British red cross society hygiene and sanitation manual

September 1956

Public Health in Occupied Italy--II THE MAINLAND TO MERANO By G. M. F R l Z E L L E , T.D., M.D., D.P.H.,

Deputy Medical Officer of Health, Metropolitan Borough of Hampstead. Colonel, late R.A.M.C. H E R E is an old proverb " Scratch a Russian and you will find a Tartar." If you scratch deeply enough through the reserve of any senior allied medical officer-naval, military, air force or civilian--who was within measurable distance of Naples during the famous typhus epidemic, he will probably coyly admit, under pressure, that he was largely responsible for bringing the epidemic to a stop. Such a statement, however, is not as fantastic as it fright appear, when we consider the number of agencies which worked together harmoniously in order to eradicate the outbreak. The success of the whole operation, in terms of the Allied war effort, can be measured by the fact that only one British soldier--a deserter--and two Americans caught the disease. A number of publications deal with the epidemic (notably by Chalke 1 in this country and by Soper and Markham 2 in the U.S.A.). It must be said here, however, that without the aid of the American Typhus Commission, the Rockefeller Foundation and the American and British Military authorities which freely seconded medical officers and made transport available to carry out this work, Allied Military Government and Allied Control Commission with their limited resources would have been powerless to cope with an epidemic on such a scale and the preventive measures necessary to keep it loealised.

Sporadic cases occurred in Sicily and at Brindisi during March but when seen by a member of the Typhus Control Unit, it was found that adequate precautionary measures had already been taken by the local authorities as a result o f the work of the Demonstration Unit.

T

In April and May, 1945, a village near Messina had an outbreak of 37 cases with nine death, while during the same period Palermo had 13 cases with one death. It is interesting here to note co-operation by a n U N R R A team which assisted in dusting the village of Capizzi and surrounding villages near Messina. After May 1945, typhus died out in Italy but attention was transferred to the northern frontiers 'where enormous numbers of returning refugees were coming over the border. Dusting stations were established at tlze reception cent~es and in consequence of their work no cases of typhus entered the country.

Smallpox Outbreaks In May of 1944, Naples began an epidemic of smallpox which spread to the surrounding ccmmunes. By June, the total number of cases had risen to 161 anp 145,813 vaOcinations had been performed both on contacts and by mass vaccination. Vaccine produced in Palermo and R o m e was used.

Typhus Demonstration Unit After the epidemic was over, a Typhus Demonstration Unit was set up by the Public Health Sub-Commission. This unit was of considerable value, as, under arrangements made with the Ministry of Interior, it visited all the provinces of liberated Italy to give medici provinciali and local doctors demonstrations in the technique of typhus control and trained teams of workers in dusting measures. Spray guns and supplies of D.D.T. were also left at each provincial centre. These demonstrations in Italy and Sicily aroused much interest and inspired the local inhabitants with confidence. Although the drama of the Naples epidemic attracted the limelight, this was not the only place where typhus occurred. In November 1944, four cases were reported from Naples Province and one suspected case from Sardinia. In December a woman aged 39 died from typhus in the village of Mugnano in the outskirts of Naples and her 14-year-old daughter recovered. Vigorous block2dusting methods prevented any further spread. The famous Regina Coeli prison in Rome was thoroughly disinfected in December and 806 prisoners dusted. In addition, constant dusting was continued in Naples throughout the winter, it being regarded as still the greatest potential danger area. 70,325 persons were dusted in December. 1 CHALKE,

Ibid., ii, 5-8.

H. D.

By the end of the first 10 days in July the number of vaccinations in Afragola, a suburb of Naples, was 30,1300. It was then found that mercuric chloride had been used in cleansing the skin. In consequence vaccination had to be begun afresh. The outbreak was obviously one of variola minor and was fortunately associated with a very low death rate. This, together with public apathy, greatly hampered the vaccination campaign. Furthermore, it was generally rumoured that the Palermo and Rome vaccines were not very efficacious and this led to many refusals. The rumour was, in fact, disproved by laboratory tests. By the end of July there had been four deaths in Afragola and two in Naples. These deaths were not an indication of the severity of the disease, as they occurred in debilitated children who might otherwise have been expected to recover. The mass vaccination was carried out by enlisting the aid of all doctors, medical students and sanitary officers available. There were three deaths in Naples City and 16 in the Province. By the autumn, the Naples epidemic had lessened but many cases continued to appear until after the cessation off hostilities. In the meantime, however, a fresh epidemic had broken out at Benevento. The Naples and Benevento outbreaks were very persistent. The vaccination state of the population at large was extremely low and much had to be done to overcome the apathy of-

(1946). Brit. reed. J., i, 977-980. (1946).

