USSBS Reports No.12, Effects of Bombing on Health and Medical Services in Japan

8/8/2019 USSBS Reports No.12, Effects of Bombing on Health and Medical Services in Japan

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THE UNITED STATESSTRATEGIC BOMBING SURVEY

THEEffects of Bombing

ONHealth and Medical Services

INJapan

Medical DivisionJune 1947


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THE UNITED STATESSTRATEGIC BOMBING SURVEY

THEEffects of Bombingon

Heatth and Medicat ServicesFN

Japan

Medical DivisionDates of Survey:

24 October31 November 1945Date of Publication:

June 1947


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)75v U(o3

U. S. SUPERINTENDENT OF DOCUMENT*AUG 28 1947

This report was written primarily for the use of the U. S. StrategicBombing Survey in the preparation of further reports of a more compre-hensive nature. Any conclusions or opinions expressed in this report mustbe considered as limited to the specific material covered and as subject tofurther interpretation in the light of further studies conducted by the Survey.


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FOREWORDThe United States Strategic Bombing Surveywas established by the Secretary of War on 3

November 1944, pursuant to a directive fromhe late President Roosevelt. Its mission was toconduct an impartial and expert study of theffects of our aerial attack on Germany, to beused in connection with air attacks on Japannd to establish a basis for evaluating the im-

portance and potentialities of air power as aninstrument of military strategy for planning

future development of the United Statesforces and for determining future eco-

omic policies with respect to the national de-A summary report and some 200 support-reports containing the findings of the SurveyGermany have been published.On 15 August 1945, President Truman re-

that the Survey conduct a similar studyf the effects of all types of air attack in the

against Japan, submitting reports in dupli-to the Secretary of War and to the Secre-of the Navy. The officers of the Survey

its Japanese phase were:Franklin D'Olier, Chairman.Paul H. Nitze, Henry C. Alexander, Vice

Chairmen.Harry L. Bowman,J. Kenneth Galbraith,Rensis Likert,Frank A. McNamee, Jr.,Fred Searls, Jr.,Monroe E. Spaght,Dr. Lewis R. Thompson,Theodore P. Wright, Directors.Walter Wilds, Secretary.

The Survey's complement provided for 300350 officers, and 500 enlisted men. The

military segment of the organization wasdrawn from the Army to the extent of 60 per-cent, and from the Navy to the extent of 40percent. Both the Army and the Navy gave theSurvey all possible assistance in furnishingmen, supplies, transport, and information. TheSurvey operated from headquarters establishedin Tokyo early in September 1945, with sub-headquarters in Nagoya, Osaka, Hiroshima, andNagasaki, and with mobile teams operating inother parts of Japan, the islands of the Pacific,and the Asiatic mainland.

It was possible to reconstruct much of war-time Japanese military planning and execution,engagement by engagement, and campaign bycampaign, and to secure reasonably accuratestatistics on Japan's economy and war produc-tion, plant by plant, and industry by industry.In addition, studies were conducted on Japan'sover-all strategic plans and the background ofher entry into the war, the internal discussionsand negotiations leading to her acceptance ofunconditional surrender, the course of healthand morale among the civilian population, theeffectiveness of the Japanese civilian defenseorganization, and the effects of the atomicbombs. Separate reports will be issued coveringeach phase of the study.The Survey interrogated more than 700 Jap-

anese military, government, and industrial offi-cials. It also recovered and translated manydocuments which not only have been useful tothe Survey, but also will furnish data valuablefor other studies. Arrangements have beenmade to turn over the Survey's files to the Cen-tral Intelligence Group, through which theywill be available for further examination anddistribution.

in


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TABLE OF CONTENTSI.


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I. INTRODUCTIONIn this report, the Medical Division has at-

to describe the system of public healthmedical care in Japan, and to analyze the

and indirect changes therein caused bywar, particularly by bombing. The reportof Bombing on Health and Medicalin Germany" was used as a general guide,the chapters which follow have been pre-

under similar headings in an endeavormake the two reports comparable.

SURVEY STAFFThe staff of the Medical Division of USSBS

of six officers and one civilian fromPublic Health Service, three officers andenlisted men from the Army. The Chief ofMedical Division; Brigadier General LewisThompson, Assistant Surgeon, United States

Health Service; could select freely theHealth Service officers attached to theand chose officers known for their

in certain fields of public health work.Army and Public Health Service officers de-to these several fields were : Major Luther

Terry, USPHS, medical education and medi-care; Lieutenant-Colonel Robert H. Flinn,industrial hygiene, venereal diseasestuberculosis; Major Robert S. Goodhart,

and Major Henry J. Rugo, A.U.S., foodand nutrition; Major Jesse Yaukey,vital statistics; Lieutenant-Colonel

B. Hilton, A.U.S., medical supplies,Ralph E. Tarbett, USPHS, and Captain

J. Houser, A.U.S., sanitary engineering.section on the number and nature of casual-after bombing was a joint contribution by

Terry and Major Jaukey Mr. Lester J.of the U. S. Public Health Service acted

executive secretary for the Medical Division.

SURVEY SCOPEAs in the German report, the Survey was

to specific cities which would give apicture. The wisdom of this de-

became apparent when we were able toa first-hand view of the over-all situation

after arriving in Japan. The cities selected wereTokyo, Yokohama, Osaka, Kobe, and Kyoto.The first four of these cities had been bombed,with destruction varying from 37 percent inOsaka to 56 percent in Kobe. Kyoto was selectedfor comparative purposes because it had notbeen bombed. It served as an excellent exampleof a Japanese city which was operating underwartime conditions without any interruption ofits sanitary facilities or public health adminis-tration. In the collection of vital statistics cer-tain other cities were added to give a somewhatbroader base line.

INFORMATION SOURCESThe information was obtained from various

sources. The fact that the American Army ofOccupation had already firmly established itselfin Japan and had set up a Public Health andWelfare Section under the able direction of Col.Crawford F. Sams made the work of the Medi-cal Division of USSBS much less difficult. Sur-veys had been made and such data collected onsanitary conditions, including water supplies.Surveys of Japanese medical and food supplieshad also been made. An excellent system ofweekly reports of communicable diseases by cityand prefectural governments had been organ-ized. All of this information was made avail-able to members of the Medican Division, andthrough the Public Health and Welfare Sectionthey maintained liaison with responsible offi-cials of the Ministry of Health and Social Af-fairs of the Japanese Government.The chief surgeons of the Eighth and SixthArmy Headquarters contributed detailed infor-

mation about their areas of occupation. TheMinistry of Health and Social Affairs of theJapanese Government, particularly the facultyof the Institute of Public Health, and the Direc-tor of the Institute of Infectious Diseases whois also Dean of the Medical Faculty of the Im-perial Tokyo University, were especially help-ful. Local information about the prefecturesand cities was obtained from health authorities,food officials, police authorities, and both publicand private hospitals. Information regarding


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water supplies and sewage disposal was fur-nished by the sanitarians in charge of theseoperations. In addition, numerous health offi-cers, physicians, nurses, factory operators anddrug manufacturers were questioned.While particular forms were not used to cover

all fields of public health, an outline used bythe Public Health Service was the basis for thecollection of uniform data relating to water-supplies and sewage disposal. The health au-thorities of certain cities also made actual sur-veys to determine existing conditions aboutwhich no information otherwise would havebeen available. It seemed generally that publichealth and medical authorities, especially thosein the Public Health Institute, gave every pos-sible assistance in obtaining the necessary data.Nevertheless, it remains impossible to judgehow accurate this information was and whetheror not the apparently cooperative spirit wasalways genuine. More especially this was truein collecting statistical data where in most casesany question resulted in the formula "that thedata had been burned as a result of fire dam-age."

