Health and medicine in Hong Kong during WW2

The following chapter describes the medical services and health conditions in Hong Kong during the fighting in 1941 and the Japanese occupation that followed. It appeared in Volume II of "The Civilian Health and Medical Services" by Sir Arthur Salusbury MacNalty, published by H.M. Stationery Office, 1955, which is part of HISTORY OF THE SECOND WORLD WAR, UNITED KINGDOM MEDICAL SERIES

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CHAPTER 3

HONG KONG

By SIR SELWYN SELWYN-CLARKE

  K.B.E., C.M.G., M.C., M.D., F.R.C.P.

Formerly Director of Medical Services, Hong Kong

PREPARATION FOR WAR

HISTORICAL SUMMARY

THE British Colony of Hong Kong includes the island of Hong Kong ceded to Great Britain in 1841, the Kowloon peninsula on the mainland and Stonecutter's Island obtained by cession in 1860, and the New Territories over which a 99-years lease was secured from the Imperial Government of China in 1898.

Hong Kong Island is about 11 miles in length with an area of 32 square miles, separated from the Kowloon peninsula by a channel about a mile wide. The Kowloon peninsula, the hinterland to a depth of about 20 miles and the nearby islands forming the Leased Territories are approximately 360 square miles in area.

A little less than a century before the start of the war, Hong Kong was a barren island sparsely settled by a few thousand fishermen and pirates. It soon became an important centre of transhipment trade, and at the time of the so-called China 'Incident' of July 1937, when Japan invaded the five Northern Provinces, Hong Kong had developed into the fifth port in the world.

From the invasion of Manchuria in 1931, followed six years later by the operations in the Northern Provinces, it soon became apparent that Japan might continue her southward drive and ultimately attack Hong Kong. The Hong Kong Government took cognisance of the situation, and co-ordinated schemes for the active and passive defence of the colony were devised.

In the autumn of 1938, the Japanese landed in force in Bias Bay, captured Canton and advanced to the British frontier, within twenty miles of Hong Kong itself.

In August 1939, ample evidence was available in the form of troop concentrations, massing of guns and mechanised transport that the Japanese intended to cross the frontier with a view to capturing Hong Kong. When the Russo-German Pact was made, political reasons on the part of Germany were probably responsible for the postponement of the threatened attack by the Japanese on British territory.

Population. At the time of the cession of the island of Hong Kong in 1841, the Chinese numbered 6,000 and the Europeans about 2,000. With the additional territory ceded in 1861, the population increased to 119,321. In 1901, after the taking over of the Leased Territories, there were 283,975 inhabitants. The expansion of trade and, to a lesser degree, the disturbed conditions in China after the overthrow of the Manchu dynasty and the foundation of the Republic in 1911, stimulated an increase in population to 456,739. In 1921 and 1931 the figure stood at 625,166 and 849,751 respectively. Fighting in the north, followed by the Japanese advance in southern Kwang Tung, produced a wave of immigration, the results of which were only partially influenced by the Japanese blockade of Hong Kong, which tended to direct the stream in the opposite direction, so that by the middle of 1941, the population figure stood at about 1,700,000, of whom rather over a third were refugees from war areas. The tightening of the blockade, the rise in the cost of living and the more imminent threat of war with Japan, assisted to a minor extent by the effect of the Immigration Restriction Ordnance, resulted in the population falling to between 1,500,000 and 1,600,000 when the Japanese started their attack on Hong Kong in December 1941.

Within a few weeks of the capitulation, the Japanese gave publicity to the fact that they proposed to reduce the number of inhabitants of Hong Kong to half a million—thus saving shipping which would have otherwise been diverted from their war effort in bringing in foodstuffs and other essentials for the population.

By repatriation (mostly forced), wholesale shootings and starvation, the population had fallen to a little over a million by 1942. By the middle of 1944, during which food prices had risen very considerably, there had been a further large drop to about 750,000, and with worsening conditions and frequent allied bombings, the figure had fallen still further to about 650,000 in June and 600,000 by August 1945.

CIVILIAN MEDICAL ORGANISATION

The Hong Kong Government Medical Department was divided into three main divisions under the Director of Medical Services, Dr. P. S. Selwyn-Clarke, C.M.G., M.C. These divisions were: Hospitals, Health and Investigation. The hospitals were administered by the Deputy Director of Medical Services, and were staffed by 42 medical officers and 348 nurses, dressers or male nurses, etc. The Professors of Medicine, Surgery, Obstetrics and Gynaecology, of the University of Hong Kong, acted as consultants in the Hospital Division. The Deputy Director of Health Services controlled a staff of 24 medical officers of health engaged in preventive work in urban and rural areas, port and social hygiene, and in school, maternity and child welfare work. These were assisted by 147 sisters, nurses, dressers and public vaccinators.

The third or Investigation Division was divided into two main groups: (a) The Bacteriological Institute with a bacteriologist and two assistants, and sharing the services of the Professor of Pathology, University of Hong Kong, who supervised autopsies in the public mortuaries. Associated with the Bacteriological Institute was a malaria bureau staffed by the malariologist and his technical assistants. 

(b) The Chemical (Analytical) Laboratory with the Government chemist and two assistants.

