HEALTH PROBLEMS IN MANILA. BY MAURICE C. PINCOFFS, M.D., BALTIMORE, MD. What I shall have to say concerning health problems in Manila applies to a period of ten weeks, one and a half years ago, -a period which now seems remote. The point of view of that time was likewise far different from that which prevails today in this meeting devoted to the discussion of the recent advances in our knowledge of disease. So I must ask you to look upon these recollections of past events as an interlude in the regular features of the program. * * * * * In the month of February, 1945, Manila, from the military point of view, was very important as a prospective American base from which it was planned to launch late in the fall a major expeditionary force against the home islands of Japan. To maintain this schedule would require the renovation and enlargement of the wrecked port facilities to accommodate a tonnage greater than that of New York City. It was apparent that this project would entail a maximum effort, not only on the part of our limited service troops, but also of all the civilian labor that could be recruited. It was also evident that the health conditions in Manila in these critical months were an essential factor. A serious outbreak of any major epidemic disease, such as cholera, plague, dysentery, influenza, or even dengue, might inflict medical casualties that would throw out the timing of this final assault. Prior to the invasion of the Philippines, thought had been given to the problems of civilian needs which would be encountered. Small units called Philippine Civil Affairs Units had been organized and trained. These were to go in with the troops and take over the tasks of re-establishing local government, of feeding and clothing the needy and of organizing an emergency medical service. In each such unit there was included one medical officer and a few enlisted men with designated medical functions. As the XIV Corps in February fought its way south into Manila it was accompanied by eight Civil Affairs Units. 18
HEALTH PROBLEMS IN MANILA It had been hoped that Manila might be kept an "open city" but the Japs had decided to the contrary. As the battle in the City developed, alarming word came back to General Headquarters of starvation, disease and battle casualties in the civilian population. Various officers were sent forward and among them I was designated to look into this matter of civilian health. * * * * * The approach to Manila was from the sea at about 10,000 feet. There under us lay the sullen rock of Corregidor, still held by the Japanese. Off to seaward moved a line of miniature warships flashing with gun fire. Cloud puffs arose on the rock. Then we were over the great empty space of the Bay and far ahead could see a long cloud of brown smoke rising from the burning city. * * * * * Two days were given to a brief survey. The essential findings were the following: The City had no water supply. The main aqueduct had been cut in many places. Approximately 800,000 people were getting their drinking water from a few artesian wells, and chiefly by digging shallow pits in the ground -the heavily infected ground -and drinking the seepage. There was no sewage disposal. With the loss of piped water the water flushed sewage system ceased to function. The pail collection system that served the outlying districts had disintegrated. Shallow ditches and just the bare ground were the resources of the population. There was little food in the city. It was impossible to say how many were dying of starvation, but emaciation and nutritional edema were obvious from looking at the population. No garbage had been collected in Manila for three or four months. The back yards and the side streets were full of sodden heaps with a haze of flies over them. The fuel supply was nil. No wood was coming across the Bay from the forests on Bataan. Thegas plant was destroyed. The people were cooking their rice over little fires fed by bits of wood from wrecked houses. The electrical plant was wrecked and the city was black dark at night. Here and there a flicker of light shone through a window from a burning wick floating in a bowl of cocoanut oil. 19
MAURICE C. PINCOFFS There were no means of communication. The telephone system was wrecked. The street cars were burned. The post-office was in flames. There had been no mail delivery for weeks. If one wanted to find someone in Manila one sent messengers out on foot to hunt him down. Civilian medical supplies were practically exhausted. None had been furnished by the Japanese for many weeks. * * * * * It is an interesting commentary on human nature that in the courtyard of the big contagious disease hospital, San Lazaro, I found later a warehouse containing many valuable medical supplies, and at its portal one of those faithful guardians who, when all authority disappeared, stuck rigidly to his instructions. These supplies were only to be given out in an emergency. No one had declared an emergency. * * * * * The hospitals that had not been destroyed were in pitiful condition. Not only the beds, but pallets and bare floors were used to make place for the civilian wounded. They lacked instruments, dressings, drugs, linen, food, water and light and, since there was no transportation to carry away the dead, in the morgues the naked bodies were stacked like cordwood and filled the air with stench. Some twenty improvised dressing stations (one could not call them hospitals), had been set up in schools and other buildings. They, too, were full. Near the fighting lines, along Taft Avenue and about the old walled city, the civilian dead lay in the streets and yards and houses where the Japanese had slaughtered them as they retreated. In this chaos the eight Civil Affairs Units were doing their valiant best to feed the population and to distribute medical supplies. Each in its area did what it could and the Surgeon of the XIV Corps lent them all the support he could spare from the needs of our own wounded. On the civilian side there was no medical organization. The office of the Health Department in the City Hall was in flames and the personnel were scattered. Individual physicians were working valiantly in the hospitals and stations. The chief recommendations made as a result of this survey were 20