JAPANESE HEALTHORGANIZATIONIt has been stated that Japan had developed

a fairly modern public health organization be-fore the war. The central government organiza-tion, the Ministry of Public Health and SocialAffairs, was organized in 1938. Although thisorganization appears well designed to controlall public health activities in the JapaneseIslands, because of the autonomous prefecturalgovernments, the central organization is not asclosely knit as, for instance, that of the BritishIsles. The Japanese public-health organizationtends more to follow the structure found in theUnited States with its National Public HealthService, its consulting service and widespreadgrant-in-aid system to the States, and the com-pletely autonomous state public-health depart-ments. However, the "paper" set-up in Japandiffers from the United States system in thatthe American state departments of healthusually are well organized and are capable ofcarrying on their responsibilities independently.The Japanese prefectural and city health or-ganizations are not well organized and theprofessional qualifications of the personnel are

below standard. Another fundamental differ-ence between the structure of United States andJapanese health organizations is that whilestate, city, and local health departments in theUnited States operate as independent units intheir governmental structure, in Japan they aredelegated to a position of less importance underthe general police authority.The police have supervision over doctors,

dentists, midwives, nurses, masseurs, druggists,prostitutes, and the insane, and the sale, com-mercial preparation, and consumption of food.They also have charge of the annual compulsorycleaning of private homes and public buildings,of drainage and wells, and of the maintenanceof dumping grounds. During epidemics thepolice attempt to prevent the spread of diseaseby house-to-house inspection. Physicians reportthe notifiable diseases to the police; the policein return report to the health section of theprefectural police department, and notify themunicipal health departments where such or-ganizations exist. Reports are finally trans-mitted to the Ministry of Health and SocialAffairs.While it is neither pertinent nor desirable to

go into any detailed discussion of the Instituteof Public Health, it is impossible not to recog-nize the direct and indirect influence this Insti-tute has had on the over-all development of pub-lic health work in Japan. Many of the profes-sors were educated for their particular fields inuniversities of the United States and Europe.Also, until 1944, the Institute was the principalteaching organization for the training of medi-cal officers, veterinarians, and nurses in thepublic health field. Only three of the staff of theInstitute were lost by induction into the mili-tary forces between 1938 and 1945. The cessa-tion of the training of medical officers andnurses in the public health field in 1944 and1945 may be considered of only secondary im-portance as the annual quota of only 50 wasnever reached in any year previous to the war.The large majority of public health officials andpublic health nurses were inadequately trained.The present Institute consists of four majordepartments (1) Department for Public Wel-fare, Research and Education ; (2) Departmentof Population Problems (formerly Institute ofPopulation Problems) ; (3) Department of Nu-trition (formerly Imperial Government Insti-


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for Nutrition Research) ; and (4) Depart-of Industrial Safety (formerly Institute

Industrial Safety). The fire which destroyedhome office of the Ministry of Health and

Affairs resulted in the transfer of theits equipment and personnel, to theInstitute. The amalgamation of the

and the Institute seriously impairedeffectiveness of both and more seriously de-

the research work of the Institute.

MEDICAL FACILITIES ANDPERSONNELThe chapter. Medical Facilities and Person-must be introduced with an understanding

the attitude of the military forces, the centraland even of the practicing physi-

himself, toward the medical care providedthe civilian public.The Japanese physician graduating from the

universities and equally well-staffedschools was well trained. However,

were a large number of other medicalin Japan where the standards were very

Despite the fact that before the war the num-of physicians per 10,000 population was

increasing, medical care for the civilianwas not good. This in part was becauseprivate hospitals, mainly pay hospitals,

the major portion of the facilities forhe care of serious medical and surgical cases;

the rural dweller and unskilled workernot afford medical care of any sort.

The military demand for physicians, thedestruction of hospitals by bombing, the

of hospital staffs, and the feeble at-of the government to provide temporary

or medical care served only to accen-the poor character of the medical services

the civilian population.

FOOD SUPPLY AND NUTRITIONThe chapter on food.supplies and nutrition isncerned with one of the most complicated yet

health problems in Japan.The Japanese approach to the control of their

supplies was not only interesting from theof the mistakes made, but also be-

cause of the more important reflection of thesemistakes in the very existence of the Japanesenation.

For a nation primarily dependent upon im-ports of food to maintain a minimum adequatediet for its civilian population, the continualdecline of these imports to almost zero during1945 produced complete dependence upon thecrops raised within the country itself.

Such government-controlled food rationing aswas possible then had an adverse effect on thecivilian diet. The Japanese farmer was not de-pendent upon the processing of his crops beforethey were placed upon the retail market. Thiswas especially true regarding rice, which hecould process himself and sell directly to theconsumer.Government price control and rationing

therefore reduced the quantity of foods in regu-lar channels and greatly increased black marketoperations. Also, as noted in the main body ofthe report, the Japanese Government attemptedto maintain the standard quantity of the staplediet through substitutions, even though thequality and caloric value was diminished.The result of the low caloric diet was most

evident in conditions related to malnutrition butnot so evident in the production of specific dietdeficiency diseases. It was noteworthy that beri-beri, always prevalent before the war, decreasedwith the low caloric diet. The extent of malnu-trition, especially among the salaried urbanworkers was manifested by weight losses, "waredema" and fatigue, and by the decrease of milkin nursing mothers and the higher mortalityrate among their babies. In addition, the de-ficiency in food supplies was reflected in thebasic health conditions of the nation as a whole,as seen in the mounting mortality rates and inthe rising fatality rates for many types of ill-nesses.

ENVIRONMENTAL SANITATIONAs would be expected, in studying the effects

of war and especially bombing on the health andsanitary conditions of any two countries, thereare certain fundamental differences which mustbe considered if understandable comparisonsare to be reached.The bombing survey in Germany was made

in the closing days of the war. In fact, it fol-


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lowed on the very heels of the Allied soldiersadvancing into Germany. In Japan, however,the medical survey began approximately 2months after the war ended and the Americansoccupied Japan. It is quite clear, therefore, thatthe immediate effects of war and bombing ongeneral health conditions and casualties haddisappeared, although the retrospective picturewas clearer because of elapsed time.The difference in the predominant type ofbombing in Japanincendiary, as compared todemolition in Germanyconfuses the compari-son more than appears on the surface.German housing and factory constructionmay be considered permanent. Japanese urban

areas and many factories were wooden in struc-ture, of a type peculiar to that country. In resi-dential areas houses are mainly contiguous,producing a compactness in living conditionsand a density of population not usually foundin the United States or in European countries.

It is apparent, therefore, that incendiarybombing of urban areas of Japan reached itsmaximum effectiveness. On the other hand, in-cendiary bombing as it directly affected healthand sanitation (except casualties resulting as adirect effect of the bombing) was peculiarlyineffective. These large urban areas destroyedby fire were, in effect, sterilized. Rats and mice,lice and fleas, were destroyed along with otheranimals and those human beings caught in theburned area. Neither food nor rubble remainedfor animal or insect existence if they returnedfrom the unburned areas ahead of the humanpopulation.

In Germany and other European countries,demolition bombing produced extremely seriouseffects on city water and sewage disposal sys-tems. As an example, in Munich (The Effect ofBombing on Health and Medical Care in Ger-many, Medical Branch, United States StrategicBombing Survey, Washington, D. C., October30, 1945, p. 238) the air raids of July andAugust 1944 caused severe damage to gravity-feed and distribution systems. It is stated thatall five of the main feed lines running into thecity were broken and that the mains weresevered in approximately 850 places. It was alsostated in this report that the Germans werecompelled to set up elaborate repair teams inall of the cities and to maintain an adequatebacteriological check on the quality of water-

supplies where breaks occurred.In Japan, incendiary bombing was again pe-

culiarly ineffective in disrupting water suppliesand sewage disposal. Several major reasons forthis ineffectiveness are immediately apparent.

Although in most of the bombed cities manybreaks in the main water feed lines occurred,repairs seem to have been made in a reasonabletime. Water-plant operations usually were notseriously interfered with although many pump-ing stations were put out of commission duringthe period of electric power failure. Also fewJapanese cities, even those with a population of100,000 and over, have sewers, and in thesecities the major part of the civilian populationis not dependent upon the average sewerage sys-tems for the disposal of human excreta. As acorollary to this, the Japanese method of dis-posal of human excreta to farms for use as fer-tilizer leaves the original source of raw watersupplies for any city in a much less pollutedcondition than in the United States or Europeancountries where sewage, treated or untreated,is emptied directly into the rivers which after-wards become sources for drinking watersupplies.

Probably the most serious danger of possiblewater pollution resulting from incendiarybombing was the thousands of leaking homeinstallations in the burned areas to which theJapanese authorities gave little or no attention.This tremendous loss of water not only madeit impossible to maintain the distribution ofwater in all residential areas, but caused lowwater pressures, which presented the possibilityof backflow of polluted water into the mains.As in Germany, the total effects of war, and

more particularly, bombing, cannot be immedi-ately assessed because years must elapse beforethe effects of undernourishment and the break-down of sanitary environment on health, as evi-denced especially by chronic diseases such astuberculosis, become fully apparent. Again, asin Germany, there was no serious increase ofcommunicable diseases in Japan although a fewepidemics did occur. The German report sug-gested that the innate cleanliness of the Germanpeople, their training in personal sanitation,and the effectiveness of public health and sani-tary organizations in maintaining a continu-ously excellent public-health program, weremainly responsible for the absence of epidemics


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the lack of increase in communicable dis-The fact that there was no general in-in communicable diseases in Japan can-

be explained along these same lines. It isrue that the Japanese people are naturally

in their personal habits, but the popula-as a whole has no conception of the prin-of personal hygiene and the Governmenttook no organized measures to instructin these precepts.