Associated with the Hospitals Division and under the direct control of the Director of Medical Services, though not forming an integral part of the Hong Kong Government Medical Department until the actual outbreak of hostilities with Japan, were a group of three Chinese hospitals and nine public dispensary clinics. These institutions were staffed with 27 medical officers and 138 matrons, sisters, nurses, dressers, midwives, dispensers, etc.

Apart from Government hospitals and Chinese hospitals over which the Government exercised some degree of control from 1938 onwards, largely as the result of having to provide a considerable subsidy annually, the Hong Kong Government Medical Department had friendly arrangements with the authorities of a number of private hospitals, some operated by missionary institutions and some by groups of private practitioners or by committees of business men and doctors.

About 300 private practitioners, mostly Chinese, and several hundred registered dentists (a mere handful being actual qualified dental surgeons), together with 731 private midwives and nurses, and St. John Ambulance members combined to augment the Government Medical Department staff.

Bed Accommodation. In the course of a detailed survey carried out in Hong Kong just before the war, it was ascertained that there were 2,939 beds for general purposes, a deficit of at least 3,000 taking the population at the time of the survey as approximately 1 millions. At that period there existed some 300 beds for dangerous infectious diseases out of a required (minimum) total of 1,250. Beds for 325 sick children were available in Hong Kong, although at least twice this number could have been readily filled. Only 383 beds were found to be available for women in childbirth, a deficit of at least 200 on a conservative basis. Laboratory and mortuary facilities which have been referred to briefly above, were quite inadequate before the war.

CONVERSION OF CIVILIAN MEDICAL FACILITIES TO WAR FOOTING

When war with Japan seemed inevitable, every possible effort was made to augment civilian medical facilities.

Hospitals. Plans were prepared to raise certain hospitals to the standard of casualty clearing stations, with full equipment for handling large numbers of wounded from air raids and long-distance shelling from land and sea. Seven hospitals were selected in each main sector of Hong Kong Island and the Kowloon peninsula, with a normal accommodation of 1,175 beds, and were prepared for the reception of 2,250 patients.

Concurrently other existing hospitals were enlarged to serve as relief hospitals and a number of premises were surveyed for conversion into hospitals should war break out, with the result that an additional 1,700 beds were made available.

One of the four principal Chinese hospitals was handed over to the military authorities, but the remaining three larger hospitals (one on the Island and the other two on the Kowloon peninsula) were retained by the Chinese for their seriously sick.

Accumulations of medical stores were formed at all hospitals and at points scattered over Hong Kong Island and the Kowloon peninsula so that the destruction of one or more stores would not deprive the services of essential materials.

First-aid Posts. In addition to casualty clearing and relief hospitals, some nineteen premises were taken over to serve as first-aid posts. For the most part, schools were used for this purpose, since it had been decided that it would be dangerous to continue schools during hostilities.

These first-aid posts were sited so as to ensure that wounded would not have to be carried for more than a mile in any district. A mobile first-aid unit was organised on each side of the harbour to be available to proceed to any area where casualties were heavy.

Ambulance Transport. Transport by hand stretcher, motor ambulance and converted lorries was arranged to enable casualty clearing hospitals to be cleared at the start of hostilities and periodically when wounded had received their major surgical treatment and were fit to be removed to relief hospitals, and for the transport of wounded from first-aid posts to the casualty clearing hospitals.

Brigaded with the ambulances and converted ambulance lorries were motor trucks for the conveyance of medical stores, food and fuel from central dumps and stores to the hospital raid posts.

SCHEME OF OPERATIONS

On Hong Kong Island there were three main areas, while the Kowloon peninsula was divided into Kowloon north and Kowloon south. Each area had an Area Medical Officer in executive charge of all medical and health services and this officer had with him the Area Medical Transport Officer and Liaison Communication Officers responsible for maintaining all forms of communication.

When an incident occurred, the A.R.P. warden reported the location, etc. to one of the Report Centres and thence to A.R.P. Headquarters. The Medical Communication Liaison Officer in turn reported casualties to the nearest first-aid post or posts and to the Area Medical Headquarters. In turn, the Area Medical Headquarters collated information and passed it on to General Medical Headquarters and to neighbouring Area Medical Headquarters, after taking such action as might be necessary to organise supplementary aid from other first-aid posts.

The staff of each first-aid post consisted of three private practitioners recruited specifically for the purpose and on eight-hour shifts, a varying number of first-aid parties of four members of St. John Ambulance Brigade stretcher bearers and a number of nurses, either members of St. John Ambulance Nursing Division or of an 'ad hoc' organisation called the Auxiliary Nursing Service brought into being as a supplementary nursing service. The aim was to have groups of 144 St. John Ambulance Brigade personnel in every first-aid post, so that 72 would be on duty for twelve hours per day in shifts. In point of fact, circumstances necessitated the acceptance of a lower standard of staffing of the nineteen posts, some of which had but two doctors and as few as twenty-four stretcher bearers. A senior member of the Medical Department was seconded to act as Supervisor and Training Officer to the first-aid post personnel.

In anticipation of the possible cutting off of communications between the island and the Kowloon peninsula, a Principal Medical Officer was appointed by the Director of Medical Services for the peninsula and Leased Territories, who was given full powers in the event of being unable to maintain communications with Battle Medical Headquarters on the Island.

The Director of Medical Services (or Medical and Sanitary Controller as he was termed from September 3, 1939) was in intimate liaison with both the Civil Government and Military Headquarters and was responsible for keeping both informed of any important incidents, including the occurrence and disposal of casualties, and matters affecting the wellbeing of the community as a whole.

