In July 1962, a group from WRAIR was sent to Southeast Asia to evaluate the existing resources for medical research and to develop plans for coordination and expansion. They surveyed the laboratories then operating in East and Southeast Asia: the Air Force's Fifth Epidemiological Flight at Yamata, Japan, with one air-transportable trailer-type bacteriology laboratory, the 406th Medical General Laboratory at Camp Zama, Japan, the NAMRU-2 (U.S. Naval Medical Research Unit No. 2) in Taipei, Taiwan, the U.S. Army Medical Research Unit in Kuala Lumpur, Malaysia, and the US Army Medical Component of the SEATO (Southeast Asia Treaty Organization) Medical Research Laboratory in Thailand,

At the completion of their survey, the study group recommended expansion of the existing medical research program to include studies of US troops and of local national troops and civilian populations, allocation of additional personnel and funds, and establishment in Saigon of a WRAIR medical research unit, similar to those in Bangkok and Kuala Lumpur, because a theater laboratory would not be able to deal with all the subjects to be covered in the expanded program.

In November 1963, as a result of the survey group's recommendations, Lieutenant Colonel (later Colonel) Paul E. Teschan, MC, was sent to Vietnam with a team of seven officers and 12 enlisted men. They quickly established liaison with United States and Vietnamese military medical staffs and installations, with the Public Health Division of USOM (US Operations Mission), AID, and, through them, with the Minister of Health, members of the Pasteur Institute, the medical school faculties, medical missionaries, and representatives of private US charitable and medical foundations. They thus had access to all populations- Vietnamese and American, military and civilian- that was required to detect problems and settings in which productive investigation could be done and to deploy and support qualified investigators.

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Initially the team studied infectious disease, combat surgery, and military psychiatry, and evaluated new medical materiel. Their first effort was a serologic survey among US, military advisers in the Delta region for evidence of viral hepatitis, leptospirosis, and dengue-related viruses.

Cholera

Cholera, absent from Vietnam for 10 years, spread from Cambodia into Saigon-Cho Lon and some provinces. Several thousand cases appeared within about 2 months, and the clinics and hospitals were soon overwhelmed. The disease was found among the destitute and frequently in immunized persons, Cholera rarely appeared in more than one member of a family and generally ran a self-limited course, perhaps somewhat shortened by antibiotics. No Americans were affected.

Dr. Richard Finkelstein, from WRAIR, and Dr. Howard Noyes, from the SEATO laboratory in Bangkok, went to Saigon to work in the Pasteur Institute. Captain Robert A. Phillips, MC, USN, and the staff of NAMRU-2 arrived from Taipei, instituted their mass treatment system of replacement of massive fluid and electrolyte losses, quickly taught it to the Vietnamese, and soon virtually eliminated further deaths from cholera.

Plague

Plague caused concern as a potential threat to U.S. troops. Darkened streets were alive with rats, and the rats were alive with fleas. In late 1962, during a plague epidemic in Saigon, Colonel (later Brigadier General) William D. Tigertt, MC, and Lieutenant Colonel Kevin G. Barry, MC, had established a small research unit with personnel from the 7th Medical Laboratory, whose efforts were directed, primarily toward plague surveillance and diagnosis. Later, the liaison already developed during the cholera epidemic led to the joint study of plague by the Ministry of Health, the Pasteur Institute, and the WRAIR team. Colonel Teschan was appointed by the Minister of Health to the reactivated Commission for Pathologic Researches in Vietnam. Such common enterprise was later extended to studies of hemorrhagic dengue which produced hemorrhagic fever in Vietnamese children and also affected U.S. troops.

During its second year, under the direction of Lieutenant Colonel Stefano Vivona, MC, the team developed a close relationship with the Pasteur Institute in Saigon; through this collaborative effort, the only plague research laboratory in Southeast Asia was constructed and oper-

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ated. From this laboratory, the extent and severity of plague in Vietnam were documented; for example, whereas only eight cases were reported from a single province in 1961, by 1966 human plague was shown to be present in every province in I, II, and III Corps areas, and in one province in IV Corps area, with 4,500 cases occurring in 1965 alone. Studies of rodent reservoirs and flea vectors of plague revealed new endemic foci, and during a pilot program for rodent and vector control in the Minh Mang district of Cho Lon, rat fleas were found to be resistant to DDT. These data, in addition to laboratory studies of the insecticides dieldrin and Diazinon, provided the Ministry of Health with information essential for reducing the vectors and controlling the disease.

The common house shrew was shown for the first time to be a reservoir of plague; an asymptomatic carrier state of virulent plague bacilli in the throats of healthy people was demonstrated for the first time in Vietnam; rat and flea survey programs and insecticide evaluation programs were expanded; and a program was initiated for production and evaluation of a lyophilized, attenuated living plague vaccine.

