PREVENTIVE MEDICINE-CIVIL PUBLIC HEALTH ACTIVITIES
Military preventive medicine activities and civil public health activities are always difficult to separate because, in practice, any sanitation and health measures which are carried out benefit everyone in a given area, not just those persons for whom the measures are taken. And in the Dominican Republic the medical mission was usually aimed at both the civil populace and the military at the same time.
Medical intelligence for the operation was outdated and not available to the medical personnel when they first went into the Dominican Republic. The whole operation was a rush job and most personnel reported to the area with some preconceived ideas, but with little briefing and no experience in any combat area. It was only after arriving in Santo Domingo
that a reliable picture of the city's public health was obtained. Valuable medical intelligence was rendered by the Dominican military, city health officials, and especially by the Pan American Health Organization, affiliated with the World Health Organization. Only then was the Army Medical Service able to provide meaningful medical assistance to the civil populace as well as to protect the health of U.S. troops.
The Force Surgeon's Office maintained liaison with health organizations in the country, while the 714th Preventive Medicine Detachment carried out most of the Army's preventive medicine-civil public health practices. The detachment consisted of two control sections with one sanitary engineer and one entomologist. The 69th Veterinary Food Inspection Detachment also made a significant contribution, and there was cooperation from the three Medical Corps officers and a sanitary engineer of the 42d Civil Affairs Company during its one-month stay on the island, as well as from decontamination sections of a Chemical Corps unit. After the Civil Affairs Company was redeployed, a preventive medicine officer was assigned as IAPF Surgeon, and the sanitary engineer went with the 714th Preventive Medicine Detachment.
Public Service Functions
For all practical purposes, public services ceased entirely during the fighting. Public health officials in the Dominican Republic and Santo Domingo were political appointees, making their services even more subject to disruption during political disturbances. Many private physicians fled the city. Even the health services of the Dominican Red Cross and the Pan American Health Organization were disrupted by loss or destruction of equipment and by shortages of personnel. The Pan American Health Organization lost $30,000 in equipment, and the Army spent many man hours, but no money, in helping them obtain new equipment. The Army also loaned equipment to the Pan American Health Organization, the Dominican Red Cross authorities, and the Ministry of Health, and issued thousands of dollars in medical supplies to help the organizations function effectively.
All Dominican water sources inspected during the operation were considered nonpotable by U.S. military standards; inadequate sewage disposal facilities and subsequent runoff of human and animal wastes into ground water supplies were the primary sources of contamination.
Santo Domingo obtained its water from a surface supply located some 35 miles northwest of the city. The reservoirs, which used a slow sand filter system, were constructed by the U.S. Marines in 1924.
The first weeks of the 1965 operation were during the dry season and the river level was so low that no intake was possible. The city was dependent on water stored in tanks. A number of city water mains were broken during the revolt and there was a serious water shortage. Fortunately the rainy season began, but the rains damaged the sand filters at the reservoirs, and repairs and cleaning were not possible because of the disruption of public services. Thus, during much of the military operation, the city's water was unfiltered.
The Army lent chlorination testing equipment to representatives of the Pan American Health Organization, which was attempting to restore some public services, and helped them requisition chlorine to be added to the water system at several points. Army medical personnel also helped repair chlorination equipment. Still, even late in the year, there were several breaks in the water system where contamination was introduced, and tests at various points revealed no significant chlorine residual. Cultures often produced coliform organisms.
With such deficiencies in the public water system, the Force Surgeon and the local medical authorities became concerned in May with the possibility of a typhoid epidemic in the city. The Army lent four jet injector guns to local Red Cross authorities and issued them 300,000 doses of typhoid vaccine to be used in inoculating Dominican civilians.
Although LTC McCaleb was shown several civilian patients in another province (Monte Cristi) who were said to have typhoid, no significant incidence of the disease developed in Santo Domingo.
The Army used water from several sources, including city water, which was distributed at several supply points after it had been filtered through Engineer equipment. A chlorine residual of 5 p.p.m. was maintained.
Garbage Collection and Disposal
Many of Santo Domingo's refuse trucks were damaged, destroyed, or stolen during the fighting. The stench, the great swarms of flies, and the unending piles of garbage which collected in all the streets during the fighting testified to the breakdown of the collection and disposal service in the city. Even after the Army furnished trucks and directed personnel to sweep the streets the problem continued. Stray dogs, rummaging children, and the continuing violence saw to it.
