Achievements of UNR Till as an International Health Organization WILBUR A. SAWYER, M.D., LL.D.,`F.A.P.H.A. Director of Health, United Nations Relief and Rehabilitation Administration, WasAington, D. c. S 0 astounding is the magnitude of the overall performance* of the United Nations Relief and Rehabilitation Ad- ministration, with its mammoth ship- ments to war-ravaged countries of food, clothing, agricultural seeds, implements, and other essential supplies, that the strictly health functions are dwarfed by comparison. Nevertheless, in order to meet its responsibilities during the emer- gency, the Health Division of UNRRA had to expand until it became by far the largest international health organiza- tion which the world has yet seen. This is true even if the coijperating Division of Medical and Sanitation Supplies* is not included. The extent of UNRRA's operations was dramatically illustrated by a com- ment of Mr. Noel-Baker l at the recent session of the Council of UNRRA at Geneva: During the war I was a Minister under Mr. Churchill in our Department of War Trans- port, and month by month I used to watch the convoys which brought to Britain the food and the raw materials with which we fought the war. The scale of UNRRA's supply operations each month is now equal to the total import programme of the United King- dom in those historic times. For UNRRA's entire period of active operations lasting about three years, the o The Division of Medical and Sanitation Supplies. nJponsible for procurement and distribution, is in the Bureau of Supply, while the Health Division, under the Director of Health, is in the Bureau of Services. total budget amounts to approximately 3 billion 7 hundred million dollars. When the Administration closes its books next year it is estimated that its health work will account for close to 168 million dollars. The largest por- tion of this amount, or about 146 million dollars, will have been spent for pro- curement and shipment of medical and sanitation supplies. By June 30, 1946, 105,000 tons of sera and vaccines, chemicals and drugs, hospital equipment, and laboratory supplies had already been dispatched, and about an equal amount was still to go forward. The estimate of 22 million dollars for the health activities exclusive of expendi- tures for supplies was reached by pro- rating the total estimated operational and administrative expenditures up to December 31, 1946, according to the numbers of international employees engaged in health and the number in the total functions and thus determining the share belonging to health. The maximum annual expenditure of UNRRA for health is that for 1946, estimated as about 14 million dollars for the activities of the Health Division plus 68 million dollars for the procure- ment and shipment of medical and sani- tation supplies. This gives an estimated sum of 82 million dollars for health, medicine, and sanitation during that year. The annual sum for health activi- ties was substantially increased by allot- ments by certain governments from the proceeds of sales of part of their c411 AMERICAN JOURNAL OF PUBLIC HEALTH Jan., 1917 UNRRA supplies. Such sales to persons who could afford to buy were permitted on condition that the net proceeds in local currency should be turned back into relief and rehabilitation activities. The size of UNRRA's effort in the field of international health can best be appreciated if we mention for com- parison a few other important annual health budgets. The League of Nations Health Organization had the equiva- lent of U. S. $414,078 in its largest annual budget, the one for 1931, and did valuable pioneering work with these resources. The Interim Com- mission of the World Health Organ- ization is reported to have a budget of $300,000 for the remainder of 1946 and $l,OOO,OOO for 1947. The Inter- national Health Division of the Rocke- feller Foundation for the calendar year 1945 had a budget of $2,200,000 for its regular program and expended also $157,016 from the special war funds of the Rockefeller Foundation Health Commission. The United States Public Health Service has a total budget for the fiscal year ending June 30, 1947, of $88,423,516, including $290,700 for its new Office of International Health Rela- tions. All the 48 states of the United States of America together appropriated about 50 million dollars for health for the year ending June 30, 1946, and the corresponding figure for the local gov- ernments is about 70 million. These comparisons bring out the magnitude of UNRRA's total expenditures for health. They had to be large because the re- quirements for relief health services and TABLE 1 International and Local Professional Health Personnel by Profession and Place of Duty June 30, 1946 Place of Duty 1 Headquarters-Washington European Regional Office AibilUiZl AUSti Belgium Byelorusafa China Czechoslovakh D0deCatX.X Ethiopia FraXa Germany Greace Hungary Italy Middle East Poland Ukraine Yugoslavia 1 4 - 489 , Sanitary Other Physi&nr NUNeS Engineers P&?S&~l 7 0 2 1 4 10 2 2 0 1 1 0 0 0 0 36 1 28 0 0 1 0 1 0 9; 0 0 0 8 18 32 14 20 1 0 0 1 0 5 : : 1 8 1 cl 2 0 0 280 7 348 21 1 32 : 1 26 0 2" 0 0 i 2 11 9 2 2 x : i 1 0 0 2 2 1 30 512 36 61 1: 4 4 Total 14 15 a:* 2 1 174 * A 4 2 640 ' 114 0 59 = 171 9 1 9 1,134 g Grand Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._.............................. lThere wz~ no professional health personnel in Finland, Korea, or the Philippines, where LO.%1 Em~loyea 0 0 0 0 3 0 11 1 0 0 2 43 4 79 0 1 79 0 1 4 0 5 229 1,134 -- 1,363 activity wa5 exclusively on supplies. 9 Occupied exclusively with Displaced Persons: Austria, 55, Germany 640, Italy 5, Middle Easl 17. Total 717. * Including I` program personnel " for clinical work and teaching. 113 (59 Physicians, 17 Dentist+ 20 Nurses, 5 Sanitary Engineers, 12 Other). 4Including 34 Physicians and 9 Nurses. EIncluding 20 Physicians, 19 Nurses, 24 Sanitary Enginews, and 16 Other. a Including 25 Physicians, 10 Dentists, 44 Nurser. p.37 ACI&WEMENTS.OF UNRRA TABLE 2 International Professional Health Personnel by Profession and Nationality Notionoli0' June 30, 1944 Physician5 Dcntirts NUWS Australia Austria BelgilUU Bolivia B&i1 Callada ChilM COlOdii Cuba gxm~vakia Dominican Republic Eire El Salvador Equador France GEeCG Hawaii Holland Honduras Iran If4 Luxembourg Mexico New Zealand Norway Palestine Poland South Africa stateless Switzerland u. IL u. s. USSR Venezuela Yugoslavia UllkIKlWll TOtal. I 2 28 1 9 8 : 13 20 9 1 18 2 5: 6 1 13 0 i 3 12 1 2 3 31 1: a 100 90 : 3 19 12 1 76 0 0 28 0 0 0 1 43 0 21 8 50 0 0 68 0 0 13 1 0 6 5 0 2 : 4 1:: 0 0 0 10 489 30 supplies were extreme at this time of unprecedented emergency. THE STAFF OF THE HEALTH DIVISION The professional staff of the Health Division at Headquarters in Washing- ton, at the European Regional Office in London, in the China Office, in the dis- placed persons operations in Germany, and in the Missions to the several assisted countries,,is shown by numbers, professions, and nationality in Tables 1 and 2, as of June 30, 1946. At that time recruitment of new personnel ceased and numbers were already be- ginning to decrease. The recruitment of a large profes- sional staff during the war was extremely 512 difficult. 