1. GENERAL

Military and civilian personnel in Northeastern Africa and the Western Asiatic countries may be exposed to serious health hazards, both because of the presence 'of diseases hot commonly encountered in the United States and because of the relatively high incidence of certain other diseases that do occur on our continent. Some of the countries included in the area mentioned above have acceptable health departments, and a few of the larger cities have good health organizations. In normal times these health organizations may compare with certain cities in the United States. However, viewed as a whole, and considering the influence of the war, health conditions are much less satisfactory than in our country. Therefore, the soldier who values his health must be alert at all times to the possibility of illness and must guard against it by observing certain hygienic and sanitary precautions. A soldier's carelessness in this respect may result in his catching diseases, some of which may be serious; but attention to known health precautions should prevent all or most ailments for persons required to live in this part of the world.

These notes are designed to cover some of the potential hazards in a large general area, so that all the conditions enumerated may not apply to a particular locality. Common sense and good judgment, together with information acquired from local health authorities and Army medical officers, should serve to indicate which of the precautions outlined below can be modified or dispensed with to meet varying local conditions.

2. WATER

Drinking water contaminated with waste from the human body is one of the most common sources of infections of the intestinal tract, including the common diarrheas, typhoid fever, paratyphoid fevers, amoebic dysentery, bacillary dysentery, and, in some areas, cholera and schistosomiasis (infection with bloodworm or fluke). Guinea worm infection may also be acquired from water. Improper methods of disposing of human wastes, as well as inadequate treatment of water contaminated by these wastes, are direct causes of impure water.

Facilities for the purification of water are usually found only in the cities, and in the oil company settlements located at fields and at stations along the pipe lines. However, even in cities, the water frequently is not free from disease germs, either because of poor equipment, or because of a lack of supervision of available purification facilities, or both. In certain instances, safe water produced at the water plant is contaminated while passing through faulty water mains or when carried in unsanitary containers (tins, jars, animal skins, and so forth). In many cities, water distribution reaches only a limited area and thus supplies only a small percentage of the inhabitants, usually those in the European settlements.

The probability of outbreaks of various communicable diseases, especially water- and food-borne diseases, is greatly increased as a result of religious pilgrimages, from all parts of the Mohammedan world, to Mecca and other shrines.

While safe water may be found in some localities in Moslem countries of Northern Africa and Western Asia, it is generally advisable for army personnel stationed or traveling in this part of the world to consider all water unsafe for human consumption unless approved by a medical officer. The use of ice from such water presents the same problems as the water itself.

Carbonated drinks made from local water supplies should not be regarded as altogether safe. Soft drinks (noncarbonated--for example, orangeade) are dangerous unless known to have been prepared under hygienic conditions and pasteurized.

Liquids recommended as safe for human consumption are:

a. Boiled water (boiled from 3 to 5 minutes).

b. Water properly treated with chlorine (see below; see also War Department Basic Field Manual 21-10, Military Sanitation & First Aid, par. 20c).

e. Beer and wines, when properly prepared and bottled.

f. Fruit juices, undiluted and freshly prepared--preferably by oneself.

Water treated under the supervision of British or U.S. Army Medical Department personnel is safe and should be used, where available, in preference to any other.

As a general rule of water chlorination, if the odor of chlorine is detectable after a contact period of 30 minutes, the water is safe, provided the odor does not come from concentrated chlorine that has been spilled on the hands or on the water container. It is therefore advisable for a person other than the one who treated the water (his hand may carry the odor) to perform the "odor test." If the water is muddy or contains large quantities of dirt and suspended matter, some form of filtration should be employed whenever possible. The resistant form of the organism which causes amoebic dysentery may not be destroyed by chlorination alone, so that nitration before chlorination or boiling will be desirable.

Under field conditions where troops cannot obtain safe water, they can purify water in their canteens by the use of halazone tablets. Two tablets (4.0 MF or 1/16 grains) are required for each canteen (one quart) of water. If the water is especially muddy, one or two additional tablets may be necessary. Where high-test calcium hypochlorite is used, the procedure is as follows:

The standard U.S. Army tube is broken, and the contents are dissolved in a canteen of water. One canteen-top full (approximately 1 1/2 teaspoons) may then be added to each full canteen of water which is to be treated. Regardless of the method used, the water should be allowed to stand for 1/2 hour, and the "odor" or "taste" test should be applied. If one can detect the free odor of chlorine, or can taste chlorine when the water is applied to the tongue, a chlorine contest of at least 0.4 parts per million is indicated, and the water may be considered safe. One should be certain that the odor of chlorine does not come from concentrated chlorine spilled on the hands or the water container by careless handling. Where practicable, some form of filtration should be employed if the water is muddy or contains large amounts of organic material. This will aid also in eliminating the resistant form of the organism which causes amoebic dysentery.

