and on May 2. 1944, there was published by Command of General Eisenhower, an ETOUSA directive which said, in part: "The practice of prostitution is contrary to the best principles of public health and harmful to the health, morale and efficiency of troops. No member of this command will, directly or indirectly, condone prostitution, aid in or condone the establishment or maintenance of brothels, bordellos or similar establishments, or in any way supervise prostitutes in the practice of their profession or examine them for purposes of licensure or certification. Every member of this command will use all available measures to repress prostitution in areas in which troops of the command are quartered or through which they may pass." Subsequently, other and more specific directives were issued concerning the use of off limits authority to implement the basic directive. Many of the French were surprised when we did not take over and operate bordellos for our troops, and some expressed the not unexpected opinion that they thought us slightly mad for attempting to deprive our men of the soldier's inalienable right to be served by a professional whore. When convinced, however, that this was a matter of carefully studied policy on the part of the Supreme Command, and was bona fide, the French authorities offered unexpected assistance. On September 15, 1944, which was as soon as action could be taken by the provisional government, the Minister of the Interior addressed instructions to all of the prefects of police in France to take immediate and effective action toward the repression of clandestine prostitution, and to form the keepers of licensed brothels to forbid American military personnel entry to their premises on penalty of being closed for violation. The feasibility of this second step depended, of course, on the assumption that we would provide sufficient police and command control of our troops to prevent disorder in case soldiers attempted to force entry when barred from brothels to which others have free access. In large areas and with large concentrations of troops, this has been done most efficiently, and it is reflected in low rates for venereal disease acquired in those areas and by the troops stationed in them. In other areas, the local commander has been either unsympathetic to the plan, or unable to supply this type of cooperation to the French, who understandably will not act without assistance from us. Paris is wide open, and this is reflected by the fact that as this was written, the venereal disease rate among troops on duty in Paris was 37 times as great as that of the rest of the Armies, and that for the entire United States Army on the Continent, 62 percent of all of the venereal infections acquired in France came from the Paris area, in spite of the fact that only a small fraction of the troops had had access to Paris at all. To complete the contrast is the situation with regard to the practicability of epidemiologic investigation. In the British experience, you will recall, we could get information worth following for epidemiologic study in 86 percent of cases. In France, however, only a negligible number of our soldiers who acquire a venereal disease are able to give useful information regarding the identity of their contact, and with the language difficulty, names and ad 1 dresses which sound authentic all too often turn out to be wrong when an attempt is made to identify the named individual. In some places where there is a large body of troops more or less permanently stationed in a small community, it has been possible to gain some measure of success with the type of epidemiologic investigation used in the United Kingdom. In the large cities and especially in Paris, however, this method so far has been of little value. It must not be concluded from what I have just said that we have accepted an attitude of defeatism. Far from it. I believe, and can from the record document this belief, that a well-rounded program of venereal disease control when pursued with intelligence and energy, cannot fail to be effective even under the most trying circumstances. There is no magic word, there is no secret formula, but the fullest exploitation possible under the circumstances of each of the several methods which are available for the attack cannot fail to produce results. The final phase of this contrasting picture is just being written. We went from England, a friendly ally with essentially the same language and social customs, to France, an equally friendly ally, but with a different language and social customs. We are now entering enemy territory where the language and social customs again are different, and where the people are hostile. Just what will develop for the Army of Occupation remains to be seen. I know that you join me in hoping that these developments will be soon and, from the standpoint of my responsibilities in the European Theater of Operations, I can only hope that when hostilities do cease, we can evacuate our troops from France with the greatest possible speed. THURSDAY EVENING SESSION November 9, 1944 The meeting reconvened at 8:15 o'clock. Dr. Thomas Parran presided. The Chairman: When this conference was planned, we thought of it as a U.S.A. conference. However, we were anxious