0 0 0 0 0 : z 25 0 0 0 0 0 : 0 0 2 0 0 0 : : 00 0 0 0 1 0 :: 0 0 0 0 0 : 0 0 :; 0 0 1 3 Total 19 3 104 1 10 39 : :J' 53 3: 2 1 101 7 2 a2 1 3 13 1: : 3 34 4 13 12 206 263 1 3 4 32 36 67 1,134 In Great Britain and the United States, military needs had pri- ority. Many other areas which were drawn on later were at first inaccessible. The Surgeon General of the United States Public Health Service and the Chief Medical Officer of the British Ministry of Health appreciated the in.. ternational importance of the health activities of UNRRA and helped arrange for the temporary release of experienced personnel from positions in their countries. The U. S. Public Health Service also assigned many of its commissioned officers to service with UNRRA and in September, 1946, there still remained on duty with the Health Division 34 medical and 4 dental of- 44 ~IMER~CAN JOURNAL OF PUBLIC HEALTH ficers, 66 nurses, and 16 sanitary engineers. The international professional staff was recruited principally from the 48 nations now participating in UNRRA and on. as broad an international basis as possible. From Table 2 it will be seen that the 1,134 professional persons in the international (" Class I ") cate- gory, included nationals of 35 countries and a few classified as stateless or un- known. The posts of greater responsi- bility were also widely distributed among the nations, as will be illustrated by a few examples. At Headquarters in Washington, the Director of Health came from the United States, the Deputy Director of Health from Czecho- slovakia, the Chief of the Far Eastern Branch from China, the Chief of the Epidemic Control Branch from Brazil, and the Chief of the Branch of Medical and Sanitation Supplies from the United Kingdom. In the European Regional Office, the Regional Director of Health is from the United Kingdom, his Deputy from the United States, and the Chief of the Branch on Medical Services to Displaced Persons from France. Chief Medical Officers for Country Missions and the China Office have been drawn from many countries; to cite only a few examples, from Yugoslavia for China, from Greece for Ethiopia, from the United States for Poland, and from the United Kingdom for Italy and Greece. The Chief Field Medical Officer in China is from El Salvador. The international doctors and nurses fall into two categories, those with public health training and experience and those primarily concerned with the care of the sick. The public health group was invaluable in the administra- tive and supervisory offices, and in field work in their specialties. Most of the clinical staff were assigned to assembly centers for displaced persons or to hos- pitals and clinics for the general popula- tion, although a few were primarily Jan., 1947 engaged in teaching and demonstration. The volume of accomplishment was far beyond what the size of the UNRRA staff would indicate, for staff members worked side by side with a much larger personnel of the local health depart- ments and medical institutions. In China, coijperation by the Health Divi- sion was facilitated by a parallel organ- ization, the Health Commission of the Chinese National Relief and Rehabilita- tion Administration. In the 15 regions, the UNRRA personnel coijperated with their Chinese opposites in a combined effort to restore public health and medi- cal activity to at least pre-war effective- ness as rapidly as possible. Several hundred doctors and dentists found among the displaced persons were asked by UNRRA to help care for their fellows in the assembly centers. For example, in the British and United States occupation zones of Germany at the end of July, 1946, there were 152 dental clinics staffed by 311 dentists, nearly all displaced persons. Certain principles determined whether a country desiring assistance needed a Mission and heahh services. Such assistance was available to invaded countries seriously damaged, and finally liberated from the enemy, which did not have enough foreign exchange to purchase the imports they needed. This was the case with Greece, Poland, Czechoslovakia, Yugoslavia, Albania, Ethiopia, China, Byelorussia, and the Ukraine. Work was done also in ex-enemy countries under conditions determined by the UNRRA Council. These were Italy, Austria, and Hungary. In Ger- many, UNRRA assistance was given solely in the care of displaced persons. Limited assistance was given to the Dodecanese, Finland, Korea, and the Philippines. In the assisted countries, the health staff, headed by a chief medical officer, is an integral part of an UNRRA Coun- vi. 37 ACHIEVEMENTS OF UNRRA 45 h M&&n, and is, under the overall &ction of the Chief of Mission and h+, deputies. For technical guidance and gene& health policies there is, nevereelest+ a close dependence on re- gional offices and headquarters. The international professional health staff in a Country Mission varies from one medical officer in Czechoslovakia and &e Ukraine, for example, to 174 pro- fessionally trained people in China. However, what we have come to think of as a I` standard mission," has at least a chief medical officer with public health training, a chief public health nurse,`and a chief sanitary engineer at Mission headquarters, with field personnel in the districts assigned according to need. The large staff of 640 persons in Ger- many is occupied only with the care and health protection of displaced per- sons. Similarly engaged are 55 persons in Austria (29 physicians, 26 nurses), 5 in Italy (3 physicians, 1 sanitary engi- neer, and 1 nurse) and all 17 of the persons in the Middle East. ORIGIN AND FUNCTIONS OF THE HEALTH DIVISION When the future historian evaluates the work of UNRRA's Health Division, he will probably attribute greater sig- nificance to its service in bridging the war-caused gap in the evolution of inter- national health organization than to its relief operations of a purely emergency nature. Many of the national health departments, on which the world health structure must rest, were inhibited or broken by the most widespread and destructive of all wars. There was an unprecedented shortage of materials, apparatus, transportation, communica- tions and buildings essential to the pro- tection of health and the maintenance of medical care. There was, in addition, disorganization, loss of trained per- sonnel, and isolation from the newer health knowledge. The international bodies such as the League of Nations Health Organization and the Interna- tional Office of Public Health in Paris, to which the affected national health de- partments would naturally turn for guidance and leadership, were cut off from most of their field of activity an& were largely prevented from functioning, The International Health Division of the Rockefeller Foundation had been forced to terminate most of its activities in Europe, and had as a result deflected more of its attention to South America. The Pan American Sanitary Bureau, operating only in the Americas, was less disturbed. The experiences of these organizations, and the experts they had trained, were most valuable for the restoration of health departments in the liberated countries