred in December. For the first time in the history of the theater, venereal disease became a serious problem among combat troops. The rate in white combat troops of the Fifth U.S. Army rose to over 100 per 1,000 per annum in December (fig. 31.)46 Almost all of the Fifth U.S. Army troops with venereal disease gave Naples as the source of their infection which had been acquired during their 3-day stay at the Fifth Army Rest Center in the city. A brothel was operated for Fifth Army troops a short distance from this center.
Efforts were made through the Allied Military Government to secure better civilian police control of clandestine prostitutes. Some action along these lines was taken during December, and several civilians were arrested for soliciting and liven long sentences at hard labor. A noticeable decrease in the boldness of solicitation followed these arrests, but no genuine changes were brought about in the situation, and the venereal disease rates continued to rise. As a result of the high incidence of venereal disease and the threat of a typhus epidemic, Naples was put off limits on 27 December 1943 to all troops not on official business and brothels were placed off limits on 29 December. Rates in troops in both the Fifth U.S. Army and the Peninsular Base Section showed a slight drop in January, and a further decline occurred in ensuing months.47
Throughout 1944, Naples continued to be the source of much of the venereal disease of this theater. During the year, it was the main port and supply base of the theater. For the first half of the year, it was the only center to which men could retire for rest and diversion once they had been withdrawn from the battleline (fig. 32. It was the assembly point of the Seventh U.S. Army for the invasion of southern France.
The widespread devastation and economic distress left in the wake of the retreating German armies, superimposed on a city that had long been notorious for its widespread prostitution, produced a serious situation. The ranks
46Essential Technical Medical Data, NATOUSA, for January 1944.
47Statistical Venereal Reports, NATOUSA, for January, February, March, and April 1944.
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FIGURE 31.-Soldiers arrive at a Fifth U.S. Army venereal disease treatment center that was established to handle the tremendous load of cases originating from the Naples area.
of the professional prostitutes were augmented by an ever-increasing number of amateurs. There was a great scarcity of food, even under Allied Military Government control. In his annual report for 1944, Brig. Gen. Joseph I. Martin, Surgeon, Fifth U.S. Army, stated:
Food could be found in the black market, but in the breakdown or standstill in the entire economic life of Italy only the prostitute earned an income which could pay the inflationary black market price for the available food.
It was not lust, but necessity, not depravity of the soul but the surge of instinct to survive which led numerous women into the ranks of the amateur prostitutes on whom regulatory legislation had little or no effect.
The Toledo district, an especially squalid neighborhood north of Via Roma in Naples, was placed off limits on 1 January 1944. This made a large number of houses of prostitution unavailable to military personnel. The military police picked up large numbers of prostitutes, and some hospitalization was furnished by the aid of the Allied Control Commission.
During most of the year, two venereal disease control officers, one regularly assigned and the other on temporary duty with the Surgeon, Peninsular
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FIGURE 32.-Soldier seeking diversion and recreation in Naples. (From a series of posed educational photographs made for the Fifth U.S. Army surgeon.)
Base Section, worked in the Naples area. A very comprehensive educational program was carried on (fig. 33). Great emphasis was placed on station prophylaxis, and there was no part of the city where a soldier was many blocks from a well-equipped and effectively operated prophylactic station.
After their early experience in Naples with brothels, the off-limits policy became fairly well established and was followed as the Allied armies advanced up the boot of Italy past Rome, Leghorn, Pisa, and Florence, except in a few instances where military expediency and the shortage of military police caused several days' delay in publishing off-limits orders.
Prostitutes soon refused to work in brothels as they discovered that they could command such fantastic prices as 10, 15, or 20 dollars outside as compared to the rate of 20 to 50 lira inside the brothels. (One lira was equal to one cent.) Clandestine prostitution became a tremendous problem. While some of this was undoubtedly due to the existing adverse economic conditions, a great amount was also due to the moral standards of the Italian people. There was an almost complete breakdown in civilian law enforcement with failure to enforce existing laws against soliciting, which had been carried on flagrantly by men, women, and children.
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FIGURE 33.-Comprehensive educational program in venereal disease control, Naples. A. Soldiers look at an instructional, photographic exhibit. B. Classroom for instruction in the prevention of venereal disease.
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There was a large reservoir of venereal infection in the civilian population, due in part to the serious shortage of antivenereal drugs which according to Italian physicians, had existed for nearly 2 years. The history of the Fifth U.S. Army Medical Service for 1944 recorded that 60 percent of all women in Italy had some form of venereal disease, and that 95 to 100 percent of all prostitutes revealed laboratory or clinical evidence of one or more venereal diseases.
On 6 March 1944, the Regional Commissioner of Region 3 for the Allied Control Commission issued Order No. 18, designed to control prostitution in the provinces of Naples, Avellino, and Benevento. The order, in substance, stated:
1. It is unlawful for any operator or any occupant of a place of prostitution, whether or not declared to be such a place, to permit any soldier other than a soldier engaged in the performance of official duty to enter such place of prostitution.
2. It is unlawful for any female person who is afflicted with any venereal disease to have licentious connection with any soldier.
3. It is unlawful for any person in any manner to solicit or invite any soldier to have licentious connection with any female or to guide or offer to guide any soldier to any place of prostitution, whether or not the place is declared a place of prostitution.
There was never any serious effort on the part of the civil authorities to enforce this order.
Corsica.-Conditions in Corsica differed greatly from those encountered at any other place in the Mediterranean theater. Economically, Corsica had not been hurt by the war or by German occupation. The population lived mainly by agriculture and fishing. During the occupation, they received a good price for their produce. The people themselves drove the Germans out of Corsica with very little assistance from the Allies. The Corsicans, a very proud race, did not mix readily with U.S. troops and in fact seemed rather to resent their presence on the island. The U.S. force on the island was never very large. There was not sufficient level terrain to build many airfields. Consequently, the entire U.S. population, including air, medical, and service troops, was never over 15,000.
All brothels were immediately placed off limits to U.S. troops. Clandestine prostitution was at a minimum. Prophylactic stations were provided in the two larger centers of population, Ajaccio and Bastia, as well as in all unit areas.
The venereal disease rates among both white and Negro troops stationed on the island of Corsica compared favorably with those attained in the United States during the same period.
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PROPHYLAXIS
Prophylaxis was considered by many to be the chief weapon against venereal disease in the North African Theater of Operations, although its value was never definitely proved. It is true that large numbers of prophylactic treatments were administered with very few reported failures. On the other hand, venereal disease rates paralleled prophylaxis rates in nearly all areas. The explanation of this phenomenon was felt to be that prophylaxis was reasonably successful but that there was a constant percentage of the men exposed to venereal disease who failed to take an effective prophylaxis, and that consequently disease rates always paralleled exposure rates. Every effort was made to provide adequate prophylactic facilities in all communities (fig. 34).
COOPERATION WITH CIVIL AUTHORITIES
No epidemiological programs of any sort were in operation in any of the Mediterranean countries. No attempt was made to discover or trace sources of infection, and this approach was entirely new to physicians and others concerned with the venereal disease problem.48 In an effort to stimulate the development of contact-tracing activities by civilian health departments, the venereal disease contact history form was revised in April 1943 to provide space for description and identification of the contact. This form was required to be completed on all new cases of venereal disease among U.S. personnel and referred to civilian health authorities through base section headquarters. This procedure proved to be of very little practical value for several reasons. Information obtained was seldom sufficient to identify definitely the contact, and French authorities refused to take action on anything less than definite identification. Nearly all of the contacts reported were registered prostitutes who could have been readily apprehended without benefit of the report. Finally, of the few contacts who were picked up as a result of the report, practically none were diagnosed as infected because of the inadequate diagnostic methods used.
In Italy, early cooperation with civil authorities consisted of those previously described measures taken through the Allied Military Government and the Italian police to enforce existing laws against pandering and soliciting. Later attempts to improve the medical program met with little success, but an examination and treatment clinic was set up in Naples, and a few beds were set aside for hospitalization of patients with infectious syphilis (fig. 35). These facilities were small, however, and civilian medical personnel were few, were poorly trained, and required constant U.S. supervision. No noticeable effect was produced on the overall venereal disease problem by this program.
48Essential Technical Medical Data, NATOUSA, for July 1943.
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FIGURE 34.-An excellent, well-kept and well-operated prophylactic station at Staging Area No. 1, Naples, Italy, April 1944. A. Exterior. B. Interior.
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FIGURE 35.-A civilian examination and treatment clinic in Naples, operated with U.S. Army supervision.
EDUCATION
Conditions in the North African theater made necessary an almost complete change in venereal disease educational methods and objectives from those employed in the United States. The most basic and significant change lay in the identity of the group at which the program was chiefly directed. In the United States, educational material had been designed for and directed at the soldier who was in danger of acquiring venereal disease, and education was successfully carried out because the basic truths in regard to venereal disease had been accepted by the American public and Army authorities and had been enunciated in War Department directives. In the North African theater, this was not the case, for, although the same directives existed, the theater commander was under no obligation to carry them out. It was apparent from the outset that the basic principles of venereal disease control were not understood by those in command and that policies established by War Department publications were not to be followed. This was particularly true with regard to the attitude toward prostitution and the belief that supervision and regulation was a venereal disease control measure. The attitude
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also applied to other phases of the venereal disease control and treatment program, such as the staffing of prophylaxis stations and the imposition of penalties on men acquiring venereal disease. In addition to the almost universal lack of understanding of the problem among line officers, it was found that a similar state of affairs existed among many medical officers, particularly those in responsible positions.
A widespread belief existed among commanding officers that venereal disease could be prevented through the imposition of penalties on patients and their unit commanders. The publication of directives requiring court martial of individuals acquiring venereal disease was seriously considered on several occasions and was prevented only by constant vigilance on the part of the theater surgeon. In several organizations, unit commanders were penalized for high rates in their units by being denied promotions and by being given poor efficiency ratings. Such measures operated to cause concealment of venereal disease cases without materially influencing the actual incidence. The penalty idea was also frequently carried into venereal disease treatment centers where patients were denied ordinary hospital facilities and care. Strenuous work details and drill programs were organized under line officers. These procedures greatly interfered with the proper treatment and care of venereal disease cases, particularly gonorrhea, and retarded cures with a resultant increase in periods of disability.
As a result of this situation, the major venereal disease educational effort was directed toward command in an effort to obtain approval and implementation of the basic principles of venereal disease control. Data showing the inefficiency of existing policies were collected in the theater, and reports and recommendations urging adoption of scientific principles of venereal disease control were repeatedly submitted.
The same data were brought to the attention of both line officers and medical officers of all echelons through personal contact by the venereal disease control officers of major commands in the theater. The progress of this program was slow and discouraging as it entailed the destruction of perfectly sincere though unwarranted beliefs of the individuals concerned. It was, however, highly essential to the success of the venereal disease program as a whole, as no single phase of it could function properly unless those in command had a proper understanding of the basic procedures.
SUMMARY
The same basic factors contributed to the venereal disease control problem in all sections of the Mediterranean theater. These factors were an extremely high rate of infection among the civilian population, lack of any adequate civilian control programs, and the inability of command to understand the scientific principles of venereal disease control. As time progressed, the third factor was gradually eliminated, and by 1945 these principles had been officially adopted in the theater. The first two factors were never corrected,
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although the Army made attempts to correct them by actually taking over civilian health department functions. The program finally developed produced some decrease in the incidence of venereal disease among troops but was never successful in bringing down rates to an altogether satisfactory level.
LEONARD A. DEWEY, M.D.
Part III. European Theater of Operations
BASIC CONCEPTS OF CONTROL
A Venereal Disease Control Branch49 was created in the Preventive Medicine Division of the Office of the Chief Surgeon, ETOUSA (European Theater of Operations, U.S. Army), on 25 September 1942.50 Before that time, general overall supervision of the venereal disease program, including both treatment and preventive activities, had been exercised by the Professional Services Division of the same office. On 25 September 1942, supervision of preventive and control activities passed to the newly created Venereal Disease Control Branch of the Preventive Medicine Division. Supervision of treatment was retained by the Professional Services Division throughout the life of the theater. The present discussion is limited to aspects of prevention and control of the venereal diseases.
When the Venereal Disease Control Branch was formed, a full-time venereal disease control officer was attached to the Office of the Surgeon of the Western Base Section which then contained the majority of service troops. Among the combat units which were then present, the 1st Infantry Division, the 34th Infantry Division, the 1st Armored Division, and the Headquarters, II Corps, had full- or part-time venereal disease control officers who functioned for their organizations and, to some extent, in liaison with civilian communities.
The Eighth Air Force Composite Command had a full-time venereal disease control officer who was energetically pursuing a well-rounded program including efforts to develop cooperation with the civilian authorities in Northern Ireland. None of these officers were in a position, however, to develop a comprehensive program embracing all of the necessary control activities.
At the outset of the operation of the Venereal Disease Control Branch, a protocol was drawn up to reduce to a working classification the responsibilities of the branch and the activities to which it should devote major attention. These activities were classified into the following categories: The development and coordination of educational programs for men and offi‑
49The Venereal Disease Control Branch was continuously under the direction of Maj. (later Col.) Paul Padget, MC. Major Padget took over responsibility on 26 September 1942 and remained until activities ceased on 30 June 1945. Capt. (later Lt. Col.) Raymond Heitz became his principal assistant on 18 January 1943 and served continuously throughout the operations. Capt. (later Maj.) Charles P. Anderson joined the division the same day and remained for more than a year until he took up duties as venereal disease control officer in the Eastern Base Section anal later in the Seine Base Section, Paris.
50Annual Report, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA. 1942.
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cers including medical officers; planning for, and the supervision of provision of, proper prophylactic facilities and materials, both mechanical and chemical; epidemiological studies to determine the extent and location of venereal disease problems, with particular reference to causes of high venereal disease rates and the remediable factors; initiation and maintenance of cooperative relationships with other military and civilian agencies seeking the same objectives; consultation with command regarding policies and administrative procedures relating to venereal disease control; consultation on methods of diagnosis and treatment for those who become infected.
In the period of the existence of the branch as such, from the time of its original formation until the dissolution of ETOUSA, it was never found necessary materially to alter the original protocol for content. As situations developed and circumstances changed, marked alterations in the distribution of emphasis were found to be necessary, and these perhaps constitute the most significant experiences to be related.
These changing circumstances were of infinite variety and constant occurrence but, for the purpose of this narrative, may be divided into six phases: (1) The early problems in the United Kingdom when the military situation was that of creating a base of operations; (2) the later situation in the United Kingdom when, the bases being well established, major problems were created by the tremendous concentration of U.S. troops in the already overcrowded British Isles; (3) the phase of planning for and mounting the invasion of the Continent; (4) the continental phase from the beachheads to Paris; (5) the continental phase from Paris to the Rhine; and (6) the continental phase after the investiture of Germany.
The narrative will be constructed, therefore, on the plan of discussing, insofar as it is applicable, each of the items of the original operating protocol as it was developed in the successive phases.
EXPERIENCE IN THE UNITED KINGDOM
Early Problems
Educational activities.-From the very beginning, there was a serious need for educational materials which was finally resolved only long after this phase of the operation was over. An adequate number of copies of the Training Film 8-154, entitled "Sex Hygiene," was made available in the autumn of 1942, but the majority of the men had seen this film so many times during their training period that it had lost much of its effectiveness. Accordingly, requests were made for duplicate negatives of the films being displayed in the United States by the American Social Hygiene Association. Copies were made and widely displayed, and, since the films were fresh material, they were well received in spite of the fact that their appeal was directed much more toward civilians than toward a military population.
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Lacking supplies from the United States, posters and other types of visual aids were developed locally. This resulted in material which was sometimes excessively crude, was usually badly reproduced since almost all of it was done on the standard mimeograph, and rarely contained a new appeal. These disadvantages were offset to some extent by the development of poster contests with prizes, usually in the form of special privileges. Where this idea was enthusiastically carried out, the publicity attendant upon the contest was frequently of more value than the resulting posters.
Both because of the circumstances and because it was the considered opinion of those responsible that it constituted the most fruitful method, the educational program depended to a large extent upon word of mouth in informal discussions. In promoting this idea, the full-time venereal disease control officers devoted their attention to discussions with medical officers and with commanding officers of the higher echelons. In the discussion with the medical officer, however, it was emphasized that a large part of his responsibility was to see to the proper education of the junior officers of the command to which he was attached, who in turn would be charged with the education of their noncommissioned officers and men. Early in 1943, the suggestion was made that the education of the rank and file of soldiers be made the responsibility primarily of the noncommissioned officers.
Courses of instruction in venereal disease control for officers were included in the officer's instruction courses at the Medical Field Service School, Shrivenham, England.51
Provision of proper prophylactic facilities.-Up until the end of 1942, all of the condoms available, save those which forehanded commanders had brought with their unit supply, were being procured from British sources of manufacture. These articles were totally unsatisfactory for two important reasons. In the first place, they were too small, and, secondly, they were made with a deep constriction about 3 centimeters back from the closed end-the effect being to give them a freely hanging tip to which our soldiers objected strenuously. They were, however, of good quality latex and withstood inflation tests without difficulty. By the end of 1942, condoms of American manufacture meeting standard specifications were available for purchase in the post exchanges, but free issue was not to come until later.
Up to the end of 1942, there were no supplies of the pocket chemical prophylactic kit available, but early in 1943 a small supply of V-Packettes was received. In order to utilize these to the greatest advantage, they were earmarked for issue solely to organizations of the Eighth Air Force. Almost immediately there began to appear isolated reports to the effect that the silver picrate jelly in the V-Packette was painful to the urethral mucosa, and therefore the men were tempted to avoid its use. Alternatively there were reports that the jelly was so irritating as to produce a nonspecific urethritis. These
51Circular No. 22, Headquarters, ETOUSA, 23 Feb. 1943, sec. II.
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reports, however, were isolated, and in general the kit was well received and used as extensively as available supplies would allow.
During this phase of the operations, there was very little use made of station prophylaxis. This was in sharp contrast both to what had been seen in the training camps in the Unites States and to what was later observed on the continent of Europe. There were a number of reasons for this which probably must be taken in summation in order to afford an adequate explanation for the observed phenomenon. There was, of course, a prophylactic station as an integral part of every regular Medical Department installation. It is a matter of common experience that these prophylactic facilities are not as extensively patronized as ad hoc prophylactic stations set up in convenient locations outside of military installations. In the United Kingdom the small use of the prophylactic facilities in Medical Department installations continued, but there was a general and equally small use made of the ad hoc installations as well. A number of reasons for this were readily apparent.
In the first place, it was difficult, sometimes to the point of impossibility, to secure from the British adequate quarters in which to house a prophylactic station. There was a critical shortage of housing; all requisitions for space had to be approved by the British Ministry of Works; and, in the face of the enormous demands which were being placed upon them by the influx of U.S. troops, they were unwilling to release for use as a prophylactic station quarters which were suitable for any other purpose. In the second place, when stations were established, it was impossible to mark them in a manner to make them easy to find. British sensibilities forbade the display of prominent signs, and the rigid requirements of the total blackout forbade the use of the conventional green light. Perhaps the most important reason for the small use of station prophylaxis arose from the fact that the vast majority of the sexual exposures were wholly uncommercial and on a friendly basis. Surveys among soldiers revealed that under these circumstances they were much less impressed with the desirability or necessity of prophylaxis after exposure.
Epidemiological studies.-The original epidemiological studies were conducted on two lines. The first related to investigation of the circumstances prevailing within organizations reporting exceptional venereal disease rates. In these surveys, units with rates conspicuously lower than the average for comparable organizations were studied, as well as those whose rates were higher. From the former group, many valuable ideas were gained which were passed along for utilization where applicable. The latter were studied with particular reference to the educational status of the troops, the facilities for prophylaxis, the existence of recreational facilities, and the type of control exercised by command over the environment.
The second type of epidemiological work was based on the use of ETOUSA MD Form 302. This was developed before WD MD Form 140 and was so applicable to the particular problems encountered that it continued
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in use throughout the life of the theater. Long before it was possible to make use of the contact information contained on these forms they were subjected to periodic analysis by the Medical Records Division to determine the distribution of places of exposure. With this information, studies were made of the conditions found in the civilian communities which were reported as sources of venereal infection out of proportion to their population or the number of troops stationed in the vicinity. Where possible, factual information of this type was used for discussion with local civilian authorities.
Cooperative relationships with other agencies.-During this first phase, excellent cooperative relationships were established with the appropriate officers of the British Army, the Canadian Army, the Royal Air Force, and the U.S. Navy. The closest contact and most cordial relationships were maintained with all of these agencies throughout the war, but more than an exchange of amenities was seldom required. Respects were also paid to the appropriate medical officers of the Royal Navy. Similar relationships were established with the offices and branches of the British Ministry of Health, but, with this agency, there was from the outset a closer working relationship which was necessary to carry out the prevention and control programs involving American troops in the United Kingdom.
The excellent cooperative relationships which were enjoyed with the Ministry of Health began under exceedingly happy auspices. The chief of the Preventive Medicine Division, Lt. Col. (later Col.) John E. Gordon, MC, had since 1940 been in intimate association with the British Ministry of Health, first as a civilian expert on loan from Harvard University and later as the head of the American Red Cross-Harvard University Field Hospital Unit. Through him introductions to all of the proper people were readily arranged, and the Chief Medical Officer of the Ministry of Health, Sir Wilson Jameson, proved from the outset to be interested in the venereal disease problems and was most helpful. His blessing assured easy access to local medical officers of health who, each in his own area, were virtually autonomous. The cordial relationships established with those local medical officers of health during this first phase were of incalculable value in facilitating the development of the scheme of contact investigation which came a little later.
It was readily obvious that not only would it be fruitless to attempt to establish working arrangements with the civilian police authorities, but, more importantly, such efforts might be misunderstood by the British as reflecting desire on our part to meddle in affairs which they considered strictly their own and so might occasion resentment. The fruitlessness of such an attempt arose out of the fact that the British consider sex behavior as entirely a personal matter not subject to legislation or regulation. Public opinion frowned upon brothels, so very few were known to exist. Outside of London itself, there was relatively little commercialized prostitution. Whether professional or amateur, however, so long as the woman ostensibly was acting as a free agent, and so long as a procurer or facilitator was not readily apparent, there
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were no laws in the British Isles to govern her behavior providing she conducted herself in such a manner as to avoid other breach of the peace, except for one London Statute of 1828 which forbade obstruction of free passage in a public way. This was interpreted by the metropolitan police as involving the laying on of hands, so that if a professional prostitute on the streets of London actually attempted to manhandle her prospective customer, she might be brought before the magistrate in Bow Street police court or fined forty shillings, or both.
Only two other civilian agencies need be mentioned at this time, the British Social Hygiene Council and the Central Committee for Health Education. The former was essentially analogous to the American Social Hygiene Association while the latter was made up of chosen members of the former with the direct although somewhat behind-the-scene sponsorship of the Ministry of Health. It acted as a medium for the dissemination of health information with (although not so stated) especial emphasis on the venereal diseases. Cordial and cooperative relationships with both of these agencies were established from the outset, and the chief of the Venereal Disease Control Branch sat from time to time on committees of these organizations. Since their objectives were largely the development of a long-range program for the British population, little if any of their activities had immediate bearing on the problems of the U.S. Army.
Consultation with command.-From the outset, it was determined as a matter of policy that the Venereal Disease Control Branch, Preventive Medicine Division, Office of the Chief Surgeon, would insofar as practicable limit its consultations with command to the performance of staff function, courtesy calls on commanding officers when visiting posts, and consultation on specific questions when requested. It was considered much more desirable to deal in general with the senior medical officer in an organization or an installation, to make to him both general and specific recommendations-not only recommendations relating to his activities but also recommendations which he might make to command-and then to leave to him the responsibility for developing local plans in keeping with general policy but with a view to local problems. It was the consensus of all concerned that the latter policy made for better relationships between the surgeon and his commanding officer, had the advantage of avoiding the natural resistance which sometimes develops toward gratuitous suggestions from outside, and facilitated the development of more workable venereal disease control programs.
In the performance of the staff function, an unvarying policy was adopted to keep command directives concerning venereal disease control at the absolute minimum. It was considered best to rely on a few simple directives containing clear statements of basic principles and then to allow each organization to work out the details in the manner most suitable for its problems and personnel, with assistance from the central office when specific problems arose.
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Consultations on methods of diagnosis and treatment.-The closest and most cordial relationship existed between the Venereal Disease Control Branch of the Preventive Medicine Division and the branches of the Professional Service Division which were charged with treatment. There was constant informal interchange of information and suggestions, and no important steps were taken by either without consultation with the other. The chief of the Venereal Disease Control Branch, however, had no formal association with the care of patients.
Later Development
Changes in organization and administration.-With the developments which followed as a natural consequence of the increasing troop strength, a number of important changes were made in the organization and administration of the venereal disease control program.
In the earlier phase, the entire program was administered directly from the Office of the Chief Surgeon. During the second phase, which began in the spring of 1943 with the creation within the various echelons of surgeons' offices of competent staffs in preventive medicine, the administrative responsibility for the routine activities in venereal disease control was transferred largely to the respective base sections for the Communications Zone troops, to the surgeon of the Eighth Air Force (later to become U.S. Tactical Air Force Surgeon when portions of the Ninth Air Force began to arrive for the Air Force), and to the headquarters of corps and armies as they arrived.
The Venereal Disease Control Branch thus became in large measure an agency for collecting and disseminating information and coordinating the activities of the various echelons which were actually operating the venereal disease control program and also became the medium through which suggestions on general policy and procedure could be channeled to command. In one important particular, however, which will be brought out in the discussion of contact investigation, the branch retained active operational direction of what at this time was a pioneer project in the British Isles.
Intensification of education.-Early in 1943, a study was made of the educational status of troops arriving in the European theater from the continental United States. Information was sought of the adequacy of the information of the soldier concerning the general nature of venereal diseases, the method of their transmission, and the available methods for their prevention. The result of this survey indicated the necessity for intensification of the educational program in the European theater and afforded the suggestion which was transmitted informally, that there be intensification of the educational program for the troops during their training period in the United States.
Through an informal arrangement with the Surgeon of the Central Base Section, the venereal disease control officer for that base section was placed in overall charge of the educational program. He procured the services of a
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professional artist who, upon designs and suggestions which had been previously approved by a board appointed for the purpose, created a series of educational posters which compared favorably with those acquired 2 years later from the United States. At the same time, the Central Base Section was made the testing ground for various types of educational approach, and, so far as the European theater was concerned, it was here first demonstrated that the venereal disease noncommissioned officer trained to lead informal small discussion groups was a powerful factor in venereal disease education.