to have with us our colleagues from the south and from Mexico, with whom we have been carrying out important cooperative activities along the border, and we were, of course, anxious to have our colleagues from Canada with whom we have been working so closely-especially Colonel Donald Williams, whom we claim as almost one-half on this side of the line. We then found that there were in the United States a number of medical officers from other United Nations whom we have been very glad to greet here this evening. As most of you know, the progress of our agenda has been such that it was possible to have presented to you today two papers which were scheduled for this evening, and that gives us this whole evening to hear from our friends who represent the other United Nations. I think it is appropriate to recall that action among the United Nations has been moving forward in many fields in addition to the strictly military fields. You recall the declarations from Moscow by our own Secretary of State, Mr. Hull, and the foreign ministers of the largest of the United Nations and the historic meeting in Teheran, participated in by Marshal Stalin, Mr. Churchill, and the President, preceded by conferences in Cairo in which Generalissimo Chiang Kai-shek also participated. There was the conference at Bretton Woods a few months ago, where the world monetary system of the future was outlined and agreed upon, and the more recent over-all meeting at Dumbarton Oaks where the world security organization was gestated, if not born, and at the moment there is in progress at Chicago a United Nations conference dealing with the postwar problems of civil aviation. During this time of war the United Nations have not been unmindful of the human problems with which each of us individually and all of us collectively will be confronted when victory is won. To this meeting, representing as it does the public health workers of this country, I would recall that the first of all of the conferences among the United Nations was that conference called in the early spring of 1943 at Hot Springs, Va., to deal with problems of food and agriculture. The fundamental problem of food for the people, of human nutrition, was a dominant consideration in that meeting of diplomats, agricultural experts, nutritionists, and public health officers. Out of that conference came a unanimous report for an interim commission which has perfected a report, outlining a future world organization to deal essentially with problems of human nutrition and with the ways and means by which agriculture can adapt itself to meet the nutritional needs of the people. Then there was the first meeting of the Council of the United Nations Relief and Rehabilitation Administration in Atlantic City just one year ago. Again the problems of health, of food, of epidemiologic control were of first concern. Ways and means were outlined by which the needs of the people, relief from suffering, control of epidemics, could be effectuated in each nation as it is liberated from enemy control. The UNRRA, however, is a temporary organization. The world organization concerned with food and agriculture will contribute much to public health, but it is not primarily a health organization. Those of us who have been considering this problem realize that one of the important sectors of international action lies in the field of public health. This has been referred to in recent months by Mr. Raymond Fosdick, President of the Rockefeller Foundation. "Public health," says Mr. Fosdick, "is one of the rallying points of unity for international collaboration." So it seems appropriate this evening that we should devote this session to an important segment, namely, problems of venereal disease control in the larger area of public health on an international sphere. If it is true-and I think all of us agree with Mr. Fosdick that it is truethat public health is a rallying point of unity for international collaboration, then the venereal diseases, world-wide in scope, large in their effects upon 85 the health status and the progress of nations, should be, shall I say, a nucleus in this rallying point, this area of unity for international collaboration. I shall not attempt to present to you each of our guests, but shall leave it to the chief of each delegation to present the members of his delegation. Our first speaker is one of the leading authorities in the world on problems of international health. For many years an official of the Health Section of the League of Nations, his work took him into many nations. Within the past month I asked him into how many nations of the world his duties with the League of Nations had taken him. He replied, "All but two." So I have the very great pleasure to introduce to you the representative of the Chief Medical Officer of the British Ministry of Health, Dr. Melville MacKenzie. INTERNATIONAL CONTROL OF VENEREAL DISEASES IN THE POSTWAR PERIOD: WITH SPECIAL REFERENCE TO ENGLAND AND WALES MELVILLE MACKENZIE, M.D., Principal Regional Medical Officer, I should like in the first place to apologize for the absence of Sir Wilson Jameson, Chief Medical Officer of the Ministry of Health. Sir Wilson asked me to express his sincere regret that owing to pressure of work he was unable to accept