HEALTH PROBLEMS IN MANILA that a central organization be established -a provisional Department of Health and Welfare under American auspices - with authority to coordinate the medical efforts of the Civil Affairs Units and the civilian physicians; and that the resources of this organization be supplemented by the attachment of eight Malaria Control Units, three Malaria Survey Units, an Army Medical Laboratory, a Medical Supply Unit and an adequate number of medical officers with experience in sanitation and public health. The results of making recommendations in the Army are very similar to the consequences in civilian life. A few days later I found myself on my way back from Advance G.H.Q. to Manila in a jeep, with verbal orders to take over the administration of health and welfare in the city. * * * * * From the sugar plantation that housed G.H.Q. back to Manila was about 70 miles on the axial highway south down the Lingayen Valley -a good road, mostly concrete, but it was necessary to ford the shallow rivers for the bridges were gone. All the supply transport of the forces fighting in Manila was using that one road -trucks, jeeps, command cars, artillery, tanks and ducks. The civilian traffic used the earjthen shoulders. Long lines of refugees singly and in family groups, on foot, in wains drawn by caribao, in high two-wheeled caratellas drawn by a diminutive horse, were moving out from Manila or, on the other side of the road, moving back in with food bundles on their heads or on a shoulder or swung on a pole, or piled in carts. * * * * * Giving thought on this long dusty drive to the problems ahead it began to appear clear that the two most urgent needs were: (1) a headquarters and key personnel and (2) establishment of disease reporting -men to depend on and a means of keeping track of the disease situation. The Headquarters was established in the administration building of the San Lazaro Contagious Disease Hospital. There we worked, ate Krations, and slept during the early days. In the matter of key personnel I had the advantage of having served in the theatre since its early months in 1942. I knew whom to ask for and my requests met friendly reception. In addition to Amer21
MAURICE C. PINCOFFS ican medical officers I was soon able to attach a number of welltrained Filipino physicians, most of whom had served formerly in the faculty of the Institute of Hygiene. Time forbids the naming of more than the key men in the organization, but the initiative, energy and ability of the whole group were what made possible the accomplishments of the Department of Health and Welfare in the first hectic months. Among the earliest of these officers to report was Lt. Col. A. Parks, who served ably as my Deputy and continued on as Director when I left. Afirst step in obtaining reports on communicable disease was to divide the city into eight districts, each of which contained a Civil Affairs Unit. The medical officer of this unit became the District Health Officer. Each hospital in the District became a center to which practicing physicians of the neighborhood were attached and to which they reported cases of communicable disease daily. A man from the District Health Office made the rounds of the hospitals in the district on a bicycle, collecting these reports. From the Districts the reports came in by jeep to Headquarters at San Lazaro, together with a statement of action taken. This simple system was in operation before the end of the first week. We were then first assured that no epidemic of cholera or smallpox was in progress and that no cases of plague were recognized. Cholera indeed was reported a number of times. There was great dread of it among the older civilians. All such cases when moved into San Lazaro proved, however, to be severe bacillary dysentery. * * * * * A simple but apparently insoluble difficulty halted the organization of disease reporting for a day. That was the lack of paper and printing facilities for making forms. Our good luck held, however. A medical officer who had formerly served in Manila dropped in to headquarters. The responsibility of providing forms was promptly assigned to him. He found an abandoned government printing press in Bilibid prison and in a dusty corner of the same room a stack of many thousands of communicable disease report forms. It is probable that this saved a valuable week of time. * * * * * The Communicable Disease Section, under Dr. Tomas Gans, was soon strengthened by assigning an epidemiologist to each Health Dis22