There were serious interrruptions in the op-of health departments and sanitary

when fire and atomic bombingto a standstill the already poorly or-departments of prefectural and city

For example, the disposal ofexcreta, garbage, and other householdhalted for long periods of time and re-in gross unsanitary conditions in the

sidential areas. Possibly the exodus of thefrom these areas, the destruction ofincluding flies and animal pests and

immediate breeding places, may have hadsalutary effect.

INDUSTRIAL HEALTHAND HYGIENEThe chapter, Industrial Health and Hygiene,

brings out quite clearly the lack of inter-of the armed forces and the central govern-

in the walfare of the civilian industrialUntil the beginning of the war, Japan

taken forward steps in modern industrialpractices. The establishment of theHygiene Institute, the training ofpersonnel and the enactment of

Factory Act had done much to protect theThe abrogation of the Factory Act by the

government and the military cliques leda situation which gravely affected the healththe industrial worker. A direct measurementfatigue other than reduced productivity andincrease in absenteeism and sickness ratesdifficult to obtain, yet labor conditions in

were saturated with all the elementsto produce fatigue under ordinary cir-

Extremely long hours of work, theof the continuous work period to 11

14 days, shortages of food, destruction ofand transportation facilities, and con-long travel time to work formed the

ideal set-up for the promotion of fatigue andconsequent absenteeism.

According to the data available, absenteeismhad increased to between 20 and 30 percent by1943, and rose to approximately 50 percent inprivate industries after the raids in 1945. Inindustries controlled by the military the risewas much less spectacular but neverthelessthere was a definite rate increase of somewhatover 10 percent. How much of this absenteeismwas caused by illness and how much by thepathological condition of fatigue is only con-jectural, but its reflection on production ismeasurable. It has been stated in the reportsof other divisions of the Survey that productiondecreased in 1945 in certain industries at arate not entirely explainable either by lack ofraw materials or by the destruction of factor-ies. While absenteeism may have been impor-tant in this decrease in production, probablythe most fundamental cause of all was thereduced productivity of the worker because offatigue. The most important cause of fatiguein both the absentee and the worker on the jobwas lack of food.

AIR-RAID CASUALTIESUnquestionably the greatest single factor

which left its imprint on the Japanese peoplewas the continued decrease of their food supply.On the other hand, the most direct effect ofbombing on the civilian population was theseverity and heavy toll of casualties. The de-struction of the civilian population of any coun-try, even if it occurs as an incident in the de-struction of military objectives, is not pleasantto contemplate, especially when the majorityof such casualties are women and children. TheGerman report estimated there were approxi-mately 500,000 fatalities from bombing duringthe war over a period of between 5 and 6 years.The estimated number of fatalities in Japanwas approximately 333,000 in less than 1 yearof bombing. It is quite evident, therefore, thatwhatever yardstick is used, whether fatalitiesper ton of bomb dropped, or fatalities permonth, the number of fatalities caused by bomb-ing in Japan was proportionally much greaterthan in Germany.

This chapter also shows the interesting dif-ference in the nature of fatalities caused bypredominantly incendiary ' bombing as com-pared to high-explosive bombing. Burns were


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the outstanding cause of death in Japanesecities. In the first four of the five large citiesstudied, Tokyo, Kobe, Osaka, Sendai, and Na-goya, burns accounted for approximately 56 to84 percent of the fatalities. In Nagoya, how-ever, where high-explosive bombing predomi-nated, burns accounted for only 25 percent,while deaths from direct blast were 54 percent.The German report indicated that a carefulstudy was made of burn and suffocation fatali-

ties and that in incendiary raids 80 percent ofsuch fatalities were due to carbon monoxidepoisoning. No such study was made by Japan-ese authorities. Thus while the percentage ofburn fatalities was quite high, it is impossibleto break down this broad classification anddetermine the number of deaths caused eitherby carbon monoxide poisoning or suffocationprior to the actual burning of the already deadbody.

It is possible only to conjecture that becauseof the inflammable structure of Japanese urbanareas and the density of population in theseareas, the number of fatalities from burns washigher than in German cities.

INFECTIOUS DISEASESBeginning in 1942 typhoid and paratyphoid

fevers showed a definite increase for Japan asa whole. This increase persisted to the end ofthe war although the rates in 1945 after thebombing were no higher than during 1943 and1944. On the other hand, dysentery did show amarked increase over previous years duringthe late spring and summer months of 1945.In Kobe, after the June incendiary bombing,there was a sharp rise in typhoid and paraty-phoid fevers that reached a peak in August anddeclined somewhat in September and October.The public water supply of this city and itspotability is discussed in detail in the mainbody of the report. The possible relationshipof this water supply to the epidemic could notbe ignored. In Nagoya, after a serious June airraid with demolition bombs, the extreme in-crease of dysentery in July also reached itspeak in August. This city also had a rise intyphoid and paratyphoid fevers which reacheda peak in September. It is impossible to dis-associate the epidemic from some factor in theenviromental sanitation which affected the en-tire population, and this fact again apparentlypoints towards the public water supply. Tokyo

did not show any increase in typhoid, para-typhoid or dysentary in 1945, but Yokohamadid have an increase in typhoid and paraty-phoid fevers. However, Kyoto, which was un-bombed, had about the same increase over thesame period of time.

In evaluating health conditions in Japan itis difficult not to believe that the high preva-lence of dysentery, ekiri, and typhoid and para-typhoid fevers, is accounted for in greatmeasure by the contamination of foods from theuse of human excreta as fertilizer and by theprevalence of flies during the summer season.Such a conclusion is unavoidable in view ofconditions similar to those found in the UnitedStates and other countries in the early part ofthe century, and in view of the seasonal distri-bution of these diseases. Also, as noted above,the war itself with its resulting movement ofpopulation groups, the necessity of foraging inthe country, and the gradually increasing lackof attention to sanitary and health matters,affected the prevalence of certain communicablediseases.The effect of the bombing of urban areas on

sanitary and health conditions was not confinedto the bombed area but included those areaswhich received the evacuees. Available dataindicate that the number of persons evacuatingthe target areas in Honshu, Kyushu and Shi-koku for other areas in these islands was ap-proximately 27 percent of the island populationexclusive of the bombed cities. The impact ofadded population of this magnitude in the smallcities and villages must have produced over-crowding and overtaxing of medical and sani-tary services.

In the chapter on tuberculosis it has beenpointed out that this disease may be consideredJapan's most important public health problemand is so recognized by the Japanese them-selves, especially those in high authority. Therestill exists a conflict of opinion as to the bestmethod or methods for controlling this disease.BCG (an attenuated or modified culture ofbovine tubercle bacilli) has been used exten-sively in an attempt to immunize certain pop-ulation groups, and the central government hasreported favorably on its use. Nevertheless, anumber of the more able public health officialshave insisted that national control measuresmust be based on an active case finding pro-

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gram. Such a campaign was started in industrywith good results.

However, the direct effects of bombing suchas the destruction of urban areas, the evacua-tion of people to semi-urban and rural areaswith consequent exposure of otherwise unin-fected groups to open and active tubercularcases among the evacuees, and the generaleffects of an inadequate diet will have an ex-tremely unfavorable effect on any controlmeasures used against this disease for a longtime in the future.

MEDICAL SUPPLIESThis chapter tends to prove what might have

been obvious in the beginning. Japan enteredthe war without adequate stocks of medical

supplies, especially for the civilian population.In addition, she was largely dependent uponGermany and the United States for imports ofcertain new drugs, particularly those whichwere technologically difficult to produce. Also,Japan depended on imports of crude chemicalsfor the preparation of such drugs as she wasable to manufacture. As in her problem of im-ported food supplies, the failure of any of thesemany factors resulted in the disruption of theentire medical supply system. This was re-flected mainly in the lack of drugs for civilianusage. The quantity of drugs going into themilitary services remained practically constantduring the war, whereas the quantity of drugsfor civilian use decreased approximately 40 to60 percent by 1945.


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II. MEDICAL FACILITIES AND PERSONNELThis section comprises insofar as possible an

account of the character and availability ofmedical care in Japan during the years of thewar with the United States. At times the gen-eral effects of the war, such as shortages of allkinds, the naval blockade, and the increasingdemands for supplies and personnel, madebombing more effective than it might havebeen otherwise. To appraise the effects of bomb-ing on medical care, an over-all picture isneeded of prewar, wartime pre-bombing andpost-bombing conditions.