Dispersal Areas. In the hope of limiting the number of casualties from bombing or shelling, steps were taken to establish dispersal areas on the Hong Kong Island. These dispersal areas were situated in open country mostly on the north side of the Island and were planned to accommodate the inhabitants of the highly congested parts of the city. Cooked food, water, sanitary arrangements, a quantity of wooden planks for covering over slit trenches, and medical care were provided in these dispersal areas.

In order to familiarise the personnel employed and the general public, exercises were carried out before the declaration of war by Japan, in which relief hospitals were established, casualty clearing hospitals were partially cleared for the reception of wounded, first-aid posts were opened and stretcher and ambulance transport dealt with mock wounded. An exercise of this nature was actually completed satisfactorily six days before the Japanese attack.

SUPPLIES

With the experience gathered in the feeding and care of many thousands of refugees and destitute in Hong Kong, the Medical and Sanitary Controller was in a position to make recommendations regarding food reserves. Rice, groundnut oil, soya beans, dried and salted fish, dried vegetables and salt were among the more important constituents of the siege rations for the bulk of the Chinese population, to which were added ghee, atta and curry for the relatively small Indian population.

For those consuming a Western dietary, flour, frozen and tinned meat, bacon, sugar, butter and vitaminised margarine, powdered milk, cheese, rice bran biscuits, etc., were stored.

Every effort was made to secure a reserve for a population of 1 millions for a period of 130 days, although the war came too early to make this possible.

Stocks of fuel, for the most part on Hong Kong Island, were also laid in by importations and by extensive plantation cutting in the Leased Territories of the Colony.

But for the above-mentioned food stores, it is probable that the deaths from starvation in Hong Kong would have been far in excess of the very considerable number that did occur after the capture of the Colony by the Japanese.

PERIOD OF ACTIVE HOSTILITIES: DECEMBER 8-25, 1941

MOBILISATION

The long-expected blow fell on the morning of December 8, 1941 simultaneously with the destruction of the greater part of the United States Pacific Fleet at Pearl Harbour, and followed rapidly by the sinking of H.M.S. Prince of Wales and Repulse in Malayan waters.

Not long after midnight on December 8, warning was received by the Hong Kong Government that the Japanese troops were preparing to cross the border into British territory. The pre-arranged code word for the immediate mobilisation of all services connected with the active and passive defence of the Colony was broadcast to naval and military commanders and to all departmental heads and members of essential services. The Director of Medical Services recalled all doctors, nurses and midwives from isolated hospitals and public dispensaries in the Leased Territories. This staff brought with them the more valuable instruments and medical supplies and took up their allotted stations in Kowloon.

Approximately 1,000 stretcher bearers and nurses belonging to St. John Ambulance Brigade manned the nineteen first-aid posts on the Kowloon peninsula and on Hong Kong Island, where they were placed under the supervision of sixty private practitioners.

Lorries were converted into ambulances by means of pre-fabricated steel frames and these were employed in removing patients from previously designated casualty clearing hospitals to relief hospitals and to their homes. Some 140 private practitioners and 450 European and Asiatic women members of the Auxiliary Nursing Service were posted to these civilian medical defence units. Emergency medical stores were established at various points on the Kowloon peninsula and on Hong Kong Island to minimise loss from bombing and shelling and to render it possible for hospitals and aid posts to be replenished as speedily as possible. A cleansing station was opened at Kowloon Hospital on the peninsula and a second and third at the Queen Mary Hospital for Western Hong Kong and at Happy Valley for Eastern Hong Kong. Fortunately, no gas cases occurred.

Medical transport parks consisting of ambulances and lorries for conveying medical supplies, food and fuel were established in the two main sectors on the peninsula and in the three sectors into which Hong Kong Island was divided.

Strenuous efforts were made to induce non-essential persons to leave the Island for the mainland and to evacuate densely crowded districts to dispersal areas in the hills and open country.

THE AIR RAIDS

The response to the appeal to doctors, nurses, ambulance and lorry drivers, stretcher bearers and auxiliary medical grades to report to their battle stations was immediate. Preparations were very near to completion when the first bombs were dropped by the enemy on Kowloon at 8 a.m. on December 8, 1941. Medical Headquarters had meanwhile moved into Battle Headquarters on the north side of the Hong Kong and Shanghai Bank Building, from which special wires had been laid to Military Headquarters, the government offices and civil defence services.

Numbers of civilian casualties resulting from the raid were collected by St. John Ambulance personnel and conveyed by ambulance to the Kowloon and Central British Casualty Clearing Hospitals on the mainland.

Air raids followed on Hong Kong Island, but casualties were relatively slight in the earlier stages of the fighting.

CAPTURE OF KOWLOON

In spite of the destruction of road bridges and railway tunnels and the courageous rearguard action of the British and Indian troops, including units of the Hong Kong Volunteer Defence Corps, the Japanese troops succeeded in advancing rapidly from the Sino-British frontier to the hills protecting Kowloon from the north.

Within two days the Japanese were able to capture the Jubilee Redoubt, an important strongpoint in these hills. As a result the main water supply for Kowloon and, in part, for Hong Kong Island which was derived from this region, was put completely out of action.