HEALTH PROBLEMS IN MANILA trict and a clinical consultant to the central office who made rounds of the hospital wards over the city to check on undetected cases. All cases of communicable disease of epidemic potentiality were transported to San Lazaro where, with the help of the Army Laboratory, under Lt. Col. Tigert, we were able to make dependable diagnoses. With the development of a section on statistics, the re-establishment of death certification and the restriction of burial to the cemeteries administered by the Health Department, we regained within a few weeks normal control of information as to the communicable disease situation in the city. It was evident even in the first week that enteric diseases were the immediate epidemic hazard and that sanitary measures must be our chief reliance in combating them. The Sanitary Section in the Headquarters of our organization was headed by Colonel Gottlieb Orth, M.C., a man of untiring energy, great organizing ability and unfailing good humor. A central Sanitary Engineering and Transportation Group was organized for city-wide functions, utilizing personnel of the Sanitary Corps and former Filipino employees. In addition, a Malaria Control unit served as a Sanitary Group in each of the eight Health Districts. Avital need was a safe water supply. Manila's water supply had been the best in the Far East, but the major reservoir in the mountains was still in Japanese hands. We had been fortunate in recapturing the lower reservoir with its chlorinating plant intact, but the conduit to the city was broken in many places and within the city the reticulation had innumerable broken mains and leaking pipes. It was a combined military and engineering operation to restore' the water supply. The engineers would mend the conduit and the Japs would steal in at night and blow out a new section. But soon there was a fairly constant trickling flow to the central portion of the city. The resulting drain on the lower reservoir was too great, however, and as the water level fell it became more and more vital to recapture the main reservoir. For all of the three months until the Sixth Army had fought its way over the steep ridges to the main dam and seized it in a final surprise attack, Manila was on short water rations and lived in dread of another water famine. Meanwhile the Sanitary Section of 23
4MAURICE C. PINCOFFS the Health Department was checking all water points for contamination and using the scant methods of publicity available to advise boiling of all water. The Sanitary Section set out to clean up the city: The dead were collected from the destroyed area and from the hospital morgues and buried. At first in trenches dug by bulldozers in the open ground about the walls of the old city then, with grace of services by a priest, in trenches in the cemeteries and finally in single graves in more civilized fashion. Our scant personnel on this work buried 5743 bodies in the first ten xeeks. The re-establishment of sewage disposal in the devastated city presented a formidable problem. Central 'Manila had been served by water borne sewage, including manypublic comfort stations. The outflow was pumped into the Bay. Much of this system was destroyed and all of it inoperative until the water supply was restored. In the better residential section there had been many private cesspools. No tank wagons or pumping units for emptying these had survived the war period. The major portion of the city had depended upon the collection of sanitary pails from private homes and public comfort stations. The trucks that made the collections had been worn out or seized by the Japanese Army. Whencollections ceased the inhabitants had burned both the wooden pails and most of the wooden comfort stations to meet the fuel shortage. The first expedient we employed was to build crude, burlap screened, public pit latrines and keep them oiled. Later, with the return of the water supply, we put back in use as many as possible of the water flushed toilets and lastly, as material and transportation became available, we began the re-establishment of the pail collection system, using half oil drums for pails. By every means of publicity available, including house to house visits, we encouraged the private construction of pit latrines for the emergency period. In the first ten weeks the Sanitary Section built 213 public pit latrines, restored 32 'water flushed public comfort stations and collected 22,639 sanitary pails. Much remained to be done in the ensuing months. Though garbage and trash collection was a major task and vital to the control of flies and rats, it was not of the magnitude it would 24
HEALTH PROBLEMS IN MIANILA have been if the population had not been on starvation rations. The Central Sanitary Section established garbage collection routes as fast as trucks could be obtained. The District Sanitary Groups (Malaria Control Units) manufactured garbage cans from oil drums, lettered them proudly with any color paint available, "Manila Department of Health and WRelfare U. S. A."; and set them out on the sidewalks. In addition each Sanitary Group cleaned and recleaned its district block by block. Two main garbage fills were established- kept compacted and rubble covered with bulldozers, and sprayed daily with DDT in oil. During those initial 10 weeks, 4500 garbage cans were set in the streets, 15,000 truck loads of garbage were hauled and dumped and approximately 12,000 city blocks were cleaned up and recleaned. It was not our problem to distribute relief rations, but other important duties connected with the food supply were our responsibility. As the fighting area moved on into the mountains, food from the valleys began to come into the city. Pigs