and in carrying for- ward the health work of UNRRA, To face the challenging situation, UNRRA's Health Division was created . in December, 1943. Forty-four nations had signed an agreement on November 9 establishing the United Nations Relief and Rehabilitation Administration. The Health Division started operations shortly after the first Council session, meeting in Atlantic City, had laid down in detail the purposes and objectives of the new agency, and had given it the necessary framework of instructions and authority.2 The functions of the Health Division may be summarized briefly as follows: 1. Assistance to national health authorities a.in the prevention of war-engendered epidemics, b.in the rapid restoration of national health departments, c. by assignment of technical staff for con- sultation and cooperation, d. in determining the requirements in med- ical and sanitary supplies to replace losses through destruction, looting, and the cut- ting off of sources, and in cooperating with UNRRA's Bureau of Supply in re- lated technical matters of procurement and distribution. 2. Revision and administration of international sanitary conventions for maritime and aerial quarantine, as applied to signatory mem- 46' AMERICAN JOURNAL OF PUBLIC HEALTH Jan., 1947 bers of the United Nations, and the carrying out of the specific duties imposed on UNRRA by the revised conventions. 3.Provision and technical supervision of medical and sanitary personnel for the care and health protection of persons displaced by war wherever UNRRA has responsibility for them in assembly centers, or camps, or during travel back to their countries. 4.Trainmg of professional health and medical personnel of the assisted countries, in preparation for relief and rehabilitation work, through study fellowships in foreign lands and by supplying teachers and lec- turers for courses in the assisted countries. PREVENTION OF EPIDEMICS The great wars of history have been accompanied and followed by sweeping epidemics, usually directly related to the devastation and hardship. In the recent World War, since the destruction was more widespread than ever before, the greatest catastrophes were to be ex- pected, Multitudes of people were being driven from place to place. Thousands were crowding into makeshift dwellings. Scarcity of food, clothing, medical care, and even of pure drinking water was almost universal. .4nd most of the health departments that had survived the war had been completely disrupted and so largely deprived of necessary per- sonnel and supplies that they were quite ineffectual. The only hope of avoiding major health disasters lay in the advances in medical science made since the previous World War and in early organization to apply this new knowledge effectively. Appreciating the appalling risks to world health, the Council of UNRRA gave the Health Division a wider man- date with regard to epidemic prevention than in its other fields of activity. It authorized measures to control epi- demics not only in liberated areas but also in enemy and ex-enemy countries with the purpose of preventing the spread of such epidemics to United Nations areas or to displaced persons of United Nations nationality. Of the war-engendered epidemics to be expected, the one that presented the most alarming threat was typhus fever. Consequently, the Health Division felt the highest degree of responsibility for curbing it. Without control, widespread epidemics of typhus were inevitable. With control, safety was possible be- cause of the effective new weapons which had been developed against the disease. UNRRA was in a position not only to secure and distribute vast quantities of DDT delousing powder, but through its field staff it could give directions as to the method of application. The results have been highly grati- fying. No great runaway epidemics of typhus have occurred as the result of the recent war. Credit must be given first to those who devised the practical and effective methods of delousing fully clothed persons by powdering with DDT. The Bureau of Entomology of the U. S. Department of Agriculture, the International Health Division of the Rockefeller Foundation, and the United States of America Typhus Commission all contributed invaluable evidence ob- tained through experiments and field trials. Before UNRRA had free access to some of the critical areas, the occu- pying armies, the U. S. A. Typhus Com- mission, and the International Red Cross here and there helped the local health authorities to keep the situation in check. As soon as the shipping lanes were cleared, UNRRA dispatched thou- sands of tons of DDT powder and many hundreds of dust pumps. UNRRA staff was sent in to help organize control and to give instruction in methods. A limited amount of typhus vaccine was supplied also but it was not used on a large scale in the general population, and therefore played only a secondary r6le. The size of UNRRA's effort is disclosed by the large amount of 10 per cent DDT delousing powder which is being distributed to the various coun- tries, as shown in the first column of +CHIEVEMENTS OF UNRu 47 TABLE 3 Total Program for Shipping DDT, by Recipient Countries Fm Ty9hn.s Controi Far Malaria Control L --- 10% DDT `20% DDT 26% DDT POW&7 SOlUfiO~ Solution In Powbis In Galhs In Gallons 198,100 2.394,410 216,040 170,000 205,175 8.900 224;640 100,000 ..,. 2,014,980 1,254,236 39,000 . . . . . . . . . . . . 275,204 . . . . . . . . . . . . . . . . . . . . 90,000 50,000 130,000 . . . . 4,000 253,cao . . . . 225,000 . . . . .,.. . . . . 270,000 - --- -- Totals 6,786,481 404,204 932,000 (3,393 tom) Table 3. The other columns showing dence was 33,929 cases in May. For the amounts of DDT being shipped for 1945 our reported figures began with use in malaria control will be referred April, and the comparable peak seems to later. A single dusting of one per- son requires about 2 ounces of the 10 per cent DDT delousing powder, and it is effective for several weeks. Probably the most practical estimate of the general results of the campaigns against typhus can be obtained by com- paring the typhus incidence in Poland in the years 1919 and 1920, immedi- ately after World War I, with the avail- able figures for part of the corresponding period of 1945 and 1946, after World War II. This is done in Table 4 and Chart 1. In 1919, the maximum monthly inci- to have been reached also in Nay with 2,987 cases, or less than one-eleventh as many as in May, 1919. In 1920 and the early part of 1946, the correspond- ing maximum figures, both of them in January, were 34,530 and 1,235, giving a ratio of approximately 28 to 1. The data for 1919-1920 are for Congress Poland and Galicia only, while those for 194.5-1946 relate to the present ter- ritory of Poland, including the three former German provinces which came under Polish administration in Septem- ber, 194.5. Eastern Galicia is therefore excluded in the later period, but Poland lOOc/o DDi POWdl7 In Pou?uis 24,000 250,000 6,450 . . . . 533,100 ,... 406,000 ,... 