During this period, all of the base section venereal disease control officers carried on extensive educational programs, working largely through the medium of the unit medical officer, and were made personally responsible for wide display of the available films which included the then shopworn Training Film 8-154 and the American Social Hygiene Association films entitled "In Defense of the Nation," "With These Weapons," "Health is a Victory," and "Plain Facts."
The branch in the Office of the Chief Surgeon prepared and sponsored for publication in the theater newspaper, Stars and Stripes, a series of educational and informational articles on the venereal diseases, and members of the staff of the branch lectured periodically to medical officers at the Medical Field Service School (fig. 36).
Provision of prophylactic facilities and materials.-The relatively small use of station prophylaxis continued during this period, but, even with only a small percentage of the troops who were being exposed seeking it, the troop strength was increasing so rapidly and there were so many venereal exposures that the available ad hoc stations came in for enough patronage to justify their existence. Relentless pressure from the U.S. Army had by this time served somewhat to wear down the British objection to granting space for this purpose, so that in the larger population centers it was possible to provide decent premises of reasonably convenient location. Also, local arrangements in many instances had gained the approval of the blackout warden for the use of a shaded and much subdued, but at the same time visible, green light, as a marker at night. The most important advance in this direction was made through an agreement with the American Red Cross whereby the Army was given space for the operation of prophylactic stations on the premises of Red Cross clubs.52 This arrangement was ideal since men on pass or furlough were virtually required to stay in Red Cross hostels because of the shortage of housing facilities among the civilian population and so found a prophylactic station right in their path when they returned to quarters after a sexual exposure.
Another important advance was made in the facilitation of widespread use of prophylactic materials by the War Department authorization for free issue of condoms and chemical prophylactic kits.53 In developing the mech‑
52Club Division Circular No. 187, Director, Club Operation Division, 14 July 1943, subject : Establishment of Prophylactic Stations.
53Circular No. 17, Headquarters, ETOUSA, 19 Feb. 1943, sec. II, Control of Venereal Diseases.
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FIGURE 36.-The mother motive was used in this pair of posed photographs prepared by the Office of the Chief Surgeon, ETOUSA, for the venereal disease educational program. A. The soldier in England. B. The mother at home.
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anism of this free issue, it was found impracticable to have the actual distribution done by the Medical Department. This was because of the fact that in both of the larger groups of troops, the Service Forces and Air Forces, it was not uncommon for men to be quartered at considerable distances from the Medical Department installations from which they received medical care. Under these circumstances, the soldier would seldom be near the dispensary unless reporting for sick call, and the Medical Department had no personnel to devote to the task of supervising a general distribution of prophylactic materials in barracks and dayrooms. Accordingly, the Medical Department continued procurement of prophylactic materials, but by arrangement the quartermaster accepted responsibility for storage and issue. Up until the continental invasion, storage and issue was with Class I supplies; on the Continent, it was found more practicable to store and issue with Class II and Class IV supplies. This arrangement was subject to a certain amount of criticism from outside the theater, but to those who saw it function it seemed a simple and practicable solution to a minor supply problem.
In May 1943, there was instituted a trial of sulfathiazole by mouth for the prophylaxis of gonorrhea and chancroid. The results of the first 3 months' trial in three typical Negro organizations54 with appropriate controls were so encouraging that recommendations were made for use of the method according to the principles laid down in Circular Letter No. 146, Office of the Surgeon General, U.S. Army, 12 August 1943.
Epidemiological studies.-Both routine and special epidemiological studies were carried out in much the same manner as originally planned, with an attempt to focus attention and direct effort toward organizations with unusually high venereal disease rates and communities which were reported as providing more than their proportionate share of venereal infections (fig. 37). A special type of epidemiological study is described in the following section under the heading "Contact Investigation."
Cooperation with other military and civilian agencies.-In April 1943 under the auspices of the British Home Office, there was held a meeting which was attended by a large number of the higher dignitaries of the British Government and by representatives of the U.S. and Canadian Armies. After an extensive discussion of the problems caused by the venereal diseases both in the services and in the British civilian population, it was agreed that a committee would be formed to be known as the Joint Committee on the Venereal Diseases, which by its articles of reference was charged with making recommendations both to the services and to the British Government with regard to future policies and procedures in venereal disease control. Nothing happened until, under continuing pressure from the American side, the committee finally had a first meeting in June 1943. The chairman was Sir
54Essential Technical Medical Data, Headquarters, Services of Supply, ETOUSA, for September 1943.
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FIGURE 37.-The British public house, colloquially "pub," was the soldier's club as well as the club of the common man of Britain.
Weldon Dalrymple-Champneys, Bart., of the Ministry of Health, and the members were as follows:
Brig. T. E. Osmond, RAMC
War Office
Air Commodore T. McGlurkin, RAF
Air Ministry
Lt. Col. M. H. Brown, RCAMC
Canadian Army
Col. John E. Gordon, MC
U.S. Army
Mr. T. Lindsay
Ministry of Health
Mr. T. Mathew
Home Office
Chief Constable E. A. Cole
Metropolitan Police
Dr. M. M. Goodman
Department of Health for Scotland
Mr. E. A. Hogan
Department of Health for Scotland
Mr. J. S. Munro
Scottish Home Department
Surgeon Commander D. Duncan, RN
Admiralty
Mr. H. R. Hartwell, Secretary
Ministry of Health
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Eight meetings of this committee were held between 25 June and 24 September 1943, and at the last meeting there was brought in a series of 16 recommendations. The first 8 of these were specific recommendations for the development and extension of an educational program; recommendations numbers 9 through 14, inclusive, dealt in detail with a program for contact tracing; and the last 2 concerned the desirability and feasibility of routine serologic testing of certain classes of patients, especially pregnant women. Up until that time the committee had given considerable promise of accomplishment, but at the last meeting it bogged down on a discussion of prostitution and was never revived.
The cooperative relationships with the other military and civilian agencies previously named were continued.
During July and August 1943, Dr. Moore, representing the Subcommittee on Venereal Diseases of the National Research Council, of which he was chairman, and, upon invitation from the British Ministry of Health and the theater surgeon, made an extensive tour of the British Isles with particular reference to the interrelationships between the military and civilian venereal disease problems. This visit was the subject of two reports; one of these was confidential to the theater surgeon with copies to the Secretary of War and The Surgeon Genera1,55 and the other, which was more widely circulated, was to the Committee on Medical Research, Office of Scientific Research and Development. As a result of the visit by Dr. Moore, the British and Americans were better able to appreciate each other's problems and, with better understanding, were able to develop and carry out improved mutually supporting programs for the control of venereal disease in the United Kingdom.
At the time of arrival of the first U.S. soldiers in the British Isles, the only venereal disease control measure practiced among the civilian population was the attempt to provide conveniently located free-treatment facilities. Discreet little advertisements announcing the location of these treatment facilities were posted in public latrines, but there was no other educational program. There was no reporting of the venereal diseases either by clinics or by private physicians. Moreover, at that time under the provisions of the 1916 Venereal Disease Act, the patient was guaranteed privacy and secrecy to the extent that even to imply that he might have a venereal disease constituted libel. This, of course, rendered any type of epidemiological work and contact tracing impossible because no infected person could afford to risk an action for libel by giving the name of one with whom he had had sexual contact and who therefore might have a venereal disease.56
In the autumn of 1942, however, under pressure from the Ministry of Health for an amplification of the existing methods of venereal disease con‑
55Memorandum, Lt. Col. Thomas B. Turner for The Surgeon General, 6 Sept. 1943, subject : Report of Dr. J. E. Moore on Venereal Disease Control in E.T.O., with enclosure thereto.
56(1) Final Report of the Commissioners, Royal Commission on Venereal Diseases. London: His Majesty's Stationery Office, 1916. (2) May, Otto : The Prevention of Venereal Disease. London: Oxford University Press, 1918, p. 146.
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trol, the Privy Council drew up and eventually approved a regulation under the Defense of the Realm Act, known as Defense Regulation 33B, which became operative in November 1942.
Under the provisions of this regulation, a patient with a venereal disease was given an opportunity to name if he chose, after having been warned that there were severe penalties for false information, the individual he would identify as "the source of infection." This information was transmitted by the physician receiving it to the local medical officer of health of the place of residence of the named individual. The medical officer of health, if satisfied that the information was valid and that it had been given in good faith, held it for file and, if he received a second notification concerning the same individual, was empowered by the provisions of the regulation to serve upon this source of infection certain legal documents requiring the individual to submit to examination and treatment if necessary.
Numerous other legal documents were involved in making final disposition of the case, but from the standpoint of the Medical Department the important thing was that here for the first time was a mechanism whereby an individual with a venereal disease could legally give the name of sexual contacts, even though legally he did have to contend that one particular individual was the source of infection.
A review of the records showed that, insofar as information given by U.S. soldiers was concerned, there would be very few actions taken under the strict provisions of Regulation 33B because it was relatively unusual for one woman to be named twice with sufficient identifying particulars to make operative the legal provisions of the regulation. As has frequently been experienced elsewhere, many promiscuous women were named by more than one soldier, but, more commonly than not, only by partial name or partial address, whereas under the letter of the regulation complete names and address were required before action could be taken. It was therefore apparent that we could expect little from the operation of the letter of the regulation by the British authorities.
This being the case, authority was gained from the chief surgeon to utilize a staff of Army nurses as contact investigators and, with the concurrence of Sir Wilson Jameson, the medical officers of health of six counties in East Anglia were approached for the purpose of securing their concurrence in the operation of the scheme.
Briefly, the scheme was that the nurse would interview the soldier with a venereal disease, would gain from him as much information as she could by skillful and tactful questioning regarding the identity of his venereal contacts, and then would attempt to identify these women. If identification could be accomplished, the women were to be tactfully approached and informed that the medical findings on a friend who was a U.S. soldier suggested that the woman herself might be in need of medical examination which could be obtained from a private physician or at a designated clinic.
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In the beginning, there were many who were dubious that the scheme could be made to work, primarily because of fear that the women would take offense at being approached at all on so delicate a matter and particularly at being approached by a U.S. Army nurse who, for reasons of theater policy, was required to remain in uniform. However, of the original group of medical officers of health approached, only one officer refused to give support to the proposal, and this individual capitulated soon after the scheme began to operate successfully in neighboring counties.
Fortunately, the fears were entirely unfounded. Of the first group of nearly 500 women approached, only 1 took offense, and there seemed to be reasonably good evidence that she was a professional prostitute. Four percent of the group took no offense but nevertheless did not accept the suggestion to submit to examination. More than 76 percent of those identified followed the suggestion that they report to a clinic or private physician. The efficiency which the previously existing system had exhibited in controlling the venereal diseases was brought out by the fact that, of the entire group, only 15 percent had applied for medical care before the visit from the U.S. Army nurse. The remaining 5 percent were found in jails or other institutions.57
The success which attended the operation of this scheme made a great impression on the British health officials and, as a matter of fact, induced them in many areas to attempt something of the sort on their own initiative. The happy effect which this had on Anglo-American relationships was more than offset during this same period by recruiting reports which reached the British concerning the number of soldiers with venereal disease who were disembarking in their ports to mix with and infect their people. This had been duly reported,58 but it continued to such an extent that it finally became diplomatic issue and occasioned, on the 24th of February 1944, a letter from Mr. John G. Winant, U.S. Ambassador to the Court of St. James's, to General George C. Marshall.
Consultation with command.-Efforts to have published a 1943 version of General Pershing's famous General Orders No. 77, Headquarters, American Expeditionary Forces, dated 18 December 1917, which clearly define the responsibility of the unit commander in venereal disease control, resulted in the publication on 31 December 1943 of a letter addressed to each unit commander in the European theater from Maj. Gen. (later Lt. Gen.) Jacob L. Devers, then commanding. This letter contained the following passages: "* * * Contraction of venereal disease is considered evidence of improper indoctrination of the individual which is an indication of poor leadership on the part of the unit commander. * * * The responsibility for proper schooling in preventive measures lies with the unit commander; it is inalienable from
57Gordon, J. E.: Control of Venereal Diseases-an Epidemiological Approach. Lancet 2 : 711715, 2 Dec. 1944.
58Letter, Brig. Gen. Paul R. Hawley to The Surgeon General, 23 Apr. 43, subject : Syphilis Registers.
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command. It is essential that commanding officers devote their personal attention to the control of venereal disease. * * * The percentage of physically fit soldiers in a command is strong evidence of the efficiency of the commanding officer."
Planning and Mounting the Continental Invasion
Separation of functions.-During the phase of planning and mounting the invasion of the Continent, the activities concerning the venereal disease control program within the United Kingdom were largely turned over to the base sections for operational management, most of the groundwork having been accomplished by this time. With the great increase in the troop strength (fig. 38), and the crowding which it inevitably produced, the problems of liaison with the British civilian authorities became increasingly important and were accordingly given a large portion of the effort of the Venereal Disease Control Branch.
Educational programs for men, officers, and medical officers.-The branch continued routinely to contribute material for stories in Stars and Stripes and its weekly feature magazine, War Week. On 27 April 1944,
FIGURE 38.-The American soldier finds Britain to his liking.
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there was published material designed for the basis of an informal talk between company-grade officers and their men in the marshalling areas just before invasion,59 and this was later made the basis of stories in Stars and Stripes, War Week, and Army Talks. Otherwise, aside from continuing to participate in the teaching activities of the Medical Field Service School, virtually all of the remainder of the educational activities were operated by the base sections, armies, and the Air Forces.
Provision of prophylactic facilities.-By the spring of 1944, there was an adequate distribution of prophylactic stations all over the British Isles, the majority of the extracantonment installations being in the Red Cross hostels. These were never widely patronized, but they were used enough to justify their existence.
By this time, also, the supply of condoms had been stabilized to the point of allowing an issue at the rate of six per man per month and also of providing for sale in the post exchanges for those who cared to purchase. The rate of sale tended to fluctuate slightly but commonly averaged about 1.7 per man per month. The supply of chemical prophylactic kits was still irregular and, since these items were shipped with a low priority, the supply position remained totally unpredictable. Late in 1943, the Eighth Air Force had conducted some clinical trials of a one-tube prophylactic kit which had been prepared for them in England according to a formula of sulfathiazole, 15 percent, calomel, 33 percent, and lanette wax base to make 10 grams. The clinical trials conducted with the small numbers of this item available occasioned a request to the Office of the Surgeon General for a supply of a similar item in a more suitable base which at the time was under clinical trial in the United States. This request was granted. The item was placed on procurement, but unfortunately it was given the same number as the old tube item; consequently, it is impossible to determine when it first reached the theater.
Epidemiological studies.-The general epidemiological studies continued, and it was found that certain of these studies, particularly the consolidated analysis of place of exposure, could be done more easily in the central office and handled there as a unit rather than by the individual base sections. Consequently, this was one activity which was not delegated. For the same reasons, the central branch continued to do special epidemiological studies where these were indicated.
Cooperation with other agencies.-During this period, the number of troops in the United Kingdom was so great that it was deemed necessary and desirable to extend the scope of the contact investigation program until finally eight nurses were engaged in this activity. They worked, however, under the direction of base sections, although they maintained the closest liaison with the central office. During this same period, at the suggestion of the Ministry
59Letter, Headquarters, ETOUSA, to Commanding Generals, American Component, Allied Expeditionary Air Force ; First U.S. Army Group ; U.S. Strategic Air Forces in Europe ; Each Army ; Base Sections ; and Headquarters Commandant, ETOUSA, 27 Apr. 1944, subject : Briefing in Marshalling Areas, enclosure 2 thereto.
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of Health, numerous local medical officers of health, influenced to some extent, no doubt, by the fact that the skies had not fallen when the U.S. authorities had started contact investigation, had organized teams of their own, working on an informal basis without waiting for the second notification required by the letter of Regulation 33B. These activities were of great assistance to U.S. nurses in their work, and the success of the entire scheme is reflected in the low venereal disease rate which was attained in the theater over this period.60
The other cooperative activities were continued without significant change.
Consultation with command.-As a part of the routine job of mounting the continental operation, the directives regarding the prevention and control of the venereal diseases were gathered together and clarified for the benefit of the forward echelon and the advance section of the Communications Zone. While this was being done, it became apparent that it would be desirable to gather material covered in several directives into one compact directive and also to reinforce certain points of existing regulations. Accordingly, there was published on 2 May 1944 Circular No. 49, Headquarters, ETOUSA, which covered all of the command aspects of the prevention and control of the venereal diseases. It is to be noted that in the 15 months of the existence of the theater after the publication of this directive it was not found necessary to amend or alter it.
In anticipation of problems which would be encountered on the Continent, this directive contained the following paragraph:
The practice of prostitution is contrary to the best principles of public health and harmful to the health, morale, and efficiency of troops. No member of this command will, directly or indirectly, condone prostitution, aid in or condone the establishment or maintenance of brothels, bordellos, or similar establishments, or in any way supervise prostitutes in the practice of their profession or examine them for the purposes of licensure or certification. Every member of this command will use all available measures to repress prostitution in areas in which troops of the command are quartered or through which they may pass.
A broader and more general order was published by Supreme Headquarters, Allied Expeditionary Force, on 24 May 1944.
Consultation on methods of diagnosis and treatment.-The increasing frequency of the diagnosis of nonspecific urethritis was disturbing and gave rise to the fear that this was being used as a subterfuge to evade making a diagnosis of gonorrhea. Consequently, on 10 March 1944, the Office of the Chief Surgeon, Headquarters, ETOUSA, published Circular Letter No. 31 concerning the diagnosis and reporting of the venereal diseases which set down criteria permitting a clinical diagnosis of gonorrhea and purposely made any other diagnosis in the case of acute urethritis so difficult as to discourage evasive diagnoses unless there was good clinical or epidemiological evidence upon which to base doubt of a diagnosis of gonorrhea. It was
60Annual Report, Preventive Medicine Division, Headquarters, ETOUSA, 1944.
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recognized that this would lead to an occasional erroneous diagnosis of gonorrhea, but, with the removal of penalties for the venereal diseases, it was felt that the injustice occasioned by this error would be more than offset by the better management of the patient.
EXPERIENCE ON THE CONTINENT
The Continental Beachheads to Paris
Changes in organization, administration, and emphasis.-With the invasion of the Continent, the complexity of the venereal disease control problem was greatly increased. For many months after D-day the operation of bases, the provision of facilities for hospitalization, the staging of troops, and the operations of the Eighth Air Force called for such a troop concentration in the United Kingdom that the extent of the venereal disease problems there remained essentially unchanged. Shortly after the transfer of the headquarters of the European theater to the Continent and with the formation of the United Kingdom Base, the Venereal Disease Control Branch of General Hawley's Preventive Medicine Division transferred the responsibility for the program in the United Kingdom to the Venereal Disease Control Branch, Preventive Medicine Division, Office of the Surgeon, United Kingdom Base, which continued the operations with few modifications of the original protocol.
The main activities in venereal disease control from this time on lay in the development of a program which was suitable to the differing conditions which were encountered on the Continent (fig. 39). As was noted above, it was not found necessary at this time to make major alterations in the protocol under which venereal disease control was set up and maintained in the United Kingdom, but the marked differences in the problems encountered necessitated a revision of the distribution of emphasis.
In the United Kingdom, conditions were such that the major emphasis of the extracantonment venereal disease control program was properly and most fruitfully directed toward contact investigation and to closely allied epidemiological methods. There, also, with the virtual absence of openly organized prostitution, and with British law and custom diligently respecting the rights and privileges of the individual, no attack on the venereal diseases through repression of prostitution was possible. On the Continent, quite a different situation prevailed.
Prostitution and its problems.-Prostitution was recognized and accepted as a part of the social structure; in contrast, epidemiological studies were not so fruitful as they had been previously. It was obvious, therefore, that a determined program for the repression of prostitution was the method best calculated to minimize the incidence of venereal infection. In areas where this was done as it was done consistently in areas under the control of the Advance Section of the Communications Zone, the troops enjoyed a low
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FIGURE 39.-France welcomes America.
venereal disease rate. In areas where it was not done, the venereal disease rates were a direct measure of the degree to which prostitution was tolerated, condoned, or encouraged.
Obviously, it was impracticable for the headquarters group to initiate and carry out the development of a long-range program during the first month after D-day. The education of troops and the provision of prophylactic materials had been taken care of during the period of training and of mounting the operation, and at this point "on-the-spot" activities had to be left to those who were there. On 6 July, however, the chief of the Preventive Medicine Division paid a visit to France.
There he found, in Cherbourg, houses of prostitution being run for, and indirectly by, U.S. troops, with the familiar pattern of the designation of one brothel for Negro troops and the others for white, with military police stationed at the doors to keep order in the queues which formed. This is exactly what had been anticipated and was the specific reason for the incorporation in Circular No. 49 of the paragraph quoted previously. In a consultation with Col. Charles H. Beasely, MC, Surgeon, Advance Section, Communications Zone, the undesirability of this procedure was made readily
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apparent, and proper consultation with command succeeded in having these brothels effectively placed off limits.61
During the remainder of the summer of 1944, almost the only control methods applicable were the provision of prophylactic facilities and the utilization of the off-limits authority. During the first months of the continental operations, all towns were placed off limits as a matter of general policy, with the principle of the prevention of the venereal diseases only of secondary consideration. As the supply lines lengthened, as Cherbourg became more and more important as a port, and as larger cities, such as Le Mans and Rennes, were captured and developed into supply centers with complements of static troops, a more selective use of the off-limits authority was developed. There was no unanimity of opinion, however, as to how it should be used or, for that matter, as to the attitude which should be adopted with regard to prostitution.
The history of venereal disease control problems in France had been largely one of differences of opinion between those who favored segregation and licensure of prostitution and those who opposed it. Unfortunately, because of the nature of the subject, it had never been possible to gain a free and open discussion; it was generally accounted that, since the War Department policy was clearly stated and specifically directed repression of prostitution, it was necessary to give apparent support to such a policy, even while acting contrarily.
The contrary was done in many instances in spite of the clear directive contained in Circular No. 49.
Prophylaxis.-During this period, the most reliable estimates indicated that there was on the average much less venereal exposure than had been taking place among the same group of troops in the United Kingdom. There were at least three readily discernible reasons for this. Early in the campaign, large numbers of civilians, especially those of the camp-follower type, had either fled before or had been carried with the retreating German Armies. The circumstances of active military operations reduced both the opportunity and inclination for sexual exposure. Finally, the language difficulty interposed a very real barrier during this phase.
In spite of these factors making for a reduction in the amount of venereal disease exposure and the observations that this was the case, the use of station prophylaxis increased tremendously among troops in France as contrasted to the experience of the same troops in the United Kingdom. It was relatively easy to provide the facilities for this by virtue of the fact that the enemy in garrisoning the towns which the Allies were taking had without exception built and equipped an adequate number of well-located prophylactic
61(1) Annual Report, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, 1944. (2) It is to be noted that Cherbourg was not under the command of the Advance Section at the time these brothels were being operated in this fashion. The area passed to the Command of Advance Section the day after this recorded conversation, and placing the brothels off limits was one of the first command functions exercised.
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stations. These were equipped according to standards identical with US. Army standards, and, aside from the occasional difficulty of providing running water because the local water supply had been disrupted, they were usually ready for immediate use.
Epidemiological studies.-At this time, epidemiological studies were continued but on quite an elementary basis, since the military situation precluded the gathering of much accurate information. As static troops were moved in for the operation of the supply line, the same type of routine epidemiological studies which had been made in the United Kingdom were organized.
Cooperation with other agencies.-In the process of cooperation with other agencies, a new element which had not been previously encountered was introduced-the War Department G-5 (civil affairs) branch of the Army. This agency sometimes created extraordinary complications, since apparently there was no overall policy or procedure concerning venereal disease control in the organization and there were virtually as many different policies as there were civil affairs detachments in operation. Just as was true in command, these ranged all the way from an enlightened attitude toward the role of prostitution in the spread of the venereal diseases to a firm conviction that the operation of brothels was a duty which the Army owed to the individual soldier.
Where civilian governments continued to exist, they were at this time exceedingly willing to be cooperative but, in general, were unable to do anything for the U.S. Army or their own population that the U.S. Army itself could not do. With regard to the repression of prostitution, many of the French thought U.S. Army officials were mildly mad, but their temper at that time was to assist these officials to do anything that they wished.
Consultation with command.-During this period, consultation was limited almost entirely to a discussion of the desirability or undesirability of operating GI brothels. In some instances, the effort was made to educate officers who believed that the Army should operate brothels for the benefit of the soldiers, but it was soon learned that such educational efforts were largely futile. Apparently, a belief in the desirability of licensed prostitution is not subject to logical analysis or discussion62 but, instead, is based on the sort of faith that leads a small boy to believe that if he places a horsehair in a bottle of water it will turn into a snake.
From Paris to the Rhine
Changes in the situation.-In the liberation of Paris in the last days of August 1944, the general picture again changed (fig. 40). For obvious reasons, Paris quickly became the center of operations for U.S. Army activities on the Continent, the number of troops stationed there rapidly increased,
62Padget, P.: U.S. Army Experiences in Venereal Disease Control in the European Theater of Operations. Am. J. Syph. 29 : 352-360, 1945.
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FIGURE 40.-The liberated takes her liberator down a dark street.
the city became the natural objective of every soldier on pass or furlough, and countless numbers of soldiers, in groups all the way from one or two to entire convoys, "got lost" on their way from hither to yon and wound up in Paris for a bit of sightseeing. The German occupation had done nothing to improve the morals and behavior of the Parisian women of the brothels and boulevards, and the lack of food and, later, of fuel gave the U.S. soldier with a K ration an unbeatable bargaining position.
The immediate result was the beginning of a rapid rise in the venereal disease rate, an increase which did not level off until the rate had approximately doubled. Here again the previously employed methods of control were placed into operation, but, again, it was necessary to rearrange the emphasis. In the first place, it was necessary to consider the problem of prostitution all over again with the command of the Paris area. For example, on 2 September 1944, the provost marshal of the newly formed Seine Base Section (Paris and vicinity), stating that be was acting at the direction of the commanding general, made a tour of Paris brothels accompanied by a representative of the Brigade Mondaine for the express purpose of selecting certain houses of prostitution to be set aside for officers, others for white enlisted men, and still others for Negro enlisted men.