So many elements enter into the constitutionof good medical care that it is difficult to ap-praise the whole accurately, except as theseparts are removed and analyzed individually.Although such a procedure is fraught with thedanger that in examining an individual part,its relationship to the entire mechanism andto the end product may be forgotten, it wasfelt that medical care could best be appraisedby studying the more important elements asthey related to the whole program. Thus, thepresentation has been broken down into divi-sions on hospitals, medical education and med-ical personnel. The development of a publichealth program in Japan, as in any other coun-try, has been important in the advancement ofthe people. However, a special section is notbeing devoted to this problem since it could becovered in the sections mentioned above.

HOSPITALSHospital facilities in Japan, even prior to

the war with the United States, were not asplentiful as in most of the Western world. TheJapanese people, especially those in small townsand rural areas, were not accustomed to receiv-ing hospital care for their illnesses. Unlessvery ill, people did not go to hospitals, andmany who would have been hospital patientsby United States standards never received hos-pital treatment in Japan. Often there was noteven a physician in attendance. Few of thecommon people could afford hospital care, andthere were few "charity" hospitals as we under-stand the term. Within recent years, there hasbeen a definite trend toward the developmentof hospital facilities in urban centers for thosewho were unable to pay all or a part of the

expenses involved, but this development hadnot reached significant proportions.Another factor to be considered in discussing

Japanese hospital facilities is the use of theterm "bed capacity." The rooms in most hos-pitals were much like the rooms in Japanesehomes, with Tatami floors, and the bed wasmade by spreading bedding (Futon) upon thefloor. Thus the bed capacity of a given hospitalmight vary considerably with no change in thephysical structure, sinqe the term merely indi-cated potential beds as represented by adequatefloor space upon which a patient could beplaced. On the other hand, the larger city anduniversity hospitals were usually fairly wellequipped and used Western beds throughout.This further complicated an interpretation ofthe figures on bed capacity because an unknownpercentage of those beds were really fixed struc-tures. However, since the term "bed capacity"appeared to be the clearest means at hand ofexpressing the size of an institution it wasused with the proper reservations.A further point of divergence from the com-mon practice in the Western world was that in

Japanese hospitals family members or servantsoften remained in the hospital to attend thepatient. Even in the larger and more modernhospitals which were equipped with beds, fre-quently a small roll-away type of bed for theattendants was kept under the patients' beds.This feature imposed a greater load upon thehospital insofar as space was concerned, butoften relieved the hospital of a great deal ofthe burden of nursing care.Food for hospital patients was handled dif-

ferently in various institutions. Prior to thewar the more modern hospitals furnished allnecessary food for the patients. Some of thesmaller hospitals and clinics did not furnishany food. The usual practice, however, was forthe hospital to furnish the more common basicfoods, such as rice and some type of soup. Thefamily was expected to supplement these withany additional food needed or desired by thepatient. The family attendant usually preparedthis food over small charcoal braziers in a roomadjacent to the patient's room or ward. As thewar progressed, hospitals relied more and moreupon families to furnish food for the patients,

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and some hospitals required that the familyfurnish all food.Most of the many private hospitals in Japan

were small (10 to 50 beds). Table 1 shows thatall of the private hospitals averaged only 29beds each. These small hospitals were oftenreferred to as clinics by the Japanese, partic-ularly when a few hospital beds were main-tained in connection with a physician's office.Such hospitals or clinics have been excludedfrom all figures in this report if they had lessthan 10 beds. The larger and the better hos-pitals usually were controlled by some phaseof the Government. Usually those entirely orpartly controlled by the Imperial Governmentwere referred to as government hospitals, andthose under the supervision of the prefecturalor city governments were called public hos-pitals. There were both public and privatecharity hospitals, primarily intended for freepatients, but roughly 20 percent of their oc-cupants paid fees. In addition there wereprivate and government controlled specializedhospitals for mental diseases, tuberculosis,leprosy, communicable disease and prostitutes.These were usually listed separately when datarelative to them were compiled. The last prewaryear for which there was complete informationrelative to the number of hospitals and numberof beds is 1938, and the data are shown inTables 1 and 2. A discrepancy in these tablesbetween the total number of hospitals andbeds was due to the omission of isolation wardsand hospitals which were open only when sta-tutory communicable diseases occurred. Somecommunicable disease hospitals apparentlywere also omitted.The number of hospital beds per 1,000 pop-

ulation in Japan before and after the war canbe compared with similar figures for the UnitedStates (Table 3).

Table 1.Number of hospitals in Japan1938

Table 2. Hospitals in Japan1938

Type of hospital


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Another serious effect upon the operatingefficiency of Japanese hospitals was the short-age of personnel, especially physicians. Gener-ally speaking, the Japanese armed forcesdepended almost entirely upon a nucleus ofolder regular service officers plus a very largenumber of younger physicians. As most of thelarge modern hospitals had utilized a systemsimilar to large American hospitals wherebyyoung physicians in training carried out a greatdeal of the routine duties, the removal of thesemen from the hospital staffs was sorely felt.Even though a large number of small hospitalsand clinics were less dependent upon the young-er physicians and consequently were not asseriously affected by this factor, the more im-portant institutions had to curtail operations.The hospitals of Japan were not affected asseriously as the hospital system of the UnitedStates would have been under similar circum-stances, but the effects were of significant pro-portions.

In addition to the shortage of physiciansthere was a shortage of other technical per-sonnel. Nurses were poorly trained and inade-quate in numbers. Medical technicians werealmost completely absent except for the oldergroup. However, common laborers employed inhospitals seemed to be fairly adequate in num-ber.The loss of personnel due to evacuation of

the cities also seriously affected the hospitals.The precautionary destruction of homes in thecreation of firebreaks rendered many doctorsand nurses homeless, and they left their posi-tions to move to the country. However, thepersonnel loss due to bombing of homes andoffices and to fleeing the cities because of fearof bombing was far more significant. For in-stance, the director of St. Luke's Hospital,Tokyo, stated that the latter was the most ser-ious effect that the war had upon that hospital.Because of the fear of bombing, 100 of 150nurses and 15 of the remaining 30 physicians(the military services had already taken 30 ofthe original 60 physicians) fled the city. It wasnotable that of all the professional personnel,the most dependable to remain on the job andto perform their work properly were the stu-dent nurses. It was said that "they were moredevoted to the ideals of Florence Nightingaleand stuck to the job almost to an individual."

The evacuation of valuable equipment, withthe removal of much X-ray equipment and otherinstruments ordinarily considered essential tothe operation of a hospital, certainly affectedthe quality and probably the volume of workof these institutions.

Other conditions which affected the operationof hospitals were shortages of equipment andsupplies, disturbances of hospital routine dueto preparations for or fear of air raids, andloss of time consumed in foraging for food.The conditions relative to medical supplies andequipment are discussed elsewhere in this re-port and suffice it to say at this point that theshortages were extreme in many instances.Earlier in the war a few hospitals were ableto lay in sufficient stocks to be supplied muchlonger than others, but for the last year ofthe war practically every civilian institutionfaced dire shortages. At the same time, militaryhospitals and depots often had supplies suffi-cient for six months or more stored in the samecity. Air-raid precautions were time consumingfor the personnel and often quite expensive tothe hospitals, though nothing like the prepara-tions in civilian hospitals in the Europeantheater. Loss of efficiency due to fear of bomb-ing was a factor of some importance but wasone of those intangibles difficult to appraiseaccurately. In many instances the shortage offood became so severe that it was necessary forhospitals to feed their employees in order tokeep them. When this could be done it wasfairly successful, but when this was not possiblethe time lost foraging for food appeared to havebeen considerable.Direct Effects of Bombing

The principal direct effect of bombing wasactual destruction of hospitals. Exclusive ofthe atomic bombings, 969 hospitals were com-pletely destroyed and 50 were partially de-stroyed, with a loss of 51,935 hospital beds.Table 4 shows the damaged and destroyed hos-pitals and bed capacity by prefectures as re-ported by the Ministry of Health and SocialAffairs. If demolition bombs had been predomi-nant, a far larger percentage of partly destroyedinstitutions could have been expected (Figure1). However, high-explosive bombs played analmost insignificant role in this picture. Only afew hospitals located near strategic industrial

10


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4. Number of hospitals and hospital beds inJapan destroyed by bombing 1

Prefecture

igi

in i'-M\\ a

...

ie

Town or \ illa^i-

X . : 1 1 : 1 , . ) CitjAomori CitjKamaisbi City.Sendai City

Taira CityMill' CitjHitaobi CitsQtsunomiyaMebashi CitjMaoka Town.KumagayaCbiba CitjTyochi CityFunabasbi.IchikawaTokyo City.Bachiogi CityKitatama.YokohamaKawasaki.HiratsukaNagaoka..Toyama.Fukui ...Turuga....Kofn City.GifuOgakiHamainatsu.SbizuokaNamazuShimizuKoyamaNagoyaToyohashi. ..Hk:i/:iki_. ...Ichinomiya..KuwanaYokkaicbiTsuOsakaToyonakaSakaiKobe..HiiiH'ji

isaki...Xishinoniiya.Wakayama..