20,000 157,525 55,000 1,452,075 TABLE 4 Typhus Fever in Pokand, 1919-1920 and 1945-1946 JUUIy 14,207 FebIW3~ 34,530 March 17,061 25,858 April 23,272 27,843 May 28,190 24,616 33,929 JUW 24,339 July 20,445 12,329 @ust 22,287 5,366 September 14,735 1,388 October 11,986 1,650 Nwember 12,980 2,195 December 12,382 3,013 18,333 4,576 Number oj Cares v- 1920 I Number of Cares L 1945 . . . . . . . . . . . . 1,867 2,987 1.795 1;536 794 782 869 601 682 - 1946 1,235 635 516 417 221 89 99 78 47 . . . . . . . . 48 AMERICAN JOURNAL OF PUBLIC HEALTH Jan., 1947 CHART l-Typhus fever incidence in Poland after World War I in comparison with the incidence after World War II west of the German frontier of 1914 is included, which makes the two sets of figures fairly comparable. Moreover, the differences observed in the compari- sons are so great that we are not. attempting here to make allowances for changes of area or population. It is evi- dent from the chart that typhus in Poland is being conquered and that the war emergency with respect to this dis- ease is over. In fact, we are given hope that Poland could exterminate typhus before long by the modern methods which have been introduced. This result could be hastened by international planning with participation by Poland's neighbors as well. A flare-up of typhus fever in Yugo- slavia was also to be expected, for it was in Serbia that the great epidemic of 191.5 occurred early in the previous World War. During that visitation, over 150,000 people died of typhus within a period of 6 months, and the daily admissions for typhus to military hospitals alone rose to the staggering height of 2,500. Nothing comparable was permitted to occur in the recent war, although the disease was epidemic in Croatia and Serbia before effective control could be initiated. The U. S. of America Typhus Commission was invited early to Yugoslavia to help con- trol typhus. The Commission organized control by DDT dusting and vaccina- tion and trained many persons in the .i.:; ,yf?l. 3z "' ACHIEVEMENTS OF UNRRA 49 `ðods. Later UNRRA took over and two sanitary engineers to its Poland .a&& to advise and to provide the Mission in the hope that they can assist &cessalY supplies. Typhus in Yugo- the trained sanitary engineers of the &via is steadily responding to control. Ministry of Health in discovering and There were about 50,000 cases in 1945, correcting some of the responsible con- but only 3,000 in the first half of 1946. ditions in the post-war environment. The same rosy picture cannot be In Table 5 and Chart 2 is shown painted for another serious preventable for comparison the monthly incidence of disease. During my visit to Poland typhoid and typhus fevers from April, in November and December, 1945, I 1945, to August, 1946. The great seri- was astounded at the amount of typhoid ousness of typhoid and the present low fever then present. It was being largely incidence of typhus are clearly shown. attributed to the great amount of migra- The typhoid fever maximum in October, tion and to contact between cases. 1945, was 17,629 cases and the peak in Unfortunately, we had no .new tech- May of the same year for typhus was niques, comparable to the use of DDT only 2,987 cases. The three former in a dust gun, that could be used for German provinces now under Polish ad- combating epidemics of typhoid. Since ministration are included only from then the Health Division has assigned September, 1945. Later returns show R i i CHART Z-Comparison of typhoid fever and typhus fever incidence in Poland, April, 1945-August, 1946 . 50 ". ABEEIUC~ JOURNAL OF PUBLIC HEALTH Jan., 1947 TABLET Typhu; and Typhoid Fkoer in Poland, April, 19+August, 1946 Number of Cases r L \ Tyfihoid Fcvw Tjrphw April, 1945 1,871 1,867 Miy 2,825 2,987 JUne 3,835 1,795 July 7,457 1,536 August 10,628 794 September 16,569 782 October 11,629 869 November 10,999 601 December 6,345 682 January, 1946 5,983 1,235 February 3,551 635 March 3,180 516 April 3,110 417 May 2,335 221 Jmle 2,088 89 July 3,475 99 August 2,680 78 September 2,605. 47* o Provisional figwes year when an epidemic was developing in Chungking. An UNRRA team of 7 physicians and 2 sanitary engineers, with 6 tons of needed medical supplies, was flown to India and over the Hump to that city. Unfortunately, one in- stallment of the supplies was lost over the Himalayas. The team took part in the control of the epidemic and the care of the sick.4 that typhoid seems definitely to be coming under control. Early in March of this year (1946), I saw in the Contagious Disease Hos- pital of Canton the first five cases of cholera of the recent epidemic. Subse- quently, other cities of China were in- volved successively. The experience of the larger ones is shown in Table 6. By mid-summer, cholera became active also in southern Manchuria, where it flared up in numerous localities. In July alone, 11,910 cases and 4,697 deaths were re- ported from 26 cities and 2 rural areas of Manchuria. The war and post-war conditions that Assistance to the Chinese authorities brought a marked increase in the preva- in the control and treatment of cholera lence of typhoid fever in countries of continental Europe would have spread has been promptly given by the medical staff of UNRRA. Cholera vaccine for cholera also, had it not been completely mass immunization, and even calcium absent. In fact, the disease had not hypochlorite for water purification, were extended west of Iran since 1931. In flown to Canton early in its epidemic. China, on the other hand, cholera is Since then several emergency shipments endemic and was quite active in the of material necessary for fighting cholera summer season of 1946.3 UNRRA was and for treating the sick with intra- first called on for emergency help in venous salt solution and plasma have fighting cholera in June of the previous been sent by air directly to China from TABLE 6 Cholera Cases in Certain Chinese Cities, 1946 YOnlh Cantorr Shanghai Nanking March 548 Ati. 1,196 it Et 5 A&u& 1,097 853 250 2,468 816 27t 209 ot 4 37 933 300 September 22' 171 22 Total, Cases 4,003 4,415 535 Deaths 1,208 352 31 Case Mortality cent per 30.2 8.0 5.8 Population in thousands 1,ooO 3,500 700 o 20 days only t Excluding imported cases Foochow z 0 22 422 204 44 o 692 133 19.2 325 gig* J;! ACHIEVEMENTS OF UNRRA 51 Toledo, ijhio. In Shanghai, two million cholera vaccinations had been performed `by early July and this may have been one- reason that the epidemic WAS ~OS- ing momentum by the middle of that month. Investigations in connection with the cholera epidemics in Canton and Shanghai were carried out by an epidemiologist of the China Office. Plague was almost completely kept out of the European post-war picture. It gained entry to the port of Taranto b southern Italy when the disease was present in the island of Malta. From September 3, 1945, to October 25, there were 25 cases in Taranto with 12 deaths. An anti-rat campaign was initiated. All the premises in the infected area were sprayed with 5 per cent DDT in kero- sene to kill the potentially infected fleas, and about 20,000 workers were dusted weekly with 10 per cent DDT powder. UNRRA, as part of its coiiperation, made available the advice of an expert on rat extermination. There was no spread to other cities. In China, plague was a greater prob- lem, but there was no really extensive