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Education.-During this period, the educational program again had to be largely developed locally because of the difficulty of getting the necessary transportation priority for bringing in supplies. Helpful and newsworthy stories were published by Stars and Stripes, and, as base sections developed on the Continent and venereal disease control officers were assigned thereto, the program of word-of-mouth education was continued.
Prophylaxis.-With the liberation of Paris, the demand for prophylactic facilities in that city became enormous and was well supplied under the auspices of the venereal disease control officer of the Seine Base Section. Elsewhere in the larger cities as they were occupied, the policy was continued of attempting to acquire space for prophylactic stations in the American Red Cross hostels. This was not quite so successfully accomplished as in the United Kingdom, but a number of such installations were made and successfully operated. During this period, adequate supplies of individual prophylactic materials, both chemical and mechanical, were available.
Epidemiological studies and cooperation with other agencies.-Even before the liberation of Paris, it had been possible to get routine epidemiological studies under way in the areas in which the troops were static. Shortly after the Army reached Paris, through the cooperation of the Ministry of Health of the De Gaulle Government, it was possible greatly to extend these studies, and they soon approximated in scope and detail the well-organized scheme which had been conducted in the British Isles. Not the least important of these was a weekly analysis of the place of exposure which, during the latter part of 1944, consistently showed Paris to supply a large fraction-sometimes as much as two-thirds-of all the venereal infections acquired in France.
Contact investigation was already under way in Cherbourg at the time headquarters was established in Paris and was soon extended to include all of the areas in which large numbers of static troops were located. Contact investigation was not as successful in France as it had been in England, primarily because the language difficulty in France handicapped the soldier in his attempt to give accurate identifying information concerning his venereal contact (fig. 41). With the extensive cooperation of the French health authorities and, through them, the French police, an exceedingly worthwhile contribution was made toward the reduction of the venereal disease problem.
In this regard, there is one point which is worthy of emphasis. It was standard policy and procedure to regard the activities of the Medical Department in venereal disease control as strictly related to medical and public health activities, reserving the policing aspects of venereal disease control to the military police on the one hand and to civilian police on the other. Certain individuals, from time to time, departed from this, but the policy itself was unvarying and was generally accepted and applied. This had two important effects, both of which may seem at this range to involve legal hair-
248
FIGURE 41.-Language difficulties were not insurmountable barriers to the soldier in France.
splitting, but both of which were, at the times and places in which they were applied, of crucial importance in avoiding the creation of unpleasant incidents between the U.S. Army and the civilian population.
The first one was that epidemiological information concerning a civilian venereal contact was invariably transmitted by U.S. Army officials to the appropriate health agency. The Medical Department knew, of course, that local custom in most instances resulted in that information being handed forthwith to the police without intermediate action on the part of the health officials, but nevertheless the Medical Department's dealings were entirely with the health agency.
The second point was that on the many occasions on which U.S. Army military police accompanied the civilian police either on raids or in apprehending civilian women, they went along for the real purpose of protecting the civilian police in the event there happened to be any U.S. soldiers about who resented the apprehension of the civilian women.
Since U.S. Army officials were alone in their particular sphere of influence at this point, there was very little opportunity for cooperating with other military agencies. Occasionally, however, the opportunity presented itself in France for the continuation of the close and cordial relationships
249
which had been experienced in the United Kingdom. Formal exchange of courtesies with the appropriate officers of the French Army was effected in every instance in an atmosphere of extreme good will. This relationship with the French was, at the end of the year, reviewed in the following words.63
Not the least helpful of the present activities is the cooperation which has been gained from the French Ministry of Health. M. Cavaillon, who is the Chief Medical Officer of the Ministry, has long been interested in the venereal diseases and was not only willing, but positively eager, to offer us any cooperation which was possible in venereal disease control. He realizes the crucial importance of the venereal diseases to French public health and also is keenly aware of the undesirability of legalized prostitution. There have been many meetings with M. Cavaillon, the first on 31 August. The most important meeting, however, was on 8 September, when he was presented with a letter from the Chief Surgeon for transmittal to the acting Minister of Health, requesting cooperation of the French in excluding our troops from brothels. This eventuated on 15 September in a letter from Minister of the Interior to all Prefects of Police in France, informing brothel keepers that they must exclude American military personnel from their premises on penalty of having the brothel closed for violation. The French have made a serious effort to implement this regulation, but unfortunately in many areas, the local American commander has been unable, or unwilling, to assist in the policing problem involved. The French quite understandably refuse to attempt the policing of U.S. soldiers without help from our military police, so the brothels flourish.
The lack of consistency reflected here has led the French Health Authorities to the belief that we are mildly confused in reconciling the established policy with actual procedure. The Chief Medical Officer of the Ministry of Health was quite uncomplimentary in the comments that he made concerning a report to him from the Medical Officer of the Department of the Meuse concerning the operation of brothels in Commercy and elsewhere by the United States Army.
On the strictly medical level, however, there has been worked out a cooperative scheme between ourselves, the Ministry of Health and local health authorities, from which is being built an effective control system, based primarily on contact tracing. At the present time this is being somewhat impeded, on the one hand by the difficulty of getting reliable identifying information from American soldiers regarding their French contacts, and on the other by the lack of personnel on the part of both ourselves and the French civilian authorities to do the field epidemiologic work. Increasing familiarity with language and place names is serving to ameliorate the former difficulty and as the year ends there is some hope that a temporary loan of nurses from UNRRA may relieve the problem of personnel.
With the liberation of Belgium, in general the same policies and procedures were practiced as had been developed for France. The Belgians proved themselves to be most cooperative, and in Liége, which was the only one of the large cities in the U.S. Army's zone of influence and which late in 1944 and early in 1945 became the hub of the supply system for the front, the cooperative relationship between U.S. Army officials and civilians was excellent. An Essential Technical Medical Data report from Headquarters, ETOUSA, for the month of March 1945, dated 16 May 1945, contained the following:
On 28 March 1945, there began at the Hospital Recollets in Liége, the final step in a complete venereal disease program for that community and our troops stationed there.
63See footnote 61 ( 1 ), p. 244.
250
Since November there has been a well organized and efficiently functioning veneral disease program, including a contact tracing scheme which has worked out in cooperation between ourselves and the civilian authorities. It has been handicapped, however, by the lack of adequate treatment for the women found to be infected. Because of the unique situation in Liége and particularly the high degree of cooperation which has been given by the civilian authorities, authority has been granted to utilize 400 ampules of penicillin a month in the treatment of selected civilian women. The protocol of the procedure is attached * **. This protocol and the circulars to which it refers, have been translated into French and Flemish for the benefit of the various staffs of hospitals and the first patients have been treated.
The protocol referred to provided that penicillin would be used for no other purpose than for the treatment of women known or reasonably suspected of having been sex contacts of U.S. soldiers with a venereal disease, except when such women were found to have late syphilis. The treatment was directly under the supervision of an officer and nurse of the Medical Department of the U.S. Army, and carefully drawn criteria for diagnosis and determination of cure were supplied.
During this period, the consultations with command were limited almost entirely to efforts to break up the still existing habits of many commanding officers of punishing noncommissioned officers for acquiring a venereal disease by reducing them to the ranks. This is exemplified by the publication by the Commanding General, Headquarters Command, ETOUSA, of a directive creating an efficiency board to review the case of any noncommissioned officer who acquired a venereal disease with accompanying memorandum to the members of the board making it clear that the commanding general expected every noncommissioned officer brought before this board for having had a venereal disease to be reduced to the ranks for inefficiency.
The Continental Phase After the Investiture of Germany
After the invasion of Germany, two new problems of crucial importance were encountered. Both of these had been anticipated, but for neither had satisfactory plans been made. The first of these was the problem created by displaced persons. These persons had been encountered before the actual invasion of Germany took place but were found in increasing numbers as the armies pushed deeper into Germany and released the camps of slave labor.
The social and economic problems which these people presented were terrifying. The circumstances under which they had been living were such as to leave them with virtually no sense of moral responsibility. Promiscuity was the rule rather than the exception, and the incidence of the venereal diseases among them must have been high, although there was no reliable information on this subject.
The second of the problems was that caused by the nonfraternization policy (fig. 42). This problem was discussed in the annual report of Maj. Gen. Paul R. Hawley's Preventive Medicine Division for the first half of 1945, as follows:
251
FIGURE 42.-American soldiers at a resort in Germany take a dim although not disinterested view of the nonfraternization policy.
In anticipation of the special problems which would arise with the cessation of hostilities, the effort was made to obtain clarification of policy with regard to the venereal diseases acquired in enemy countries. As early as November 1944, a decision was requested regarding the advisability of application for prophylaxis or for treatment for venereal disease being considered as prima facie evidence of fraternization with the enemy. No clear statement of policy was obtained, so that with the occupation of Germany, especially after the cessation of hostilities, there was lack of uniform policy. Some commanders attempted to establish a program, but others went so far as to refuse to establish prophylactic stations on the assumption that to do so would be encouraging fraternization. In some organizations, men were tried before a summary court-martial, and fined the usual $65, simply for reporting with a venereal disease.
A letter order on 11 June 1945 from Headquarters, ETOUSA, concerning policy on relations between Allied occupying forces and inhabitants of Germany, clarified the situation. A portion of this letter order follows:
2. The contraction of venereal disease or the facts concerning prophylactic treatment will not be used, directly or indirectly, as evidence of fraternization or as evidence of violation by the individual of the policy on nonfraternization with the inhabitants of Germany.
252
With the slowing down of the armies and the final cessation of hostilities, the supply problem became very much better, and, at long last in the late spring of 1945, a series of shipments of venereal disease posters totaling 70,000 was received from the United States. This represented the first poster material received for distribution in the European Theater of Operations proper, although, some time before the date of the receipt of this material on the Continent, similar supplies had been received in the United Kingdom Base. Copies of the educational films entitled "Pick-up" and "For Your Information" also were made available during this period.
The cessation of hostilities (fig. 43) was followed immediately by a sharp
FIGURE 43.-Lovely companions made beach lounging a "must" for combat soldiers who were lucky enough to visit the Riviera Recreational Area during the last stages of the war and thereafter.
upward trend in the incidence of the venereal diseases. Unfortunately, this skyrocketing venereal disease rate was accompanied by such a kaleidoscopic shifting in the makeup of the commands in the theater and by so complete a redistribution of responsibility that during this period very little which was effective in organized venereal disease control could be accomplished.
Another minor misfortune occurred at this time in the withdrawal from issue of the V-Packette and the substitution therefor of the one-tube prophy‑
253
lactic kit of which adequate supplies were not available. This created a critical supply problem for what was already a critical period in the venereal disease experience of the theater, and there was much speculation as to whether or not this limitation of prophylactic supplies materially contributed to the increasing venereal disease rate.
Before this period the issue of condoms had been cut from 6 per man per month for issue and an average of 1.7 per man per month for sale through the post exchanges, to a total supply of 4 per man per month for both issue and sales purposes. This otherwise undesirable move had been necessitated by directions from the Office of the Surgeon General based on the supply problem.
Efforts were made to continue epidemiological studies, but, with the cessation of hostilities and the tremendous amount of troop movement which developed immediately thereafter, these studies proved to be of less value than at any time during the life of the theater.
Cooperative relationships which had been developed with other agencies were maintained, and during this period a beginning was made toward the development of a venereal disease control program applicable to the people of Germany for the protection of the army of occupation.
PREVALENCE AND INCIDENCE OF THE VENEREAL DISEASES
Review of theater rates.-It remains to assess the conditions that existed and the methods that were used in the control of the venereal diseases in terms of the amount of venereal infection experienced by troops of the U.S. Army and to examine the distributions of the several diseases among various elements of the U.S. forces in Europe. The total venereal disease rate will be used as the index.
The initial phase of operations in Europe has been defined as the period dating from the arrival of troops in February 1942 through the mounting of Operation TORCH at the end of 1942. During the first months after the establishment of the theater, the rates for the venereal diseases were decidedly good, as would be anticipated for troops newly arrived in a strange country with much to do in becoming established in a new environment and in building a military structure. For the first 8 months of 1942, the rates for troops in the European theater were better than those for the United States despite long experience in many wars indicating that higher rates almost invariably occur among troops away from home. For a good part of this time, the theater rates were half those of troops in the Zone of Interior.
As greater acquaintance developed with the United Kingdom, and as the first flush of other interests in a new country subsided, the rates for the venereal diseases began to increase. This was first noticeable in August and progressed continuously through December to reach a rate of 58 per 1,000 per year which was never again duplicated until the troops reached France.
254
The experience of the early months of the second phase of operations in the United Kingdom was characterized by a more or less fixed incidence of the venereal diseases at a level slightly in excess of 50 per 1,000 per year, after which a steady, downward trend took place in the frequency with which these diseases were noted. This downward trend continued until D-day and the invasion of Normandy. The annual rate for 1943 was 43, compared with that of 26 for troops in the United States.
The decidedly low level to which rates for the venereal diseases had declined in 1944 was one indication of the seriousness with which U.S. soldiers undertook the obligation of preparing for the invasion and of the hard work that went into it. For a number of months just before D-day, the rates for theater troops were actually better than those for troops in the continental United States. The increase just before D-day was much less than had been anticipated as a result of the frequently expressed "last fling" attitude.
Normandy became the business of the day, and troops engaged in the assault on the Continent had such an excellent record with respect to venereal diseases that the rates for the entire theater were carried with it; venereal disease in the Army dropped to a level of 20 per 1,000 per year, a truly excellent record of itself and one which essentially matched that of the early days of the theater but unfortunately was never to be attained again.
The average rates for the venereal diseases among troops of the U.S. Army stationed on the European Continent were never as good as those which marked their stay in the United Kingdom. It was appreciated in advance that they would not be. A rate of 25 per 1,000 per year had been set as the criterion of satisfactory control in the United Kingdom. Based on the same standards of a reasonably attainable goal, a rate of 50 was taken as a satisfactory basis upon which to judge European performance.
The rates became greater as continental operations were extended. The effect of the transfer of theater headquarters and of general activities to Paris was evident when the rates for October touched 58. A moderate improvement was noted in the next succeeding months, and, indeed, the curve of incidence acquired a fastigium as it had in England once conditions became more or less stabilized.
The approaching end of the war and the contact with new people and new conditions led to a decided rise in rates in March and April. When V-E Day finally arrived, the inevitable letdown took place, and the rates for venereal diseases soared. In May, the rates were greater than in April, and June saw the highest rate in the history of the theater, with every indication that the end was not yet and that army of occupation would have an experience with those communicable diseases greatly exceeding that of the period of wartime operations (fig. 44).
Rates in the major forces.-The average long-term incidence of the venereal diseases in the United Kingdom was maintained at a satisfactory level. Nevertheless, the three principal forces constituting the command, the Ground
255
FIGURE 44.-Athletic activities were fostered as a form of substitutive activity, Garmisch‑Partenkirchen, Germany, June 1945.
Forces, the Air Forces, and SOS (the Services of Supply) showed certain variations in the frequency with which these diseases occurred. The year 1943 is taken in illustration of experience in Great Britain, and the period September 1944 to June 1945, for continental operations (tables 19 and 20). Troops of the Ground Forces regularly and consistently had the best record in the United Kingdom. There was not much to choose between the experience of the Services of Supply and that of the Air Forces, but, in general, the highest rates for any of the three groups were among troops of the Air Forces, the only troops then actively engaged in combat. Much the same relationship was maintained during operations on the Continent, although no doubt existed then that Communications Zone troops outdistanced all others.
The Air Forces continued a very close second. The best rates by far were those of the Ground Forces, although in the final week of the theater, the week ending 29 June 1945, the Ground Forces, came into their own and led all three forces with a rate for the week of 140 per 1,000 per year.
256
TABLE 19.-Incidence rates for venereal disease, all forms, in the U.S. Army in Great Britain, 1 January 1943 to 30 June 1944
Week ending-
Ground Forces
Air Forces
Services of Supply
Week ending-
Ground Forces
Air Forces
Services of Supply
1943
1943-Con.
Jan. 1
47
75
71
Oct. 1
22
35
40
Jan. 8
47
63
65
Oct. 8
26
(1)
(1)
Jan. 15
46
42
68
Oct. 15
23
34
31
Jan. 22
37
45
46
Oct. 22
18
37
32
Jan. 29
17
59
88
Oct. 29
8
35
34
Feb. 5
34
49
52
Nov. 5
9
35
23
Feb. 12
(1)
(1)
(1)
Nov. 12
16
29
30
Feb. 19
83
76
62
Nov. 19
11
28
35
Feb. 26
53
64
58
Nov. 26
17
28
30
Mar. 5
(1)
(1)
(1)
Dec. 3
18
23
28
Mar. 12
60
58
50
Dec. 10
13
29
31
Mar. 19
42
50
57
Dec. 17
22
30
27
Mar. 26
44
70
39
Dec. 24
13
26
23
Apr. 2
22
57
50
Dec. 31
20
22
26
Apr. 9
37
72
49
1944
Apr. 16
51
53
59
Jan. 7
14
23
20
Apr. 23
42
60
50
Jan. 14
16
33
19
Apr. 30
30
58
40
Jan. 21
15
31
30
May 7
32
35
35
Jan. 28
16
29
31
May 14
48
57
40
Feb. 4
15
23
24
May 21
36
47
63
Feb. 11
16
26
21
May 28
31
34
44
Feb. 18
16
28
24
June 4
35
34
37
Feb. 25
15
27
23
June 11
20
43
42
Mar. 3
17
21
20
June 18
27
31
33
Mar. 10
13
23
15
June 25
50
33
30
Mar. 17
16
27
21
July 2
(1)
(1)
(1)
Mar. 24
15
23
28
July 9
24
36
36
Mar. 31
17
28
24
July 16
27
44
33
Apr. 7
18
29
20
July 23
43
39
29
Apr. 14
16
33
23
July 30
35
39
38
Apr. 21
14
31
23
Aug. 6
21
29
29
Apr. 28
13
28
18
Aug. 13
20
40
35
May 5
11
28
14
Aug. 20
21
36
37
May 12
14
30
19
Aug. 27
10
43
41
May 19
14
33
15
Sept. 3
21
33
33
May 26
17
29
23
Sept. 10
10
37
45
June 2
13
33
18
Sept. 17
26
33
40
June 9
19
32
20
Sept. 24
27
32
43
June 16
22
31
20
June 23
19
31
17
June 30
12
38
19
1No data available.
Source: Division of Medical Records, Office of the Chief Surgeon, ETOUSA.
257
TABLE 20.-Incidence rates for venereal disease, all forms, in the U.S. Army, by major commands in continental Europe, 1 September 1944 to 29 June 1945
Week ending-
Ground Forces
Air Forces
Communications Zone
Ground Forces Replacement Command
Week ending-
Ground Forces
Air Forces
Communications Zone
Ground Force Replacement Command
1944
1945-Con.
Sept. 1
4
---
15
---
Jan. 26
17
73
92
67
Sept. 8
10
---
15
---
Feb. 2
16
69
81
72
Sept. 15
17
---
27
---
Feb. 9
19
68
79
95
Sept. 22
27
102
45
---
Feb. 16
22
76
81
75
Sept. 29
28
120
76
---
Feb. 23
21
61
73
88
Oct. 6
24
95
78
---
Mar. 2
18
60
66
75
Oct. 13
26
103
88
73
Mar. 9
18
66
67
82
Oct. 20
26
111
93
98
Mar. 16
22
72
79
67
Oct. 27
27
101
90
80
Mar. 23
22
74
80
74
Nov. 3
21
77
96
46
Mar. 30
22
65
80
90
Nov. 10
23
89
86
42
Apr. 6
18
62
62
68
Nov. 17
22
87
78
48
Apr. 13
19
70
71
76
Nov. 24
23
75
85
66
Apr. 20
18
64
80
72
Dec. 1
20
81
83
67
Apr. 27
29
68
72
99
Dec. 8
24
82
91
93
May 4
31
56
69
76
Dec. 15
27
99
88
90
May 11
42
69
70
76
Dec. 22
24
78
89
74
May 18
53
89
91
79
Dec. 29
21
70
74
68
May 25
68
74
92
75
1945
June 1
70
75
82
104
Jan. 5
19
58
76
61
June 8
86
94
96
128
Jan. 12
20
69
92
50
June 15
91
100
94
143
Jan. 19
20
68
93
56
June 22
93
107
117
155
June 29
140
120
107
153
The Ground Forces Replacement Command, a continental organization, had decidedly high rates for the venereal diseases throughout the course of operations. Comparison with the Ground Forces themselves is striking. If the entire period of continental operations is considered, the ranking position of the Communications Zone remained safe, but the Ground Forces Replacement Center displayed a burst of speed at the end that outdistanced all others. The venereal disease rate for that organization during the week ending June 1945 was 153 per 1,000 per year.
The Services of Supply and the Communications Zone.-Three large base sections, the Western Base Section, the Eastern Base Section, and the Southern Base Section, a smaller Central Base Section which included the metropolitan district of London, and the North Ireland Base Section which was somewhat isolated and of lesser troop strength, comprised the organization of the Services of Supply in Great Britain.
Over the course of the many months in the United Kingdom, the Western Base Section had the poorest record of the several base sections (table 21).
258
TABLE 21.-Incidence rates for venereal disease, all forms, U.S. Army Base Sections, SOS, in United Kingdom, 1 January 1943 to 30 June 1944
Week ending-
Central Base Section
Eastern Base Section
Southern Base Section
Western Base Section
Week ending-
Central Base Section
Eastern Base Section
Southern Base Section
Western Base Section
North Ireland Base Section
1943
1943-Con.
Jan. 1
---
68
50
107
Oct. 1
6
47
27
63
(1)
Jan. 8
---
45
71
97
Oct. 8
(1)
(1)
(1)
(1)
(1)
Jan. 15
---
73
68
88
Oct. 15
0
27
23
61
(1)
Jan. 22
---
36
53
67
Oct. 22
6
46
22
43
15
Jan. 29
---
60
125
110
Oct. 29
15
32
29
52
28
Feb. 5
---
71
33
57
Nov. 5
20
27
12
36
33
Feb. 12
---
(1)
(1)
(1)
Nov. 12
10
31
15
55
7
Feb. 19
---
75
71
54
Nov. 19
32
55
16
50
11
Feb. 26
---
79
21
102
Nov. 26
4
31
26
78
17
Mar. 5
---
(1)
(1)
(1)
Dec. 3
9
28
16
42
89
Mar. 12
---
51
19
92
Dec. 10
18
36
14
55
24
Mar. 19
---
52
58
85
Dec. 17
4
24
19
50
21
Mar. 26
---
43
21
69
Dec. 24
15
37
17
24
29
Apr. 2
---
39
53
73
Dec. 31
10
24
19
48
11
Apr. 9
---
54
50
49
1944
Apr. 16
---
40
44
118
Jan. 7
13
27
16
30
0
Apr. 23
---
53
38
67
Jan. 14
20
14
9
34
23
Apr. 30
---
58
36
33
Jan. 21
6
27
29
44
15
May 7
15
21
30
79
Jan 28
9
46
17
41
61
May 14
0
34
49
58
Feb. 4
18
26
21
31
24
May 21
15
66
73
62
Feb. 11
11
31
15
32
11
May 28
29
52
48
33
Feb. 18
26
30
19
32
4
June 4
56
40
32
42
Feb. 25
14
23
17
39
10
June 11
41
54
29
45
Mar. 3
6
30
17
19
33
June 18
66
39
34
21
Mar. 10
5
21
10
20
21
June 25
22
21
33
57
Mar. 17
8
31
15
27
21
July 2
(1)
(1)
(1)
(1)
Mar. 24
13
35
29
28
33
July 9
20
42
37
34
Mar. 31
17
47
22
20
19
July 16
9
44
20
52
Apr. 7
41
27
18
18
13
July 23
18
19
31
46
Apr. 14
5
31
29
19
17
July 30
53
58
16
36
Apr. 21
13
17
21
29
27
Aug. 6
32
41
26
19
Apr. 28
25
41
15
16
6
Aug. 13
23
42
26
43
May 5
5
7
14
14
24
Aug. 20
22
34
45
47
May 12
10
---
16
27
13
Aug. 27
0
29
46
78
May 19
5
---
10
23
13
Sept. 3
0
30
29
63
May 26
13
---
35
17
22
Sept. 10
34
37
36
67
June 2
13
---
15
24
32
Sept. 17
7
48
14
79
June 9
12
---
27
15
10
Sept. 24
20
36
41
69
June 16
18
---
14
29
(1)
June 23
21
---
14
23
(1)
June 30
7
---
15
30
(1)
No data available.
Source: Division of Medical Records, Office of the Chief Surgeon, ETOUSA.
259
The rates in the Eastern Base Section were always relatively high. The best long-term record of the three principal sections went to the Southern Base Section, considering troop strength and the concentration of activities in that region. Particularly favorable comment is directed to the Central Base Section in London, with a first-class record achieved under difficult circumstances. The program of control was under competent direction and had the active support of command. The North Ireland Base Section had a consistently good performance.
There was not much to choose among the various sections of the Communications Zone in France. The rates for all sections were higher than the theater average, and the Seine Base Section in Paris maintained leadership with no difficulty until it yielded precedence to the Delta Base Section as that organization came into the European theater in November 1944 (table 22). No single major organization of the theater ever approached the rates that organization had in the Marseilles region.