and chickens and even cattle wvere slaughtered in city back yards and vegetables and greens wvere peddled from filthy carts. Shabby eating places sprang up along all the main streets. It was vital to re-establish the abattoirs and the city markets and to supervise the restaurants and bars. .Many of the small abattoirs and market sheds were partially or completely destroyed and their personnel scattered. They were, however, repaired and cleaned and connected with the water supply. Butchers' implements were obtained from the army stores. In ten weeks we had five abattoirs functioning wvith meat inspection in force. They were killing 1500 head of cattle and pigs a week small for Chicago but quite a help in Manila. s* * * * * An abattoir in Manila is a concrete floored shed with open sides. Carcasses hang on hooks from the rafters. A vat for scalding is steaming at one end. Uneasy steers are led in at the other. A brown Filipino, naked except for a breech clout, stands waiting with a sharp pointed dagger clenched in his right hand. As the steer reaches him he leans over and stabs the animal just belowv the occiput, severing the cord. The steer falls on its side heavily and other naked brown men seize the legs and drag the body to the chain and block. 25
MAURICE C. PINCOFFS With similar haste the public markets, or what was left of them, were renovated, sixteen in all. Inspectors were installed, cleanliness enforced and weekly spraying with DDTin oil carried out. The inspection of restaurants and bars fell to Major Caserta, a vigorous, conscientious man, who madelife miserable for transgressors. A minimum sanitary code was printed and distributed. Failure to obey meant closure. Opening without permission meant a stay in Bilibid prison. By the end of ten weeks Major Caserta's men were inspecting 2000 eating and drinking places weekly. * * * * * Major Caserta entered a new restaurant on Rizal Avenue and was questioned by three young American officers sitting at a table, as to whether it was a safe place to eat. At his suggestion they accompanied him on his inspection of the kitchen. A Chinaman on a low stool was washing the dishes in a deep pan on the floor. The water was even hot as required. But there was one little break in technic. The Chinaman's naked feet were in the pan with the dishes. * * * * * The Provost Marshal, a hard bitten cattleman from Nevada, was a true, and a tried, friend of the Department of Health and Welfare. With his help we raided many bars suspected of selling poisonous liquor, causing deaths and blindness among our troops. Convictions before Filipino courts were, however, hard to obtain. Insect and rodent control was also a problem of the Sanitary Section. The swarms of flies were attacked from many angles: cleaning up of refuse, oiling of latrines and DDTground and house spraying. Finally we called on Far East Air Force, who took on the task of spraying the city from the air with DDT in oil every two weeks. The results were controlled by fly catching stations in different parts of the city. It was an interesting sight to see four to six C-47's flying well spaced in line, a few hundred feet up over the roof tops, emitting a faint white mist of DDT in oil. The fly count after the first flight dropped 70 per cent. Old inhabitants told us after that, that they had never seen so few flies in Manila. The Aedes mosquitoes in Manila are vectors of dengue, but there are no Anopheline vectors of malaria within the main city. The Aedes 26
HEALTH PROBLEMS IN MANILA mosquito moves into the houses and is difficult to control. Our malaria control units did their best. I am not certain whether we can attribute the scant incidence of dengue in our troops to these control efforts or whether we were fortunate in its being an off year for the disease. Innumerable rats roamed the waterfront and the devastated districts. Rodent control of an effective type was beyond our strength. A small Navy rodent control unit cooperated by constant sample trappings of rats and counting their plague fleas. We were reassured by the continued reports of a low plague flea index. Venereal disease among American troops was becoming a problem to the XIV' Corps even during active combat in the city. After March 2 the civilian aspects of these diseases became one of the tasks of the Department of Health and XVelfare. In the face of the disturbed conditions in the city and the critical scarcity of Military Police to maintain even security, it was out of the question to attempt suppression of prostitution. We therefore undertook systematic mass treatment, setting up for the purpose a special Section on Venereal Disease under Captain Ray Trussell, NI.C. Starting without personnel or supplies he built up a city-wide system by which all known prostitutes reported or were transported to three large treatment centers. There they received sufficient mapharsen, bismuth and penicillin to diminish greatly the likelihood of their transmitting syphilis, and briefly at least to lessen their capacity for passing on gonorrhea. Against chancroid, which was very prevalent, we had no effective quick therapy. We isolated such cases in prison wards to the extent of our bed capacity. Tuberculosis is a national tragedy in the Philippines. The mortality rate in Manila, as calculated during our brief experience, is on the order of 650 per 100,000 per year. I feel that many cases are missed or called pneumonia and that the actual rate is even higher. In the face of this overwhelming incidence the best we could do was to establish beds for primary pneumothorax and maintain clinics for refills. We set up 200 beds and accomplished approximately 2500 refills. This was only a gesture. As I have said earlier, our chief fear was of the enteric diseases, cholera, severe forms of dysentery and typhoid fever. We were spared cholera, chiefly I feel because the endemic centers on Luzon had been wiped out before the war, the Japanese had 27