epidemic after the country was liberated and opened to UNRRA. Since then, the focus centering in Fukien Province has been active.6 In the early months of 1946, there was much concern over reports from Mukden of pneumonic plague in Manchuria. There were 39 cases with 36 deaths, and the recovery of 3 was attributed to treatment with sulfadiaxine. This small outbreak stopped abruptly, but there were 13 additional fatal cases of plague early in March about 70 miles from Mukden. The National Health Administration is continuing the study and control of plague in the Fukien area, using supplies sent by WRRA, such as plague vac- cine, sulfadiazine, DDT for killing fleas, and poison for rats. UNRRA has also assigned to this work a team consisting of an epidemiologist, an entomologist, and a sanitary engineer. Since Kala-azar is a disease trans- mitted by a bloodsucking fly, a species of Ptiebotomus, it can hardly be re- garded as a result of the war, although aggravated by the resulting neglect. There are about three hundred thousand persons near the Yellow River in Honan, Kiangsu, and neighboring Provinces, who have this serious disease in acute form and urgently need treatment. They have been cut off by the war from the source of supply of the antimony drugs that would cure them. UNRRA's Chief Medical Officer in China has urged that for the time being these drugs be given priority over all other medical supplies in shipments to China. Unfor- tunately, the world's entire manufactur- ing capacity for antimony drugs is not enough to fill the needs promptly and it is proving necessary to bring about the expansion of the facilities for production. The medical officers of WRRA and CNRRA are not satisfied . to limit their program to treatment alone and are hoping to use DDT sup- plied by UNRRA in an attack on the Phlebotomus responsible for trans- mitting the disease, thus initiating a program of real prevention. This may not get into full swing until more is known of the insect and its habits. For several years: diphtheria has been the leading epidemic disease in a large part of Europe.e Great quantities of diphtheria toxoid for immunization and antitoxin for treatment are being shipped -by UNRRA to the assisted countries. The amount of diphtheria toxoid in the supply program is 6,015,960 ml., or enough to immunixe 2,406,384 persons. Diphtheria antitoxin is being supplied up to a total amount of 5,167,080,000 units. Material for the Schick test also is provided. CURBING ENDEMIC DISEASES The incidence of tuberculosis has gone up so high in the war-ravaged countries that this disease presents a serious and 52 AMERICA& JOURNAL OF PUBLIC HEALTH Jan., 1947 lasting post-war problem, as it did after the first world war. Tuberculosis ex- perts on UNRRA's staff have made! surveys in many countries, using mass radiography, have analyzed the problem, have given advice as to the control of the disease, and have assisted in restor- ing and correcting the institutions for the tuberculous. Such a program has reached an advanced stage in Greece, for example, but is still far from complete.' The Greece Mission has a Chief Tuber- culosis Consultant and under him are five area teams, each consisting of a tuberculosis specialist, nurses experi- enced in this disease, a radiologist, and a clerk. These teams travel from vil- lage to village, examining people to determine the extent of the problem, inspecting sanatoria and helping set up clinics, advising the authorities, and training technicians in the use of radio- graphic units. Some 70,000 persons have already been examined by mass miniature radiography. When tuber- culosis has been dependably diagnosed, an effort is made to arrange for supple- mentary rations. Interest has been stimulated, an advisory National Tuber- culosis Council has been organized, and there is large-scale coijperation from voluntary agencies. Supplies from WRRA have been given to nearly every sanatorium and dispensary in Greece. Such supplies range from bed- steads and x-ray apparatus to drugs and special surgical instruments. All this is of great assistance to the govem- mental health authorities, who are fac- ing an otherwise insuperable problem, for in Greece as in the other liberated countries the surveys reveal a marked increase in tuberculosis. . The results of the tuberculosis survey ln Poland have been published by an UNRRA specialist.8 He reports that the restoration of the sanatoria is going ahead and that much equipment has come from UNRRA. In Italy, the war against tuberculosis is benefitting not only from the UNRRA surveys and , equipment but also from generous allot- ments by the government from the pro- ceeds of sales of WRRA supplies. Wars produce a marked increase in venereal diseases, and World War II was no exception. Fortunately, treat- ment has become myth more Fffective in recent years, and the knowledge of methods of control has also advanced. UNRRA has supplied large quantities of drugs useful in treating diseases of this class and has supplied information about their use. A specialist in venereal disease control and treatment has been attached to the UNRRA Mission in Poland, and several of the other medical officers possess special knowledge and experience in this field. In the treatment and control of many diseases beside those here .mentioned, there is a growing dependence on spe- cific and effective drugs. Many of the older effective drugs were not generally available in the occupied countries dur- ing the war. The more recent ones were not known when the war started and had not been brought in when UNRRA began operations. The physicians and health officers were eager to get the newer drugs and biologicals and infor- mation regarding their effectiveness, safety, and methods of use. To illus- trate the quantities in which drugs were supplied by UNRRA, I shall give a few items from UNRRA's total procurement program for the assisted countries: penicillin, 809,550 million units; insulin, 663,690 thousand units; various sulfa drugs, 1,074,265 lbs.; acetyl-salicylic acid (aspirin), 1,207,OOO lbs. CAMPAIGNS AGAINST MALARIA Several of the liberated countries assisted by UNRRA have suffered long and intensely from malaria. The war increased the problem by disrupting drainage systems, depriving the public of suppressive and curative drugs, and in general interrupting the existing voz* 37 ACHIEVEMENTS OF UNRRA activities against malaria. An extraor- dmary opportunity for widespread and systematic malaria control presented itself to the Health Division after these countries were liberated, and no time was lost by the. sanitary engineers of the Division in organizing the field operations. The new methods which made cheaper and more effective con- trol possible were the residual spraying of houses with DDT solution to destroy the adult mosquitoes and the distrtibu- tion of the same insecticide from hand pumps or airplanes on water surfaces to kill the larvae. The largest of the campaigns planned by UNRRA personnel in cooperation with the governmental health authorities were in Italy and Greece. The results were highly successful and the pro- cedures were most popular. Not only did mosquitoes