Finding that the Japanese had advanced still further by the afternoon of December 11, and had penetrated into the outskirts of Kowloon itself, orders were given to withdraw most of the staffs of first-aid posts and subsidiary hospitals in the more advanced positions and to concentrate the personnel and more valuable equipment in the three main hospitals on the peninsula.

With the approval of the Governor and Commander-in-Chief, a personal appeal was made to the medical and nursing staff of units on the peninsula to remain at their posts to care for the wounded and sick, although the occupation of Kowloon by the enemy was a foregone conclusion by that time. The staff responded without a moment's hesitation. Among hundreds of workers, only two deserted their posts. In their partial defence, it must not be forgotten that there was no illusion as to the indignities and cruelties that they might suffer under the Japanese.

Within four days of the actual outbreak of war in Hong Kong, the whole of the peninsula was in Japanese hands and enemy batteries were established in Kowloon. These batteries shelled the northern face of Hong Kong Island, directing their fire on British battery positions and pill-box machine-gun emplacements guarding the shore line, ammunition, food and fuel dumps, transport parks and other military objectives. As the area is very restricted, it was inevitable that several hospitals and first-aid posts suffered considerable damage from both shelling and bombing. The Canossa Relief Hospital, for example, was completely destroyed; the main portion of St. Paul's Casualty Clearing Hospital was so damaged by large calibre shells that it had to be evacuated; two first-aid posts received so many direct hits that they had to be closed, and the Matilda Relief Hospital on the Peak had ninety shells, fortunately mostly of comparatively small calibre, on the building and in the garden. In the last named institution, the staff most courageously continued their work in the basement, the upper fabric having been riddled and the wards being quite uninhabitable.

It is of interest to note that some of the hospitals, including St. Paul's, suffered severe damage from Allied aircraft late in the Japanese occupation, and for the same reason, that is to say, their proximity to military objectives.

CAPTURE OF HONG KONG

After occupying Kowloon, the Japanese sent over a Peace Mission to Hong Kong. This was turned back with the answer that there would be no surrender. A similar reply was given to a second envoy a few days later.

THE MEDICAL SERVICES

On the night of December 18/19, the Japanese effected a landing at North Point and, a little later, at the north-eastern extremity of Hong Kong Island.

Soon after the Japanese landing at North Point, they entered St. Paul's Casualty Clearing Hospital and removed several of the British medical staff to North Point Camp which was converted in the earlier stages into a mixed internment camp for civilians and troops. Later, the Japanese allowed the doctors to return temporarily to the hospital for duty. As the advance progressed more hospitals and aid posts were captured, in some cases the non-European personnel being able to effect their escape.

At one hospital, an infamous incident accompanied the overrunning of the area on December 23. Several members of the nursing staff were criminally assaulted and had to be removed to the Queen Mary Casualty Clearing Hospital for medical treatment. A still worse outrage took place in another hospital where the Commanding Officer and another R.A.M.C. officer were killed while attempting to protect their patients and nursing staff. Patients were bayoneted and four nurses were criminally assaulted, three being killed. Apart from the killing of prisoners which took place both before and after the final surrender, there were comparatively few deliberate attacks on medical and nursing personnel.

After a hotly contested battle at the strategic centre of the Island, the Governor was compelled to agree to an unconditional surrender at 4 p.m. on December 25, 1941, after eighteen days' resistance.

During the period of hostilities the closest possible liaison was maintained between the civil medical and the military authorities.

To assist the latter authorities to meet their needs for beds for casualties, the Tung Wah Eastern Hospital was completely cleared of patients and civilian staff and became a military hospital for Indian troops; beds for casualties occurring in the Forces were reserved in the Queen Mary Hospital, War Memorial Hospital and in other institutions. In the Queen Mary Hospital alone, over four hundred out of the 1,200 seriously wounded admitted during the fighting, were members of the naval and military services.

THE SANITARY SERVICES

As well might be assumed, the sanitary services suffered serious disruption during the fighting. The normal arrangements for the disposal of nightsoil broke down, dumping into the harbour had to be resorted to and refuse depots had to be established at several points on the Island and peninsula.

As the Japanese advance continued, the formation of new dumps, even in built-up areas was unavoidable. At the time of the surrender the disposal of refuse became an almost insoluble problem and large heaps were to be encountered all over the town.

Bombs and shells which destroyed roads, bridges, and actual transport were also responsible for causing considerable damage to sewers and drains, which became blocked with debris, the contents pouring over the roadway.

Electric power on the Island failed a week before the termination of hostilities when the Japanese took North Point. All water supplies dependent upon electric power for pumping failed at this juncture. The people were seriously inconvenienced and their health endangered by having to obtain water from polluted hill-streams and wells. Electric power for heating and gas being no longer available and coal and wood fuel at a premium, it was difficult to devise a satisfactory method of rendering water safe by boiling, and chlorination was impracticable, except in institutions.

A city without light or water, with many buildings in ruins, with streets and open spaces littered with refuse and with sewers blocked by shell and bomb, or by the lack of water for flushing purposes, presents a gloomy and depressing picture. Added to this, labour and transport for collecting and burying the dead constituted another problem.

Despite the manifold handicaps, the staff of the health department emulated their colleagues in the hospital service in their endeavour to maintain some degree of municipal hygiene; one measure after another had to be improvised in an attempt to cope with the situation.