TABLE 22.-Incidence rates for venereal disease, all forms, U.S. Army Base Sections of the Communications Zone in continental Europe, 1 September 1944 to 29 June 1945
Week ending-
Advance Base Section
Continental Advance Base Section
Brittany Base Section
Channel Base Section
Delta Base Section
Normandy Base Section
Loire Base Section
Oise Base Section
Seine Base Section
1944
Sept. 1
12
---
10
---
---
16
(1)
---
(1)
Sept. 8
11
---
22
---
---
14
28
---
11
Sept. 15
26
---
22
(1)
---
27
36
---
83
Sept. 22
67
---
36
---
---
21
51
---
98
Sept. 29
110
---
28
63
---
46
72
---
128
Oct. 6
96
---
96
119
---
40
10
264
94
Oct. 13
125
---
82
117
---
28
222
82
164
Oct. 20
122
---
129
155
---
35
50
96
186
Oct. 27
98
---
76
124
---
52
135
252
134
Nov. 3
98
---
86
144
---
49
98
250
151
Nov. 10
80
---
91
136
---
42
120
153
153
Nov. 17
67
---
101
88
---
48
63
176
115
Nov. 24
86
(2)
125
89
(2)
40
100
148
121
Dec. 1
66
---
88
111
---
47
(3)
131
146
Dec. 8
99
---
105
87
---
59
---
140
136
Dec. 15
79
63
118
87
178
54
---
93
128
Dec. 22
79
73
114
80
165
50
---
100
136
Dec. 29
55
29
100
66
139
62
---
93
98
1945
Jan. 5
58
16
81
91
179
46
---
82
88
Jan. 12
72
33
128
87
179
47
---
106
133
Jan. 19
91
62
127
80
169
54
---
92
115
Jan. 26
66
50
146
92
167
61
---
105
115
Feb. 2
52
66
96
77
180
56
---
72
128
Feb. 9
45
56
98
86
133
76
---
93
122
Feb. 16
48
66
(3)
88
153
79
---
81
101
Feb. 23
45
57
---
87
137
65
---
83
93
Mar. 2
37
49
---
83
100
60
---
99
78
Mar. 9
36
42
---
82
110
70
---
70
106
Mar. 16
43
33
---
118
155
80
---
80
92
Mar. 23
50
69
---
94
159
74
---
81
95
Mar. 30
45
74
---
111
143
85
---
69
66
Apr. 6
39
46
---
83
96
63
---
52
89
Apr. 13
38
42
---
66
101
83
---
65
94
Apr. 20
46
65
---
77
96
96
---
76
111
Apr. 27
50
60
---
73
105
76
---
66
99
May 4
47
39
---
66
125
72
---
69
90
May 11
48
31
---
87
102
75
---
65
93
May 18
50
30
---
120
128
101
---
87
145
May 25
49
81
---
96
121
93
---
104
109
June 1
46
50
---
63
105
99
---
83
118
June 8
65
72
---
109
130
104
---
94
81
June 15
57
79
---
94
140
68
---
82
109
June 22
63
69
---
96
167
103
---
112
119
June 29
80
67
---
101
137
102
---
119
105
1Activated.
2Assigned Communications Zone, ETO.
3Inactivated.
Source: Division of Medical Records, Office of the Chief Surgeon, ETOUSA.
Rates in the Air Forces.-The Eighth Air Force remained continuously in Great Britain and the rates for the venereal diseases quoted for Air Forces in Great Britain are essentially those of the Eighth Air Force. The Ninth Air Force operated on the Continent, and continental Air Force troops were principally of that command (table 23).
Venereal diseases among men of the Ninth Air Force were more frequent than for those of the Eighth Air Force; but the differences were not great, and the spread was by no means comparable to that for Communications Zone troops under the two conditions.
261
TABLE 23.-Incidence rates for venereal disease, all forms, U.S. Army Air Forces, 1 September 1944 to 29 June 1945
Week ending-
Continental Europe
United Kingdom
Week ending-
Continental Europe
United Kingdom
1944
1945-Continued
Sept. 1
---
52
Feb. 2
69
34
Sept. 8
---
51
Feb. 9
68
38
Sept. 15
---
55
Feb. 16
76
45
Sept. 22
102
57
Feb. 23
61
47
Jan. 29
120
54
Mar. 2
60
35
Oct. 6
95
62
Mar. 9
66
42
Oct. 13
103
71
Mar. 16
72
55
Oct. 20
111
78
Mar. 23
74
58
Oct. 27
101
61
Mar. 30
65
61
Nov. 3
77
56
Apr. 6
62
50
Nov. 10
89
83
Apr. 13
70
29
Nov. 17
87
59
Apr. 20
64
55
Nov. 24
75
62
Apr. 27
68
58
Dec. 1
81
46
May 4
56
62
Dec. 8
82
48
May 11
69
57
Dec. 15
99
54
May 18
89
72
Dec. 22
78
56
May 25
74
64
Dec. 29
70
59
June 1
75
47
1945
June 8
94
49
Jan. 5
58
44
June 15
100
60
Jan. 12
69
54
June 22
107
63
Jan. 19
68
55
June 29
120
58
Jan. 26
73
54
Source: Division of Medical Records, Office of the Chief Surgeon, ETOUSA.
Rates in the field armies.-Until completion of active operations in May 1945, the venereal disease rates for field armies were consistently the best of all troops of the theater, so much so that there was scant comparison. Differences among the five armies constituting the Ground Forces are difficult to demonstrate (table 24). Sometimes one army had the best record for a month or so, sometimes another. The behavior of all was characterized by a sharp rise as the war ended, with no question remaining of where the explanation lay for the greatly increased rates of the theater as a whole, which characterized the final weeks.
Rates during active operations.-Venereal diseases were very definitely more frequent among troops serving on the Continent than among those in
262
TABLE 24.-Incidence rates for venereal disease, all forms, U.S. armies in continental Europe, 1 September 1944 to 29 June 1945
Week ending-
First U.S. Army
Third U.S. Army
Seventh U.S. Army
Ninth U.S. Army
Week ending-
First U. S. Army
Third U.S. Army
Seventh U. S. Army
Ninth U.S. Army
Fifteenth U. S. Army
1944
1945-Con.
Sept. 1
1
7
---
---
Feb. 2
20
12
12
17
---
Sept. 8
12
9
---
17
Feb. 9
29
14
16
17
---
Sept. 15
28
14
---
4
Feb. 16
30
15
16
26
---
Sept. 22
35
21
---
11
Feb. 23
27
17
16
25
---
Sept. 29
30
33
---
4
Mar. 2
20
18
16
18
14
Oct. 6
23
33
---
11
Mar. 9
23
16
16
18
7
Oct. 13
27
34
---
9
Mar. 16
26
15
18
23
26
Oct. 20
30
30
---
10
Mar. 23
30
13
19
22
20
Oct. 27
27
32
---
14
Mar 30
21
16
18
29
17
Nov. 3
26
25
---
13
Apr. 6
19
10
18
18
26
Nov. 10
26
30
---
15
Apr. 13
18
10
20
23
26
Nov. 17
24
23
---
17
Apr. 20
17
11
13
24
26
Nov. 24
26
20
123
18
Apr. 27
35
15
33
34
31
Dec. 1
20
16
20
23
May 4
37
17
24
34
42
Dec. 8
26
18
20
22
May 11
50
24
39
46
55
Dec. 15
22
20
20
29
May 18
(2)
35
44
60
74
Dec. 22
26
21
14
24
May 25
---
40
70
77
93
Dec. 29
18
14
23
21
June 1
---
48
64
78
101
1945
June 8
---
56
89
110
94
Jan. 5
20
16
15
14
June 15
---
84
102
92
75
Jan. 12
29
15
13
15
June 22
---
84
101
(2)
96
Jan. 19
28
17
15
16
June 29
---
126
162
---
113
Jan. 26
26
14
10
17
1First report received.
2Redeployed.
Source: Division of Medical Records, Office of the Chief Surgeon, ETOUSA.
the United Kingdom Base. The commonly expressed belief that the greater rates for the theater during the time of active operations were completely an expression of the forces serving on the Continent was not wholly true, for the venereal diseases were more common in both localities. The rate for the period September 1944 to June 1945, inclusive, in the United Kingdom was 47 per annum per 1,000 average strength compared with 35 for the year 1944; and the frequency of these conditions among troops on the Continent for the September 1944-June 1945 period was no more than 59 per annum per
263
1,000 average strength. The general increase was a function of both commands (table 25).
TABLE 25.-Venereal disease, all forms, in the U.S. Army, in the United Kingdom and on the Continent, by month, September 1944 to June 1945
Month and year
Total
United Kingdom
Continent
Cases
Rate
Cases
Rate
Cases
Rate
1944
September
5,695
35
2,673
40
3,022
31
October
7,876
57
2,203
53
5,673
59
November
7,311
48
1,935
48
5,376
48
December
11,223
50
2,379
40
8,844
53
1945
January
9,472
48
1,968
39
7,504
52
February
9,284
45
1,797
38
7,487
47
March
12,747
48
2,454
48
10,293
48
April
9,985
46
1,780
46
8,205
46
May
13,705
62
1,856
62
11,849
62
June
27,705
105
13,048
66
124,657
113
Total
115,003
56
22,093
47
92,910
59
1Data are only estimated.
Differences in rates in white and Negro troops.-The usual difference between venereal diseases among white and Negro populations was consistently observed among troops of the U.S. Army serving in Europe. The rates for both groups were higher on the Continent than in the United Kingdom, but the relative difference remained almost identical, about 1 to 4.5 (table 26).
Types of venereal disease.-The distribution of the venereal diseases according to clinical form, grouped as syphilis, gonorrhea and those other than syphilis and gonorrhea, is presented in table 27, for each of the 4 years of the existence of the European theater. Gonorrhea constituted the great bulk of infections; the rates for syphilis remained fairly similar throughout the years except for a rather well marked increase in 1943, when the proportion of syphilis to other forms of venereal disease was increased. The rise in rates for the group classed as other venereal diseases and noted in 1945 was distinctly related to the troops arriving in the European theater from Italy,
264
where the incidence of chancroid was measurably great. The monthly reports of syphilis show a uniform distribution throughout each year. The high incidence in 1943 is shown to be particularly a function of the latter part of that period (table 28). Similar data are presented for gonorrhea in table 29.
TABLE 26.-Venereal disease, all forms, in the U.S. Army, European theater, Negro and white, by month, February 1944 to June 1945
Month and year
Total
White
Negro
Cases
Rate
Cases
Rate
Cases
Rate
1944
February
2,115
20.1
1,426
22.0
689
127.3
March
2,590
25.1
1,775
18.6
815
106.4
April
2,451
26.4
1,707
19.9
744
102.9
May
2,291
22.8
1,632
17.6
659
82.5
June
2,993
23.5
2,137
18.1
856
83.3
July
2,371
21.8
1,753
17.3
618
83.1
August
2,594
20.4
1,906
16.3
688
69.0
September
5,695
34.8
4,282
28.3
1,413
113.5
October
7,876
56.6
5,469
42.8
2,407
212.1
November
7,311
48.0
5,027
35.9
2,284
182.4
December
11,223
49.5
7,764
37.2
3,459
190.8
1945
January
9,472
48.3
6,179
34.5
3,293
196.2
February
9,284
45.1
6,290
33.3
2,994
173.3
March
12,747
48.2
8,842
36.4
3,905
179.3
April
9,985
45.6
7,221
35.9
2,764
154.6
May
13,705
61.8
10,432
51.9
3,273
177.6
June
27,705
105.2
20,463
84.9
7,242
324.4
Total
132,408
47.6
94,305
36.9
38,103
169.4
TABLE 27.-Incidence of venereal disease in the U.S. Army, European theater, by clinical form and year, February 1942 to June 1945
Disease
Total
1942
1943
1944
1945
Cases
Rate
Cases
Rate
Cases
Rate
Cases
Rate
Cases
Rate
Syphilis
21,929
6.9
420
5.8
2,798
10.6
8,269
5.6
10,442
7.6
Gonorrhea
119,780
37.7
2,196
30.2
7,945
30.1
41,824
28.4
67,815
49.5
Other
6,886
2.2
119
1.7
601
2.3
1,525
1.0
4,641
3.4
Total
148,595
46.8
2,735
37.7
11,344
43.0
51,618
35.0
82,898
60.5
265
TABLE 28.-Incidence of syphilis in the U.S. Army, European theater, by month, February 1942 to June 1945
Month
Total
1942
1943
1944
1945
Cases
Rate
Cases
Rate
Cases
Rate
Cases
Rate
Cases
Rate
January
2,067
7.7
---
0
112
10.2
567
9.2
1,388
7.1
February
2,096
7.4
1
3.2
50
5.9
606
8.6
1,439
7.0
March
2,714
7.2
3
3.8
32
3.9
738
7.1
1,941
7.3
April
2,230
6.9
2
2.3
105
9.9
687
7.4
1,436
6.6
May
2,390
7.2
9
4.2
104
11.0
613
6.1
1,664
7.5
June
3,308
8.1
8
2.3
86
7.1
640
5.0
2,574
9.8
July
706
5.3
28
4.4
220
11.5
458
4.2
---
0
August
796
5.1
59
6.7
295
15.2
442
3.5
---
0
September
1,034
5.2
47
3.7
337
14.4
650
4.0
---
0
October
1,245
6.5
107
6.4
401
10.9
737
5.3
---
0
November
1,317
6.4
96
8.6
395
9.6
826
5.4
---
0
December
2,026
6.7
60
6.4
661
10.2
1,305
5.8
---
0
Total
21,929
6.9
420
5.8
2,798
10.6
8,269
5.6
10,442
7.6
Comparison with other theaters of operation.-Comparison of the rates for the venereal diseases among troops of the European theater with those of U.S. troops serving in the United States shows the experience of the theater to be commendable (table 30). The rates were greater, but rates are always greater among troops serving in a foreign country. Compared with the experience of the British Army serving at home, the rates for U.S. troops in Great Britain were measurably higher.
TABLE 29.-Incidence of gonorrhea in the U.S. Army, European theater, by month, February 1942 to June 1945
Month
Total
1942
1943
1944
1945
Cases
Rate
Cases
Rate
Cases
Rate
Cases
Rate
Cases
Rate
January
9,396
35.0
---
0
512
46.8
1,451
23.6
7,433
37.9
February
9,067
31.8
2
6.5
410
48.5
1,428
20.3
7,227
35.1
March
12,103
32.1
11
13.9
378
45.6
1,749
16.9
9,965
37.7
April
10,260
31.7
11
12.5
460
43.5
1,646
17.7
8,143
37.2
May
13,464
40.4
29
13.6
322
34.1
1,601
15.9
11,512
52.0
June
26,195
64.5
24
6.8
335
27.6
2,301
18.1
23,535
89.3
July
2,594
19.3
103
16.1
627
32.8
1,864
17.1
---
0
August
2,926
18.9
155
17.7
654
33.8
2,117
16.7
---
0
September
6,128
30.7
450
35.5
730
31.3
4,948
30.2
---
0
October
8,598
44.7
538
32.2
1,043
28.5
7,017
50.4
---
0
November
7,820
38.2
416
37.3
1,051
25.7
6,353
41.7
---
0
December
11,229
37.3
457
49.0
1,423
21.9
9,349
41.3
---
0
Total
119,780
37.7
2,196
30.2
7,945
30.1
41,824
28.4
67,815
49.5
266
TABLE 30.-Incidence rates for venereal disease, all forms, in the U.S. Army, by theater or area and year, January 1942 to June 1945
Theater or area
All venereal diseases
Gonorrhea
Syphilis
Venereal diseases other than gonorrhea and syphillis
1942-45
1942
1943
1944
1945
1942-45
1942-45
1942-45
Continental United States
33
39
26
33
44
26.0
4.8
1.9
Overseas:
Mediterranean
91
35
56
111
102
54.9
12.4
23.2
Africa-Middle East
67
86
69
60
75
29.0
13.6
24.7
Latin America
54
74
58
36
27
31.7
10.1
12.1
China-Burma-India
50
64
53
51
47
22.7
11.5
15.8
Europe
47
38
43
35
61
37.7
6.9
2.2
Southwest Pacific
26
33
15
7
57
17.0
3.1
5.4
North America
12
10
10
14
18
10.0
1.5
.4
Alaska
5
7
3
5
9
3.8
.8
.1
Pacific Ocean Area
6
11
5
5
3
4.3
1.2
.3
Total overseas
44
33
34
41
57
30.4
6.6
7.2
Total Army
37
38
28
37
52
27.6
5.5
3.9
Among U.S. troops in the various theaters of operation, those in the European theater fared best by far. The highest average rate attained in any area was the overall rate of 90.5 per annum per 1,000 average strength which was attained in the Mediterranean. The rate of 67 attained in the Africa-Middle East theater was next highest, and the Latin American area rate of 54 was not far below. The overall rate of 47 for venereal disease in the European theater ranks fifth among the rates in the nine oversea areas (table 30).
PAUL PADGET, M.D.
Part IV. Other Oversea Areas and Theaters
U.S. ARMY FORCES IN THE MIDDLE EAST
Before the formation of USAFIME (U.S. Army Forces in the Middle East), it was known that U.S. Army troops in this area would be confronted with a venereal disease problem that was entirely different than that encountered in the continental United States.
The USMNA (U.S. Military North African) Mission made a study of venereal disease in Egypt and adjacent areas in the latter part of 1941. The surgeon for the mission was Maj. (later Col.) Crawford F. Sams, MC, who
267
reported that the question of venereal disease and prostitution in the Middle East was an enormous one-one that would cause considerable trouble in any group of troops or civilian workers coining into the area.64
The civilian venereal disease situation was later described as characterized by an enormously high rate, semiofficial toleration of brothels, and numerous outlawed brothels.
Not only was the venereal disease rate very high among the civilian population, but most of the cases were untreated. Statistics were incomplete, but available records at that time indicated that at least 12 percent of the population was infected. In the lower social strata, the percentage of people infected was believed to be much higher than that for the nation as a whole. A control program, consequently, would have to take into account the differences in native customs and mores.65
Administration and organization.-When USAFIME was originally organized on 16 June 1942, its headquarters was located at Cairo, Egypt. The theater was composed of the Eritrea, Delta, Levant, and Persian Gulf Service Commands and the U.S. Ninth Air Force. Later, the Delta Service Command was subdivided into the Delta and Libyan Service Commands, and, still later, in September 1943, the U.S. Army Forces in Central Africa were redesignated the West African Service Command of USAFIME. At the same time, the U.S. Army Forces in Liberia was incorporated into USAFIME without change of name. The Persian Gulf Service Command (Iran) was made a separate command in December of 1943, became known as the Persian Gulf Command, and existed as a separate command until July 1945 when it was again made a part of USAFIME. USAFIME, at that time, was redesignated AMET (the Africa-Middle East Theater). The control program in Iran is presented under the Persian Gulf Command.
Maj. (later Col.) Thomas G. Ward, MC, was appointed theater medical inspector by Colonel Sams, Surgeon of USAFIME. Major Ward also assumed at that time the duties of director of preventive medicine and thus became the first venereal disease control officer. In November 1942, Capt. (later Lt. Col.) Herbert S. Traenkle, MC, reported as full-time venereal disease control officer for the theater.
The various subdivisions of USAFIME had venereal disease control officers in either full- or part-time capacities. In Liberia, Lt. Col. (later Col.) Justin M. Andrews, SnC, Assistant Chief of the Preventive Medicine Branch, acted as the venereal disease control officer until Captain Faison was sent by the War Department to take over control duties in a full-time position. Sub‑
64Letter, Maj. Crawford F. Sams, MC, Surgeon, USMNA Mission, to The Surgeon General, U.S. Army (through : Chief, USMNA Mission), War Department, Washington, D.C., 2 Jan. 1942, subject : Sanitary Survey Heliopolis, Egypt.
65Letter, Maj. William A. Brumfield, Jr., MC, to Assistant Chief of Staff, G-1, War Department, Washington, D.C. (through : The Surgeon General, U.S. Army), 2 Mar. 1943, subject : Report of Investigation of Venereal Diseases Among United States Army Forces in Central Africa, the Middle East, and India.
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sequent venereal disease control officers in this area were Capt. Alfred C. Thomas, MC, and Capt. James H. Nickens, MC.
The officer in charge of venereal disease control in the Levant Service Command was Capt. (later Maj.) Thomas C. Brandon, MC, who was also the medical inspector. The organization in the Eritrea Service Command included Maj. Irving Rathgel, MC, medical inspector, and in the Libyan Service Command venereal disease control was carried on by Maj. (later Lt. Col.) Dan Crozier, MC, medical inspector.
Egypt (Delta Service Command).-In Egypt, which had been occupied by British Army Forces, a military venereal disease problem existed before the arrival of U.S. troops. The incidence rate of the venereal diseases in the British Army varied between 3.5 and 4.5 per thousand per month. Practically all this disease was acquired in Cairo or Alexandria, which men visited on leave if they were not stationed in the vicinity of these cities. The venereal diseases were classified as 30 percent gonorrhea, 30 percent soft chancroid, 10 percent syphilis, and 30 percent miscellaneous venereal diseases.66
The Surgeon, Delta Service Command, after surveying the area commented in his annual report for 1942 as follows:
Venereal diseases have not been unduly alarming considering the surrounding influences. Prostitution is very common among the native population and [is] not infrequently considered an honorable profession. Treatment and control measures of venereal diseases among the lower classes are practically non-existent. Reliable statistics on the incidence are not available but it is definitely known that the population is heavily infected. This [Egypt] being a foreign and independent country the U.S. Army exercises no governmental power. It is therefore purely the responsibility of the Egyptian Government to institute and enforce such regulations as are attempted in the civilian population. During the first half of 1942, Government approved and regulated houses of prostitution were permitted. The houses were so carelessly supervised and medical examination so inadequate that none could be classed as "controlled houses." The government then saw fit to eliminate, by law, houses of prostitution. This did not improve the situation or necessarily make it worse. At times there is a half-hearted attempt by the police to enforce such laws as do exist. This was probably more for "effect" rather than a sincere effort to improve conditions. Consequently, there exists an unusually large number of "streetwalkers," "taxicab prostitutes," "undercover houses," "pimps," and other forms of [prostitution] not commonly known in the United States.
The problem in Egypt was fundamentally that of a never-decreasing supply or source of venereal contact. Prostitution was either condoned, accepted, or regulated, and sexual promiscuity was more or less general. Population differences influenced the character of social intermingling between U.S. Army troops and local civilians. There were many white and Negro soldiers in this area. The Anglo-Egyptian Sudan, which normally had had a large population of Negroid peoples, dark-complexioned Arabs, and few white persons, now harbored a considerable number of Rumanian refugees. Egypt proper had an influx of peoples from all over Europe, which changed its heretofore predominantly Arab population.
66See footnote 64, p. 267.
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The peoples of the Nile area now represented a higher level of culture than other peoples in the Middle East. They were more intelligent, the government was better organized, and the economic conditions were more stabilized. The white soldier was attracted by these people, and there was ample opportunity and even inducement for sexual exposures with resultant venereal disease. These facts were proved by the venereal disease rates for the months of July, August, and September 1942, which included a rate of 88 per 1,000 per annum for the Headquarters Section at Cairo and a rate of 84 per 1,000 per annum for the Delta Service Command (Egypt). For the same period, the rate for the theater as a whole was 43 per 1,000 per annum.67
Palestine (Levant Service Command).-This command was very small, and venereal disease was prevalent among troops stationed there, but the mean strength of the command was, at the most, insignificant when compared with the other commands. Palestine never presented a problem from the standpoint of venereal disease. However, because of the government's attitude toward prostitution, it was difficult for Army authorities to launch any kind of antiprostitution program. The existence of prostitution was not officially recognized in Palestine. The British succeeded in having so-called gynecological clinics established ostensibly for the treatment of all diseases of the female reproductive system. Actually, they were little more than clinics for the treatment of venereal diseases. These clinics were designed to reduce infectious venereal disease among the female population and thereby to reduce the risk of exposure to soldiers.
Eritrea and Anglo-Egyptian Sudan (Eritrea Service Command).-Venereal diseases among U.S. Army Forces stationed in this area did not constitute a serious problem.
Central Africa (West African Service Command).-This area comprises the countries and colonies extending from the west coast of Africa eastward through French Equatorial Africa and then southward to include the Belgian Congo and Kenya Colony. The command for the most part had representatives from all the forces including Services of Supply. Troops were dispersed into relatively small groups at airfields along the Air Transport Service ferry route, and stations at Accra represented the largest concentration of troops.
The population in this area was almost completely indigenous. The people were illiterate and primitive in dress, manners, and customs. Their homes were crude huts of thatched grass; their towns were dirty, lacking in sanitation, and generally uninviting.
There was no venereal disease problem among the white troops in this area, but a different situation was encountered with U.S. Negro soldiers. The native of this region was racially the same as the American Negro soldier, and friendships were begun from the time of the first arrival of U.S. troops. Sexual promiscuity was more or less universal among the natives. There was
67See footnote 65, p. 267.
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no such thing as prostitution. Extramarital sexual relationship was the social custom, and women, before. marriage, were termed "free," with no social stigma against sexual indulgences.
For the first month that Central Africa headquarters reported, September 1942, the venereal disease rate was 429.2 per 1,000 per annum. The venereal disease rate among the natives was at this time undetermined. There were no reliable data available for the civilian population of Central and West Africa. The civilian health authorities confessed that they had little interest in venereal disease, since there were so many other public health problems which to them were of greater importance. Gonorrhea and chancroid were very prevalent in the cities and less so in the rural areas.
Liberia (U.S. Army Forces in Liberia).-This area proved troublesome for the entire period during which U.S. troops were stationed here (fig. 45). The venereal disease control problem in Liberia was the headache of everyone in USAFIME. The highest rate in the theater occurred here and was never significantly lowered. Occasionally, the rate was lowered for short episodes by extensive control, but these decreases were only sporadic and the high rate prevailed throughout most of the period.
FIGURE 45.-Early preparation for the arrival of American troops in Liberia, Africa, mid-1942.
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Roberts Field, the Army base where most troops were stationed, was near Monrovia, the country's capital (fig. 46). Many native villages were in close proximity to Army camps. Chancroid and gonorrhea were rampant, and there was a high percentage of syphilis. The natives were, again, all Negroid, similar to those in Central Africa (fig. 47), and had similar ideas as to sexual promiscuity. The U.S. troops in this area were nearly all Negro engineers, and there was no want of companionship. The physical attractiveness of native women was not unlike that of women the Negro soldiers were accustomed to in the United States, and, furthermore, there were no color or social barriers to their seeking companionship and sexual gratification. Within a short time after the arrival of these troops, the venereal disease rate was over 600 per 1,000 per annum.68
The control of venereal disease here was as important as malaria. For the months of August, September, October, and November of 1942, the venereal disease rate averaged 650 per 1,000 per annum. On 1 September 1942, a plan to control venereal disease in U.S. troops and the native popula‑
FIGURE 46.-Typical street scene in a Liberian city.
68Annual Report, Surgeon, U.S. Army Forces in Liberia, USAFIME, 1943.
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FIGURE 47.-Group portrait of Liberian girls in dancing costume and makeup.