3. WATER ECONOMY IN DESERT AREAS

Day temperatures may go as high as 130° F. in desert climates. This subjects the human body to severe stress, especially with regard to loss of water and salt. Exertion under these conditions is accompanied by much sweating. As a result, not only are large quantities of water lost, but also much body salt, which is in solution in the sweat. Under extreme conditions, as much as 10 quarts of water daily may be lost by sweating, although in hot, dry climates so much evaporation occurs that one is not conscious of this excess of perspiration. In fact, evaporation of sweat in high temperatures is the principal method by which the body is able to cool itself and thus maintain a normal temperature.

In temperate climates, except under conditions of strenuous physical exertion during warm weather, salt and water lost by sweating are replaced by a normal diet and moderate drinking of water; however, in the heat of the desert, more than ordinary quantities of salt and water must be consumed in order to maintain normal body requirements for these chemicals. Experience of desert armies indicates that an average of 5 to 6 quarts of water per man per day may be all that can be supplied for all personal purposes. Under extremes of temperature and physical exertion, up to 10 to 12 quarts are likely to be necessary. In emergencies, 2 to 3 quarts per day may suffice, but on such a restricted water ration, physical efficiency is reduced after a short interval, probably 2 or 3 days. Therefore, under desert conditions where water supplies are inadequate, it is imperative to conserve water: before consumption, by care of water supplies, and after consumption, by avoiding unnecessary physical exertion and exposure to the sun, thus reducing sweating. Salt lost in perspiration should be replaced. (See subparagraph c below.)

Take the following precautions:

a. Stay in the shade as much as possible. Heavy work should be done at night, very early in the morning, or late in the afternoon. When work during the hot hours of the day is necessary, frequent periods of rest are advisable.

b. Drink water slowly and in small amounts (not more than an ordinary glassful at a time), but more frequently than in temperate climates.

c. Take two tablets of salt (equivalent to 20 grains, 1.3 grams, or 1/4 teaspoonful) with every full canteen (1 quart) of water consumed. (See W. D. Circular 129, dated July 5, 1941, and Circular 169, dated Aug. 14, 1941.)

d. Avoid unnecessary physical exertion, and thereby prevent excessive sweating.

e. Wear headgear, preferably a sun helmet, when exposure to the sun is necessary for an appreciable length of time. Outer garments should be loose-fitting so that sweat will evaporate easily. Shorts are satisfactory during the day, especially indoors, but from dusk until morning long trousers and long sleeves are imperative. The often-repeated suggestions to wear stomach bands, spinal pads, and similar devices to prevent diarrhea have no scientific basis and are harmful since they interfere with normal heat loss from the body.

f. The use of a superior grade of dark glasses is advisable under some conditions. The Calabar lenses, now widely used by Air Force personnel, are satisfactory.

g. Cool water evaporates slowly, and is more palatable and thirst-satisfying than warm water. Protect water supplies by keeping them in closed containers in the shade. Use insulated containers wherever possible.

h. Where conditions permit, such foods as canned tomatoes may be advantageous not only as rations, but also because they supply additional fluids.

i. Fluids are lost not only through sweating, but also through vomiting and diarrhea. Individuals suffering from these conditions, or from illnesses accompanied by fever, are susceptible to the effects of heat and should not be sent out from bases or camps until they have recovered completely.

4. FOODS

a. General

Foods are the second great source of intestinal diseases. They involve even greater hazards for the uninitiated or unwary, since foods are not only subject to contamination, just as water is, but are also a fertile place for germs to grow. Refrigeration facilities for preventing or reducing bacterial growth (spoilage) in foods, especially meats and milk, are inadequate or lacking in many localities in this part of the world. In most instances, meat is not inspected, either before or after slaughter; as a result, meat from animals infected with tuberculosis, undulant fever, anthrax, trichinosis, and so forth, may be distributed for human consumption. Heat (cooking) is the only practical and effective agent for destroying bacteria in foods, but even well-cooked foods are subject to recontamination (by food handlers--cooks and waiters--or by flies, other insects, or small animals) and thus may become unsafe for consumption. Only well-cooked foods, freshly prepared, preferably consumed while hot, and not reheated, are safe for human consumption. Exceptions are bread and crackers, which may be considered safe unless mechanically contaminated.

Foods for lunches, as commonly prepared before short missions (flights, patrols, and so forth) in the United States, are likely to spoil in a short time under tropical or desert conditions. Therefore, it is recommended that sandwiches should not be made before departure, but that such foods as canned meats and other tinned goods, bread, crackers, thick-skinned fruits, and so forth, be carried. The Army canned field ration is a practical, safe food for the above uses. If canned foods are used, they must be eaten soon after the can is opened.

b. Milk

Improperly handled dairy products (milk, cream, butter, cheese, etc.) constitute one of the most dangerous groups of foods. Disease-free dairy herds, pasteurization, and adequate refrigeration are not commonly encountered in Asia or Northern Africa. Raw milk not subjected to these safeguards may carry the following: dysentery, typhoid and paratyphoid fevers, common diarrheas, diphtheria, tuberculosis, undulant fever, septic sore throat, and other infectious diseases.