CASUALTIES

Any close calculation of the number of casualties was impossible for several reasons. In spite of every effort made to preserve records of this period from destruction, the majority were lost owing to the deliberate policy of the Japanese to destroy all links with the previous British regime. Furthermore, the staff were only allowed to operate under sufferance by the Japanese after the capitulation, so that the bodies of persons who had died during the fighting (especially those on the hills and open country or under demolished buildings) were still being gathered up in March 1942, three months after the local war had ended. In fact, units of the Graves Commission operating in the Colony after the liberation, recovered a number of bodies that had not received proper burial.

During the actual fighting rather over 1,400 members of the Hong Kong garrison were killed, missing, believed killed or died of wounds, while 1,678 were wounded. The garrison numbered about 12,000; consequently the number killed represented about 11.6 per cent. of the total strength. The ratio among the civilian population was, of course, very much lower during actual hostilities.

It is estimated that about 2,000 civilians were killed or died of wounds during hostilities and about the same number of seriously wounded civilians received treatment in hospitals, lighter injuries being dealt with at first-aid posts. Only an approximate estimate is available of civilians who received first-aid treatment in the streets and at first-aid posts, owing to the records being destroyed. The figure given was 3,000. In other words, the sum total of civilians killed, died of wounds or injured (seriously or slightly) during hostilities was about 7,000, a remarkably small number in view of the fact that about 1 million persons were at risk.

PERIOD OF JAPANESE OCCUPATION—DECEMBER 1941-AUGUST 1945

PRELIMINARY PERIOD OF CHAOTIC CONDITIONS

Christmas Day, 1941 was, without any doubt, the most gloomy in the whole hundred years' history of the Crown Colony. Looting and unprovoked assaults on men and women were the disorder of the day. It must be remembered, however, that Hong Kong resembled Aladdin's Cave to the average Japanese soldier and the temptation to collect wristwatches, fountain pens, money and jewellery was no more easy to resist than had been the removal of objets d'arts by armed detachments of the Great Powers during the suppression of the Boxer Rising forty years earlier. Moreover, a considerable portion of the actual looting and destruction of property was carried out by the rowdy elements among the Chinese.

Later in the occupation period Chinese looters were responsible for removing from premises piece by piece, all wood, windows, floors, stairs, roofs, fences, seats, etc. sometimes at the risk of their lives. When it is recalled that conditions of living deteriorated so rapidly and to such an extent that tens of thousands died of starvation and that even cannibalism became a commonplace affair, it is difficult to blame these unfortunate people.

Unhappily, economic conditions worsened to such an extent that, to save the lives of their children, many of the poorest gave their bodies to the invaders in return for Japanese army or looted British rations. Immediately the unconditional surrender of Hong Kong had taken place, at 4 p.m. on December 25, 1941, the Japanese Military Commander issued an order prohibiting all pedestrian and wheeled traffic.

Many wounded still lay about the hills and scattered through the town; the streets were cluttered up with dead, debris from damaged houses and refuse; the sewers had been holed and blocked and their contents poured over the roadway; the water mains had been damaged by shell and bomb and no unpolluted drinking water was available; electric light and power had failed early in the period of hostilities.

MEDICAL ORGANISATION DURING THE OCCUPATION

The Director of Medical Services sought out the Japanese Commander and obtained permission to operate ambulances, hearses and refuse lorries and to carry supplies of food and fuel to the hospitals, aid posts and billets containing wives and children of volunteers, members of the essential services and others. This permission was not accorded so much from humanitarian reasons, but because the Japanese Military Commander wished to protect his troops from dangerous infectious disease. Permits were also obtained for five members of the Waterworks Engineering Department to leave their billets to carry out repairs to the waterworks in order to secure a minimal supply for hospitals and the general public.

At the beginning of January, 1942, the Japanese Medical Authority established its own department. Having little knowledge of the framework of civil medical and health work, the Japanese Head caused the British Director of Medical Services to be appointed as 'Adviser'. This enabled him to move about the town and to persuade such of his technical, medical, nursing, health, investigation and cleansing staff as were needed to remain at work for the benefit of the community. The Japanese closed all banks and refused to pay medical and health personnel for several months; hence it became necessary for every effort to be made to induce the coolies and others on absolutely essential work to carry on without pay and with only a meagre ration of rice and fuel to keep them going. As can be imagined, this was no easy task. But this arrangement made it possible later to assist military and civilian interned persons, the widows, wives, children and dependants of volunteers in the Hong Kong Volunteer Defence Corps, and of persons in the camps or killed in action. In this way, food and medical care was provided for the 3,500 wives and dependants of volunteers and essential service workers who were accommodated in emergency billets in the mid-levels on Victoria Peak.

A few days after the surrender, the British Forces were interned in prisoner-of-war camps; they numbered about ten thousand, of whom about 2,000 were Indian troops.

Because of the overcrowded and insanitary conditions of these camps in the early stages, combined with under-nourishment, bacillary dysentery broke out.

On January 4, 1942, the Japanese authorities ordered the internment of about 1,600 ‘enemy' civilian nationals in Hong Kong and 500 on the Kowloon peninsula. Before this date, Sir Mark Young, Governor of the Colony, had been imprisoned in the Peninsula Hotel; he was subsequently removed to the north, and ultimately to Manchuria.