(Photograph courtesy of Dr. Justin M. Andrews.)
tion was formulated at a conference which included representatives of the Liberian Health Department, the Medical Director of the Firestone Tire and Rubber Company plantations, and U.S. Army officers. A plan was made whereby so-called tolerated women's villages were started adjacent to Army camps. A very interesting and detailed account of this procedure was written by Major Brumfield, (p. 278) who made a careful survey of the venereal disease problem in Liberia in November and December 1942. The following description is taken from his report to The Surgeon General:
* * * Out of this conference came the proposals that the Liberian Government set up villages for native women in the area contiguous to the military reservation; that women infected with venereal disease would not be permitted to live in these villages; that soldiers would be permitted to visit these villages but that passes to distant native communities would be infrequent; that effort would be made through education and recreation facilities to discourage sexual contacts between the villagers and soldiers. Although it was recognized that such a plan presented many undesirable features it was agreed upon as a distinct improvement over the then existing conditions, and as the most feasible solution in view of the natives' morals and customs.
Accordingly, two women's villages were established by the Liberian Government in an area adjacent to but not a part of the U.S. Military reservation (fig. 48). Women seeking admission to the villages were examined for venereal disease, particularly for
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FIGURE 48.-Group of girls in "Bandtown." Note homes of thatched construction in background. (Photograph courtesy of Dr. Justin M. Andrews.)
evidence of venereal ulcers or vaginal discharge. If found free of demonstrable venereal disease they were photographed and tagged and permitted to enter the village. The homes of thatched construction were sold to the women at a nominal price ($15.00 for a 3-room cottage). Community sanitary facilities were taken care of by the Liberian Government (fig. 49).
The residents of the women's villages are examined weekly. Any woman showing any evidence whatsoever of infection has her tag taken up and is treated until all signs and symptoms have disappeared. The tag is then returned and she is again permitted to enter the women's village. The tags, in addition to showing that the women have been examined and found free of obvious venereal disease, serve as means of identification. Wherever it is apparent that several soldiers may have acquired infection from the same woman, she is removed from the village irrespective of the results of physical examination.
The construction of the women's villages must not be construed as the entire program of venereal disease control of Roberts Field. It is simply an attempt to cope with a very bad situation. The intensive program of morality lectures, lectures on the medical aspects of the venereal diseases, and of recreation is being vigorously pursued.
It is useless to talk about the repression of prostitution and reduction of sexual promiscuity in Liberia. These practices are deeply ingrained * * *. It is impossible to reduce the venereal disease rates in the entire population. The next best thing is to reduce the rates among a part of the population and to limit association of soldiers to this group. The women's villages have been established for this purpose.
That this program produced some result was manifested by the decrease in the rate from 715 per 1,000 per annum in November to 470 per 1,000 per annum in December 1942. The prevailing diseases were chancroid and gonorrhea, and, in an effort to try to get a higher protection rate, Captain Faison, the venereal disease control officer, compounded a single prophylaxis
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FIGURE 49.-Group of girls in a "palaver" hut-community center for the village. (Photograph courtesy of Dr. Justin M. Andrews.)
ointment which consisted of mercurous chloride ointment and sulfathiazole powder, two parts ointment to one part powder by weight. Captain Faison instituted a program in which men going on pass were given 2 grams of sulfathiazole to be taken by mouth and a quantity of the ointment to be applied to their genitalia following contact. If a man returned from pass and had not used the ointment or taken the oral medication, he was given 4 grams of sulfathiazole.69
The control measures, as instituted by Captain Faison, were put into effect, and, in the venereal disease report for USAFIL (U.S. Army Forces in Liberia) for the 5-week period ending 29 January 1943, the rate was 470 per 1,000 per annum. Many troops still persisted in not taking any prophylaxis and the incidence rate remained high. However, of 184 men who took prophylaxis during the month, none had developed venereal disease during this period.
The station surgeon at Roberts Field in reporting the venereal disease problem in Essential Technical Medical Data summed up the situation as it appeared in November 1944:
69Letter, Lt. Col. Justin M. Andrews, SnC, Assistant Chief Health Officer to The Chief Health Officer, Roberts Field, Liberia, 5 Jan. 1943, subject: Venereal Disease Control Activities at Roberts Field, Liberia.
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It seems that everyone, but those who contract these diseases, is cooperating in an all-out effort to put the brakes on this business. However, it continues rampant to date in spite of all that the command and the Medical Department have been able to do. It is the opinion that the venereal diseases will continue to be our number one problem and that it will tend to remain high. The closeness of the native villages, inhabited by many infected women who deliver themselves and sell their wares to soldiers almost at their door step and the increased disregard for using protective measures by the men, during or following contacts, have been almost uncontrollable factors. Many of these men have been tried by Courts Martial, recently, for being caught off-limits, but it is humanly impossible to watch every man at all times. In fact, the greatest offenders are those who should enforce law and order, the MP personnel. The widely publicized quick cure of gonorrhea by use of penicillin, and the new public law, as to pay forfeiture, have added to the venereal disease control problems in this area.
Due to the lack of civilian medical facilities in this area, it has been necessary for us to take extreme measures in our effort to control venereal disease among our troops. Almost 100 per cent of our cases are contracted by men who make contacts in "off-limits" villages, who use neither mechanical nor chemical prophylaxis, and who do not report to a station for supervised prophylactic care. With the permission of Liberian authorities, all native women within ten villages nearest the military area, where men are known to make sex contacts, are being examined by our VD control officer, and are to be treated for whatever venereal disease they may have. Treatment for syphilis will be given at a central village dispensary. Sulfathiazole is to be given, under supervision, to all men and women in these villages who have gonorrhea. These measures, though unusual and extreme, are highly advisable for this particular situation. Whatever the reasons are, in the minds of so many enlisted men who fail to utilize protective measures and who persist in making contacts with known, infected women, we can only deduct that they are flimsy ones. Frank carelessness, laziness and disregard of health and regulations are strikingly in evidence in too many instances.
Summary.-By the end of 1944 the original purpose of the USAFIME had been fulfilled. Many activities were terminated and others curtailed. The prime mission of the command at this date was to maintain Air Transport Command routes. However, the Surgeon, USAFIME, deplored the fact that the theater rate had reached a peak of 83 per 1,000 average strength per annum for the 4-week period ending on 24 November 1944. The rate for the same period for our forces in Liberia was 700.18 per 1,000 per annum. The average strength for the command was 19,885 and that for Liberia, 595.
With the beginning of 1945, no new control programs were attempted. The rate for the theater was still high with no noticeable changes. For the 4-week period ending on 23 February 1945, the average strength of the command was 20,659, of which 824 were Negro. The venereal disease rate for white troops was 56; for Negro troops, 631; and for the aggregate, 79 per 1,000 per annum. The strength of Negro troops for the command was about 4 percent, but this group raised the total venereal disease rate approximately 40 percent or 23 per 1,000 per annum. The command at this time had headquarters at Cairo with the bulk of the troops assigned to Air Transport Command posts scattered over wide isolated areas.
During the 4-week period ending on 25 May 1945, when the average strength of the command was 29,809 troops, the venereal disease rate for the
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aggregate was 62. The rate for the white troops was 55 and that for the Negro troops, 278. In discussing prevailing rates, in Essential Technical Medical Data for June 1945, the theater surgeon made the following remarks:
The incidence of venereal diseases increased from the rate of seventy-nine (79) per thousand per annum in January to ninety-one (91) per thousand per annum in April, then fell to sixty-two (62) per thousand per annum in May. Based on information from incomplete reports the rate for June will be approximately eighty-four (84) per thousand per annum. The incidence of these diseases was highest among the colored troops in Liberia. Fifty-eight (58) new cases, thirty-five (35) gonorrhea, ten (10) syphilis and thirteen (13) others, occurred among this personnel during the period, giving a rate of 1,024 per thousand per annum. These troops, comprising approximately 2 percent of the total strength of the command, contributed approximately 35 percent of this total number of venereal disease cases occurring in the theater. Educational, punitive and many other measures have failed to control effectively the venereal diseases among this group.
PERSIAN GULF COMMAND
The mission of the Persian Gulf Command was to convey supplies from the Gulf ports of Iran across the country (including a portion of Iraq) to the Caspian Sea and the Soviet border and the maintenance of highways and railroads necessary to carry out this mission.
Originally, the command consisted of a few troops scattered in small units along a thousand miles of crude highways and railroad. Rough terrain and extremes of heat and cold made communication and organization difficult. Supplies of all kinds, including medical equipment, were late in arriving.
Northern Iran and Iraq had a conglomerate population. In addition to the native white and Arab population, this area also had an influx of refugees from the German-occupied countries in Europe, and therefore this northern area possessed a large white population. Southern Iran, on the other hand, had a very small white population.
Of the towns in the north, Teheran, the capital of Iran, was the most important. Here were located the headquarters of the Persian Gulf Service Command, and also the headquarters of the U.S. Army Engineers. In the southern area, the most important towns were Ahwaz, Iran, and Basra, Iraq. These towns were more or less native, the former having a small European section.
Venereal diseases (syphilis and gonorrhea) were rife among Persians of all ages, and it was estimated that 80 percent of the population was infected. Infection was spread from urban areas to rural communities by charvadars (muleteers), native soldiers, and the nomadic habits of many of the people. Therefore, troops sent to this area were confronted with a civilian population that had a high venereal disease infection rate.
As might have been expected, the venereal disease rate among U.S. troops in this area was high-among the highest of any of the theaters where U.S. troops were stationed. Control of the excessive rate presented a difficult
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problem. The high rates encountered were simply a part of a general disease picture which reflected conditions prevailing in this region.
Civilian collaboration.-Although Great Britain established a protectorate over Iran in 1940, the country, nevertheless, was an independent kingdom, and the regulation of internal affairs was left entirely to the Iranian Government.
The health service, though organized, was inadequate. Trained personnel were at a minimum, and what public health was being done was more or less government aid by hospitalization of the indigent sick. Very little had been done in the way of general or local sanitation, a problem which the Iranians felt was more important than the control of venereal disease. Therefore, in many ways, the local civil authorities were of little assistance to the Army in its venereal disease control program. Little or no cooperation was obtained from the federal or local Iranian police, whose income depended partly on what they could obtain as fines from those persons they apprehended.
Prostitution.-Prostitution in Iran was widespread and universal. It was an accepted social custom and there was no stigma attached to it. There were no segregated areas in the larger towns and cities, and the prostitutes were not registered by the police. When they were arrested, it was not because of prostitution but because of vagrancy.
Teheran, the Iranian capital, presented a serious venereal disease problem. Typical of a large city in the Middle East without an adequate venereal disease program, Teheran was teeming with prostitutes. The U.S. soldier stationed in a land that afforded little entertainment and possessing unlimited amounts of money fell easy prey to the prostitutes, many of whom were of European descent or were refugees from the occupied countries. Any real repression of prostitution in cities like Teheran, or over the entire country of Iran, would have required a change in public opinion which at that time was impossible.
Ahwaz, the city next in importance after Teheran, was more of a native city, as few Europeans lived in this area. It was impossible to describe the filth and poverty of this city. The streets for the most part were unpaved and had sewage running in the middle of them. The sewers drained into open ditches at the sides of the larger avenues. The prostitution districts of Ahwaz were most disreputable.
Control of prostitution in Iran was difficult even with the stepped-up venereal disease control activities of the Iranian Government. There was no national law against prostitution. Native travel was unrestricted. Therefore, a check on girls was all but impossible, and as fast as girls were apprehended by the civil police others appeared. The demand was great, and the source was greater.
Organization.-Cognizance of the prevalence of venereal disease in the Persian Gulf Command was taken by those in authority as early as 1942.
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At the beginning, the Persian Gulf Service Command was a part of the theater known as the U.S. Army Forces in the Middle East. The theater headquarters was at Cairo, Egypt, and a plan was set up for the control of venereal disease in Iran subsequent to a survey made by Major Brumfield, who visited the area in November and December 1942.
A full-time venereal disease control officer, Captain Traenkle, was assigned to the Office of the Surgeon, USAFIME. Captain Traenkle from the beginning realized that the Persian Gulf Command presented many problems in preventive medicine and that any venereal disease control program would be a part of the whole program to protect, insure, and maintain the health of U.S. Army troops in this area.70
On this premise, a full-time venereal disease control officer for the Persian area, Capt. (later Maj.) Louis W. Abbamonte, MC, was assigned to the command surgeon's office with headquarters at Teheran. A similar full-time venereal disease control officer, Capt. (later Maj.) Nils B. Hersloff, MC, was appointed to the Desert (Ahwaz) District. Part-time venereal disease control officers for the other two districts, Mountain and Gulf, were appointed from the district surgeon's office. In the Persian Gulf Command, all commanding officers of units or posts within the command were responsible for a venereal disease control organization of their own to combat local problems.
Incidence and control measures.-The high rate in the Persian Gulf Command, as compared to the theater as a whole, was explained by the large majority of Negro troops, the relatively small number of white females available for contact with white troops, the lack of adequate prophylactic stations in the isolated camp areas, and boredom resulting from lack of recreational facilities.
By spring of 1943, the most difficult problems of control, unhampered prostitution and lack of proper prophylactic facilities for men who were in transit convoying supplies, were widespread. Communication and organization of command were difficult. Supplies of all kinds, including medical supplies, were still inadequate. Housing conditions, at best, were still poor in a land characterized by extremes of heat and cold. Finally, from the beginning of 1943, approximately four or five thousand new troops had arrived in the area each month, the majority of whom were Negroes.71
Recommendations for correcting such conditions as soon as possible were made by Captain Traenkle who surveyed the area in May 1943. He recommended that towns where no control was possible be placed off limits, that military police be increased in order to patrol towns and adjacent vicinities for the apprehension of wandering prostitutes, and finally that more instruction be provided troops in the need for correct and adequate prophylaxis as
70Letter, Capt. Herbert L. Traenkle, Venereal Disease Control Officer, to The Chief Surgeon, USAFIME, 29 May 1943, subject: Venereal Disease Control in the Persian Gulf Area.
71(1) Letter, Capt. Louis W. Abbamonte, MC, Venereal Disease Control Officer, to Commanding General, Headquarters, Persian Gulf Service Command, 19 July 1943, subject: Venereal Disease and Controlled Prostitution. (2) See footnote 70.
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soon as possible after contact. A command bulletin from Teheran in October 1943 further outlined a comprehensive program of education and preventive measures for the control of venereal disease (fig. 50).72
FIGURE 50.-Sign warning soldiers of venereal disease at Camp Amirabad, Iran, November 1943.
72Bulletin No. 9, Headquarters, Persian Gulf Service Command, USAFIME, 19 Oct. 1943, Section I (supp.): Prevention and Control of Venereal Disease.
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At the end of 1943, the rate was still exceedingly high, and the seriousness of this continued high incidence was brought to the attention of unit commanders throughout the command. In addition, certain deficiencies in prophylaxis methods were corrected. Attendants of prophylactic stations were inadequately trained to render this treatment, and facilities in many of these stations were either inadequate or being used with a faulty technique (fig. 51).
FIGURE 51.-Interior facilities of a prophylactic station at Andīmeshk, Iran.
The first 6 months of 1944 saw an excellent reduction in venereal disease rates. By July 1944, the venereal disease rate had decreased until it reached its all time low of 43 per 1,000 per annum. An analysis as to the causes of this satisfactory decrease revealed that at this time all units were performing at peak efficiency. The tonnage to the U.S.S.R. reached its maximum. Such a program required the best effort on the part of each soldier and officer. Any time remaining after a day or night of hard work could easily be spent in pleasure derived from participation in many activities planned by various services and agencies.73
73Annual Report, Surgeon, Persian Gulf Service Command, USAFIME, 1944.
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This was the picture until July 1944. From then on, the overall effort slackened, and a rise in the venereal disease rate occurred. Partly responsible for this rise was the fact that certain motor transport and engineer units, made up entirely of Negro troops, had been alerted for transfer to other theaters and were staged for a prolonged period of time during which the venereal disease rate for these units markedly increased. This increased overall rate also coincided with the discontinuance of loss of pay for contracting venereal disease and with the introduction of penicillin in the treatment of gonorrhea and syphilis. Many observers in the area believed, after talking to medical officers and patients, that the average soldier's outlook on venereal disease had undergone a drastic change. "Why shouldn't we take chances?" the soldiers said, "We don't lose our pay and one can be cured of gonorrhea in one day and syphilis in one week."
The rise in the venereal disease rate only intensified the desire by those in authority to combat the menace, and, in November 1944, Headquarters, Desert District, took the drastic measure of presenting a demonstration of the ravages of venereal disease using infected native prostitutes from Andīmeshk as exhibits. These prostitutes voluntarily admitted themselves, by affidavit, to the 19th Field Hospital for treatment, observation, and exhibition. Subordinate commands were notified of the exact dates and places where the demonstration would be held for their officers and men. The complete program was in the form of a lecture-demonstration. The post commander opened each period with a talk on military aspects of venereal disease, passing on the desires of the district commander in this respect. The chaplain followed with a short talk on moral and religious aspects of bodies free from venereal disease. Then medical officers gave short but thorough talks on various venereal diseases, stressing the correct and exact use of prophylaxis. The medical officers then exhibited the native prostitutes to the personnel of the command with explanations relative to each prostitute's disease, prognosis, and health hazard to the community. Each session ended with a question-and-answer period. The immediate reaction of the men to these demonstrations was that of shock and revulsion.
The commanding general of the Persian Gulf Command was so impressed with the lecture-demonstrations as given in the Desert District that, on 14 December 1944, he directed that similar demonstrations be given in the other districts. He made the allowance, however, that when infected prostitutes could not be obtained for the purpose, the demonstration of similar lesions in the male could be substituted.
Accordingly, similar demonstrations were carried out extensively throughout the ports, the Gulf District, and the Mountain District with the use of infected males. In all cases, followup posters were designed and distributed which stressed continence and the need for early and complete prophylaxis if continence was not practiced. The effectiveness of this program was never really evaluated. For the month of January 1945, there was a slight increase
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in the venereal disease rate which was believed to have been due to voluntary reporting of venereal disease by individuals who had witnessed the demonstrations and had become properly alarmed. The medical officer at Hamadan, Camp Park, reported that within 24 hours after the demonstration three soldiers voluntarily submitted themselves for treatment of unreported genital lesions. On 27 January 1945, in his report of the whole program to the Commanding General, Persian Gulf Command, the commanding officer of the ports and Gulf District commented as follows:
* * * it should be one of the finest educational demonstrations of its kind that the majority of troops have ever had the opportunity to attend. Those to whom we have given a lasting impression to remember throughout their life-time will be better, wiser and happier men for having seen these cases. It was an opportunity for them to both hear and see the truths about venereal disease at one time, an opportunity rarely offered the average citizen-soldier.
With the March 1945 rate of 55 per 1,000 per annum, the rate showed a slight decrease until the last report of August which was 48 per 1,000 per annum. However, it was the opinion of the theater surgeon that efforts to lower the rate further were nullified by the termination of the war with Japan which caused a letdown among the troops. Control among men stationed as security details in isolated abandoned camps became increasingly difficult because of the attendant monotony and boredom of this type of duty.74
Summary.-The overall picture of the venereal disease control program in the Persian Gulf Command was one of moderate success. Characterized at the onset by an excessive rate of 116 per 1,000 per annum, it gradually declined until by the summer of 1945 the rate had reached a more or less steady plateau of about 55 per 1,000 per annum. This command had a large proportion of Negro supply troops who contributed over 80 percent of the venereal disease incidence rate. The Negro rate was also gradually lowered from a high of 482 in March 1943 until the summer of 1944 when it had leveled off to around 150. In the winter of 1944-45 and the spring of 1945, Negro rates again became excessive (361) until they reached the level of the rates for the spring of 1942.
THE PACIFIC AND THE ASIATIC MAINLAND75
Hawaii76
The venereal disease rate for the Hawaiian Department in 1941 was 14.1. During 1942, it declined to 9.6. During the first 5 months of 1942, control
74Essential Technical Medical Data, Persian Gulf Service Command, for August 1945.
75The history of venereal disease control activities in the Pacific and on the Asiatic mainland, except in the Philippines, is based primarily on material which has been summarized from reports written by officers in charge of venereal disease control activities in the areas concerned. When the authors were known, they have been given full credit. However, some of these reports were included in overall theater histories, and individual authors were unidentifiable. In such instances, the theater history has been credited.
76History of Preventive Medicine, U.S. Army Forces Middle Pacific, Office of the Surgeon, December 1941-September 1945. [Official record.]
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measures followed established policies, and included education, operation of a number of prophylactic stations, monthly physical inspection, and reporting of information concerning probable sources of infection to military police. Early in 1942, a very competent venereal disease control officer was appointed by the department surgeon. This officer, in cooperation with the Director, Venereal Disease Control Division, Territorial Board of Health, made a very thorough study of factors affecting the incidence of venereal disease in the command.
Many aspects of the situation in Hawaii were unique. A system of organized prostitution existed in the Territory. Houses of prostitution had attending physicians who examined the operators at regular intervals. Some of these house physicians were physicians of high professional ability, and the practice was lucrative. There was a great excess of males over females in the community (fig. 52). Large numbers of troops and single male laborers were being added to the wartime population. There was a curfew, a blackout, and moderate prohibition, and the entire civilian population had been registered and fingerprinted. Travel between the Hawaiian Islands and the U.S. mainland was under absolute control. There were strong forces in
FIGURE 52.-Fort and King Streets, Honolulu, Hawaii, February 1945. Note preponderance of males, mostly servicemen.
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the civilian community favoring the presence of organized prostitution. These forces included both a large group who obtained handsome financial support from a reportedly 10-million-dollar business and others who felt that the prostitution system had contributed to the low venereal disease incidence in the islands and was a protection to respectable women and girls of the community.
Considerable thought was given to the possibility of closing houses of prostitution. Venereal disease rates did not indicate that prostitution affected adversely the health of troops in the Hawaiian Department. To the contrary, venereal disease rates in the Hawaiian Department were approximately one-fourth those for the Army on the U.S. mainland. There was some concern as to what effect the closing of houses of prostitution might have upon the large community of single males under stress of hard work, wartime conditions, blackout, and curfew. There was apprehension that an increase in sex crimes might result from such action. Although a mere order by the military governor could have abolished organized prostitution in the Territory, no such action was taken.
The course taken by the Army toward the control of venereal disease in 1942 took the form of a vigorous program of prophylaxis, case finding, and thorough treatment. On 21 May 1942, the office of the military governor issued General Order No. 107, Section I of which outlined the control of communicable disease in the Territory of Hawaii and applied particularly to the control of venereal diseases. Physicians, both military and civilian, were required by General Order No. 107 to report by special messenger to the Territorial Board of Health all contacts within 24 hours after diagnosis of a case of venereal disease.
The Territorial Board of Health energetically followed up all contact reports, and large numbers of infected women and men were quickly placed under treatment.
An intensive drive was carried out by both military and civilian police to pick up and examine all streetwalkers in order to determine whether or not they were diseased. Hospitalization was provided under military control for all recalcitrant persons who did not take adequate treatment, for prostitutes who were found to be infected and who had not been reported by their private physicians, for prostitutes found to be infected after having been pronounced cured by their private physicians, and for streetwalkers. In December 1942, arrangements were completed for the hospitalization of all prostitutes found infected. Four well-equipped prophylactic stations were operated in Honolulu, and one in Wahiawa. As many as 50,000 prophylactic treatments a month were given in these Army stations.
This system of organized prostitution continued until the latter part of 1944. During this time, considerable controversy took place in the islands and in the United States concerning the organized prostitution existing in Honolulu. Those in favor of organized prostitution pointed to the low
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venereal disease rates among military personnel in the islands and contended that, should organized prostitution be abolished, there would be an immediate rise in sex crimes and other criminal activities. Others opposed prostitution, not only on the obvious moral grounds, but also on the basis that experience elsewhere proved sex crimes and venereal disease were both reduced when organized prostitution was abolished. Hawaiian prostitution was almost a cause célèbre in the Army and among church and civilian health agencies.
In September 1944, after many conferences with local authorities, the houses of prostitution in Honolulu were closed. Similar houses in other places in Hawaii had been closed previously. After this action, there was no increase in sex crimes or other criminal practices and there was an additional decrease in the already low venereal disease rate among Army personnel. Concomitantly, there was a striking decrease in the number of prophylactics given in Honolulu.
From this experience, it may be concluded that the proponents of organized prostitution were mistaken as to its benefits.
Additional venereal disease measures employed in the Territory of Hawaii included the practice of inspecting all incoming personnel and requiring that a Wasserman examination be given each individual who, on physical inspection, was thought to have syphilis. By this technique, cases of gonorrhea and syphilis were picked up and treated in hospitals and the civilian population on the Hawaiian Islands was protected.
Australia and the Southwest Pacific
The control of venereal disease among troops based in Australia was a problem very closely related to the reservoir of venereal disease infection among the white civilian population. Fortunately, the venereal disease rates among civilians in Australia were low77 at the time U.S. troops were first stationed there in 1942. This could have been attributed at least partially to the fact that general standards of morals and living conditions in Australia were among the highest of any of the nations of the world. The population consisted mainly of white people. There were none of the squalid or poverty-stricken slums found in many other countries. There had never occurred the severe famines of venereal disease. Before the war, Australia was a slowly industrializing nation of above average health. Venereal disease was not a health problem before 1942. There was licensed prostitution in most of the cities or communities of average size; this, however, did not become a problem until after the beginning of war in 1939. With the mobilization of Australia's army and the arrival of thousands of U.S. troops in 1942, a venereal disease control program finally became necessary. Throughout the war, Australia was used as a rest area for troops stationed on island groups nearby or in New Guinea (fig. 53). Hence, venereal disease rates
77Report, Lt. Col. Ivy A. Pelzman, MC, Venereal Disease Control Officer, Southwest Pacific Area (undated), subject: Venereal Disease in Australia.
from these areas reflected the rates in Australia and the efficiency of control measures in the centers of population.
Incidence in the civilian population.-A large number of cases of venereal disease appeared during and after World War I. It was difficult to determine in a satisfactory way just what the trend of incidence of venereal disease had been since 1920, but available statistics indicated that from 1920 to 1938 there had been a very definite decline in the incidence of syphilis, which, in its primary stage, had become a rarity. Gonorrhea showed some, but no marked, decline. With the arrival of Allied troops in 1942-43, there was a consistent increase in both syphilis and gonorrhea in those ports and areas where Allied troops were stationed. Civilian records showed this increase as most marked in females, since by this time the services had absorbed a large quota of the younger Australian males. As had been the experience in other countries, there was an increase in infection of a relatively high proportion of girls in the teens and early adult life, and there was the usual experience of difficulty in controlling the promiscuous young girl.