OkayamaHiroshima. ..KurcSnimnnoseki.Ube...Tokushima...Takamatsu-.Matsuyama..ImabaruUwagimaKochiMojiYabataOmutaKurumeFukuokaNagasakiSaseboKumamoto...

... AraoOitayazaki MiyazakiMiyakonojo..NobeokaKagoshima.iMakurazaki..YayatoKaseda

Total..

Number of hospitalsdestroyed

Totallj Partially Total

2459NoneNone219

111

12

209il

23341

.;.,133

111

None131

None88131211

1

4843226None6242591565None

14NoneNone2330595162014111427

1119102042151

NoneNone

I

None

None

Nonelli

i

l

NoneNoneNone

131

1111


20/265

12


21/265

else. The Japanese disregard for humanwas often astonishingly apparent.

The lack of any significant air-raid protec-in Japanese hospitals was particularlywhen compared with the elaborate plansout in the European theater. The Ger-

constructed complex and formidable air-shelters and bunkers to protect patients

raids, and evacuated many patients toconstructed hospitals in the rural(Details of these plans can be obtained

consulting the report of the Medical Divi-of USSBS in Germany.) Although the

blacked-out hospitals during raids,patients to inside corridors, basements

other comparatively safer portions of theand set up special operating androoms to take care of casualties, the

shelters were usually pathetic in typenumber. The Imperial government estab-a set of recommendations relative to pre-

shelters, etc., and agreed to pay halfthe expenses involved. The hospital author-

at first did not believe they would beand were skeptical about getting suchassistance, so that very few of themthe government's directions. As prac-

no steel or cement was available forconstruction of shelters, the final outcomethat few shelters were constructed; thebuilt were ineffective; and in most in-

getting reimbursement for even a partsuch expenditures was difficult.Since there was little protection afforded,

were reticent about entering hospitalsmany patients able to travel sought refuge

the country. The number of hospital patientsbut many needing treatment suf-

from lack of care. Such conditions causeddeterioration of morale as well as a declinethe population's effectiveness due to illness.

the circumstances, it was surprising thatserious outbreaks of communicable dis-did not occur.

The actual number of hospital patients killedair raids could not be determined. In most

records were destroyed along withhospitals. By interrogation of individualscould learn of a few patients killed herethere, but in general, the Japanese seemed

to admit the number lost. Even where

piece-meal information could be gathered, therewas not adequate time to gather enough datato reach any definite conclusions. However, itis safe to say that thousands of patients losttheir lives when hospitals were destroyed andthat the proportion of deaths probably wasmuch larger than among the general populationof destroyed areas.The loss of irreplaceable equipment and sup-

plies in ruined hospitals was an especially seri-ous problem. Since many of the hospitals de-stroyed were small units located in Japanesetype buildings, they could have been restoredto their prebombing status without too muchdisturbance of service if the equipment couldhave been saved. There were severe shortagesof medical supplies even prior to bombing, andthe loss of such supplies in bombing aggravatedthe problem. For several months before theend of the war civilian hospitals were almostwithout even the basic articles. Many psycho-pathic hospitals were without adequate seda-tives. Insulin, digitalis, sulphonamides andother basic drugs were so scarce that large gen-eral hospitals were often completely without orhad only negligible quantities.

Hospital administrations repeatedly com-plained of the effects of bombing on hospitalpersonnel. Often after air raids they had towork continuously for 24 to 48 hours. In short,a greatly reduced hospital staff carried as in-creased burden and at the same time got in-sufficient rest and had difficulty in getting toand from work. In time the effects became moreand more evident. Morale was low. There waslittle with which to work. Hospitals deterioratedand in many instances would have closed hadthe pressure of wartime conditions not beenso great. Actually, few hospitals did close, butmany could have closed rather than continue asthey were. The hospitals were probably inworse condition, both physically and function-ally, than they had been since the beginningof this century.Post-War StatusThe Medical Division of USSBS entered

Japan about two months after the cessation ofhostilities. After the war ended the people hadbeen so stunned and were so uncertain as towhat to expect of their conquerors that prac-tically no constructive or restorative work was

13


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Table 5. Hospitals, bed capacity, occupancy and out-patients by prefectures, 15 September 19U5

Table 6. Number of Japanese persons requiring medi-cal care or hospitalization, October 1945 1

Prefecture


23/265

75.1 percent for 1944. Since these figures weresuch a complete contradiction to the reportedhealth conditions of the Japanese, the PublicHealth and Welfare Section of SCAP askedthe Japanese government to compile and submita list of the number of Japanese persons re-quiring medical care or hospitalization. Thereport was submitted on 21 October 1945 andis shown in Table 6. It was estimated that395,500 persons were in need of hospital careand 1,483,500 needed out-patient care. Whenthese figures were compared with the numbersactually receiving treatment, a tremendous in-consistency was noted. In other words, thoughthere was a large number of vacant hospitalbeds only one of three needing hospital careand one of six needing out-patient treatmentwere actually receiving it. There are severalcontributing factors which may help to explainthis inconsistency. Whereas the number of pa-tients receiving treatment was an actual count,the number needing care was an estimation,and it was suspected that in their desire forsympathy the Japanese may well have over-estimated the latter figure to a considerabledegree. Also, most of the hospitals are locatedin large cities, and the population was stillwidely scattered over the rural areas. Few ofthe larger cities had been reoccupied by morethan 50 percent. Consequently, many of thepersons needing care were not in locationswhere they could receive it. Too, the Japanesehave always been very mercenary in their dis-tribution of medical care, with few patientsadmitted to hospitals unless they were able topay. With the economic upheaval of the time, avery large percentage of the Japanese wereactual paupers. The government financed med-ical care for those injured in air raids but freecare for other illnesses and injuries generallywas not provided. Thus, many who needed itwere probably unable to obtain medical andhospital care because they could not pay for it.

In an attempt to determine whether theseconditions would be sustained over a long pe-riod the Public Health and Welfare Section ofSCAP requested the Japanese government tosubmit weekly reports on the numbers of hos-pitals, in-patients and out-patients by prefec-tures. These reports from 12 October to 9November 1945, are shown in Appendices A-l,

A-2, and A-3. Though the figures were notcomplete for all prefectures there was sufficientinformation to indicate the trend over this five-week period. A composite study of 23 prefec-tures for which the reports were complete isshown in Table 7. Over the five-week periodthere was a gradual decrease in the number ofin-patients. While there was more fluctuationfrom week to week, there was a slight decreasein the number of out-patients over this period.Study of the individual prefectures reveals thatmost of them remained essentially unchanged,several showed slight decreases in the patientload, while Tokyo alone showed a significantsustained increase in both in-patients and out-patients.

These figures indicate that the hospital fa-cilities for the period studied were not over-burdened nor even filled to a degree consistentwith most economical operation. Many peoplewho needed care were not receiving it, butfurther study of the entire Japanese healthsituation would be necessary before one couldreach more definite conclusions.Table 7. In-patient and out-patient load of Japanese

hospitals as reported by 23 prefectures (complete)from 12 Oct. to 9 Nov. 1945

1,398 Hospitals


24/265

hat the over-all hospital bed-population ratioin Japan was 3.9 beds per 1,000 population for1945 while the State with the lowest ratio inhe United States was Mississippi with 4.98.New York State had the highest ratio with15.34, and the over-all figure for the Unitedtates was 9.77. Thus the comparative numberof hospital beds in Japan at the time of thesurvey was far less than half those in thenited States. A considerable proportion of theJapanese hospitals were of temporary andmergency nature and will have to be replacedr abandoned within the next few months orThe number of proposed and established

centers by prefectures for Japan in 1945s shown in Appendix A-4. It portrays an offi-

interpretation of clinical facilities avail-ble to the public but actually is a poor index.ost of these centers were not in effective op-and all were poorly staffed. The sameay be said to be true with regard to the offi-ial government report on materal and child

work (Appendix A-5).The situation with regard to hospital fa-

in Japan was not hopeless or even criti-al at this time. Only half of the available bedsere being utilized, but that was certainly no

indication of the needs of the Japanese people.t was in part a reflection of the continuing un-settled state in Japan. To a great extent, theconomic recovery of the Japanese nation would

influence future developments in hospitals.Only with a better balanced economy couldJapan construct and operate the hospitals thatwill be needed within the next few years.