Mr. F. C. Gimson (later Sir Franklin Gimson), Colonial Secretary, and several members of the Executive Council were placed under detention in the town of Victoria. Some 400 residents with the late Sir Atholl MacGregor as their leader were confined, temporarily, to houses on the Victoria Peak, but the Director of Medical Services with the bulk of his staff was allowed limited freedom to carry on in the hospitals, etc. All the smaller groups were eventually interned. The accommodation provided at first for British, American and Dutch nationals consisted of low-class Chinese boarding-houses, some of which had been brothels. It is to be presumed that the Japanese made this selection with a view to destroying what little remained of British 'face' or prestige. The rations issued at that time consisted of 8 oz. of rice per day, occasionally a small portion of water buffalo, rarely any salt or oil and no vegetables. Pine logs were issued for fuel. The diet was a spartan one for those accustomed to European food.

In order to mitigate the hardships in some degree, the Director of Medical Services and his staff, while still at liberty, made every effort to distribute all manner of supplies to the boarding-houses. Six American nationals gave considerable help by driving ambulances and supply trucks during the period.

The Japanese authorities refused to allow the International Red Cross to function in Hong Kong for over a year. In consequence, it became necessary to create an informal welfare committee to raise funds, under cover, so that help could be given to interned persons and to noninterned wives and dependants of prisoners-of-war and civilian internees in the form of grants for subsistence, food, clothes, shoes, etc.

The overcrowded and unhygienic nature of the boarding-houses referred to above, situated amid congested and insanitary surroundings, was the subject of repeated representations to the Japanese.

At one stage it was proposed to rehouse all interned civilians on Kowloon peninsula, but eventually the authorities were persuaded to utilise the Stanley peninsula for the purpose and about 2,500 civilians were moved there from Victoria and Kowloon and from residences on Victoria Peak.

STANLEY CIVILIAN INTERNMENT CAMP, 
     JANUARY 1942-AUGUST 1945 

STAFF

It was fortunate that among the 2,500 individuals who were interned at Stanley, there were no less than forty doctors, two dentists, a distinguished biologist, six pharmacists, one hundred trained nurses, six masseuses, and a host of auxiliary nurses. These professional men and women consisted of Government servants, members of the staff of the Hong Kong University, private practitioners and the staffs of private and mission hospitals. All these individuals pooled their talents and resources and worked as a harmonious whole for the benefit and welfare of the entire community.

The Deputy Director of Medical Services was appointed Camp Medical Officer by the representatives of the internees and very soon after internment the medical organisation was established on a firm and co-operative foundation.

HOSPITAL

A three-storey building, formerly used for accommodating single Indian warders, was transformed into a very efficient, though poorly equipped, hospital. The hospital had 74 beds, 37 for females and 37 for males, usually filled to capacity. The turn-over was rapid, patients having to be discharged early to make room for more acute cases. The number of new admissions per month varied between 90 and 150. Disorders of the alimentary tract including bacillary dysentery, accounted for most of the admissions. Operations were performed regularly, even after the electricity had been cut off and lighting was limited to the amount of daylight that could be reflected into the wound by means of a reflector. The induction of anaesthesia often presented a serious problem owing to the shortage of chloroform and ether. Whenever feasible, spinal anaesthesia was the method selected.

Sanatorium. By 1943, the number of cases of open pulmonary tuberculosis had increased from 7 to 14. A small building, known as the Leprosarium, was cleared of its occupants and transformed into a sanatorium for the treatment of cases of pulmonary tuberculosis. Treatment was handicapped by the absence of radiography, but this did not prevent collapse therapy being regularly carried out. The only other treatment that could be given to these unfortunate sufferers was regular doses of sharks' liver oil, soya bean milk, peanut butter or margarine, according to available stocks held by the Camp Supplies Officer and the International Welfare Committee.

District Clinics. The camp was conveniently divided into three districts. The average population of each was about 850. Each district had a clinic or surgery which was in charge of a medical officer. Here daily out-patients were attended and surgical dressings applied. Here also were kept the records and the medical history sheets of every internee who attended, and daily returns were made to medical headquarters situated at Tweed Bay Hospital. Whenever necessary, patients were sent to the special clincs for further advice and treatment. In this manner a detailed record was kept of the state of health of all internees.

SPECIAL CLINICS

Surgical. A surgical specialist attended each morning from 9 to 12 in the out-patient department at Tweed Bay Hospital.

Nutrition. All cases attending district clinics and found to be suffering from symptoms attributable to lack of a suitable diet were referred to the nutrition clinic, which was in charge of a medical specialist and several assistants. The results of treatment were carefully watched and reported. The functions of this clinic had a two-fold advantage, firstly, the standardisation of diagnosis and, secondly, economy in the use of drugs, such as thiamin and nicotinic acid, and in the consumption of yeast and sharks' liver oil. Moreover, the physician in charge kept a detailed record of all food consumed, i.e., the daily rations as supplied by the Japanese, food purchased at the canteen, and food received from time to time from the International Red Cross. It was possible in this way to correlate the incidence of avitaminosis and loss or gain of bodyweight with the state of the diet throughout the period of internment. Other special clinics were: ophthalmic, ear, nose and throat, dental, gynaecological, ante-natal, social hygiene, diseases of the skin, massage and electro-therapy.

Though a special clinic was not held for this purpose, one of the lady doctors made it her special work to attend to the health and welfare of infants and school children.

Drugs. At first, the drugs available were mainly those brought into the camp by the medical staff of the various hospitals. In addition, private doctors brought in a considerable supply from their personal stocks. The bulk of the stock contained in the small medical store in Tweed Bay Hospital was brought direct from the Queen Mary Hospital.