A8AURICE C. PINCOFFS guarded efficiently against its importation from China during their occupation, and after we came in, the port for many months had no shipping contacts with the Asiatic mainland where the disease was prevalent. During that period effective quarantine measures if needed would have been very difficult to improvise. Dysentery, often fatal, was very prevalent when we arrived, but not epidemic. In the first weeks the reported cases averaged 1500. As our sanitary efforts gained headway, the incidence of dysentery fell steadily and at the end of the ten weeks period it had been reduced to 300 cases weekly, or 25 per cent of what it had been. The safer Nater supply was probably the main factor, but the lessening of open fecal contamination of the ground and the slaughter of flies no doubt played a part. That a raging epidemic of typhoid did not occur can hardly be attributed to our efforts. It could have gotten beyond control before we arrived. That in spite of an incidence of 40 or more cases of typhoid a week no epidemic occurred is I believe due to the fact that we were dealing with an immunized population. The work of Worcester, the MIinister of the Interior (too little known in this country) and of Victor Heiser had resulted many years before in a code of health laws in Manila more advanced than those of any American city with which I am acquainted. Among these regulations was the requirement of universal and repeated immunization of the population against typhoid fever. This had been carried on with a reasonable degree of efficiency in MIanila for twventy or more years. I believe it had much to (1o with saving the civilian population from a typhoid epidemic. I have devoted most of the time allotted me to our efforts in preventive medicine since that was our more important task, but I should like to deal briefly with our problems in medical care. At first we were chiefly concerned with obtaining the bare necessities: water, food, medical supplies and surgeons for the civilian wounded who were estimated at 4000. The mortality among them was very high. * * * * * Gangrene and tetanus were very prevalent. Over 300 civilians are estimated to have died of the latter disease. It is interesting that among approximately the same number of casualties in our troops, in 28
HEALTH PROBLEMS IN MIANILA the same battle, not a single case of tetanus was reported. Prophylactic vaccination and adequate early surgery made the difference. * * * * * As rapidly as possible the Hospital Division of our Section on Medical Care, headed by Dr. Patrick A. C. Manahan, moved the orthopedic casualties out to the psychopathic hospital, where the leading orthopedic surgeon of Manila was placed in charge. This hospital on the outskirts of Manila has 3000 beds. When the Japanese came in, it contained approximately 3000 psychotic patients. The Japanese saw no need of providing adequate food for insane Filipinos. There were, as a result, 2624 deaths in this institution in three years. These empty beds we used for the casualties. Our medical supply depot sustained and helped to re-equip all the hospitals and clinics in the city. Amajority of the city's physicians were employed and paid by the Department. A food purchasing truck made biweekly trips into the country and brought back vegetables and fruits to supplement the inadequate relief rations in the hospitals. One by one the provisional hospitals were closed and the work of the regular hospitals supported with more resources. The Philippine General Hospital, heavily damaged in the battle, reopened some of its wards under the able directorship of Dr. A. Sison and with the help of our Department. At the end of ten weeks much remained to be done but order Nas reappearing out of chaos. X * * * * The change in the Children's Hospital near Santo Tomas typified the improvement. I saw this hospital first during the battle. WYounded, with bloodstained bandages, were making their painful way to it along the avenue, on foot, or supported by a friend, or carried on a litter. The entry was jammed. Inside, the floors were covered with the wounded. There was a stench of gangrene. The crash of artillery fire from a battery position in a nearby street added to the confusion. There was no water, attendants said, no food, no instruments. I found, however, a little woman physician quietly giving orders, a pediatrician, formerly a pupil of both Blackfan and P'ark. She was director of this lamentable hospital and quite undaunted by the situation. 29
30 MAURICE C. PINCOFFS And on the last day of my ten weeks' tenure, a bright sunny day, I visited the Children's Hospital for the last time. The halls were spotless, the ward beds were neatly arranged; there were clean sheets; in the kitchen there was good food. Out in the courtyard was a milling crowd of smiling Filipinos in their best embroidered shirts, all carrying babies. Little Dr. Fe del Mundo had organized a "Well Baby" competition and it was fiesta day in the Children's Hospital.
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