Only properly bottled pasteurized milk (meeting Medical Department standards), canned evaporated milk, condensed milk, powdered milk prepared with boiled water, or milk boiled immediately before use can be recommended. All other milk should be considered unsafe, as should ice cream prepared with local milk, and also cream for coffee and cereals.

c. Fruits and Vegetables

Soil pollution by human waste is common in this part of the world. When fertilized with this waste, the outer surface of vegetables grown by the native farmers are almost certain to be contaminated. Any of the intestinal diseases may be acquired by the consumption of uncooked vegetables. Therefore, only freshly cooked vegetables should be eaten. Such standard items of the American diet as salads made of lettuce, other uncooked leafy vegetables, or raw carrots and other root vegetables, cannot be eaten with safety. The dipping of vegetables in chemical solutions such as potassium permanganate does not protect against intestinal infections. Thick-skinned fruits requiring peeling--citrus fruits, papayas, mangoes, and melons, for example--are safe for human consumption provided they are not mixed with raw vegetables in salads. It is considered advisable to scald the skins of these fruits before peeling and eating.

5. CLOTHING

The prevalence of certain skin diseases, particularly "dhobie itch," necessitates frequent change of underclothing and socks. Light-weight clothing suitable for summer wear in the southern United States is satisfactory except in certain mountainous areas, and in Iraq and Iran where winter temperatures as low as 0° F. may be anticipated (January). Marked variations of temperature between day and night in the desert necessitate both warm and tropical types of clothing. Cases of pneumonia have been reported in increased numbers among aviators flying under desert conditions, and are thought to be caused, in part, by the drastic change from the high temperature of ground levels to the cold of high altitude (and vice versa), when the aviator has no opportunity to change to clothing suitable for either one extreme or the other.

Care should be taken to put on a sweat shirt, jacket, or similar garment immediately after violent exertion. The wearing of headgear, preferably a sun helmet, is required when exposure to the sun is necessary. Shoes should be worn at all times as a precaution against hookworm disease. Because of the prevalence of certain eye diseases--for example, trachoma, gonorrheal ophthalmitis, and pink eye--it is necessary to avoid contact with personal articles, such as towels and pillowcases, used by other persons.

6. BATHING

Daily bathing is advisable when the water supply will permit. It is important to clean and dry thoroughly all skin folds of the body (crotch, groin, navel, armpits, around the scrotum, and between the toes) in order to prevent fungus infections such as "dhobie itch." The daily use of Army-issue foot powder on the parts of the body noted above is also a good preventive measure.

Fresh waters, such as lakes, rivers, streams, swamps, irrigation ditches, flooded rice fields, and so forth, in the area covered by this survey often harbor the young forms (larvae or cercariae) of various bloodworms or flukes. These flukes enter the body through the skin of swimmers, bathers, or persons wading in such waters. The flukes may also be present in contaminated drinking water that has not been boiled or sufficiently treated with chlorine. They may cause serious diseases of the bladder and intestines. (These diseases are known as urinary bilharziasis or schistosomiasis and intestinal bilharziasis or schistosomiasis, respectively.) An early symptom of these diseases may be a skin rash. The urinary type is more common in this part of the world and in some areas affects from 20 to 40 percent of the native population. The cercariae are harbored by certain types of snails, and when discharged into the water cannot survive longer than 48 to 72 hours without a suitable host. Thus if water for bathing is impounded for such a time, and is free of snails, it becomes safe for bathing purposes, but not for drinking. Salt water bathing and swimming, except at beaches near the mouths of fresh-water streams or near city sewage outlets, present no disease hazard.

7. HOUSING

Clean and adequately screened quarters should be obtained if possible, and each individual should carry his own mosquito net. Shoes, clothes, luggage, and bureau drawers should be inspected carefully, since scorpions, spiders, and other insects prefer dark, warm places for rest, and may crawl into such places at night. Dwellings in the poor sections of the cities and in rural regions are dirty, and may harbor insects and pests of many descriptions. Of these vermin, mosquitos, flies, fleas, lice, bedbugs, and ticks are most dangerous and obnoxious to man. Because of the presence of these insects, it is wise to refrain from sleeping in quarters of this kind.

¹ This section is based on information prepared by the Division of Medical Intelligence, Office of The Surgeon General, U.S. Army. It deals with only part of the health problems found in the Middle East area.