After a time replenishments became more difficult but, thanks to the efforts of the Medical Department, valuable additions were made, especially of preparations such as sulphanilamide and sulphapyridine, nicotinic acid, thiamin and 'multivite' capsules, the price of which in the open market had soared almost to impossible heights. The Swiss delegate of the I.R.C. sent in medicines occasionally, but at exorbitant cost, which made it necessary for the Camp Medical Officer to issue repeated instructions for the exercise of the strictest economy in their use. The most valuable additions to drugs and dressings were those received from the British and Canadian Red Cross Societies.

It would be ungracious to omit to mention that the Japanese authorities did, from time to time, send medical supplies into camp. Welcome as they were, the actual items were not always in response to specific requests, but appeared to be merely such stocks of preparations as they happened to possess. Perhaps the most valuable of their contributions was the supply of stationery. Until March 1943, prescriptions had to be written on scraps of paper, cigarette wrappings, etc. The medical notes of in-patients were recorded on the backs of temperature charts, and many of these had to be used over and over again.

Equipment. As in the case of drugs, most of the surgical instruments and other hospital equipment were brought into camp at the time of internment by various doctors and persons connected with the outside hospitals, but, again, the majority from the Queen Mary Hospital. It was possible by the pooling of equipment from all sources to provide for the hospital, including the operating theatre, and the district clinics. For weeks after internment, the Director of Medical Services, on his periodic visits, never failed to supply additional equipment—as for example, a microscope, a diathermy machine, etc. Repeated requests were made to the Japanese authorities for a portable X-ray set, but without success. During the first eighteen months nearly two hundred patients were taken into town to be X-rayed, but for the last two years no radiography was permitted. Though frequently required, it was not possible to obtain a cystoscope.

Some very ingenious surgical appliances were manufactured at the camp workshop by the skilled engineers. They made excellent aluminium splints, bone-holding forceps and a high-pressure steam steriliser.

MISCELLANEOUS ACTIVITIES

Diet Kitchens. After the early months of internment it became very apparent that something would have to be done about making the diet as supplied by the Japanese more suitable and palatable for very young children, elderly invalids and those suffering from chronic peptic ulcers. The setting up of these special kitchens was made possible by the fact that there were available in the camp a number of electric cookers. The International Welfare Committee provided the extra foodstuffs. The district medical officer exercised general supervision, but a trained nurse- -a specialist in dietetics—was in charge of each kitchen. She had the assistance of other women experienced in invalid cooking. These kitchens proved a great success. The time came when the electricity was cut off and firewood became scarce, and these kitchens were forced to close. A very definite deterioration in the health of many of the regular patients followed.

Milk. A limited number of 8-oz. bottles of unpasteurised cows' milk were sent into camp daily, though the supply was somewhat irregular and diminished considerably as time went on. This was kept for the hospital and children under five years of age. Full cream powdered milk was reserved for infants only but this supply was exhausted by January 1945. Thirty to forty pints of soya bean milk were made daily. This was reserved for use in the hospital and sanatorium and for debilitated out-patients.

Yeast. Next to loss of body-weight the earliest manifestations of food deficiency were those due to lack of vitamins B, and B2. Owing to the difficulty of remedying this deficiency medicinally, it was decided to manufacture a limited quantity of yeast for oral administration. The daily dose of 3 to 4 oz. proved efficacious though the media consisted of weevil-infested flour, soya bean residue and sweet potatoes.

Medical Meetings. An association consisting of all doctors, dentists and pharmacists was constituted somewhat on the lines of the British Medical Association. A president and vice-presidents were elected annually, also a secretary. Many interesting and instructive papers were read. Minutes were duly read and confirmed and complete records of all discussions were kept.

Pathology and Bacteriology. The Government Pathologist continued his work in the camp to the best of his ability. His small bed-living room was his laboratory. He was severely handicapped by the lack of materials and technical equipment. His work was almost entirely confined to the examination of blood films, sputa and stools, and doing red and white blood-cell counts. He was occasionally called upon to perform post-mortem examinations. Towards the end of internment the supply of bacteriological stains gave out. Malaria and pulmonary tuberculosis had to be diagnosed on clinical grounds alone.

Births and Deaths Registration. No time was lost after internment in opening fresh registers for the registration of births and deaths respectively. They conformed as closely as possible to the official registers kept in peace-time. Copies of the entries in the registers, in the form of birth and death certificates respectively, were made out and given to the interested parties. The death rate each year remained remarkably low; for instance, during the year 1943, there were only 18 deaths, and the majority of these were of persons over the age of 60. The infant and maternal mortality rates were so low as to be negligible.

In point of fact, only 127 deaths were recorded in Stanley Civilian Internment Camp in an average population of 2,500 over a period of forty-four months, which amounts to a death rate of rather under 14 per mille per annum. When it is recalled that there were many elderly people and young children in this population group (51 babies for example) and that the caloric value of the rations was under 1700 per head per day and very deficient in protein, fat and vitamins, this uncorrected deathrate, which is very little above that of peace-time England, reflects considerable credit on the medical, nursing, health and welfare staff in the camp, and on the efforts of welfare agencies in the town and non-interned Chinese and neutral friends who sacrificed their possessions (and sometimes their liberty and lives) in their efforts to mitigate the rigours of internment.