2 SOPER, F. L., DAVIS,W. A., MARKHAM,F. S., 8r RIEHL, L. A. (1947). Amer. J. Hyg., 5, 305-334. 311

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both the general public and officials, especially as there was little mortality. I n addition to the Naples and Benevento epidemics, outbreaks occurred here and there through Southern Italy throughout the summer of 1944 and the winter of 1944--45. A small outbreak occurred in Palermo but was quickly stamped out by the local authorities. As may be imagined, this generalised smallpox caused the Allied Control Commission much anxiety which was shared by the military authorities. All Italians employed in Allied messes, stores, workshops, etc., had to produce a valid certificate of vaccination as a requisite of employment. Vaccine prepared in Palermo, Rome and later Siena was used and vaccine was flown over from America as well.

Typhoid A small outbreak of typhoid fever occurred in Benevento during March and April 1944 with 62 cases and eight deaths. This subsided during May and June but flared up again in July and August with 202 cases and 20 deaths. A n epidemic of such proportions naturally alarmed and Allied authorities and local investigation showed that there were many open sewers which attracted flies, that the river was contaminated by fractured sewers and that vegetables were being fertilised by human manure. Case reporting was poor and many cases were not isolated. To combat these conditions a campaign was instituted both from the pulpit and by poster urging the populace to boil water, milk and vegetables before use. Bathing was forbidden in the river. The repair of fractured sewers was undertaken and immunisation by inoculation rather than by oral vaccine (which was popular with the Italians) was instituted. Isolation of all cases i n hospital was insisted u p o n and the hospital accommodation was doubled. Much valuable assistance was given by the British School of Hygiene a n d by the pathologist of South African 106 General Hospital. A Sister of the South African hospital, one Newfoundland soldier and a British soldier contracted the disease. The two former gave a history of having bathed i n the river.

Between June of 1944 and February of 1945 there were 459 ascertained and 245 suspected cases. The outbreak was due to a fracture of the aqueduct supplying water to the town, the polution of surface wells, the absence of a piped system of sewage and carriers. By February, 10,0t30 of the inhalzitants had been immunised with T.A.B. vaccine and immunisation was proceeding at the rate of 1,5130 a day. Although" some thousands of Allied troops were stationed in tl~e city, not one case of typhoid developed amongst the soldiery. As this epidemic occurred within the Army area, the chief work in its eradication was carried out by the local D.A.D.H. assisted by American Mobile Bacteriological Laboratories By the middle of March 40,000 primary and secondary inoculations had been carried out, the water supplies had been rectified and chlorinated and the epidemic was at an end.

Malaria Malaria, for hundreds of years the scourge of Southern Italy, Sicily and Sardinia, had been gradually reduced since 1887 by land reclamation. The malaria mortality rate per million had fallen from 104 i n 1924 to 14 in 1939. The Germans i n their retreat northwards systematically destroyed the great land reclamation schemes or bonifiche. The smashing of pumping stations, blocking of canals and diversion of rivers flooded thousands of acres of farm land, drove the peasants from their homes and vastly increased anopheline breeding. South of Rome alone, it was estimated that 98,000 acres were flooded. Further breeding places were created by mine and bomb craters, while the disruption of services meant" the loss of supplies and equipment for civilian use. The situation thus created was an enormous potential danger to the fighting strength of the Allied forces. That this danger did not eventuate was due'largely to the tremendous efforts and achievements in control measures and also to the greatly improved anti-malaria disciplifie amongst the troops, whose sickness rate from malaria was very high during the Sicilian fighting. This lack of anti-malaria discipline was due to two fallacious ideas, firstly that the individual was strong enough to shake off a mere malarial attack and secondly that the taking of " A t e b r i n " was a subtle method employed by higher authority to undermine sexual vigour.