Malaria

During its third year, 1965-66, under the direction of Lieutenant Colonel (later Colonel) Robert J. T. Joy, MC, the medical research team expanded its mission to include specific research studies by individual team members, support of other research studies by outside investigators, and collection of medical information or health data for WRAIR, which would serve as a guide for research in the laboratories of the USAMRDC (US Army Medical Research and Development Command). Specific areas of interest included malaria, plague, gastrointestinal disease, fevers of undetermined origin, combat psychiatry, environmental stress, and other causes of morbidity and mortality in US soldiers.

The data collected warned the team of the possibility of a rise in the number of cases of chloroquine-resistant falciparum malaria and they devoted much of their effort to this disease. Among their contributions were the discovery of asymptomatic malaria, with its potential for importation to the continental United States; documentation of failures of malaria discipline and personal protective measures, which provided information needed for control; introduction of new therapeutic drugs (Fanasil and pyrimethamine) and other regimens for the treatment of malaria; and provision of consultative advice to the various command surgeons. A major contribution to the control of malaria in Vietnam was the introduction of DDS (diaminodiphenylsulfone). The efficacy of this drug as a prophylactic agent was confirmed in volunteers in the United States, and in 1966, a field test in Vietnam proved its value in

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combat troops. Subsequently, it was routinely used by military personnel in Vietnam for prophylaxis against falciparum malaria.

The team recommended that a central rehabilitation hospital for malaria patients be established and used simultaneously as a center for studying the disease and the evaluation of new therapeutic agents. This hospital was approved by The Surgeon General and became the 6th Convalescent Center at Cam Ranh Bay. A formal link with the Navy preventive medicine unit in Da Nang provided for the collection of specimens by the Navy unit, with laboratory support from the team, and for the exchange of information and research data. The 61st Medical Detachment of the 20th Preventive Medicine Unit (entomology) was established and worked with the team in the laboratory.

In the fall of 1966, the team in essence drafted a USARV regulation on malaria control guided by letters and comments from Colonel Tigertt; a medical research team for malaria survey for USARV was established; and Captain Anthony T. C. Bourke, MC, was appointed the USARV consultant in malaria.

Stress

Studies done by the medical research team of neuroendocrine stress caused by combat, in helicopter crewmen and Special Forces "A" Detachment members, contributed significantly to the understanding of the pathophysiology, of stress in, the soldier. Studies of heat stress incurred by crews of the Mohawk (OV-1) aircraft led to changes in clothing and to ventilation of the cockpit, measures which materially improved crew comfort and efficiency. Collaborative studies with the Department of Neuropsychiatry of the ARVN Cong Hoa Hospital led to a better understanding of the stresses of combat affecting both American and Vietnamese soldiers.

Fever of Undetermined Origin

A major collaborative study done by the team with the 93d Evacuation Hospital and the SEATO laboratory in Bangkok resulted in determining the specific etiology of FUO in 60 percent of patients studied. Of the cases diagnosed, 50 percent were due to dengue, with Chikungunya, scrub typhus, and malaria accounting for most of the remainder. These laboratory results, carefully correlated with clinical findings, enabled clinicians to suspect these diseases, in the absence of classical findings, early in the course of hospitalization.

Renal Failure

In February 1966, Colonel Barry arrived at the 3d Field Hospital in Saigon to institute clinical research studies in patients with malaria,

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including studies of body water, extracellular fluid, blood volume, and renal function. Because the only facilities for performing hemodialysis were in Japan and the Philippines, delays in evacuation and treatment of patients with acute renal failure often resulted in increased morbidity and mortality. Colonel Barry, recognizing the need for in-country treatment of this complication, established the first renal unit in Vietnam at the 3d Field Hospital.

The Field Epidemiologic Survey Team

The war in Vietnam pointed up deficiencies in the knowledge of certain important tropical diseases and, more significantly, the deficiencies in the ability to predict noneffectiveness and in the application of preventive techniques. It also provided the opportunity for a unique and valuable experiment in medical support of military operations in a hostile environment.

The FEST (Field Epidentiologic Survey Team) was organized in May 1966 by Lieutenant Colonel Llewellyn J. Legters, MC, preventive medicine officer of the USA John F. Kennedy Center for Special Warfare at Fort Bragg, N.C., who recognized that a research group operating in the remote areas where U.S. military forces were being committed could study the epidemiology of tropical diseases in the environment where most of them were transmitted.