FIGURE 53.-Many U.S. soldiers and sailors enjoyed the hospitality and companionship of Australian women as pictured in these "Midway Night" activities at an American Red Cross club in Brisbane, Australia, March 1945.
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As was true in most other countries, the majority of patients with venereal disease in Australia gave as their source of infection the so-called enthusiastic amateur, not the professional prostitute. Although there were known brothels in all of the larger cities and towns, they were under a fairly adequate system of inspection until after 1939 when the mobilization of troops throughout Australia gave sudden impetus to commercialized and clandestine prostitution with a resultant rise in venereal disease rates.
Control in the civilian population.-The control of venereal disease among the civilian population depended almost entirely upon the activities of the chief health officer of each of the six states. This power was vested in the chief health officers by the National Security Regulations of the Commonwealth Government, which became effective on 1 September 1942. These regulations empowered chief health officers to take uniform steps for the compulsory medical examination of persons suspected of having a venereal disease and for their detention for treatment upon proof of infection. Unfortunately, in all except one of the states, the health department did not take full advantage of the powers given them under the National Security Act. The authorities appeared to fear enforcing legislation which might interfere with the liberty of the people. There was a general reluctance to institute practices which would bring venereal disease out into the open.
In addition to the general reasons given above, the shortcoming of civil venereal disease control activities could be attributed, in part, to the following specific reasons: Critical shortage of clinic facilities, particularly those for inpatient treatment; too long a delay in apprehension and examination of venereal contacts due to staff shortages; inadequate criteria and methods for diagnosis and tests of cure; practically no checkup and followup of delinquency in treatment; no effort to rehabilitate promiscuous girls; and insufficient epidemiological and contact-tracing work. However, these matters received far greater consideration after these assessments were made early in 1942, and many steps were taken to improve the situation.
Incidence in U.S. military forces.-The arrival of U.S. troops in Australia in the early months of 1942 soon gave rise to the necessity for venereal disease control measures. One of the earliest monthly venereal disease reports from Australia contained a rate of 63 per 1,000 per annum for an engineer unit stationed near Melbourne. The venereal disease rate for the 41st Infantry Division for the month of April 1942 was 13.3 per 1,000 per annum. By the month of May 1942 it had risen to 29.9 per 1,000 per annum, and by the end of June it had dropped to 22.0 per 1,000 per annum.78 The venereal disease rate for the 32d Infantry Division during June 1942 was 9.03 per 1,000 per annum. By October 1942 the rate for this division had jumped to 31.379 The peak venereal disease rate for all troops in Australia in 1942
78Semiannual Report, Surgeon, 41st Infantry Division, SWPA, for 1 Jan.-30 June 1942.
79Sanitary Reports, Surgeon, 32d Infantry Division, Southwest Pacific Area, for June and October, 1942.
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(60 per 1,000 per annum) was reached during August. There was a general decline in the rate during 1942 which could be attributed not only to improvement of venereal disease control measures but likewise to the increased offensive action in the north. The latter resulted in the transfer of a large portion of the personnel out of the areas near the larger cities to locations where men were on the alert and there were fewer contacts. The problem of venereal disease control in the Southwest Pacific was rendered quite difficult due to the distribution of troops over a large area, in many instances in small units. Altogether there were 1,228 cases of venereal disease reported for the year 1942, with an average overall rate of about 35 per 1,000 per annum. However, the incidence of gonorrhea as reported did not fully reveal the entire picture, since there were many cases of so-called nonspecific urethritis, etiology undetermined.
During 1943, the incidence of venereal disease began to taper off gradually, with the exception of venereal disease rates among Negro troops. Although Negro troops stationed in SWPA (Southwest Pacific Area) made up about 6 percent of the total troops in that area, they were contributing 25 percent of the venereal cases. A certain Negro Quartermaster Truck Regiment80 recorded the following rates:
Month:
Rate1
December 1942
88
January 1943
119
February 1943
243
March 1943
290
1Number of cases per annum per 1,000 strength.
Evidence from early 1943 through 1945 showed the preponderance of venereal cases among Negro troops. The venereal disease rate for Negro troops in 1943 ranged from a high of 102.07 per 1,000 per annum to a low of 34.6, with an average rate of 56.7 for the entire year of 1943. Due to the Australian white race policy, there were very few of the yellow or colored races on the Australian mainland, and, in practically all instances, the contacts of the Negro troops were white Australian women of the lower social strata.
Venereal disease incidence for 1944 and 1945 continued to decrease for the entire Southwest Pacific Area. During the summer of 1944, there was an increase in the strength of the command in the advanced area with a resultant decrease on the mainland. As there was little opportunity for sexual exposure in the advanced area, there resulted a corresponding monthly decrease in the venereal disease rate. The decrease in the strength of the command on the mainland was counteracted, however, by the large number of individuals coming to the mainland on furlough, and it was these men who continued to present the real venereal disease problem. The men on furlough each month made up only 2 percent of the strength of the command, but they contributed approximately 50 percent of the number of venereal cases
80Sanitary Report, Surgeon, 48th Quartermaster Truck Regiment, SWPA, for March 1943, enclosure 1 thereto.
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each month.81 Some furlough areas showed an extremely high incidence. The rates in the Sydney and Brisbane areas continued to be high. In both areas, the incidence in Negro troops was excessive. In Brisbane, the rate among Negro troops in November 1944 was 1,151 per 1,000 per annum.82 By early 1945, the venereal disease rate for the entire Southwest Pacific Area had leveled off at approximately 7 per 1,000 per annum. The rates for January and February were 5.5 and 8.5, respectively.
Control in U.S. military forces.-The earliest efforts for the control of venereal disease by the U.S. Army in the Southwest Pacific Area consisted primarily of the methods suggested by unit venereal disease control officers and use of facilities provided by Australian military and civilian authorities. These venereal disease control measures were similar to those employed in the United States.
A cooperative relationship was established and maintained between military and civilian authorities throughout Australia for the purpose of suppressing prostitution and apprehending venereal disease contacts. The Surgeon, Base Section No. 2, reported in April 1943:
Since the houses of prostitution in Townsville and Cairns have been placed "off limits" to U.S. troops, there has been a notable decline in the incidence of syphilis. Apprehension and detention of infected women has improved slightly. At present there are seventeen * * * women under treatment for venereal disease in the Townsville General Hospital; most of them being there as a result of activities of the local Police in conjunction with the Venereal Disease Control Officer.
An investigator of the Provost Marshal's Office was assigned to the venereal disease control officer in each base section to assist in obtaining contact information. By means of close liaison with civilian vice squads and local health authorities, this investigator aided materially in the apprehension of venereal disease contacts. There was a continued improvement in contact information, and in early 1944 an average of 60 percent of contacts reported were apprehended and placed under treatment. In several communities where houses of prostitution existed, the areas were declared off limits to U.S. Army personnel. Certain cafes and hotel lounges, given as locations of many contacts, were likewise declared off limits.
The educational facilities available, such as posters, pamphlets, informative matchbook covers, movies, and sex hygiene lectures, were used continuously in an effort to reduce the number of venereal disease cases. The following is from the report on one regimental surgeon concerning his education program:
Posters * * * depicting the importance of prophylaxis have been prepared by this detachment from materials purchased from the Regimental Fund. Each company, as well as Regt Hq Det, has received a poster and these are now displayed in company orderly rooms, or latrines-locations where the most men will see them the most times. Since several different posters were made, it is planned to rotate them from time to time * * *. A dramatization of the evils of sexual intercourse * * * has been written
81Essential Technical Medical Data, USASOS, SWPA, for September 1944.
82Essential Technical Medical Data, U.S. Army Forces, Far East, SWPA, for December 1944.
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and is now being played to different companies * * *. All roles are played by enlisted men of the medical detachment.83
During 1943 and 1944, leave and furlough ships traveling between the advanced zone and Australia had, as part of their permanent personnel, transport surgeons who gave talks on venereal disease, supervised the showing of venereal disease films, and directed the exhibit of posters. Mechanical and chemical prophylactic units were distributed to all leave personnel aboard the ships and they were provided with various venereal disease pamphlets and folders listing the addresses of all prophylactic stations on the mainland. On the return trip to the advanced zone, venereal disease inspections were made and all the ships were provided with facilities for diagnosis and treatment.
Conclusion.-From the first stationing of U.S. troops in the Southwest Pacific Area in 1942, the constant efforts of unit medical officers and, later, the full-time efforts of venereal disease control officers tended to reduce the danger of venereal disease among these troops. The full cooperation of Australian health and police authorities with U.S. Army military police and medical authorities aided greatly in control efforts. Prophylactic facilities and equipment were made easily available near all areas that might be reservoirs of infections. All available educational measures were used. The result was the lowering of venereal disease rates for U.S. troops in this area from a peak (reached only once) of 60 per 1,000 per annum to about 7 per 1,000 per annum over a period of approximately 3 years.84 The operations to follow, unfortunately, were destined to upset again these rather tranquil rates.
The Philippine Islands
Soon after the invasion of the Philippine Islands, venereal disease became the most important medical problem. The incidence rose sharply from the January-February rates to 123 per 1,000 in May of 1945. Among Negro troops it reached 637 per 1,000 per annum. The Japanese had segregated and attempted to examine prostitutes, but, as the Japanese were driven out, these women scattered over the entire islands. The laws of the Philippine Commonwealth declared prostitution illegal, but it was condoned by the police and the courts. In such a setting, prostitution was rampant, contact-tracing poorly carried out, and the treatment of apprehended prostitutes haphazard. The incidence of venereal disease in the Southwest Pacific Area continued to increase as greater areas of Luzon were secured. In the Manila area, various estimates showed approximately eight thousand prostitutes. In
83Sanitary Report, Surgeon, 48th Quartermaster Truck Regiment, SWPA, for February 1943, enclosure thereto.
84The peak mean rate for any one month during this 3-year period, as compiled from Statistical Health Report summaries, was 45.8 per thousand per annum in May 1942, and the lowest rate of 4.2 occurred in November 1944.-J. B. C., Jr.
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addition, opportunities for clandestine prostitution existed in every field, in any wrecked vehicle, behind any stone wall, and even in frontline gun emplacements and foxholes (fig. 54).
It was soon evident that there was almost a complete lack of planning to compete with the venereal disease problem in the Philippines. There was a lack of trained personnel, short supply of educational and prophylactic materials, and insufficient education of troops as to what might be expected. Because of the extremely high rates even among fighting personnel, the deputy surgeon of the theater invited Colonel Sternberg and Dr. Moore, Consultant in Venereal Disease to The Surgeon General, to the Philippines to review the situation and to make such recommendations as seemed indicated. After a complete survey of the situation, Dr. Moore and Colonel Sternberg submitted on 6 June 1945 an analysis of the situation and their recommendations to The Adjutant General through the Commander in Chief, SWPA. This report was, for all purposes, a complete analysis of the prob‑
FIGURE 54.-A section of war-ravaged Manila which provided unlimited opportunities for clandestine prostitution.
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lem encountered in Asiatic areas as of that time. An abridgment of the report follows:85
Rates and trends.-The venereal disease rate in SWPA is rapidly increasing to a level so high as to interfere with the military efficiency of the command. The increase is limited to troops in the Philippine Islands, principally in Luzon and Leyte. In Luzon and Leyte, the increase has been progressive over the 4-month period, January through April 1945, and is apparently continuing. The April rates for troops in Luzon, including Sixth Army, Base Sections, and U.S. Army Services of Supply, are approximately 100 per 1,000 per annum; in Leyte, about the same. The overall April rate for Base X is 268 per 1,000; and in some small units of Base X and of the Sixth Army the rates have reached the alarming figures of 2,000 to 4,000 per 1,000.
If the approximate April 1945 rate of venereal disease incidence in the Philippine Islands continues without increase or significant decrease, there will be among each million men stationed in this area about 6,000 cases of syphilis, 9,000 cases of chancroid, and 85,000 cases of gonorrhea per annum.
In absence of more vigorous control measures, the high rates in Luzon and Leyte may be expected to continue or still further to increase; a similar though perhaps lesser increase is probable in Mindanao as active combat ceases. The problem will become one of even greater importance as larger numbers of troops enter the Philippine area for leave or for staging in preparation for future operations. Available information likewise indicates a problem of equal magnitude should subsequent military operations involve large American forces in China, Japan, or both.
Venereal disease control measures involve not only the U.S. Army itself but also the civilian populations with which it comes in contact. In Allied Nations (the Philippine Commonwealth and China), the cooperation of the Army in civilian control measures represents a most difficult and delicate problem in international relations, the approach to which demands the utmost in tact and diplomacy.
Contributory factors.-The comparative rates in SWPA, ranging from very low to very high, reflect in part the incidence of venereal disease in the several civil populations encountered and in part the extent to which troops engage in sexual commerce with these populations. In the Philippine Islands, the rapidly rising venereal disease rate is not limited to troops stationed in or with ready access to Greater Manila (though this area is certainly the worst spot) but involves also personnel in smaller communities and in rural areas. Contributory factors in the Philippines are as follows: (1) Previous sexual starvation of troops stationed for months or years in Pacific islands; (2) the large number of professional and clandestine prostitutes, almost certainly increased by civilian destitution, and the extraor‑
85Letter, J. E. Moore, M.D., Consultant to The Surgeon General, and Lt. Col. Thomas H. Sternberg, MC, to Adjutant General, U.S. Army, Washington, D.C. (through: Commander-in-Chief, SWPA), 6 June 1945, subject: Venereal Diseases in the U.S. Army in the Philippine Islands, and Recommendations for Their Control.
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dinarily high incidence of venereal disease among these women, 75 percent of whom have one or more venereal diseases (fig. 55); (3) unusual lack of recreational facilities, especially in the Manila area; (4) unlimited access to alcohol in the Manila area; and (5) misconceptions among military personnel as to the "safety" of prostitutes and the uniform success of prophylactic and treatment measures.
Control program for the Army.-Recommendations for strengthening the venereal disease control program in the U.S. Army in SWPA include the following:
1. Increase the number of venereal disease control officers and assign full-time control officers with adequate transportation to each major Army or Air Force command, each field army, and each smaller unit (division et cetera) whose venereal disease rate and geographical location warrant assignment of a full-time control officer. These control officers should so far as possible possess special training in the venereal diseases and in public health. To the extent that such specially trained officers are not now available in SW PA, they may be obtained on request from The Surgeon General.
2. Prosecute immediately a vigorous educational program through both medical and command channels, utilizing lectures, posters, pamphlets, radio,
FIGURE 55.-House of prostitution with signs proclaiming hours of operation and indicating the nearest U.S. Army prophylactic station.
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special demonstrations, and films; some of these materials may be obtained through requisition from The Surgeon General, War Department, Washington, and some should be locally produced. The portion of the education program directed toward troops should be written in G.I. language and so presented as to attract attention and interest. To this end, request the assistance and services of the Information and Education Section, USAFFE, for purposes of determining types of material and methods of presentation most likely to be effective under conditions existing in SWPA; further, this information should be obtained through a special study carried out under the aegis of the Information and Education Section by a research team requisitioned from the War Department for temporary duty. A general health education program should also be directed to women of the Armed Forces serving in SWPA, to include information relative to the venereal diseases and their prevention. Finally, this educational program, in addition to imparting ordinary information to troops in respect to the venereal diseases and their prevention, should stress the following: (1) Methods which line and medical officers should employ in the control of venereal disease; (2) the fact that syphilis is still a serious disease despite penicillin and that penicillin has no therapeutic effect in chancroid, lymphogranuloma venereum, and granuloma inguinale; (3) the fact that prostitution cannot be made safe through medical examination and that over 75 percent of prostitutes in this area are infected with one or more venereal diseases; (4) the increased importance of prophylaxis, particularly the proper use of the condom; and (5) the regulations regarding rotation or shipment home in respect to infectious venereal disease.
3. Lay increased emphasis, through the Commander in Chief, on the responsibility of commanding officers for venereal disease incidence, in accordance with the provisions of AR (Army Regulations) 40-210, 25 April 1945, and take disciplinary action against commanding officers whose units continue to show high rates if all available control measures have not been employed.
4. Improve the statistical organization so as to provide and disseminate more quickly to medical officers and commanders available information as to current venereal disease rates in all units of the command. To accomplish this, an officer especially trained in medical biostatistics should be assigned to the Surgeon, USAFFE.
5. Increase the number of readily accessible prophylactic stations in Manila and other large cities and towns, and requisition from the War Department, or preferably activate within the theater, prophylactic teams as authorized by Tables of Organization and Equipment 8-500, 18 January 1945 (fig. 56). This recommendation is desirable in spite of the commendable provisions so far accomplished, since the presently existing stations are overworked and will certainly be inadequate to meet the needs of additional troops arriving in this area. Improve as rapidly as possible
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FIGURE 56.-A poor and inadequate prophylactic station in Manila.
prophylactic stations in Manila with respect to size, equipment, and privacy, and request the U.S. Navy to open a suitable number of prophylactic stations in Manila to provide for its own shore-based personnel and fleet personnel on shore leave (fig. 57). Mechanical prophylactics (condom) and PRO-KITS should be made freely available to all military personnel going on pass or leave and to all Army and Navy personnel at prophylactic stations, information stations of the military police, and such other centrally located points in Manila as may be indicated. Authorize, in view of the demonstrated efficacy of a sulfonamide in a single oral dose of 2.0 gms. as prophylaxis against gonorrhea and especially chancroid, and in view of the high incidence of chancroid in this theater, oral sulfadiazine prophylaxis as an optional measure for the entire command (in addition to other prophylactic measures), and as an obligatory measure for those units with excessively high rates, especially those without medical officers or local prophylactic station facilities.
6. Continue to use the 93d Field Hospital as a special venereal disease hospital and expand its facilities at once to include a medical officer specially trained in syphilology (available through The Surgeon General's
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FIGURE 57.-U.S. Navy personnel look for entertainment in Manila.
Office on request) and a complete laboratory equipped for serologic testing of blood and spinal fluid and bacteriologic culture of the gonococcus and Hemophilus ducreyi. (This provision will materially reduce the average number of days of hospitalization.) Create a special unit of clinician, bacteriologist, and pathologist at the 93d Field Hospital to investigate improved methods of prophylaxis, diagnosis, and treatment of so-called chancroid and to study its epidemiology. Activate additional special venereal disease hospitals as the need arises.
7. Alter throughout the theater the standard treatment of gonorrhea (now 100,000 units of penicillin in 5 divided at 2- to 3-hour intervals) to either one of the following two optional alternatives: (1) A total of 200,000 units of penicillin in aqueous solution given intramuscularly, 50,000 units per injection for 4 doses at 2-hour intervals, or (2) a total of 500,000 units of penicillin given orally in aqueous solution, 100,000 units every 2 hours for 5 doses.
8. Arrange for the Special Services Office, in collaboration with the American Red Cross, to develop a coordinated and greatly expanded plan for the immediate development of increased recreational facilities in the Philippine Islands, especially in Manila and other locations which may be
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designated as leave or rest areas. These should include a central billeting office and billeting facilities for personnel of all ranks on pass or leave, including mess, bathing, and similar facilities. Further, the plan must provide for lounges; rest, writing, and indoor-game rooms; soft drink, beer, and snack bars; dances; motion pictures; beach bathing facilities; organized sightseeing; athletics; and large post exchange centers complete with bowling alleys, pool tables, restaurants, barbershops, soda fountains, clothing stores, et cetera. The plan must also give high priorities for transportation material, and labor for such construction as may be necessary to develop rest and leave camps, Red Cross installations, and all other athletic and recreation activities. Obtain a large increase in feminine Red Cross personnel and assign additional enlisted and officer personnel to special services in bases and base sections.
9. Arrange for the Chief of Chaplains to reiterate to all chaplains of units the desirability of frequently repeated emphasis by them to all ranks of the value of continence as a measure of disease prevention.
10. Institute disciplinary measures which should include the following:
Establish in Manila a curfew at 2300 for all personnel not actively engaged in the performance of duty, and, wherever possible, institute a bed check at 2330 for troops. Instruct unit commanders to give any personnel returning in an intoxicated condition compulsory prophylaxis, including oral sulfadiazine, whether or not exposure is admitted.
In troops stationed outside the Greater Manila area, permit entry into Manila to all ranks only while on duty, on special extended leave or on 24-hour passes, the latter to be granted to any individual not oftener than once a week. Whenever possible, arrange for men who are proceeding to Manila on leave or pass, whether for 24 hours or longer, to travel in groups under the charge of an officer or a noncommissioned officer.
Instruct all ranks that return to the United States, whether while on leave, while on rotation, or for separation from the Service, will not be granted to personnel with venereal disease during the infectious stage. Coupled with this information should be educational material concerning the frequent medical difficulty of determining noninfectiousness especially in syphilis.
Exclude civilians from all camp areas, except on official business.
11. Measures for the control of prostitution should include the following:
The work of the Manila Department of Health and the Provost Marshal of Manila in respect to examination and treatment of infected women should be continued and greatly expanded. In conformity with Philippine law making prostitution illegal and with War Department policy pertaining to prostitution in oversea theaters, have the Provost Marshal General, in cooperation with the Philippine authorities, carry out a program of vigorous repression of prostitution. The mere scattering of prostitutes from organized houses to individual operation as streetwalkers will reduce the number
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of potentially infectious contacts with military personnel. Despite such scattering, prostitutes may still be apprehended, examined, and treated if infected.
Request the Philippine Commonwealth Bureau of Health to establish detention and treatment camps, in the Manila area and elsewhere as may be necessary, to permit the treatment of prostitutes, professional and clandestine, found to be infected with venereal disease.
To the extent to which civilian cooperation in carrying out the two preceding recommendations cannot be obtained, employ all appropriate military measures including the off-limits policy, to minimize the availability of prostitutes to military personnel.
Measures applicable to the civilian population.-It is understood that the U.S. Army is charged with responsibility for the Manila Department of Health and the Manila Police Department on a temporary basis only, pending the independence of the Philippine Commonwealth; moreover, the assumption of these functions by the U.S. Army applies to Greater Manila only. The problem of venereal disease in the civilian population, on the control of which depends in large part the incidence of these diseases in military personnel, is however one which extends far beyond Greater Manila to the Philippine Commonwealth as a whole, and far beyond the prostitution problem to the entire infected civilian population, male and female alike.
It is believed that so long as the Philippine Commonwealth remains in the status of an insular possession, funds for venereal disease control in the civil population could be made available to the Department of Health and Welfare of the Philippine Commonwealth from the U.S. Government through the U.S. Public Health Service. These funds might be accompanied, if desired, by the loan of trained venereal disease control officers of the U.S. Public Health Service to the Philippine Department of Health and Welfare. Further, it is believed that Federal funds and personnel through the Public Health Service could probably be made available to the Philippine Commonwealth after its change to an independent status. The provision of aid of this nature should be of inestimable value to the Philippine Commonwealth in the inauguration and prosecution of a program of venereal disease control in the civil population throughout the islands, should improve the public health of the people, and should provide employment to a substantial number of Philippine medical and ancillary personnel.
It is therefore recommended that, through appropriate governmental channels, negotiations be inaugurated with the Government of the Philippine Commonwealth looking toward a request from that Government to the Government of the United States for funds and U.S. Public Health Service personnel to be expended in cooperative effort with the Philippine Department of Health and Welfare for a program of venereal disease control in the Philippine civilian population. This program should be carried out for at least the period of time that substantial numbers of U.S. troops are stationed in the Philippine Islands.
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Dr. Moore and Colonel Sternberg completed their report by recommending priority for personnel, transportation, construction, supplies, and equipment to facilitate the immediate prosecution of the program which they had outlined. In addition, they commended the following officers, who had worked indefatigably in attempting to curb the incidence of venereal disease among military personnel stationed in the Philippine Islands:
Col. J. P. Holland, Provost Marshal of Manila.
Col. Maurice Pincoffs, MC, formerly Director, Manila Department of Health.
Lt. Col. J. H. Carson, MC, Commanding Officer, 93d Field Hospital.
Maj. J. V. Ambler, MC, Venereal Disease Control Officer, Base X.
Capt. Ray Trussell, MC, Venereal Disease Control Officer, Civil Affairs Section, USAFFE.
This extensive report by Dr. Moore and Colonel Sternberg soon came into the hands of Brig. Gen. (later Maj. Gen.) Guy B. Denit, Surgeon, USAFPAC (United States Army Forces in the Pacific), who took immediate and vigorous action to implement the recommendations made therein. By the time General MacArthur's headquarters (USAFPAC) was ready to forward the report to The Adjutant General, the following actions, among others, had been taken:
1. Command action.-A letter was directed to all commanding generals of major commands emphasizing their responsibilities with respect to venereal disease control. A parallel directive, Circular Letter No. 29, was issued by the surgeon, General Denit, to subordinate medical officers outlining in detail the salient points of the report submitted by Dr. Moore and Colonel Sternberg and specifying how the recommendations could be implemented within the command.
2. Education.-A vigorous information and education program was started. A research team of information and education officers trained in venereal disease control was in transit from the United States to work on this program in collaboration with venereal disease control officers.
3. Recreation.-Special Services operations in the Manila area had increased tremendously under the great handicap of destroyed facilities. Repair of existing facilities had enabled the base to restore basketball courts, swimming pools, bowling alleys, moving picture theaters, and reading rooms. Rizal Stadium, of Olympic size, was the focal point of athletics serving as an exhibition ground for unit teams. This work was constantly being pressed to fulfill the responsibility of providing recreation for the men and for the purpose of attacking the problem of venereal disease. Billeting facilities in the form of a Manila leave area were provided for all ranks.
4. Prostitution.-Plans were being made to institute an active program of placing out of bounds all known houses of prostitution in the Manila area. This would include the apprehension and trial of prostitutes, maintainers, and other personnel engaged in prostitution. The commanding
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officer of the Military Police Command had been advised of his responsibilities. The Secretary of Justice of the Philippine Commonwealth had assured complete cooperation. Special night courts were established in proximity to the social hygiene clinics (fig. 58). Plans were also being made for extension of this program to other bases. The Manila Health Department, assisted by U.S. Army officers detailed to that section, was
FIGURE 58.-Social Hygiene Clinic and Hospital No. 3 in the city of Manila.