Local Indifference By September 21st there had been 392 cases with 37 deaths, one of the deaths being a local doctor. Even with this death rate the populace and local authorities remained indifferent to control measures and appeal was made to Rome to send a medical inspector from the Central Authority to stimulate co-operation. The epidemic was controlled by November, but interest was by then focused on a new area, for late in October an .epidemic began in the Republic of San Remo. The normal population of the Republic. which is approximately 14,000, was swollen by an influx of refugees from the north and also from Rimini, where an epidemic had broken out. The outbreak in San Marino was traced to a fault in an aqueduct. Some 810 cases occurred there and about 340 in Rimini. The rnortality in both epidemics was 93 persons. T h e epidemics were suppressed before the end of the winter and much assistance was rendered by Army Medical Services and nurses of the British and American Red Cross. Another epidemic occurred in Prato, a n industrial town o f 80,000 inhabitants, situated 12 miles from Florence.

Control Unit I n March 1944, Colonel Paul Russell, the distinguished American malariologist, was assigned by A.F.H.Q. to Allied Control Commission as Chief Malariologist. Within the Public Health Sub-Commission he set up a Malaria Control Branch with two units, a Control Unit and a Demonstration Unit. The Control Unit was to assist the Allied Control Commission and Allied Military Government public health officers in developing an effective civilian malaria control programme to protect the Allied Forces and to prevent malaria occurring amongst the civilians of Sicily, Italy and Sardinia. The functions of the Demonstration Unit were to develop practical methods of using what was then the new insecticide D.D.T. against anopheline larvae and adults. The Director 312

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September 1956 of the Demonstration Unit was Dr. F. W. Soper of the Rockefeller Foundation, another malariologist of international repute, who had already done much in helping to quell the Naples typhus epidemic. A feature of the Malaria Control Branch was its close collaboration and co-operation with the chief medical authorities and all the malariologists of every Allied formation i n Italy as well as with the Italian medical authorities. The Ministry of Interior allotted 191,583,337 lire to carry out work on malaria control and land reclamation in Sicily, Southern Italy and Sardinia. The Medical Supply Branch made available 11,000,000 tablets of " A t e b r i n " and 125,000 ampoules of intravenous quinine for civilian use before the onset of the 1944 malaria season. A monthly supply of 60,320 gallons of larvicidal oil was obtained from the Comitato Italiano Petroli and 55 tons of Paris green,-30 tons from British stocks, 15 tons from the Institute of Hygiene in Rome and 10 tons of captured German s t o c k P were used in the summer of 1944. 7,775 civilian labourers were employed. It is an outstanding achievement, when one considers a malarious country disrupted by war, with a disorganised public health service and serious transport difficulties, that malaria was so well controlled by military and civilian agencies that it offered no serious problem either in or behind the combat area. Dusting of flooded areas with Paris green from a tank slung below an aeroplane lent by the Army was first carried out in the area of the Volturno river, but this was soon replaced by mixing D.D.T. with oil and spraying the flooded areas from the air.

obtaining pumping machinery and in reactivating many of the pumping stations destroyed by the Germans. Thus the combination of all resources, military and civilian, and the discovery of the use of 5 % D.D.T. in kerosene both against larvae and the adult mosquito, turned a potentially dangerous situation into one in which the Military Commanders were relieved of almost all anxiety concerning the health of their troops with regard to malaria.