MEDICAL EDUCATIONDuring the war with the United States, med-

ical education in Japan deteriorated so seriouslythat it was threatened with suspension. Thecumulative effects of individually insignficantevents reached serious proportions as timeprogressed. An attempt is made here to pointout these factors and to show the end effects. Abrief explanation of prewar conditions in Jap-anese medical education is therefore necessary.Prewar StatusThe Japanese system of education is some-

what similar to the American schools but moreclosely parallels the German system. A child

enters school at about 6 years of age and at-tends primary school for 6 years. This is fol-lowed by 5 years in middle school, at the endof which time the student is about 17 years ofage. If he is working toward a medical educa-tion he may then enter high school or enter amedical college directly. Prior to the war astudent was required to spend 3 years in highschool before he was eligible for admission toone of the medical universities.About the time of the china incident a com-

pulsory military training program was insti-tuted in Japan. The age limit was rigid and afew students were taken into the military asordinary soldiers before completing their edu-cation, but after they had completed theirservice some were able to resume their medicalstudies. Many graduated from medical schoolsyoung enough so that they were able to obtainsome hospital training before being called intomilitary service. These draft regulations werecontinued up until the outbreak of war with theUnited States.

Medical schools in Japan fall into two groups.The higher class medical schools are spoken ofas medical universities and have considerableprestige. The most prominent of the universi-ties prior to the war were the nine ImperialUniversitiesseven in Japan proper, one inFormosa, and one in Korea. There were 10other medical schools of university rank. Sevenof those were established by prefectures withthe support of the central government andranked next to the medical faculties of theImperial Universities. There were three privatemedical schools of university rank in Japanproper, all in Tokyo. The medical school ofKeio Gijuku University had the highest repu-tation among the private schools and comparedfavorably with many governmental schools.Reference to War Technical Bulletin, TB MED160 shows the information which was availableregarding the schools of university rank be-fore the onset of war. A list of the schools ofuniversity rank in 1945 is shown in AppendixA-6.

In addition to the universities, there were anumber of private medical schools of lowerrank, commonly referred to as medical collegesor medical professional schools. A few of theseschools had fairly good standards but theirgraduates had considerably less prestige than

16


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the graduates of schools of university rank.Whereas the graduates of the latter were auto-matically admitted to medical practice, the gov-ernment required the graduates of the lowerinstitutions to pass the required examinations.The medical professional schools took studentsdirectly from middle school without any highschool education. They were then given medicalcourses varying between four and five years,including a premedical course which was notincluded in the regular four year course of theschools of university rank.Women were not admitted as students to the

medical schools of university rank, but in afew exceptional cases they were admitted asgraduate students to certain of the prefecturaland Imperial Universities. In 1941 there werethree medical schools for women in Japan, twoin Tokyo and one in Osaka.In addition to the civilian medical schools,there were the Army Medical School and theNavy Medical School, both located in Tokyo.Those schools did not attain any importanceuntil about 1939 and 1940 when the require-ments for military medical personnel becameprominent. All doctors taken into the militaryforces were given courses of 8 to 10 months inone of these schools. The program consisted ofan indoctrination into military procedures andcourses in diseases of particular importance tothe armed forces.

In 1938 and 1939 most government medicalschools instituted an "emergency medicalcourse" which was intended to graduate morephysicians in order to supply the demands ofthe armed forces. Actually, it simply increasedthe enrollment beyond the "fixed number" ofstudents and resulted in the graduation of twoclasses in 1941, one in March and one in Decem-ber. There were 6,253 students graduated thatyear in comparison to a previous high of 2,968in 1939 (Table 8)

The medical schools of Japan were on a par-tial wartime basis as early as 1938. Becauseof demands of the undeclared war in China andin anticipation of the coming conflict, the gov-ernment began to delete certain courses fromthe curriculum and introduce military subjects,increase the enrollment, allow an increase inthe number of schools, and take other steps totrain more physicians in a shorter period of

time. The gradual transition over several yearsin Japan was not comparable to the abruptchanges that occurred in the United States ina few months.Table 8. Number of medical schools and physicians

graduate! in Japan, 1988-i5 1

years


26/265

that would fit them for the practice of medicine.Most of the schools were privately controlledand the faculties were small and usually in-competent. In many instances the studentsperformed menial tasks about private hospitalsand medical education was a secondary issue.Students with an acceptable background or anytrue scientific ambitions would not attend theseschools. The graduates were definitely not ac-cepted by the better class public or by higherscientific organizations. Thus a large numberof persons who were neither competent or gen-erally accepted by the Japanese themselvesgraduated to practice medicine. It appears thatthe type of medicine they practiced was notfar superior to that of the licensed practitionersof acupuncture or moxicantery or the unlicensedfaith healers.

In addition to the medical schools there werenine dental colleges and 10 schools of veterinarymedicine in Japan before the war with theUnited States. Only 1 of the dental collegeswas governmental and 8 were private, while 7of the 10 veterinary schools were governmentcontrolled.

General Effects of the WarAs mentioned previously many Japanese

functions were on a wartime basis beginningabout the time of the start of hostilities withChina in 1937. The first changes evident in thefield of medical education were in 1938 and1939. The age of induction for compulsory mil-itary service was not sufficiently low to resultin any significant interference with medicaleducation at this time.With the advent of hostilities with the United

States, government control became more strin-gent. In connection with the accelerated pro-gram in medical teaching, the schools graduatedtwo classes in 1941. Due to larger classes andmore schools the number of graduates con-tinued to increase over the next few years(Table 8).Apparently, the selection of medical students

by the larger universities was made on a fairand impartial basis. Prior to the war appli-cants for admission were appraised on thebasis of their previous school record, personalinterviews and an examination in the basicsciences. During the war the Ministry of Edu-

cation directed that scientific questions couldno longer be asked on entrance examinations.As explained by one of the Osaka professors,the rationale of this ruling was as follows : Pre-medical students, both in middle and high school,worked as laborers in war plants in additionto attending school. They were not allowedsufficient time in school to really apply them-selves to their subjects and thus were not pre-pared for such examinations. It was feared bythe government that if such questions wereasked, the students would realize that theywere being held responsible for the materialthey were covering in school and would tendto shirk their war work and devote more timeto their studies. Many other evidences wereseen which illustrated the insincerity of Japan-ese authorities relative to the quality of edu-cation. While not willing to discontinue educa-tion, they continued schooling on a superficialbasis but devoted most of the students' time towork in factories producing military supplies.

Further curricular changes were also intro-duced in the medical schools. Courses in ob-stetrics, pediatrics, and the basic sciences werecurtailed as courses in military medicine wereadded. Too, the entrance requirements werelowered and the length of the medical courseswere shortened ( Table 9 ) . The exact dates uponwhich these various changes occurred were notknown since they varied from school to school.As early as 1942 medical schools began to

note shortages of supplies and equipment, andby early 1944 shortages became quite acute.Many basic laboratory exercises had to beomitted because of the lack of chemicals, andbroken or worn-out equipment could not bereplaced.

After compulsory military service had beenin effect for several years, the shortage ofyoung teachers became more acute. It was saidthat even though some of the men were beingreturned from military duty they had "losttheir clinical touch." They had been away fromthe practice of medicine for such an extendedperiod of time that they were no longer satis-factory instructors for students. The middle-aged and older teachers in medical schools werenot utilized by the military services to anygreat extent so that the medical faculties re-mained fairly intact except for the youngphysicians.

x3


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TABLE i). Schematic plan of medical education in Ja/ian

Primary schoolMiddle schoolHinli school.. -College.University

Meduniversities

Prewar(yi .11

\\:u(y I .1

3H

Mi die Jcolleges

Prewar(years)

4-5

(years)

As the war progressed the draft age wasgradually decreased from 27 to 23 years and aman was drafted even if he was in medicalschool and regardless of how close he was to

It was admitted by educators thatome medical students had been taken as ordi-ary soldiers but no estimation of the number

could be obtained, as there were no recordsertaining to this point. It appeared that the

was sufficiently powerful that theof Education or any other group was

to disagree with them when medical stu-were to be drafted. However, the im-

obtained from many sources was thatmedical students, probably less than 5

were so drafted. During the last fewof the war the pressure of the military

more manpower threatened to interrupteducation completely. It was proposed

all physically fit young men of 17 years orbe taken into the armed forces. This de-was opposed by the Ministry of Educationthe issue had not been settled at the time ofsurrender. Such a move would have meantclosing of practically every college and uni-

in Japan and illustrates the desperatein which the Japanese found themselves

1945.