The city had two methods of garbage disposal--an incinerator near the Duarte bridge and a sea cliff dump. The incinerator was damaged in the fighting; the dump, where garbage was dropped to be ground to nothing against the volcanic sea floor by an active surf, was inadequate for the whole city.
Meanwhile, the military was having its own problems. Attempts to use burning pits did not work out because of the persistent failure of units to separate combustible and noncombustible garbage. Within weeks after the start of the operation, the entire pit area was choked with garbage, wet containers which would not burn, and flies. Even after the Army assisted in the construction of two additional sea cliff dumps, helped repair the city's incinerator, and began using the city's new facilities, the fly problem could not be controlled at its own officially closed burning pits for several weeks. Garbage also accumulated alongside the city's clip dumps, but this problem was overcome after the U.S. Army loaned heavy equipment to Dominican Army engineers, who in turn cleaned up the areas.
Psychological warfare teams distributed leaflets in the city and conducted loudspeaker campaigns to arouse the citizens to clean up the streets. Fifty-five-gallon drums were placed throughout the city with "Keep the City Clean"-type slogans painted on the sides. Yet the garbage problem in Santo Domingo was far from being solved when the year ended.
Flies.--The fly problem described above was not only annoying but also a significant health hazard. Also as described above, few Army units in DOMREP had field sanitation teams, and even fewer had supplies or equipment for such teams until after the 714th Preventive Medicine Detachment conducted its sanitation courses.
Chemical Corps decontamination sections of the XVIII Airborne Corps and of the 82d Airborne Division were diverted from normal troop duty to join the 714th in conducting an insect control program. The 714th used a Malathion23 mixture in mist sprayers while Chemical Corps personnel utilized smoke generators brought in from Fort Bragg. The Chemical Corps personnel mixed Malathion with chemical smoke to produce insecticide smoke. I was not long before the Malathion damaged the machines, however, and they had to be rotated with other machines from Fort Bragg to permit maintenance. Chemical Corps officers then devised a system by which the Malathion could be introduced into the hot fog as it left the generator rather than being put directly into the machine. This system, which utilized a venturi tube injection device, was equally effective without damaging the generators.
At first, only troop areas and billets were fogged or sprayed, but later several civilian areas, including the national prison area at La Victoria and the corridor through Santo Domingo, were added to the schedule.
In civilian areas the fogging devices were preceded by psychological warfare loudspeaker trucks which broadcast an explanation of what was being done. Despite this precaution, cries of "chemical warfare" arose from some extremist groups along the western border of the zone considered held by the Constitutionalist forces. Civilians were warned that food should be covered and children brought in off the streets. But as LTC McCaleb recalled, "the latter advice was usually ignored, and the clouds contained more children than insects."24
Malathion fogging was effective for 36 to 48 hours, then had to be repeated to keep flies at endurable levels.
Mosquitoes.--The Pan American Health Organization had been conducting a malaria eradication program in the Dominican Republic for several years before April 1965. The program, directed by entomologist Morris Bradley O'Bryant, the only American on the staff of the Pan American Health Organization in the country, had made significant progress. By 1965 only three isolated pockets of malaria were known to exist, these in the western part of the country.25 But the primary vector, Anopheles albimanus, was prevalent in Santo Domingo and surrounding areas.
Dengue fever was prevalent among the younger indigenous personnel working for the Army, and the dengue vector, Aedes aegypti, was numerous in the area.
Filariasis was endemic throughout the country, where the vector, Culex pipiens quinquefasciatus (=C. fatigans), was found although the disease was more prevalent among the Negro population of coastal areas.
Two outbreaks of equine encephalomyelitis had been recorded in the country during the previous two decades, but the disease had not been typed because of a lack of local facilities for virus diagnosis.
Yellow fever had not been recorded in the Dominican Republic since the turn of the century.
Despite all the potential dangers, the U.S. military were not bothered by arthropodborne diseases in USFORDOMREP.26 The Pan American Health Organization malaria eradication program had reduced the dangers
of the other diseases somewhat, and the preventive measures taken by the Army proved effective. The use of bed nets was enforced, aerosol insecticide bombs were issued for use in billeting areas, and all personnel were directed to take malaria suppressive medication.27
The fogging with Malathion reduced danger to the civil populace as well as to the military.28
In addition to insecticide treatment, the 714th Preventive Medicine Detachment also did larviciding, but this had to be limited to areas adjacent to military compounds. The terrain and the multitude of small breeding places throughout the Santo Domingo region were too much for the limited amount of equipment and personnel in the unit.