Tuberculosis A n assessment of the general health of the population as reflected by the mortality figures for tuberculosis was impossible, as the notification of tuberculosis was not obligatory in Italy except in schools, universities, military organisations and other centres of communal life. The only reliable figures obtainable were those of the death rate and obviously in 1944 these could not be obtained for the whole of Italy, while even in the Italian Government territory it was difficult to obtain them owing to the general disruption occasioned by the war and the difficulties in communication. I n order to gain some idea of conditions, it was decided to concentrate on the returns for Rome alone. I n the first half of 1943, the mortality rate had already begun to rise in Rome even before the Sicilian landings had taken place. The death rate became high in 1944, but took a general downward trend in 1945 as conditions began to improve. Infant Mortality A similar review of infant mortality figures in Rome was undertaken. This was especially important as much alarm had been aroused by the Press, especially in America, by the publication of figures called the infant mortality rate, which were in fact the total infant death rate. The review showed that the figures at the end of the 1914-18 War were high and exceeded those of 1944, while in 1945 a drop occurred, due probably to the free distribution of milk and infant foods. However, figures and conclusions can be very misleading in war time, as the Public Health Sub-Commission reported in January, 1945. It gave the following reasons in this case : - "(1) The spread of hostilities from Sicily northwards through the mainland has resulted in the destruction of many municipal and provincial records. " (2) When the Germans retreated from Rome they took with them many important valuable documents from the Institute of Statistics. " (3) During the past year, the standard of reporting of figures concerning adult and child mortality has fallen to a new level, especially in the country districts and even yet, although communication facilities are improving, it has not reached the pre-war mark. " It is felt therefore that at the present moment any survey covering wide areas of liberated Italy would result only in figures from which erroneous conclusions would be drawn." Despite this protest, however, the Sub-Commission continued to receive demands from higher authority to submit comparative tables, chiefly it was felt, With a view to supporting one or other person's particular point of view. The problem of venereal disease is an ever-present one and doubly or trebly so in wartime. The Italian s y s t e m of licensed brothels was frowned upon by the Allied Military Authorities and they were put out of bounds. As a result, clandestine prostitution, which in Italy is a n offence, rose

Effectiveness of D.D.T. The Demonstration U n i t carried out its experiments first i n the Volturno area and later i n the Agro Romano. They discovered that effective control of adult mosquitoes entering h u m a n and animal quarters could be obtained for a period of 80 days after treatment with 5 % D.D.T. in kerosene at the rate of 60 milligrams D.D.T. per square foot of surface sprayed, and that treatment with 5 % D.D.T. in kerosene at the same rate gave a more effective adult control than treatment with 10 % D.D.T. i n pyrophyllite powder where only 20 milligrams of D.D.T. per square foot adhered to treated surfaces. These were the first large scale field experiments i n the use of D.D.T. in malaria control and the discovery of its effectiveness against the adult mosquito was of vital importance. I n preparation for the 1945 malaria season, extensive spraying operations were undertaken in the Tiber dealt and by June in this area alone 5,800 buildings containing some 47,000 rooms had been sprayed. The success of residual spraying was such that soon everyone was clamouring for it. The inhabitants found that, apart from adult control, they had never before been so free from flies, fleas and biting insects. Large scale aerial spraying was also undertaken in the Po delta and the coastal sector near the mouth of the Isonzo river and as the armies moved on in the north, house to house residual spraying was carried out. It must not be forgotten, either, that the Allied Control Commission made energetic and often successful efforts in 313

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whole country to be liberated before contemplating a change in the existing machinery. The rise in the cost of living reduced the relative value of the amounts distributed in public assistance and this bore heavily on the Maternity and Child Welfare Institution (O.N.M.I.).

by leaps and bounds, especially in the large leave centres of Rome and Naples, and the venereal disease figures became such as to occasion considerable anxiety. Prostitution was not only carried on by the professional ; many were driven to it by financial straits, by the food shortage or the high black market prices of commodities. I n addition, the moral laxity occasioned by war time affected all classes, and the hurt incredulity of one stricken gentleman will never be forgotten. " B u t she was a Contessa!" he protested. Italian law provided for the compulsory notification of venereal disease, the prosecution of an infected person conveying syphilis and the compulsory medical examination o f unlicensed prostitutes. The enforcement of these provisions, the control of unlicensed prostitution and the provision of hospital facilities for the diagnosis and treatment of infected women became one of the major problems which the Allied Control Commission had to face. Before the occupation of Rome, 19 hospitals for the treatment of infected women were established in Italian Government territory, with a total of over 2,000 beds and a turnover of 3,500 patients a month.