Effects of BombingAdded to the general effects of war, theremany conditions which could be attributedpart to bombing.One very serious effect on medical schools

the evacuation of supplies and valuableto safer areas. Chemicals and lab-

apparatus were taken from the lab-School libraries were completely or

completely withdrawn. X-ray equipmentother valuable devices were removed from

hospitals. The students were thus de-

prived of an important part of their educationand the patients received poorer medical care.By remaining in the cities, students and

teachers subjected themselves to bombing whichthey could avoid by fleeing to the country. Manydid leave; others remained only until the cityhad been bombed. Students could not afford todetach themselves completely for fear of in-duction into the military service, but they didnot attend classes regularly. Often when theyattended classes the instructor would not ap-pear and the time was wasted. Morale was poor.The amount of war duty required of students

varied from one prefecture to another, and de-pended upon the urgency of the situation. Earlyin the war, in the prebombing era, studentsspent their summer vacations in mining areasto carry out numerous tests on miners, withparticular attention to tuberculosis. They wereorganized in groups of 10 headed by an in-structor. These assignments were probablyuseful from a training standpoint when therewas adequate supervision of their work. As thewar progressed students were mobilized forlabor duties which had no relation to theirprofessional training, such as assisting inclearing away debris in bombed plants or aboutthe water front. In Osaka it was said that thepractice became so common that it threatenedto interrupt the medical school of the ImperialUniversity. The medical authorities appealedto the local government and after considerabledelay the practice was discontinued. Thereafterthe students were used on air-raid rescue orfirst-aid teams and to conduct clinics to carefor casualties. These duties often interferredwith their formal education but in the emer-gency the medical schools could not object tothis practice. Similar situations were encoun-tered in other cities and schools.An important factor which should not be

overlooked is the effect fear had on education.After bombing began, students and teachersbecame tense and fearful lest they should bedestroyed in the next raid, and were unable toconcentrate. Many of the professors relatedthat they noted this symptom among themselvesand their-students. Toward the end, many ofthe Japanese realized that the war was lostand wondered whether they and their familieswould survive until it was concluded. Despite

19


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the fact that there was a gradual deteriorationof morale, there was no evidence of suicidesamong the students, nor did they seem to showany increase in psychiatric disturbances. Thepicture was that of anxiety, with distractionand inability to concentrate.

Often after air raids there was sufficient dis-ruption of transportation that students andteachers were either delayed or were unable toreach the schools. Even though the bombing ofcities was almost entirely incendiary and con-sequently streetcar and railway tracks were notgreatly disturbed, many cars were consumed inthe flames. Operating and maintenance crewswere often killed or injured, or had fled. For aperiod of several days after one of the largecity raids, transportation was immobilized orirregular and overcrowded, and the people wereforced to suspend normal activities. Medicalstudents were busy helping to care for the in-jured or with other duties. In all, it is difficultto understand how many of the schools evenpretended to continue in existence.The direct and often severe effects of bomb-

ing were seen in the actual destruction ofschools and hospitals and in the death or injuryof students and teachers. Table 10 shows thecasualties sustained and the destruction ofteaching facilities. This information was ob-tained from the Chief of the University Sectionof the Ministry of Education about three andone-half months after the end of the war. Itwas felt to be fairly complete and accuratethough at least one apparent discrepancy ap-pears. For instance, upon visiting the ImperialUniversity Hospital, Tokyo, it was noted thatseveral of the buildings had been destroyed butthe wreckage did not appear burned out. Uponquestioning hospital authorities we were toldthat the hospital had not been struck by bombs.The debris on the grounds was said to be theremains of several combustible buildings whichwere torn down as a protective measure againstindendiary raids. It was reported that in thismanner the hospital had sacrificed almost halfof its bed capacity in an effort to protect theless inflammable main structures. Yet the Min-istry of Education reported that a part of thehospital was burned. Another discrepancy wasin the reported number of casualties resultingfrom the atomic bombing of Nagasaki. Several

local authorities reported 600 students andteachers killed, whereas the Ministry of Educa-tion stated that 399 students and 22 teachersdied of the bombing. Otherwise, the materialcoincides with information received elsewhere.

It may be noted from Table 10 that most ofthe schools and hospitals were burned but thatthere were relatively few casualties among thestudents and teachers. Hospitals and medicalschols were not selected targets, however, theywere located in the congested, highly combus-tible sections and it was impossible to avoidthem in the mass burning of cities.

It is difficult for Americans who are accus-tomed to hospitals and universities built onspacious grounds to realize at what premiumground is held in Japan, where nearly everysquare foot of land is utilized. Hospitals andschools are commonly surrounded by Japanesebuildings of highly combustible nature. Someof the hospital buildings were relatively fire-proof but nevertheless were completely guttedby flames. The fires about such buildings wereso intense that windows were broken out, evenmetal window shutters were buckled andtwisted, and inflammable interiors and furnish-ings were burned completely. All the contents,including medical equipment and supplies, wereusually destroyed and only the shell of a build-ing remained as evidence of a formerly impres-sive hospital. When the buildings were ofwooden construction they were completely con-sumed if caught in these great fires.Many hospitals and schools survived in the

burned-out cities because they were less inflam-mable and/or were protected .by surroundingbuildings of similar construction. The ImperialUniversity and Hospital at Osaka is an example.Others were fortunate in having considerableopen space about the buildings. For instance,the Imperial University and Hospital in Tokyo,located on a beautiful, spacious campus in adensely congested section of the city was un-harmed although the surrounding areas wereburned to the ground. Still other hospitals andschools were partly destroyed but some of theirbuildings across the street or located at somedistance suffered no damage from bombing. AtKeio University in Tokyo nearly all of the medi-cal school buildings and hospital containing 710of the original 900 hospital beds were consumedin the spreading fires.

20


29/265

All in all, the medical schools and teaching-hospitals of Japan suffered tremendous physicaldamage from bombing. About 20 percent of thetotal civilian hospital beds and an unknownamount of valuable equipment was consumed inthe fires of incendiary bombing. Additionaldamage was inflicted by the atomic bombing ofHiroshima and Nagasaki. Generally speaking,the higher class schools suffered less damagebecause of more fire-resistant construction andmore favorable locations. The smaller schools,the majority being of wooden construction andlocated in more congested areas, were usuallytotal losses when caught in conflagrations.Postgraduate EducationThere was little postgraduate medical educa-

tion in Japan even before the war. There wassome graduate training of physicians in thevarious hospitals, particularly those associatedwith the medical schools of university rank.The Institute of Public Health stood out as theonly formal postgraduate institution. Physi-cians who desired to receive formal training inother subjects usually went to medical centersin Europe or the United States.The wartime fate of the Institute of Public

Health was particularly interesting as it wasnot bombed, but suffered severely from warconditions and the indirect effects of bombing.The Institute of Public Health was estab-

lished under an Imperial ordinance dated 29March 1938, and is under the jurisdiction of theMinister of Health and Social Affairs. The In-stitute Building was donated by the RockefellerFoundation and was completed on 9 May 1938.Although the primary purpose of the Institutewas to train public health workers, it also un-dertook scientific investigation and research onproblems related to the health of the Japanesenation. Two practical training centers wereestablished in connection with the Institutethe urban center in Kyobashi Ku, Akashicho,Tokyo, and the agricultural center in SawaMachi, Saitama prefecture. These centers wereoperated by the city of Tokyo and Saitama pre-fecture, respectively, but from a practicalstandpoint were intended as field units of theInstitute of Public Health. Training courseswere provided in medicine, pharmacy, veterin-ary medicine and public health nursing. Thefixed number of students and the amount of

training was as follows : Medicine50 students,1 year, 1,550 hours; pharmacy20 students, 1year, 1,550 hours; veterinary medicine25 stu-dents, 4 months, 468 hours. The training in-cluded field work and excursions. In addition tothe regular course, special, postgraduate stu-dents were admitted to work on specific prob-lems. The original staff consisted of a directorof professional rank, 7 professors, 9 assistantprofessors, 9 lecturers and 19 assistants.