There was a large rat population throughout most of the Dominican Republic, but no plague was reported. Personnel of the 714th Preventive Medicine Detachment examined more than 100 live trapped rats without finding a flea. In fact, no ectoparasites were found except for a few mites.
During the uprising, the rats in Santo Domingo thrived on the excess of garbage and found excellent harborage in the numerous old buildings Several Army personnel were bitten. In fact, 82d Airborne Division medical personnel reported on 20 June that more than 20 troopers had been medically evacuated because of rat bites.29 The 714th Preventive Medicine Detachment, an Engineer utility detachment, and unit sanitation teams conducted trapping and poisoning programs which met with some success, but they did not have the means to conduct programs outside of military confines. Personnel
of the 714th also provided technical assistance to all units with rodent problems and assumed complete responsibility for some of the larger compounds and hotels utilized by U.S. Forces. Anticoagulant poisons, Fumarin and Warfarin, were used.
Some of the individual soldiers devised their own rattraps. The Force Surgeon reported that one trooper ringed his position with an exposed wire elevated from the ground on short stakes and connected to the unit power generator. Approaching rats completed the circuit between wire and ground and were electrocuted.30
A number of high-priced, apparently first-rate restaurants were located in the embassy section of Santo Domingo. These were off limits, but after things had quieted down the troops flocked to them for food and drink in such numbers that some of the restaurants added extensions to their serving areas. Recognizing that morale would suffer if the soldiers were denied access to these establishments, and that control would be difficult anyway, the Force Surgeon, personnel of the 714th Preventive Medicine Detachment, and the Acting Minister of Health developed a sanitation inspection system.
A letter rating was given (to be displayed prominently in the restaurants) based on a point system of inspection as outlined in USFORDOMREP Circular No. 40-4 (appendix F). The five most popular restaurants were inspected first. Most of them operated under deplorable sanitary conditions, but most of the restaurant managers were cooperative and conditions improved rapidly.
Before the end of the year, eight restaurants were on the list and were inspected weekly by 714th Preventive Medicine Detachment personnel. Most American patronage continued to be confined to three of these, however.
Concurrently, 714th personnel conducted inspections of wholesale businesses such as slaughterhouses, dairies, and poultry farms to evaluate the food being supplied to the various restaurants.
Four major producers of soft drinks and one brewery were located in Santo Domingo. All five plants were outside the "occupied" area and
could not be inspected. Preventive medicine personnel tested the products at random, after obtaining them from retail sources, and identified one soft drink as being of variable quality. Its unacceptability was announced to military personnel. Personnel who tested the beer, Presidente, declared it an excellent pilsner and quite safe to drink. It was widely consumed.
Normally, the mission of a preventive medicine unit relative to ice procurement would be to inspect the ice-producing facility for sanitation and to check the water used and ice produced for bacterial organisms. In the Dominican situation, however, the complete responsibility for ice procurement was delegated to the 714th Preventive Medicine Detachment. One plant was selected to receive an Army contract, but then preventive medicine personnel spent 6 weeks trying to persuade the manager to have the place cleaned and to have the raw water filtered and chlorinated to 5 milligrams per liter. After many promises and little action, the 714th found another plant. After another week of wrangling the facility was approved and a contract for ice was let. Before the year's end, four plants were producing potable ice for U.S. troop consumption.
Street vendors could be seen everywhere in Santo Domingo from dawn until dusk. Some of the more popular items they sold were soft drinks, meat pies, bakery items, frozen ice treats, and shaved ice snowballs. In spite of many official warnings (appendix G), U.S. personnel widely patronized the vendors. It was believed that such food sources accounted for most of the hepatitis among the military. The only control which could be imposed was the restriction of vendors from the immediate vicinity of billeting areas.
Extent of Medical Treatment Provided Dominican Civilians
The fact that military casualties were relatively low and that specialized units handled most of the preventive medicine activities did not mean that the rest of the Army medical personnel in the Dominican Republic were left with time on their hands. During the period of May through August, 82d Airborne Division medical personnel treated 55 Dominican civilian inpatients and had 50,792 outpatient visits. In the same period 104 civilian inpatients and 212 civilian outpatients were treated by 15th Field Hospital personnel.
In the first weeks of the operation most of these patients were either combat casualties or persons with significant illnesses, but in later weeks, to quote LTC McCaleb again, the disease spectrum "was no different than that of any stateside clinic where free care invites insignificant clientele."31