American Relief Work American charitable services then took a hand in welfare activities and the Roman Catholic citizens of the U.S.A. contributed largely to an organisation which was set up and called American Relief for Italy. The Chairman of this organisation was Mr. Myron Taylor, President Roosevelt's personal representative at the Vatican, and some 800 tons of clothing, dried milk and vitamin tablets were quickly collected. Because of the exigencies of war, it was impossible to ship all this to Italy at one time, but some 50-60 tons a month came in without interfering with military supplies. Further supplies were also collected in Spain and the Argentine. Mr. Taylor's Committee in Rome was composed of representatives from the Italian Government, the Italian Red Cross and the Public Health Sub-Commission. A distribution agency was set up and the supplies went at first to the most devastated provinces of Central Italy. Allied Military Government and Allied Control Commission welfare officers made every effort to improvise clothing from any salvage. A n example of their ingenuity is the fact that children's socks were made from unravelled salvage tent ropes. They also obtained unserviceable canvas mattress covers and other materials from which t o make clothing. In their efforts they were assisted by members of both American and British Quaker organisations. Many of the raw materials obtained were made into clothing by the inhabitants o f orphanages and other charitable institutions and distribution was effected through the Italian Red Cross and the Knights of Malta. The Public Health Sub-Commission managed to procure 364,000 blankets for distribution to hospitals and welfare institutions and by doing so filled a very pressing need. After the departure of Major Witte to another theatre in January 1944, the Welfare Branch was headed successively by Capt. E. Silveira and Lt.-Col. John McSweeney, both American Officers.

Venereal Disease Inspectorate After the occupation o f Rome, the Italian Government set up a venereal disease inspectorate and the civilian police were active in arresting suspects, but the number of cases soon became too large for hospital facilities and personnel to cope with. Even after the suppression of houses of clandestine prostitution and the jailing of 250 persons concerned, the number of hospital beds available was insufficient. Lack of transport and an insufficiency o f drugs added further problems and it is obvious that the whole situation as it existed opened up an enormous field for graft, corruption and the black market exploitation of drugs used in the treatment of venereal disease. It was only after the end of hostilities that the Italian Government accepted the offer of assistance both in drugs and medical staff from military sources, on condition that the Allied medical authorities would exercise supervision over diagnosis and treatment. Welfare in Devastation A tremendous problem facing A r m y A . M . G . Welfare Officers and later the Allied Control Commission regional organisations was that of the devastated areas. I n organising services such as feeding, rationing and the relief of destitution, they were greatly assisted by American and British Red Cross workers. A t first the two units worked together, but north of Rome the American Red Cross worked with the Fifth A r m y and the British Red Cross with the Eighth Army. Their work, along with the Allied Military Government Welfare Officers, often carried them into areas still subjected to shell fire, where they organised mass feeding. After the occupation of Rome, Allied Control Commission tried to get the Italian Government to adopt its simplified method o f working the welfare services, as was described in the section of this paper on Sicily (see p. 284), and as was adopted in the Allied Military Government areas. However, the Government would not agree to this in Italian Government territory, preferring to wait for the

Repatriates and Refugees With the cessation of hostilities it was anticipated that large numbers of louse-ridden, tuberculous and undernourished refugees and repatriated prisoners of war would return and give rise to a considerable problem. The question of establishing a complete cordon sanitaire in the north was discussed, and the Swiss Government, through the International Red Cross, offered 80 doctors and 150 soldiers from Swiss Army medical units to assist in establishing this barrier. The Swiss Red Cross also generously offered assistance in the form of mobile laboratories and hospitals, and this help was gratefully accepted and utilised in Central and Southern Italy. In June 1945, Dr. Soper and Dr. Markham of the Typhus Control Unit left Rome to make a tour of the northern areas and consult with all the agencies interested in dealing with refugees, placing special emphasis 314

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September 1956 on the importance of efficient disinfestation at all points of entry. "The quarantine system is definitely contra-indicated because the necessary accommodation is not available at points where control posts would be most effective and because it would inevitably slow up movement and drive large numbers out of the main channels of traffic, thus preventing the discovery of the obviously ill, 'thus reported.' Concurrence in this opinion was expressed by practically every administrative officer contacted throughout Northern Italy. Typhus fever, therefore, remains as the primary epidemic threat and through proper dusting the likelihood of its introduction may be minimised without seriously interfering with the rapid movement of refugees." As it was felt that there were sufficient agencies in Italy to deal with movements on these lines, the Swiss offer for the north was declined with thanks.