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carrying out an active program for the examination and treatment of hostesses and prostitutes (fig. 59). Approximately 7,000 had attended the social hygiene clinic at San Lazaro Hospital, Manila, at specified intervals. The U.S. Public Health Service was requested to provide personnel and financial assistance for the civilian venereal disease program for the Philippines by radiogram, 12 July 1945.
5. Personnel.-Four trained venereal disease control officers had arrived from the United States and were assigned to the following headquarters: Philippine Base Section, Replacement Command, Base K, and Base M. It was planned to assign similar personnel to the remaining commands and bases when they became available from the Zone of Interior. Additionally, 3 headquarters prophylactic platoons and 20 prophylactic detachments were requested from the War Department on the USAFPAC troop redeployment forecast.
The forwarding indorsement from General MacArthur's headquarters also commended Dr. Moore and Colonel Sternberg for the thoroughness of their survey of the venereal disease problem in the Philippines and for their detailed, highly constructive recommendations for its control.
FIGURE 59.-U.S. Army personnel helped in the routine checking, examination, and treatment of hostesses and prostitutes.
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As this expanded program gradually went into effect, there was considerable improvement in venereal disease rates in this area, although they never attained the low rates which were desired.
China-Burma-India Theater
The China-Burma-India Theater was established in February 1942, with the arrival of Lt. Gen. (later Gen.) Joseph Stilwell, to increase the combat efficiency of the Chinese Army. The medical section was formally established on 28 March 1942 when a Services of Supply surgeon was appointed. Before that date, the 3,000 American troops in the theater had 10 medical officers assigned to them, but hospitalization and supplies were provided by the British. The theater grew slowly during the months immediately following, and the units, mostly of the Army Air Forces, were scattered across the whole of India from Karachi to Assam and over the Himalayan "Hump" into China. Venereal disease control presented special problems since the theater was predominantly noncombatant in nature, the units were widely disseminated, and transportation was often primitive or inadequate. Furthermore, medical officers as well as commanding officers frequently budgeted too small an amount of their attention to venereal disease control when the insect-borne diseases and those arising from poor sanitation appeared to overshadow the venereal disease in relative importance. Generally speaking, venereal disease rates for white troops, the majority of whom found racial barriers, remained comparatively low throughout the entire period of operations. Rates for Negro units, however, consistently ran several times higher than the theater mean.
A full-time venereal disease control officer arrived in the theater on 26 November 1942 and was assigned to the Office of the Surgeon, Services of Supply, at the headquarters in New Delhi, where he functioned in the capacity of theater venereal disease control officer. On 31 March 1943, he was transferred to the Office of the Surgeon, Headquarters, Rear Echelon, U.S. Army Forces, CBI (China-Burma-India Theater), located in the same city. This transfer was effected in order to facilitate the administration of venereal disease control among Air Force units and other units which came under the authority of the theater surgeon but not the Surgeon, Services of Supply. The venereal disease control officer noted that the added authority attending this new assignment was of definite value to him in his dealings with organizations that were not a part of Services of Supply.
The duties of the theater venereal disease control officer were to supervise and correlate the theater venereal disease control program which included the education, recreation, and discipline of troops; establishment of prophylactic stations; and the distribution of mechanical and chemical preventives.
The theater venereal disease control officer spent half of his time traveling about the theater, personally investigating trouble points and consulting with
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officers of units having excessive rates. These field trips were the more necessary because of the lack of either full- or part-time trained venereal disease control officers. Neither the Tenth nor the Fourteenth Air Force had even a part-time venereal disease control officer, although assistant surgeons acted in that capacity when the occasion demanded. During late 1943 and 1944, the India-China Wing of the Air Transport Command had a medical officer devoting most of his time to venereal disease control. This officer cooperated with the theater venereal disease control officer in a manner that made the venereal disease control program in the Air Transport Command an excellent and highly successful one. In the fall of 1943, venereal disease became such a pressing problem at Base Section No. 2 that an officer was appointed by the base surgeon as venereal disease control officer in addition to his other duties as the officer in charge of the venereal disease ward of the 163d Station Hospital. However, his clinical duties demanded the greater part of his attention.
China was Advance Section No. 1 of the China-Burma-India Theater until the theater was subdivided on 26 October 1944 into the China and the India-Burma theaters. Since the majority of troops were stationed in India,86 venereal disease control problems centered there rather than in China. However, rates for white troops ran consistently higher in China than in India. There were no Negro troops stationed in China.
Venereal disease control in China was the responsibility of the theater venereal disease control officer. Headquarters, Rear Echelon, U.S. Army Forces, CBI, was located in New Delhi, India, and was administered by means of the organization previously described. When China became a separate theater, the venereal disease control officer remained with the India-Burma theater, and venereal disease control in the China theater was taken over by the theater medical inspector.87
India.-Since the majority of troops in the theater were stationed in India, the chief venereal disease control problems arose there. According to Major Brumfield, the U.S. soldier in India found many fine people with whom he could mingle socially. He also was subjected to influences conducive to sexual exposure and the contraction of venereal disease. Major Brumfield, himself, and others found frequent exceptions to this statement, however. For example, the theater venereal disease control officer, Capt. Malcolm A. Bouton, MC, personally observed that white troops in India usually acquired venereal disease only when under the influence of alcohol because racial barriers and the general unattractiveness of the native women to American men mitigated against normal social contacts. A survey conducted by Special Services tended to support Captain Bouton's views.
86Report, Brig. Gen. Raymond A. Kelser, Col. Robert H. Kennedy, MC, and Col. Karl R. Lundeberg, MC, to Commanding General, U.S. Army Forces, India-Burma Theater, New Delhi. India, 9 Nov. 1944, subject: Report of Medical Department Mission.
87(1) Derr, R. H.: History of Venereal Disease Control in China. [Official record.] (2) Essential Technical Medical Data, U.S. Army Forces, China Theater, for March 1945.
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Measures for the protection of the public health at the national level were under the supervision of the Public Health Commissioner of the Indian Medical Service. This service was primarily a military one, but it had a civil branch to which officers might transfer and retain their military rank and right to promotion. These officers, assigned to the Government of the United Provinces and serving as civil medical and health officers, had been recalled to military duty. This resulted in the almost complete disruption of the service. Even before the war, very little progress had been made toward the building of a sound public health program because of insufficient personnel and a lack of appreciation on the part of the illiterate native population. Sanitation, except in the European sections of the large cities, was almost nonexistent, and absolutely nothing had been done to control the venereal diseases. Furthermore, it was indicated that the inauguration of venereal disease programs would have been prevented by the more powerful religious groups who would have interpreted the effort as an insinuation of sexual promiscuity which their religions prohibit. Consequently, while promiscuity did exist, the moralists would not permit anything to be done about it, preferring to follow their own religious dictates and refusing to recognize that all of the people were not guided by them. There had been no attempt to secure case reports for venereal disease, no surveys, no follow-up of delinquent patients, and no educational program. Under existing conditions, no one had the temerity to attempt such measures, as neither the Moslems nor the Hindus would have permitted it. Obviously, there was no reliable information regarding the presence of venereal disease in the civil population. Data relative to syphilis were available from only two sources: First, autopsies on unclaimed bodies, about 15 percent of which showed evidence of syphilis, and second, serologic tests among women attending prenatal clinics, about 4 percent of which were positive. It must be remembered that these samples were highly selected, representing the lowest social group on the one hand and the more intellectual class on the other; the rate for the entire population probably lay between these extremes. As the British Commissioner of Health declared during a conference with the venereal disease control officer, vital statistics were conspicuous by their absence.
Facilities for the treatment of the venereal diseases were provided at the general clinics throughout the provinces, especially in the largest cities, but it was understood that they handled but few patients. Indians married very early in life, and attendance at a venereal disease clinic was tantamount to admission of infidelity. Few Indians were willing to admit this transgression. Accordingly, the hands of the civilian authorities were tied insofar as attempts at venereal disease control were concerned.
In spite of the strong religious opposition to sexual promiscuity, flagrant prostitution was practiced in India. The caste system protected and promoted this profession. The prostitutes were among the lowest classes and the religious sects had no interest in them. Female children of prostitutes
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were, from birth, destined to prostitution. There was no other recourse. Each of the large cities had its segregated areas of prostitution. The more expensive brothels in the principal cities offered the lighter-skinned, Eurasian women amid fairly pleasant surroundings, while the cheapest housed physically repulsive females in an environment of filth disgusting beyond description. Smaller towns and cities usually boasted of a few houses of the cheaper variety. Clandestine prostitution also was common, "tonga wallahs" and taxi drivers participated in the profit of the business. In the rural areas, such as Assam, organized prostitution was not found to any extent, but teapickers and coolie laborers were only too willing to add to their paltry earnings. This class was amoral rather than immoral.
The Surgeon, Services of Supply, CBI, observed:88
During the year [1942] venereal disease at Karachi caused alarm. Newly arrived colored contingents were responsible for the outbreak. Although there were then four prophylactic stations at Karachi, they were ineffective so far as these troops were concerned. The colored soldiers were "duck soup" to the Indian prostitute. This difficulty with colored troops has continued, and although all known education and protective measures are carried out, the problem has not been solved.
The theater strength increased rapidly during the latter part of 1943, and, with the general increase, came a shift in the disposition of troops. Calcutta, the headquarters of Base Section No. 2, became increasingly important as Karachi diminished in importance. By the middle of 1944, roughly one-third of the total theater strength was assigned to Base Section No. 2. A large proportion of the base strength was stationed in or around Calcutta and, unfortunately from a venereal disease point of view, the city was designated a rest center for men who had been isolated for many months in the jungles of Assam and northern Burma. Calcutta, then the second largest city in the British Empire, had an unenviable reputation as regards Far Eastern vice of all kinds and became venereal disease problem number one.
The brothels of Calcutta were not conveniently concentrated like those in Karachi but were scattered throughout the city (fig. 60), making the enforcement of off-limits regulations most difficult. Houses varied widely in prices charged and in relative attractiveness.
Bombay presented a similar problem except that there, as in Karachi, the brothel section tended to be more integrated in one area. Also, large numbers of U.S. troops were never stationed in and about Bombay, as was the case in Calcutta. Bombay, however, caused considerable trouble at times as a port of debarkation.
These three major cities were foci from which most of the venereal disease arose. Karachi caused trouble during the early days of the theater, Calcutta later. Bombay drew attention to itself periodically when large contingents of troops were debarking. Contact reports indicated that the majority of infections were acquired in the brothels of Calcutta, Bombay,
88History of the Medical Department, Services of Supply, China-Burma-India Theater, 1942-44. [Official record.]
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FIGURE 60.-U.S. Army military police patrol the brothel area of Karachi to apprehend any military violators of the policy making this area off limits.
and Karachi. Exposures occurred when troop movements passed through these towns and while men were visiting them on leaves. The remainder of contacts were scattered. Some of the smaller towns were declared off limits because they were foci of venereal disease.
Negro organizations, rest camps, and ports of debarkation were everpresent problems which contributed a great deal toward high rates and toward sudden unexpected fluctuations in otherwise rather stable rates.
Educational material such as posters and pamphlets was at a premium during late 1942 and early 1943 because of shipping difficulties. In January 1943, there were only two types of venereal disease posters available for theater distribution, and these were inadequate in number. This situation was relieved in April of 1943 when a booklet containing photographic miniatures of posters was received from the Office of the Surgeon General (fig. 61). These miniatures were used as samples from which local Indian printers prepared a supply of the standard-sized, colored posters, pending the arrival of shipments from the States. After these early difficulties, adequate stocks were kept on hand most of the time by the simple expedient of supplementing U.S. printed posters with the Indian version when stock levels became low
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FIGURE 61.-One of the photographic miniature posters received in the CBI Theater from the Office of the Surgeon General.
between shipments. However, the locally produced posters did not have the eye appeal of those made in the States.
The Office of the Surgeon, India-Burma Theater, feared that the lay publicity given to sulfonamides and penicillin would unfavorably influence the venereal disease educational program. This fear was borne out by casual conversations with enlisted men, many of whom thought that venereal diseases were now less serious. To offset this belief, an article on the subject was included in the December 1944 issue of the Services of Supply, India-Burma Theater, Field Medical Bulletin, a publication widely read by medical officers. The article requested that officers consider these overly optimistic views when giving lectures on venereal disease. It also requested that medical officers treating venereal disease have a private talk with each patient before discharging him, explaining to the soldier that many of the venereal diseases were still most serious and that he might not be so lucky as to be easily cured the second time.
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During late July 194489 the Research Department, Special Service Section, conducted a study of attitudes, actions, and knowledge as related to venereal disease. The study was made at the request of the theater surgeon's office to furnish some data that would be of value in focusing the educational aspects of the venereal disease control program in the theater. The questionnaire used was devised in consultation with the venereal disease control officer and administered by the staff of the Research Department, Special Service Section, Headquarters, U.S. Army Forces, CBI. The study was done on carefully randomized samples of Negro and white soldiers at two Army stations in the theater, one near a large city and the other in rural upper Assam. It was of interest to find that at the urban station 93 percent of the Negro and 27 percent of the white personnel admitted having had sexual intercourse since arriving in the theater, whereas at the rural station 71 percent of the Negro and 17 percent of the white made a like admission. Drinking seemed to have no important relationship to sexual behavior among Negro soldiers; for white soldiers, however, the association was highly significant. It was also found that the majority of sex contacts were made in brothels rather than from "pickups" or friends. An analysis of the report made by the Research Department was of aid in the handling of educational aspects of venereal disease control among white and Negro racial groups, even though many of the findings merely bore out what was already suspected. As a rule, lectures to white troops stressed the seriousness of venereal disease and the dangers of mixing alcohol with sexual relations and offered prophylaxis as a last resort. On the other hand, prophylaxis had to be the constant theme of talks to Negro units. Recreational activities which were intended as a substitute for sexual activity had less of an effect upon the venereal disease rates in Negro organizations.
The locating of prophylactic stations was difficult because Indian property owners would not rent buildings for such purposes. However, from the very earliest days of the theater, prophylactic stations were always adequate in number and strategically situated. As the theater expanded geographically and numerically, stations were added or subtracted as the occasion demanded. Karachi had four stations functioning in the fall of 1942. Calcutta had two in the central part of the city in the fall of 1943, to which nine more were added during 1944. In New Delhi, there were two downtown and one outside of town near the airfield. Bombay kept one station in continuous operation and added temporary ones during the debarkation of troops. Small towns which were in bounds and in the proximity of Army installations had one station. In addition, prophylactic facilities were available on all U.S. Army posts and installations. The addresses of offpost prophylactic stations were conspicuously displayed on unit bulletin boards, and for the larger cities schematic maps were also posted. Units in Assam were
89Essential Technical Medical Data, U.S. Forces, India-Burma Theater, August-October 1944, enclosure 2 thereto.
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provided with these maps for the convenience of men who visited Calcutta on rest leave. Later, a booklet was published which located the stations in all five of the major cities. Conversations were frequently held with the British venereal disease control and liaison officers concerning the mutual use of all prophylactic stations by personnel of both armies in order to obviate the duplication which existed. The plan was never carried out, however, as the British prophylactic scheme did not conform to the procedure outlined in U.S. Army regulations.
Supplies of individual chemical and mechanical prophylactic kits had to be stored with care because of the unfavorable climate in the China-BurmaIndia Theater. An inspection of supplies during the summer of 1944 revealed that the silver picrate, in many cases, had deteriorated to such an extent as to be unserviceable. The kits were destroyed in October 1944 by War Department order, and the new, one-tube variety was requisitioned. Condoms of best-grade rubber deteriorated during the hot summer months. The rubber tended to adhere to itself along the line of folding, and when the condoms were unrolled multiple pinpoint perforations developed at these sites of adherence. Medical supply was instructed to store these items in the coolest and driest places possible, and post exchanges were warned that stocks on their shelves must undergo rapid turnover during the hot months.
Obviously, any venereal disease control program in India was predestined to be a one-sided affair; that is, strictly military, without any semblance of the cooperation by civil public health and police authorities which one would expect to find in a similar program within the limits of the continental United States. As described earlier in this history, there were no health departments worthy of the name, and civil police expressed surprise when control of prostitution was even mildly suggested. British authorities, for political reasons and because of possible repercussions which might occur at home, decided not to attempt to regulate or supervise the brothels.
In the absence of civil public health and police cooperation, the only remaining recourse was to place all native sections and brothel areas off limits, and to enforce the regulation by patrolling them with military police. This was done at all trouble points throughout the theater, and all military personnel found in these areas were taken to the nearest prophylactic station for treatment. Company punishment frequently attended second and third offenses by the same individual.
That venereal disease rates can be lowered solely by the strict enforcement of off-limits regulations was shown in the statistical report for the 4-week period ending on 27 April 1945:
All venereal disease incidence rates showed a significant decrease for the April reporting period. The aggregate and whites rates have never been lower since the Theater had been established, and the colored rate is the lowest it has been since July 1944. The reason for these unprecedented low rates is probably due, to a considerable extent, to our efforts to prevent an outbreak among our troops of cholera and smallpox which existed in epidemic form in the civilian population during April. Because of the
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presence of these epidemics, many cities and towns were temporarily placed out of bounds for transient troops, and movement within many of the larger centers of population was restricted for personnel assigned there. Decrease in the number of venereal exposures was the inevitable result of such measures primarily directed towards prevention of diseases unrelated to venereal disease.
The lowering of actual man-days lost because of venereal disease was a problem apart from, but no less important than, control of the incidence. This aspect of the program was greatly aided by the advent, in the winter of 1943, of the ambulatory treatment of gonorrhea and the attendant lessening of days lost. Noneffective rates dropped from an average of 2.7 per 1,000 per annum for the whole of 1943, to 2.0 per 1,000 per annum for the first 8 months of 1944, and further to 1.6 for May to September, inclusive, 1944. The ambulatory treatment played a large part in the reduction, as the lowered incidence of venereal disease during that same period did not entirely account for the decrease in the rate of noneffectiveness.
There were three special problems in venereal disease control that were of paramount importance. These problems probably were not peculiar to the China-Burma-India Theater, but they deserve brief consideration here. The special problem areas were Negro troops, ports of debarkation, and rest centers.
Negro troops, although they constituted only about 15 percent of the total theater strength, consistently reported rates sufficiently excessive to affect adversely the theater rate as a whole. Educational measures did not appear to be as effective in Negro soldiers as in white troops, but this alone may not suffice to explain the higher rates among them. In addition, the Negro soldier, identifying himself with the native population as an American Indian found no racial barriers. Consequently, prophylaxis became the chief, if not the only, means of controlling general disease among Negro troops, and even this broke down because of alcoholism, superstitutions regarding prophylaxis, and the remarkable nonchalance with which this race viewed venereal disease. The rates for white troops were actually excessive only in isolated instances and under special circumstances. In fact, if it had not been for the presence of a few Negro organizations, the theater would have had an enviable venereal disease rate.
Ports of debarkation were another important problem in the venereal disease control program. Theater rates were somewhat higher on a couple of occasions when large numbers of troops debarked, but were especially high when a Negro organization was among the new arrivals. Experience showed that sick bays and dispensaries either alone or in combination aboard ship were often incapable of handling the large number of requests for prophylactic treatment, which at times ran as high as 50 percent of the strength given shore leave. Also, venereal disease control was too likely to be entirely lost in the multiplicity of administrative problems connected with the transshipment of large numbers of troops. Personnel aboard ship could not be relied upon to initiate venereal disease control measures, but they were
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expected to cooperate when the port commander and port surgeon had formulated a well-organized program before the ship's arrival. The venereal disease problem at the critical time of first shore leave was of sufficient magnitude to warrant the special attention of one officer designated by the port surgeon as responsible for the proper execution of control measures. It was felt that this procedure of having a prearranged control program and an officer present to see that it was actually carried out would pay big dividends by preventing many cases of venereal disease. The following additional measures were found necessary at ports of debarkation in the theater: (1) The setting up of temporary prophylactic station or stations, manned by shore personnel, in tents or convenient buildings at the wharf gate or gates; (2) the delivery of individual mechanical prophylactic units, on the basis of not less than two per man, to ships' adjutants (not to individual organizational commanders) for distribution; (3) the distribution to troops of information concerning the location of off-limits areas, prophylactic stations, and legitimate places of entertainment (movies and approved restaurants); and (4) the enforcement of off-limits regulations by military police familiar with the city, reinforced, when necessary, by ship personnel.
Rest camps were the third source of constant trouble, especially the one at Calcutta which was established for Negro troops on leave from the Assam and Burma jungles. The incidence of venereal disease would be low during those months when the bulk of Negro organizations were busily occupied in the rural areas of Assam, and highest when large units were sent on detached service to the Howrah rest camp in Calcutta (fig. 62). The situation was investigated by the venereal disease control officer in April 1944, and corrective action was taken. In addition to an intensification of the educational program and stricter enforcement of the curfew and off-limits regulations, the following specific measures were instituted:
1. Discipline was strongly stressed at a conference of all unit commanders, and responsible officers were called by the Commanding General of Base Section No. 2.
2. Three new prophylactic stations were added at key points within the city, bringing the total from eight to eleven.
3. Fifteen percent sulfathiazole was added to the calomel ointment used at prophylactic stations.
4. Sulfa-drug prophylaxis was authorized at the rest camp and for units of the base having excessive rates.
5. Noncommissioned venereal disease control officers were appointed in each Negro unit arriving at the rest camp.
Whether due to any one or all of the above measures, the rates of this section dropped significantly that spring and summer.
Shillong, which was the rest camp for white personnel on leave from the same areas, was also a problem but a less serious one as measured by actual numbers of cases.
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FIGURE 62.-Howrah rest camp for Negro soldiers, Calcutta, India. A. Front entrance. B. Unattended side entrance neighboring directly on a very squalid section of the city.
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During the spring of 1944, the weekly radio statistical health report was amended to include the reporting of all new cases of venereal disease. This innovation was a considerable improvement as the theater surgeon was able immediately to spot units having high venereal disease rates.
China.-The American occupied portion of China contained three major cities: Chungking, K'un-ming, and Kuei-lin, with the greatest concentration of strength located in and about K'un-ming. Total strength in China grew slowly from only a few thousand, mostly personnel of the U.S. Army Air Forces, in 1942 and 1943 to approximately 40,000 in 1945. Frequently during 1943, rates were not statistically significant because of the small mean strength involved.
Several years before World War II, a serologic survey of 10,000 persons in Chekiang yielded 20 percent positives. The experiment repeated with a similar group during the Japanese occupation in the late thirties revealed 40 percent positives. It has been estimated that from 20 to 25 percent of the working classes are infected, although such figures must necessarily be but rough approximations. Prostitutes in China, as in any country, were considered 100 percent infected. It was the consensus among those of long experience in the Far East that syphilis was a relatively mild disease with the Chinese in whom one saw many of the benign late lesions but few of the more virulent central nervous system manifestations. However, there appeared to be no attenuation of the spirochete, as the disease reverted to type when acquired by a westerner. Data regarding the other venereal diseases were wholly lacking; but it can be assumed that here, as elsewhere, they were proportionately more common than syphilis.
The general control program in China was essentially the same as that in India. There was a prophylactic station centrally located in each of the larger cities, and more were added at K'un-ming in the summer of 1944. Brothel areas were always off limits, and the entire city of K'un-ming was placed off limits after 2400 hours in June 1944 because of a rising venereal disease rate (fig. 63). Recreation facilities were adequate at hostels of larger installations but totally lacking at some small outlying posts, a situation which could not be rectified because of logistic difficulties. Personnel stationed in China were at the end of a long supply line, which meant that the amenities of life came to them later and in smaller quantities than they did to troops in India. In addition, the theater was unable to rotate personnel as planned during late 1944 and early 1945. These two factors gave rise to a morale problem, and it was noted that venereal disease rates were highest among those men who had been overseas the longest.
The venereal disease problem was a big one considering the relatively small number of men involved. Had the theater developed into a major theater of operations, venereal disease control would have been one of the chief problems in preventive medicine.
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FIGURE 63.-The brothel area in K'un-ming, China, was declared off limits. A. Entrance to the area. B. Quarters of one of the prostitutes.
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FIGURE 63. (cont.)-The brothel area in K'un-ming, China, was declared off limits. C. A typical brothel.
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Burma.-It was the opinion of the theater venereal disease control officer that venereal disease control was unnecessary in Burma as the areas occupied by U.S. engineer and combat troops were sparsely populated by headhunting, Naga tribesmen. There were no civilian populations remaining in northern Burmese towns which were wrested from the Japanese during 1944. Any venereal disease occurring among units stationed in Burma was invariably acquired while men were at rest camps in India.
THE SOUTH ATLANTIC
In a land where the prevention of tropical diseases was of prime importance in the maintenance of the health of U.S. troops, venereal disease control again played a most important part in the overall health program.
From the time that the first American cadres arrived in Brazil, the control of venereal disease was a problem of major importance. From the very beginning, venereal disease rates for military personnel in this theater were excessive.90 During the first full year of operation, 1943, the annual average venereal disease rate per 1,000 average strength was 102, and the minimum rate was 66. This rate was four times that in the United States and about six times that for white troops in the United States.
Since no Negro or Puerto Rican troops were ever stationed in this theater, rates were only for white personnel. This high rate is more impressive when one considers the fact that the average strength of the entire command included personnel on Ascension Island, who constituted one-fourth of the total theater strength. This island offered no possibilities for sexual contact, and the existence of any venereal disease on Ascension was concomitant with the arrival of new troops or with the granting of furloughs to the Brazilian mainland.
Subsequently, control programs were instigated throughout the theater that resulted in a steady decrease in the rate, which, though still far above that for the continental United States, nevertheless reflected the campaign to control venereal diseases.
Administration.-Liaison with the U.S. Navy was carried out through Lt. Comdr. John F. Shronts, MC, Venereal Disease Control Officer, Fourth Fleet, U.S. Navy. Liaison with the Navy was an important factor in venereal disease control because the Navy controlled most of the ports to which soldiers went when on pass or furlough.
All Army bases, larger posts, and medical installations had a venereal disease control officer who was a medical officer. In units that had no attached medical officers, a nonmedical officer was appointed as the venereal disease control officer and had as his assistant a noncommissioned officer from the same unit.
90Letter, Lt. Col. Thomas B. Turner, MC, to Commanding General, U.S. Army Forces, South Atlantic (through Surgeon, U.S. Army Forces, South Atlantic), 9 Nov. 1943, subject : Venereal Disease Control in the South Atlantic Theater, with enclosure thereto.