diminish and malaria almost disappear, but there was also a heavy incidental mortality among houseflies, bedbugs and fleas. The campaigns in Italy were carried out with the approval of the High Com- missioner of Hygiene and Public Health and with the cooperation of the Pro- vincial Medical Officers and the anti- malaria committees. The program de- pended mainly on residual spraying. It began in Sicily in January, 1946, and was continued first in Frosinone, then in the highly malarious strip of the south coast of Central Italy, and finally in the delta of the River PO. In the entire operation, the Italy Mission of UNRRA supplied technical supervision through its engineers. Moreover, it fur- nished 21 vehicles, 50 tons of pure DDT, 216,000 gallons of kerosene, 8,000 galloni of concentrated DDT emulsion, and the necessary sprayers. Twenty-five to 150 persons were engaged in spraying in each of the areas treated. These areas had an extent of 1,890 square miles and included about one- third of the total malarious territory of Italy, excluding Sardinia. The num- ber of houses sprayed was 50,000; other structures similarly treated numbered 143,000; and the total area of internal wall space sprayed was 3 1,405,049 square meters. The good results gave rise to the prediction that a similar scheme of operations applied to all the malarious areas in future years could reduce malaria until it ceased to be a problem. The preliminary work of an attempt to eliminate malaria from Sardinia by exterminating the anopheline species re- sponsible for transmission has been started. This will be a joint project of the Government of Italy, the Inter- national Health Division of the Rocke- feller Foundation, and UNRRA. The International Health Division is supply- ing the directing scientific staff, the o Gov- ernment is allotting funds for expenses from the proceeds of the sale of UN RRA supplies, and UNRRA is making available motor equipment, DDT, and other materials. Encouraged by the sue- cesses in eliminating Anopheles gambiae from Brazil and southern Egypt, the directors of the project are hopeful that a similar drive on the European anophelines responsible for transmitting malaria in this isolated island will result in their complete and permanent elimination. The campaign against malaria in Greece was nation-wide from the start, and was planned and directed by the Chief Sanitary Engineer of the UNRRA Mission in coijperation with the Greek health officials. The methods all in- volved the use of DDT and included residual spraying of houses, distributing an oil solution of this larvicide by hand pump on small mosquito breeding places near malarious villages, and applying 20 per cent DDT as a thermal aerosol to large and inaccessible breeding places from 10 specially equipped airplanes. It is estimated that approximately 300 tons of DDT, in terms of the pure chemical, will have been used during 54; AtiRIcAN JOURNAL 1946, or most of the supply designated for Greece in Table 3. For administra- tive purposes Greece was divided into 11 regions, in each of which there were an WRRA medical officer and a sani- tary engineer who worked in close co- operation with a Greek Government malarlologlst and a sanitary engineer. Seventeen planes were supplied by WRRA, of which 10 are used in the regions.. The other 7 are used for train- ing pilots, for inspection trips, and as a source of replacement parts. Each plane can treat 17 acres per minute, ,and approximately 285,440 acres of mos- quito breeding surface have been treated, counting each area every time it is gone over. The interval between treatments is about ,15 days. This amount of operation by airplanes has required 17,840 gallons of 20 per cent DDT. Residual spraying has been applied to over 4,000 villages and towns to approximately 300,000 houses, stables, and other diurnal resting places for mosquitoes. The results of the com- bined methods seem to have been excel- lent and the people are enthusiastic. The fall survey should give a more accurate estimate of the reduction in malaria and its mosquito vectors. The malaria experience of the Health Division seems to have demonstrated that it has at last become practicable and economical to control malaria on a national scale. VARIOUS OTHER ~ACTIVITIES It is natural that nutrition should be . a pnme interest of the Health Division in view of UNRRA's great responsibility to supply food under its relief program. Medical Nutrition Consultants and Dietitians of the Health Division made many surveys of the physical condition and diets of population groups suffering from food deprivation. Their primary duty was to report on the current state of nutritional health and to advise on matters of food and nutrition. The de- OF PUBLIC HEALTH Jan., 1947 tailed survey for Italy has already been published? Some of the specialists made observations of acute starvation in Germany, Holland, and China.. One of them organized a group of about 100 medical students and directed their efforts to save starving inmates of Belsen Camp by scientific methods. In Italy, in addition to the study cited above, there was an extensive survey by the Italian Medical Nutrition Mission sent out by the Unitarian Service Com- mittee and the Congregational-Christian Service Committee with the coijperation of WRRA. They undertook to find out, by experimental feeding of malnourished children, what important food elements were most lacking, and to advise UN RRA as to needed supplements to the diets being supplied to hospitals. This team of medical scientists and labora- tory technicians worked from April, 1945, to March, 1946, in six different parts of the country. It examined 28,651 persons, and gave service to 1,984. In China, five CNRRA-UNRRA nutrition teams investigated the famine areas to determine their nature and extent. The results confirmed the exist- ence of acute famine and general low caloric and protein intake, especially in Hunan Province. As a follow-up, spe- cial emergency supplies, including vita- min products and serum protein, were flown in from Shanghai. In the mean- while every attempt was being made to hasten the sending of quantities of food. The general conclusions in the re- ports from all countries investigated seemed to be that various degrees of underfeeding were encountered, some- times actual starvation, but that frank deficiency diseases, such as scurvy, pel- lagra, rickets, and beriberi, were less frequent than would be expected. Of these diseases, rickets is the one most frequently encountered. Consultants in maternal and child : ACHIEVEMENTSOF UNRRA 55 mth:l& made surveys and advised a+,&ments and Missions, A school feeding program is a prominent feature & &e Greek program, and the preschool -&dren al.50 receive attention. ~ Dental consultants have surveyed he needs in the several Countries for dental care and have given special atten- con to the organization of dental serv- ices in assembly centers for displaced persons. The dental consultant attached to the European Regional Office has given lectures and demonstrations to the ]oca] dental profession. . The medical and surgical side of the rehabilitation of the disabled is a