In 1940 the Institute for Nutrition Researchand in 1941 the Institute of Physique were in-corporated within the Institute of Public Health,and in 1942 the Institute of Population Prob-lems and the Institute of Industrial Safety wereadded. The new Institute then consisted of fivedepartments, each representing one of the for-mer divisions. However, the unification wasonly nominal and the various units continuedto function as independent institutes. A signi-ficant development in this connection was thatthe Vice-Minister for Health and Social Affairsbecame ex-officio director of the Institute. Sincesuch an official was a layman and did not havea scientific background, this change was re-sented by the scientific personnel and resultedin a considerable decline in morale.During the war the Institute suffered from

increasing shortages of chemicals and food-stuffs for experimental animals. Three of thestaff of 19 were taken for military service. Be-cause of the shortage of paper, The JapaneseJournal of Public Health ceased publication.The training activities of the Institute weregradually decreased each year of the war be-cause of great need of this professional person-nel for the military service. Finally, in April1944, the Ministry of Health and Social Affairssuspended all teaching activities of the Instituteexcept a junior course in nutrition, which wasan undergraduate class. Table 11 shows thenumber of graduates in the various depart-ments from the opening of the Institute through1945.As previously noted, the Institute sustained

no direct damage from bombing, but it sufferedseverely from indirect effects. When Saipanwas occupied by the United States in July 1944,the Japanese Ministry of Health and SocialAffairs, which had been housed in barrackbuildings, began searching for concrete build-ings, for fear of air raids. They moved into the

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Table 10. Effects of bombing on medical and dental schools, Japan

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11. Graduates of anuses, institute of publichealth, Japan

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number of nurses graduating and practicing. Itlooked better on paper to have 1,000 publichealth nurses regardless of their training thanto have 500 who were well trained and com-petent.There has been very strong government con-

trol of Japanese medicine. The controls weredivided between the central government andthe prefectural governors, and were usuallyadopted because of their policing value ratherthan their possible supportive nature. An indi-cation of this is that many of the so-calledpublic health functions have been in the handsof the police. For instance, the examination ofprostitutes was required at regular intervals,but the examinations were a farce. They notonly did not accomplish anything from a scien-tific standpoint but were dangerous since theyresulted in a false sense of security and theaccumulation of much inaccurate data. Actu-ally, these examinations were not required inorder to prevent the spread of disease, but tomake pretenses in that direction, and to affordthe police an easier system of checking onprostitutes' licenses.The whole system of such fallacious and pre-

tentious reasoning has resulted in a large num-ber of poorly trained persons being expected todo a job of which they were not capable. Manyof the doctors, nurses, and other personnelgraduated from inferior schools. They were re-quired to go through maneuvers that had noscientific basis and were thus encouraged in apretentious and false existence.One of the most startling examples of such

procedures was the use of BCG vaccine inprophylaxis against tuberculosis. The Japanesehave used this vaccine extensively within thepast few years and have copious volumes of dataupon its effectiveness. The results of this workappeared very significant until the data andmethods were examined more closely, when itactually appeared that the work was set up insuch a manner that it could not be interpretedimpartially and accurately. For instance, theJapanese would not diagnose tuberculosis ofthe lungs unless the tubercle bacillus was foundin the sputum ("open cases"). Cases showing-definite infiltration of the lung on X-ray orother evidence of tuberculosis which would notbe questioned in Europe or the United States,were called "infiltration of the lung", pleurisy,

or some other equally evasive term. In the Jap-anese study, detailed statistics were collectedon the open cases and their deductions and con-clusions were on this basis. The minimal andclosed cases were not considered. It had beenshown everywhere else in the world, and thisfact was known to the Japanese, that opencases of tuberculosis are late manifestations ofthe disease and represent a small percentage ofthe cases if adequate methods of detection areused. Yet the Japanese set up and carried outa vast study on the prevention of tuberculosiswhen the basic facts upon which any evaluationmust rest were entirely fallacious. It appearedthat they had previously decided the answer toa problem and then had erected an equationwhich could give no other answer.Apparently the adequacy of any Japanese

medical procedure could not be appraised onthe basis of the quantity of personnel involved,nor on the face value of reports on procedure.This must be borne in mind constantly whenstudying Japanese reports and when attempt-ing to evaluate their procedures.

PhysiciansUpon graduation from medical schools recog-

nized by the Ministry of Education, physicianswere automatically licensed to practive any-where in Japan. Graduates of foreign schoolsor unrecognized Japanese schools were requiredto pass an examination before they were al-lowed to practice. The number of foreign schoolgraduates has always been very small, andpractically all of them were Japanese or of Jap-anese ancestry, but the number of graduatesof unrecognized schools have been considerable.All licensed physicians are members of theMedical Practitioners Association of Japan(Nihou Ishikai).Graduates from institutions of university

rank have the degree of "Gakushi", meaning"university graduate." Those graduating fromlower ranking institutions (medical colleges)are simply "physicians" (Ishi, Isha), and havevery little prestige as compared with the formergroup. In addition, all graduates could obtainthe degree of Doctor of Medicine (Igaku Ha-kushi Igaku Hakase) by extensive postgradu-ate studies and the submission of a thesis, butonly a fraction of the total number of physiciansacquired this academic doctorate. Those who

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were almost entirely in the field of academicPrivate medical practice forms the basis ofJapanese medical system, however, therea number of government organizations for

practice. The government group con-largely of nonprofit hospitals and dispen-for the diagnosis and treatment of special

such as infectious diseases, tuberculo-leprosy, venereal and mental diseases, plusgroups doing general practice in connec-with railroads and other governmententerprises. A fair number of privatelyindustries also maintained their owncare programs.

Table 12 shows the total number of physi-the number in practice and the physician-

ratios from 1935 to 1944. The dis-of medical practitioners by prefecture

1938 and 1945 is shown in Appendix A-8.most detailed prewar figures available were1938, at which time there was a total of

physicians, of whom 51,837 practiced.other words, there was one practicing physi-

for 1,393 inhabitants or 7.18 physicians10,000 population. The comparative figures

the distribution of physicians in rural andareas of the United States and Japan arein Table 13. It will be noted that the sameexisted in Japan as in the United States,

a much higher physician-population ratiothe urban than in the rural areas. Viewing ita whole, the United States had about three

to Japan's two per unit of popula-these ratios applied to rural and urbanof the two countries as well.

Reference to Table 12 reveals that during the10 years the total physicians in practice in

has varied from 82 to 92 percent. Asbe expected, the latter figures were forAt this time Japan was making its great-

war effort and the demand for practicingwas at its peak. The difference be-

the total number of physicians and thosepractice was accounted for by the numbersthose in the public health service and others

in teaching and research. Probablyincluded in this group were all of thosewho were not in active practice be-of disabilities or other reasons.

A classification of physicians for 1938 isin Table 13. Of additional interest in

this regard is the large number of physicianswho were not graduates of recognized schools.About 14 percent of the Japanese physiciansfor that year fell into this group.The draft of physicians had begun several

years before hostilities with the United States,and the period from 1937 to 1941 was one ofgradually tightening military restrictions. Thetotal number of physicians (exclusive of thosein the military service) reached its peak in 1940with 65,332, though the largest number of prac-ticing physicians was in 1937. Thus it was ap-parent that the degree of mobilization prior towar with the United States was not severeenough to seriously effect the number of physi-cians in civilian practice. The principal difficultyencountered in connection with mobilizationprior to 1941 was the loss of young physicians.Up until then there had been very little actualdisturbance of the civilian practice of medicineand very few physicians were casualties.Table 12. Numbers of physicians, practicing physi-cians and physician-imputation ratios, Japan, 1935-JtJ,


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Table 13. Comparative numbers and Distribution of physicians in Japan and United States, prewar and 19UU


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would not have been critical to acare program, but conditions in Japan

so severe that even small losses would havedisproportionately great. With the

of physicians because of the demands ofarmed forces and other factors mentioned,Japanese population was extremely short of

care.It was more difficult to evaluate this critical

in Japan than it would have been in theStates. The Japanese people had neversufficiently dependent upon the legiti-

medical profession to feel a comparableas greatly as would the people of the United

Certainly the Japanese suffered fromdeterioration of the medical care program,there were so many other disturbances oflives at the same time that the medical loss

difficult to appraise in itself. But because theyon top of such severe wartime conditionseffects of bombing upon the medical profes-in Japan were more critical than theyhave been otherwise. Though this condi-

must have contributed to ending the war,outstanding features in this direction couldascertained.

Nurses have never occupied an enviable posi-in Japan. Usually they came from the lower

did not receive much respect, were in-trained, and poorly paid. Their im-

in the medical care program of Japanbeen far less than that of nurses in the rest

the world, especially the United States.The difference between nurses in the two

is based on many factors. Most nurseswomen and the oriental attitude concerningsubservience of the female has had consid-

influence on the Japanese attitude. Too,common practice that a member of the pa-family remained in the hospital to ad-

bedside care has obviated some neednurses and tended to decrease their impor-

The position of nurses in Japan has beencomparable to attendants or war aids

the United States medical

Documents

USSBS Reports No.12, Effects of Bombing on Health and Medical Services in Japan