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Advisory venereal disease control committees were organized among enlisted men. These committees proved their value by obtaining information and submitting criticism that could not be obtained from any other source. Similar committees were formed among officers at each post, base, or unit.
Control measures.-The problem of venereal disease control in Brazil differed from any similar problem within the continental limits of the United States. Troops were widely scattered at many small posts where airstrips and maintenance troops were stationed, and ferrying crews were furnished for the transatlantic air route.
Early in the history of the theater, most commanding officers in Brazil became cognizant that the control of venereal disease among their personnel was a problem of leadership which could not be shifted entirely to the Medical Department. This responsibility of commanding officers was brought to their attention by a theater memorandum91 which stated that medical officers could initiate and supervise only and that the effecting of venereal disease control measures was a command duty and function.
At the request of the Commanding General, USAFSA (U.S. Army Forces, South Atlantic), Colonel Turner made an inspection and survey of venereal disease conditions in Brazil during the period 1 November through 11 November 1943.92 Colonel Turner spent a period of about 2 weeks in the theater and visited all important posts and many minor units. He discussed problems with line and medical officers and conferred with officials of the Brazilian Government, including the Director of National Health and the director of the Venereal Disease Control Division. Colonel Turner recommended that every effort be made to enlist the support of civil health authorities in correcting bad sanitary conditions in areas adjacent to military camps; to increase the amount of instruction to soldiers concerning the dangers to health resulting from pursuing a personally irresponsible course of conduct; and to reduce contact with the highly infected civilian population by using all reasonable measures available.
Because of the excessive venereal disease rate in the theater, a conference on venereal disease control was held in the Office of the Surgeon, USAFSA, in February 1944. Present were the theater surgeon, the deputy theater surgeon, the theater medical consultant, the commanding officers of the 200th Station Hospital, near Recife, and of Ibura Field in the same vicinity, and Commander Shronts.
At this meeting, it was explained that the high venereal disease rate was caused by the high venereal infection of the civilian population and a social system that permitted prostitutes to flourish without restraint. Methods to combat these conditions were limited because of inability to control sources of infection. The conferees decided to concentrate on the education of the soldier relative to the need for prophylaxis after contact and also to recom‑
91Memorandum No. 2, Headquarters, U.S. Army Forces, South Atlantic, 10 Jan. 1944, par. 10, Venereal Diseases.
92See footnote 90, p. 316.
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mend that all available facilities for cantonment recreation be utilized in order to attract the soldier away from adjacent towns and villages in his spare time.
The social system of Brazil made it practically impossible for soldiers to meet girls of their own social standing. Because of this fact, our soldiers then sought, and were sought by, promiscuous women, both amateur and professional, a group with a very high venereal disease rate.
Posts were liberal with passes, and soldiers, because of their relative opulence, were soon sought by prostitutes. Civilian dance halls were not open to U.S. soldiers. Only at the lowest bars and dives with their accompanying filth and dirt were troops welcome.
Specific areas had their special problems. The city of Recife was described in a report as presenting the most difficult problems for the control of venereal disease. It was reported to be swarming with prostitutes who appeared to be subject to little or no limitation by local authorities. In Natal, conditions on the whole were unsatisfactory; but, as the town was small, control of military personnel was not too difficult to administer. Belem was described as a city in which conditions were more or less acceptable and control of military personnel was not difficult because transient personnel were not allowed to enter the town. Rio de Janeiro was no problem due to the fact that few troops were stationed there and recreational facilities were adequate.
After the initial period of organization and construction, specific venereal disease problems at each camp were recognized, and measures were taken to correct them as much as possible. Cantonment recreational facilities were enlarged and expanded, and every effort was made to make life for the soldier on the post more attractive. Educational measures prescribed by the War Department were followed, training films on venereal disease control were shown, literature was distributed to individual soldiers, and posters and placards were prominently displayed. Frequent lectures and informal talks were given to the men in order to keep them aware of the dangers of venereal disease.
Extracantonment measures consisted of placing adequate prophylaxis stations at central and easily available locations in towns, placing out-of-bounds areas where prostitution flourished, declaring off limits individual cafes and restaurants known to contribute to the delinquency of soldiers, and increasing numbers of military police where necessary.
Summary.-The military venereal disease control program in Brazil was intensive and, considering the obstacles, successful. From the time the program began, when rates reached 142 per 1,000 per annum for the theater and a peak of 335 for an individual post, there was a steady decline in the rate to a low point of 36 per 1,000 average strength per annum during May 1945. This decline reflected the program of civilian collaboration, education, provision of recreation, and command interest.
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ALASKA
In the Alaska Defense Command and the Alaskan Department, the control of venereal disease during the period July 1940 to July 1945 was a minor, although nonetheless important, phase of the overall control of communicable diseases. Venereal disease was a much smaller hazard to the health of troops in Alaska and the Aleutian Islands than in any other area of comparative size in which U.S. troops were stationed.
No comprehensive survey of venereal disease among the civilian white population was undertaken, except during the spring of 1941 when blood tests for syphilis were made on approximately 75 percent of the adults in Anchorage and Juneau as part of a program of blood typing for civilian defense purposes. Analysis of the results suggested a low prevalence of syphilis among white residents of two representative areas of Alaska. This was in marked contrast to the number of cases of venereal disease found among Alaskan native groups, although a complete survey was never made because of the nomadic habits of the natives. In Nome, for example, the sources of infection, the majority of whom were the Eskimo or breed girls and women, had not been eradicated because civilian police and legal procedures were inadequate. The number of Eskimo girls and women in town had gradually increased due to their migration to Nome from the surrounding villages. The migration of these individuals was not under any apparent form of control or supervision. Fortunately, the relative isolation of small native communities within the Territory and the rigors of the climate aided in cutting down the spread of venereal infection from natives to whites. During the summer months, however, coastal shipping during the canning season, with its migration of native Indian, Aleut, Filipino, Chinese, Japanese, and white cannery workers, offered an annual reinfection with acute venereal infections. Male cannery workers coming from the States brought venereal disease from brothels of the West Coast, and, as ships touched Alaskan ports, new cases were to be found among white and native prostitutes (fig. 64).
Military and civilian authorities and public health agencies cooperated in the control, suppression, and partial elimination of the white prostitutes. Much greater difficulty was encountered in trying to eliminate the promiscuous native as a source of venereal disease. In most instances, the only method of stopping contact of soldiers with the native girls and women was to place native villages or areas off limits.
Factors influencing incidence among troops.-Probably the most important single factor in the development of venereal disease by soldiers in Alaska was exposure to the reservoirs of venereal infection in the native population. Almost all Army posts on the Alaskan mainland were located near native villages or white villages having a native section. In Juneau, for example, the port surgeon reported in December 1942 that a difficult
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FIGURE 64.-A 1959 photograph of the Red Dog Saloon and Annex Rooms, Juneau, Alaska. During and before World War II, this was a thriving house of prostitution, known as Ferry Way Rooms, that catered to itinerant workers, military personnel, and local inhabitants. (Photograph courtesy of the Alaska Department of Health.)
problem existed at that station because of close proximity to the native population. Certain villages, Yakutat, King Cove, and Naknek for example, were declared off limits early because of outbreaks of venereal disease among troops soon after they were stationed near the villages.
Another important source of venereal disease was the prostitute, white, black, and native. In each of the principal Alaskan towns, there was a row of small houses containing prostitutes, one or two inmates to a house. The row or "line," as it was called, was usually in a rather well segregated area and represented nearly all of the commercialized prostitution in Alaska (fig. 65). A few native or halfbreed women solicited near bars or in back alleys, but their main object was to obtain liquor and not to give their bodies for purely monetary hire.
Control measures.-Before 1940, troops were stationed at Chilkoot Barracks in southeastern Alaska, and a few Signal Corps troops were scattered throughout the Territory. Venereal disease never became a problem until increased numbers of troops were stationed throughout Alaska in proximity to native communities or to white communities having native sections (fig. 66). The influx of large numbers of troops into native villages such as Yakutat and King Cove soon brought problems of venereal disease control. As there were no effective civilian controls, it became necessary for military
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FIGURE 65.-A section of the "line" at Juneau, Alaska. (Photograph courtesy of Alaska Department of Health.)
authorities to place these villages off limits immediately and for the duration.
Between 1 July 1940 and 1 January 1942 a mutually cooperative relationship was established between military authorities and well-organized civilian communities such as Juneau, Anchorage, and Fairbanks (fig. 67). Native districts were placed off limits either routinely or as occasion demanded. Military police were placed where needed to prevent soldiers from entering forbidden areas and to prevent disturbances of the peace in tolerated "red light" districts. Prophylaxis facilities were provided at all times in Juneau and in each area. Any man found drunk was given a prophylaxis. Prophylactic stations were set up near all Army posts where there was any possibility of troops being exposed to venereal disease in nearby communities.
After 1 January 1942, the Commanding General, Alaska Defense Command, instructed commanding officers of all posts, camps, and stations to take appropriate measures to control any and all conditions that might adversely affect the health of their respective commands. During this same period, there was a marked exodus of civilian women and children from Alaska due to the possible hazard of remaining in a war theater. Many prostitutes left with this group. By summer of 1942, increased military pressure precipitated the closing of the "line" in Anchorage. As a result, many prostitutes scattered throughout the town or moved to other Alaskan towns. The "red light" districts of other towns were allowed to remain open so long as they did not constitute a source of venereal infection. Local authorities in Seward
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FIGURE 66.-Isolated Chilkoot Barracks at Haines, Alaska.
finally closed the "line" in late 1944 after approximately 3 years of licensed operation with troops stationed nearby.
Open commercialized prostitution virtually disappeared in Kodiak, Juneau, Ketchikan, Fairbanks, and Nome during the time that large numbers of troops were stationed there. However, after V-E and V-J Days, some pressure was exerted in an attempt to revive prewar conditions (fig. 68).
Military venereal disease control policies in Alaska were almost universally effected by post surgeons and post medical inspectors in cooperation with military police and local and territorial health and civil authorities. Since the control of venereal disease was always a rather minor problem, there was never a full-time venereal disease control officer or section in either the Office of the Alaskan Department Surgeon or any of the stations in the Alaskan Department.
Sex hygiene and venereal disease information was disseminated regularly through lectures, films, pamphlets, and posters at all stations.
There was no venereal disease problem in the Aleutian Islands. There were but few natives in the Islands, and, after 1942, these were moved to southeastern Alaska. There were two or three white prostitutes at Dutch Harbor in 1941, and these were evacuated to the States in 1942.
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FIGURE 67.-A postwar photograph of buildings that constituted the "line" at Anchorage, Alaska. (Photograph courtesy of U.S. Public Health Service.)
FIGURE 68.-Since the creation of Alaskan statehood, the old "line" in Juneau (fig. 65) has been cleared away. (Photograph courtesy of the Alaska Department of Health.)
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The annual venereal disease rates among military personnel in Alaska per 1,000 population were as follows: For 1942, 6.8; for 1943, 3.2; and for 1944, 4.6.93 These low figures were a reflection of a combination of circumstances-the active venereal disease control program on the mainland of Alaska, where such a program was needed constantly, and the stationing of a large military force in an area off the mainland where no opportunity for exposure existed.
THOMAS H. STERNBERG, M.D.
ERNEST B. HOWARD, M.D.
Part V. Immediate Postwar Period
CONCEPTS OF CONTROL
As Siler pointed out in his monograph on the history of venereal disease in the U.S. Army,94 all previous wars had been followed by an immediate rise in the incidence of venereal diseases among troops. As early as 1944, there were signs that the same situation would prevail following World War II. Consequently, the Army, the U.S. Public Health Service, the Navy, and various civilian organizations began to make plans in an effort to prevent or minimize a rise in incidence after the cessation of hostilities.
The Public Health Service was instrumental in organizing a venereal disease control conference held in St. Louis from 9 to 11 November 1944, which was directed primarily toward the consideration of the immediate postwar period. At this conference, representatives of various military and civilian organizations discussed the current venereal disease control situation and made plans for the expected postwar rise in rates. Colonel Sternberg, representing the Army, discussed the subject from a military point of view. A portion of his address, which was later published in the 27 January 1945 issue of the Journal of the American Medical Association, follows:
It is even now apparent that the approaching demobilization period will be accompanied by many serious problems in the control of the venereal diseases. During and following previous wars the incidence of venereal disease always reached epidemic proportions. While the maintenance of low military rates during the first three years of the current conflict justifies a feeling of achievement by all concerned, it is noteworthy that since the 1st of January 1944 the Army venereal disease rate for the continental United States has risen steadily to a present level of 36 per thousand men annually as compared to the 1943 rate of 26.3. Furthermore, it is our belief, based on the following considerations, that the Army rate in the continental United States will continue to rise for some time and may even reach World War 1 levels :
1. It is increasingly evident that a general letdown in the overall venereal disease control program, both military and civilian, is in progress.
93Morbidity and Mortality in the U.S. Army, 1940-45, Preliminary Tables Based on Periodic Summary Reports. Prepared by the Medical Statistics Division, Office of the Surgeon General, Department of the Army.
94Siler, J. F.: The Prevention and Control of Venereal Diseases in the Army of the United States of America. Army M. Bull. No. 67, May 1943-Special Issue.
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2. The outstanding advances in therapeutic methods climaxed by the introduction of penicillin have resulted in (a) better reporting of venereal disease with a decrease in the amount of concealed gonorrhea, (b) a definite but as yet unmeasured effect on the will of the soldier to avoid venereal disease and (c) a reduction in the man days lost per thousand men annually from 1,280 in 1940 to a current record low of less than 300, giving rise to a further loss of interest in prevention.
3. As the result of overseas assignment, the group of young trained venereal disease control officers initially stationed in this country has been depleted almost to the vanishing point. While this has lowered the intensity of our venereal disease program at home, it is with a great deal of satisfaction that the downward trend of the venereal disease rates in all theaters of operation is recorded. The combined overseas rate for all American soldiers is now lower than for those stationed in the United States.
4. Troops returning from overseas areas have had an abnormally high venereal disease rate of infection, acquired after arrival in this country. This is an increasingly serious problem. It can be explained in part by the effects of long overseas duty and by the belief of these men that the girls in this country are free of infection.
It is obvious that these problems affect the civilian and military alike and present a rather gloomy picture for the immediate future. Despite this, it is our opinion that in the postwar period there will exist an unprecedented opportunity to reduce the incidence of the venereal diseases to a manageable minimum. This opportunity, to be fully exploited, will require a critical evaluation of our current control measures with a view toward their strengthening and expansion and a recognition of the changing aspects of venereal disease control brought about by more effective therapeutic weapons and by the mass wartime experience with educational and case finding procedures.
It is believed that in the planning for postwar venereal disease control the Army has much to offer in the way of material assets and experiences. It is our intention in this paper to discuss specifically these contributions not only with respect to actual demobilization procedures but also in relation to the strictly civilian activities of venereal disease education, case finding, and community action.
After the conference in St. Louis, there was considerable activity on the part of the military services and the Public Health Service toward the formulation of various plans which it was hoped would be of some effect in preventing an epidemic rise in venereal disease. However, none of these plans were of much value insofar as could be determined. The venereal disease statistics presented in appendix D reveal that, immediately after the cessation of hostilities in the European theater, the incidence of venereal infections skyrocketed. The same happened in the Pacific after V-J Day, and rates in the United States followed a similar pattern. This epidemic, as might be imagined, received a considerable amount of study and analysis by competent officers, and, although the solution never was found, it seems worthwhile to record some of these studies for the benefit of those who may at some time encounter similar problems.
WORLDWIDE EXPERIENCES
European theater.-The impact of the marked rise in the venereal disease rate in the European and Mediterranean theaters was so strong that Maj. Gen. Albert W. Kenner, Chief Surgeon, U.S. Forces, European Theater, was directed to make a survey of the situation and to make recommendations for
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its correction. General Kenner's excellent report of September 1945 to the Commanding General, ETOUSA, follows:
1. In view of the unprecedented rise of rates for venereal disease among U.S. Military personnel in the European Theater since April 1945, the following summary and recommendations are presented for your information and consideration:
a. In the Zone of the Interior during the period of mobilization and since that time, the average annual rate has been between 28 to 35 per thousand. In some Service Commands, this rate has been as high as 40 to 45 per thousand per annum. The War Department has accepted any rate below 50 per thousand per annum but has been critical of those above 35. During the pre-operational period in the United Kingdom, rates for U.S. Forces averaged between 35 and 40 per thousand per annum. With the advent of D-Day and during the first months in France, rates among combat troops were as low as 5 per thousand per annum. As was to be expected, these rates increased for U.S. Forces as a whole on the Continent as static service installations were put in place. During the early combat phase, however, for all troops on the Continent, the average rate never exceeded 50 per thousand per annum, and for combat troops a rate of less than 25 per thousand per annum, and usually lower, was maintained throughout the period of active fighting. With the approach of the end of hostilities, there became apparent an unmistakable increase in the number of cases of venereal disease. Just prior to, and subsequent to, V-E Day, the rates mounted precipitously and on the average have continued to increase up to the present time with some moderate variation on a weekly basis. At the present time, an overall Theater annual rate of 190 per thousand has been reached. If this rate is maintained, it means that of every 1,000 soldiers in the theater, 190 will have contracted venereal disease each year. Considering the present theater figure of approximately 2,000,000 men, there would thus occur 380,000 cases of venereal disease during the year if the present strength and the present rate were maintained.
b. Because of the modern treatment of venereal diseases, loss of time from this cause has been materially reduced and in fact many cases of gonorrhea can be treated on a full duty status. However, with the cessation of hostilities and the redeployment of military personnel to the Zone of Interior, emphasis has passed from the conservation of time lost from sickness to conservation of health and the return of U.S. soldiers to civilian life in the United States free from infectious diseases including venereal disease. The current Assembly Area Command and Port requirements for physical inspection and checking prior to embarkation are designed to carry out this obligation. In spite of these precautions, concealed or incipient cases found their way aboard transport and were diagnosed only after reaching the United States. This has been the cause of unfavorable comment from the War Department and has necessitated the adoption of more stringent regulations. At the present time no U.S. personnel with a venereal disease in the infectious stage is permitted to board a transport irrespective of the fact that he might be treated and cured of gonorrhea during the voyage.
c. The venereal disease situation in this theater has been cause for comment in the American press. While some of these articles have been inaccurate they have all referred to a substantial increase in the incidence of venereal disease.
2. Prior to the war period the incidence of venereal disease among Europeans was higher than that among the U.S. population. High rates during wars are a matter of historical record. With the German governmental policies and with the demoralization incident to the loss of the war, it is not surprising that there is a great mass of venereally infected women available to the American soldier. This availability was increased with the cessation of hostilities when units became static by comparison, and individual soldiers had more time away from duties. In France and Belgium and other liberated countries, a somewhat parallel situation had existed prior to invasion and their popula‑
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tions embodied a large group of infected women who had had insufficient opportunity for treatment. It is not surprising that with the cessation of hostilities and the psychological reaction and let-down incident to the tremendous victory that large numbers of contacts have been made both in Western Europe and in defeated Germany. Unfortunately also the control of venereal disease has received wide and often times unjustifiable publicity and claims. The result of the latter has been that many soldiers and officers consider the acquisition of a venereal disease a mere incident and not as the contraction of a dangerous infectious disease subject to serious complications and in which even penicillin fails to cure in a significant number of cases.
3. In broad principle, the control of venereal disease resolves itself around the repression of prostitution; the prevention of as many sexual contacts as possible; the provision of adequate substitutive and recreational activities; the provision of prophylactic materials and well organized, equipped and operated prophylactic stations; and the provision of treatment facilities for infected military and civilian personnel (fig. 69). These measures cannot, because of their diversity, be carried out by any one agency within the Army. A successful control program requires the coordination and enthusiastic participation of the Provost Marshal, Special Services Officer, and the Surgeon. Contribution can also be made by the Chaplain. The combined efforts of these agencies can only be secured to the best advantage when guided and unified by command. It is on this basis that the War Department has insisted that the control of venereal disease is a command function and responsibility.
FIGURE 69.-Dermatology and venereal disease treatment center at Stuttgart, Germany, May 1946. Penicillin for treatment of venereal disease was provided free of charge by the U.S. Military Government.
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a. The Provost Marshal has the means for repressing prostitution by the control of the individual soldier, by closing houses of prostitution, or by placing these and other premises "off limits" and enforcing this measure, and by having been delegated the authority to take into custody violators of military and civilian health laws. Experience in the theater has shown that when Provost Marshals take an active interest in measures for the repression of prostitution, excellent results have been produced, whereas when the opposite obtains, the venereal disease program is jeopardized because contacts between promiscuous women and soldiers cannot be reduced significantly.
b. The Special Services Officer is in position to furnish a variety of substitutive activities in the way of athletics, recreation, and entertainment.
c. The technical aspects of control can be contributed by the Surgeon and involves a preparation of educational material for soldiers, the furnishing of prophylactic materials and facilities, and the treatment of venereal diseases.
4. To meet the acute venereal disease situation in this theater, the combined efforts of all of the above agencies, together with complete command support, will be required. To assure this vitally essential coordination, the establishment of venereal disease control boards in major commands is strongly advocated: these boards to consist of the Chief of Staff or his representative; the Provost Marshal; the Special Services Officer; the Surgeon; and in Germany the AC of S, G-5, and the Chief Public Health Officer, G-5. A monthly meeting of these boards should be required, at which time venereal disease policies, problems and procedures would be reviewed and revised as necessary. Such a board would have the effect of concentrating into one board all of the authority and agencies required for a coordinated and effective venereal disease control program.
5. In Germany, the problem of venereal disease control cannot be disassociated as between the Military and Military Government. A concrete program with single directives or at least mutually complimentary directives only can accomplish the best results.
6. Recommendations. It is recommended that:
a. A firm Command directive reading substantially as that presented as Inclosure No. 1, be distributed with the least possible delay.
b. A Board of officers composed of the Chief of Staff or his representative, the Provost Marshal, the Medical Inspector, and the Special Services Officer be established in Headquarters, United States Forces, European Theater as a model and directing agency for similar boards in major commands as outlined in the accompanying directive and referred to above in paragraph 3.
c. A coordinated and uniform program embodying the principles outlined above be required for all commands within the Theater.
d. Full use be made of:
(1) Publicity on venereal disease.
(2) Educational, recreational, and entertainment facilities.
(3) Police power of the Provost Marshal for the repression of prostitution both organized and clandestine.
e. Authority be granted for the full utilization of prophylactic teams in all commands under the provision of T/O & E 8-500 and that facilities, equipment and materials be made available from Engineer and other sources for the establishment, and where necessary, construction of adequate numbers of satisfactory prophylactic stations.
Despite the adoption of many of the recommendations, the rates in the European and Mediterranean theaters continued at a very high level until the middle of 1946, at which time they began to subside. However, it was believed that the decrease in rates which occurred in late 1946 and in 1947 was due more to a stabilization of command and of the civilian population
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rather than to any specific measure taken, except, perhaps, the treatment of civilian sources of infection.
The Pacific.-In the Asiatic and Pacific theaters, V-J Day was also followed by a marked increase in rates. This was particularly true among occupation troops in Japan (fig. 70). The March 1946 issue of Health95 contained the statement: "The most important facts about the incidence of venereal disease overseas are the continued advance in the rate for troops in Japan * * *. From 117 in November the admission rate for venereal disease in Japan rose to about 180 in December and to 227 in January. It approximates current rates in the European Theater. In Korea, however, the situation is both stable and very favorable, according to advance reports. At 22 per 1,000 men per year the January rate for the XXIV Corps is but one-tenth that for troops in Japan."
As in the European theater, the situation in Japan improved with the stabilization of the occupation troops and with the reinstitution of civilian public health activities (fig. 71). The part played by the Public Health and Welfare Section of General MacArthur's occupation headquarters in abolishing legalized prostitution and in controlling venereal infections in the civil population of Japan is fully recorded in another volume of the preventive medicine series.96
South Atlantic areas.-The discussion on venereal disease control activities in the South Atlantic (p. 316) closed with a highly optimistic note. It was stated that all-out efforts in the area had brought about, in May 1945, the lowest rate experienced-36 per 1,000 average strength per annum. Regrettably, this excellent record could not be maintained. Following trends in the rest of the world, some of the highest rates to be experienced in the area occurred in late 1945. For a thousand average strength, the per annum rate for November 1945 was 122 and for December 1945 was 165.
Zone of Interior.-In the Zone of Interior, a marked increase in venereal disease rates occurred after V-E Day. Even more noticeable was the increase after V-J Day. The April 1946 issue of Health contains the following statement:
The April venereal disease admission rate of 84 per 1,000 men per year for troops stationed in the United States appears to be in line with the general upward trend described in the previous issue of HEALTH.
* * * * * *
There can be no doubt that the increasing incidence of the venereal diseases presents a serious socio-medical problem, for which an adequate solution requires as a minimum, an army-wide intensification of venereal disease control, and a more constructive program of recreation and education. More dissemination of information among the troops on the limitations of venereal disease therapy might have some effect in lowering the venereal disease rates.
95Monthly Progress Report, Army Service Forces, War Department, March 1946, Section 7 : Health.
96Medical Department, United States Army. Preventive Medicine in World War II. volume VIII. Civil Health Problems. [In preparation.]
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FIGURE 70.-So-called "Geisha" girls were ready to lavish their attention on the American occupation soldier.
Here again, all venereal disease control measures seemed relatively ineffective, and rates did not appear to decline until the Army of the United States was demobilized and the majority of troops was again Regular Army.
Summary.-It is obvious from epidemic venereal disease rates which were encountered in the wake of victory that venereal disease control measures
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FIGURE 71.-This high-class Japanese establishment has been judiciously placed off limits to U.S. Army troops.
which seemingly were effective during the war were not sufficient to counteract the loss of discipline, the effects of leisure time, and the general confusion accompanying a massive demobilization. If a recurrence of this situation is to be prevented, other measures will have to be adopted or discovered. It was fortunate, however, that the treatment of venereal disease made such spectacular advances during the war that, despite high rates at the close of the war, noneffectiveness from venereal disease reached an alltime low as shown in tables of appendix D. Therefore, although this venereal epidemic was distressing to those in command and probably to the majority of those infected, it was nevertheless not the major medical treatment problem that it would have been before the discovery of penicillin and other chemotherapeutic agents.
THOMAS H. STERNBERG, M.D.
ERNEST B. HOWARD, M.D.
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