The FEST, composed of Special Forces officers and enlisted technicians stationed at Fort Bragg, was trained at Fort Bragg and at WRAIR in specific laboratory and field epidemiological, skills suitable for studying diseases of special interest to the Army Medical Department and in providing medical support, preventive, and curative, to ground troops in Vietnam. Training was oriented primarily to specified scientific areas of interest such as the entomological aspects of tropical sprue, febrile illness, schistosomiasis, filariasis, dengue, and malaria.

After the training period, FEST was formally constituted as an element, of WRAIR, deployed to Vietnam on 26 September 1966, and became part of the medical research team in Saigon for administration and logistics, but was attached to Headquarters, 5th Special Forces Group.

The studies of this team which continued through 1968, diminishing as the war became conventionalized, generated valuable scientific information about malaria, plague, schistosomiasis, filariasis, tropical sprue, and other ailments.

Dermatological Research

The character of warfare in Vietnam also created unique opportunities for research on cutaneous diseases of military importance. At the, height of the rainy season, the rates of disabling skin disease among

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infantrymen were extremely high, reaching 50 percent in some rifle companies. Surgeons at the infantry battalion level were often overwhelmed by the number of soldiers displaying skin lesions of uncertain etiology which were slow to heal despite vigorous topical and systemic antibiotic therapy. Combat commanders and physicians alike became extremely receptive to scientific investigations of the common skin diseases that had defied the most heroic efforts at prevention and control.

The US Army Medical Research and Development Command sent a special field epidemiological research team from WRAIR to the Mekong Delta in 1968. The team had trained in simulated tropical combat environment at camps in the southern United States and in the Florida Everglades under the supervision of Dr. Harvey Blank of the University of Miami (Fla.) School of Medicine. Mr. David Taplin, also a member of the University of Miami faculty, conducted workshops in applied microbiology and subsequently accompanied the team to Vietnam to help establish a base laboratory.

The reception accorded the team assured them of the support so necessary for productive research under wartime conditions. The commanding general of the 9th Infantry Division, Major General (later Lieutenant General) Julian J. Ewell, pledged the full cooperation of his officers and men. The requirement for a laboratory in the Delta was more than met when the USARV surgeon, General Neel, made available a completely equipped MUST unit that provided an ideal setting for microbiological studies, with negligible risks of contamination from mud, dust, and insect life. Colonel William A. Akers, MC, Chief, Dermatology Research Unit, Letterman Army Institute of Research, promised cooperation and provided personal liaison at theater and division levels in Vietnam. Most important of all was the complete acceptance of the team by the officers and men of combat units who displayed a cheerful willingness to be examined, despite the incursions on their limited free time.

Under the leadership of Captain (later Major) Alfred M. Allen, MC, the team conducted intensive research among combat, forces, support troops, and neighboring Vietnamese populations in the Delta. They examined, American and Vietnamese infantrymen at forward company and battalion areas in active fire zones and accompanied infantry units on patrol to evaluate proposed methods of skin disease prevention. Use of portable field laboratories and special culture rnedia permitted isolation of pathogens that had eluded detection by standard methods. In less than 6 months, Captain Allen's team had precisely identified the populations most,, likely to develop common disabling skin disease, isolated the offending pathogens, measured the effects of exposure, and initiated effective new methods of prevention and treatment.

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The chief causes of cutaneous disability in American combat forces were inflammatory ringworm, ecthymatous pyoderma, and tropical immersion foot. Disease rates correlated with the degree of exposure to such things as insect bites and prolonged contact with wet clothing. Prickly heat, acne vulgaris, and tinea versicolor, while common, as a general rule were not disabling, nor was cystic (tropical) acne, which can be very disabling, a significant cause of manpower loss.

Elastase-producing fungi were found to be the major cause of inflammatory ringworm in the American combat forces. The usual athlete's foot type was surprisingly rare, being replaced by intensely inflamed, serum-oozing lesions on the dorsa of the feet, the ankles, and groin, often forming multiple small abscesses in hair follicles. The clinical features and the microbiological characteristics of the disease indicated that the infections were transmitted by a source in Vietnam rather than by irritation of old, latent infections, as previously believed. A search for sources of infection revealed that 25 percent of the wild rats tested were infected with organisms which were morphologically indistinguishable from those recovered from American soldiers.

In contrast to those found in infantrymen, the infections among support troops strongly resembled the type found among troops in training at southern United States military bases during the summer.

Penicillin treatment significantly reduced healing time of ecthymatous pyodermas in American soldiers despite a prevalence of penicillin-resistant, staphylococci. Erythromycin was also effective in a small number of cases. Tetracycline was avoided because of the high proportion of resistant streptococci recovered from the pyodermas.