respon- sibility of the Health Division, although the other aspects have fallen to welfare workers and voluntary agencies. In Athens, a rehabilitation center has been sponsored by the Greek Government, UNRRA, and the Near East Founda- tion. The Health Division has provided an orthopedic surgeon consultant. Arti- ficial limbs and materials for local manu- facture and repair are being supplied. A series of UNRRA facie-maxillary surgery teams was sent to Yugoslavia from London. The first, consisting of 6 persons, arrived near the end of 1945. These teams demonstrated the latest techniques for correcting mutilation, and trained local surgeons and nurses. In many projects which have been mentioned voluntary agencies took an effective part. This was especially the case in the work with displaced persons in the Middle East Camps and in Ger- many. Voluntary agencies provided health personnel numbering about 500 for work in Europe and an additional number for China. They also contrib- uted medical supplies for devastated areas. INTERNATIONAL SANITARY CONVENTIONS The occupation of France isolated the International Office of Public Health and interfered with its administration of the International Sanitary Conven- tion of 1926 (Maritime) and the Inter- national Sanitary Convention for Aerial Navigation of 1933. This left intema- tional quarantine in so serious a predica- ment that something had to be done about it. To meet the situation UN RRA's Standing Technical Subcommit- tee on Health for Europe promptly appointed an Expert Commission on Quarantine to draft international sani- tary agreements of an emergency na- ture.lO The Commission later submitted to the Standing Technical Committee on Health in Washington drafts for two conventions, modifying and modernizing the existing ones. Each draft provided that TJNRRA should carry out the duties previously assigned to the Inter- national Office of Public Health in Paris. After some modification in the light of the comments of member gov- ernments, UNRRA approved the pro- posed conventions and they were opened for signature at the State Department of the United States of America, the depository of the conventions. The required number of signatures was reached on January 15, 1945. The two conventions of 1944 came into effect on that date and have been administered since then by the Health Division from the Headquarters of UNRRA in Wash- ington, with the European Regional Office in London acting as a branch for the regions in its sphere-Europe, Africa, and the Middle East. Head- quarters makes notifications directly to China, Australia, New Zealand, Canada, and the United States, and through the Pan American Sanitary Bureau to the other American republics. At Headquarters, the Division is publishing the semi-monthly Epidemio- logical Information Bulletin, carrying disease reports and epidemiological analyses. The European Regional Office is bringing out an additional fortnightly Bulletin of Communicable Diseases and Medical Notes for distribution to the governments in its area. A small Weekly .s's AMERICAH JOURNAL Epidemiolog&l Bketin is also sent out from London in printed form to give prompter information regarding the appearance and movements of serious diseases.. Most of the reports to and from both offices with regard to pesti- lential diseases are transmitted by cable. The duties imposed by the 1944 con- vention for aerial navigation include the delineation of the yellow fever areas of the world for purposes of quarantine, and also laying down standards for yellow fever vaccine and designating institutes approved for carrying out tests of the vaccines. These special functions have been performed by an Expert Commission on Quarantine appointed by the Standing Technical Committee on Health. In 1946 the Commission car- ried out an exhaustive test of the im- munizing properties of the Dakar yellow fever vaccine administered by scarifica- tion, alone or mixed with smallpox vaccine. The Commission recommended that the method be certified as accept- able in the issuance and recognition of international certificates of inoculation. All the duties imposed on UNRRA by the International Sanitary Conven- tions of 1944 and the Protocols pro- longing them were of temporary and emergency nature. They will, therefore, be transferred to the Interim Commis- sion of the World Health Organization on December 1, 1946, as agreed in letters exchanged by Mr. F. H. LaGuardia, Director General of UN RRA, and Dr. G. Brork Chisholm, Executive Secretary of the Interim Com- mission. Although the Central Head- quarters of the Interim Commission will remain in New York, according to latest advices, the Epidemiological Office in charge of the administration of the con- ventions will be in Geneva. The last issue of the Epidemiological Information Bulletin will appear on December 15. The two complete volumes will form a valuable compila- tion of statistics for reference with OF PUBLIC HEALTH Jan., 1947 regard to the war and post-war period. Complete sets can still be made avail- able to libraries and institutions requir- ing them. MEDICAL CARE AND HEALTH PROTECTION OF DISPLACED PERSONS In May of 1944, the responsibility for the six refugee camps in the Middle East was assumed by UNRRA. At the end of March, 1945, there were about 40,000 displaced persons in these camps, including nearly 15,000 children. The health staff contained specialists in nutrition, dietetics, tuberculosis, mater- nal health, child health, public health nursing, and sanitary engineering, and also clinical doctors and nurses. Since then, most of these refugees have been repatriated. Each returning group was accompanied to its destination bv an UNRRA repatriation team, including a doctor and two nurses. There now re- mains only one of these camps, at El Shatt, with a few hundred refugees. A problem of greater magnitude was presented by the displaced persons un- der UNRRA care in Germany, Austria, and Italy. At the end of May, 1946, there were 826,580 such persons in as- sembly centers in the three countries. The Health Division was responsible for recruiting the necessary health personnel and giving technical supervision. An extensive immunization program was undertaken. In most of the assembly centers a large part of the medical, den- tal, and nursing services was provided by professional persons found among the displaced persons, with overall supervision by UNRRA staff. Dispen- saries have been set up and arrange- ments made for hospital care, mostly in local institutions with UNRRA super- vision. Nurses among the displaced persons are being given refresher courses, and other women are being trained as nurses' aides, in order to re- place UNRRA nurses as they are with- drawn. The health conditions in the yo1j37 ACHIEVEMENTSOF UNRM 57 assembly centers have been on the whole quite satisfactory. INSTRUCTION OF HEALTH PERSONNEL III the long run much more is gained by training the natiouak of a COUntIy to do their own health work than by introducing relays of foreigners to do it for them. For training for participa- tion in relief and rehabilitation work in the field of health, UNRRA brought many Fellows from the assisted