Surgeon General Parran's invitation to attend. He attaches great importance to this conference technically and particularly in the opportunity it offers for mutual help and the pooling of experience between our two countries. It is only by such collaboration and indeed coordination that we may hope to reach a maximum of efficiency in dealing with the problems of venereal disease in relation not only to military demobilization but also the vast and unprecedented movements involved in the return to their homes of many millions of displaced persons after the war. As an instance of the size of these problems I might mention that we have information, which we believe to be accurate, that there are at present in Europe alone, apart from the Far East and apart from the armies and apart from prisoners of war, 30,000,000 civilians who are out of their normal homes. These people will all have to come back, and that alone will suggest to you the size of one of the problems with which we shall be faced. In England and Wales the first effort at the control of venereal diseases was in 1864, when examination for infectious venereal disease of prostitutes in certain military centers was made compulsory. This was found to be of little avail and the law was repealed in 1866. The next step was in 1913 when a Royal Commission on Venereal Disease was set up, and as a result of legislation following that Commission, it was provided that arsenic drugs should be supplied freely to practitioners. It required all the authorities to set up treatment centers and to give instruction to the public in respect to venereal disease. The government paid 75 percent of the cost of these measures to local authorities. Shortly afterwards further legislation was passed forbidding anyone to treat venereal diseases except qualified practitioners and forbidding the advertisement of any remedies for venereal diseases. In 1924 the Brussels Agreement for the provision of free treatment to seamen of all nationalities was signed, and in 1935 further regulations laid down the qualifications of a venereal disease officer. His qualifications are definitely defined for the whole country by law. By 1939, as a result of these measures, 187 free treatment centers-115 in voluntary hospitals-had been created in England and Wales, and there were 13 hostels for the care and rehabilitation of girls. There were also 99 approved laboratories for free examination of venereal disease specimens. All of these measures had a very notable degree of success. There is good evidence that the new cases of early syphilis dealt with at the centers in England and Wales in 1939 were less than one-third of those in 1920. Further evidence of the decline of syphilis is seen in the following: 1. Deaths of infants certified as due to syphilis fell from a peak of 2.03 per 1,000 live births in 1917 and 1.43 in 1921 to 0.20 in 1939. 2. Admissions to hospitals for syphilis in the services stationed at home fell thus: Navy, from 8.1 per 1,000 per annum in 1921 to 1.96 in 1936; Army from 9.8 in 1921 to 0.9 in 1937; Royal Air Force from 4.1 in 1921 to 0.7 in 1937. 3. As indicating that no great amount of syphilitic infection has been left untreated in rural areas even in 1941, the number of syphilitic infections in servicemen which occurred more than 10 miles from any treatment center was only about 60. Thus the condition at the outbreak of the war was fairly satisfactory. Then came the war and with it very many factors which had profound effect on the incidence of syphilis. To quote Colonel Harrison: "Venereal diseases are spread by promiscuity and this is promoted principally by absence from home with only remote possibilities of returning there; reaction from mental strain; boredom; the possession of money to burn; gold digging; indulgence in alcohol in dosage a little higher than is customary for the individual, and, in some societies, custom and example. We have in England multitudes of temporary exiles from their own homes, many of them receiving very high wages and amongst them, as also amongst our own nationals, are numbers who periodically undergo intense mental strain and excite ment. We have also too many reckless, unstable girls who drink far too much and are determined to have a good time come what may." It takes very little imagination to understand the very many factors operating in England at present. First of all there is the gypsy life of the shelters, and the fact that hundreds of thousands of individuals are removed from their homes into new areas where they are under no parental supervision in the factories. There has been, of course, a great breakup of family life owing to evacuation of the mothers, the women with children under 5, to the country. The difficulty of the almost complete absence of familial discipline, the stationing of many individuals in very many lonely placesall these have operated to increase the amount of venereal disease in the country Prior to the outbreak of hostilities, when we realized that war might occur, through the medium of discussion with individual medical officers of health the attention of local authorities was drawn to the importance of strengthening their venereal disease machinery to meet the increased incidence which would be inevi |