The clinical and pathological features of tropical immersion foot were consistent with low-grade cold injury. Soldiers who had contracted the condition following prolonged immersion displayed increased susceptibility to repeat injury even after complete healing had occurred. Skin biopsies showed chronic inflammation and dilatation of vascular channels.

Skin infections in Vietnamese adults were strikingly different from those among Americans, even in military populations with identical exposure. Trichophyton mentagrophytes infections and streptococcal pyoderma were rare; ringworm, although fairly common, was nearly always caused by an atypical variant of Trichophyton rubrum which produced a chronic, scaly, dry rash generally confined to the waist. Vietnamese children, on the other hand, were similar to American combat troops in their frequent experience with streptococcal pyoderma and ringworm.

After Captain Allen's departure from Vietnam, dermatological research was continued by Captain Joseph Thompson, MC, Captain Joseph M. Ballo, MC, and Lieutenant Colonel Robert. T. Cutting, MC. The results of two field trials to determine the efficacy of griseofulvin in the

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prevention of ringworm, infection showed that it was significantly protective, provided the recommended dosage schedule was strictly observed.

The field dermatology research program in Vietnam was rewarding in the relatively brief span of its existence. Early application of the measures recommended on the basis of the team's findings dramatically lowered disability rates wherever they were put into effect. Research priorities were realigned to be more directly aimed at prevention of those diseases having the greatest impact on combat manpower. Laboratories in the United States focused their attention on the newly found clues to pathogenesis of the common disabling skin infections. Representative isolates of pathogenic strains of fungi and bacteria recovered in Vietnam were collected for future study. The influence of the research findings even extended to the development of new items of tropical military footwear. As a direct result of, the dedicated efforts of this team, and because of military-civilian cooperation, development of effective methods to prevent the devastating effects of skin diseases came, for the first time, within reach.

Photographic Coverage of Army Medical Activities

During the latter part of 1965 it became evident that photographic coverage of Army medical activities in Vietnam was unsatisfactory. Since the Medical Audiovisual Department, WRAIR, was capable of providing highly professional still and motion picture support of the WRAIR's diverse research activities, it was decided to field a photography team to be attached to the WRAIR research team but to be equally responsive to direction from the USARV surgeon.

Two weeks after the decision was made, four civilian volunteers, all from WRAIR, began a comprehensive coverage of surgery, helicopter evacuation, combat "medics" in action, field hospital operations, and other medical activities wherever and whenever they saw them. They formed a highly mobile and aggressive team, not only responding to requests and direction from the medical command, but also seeking out on their own initiative areas and activities requiring photographic coverage.

The Surgeon General, realizing that the team approach was the most efficient means of acquiring accurate and timely pictorial records of the Army's medical effort in Vietnam, directed that additional personnel and funds be provided to establish a permanent team of military medical photographers. This team, consisting of one officer, one noncommissioned officer, and three enlisted men, became operational in December 1967. Adhering to the pattern already established, the new group continued to work closely with the USARV medical and surgical consultants, following the action to the areas of greatest activity. Thus began the collection of thousands of color slides and hundreds of thousands of feet of

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motion picture film which later became the basis for film libraries, not only in the United States (such as these at WRAIR and at the Medical Field Service School at Fort Sam Houston), but also in Europe, Hawaii, and Asia. At least three major film productions resulted from the footage obtained, one on helicopter evacuation, another on MUST, and a third, the award-winning "Army Medicine in Vietnam."

In its fourth year, the team concentrated on surgical research and on testing the FEST concept. The research was done by a group which was attached to the team in April 1966, initially at the 93d Evacuation Hospital, later at the 3d Surgical Hospital, and finally at the 24th Evacuation Hospital. The group demonstrated that, studies of the type conducted in "shock units" in the United States can be carried out with satisfactory results on combat casualties in the field. Later studies conducted by the research group contributed to the knowledge of many other subjects.

Recognition of the seriousness of pulmonary insufficiency in shock, particularly in patients with non thoracic injuries, led to extensive research in the management of this complication. Plans were made for the development and testing of new respiratory assistance devices.

Further progress was made in the development and use of plastic polymers as tissue adhesives in controlling bleeding and repairing internal organs. Spray guns containing the adhesive were provided the surgical research team for use in treating casualties in Vietnam.

New methods for fixation of fractures of the jaw were studied, as was a new technique using a silicone plastic placed directly into oral wounds to restore temporary oral integrity until reconstructive surgery could be performed.

Other innovations under study by the research group were the use of electrical anesthesia, laser irradiation, synthetic blood vessels, plasma expanders and new additives in the preservation of whole blood. Sulfamylon ointment for control of infection in burns, and various methods for suppression of an immune response of the body to homografts, and transplants.