coun- tries to educational centers of the United States and of the United Kingdom and other countries of Europe, and arranged for their studies and tours of observa- tion. The first group consisted of 12 technical experts from China who came to the United States in 1944. After their return, many of them assumed key positions, becoming, for examples, Head of the Medical Commission of CNRRA, Director of Medical Supplies of this Commission, Director of the Anti- Epidemic Prevention Bureau of the National Health Administration, Direc- tor of Hospitals and Health Centers of the NHA, and Head of the Department of Sanitary Engineering in the National Institute of Health. In 1946 a new program of UNRRA fellowships was offered, with 44 falling to the Health Division. The recipients included physicians, nurses, sanitary en- gineers, radiography technicians, and students of penicillin production. They received their instruction in the United States, Canada, the United Kingdom, Sweden, and Switzerland. In 1946 there was set up also a special Nurse- Teacher Fellowship project. The Fel- lows were carefully chosen graduate nurses interested in teaching, 121 in number. Twenty-seven came from Italy, 20 from China, 18 from Czecho- slovakia, and 19 from Poland. This group received its special training in institutions of the Department of Hos- pitals of New York City, with brief observation trips to other centers. Twenty nurses from Austria and 17 from Greece were similarly trained in London. In another of the training projects of the Health Division, medical teaching missions were sent to Poland and Czechoslovakia to visit the medical centers and bring the newer knowledge of the war years to the medical and den- tal professions. They had been almost completely isolated during the war years. The lecturers were provided for Poland and Czechoslovakia by a voluntary agency, the Unitarian Service Commit- tee, with the cooperation of UNRRA. In Czechoslovakia, 14 lecturers from 8 universities began their tour in Prague and then went to Moravia and Slovakia, giving lectures and demonstrations in all 6 of the medical schools of the country. In Poland, the team of 7 lecturers included 2 dentists. It visited the principal cities, giving lectures to professional groups and students and leading discussions. Several lecturers had previously been sent to Poland by the Health Division, beginning in November, 1945, to get this valuable and much appreciated teaching started. In 1945 a team of 11 teachers was sent to China to start a medical train- ing program in conjunction with the National Institute of Health. The early courses in Chungking, with a total en- rollment of 258 students, covered public health administration, medicine, sur- gery, gynecology, tuberculosis, public health and hospital nursing, maternal and child health, and bacteriology. A second series of courses was given in Peiping in the spring of 1946, with 136 students. In the interval between the two series, the teachers gave refresher courses to local medical societies and schools in Shanghai, Nanking, Peiping, and Tientsin. More recently they were assigned to medical schools in Peiping, Nanking, Chengtu, and Shanghai. Other technical personnel of the Health Division working in China have co- A-CAN Jqmk~ OF PUBLIC HEALTH . operated in short courses or lectures for Jan., 1947 mately one year, after which `the World Health Organization should be fully established, the Central Committee has authorized the Director General of UNRRA to turn over $1,.500,000 to the Interim Commission. No supplement of the Commission's budget will be needed when the administration of the sanitary conventions is transferred on December 1. l&orato~ tech&&s, dentists, medical students, nurse trainees, field workers in rcdi;; control, and medical supply . The UNRRA nurse consultants in several countries, and especially in Greece, worked with the local nurse leaders in reopeniug and reorganizing schools of nursing and giving refresher courses in public health. The Health Division's project in Ethiopia is essentially an attempt through teaching to take the first steps toward creating an indigenous medical and nursing profession. III this way, the ground work will be laid for a future public health service, and meanwhile the people will benefit from service of steadily rising quality. Courses for medical " dressers " and for sanitary in- spectors are being conducted, and as- sistance is being given to the hospitals and clinics essential to this educational effort. HANDING OVER TO A PERMANENT ORGANIZATION The activities of UNRRA as here outlined are corring to au end, but many of the needs will continue and great opportunities stand open. So UNRRA has made its plans, in conference with officers of the Interim Commission of the World Health Organization, to hand over a number of its functions, on Janu- ary 1, 1947, for Europe and Africa, and on April 1 for the Far East. The ac- tivities suggested for transfer to the Commission are ( 1) fellowships and teaching, (2) the project in Ethiopia, (3) tuberculosis, (4) malaria, (5) mis- sions of experts to countries with special needs, and (6) the administration of these functions. To make possible the continuation of this work in the present UNRRA-assisted countries for approxi- The temporary Health Division will soon be giving place to a permanent and growing international health organiza- tion. On relinquishing their duties, the officers of the Health Division hope that their efforts have accomplished more than the alleviation of ravages of war. The World Health Organization should make a quicker start and be able to see its way more clearly because UNRRA, at a most difficult time, attacked the problems of international health. REFERENCES 1. Journal, Fifth Session of the Council, United Nations Relief and Rehabilitation Administratfou, Geneva, 5:146 (Aug. 17), 1946. 2. Selected Documents. First Session of the Council of the United Nations Relief and Rehabili- tation Administration, Atlantic City, New Jersey, Nov. IO-D=. 1, 1943, pp. 139-148. UNRRA, Wasiugton. 3. Stowman, Gnud. (Notes on Cholera) E~detnfe- togtcol Injomation Bulletin (UNRRA), 1~465-469, 551-561, 2:674-678, 718-720 (July 1SSept. 15), 1945, 1946. 4. Reimsnn, Hobart A., Chmg, G. C. T., Chu. L.-W., Liu, P. Y., and Ying, Ott. Asiatic Cholera. Clinical Study and Experimental Therapy with Streptomycin. Am. 1. Tro#. Med., 26:631-647 (Sept.), 1946. 5. Fan, J. H. Commuuicable Diseases in China during Recent Years. Epidemioldgical IJmmation Brrlletin (UNRRA), 1:493-521 (July 31), 1945. 6. Stowman, Knud. The Diphtheria Situation in Europe. Epidetniological Injomotion Btd-tctin (UNRRA), 2:147-l% (Feb. 28), 1946. 7. Vine, J. M. UNRRA's Health Campaign in Greece. Lancet. 250:789-791 (May 25), 1946. 8. Dauids, Marc. Tuberculosis in Polaud. Laacet, 2.51537-540 (Oct. 12), 1946. 9. Metcoff, J., and McQueeney. A. J. Clinical Malnutrition in Italy in 1945, Nutritional Status of Selected Population Groups. New England 1. Med., 235:451-460 (Sept. 26), 1946. 10. Sousa, G. H. de Paula. History of the Inter- national Sanitary Conventions, 1944. Epidemiologicat h{oynotion Bulletin (UNRRA), 1:5-12 (Jan. 15),