Hospital Centre at Merano During July it became known that about 5,000 sick Italian prisoners of war were to be repatriated and would require hospitalisation. It was reported that the Germans had established a large hospital centre at Merano, near Bolzano, where their patients were nursed in many of" the hotels of the town and in a large Bergsaglieri barracks which had been turned into a hospital. The then Deputy Director of the Public Health Sub-Commission accordingly went north to Merano and took over the hospital command from the German General in charge. There were still German sick and wounded being nursed at Merano, but by August 1st it was anticipated that 1,700 beds would be free, with a. further 1,000 by August 8th. Two Italian field hospitals with a capacity of 580 beds were set up close to Merano in July in order to deal with unexpected arrivals of hospital trains. The Italian Red Cross was to supply the doctors and nurses to deal with the anticipated 5,000 patients but only five doctors and 14 nurses could be made available at first. The Swiss Red Cross kindly sent a team of 15 doctors and 40 nurses and A.C./A.M.G. provided medical supplies and hospital rations.

Close liaison was maintained with H.Q. No. 2 District in Milan and the D.D.M.S. made available a central laboratory and a disinfestation service. 5,500 repatriated Italians had been received and 2,200 evacuated to the south. This evacuation required close collaboration with southern Italian hospitals, a knowledge of their bed states and the accurate timing of hospital trains. Many of the returning patients were tuberculous and to relieve pressure on the Merano Hospital Command, arrangements were made with the Italian authorities for the transfer of a number of these to Sondalo Sanatorium, situated near the Swiss frontier. While the bed capacity was then much in excess of the patients being cared for, it was not proposed to reduce the size of the centre in any degree, as it was never known when a fresh influx might occur. However, by then the two Italian field hospitals had been returned to the Italian Army. Between November l l t h and 30th, 1,116 patients arrived from Russia by freight train. They were in poor condition and had had no medical attention during their 37 days' journey. O n December 15th, 1945, the Italian Red Cross--under the direction of the High Commissioner for Public H e a l t h - assumed responsibility for the operation of the Merano Repatriation Hospital Command.

Conclusion The island of Sardinia has not been mentioned in the text but it must be noted that epidemiological and other problems, similar to those encountered in Sicily and the mainland, were also met with here. The object of this article has been to draw attention to the many problems encountered and surmounted by the Public Health Branch of A.M.G./A.C.C. duringtheItaliancampaign. It is believed that much good work of considerable interest was carried out, concerning which little is know0 so far outside the circle of those who were the actual participants. I n a paper of this length it has obviously been impossible to do more than scratch the surface of the subject and much detail has, of necessity, been omitted. Many problems were encountered, some of them anticipated, others unforeseen, and many lessons were learnt. When dealing with such large-scale emergencies as the Naples typhus epidemic and malaria control, the individual resources of the Allied Commission, which possessed only some manpower without equipment or transport of its own, were quite insufficient and the aid. of the Allied~ military medical authorities had to be invoked. This aid was always forthcoming to the utmost of availability and is gratefully acknowledged. Without it, the public health branqh could not have achieved what it did. In order to keep this article within publishable limits, 11 statistical tables and a section on veterinary medicine have had to be omitted. The opinions and views expressed are the author's own.

Hospital Trains Arrive When it became generally known in Europe that the Merano Repatriation Hospital Command had been established, hospital trains began arriving from Germany in such numbers as to strain every resource. I n addition 62 patients arrived unheralded from Russia, having been 35 days on the way with insuffcient food and no medical attention. At this time, the Merano project was being administered by the Allied Commission but it was planned to hand the administration over to the Italian authorities in due course. The provision of sufficient transport was obviously a fundamental necessity to the adequate r u n n i n g of the Command and A.F.H.Q. was requested to allocate 20 ambulances, six autobuses, two buses, eight medium trucks and eight heavy trucks. By September many of the initial difficulties had been overcome. A.F.H.Q. had given authority to draw medical stores and housekeeping equipment from captured enemy stocks and to maintain a pool of ambulances and vehicles. The American Red Cross had made a shipment of 17,691 hospital garments and the first delivery of coal had arrived.

We regret that owing to extreme pressure on space we were compelled to omit the statistical tables which Mr. Bevan prepared for his paper on "The Behaviour and Educational Attainments of Deprived Children," published in our June issue. If readers wish to have detailed statistical information in amplification of the article, the author will be pleased to supply it. 315