Vital Statistics. The population of the camp varied from a maximum of 2,863 in April 1942 to 2,400 in 1945 with an approximate average of 2,500. The main reductions were caused by the repatriation of U.S. Nationals in 1942 and Canadians in 1943. Children under sixteen numbered about 300 in 1942 and remained about that figure. Over sixteen, males exceeded females by about 50 per cent.

The annual birth and death rates per 1,000 were as follows:

Year    Births    Deaths

1942    83    113

1943    40    72 (excluding deaths by execution)

1944    52    160

1945 (8 months) 41    112 (excluding bomb victims)

The birth rate was naturally low as the majority of the married women in camp were wives of prisoners-of-war in military camps but in the circumstances it might have been lower. The deaths for 1945 do not include 14 internees who were killed by a bomb during an American air raid. The death rate was low, surprisingly low in fact, when one considers the conditions in camp and the high incidence of malnutritional diseases. Several deaths were due to causes which could be regarded as the direct result of inadequate food supplies, while many others had an associated condition of malnutrition. That there were no deaths by suicide or even murder-is remarkable in view of the serious overcrowding and the nervous strain resulting from the sharing of rooms by social and racial incompatibles.

THE INTERNATIONAL WELFARE COMMITTEE

The International Welfare Committee was brought into being in Stanley Camp to assist the Hong Kong Informal Welfare Committee which had been established in Hong Kong with the object of meeting the urgent requirements of civilian interned persons, prisoners of war and non-interned wives and families of inmates of these camps.

When the Japanese authorities rounded up the enemy civilians in Hong Kong in January 1942, for the purpose of interning them, many of the latter were without any personal possessions, clothes and household equipment of any kind. It became apparent in the Chinese hotels, which were the first stage of internment for many people, that some relief organisation would be necessary to provide the barest necessities for those who had lost everything. It was also obvious that the Japanese authorities were not prepared to make any distinctions in their treatment of infants, young children, the sick and the elderly among the interned community, and that some assistance would have to be given to those categories whose special needs were unprovided for, particularly in matters of diet.

As soon as the camp on the Stanley Peninsula was established, the representatives of the three national communities, the Dutch, American and the British, were asked to nominate representatives for a committee to deal with distress. A meeting was convened on February 4, 1942, and the International Welfare Committee thereupon came into being with Miss M. S. Watson as chairman. In July 1942, Mr. F. C. Gimson took the chair. Miss M. S. Watson became deputy chairman.

A small quantity of money and clothing had been collected and brought into the camp for immediate distribution. As soon as the camp canteen was established, arrangements were made for a very small profit to be added to the selling price of each article, this profit being handed over to the International Welfare Committee and distributed in the form of valuable foodstuffs on the advice of the medical panel. By far the largest part of the supplies received during the first year of internment were sent in by Dr. Selwyn-Clarke, who was allowed to remain in the town for relief and humanitarian work for sixteen months until his imprisonment by the Japanese authorities in May 1943.* [* Dr. Selwyn-Clarke was condemned to death, but the sentence was not carried out. He remained in solitary confinement until removed to an internment camp on the Kowloon peninsula.] By  organising the Informal Welfare Committee, and keeping in personal contact with the Stanley Camp, he was able to arrange for the supply of foodstuffs, clothing, toilet articles, drugs and hospital supplies.

After his arrest this personal contact was lost, and the International Red Cross delegate took over the problem of supplies. The purchase of essential special diets, etc., became increasingly difficult and it was necessary for the Committee's panel of doctors to limit severely the quantities available for the sick and young children. The situation was relieved to a small extent with the arrival of British Red Cross parcels and supplies in November 1942, and the Canadian parcels in September 1944. A certain proportion of valuable foods was set aside for allocation by the medical panel, and by very careful distribution, was made to last until the Colony was relieved in August 1945.

INFECTIOUS AND INSECT-BORNE DISEASES

The diseases under this heading of chief concern to the camp were dysentery, diarrhoea, typhoid, tuberculosis, typhus and malaria.

Diarrhoea and Dysentery. In the early days of the camp, conditions favoured the spread of fly-borne disease, and the prevalence of diarrhoea and dysentery at that time was not surprising, particularly as many people had been infected in the Chinese hotels where they had been confined before entering Stanley. A large number of cases of diarrhoea could be attributed to an unsuitable and unaccustomed diet and possibly to bad cooking. In the absence of laboratory facilities, it is likely that many cases diagnosed as bacillary dysentery on clinical grounds were, in fact, cases of acute enteritis. The situation was at first serious with 350 cases of dysentery in the first three months of internment, but conditions improved and the total for the year was 410. Figures for 1943, 1944 and 1945 (8 months) were 191, 172 and 67 respectively. Although the dysentery was of some severity it responded rapidly to treatment with drugs of the sulphonamide group, of which there were limited supplies in camp. Only two deaths were certified as directly due to dysentery.

Typhoid Fever. Internees were inoculated against typhoid either before arrival in camp or shortly afterwards and again in 1943 and 1944. Fourteen cases of typhoid occurred, with one death.

Tuberculosis. Thirty-three cases were registered during the first year but many of these were old cases. Spread of this disease was favoured by malnutrition and overcrowding, but this was largely balanced by a good climate and an open air life. Only a comparatively small number of new cases were diagnosed and at the time of release only fifteen cases were receiving hospital treatment. There were seven deaths. That undernourishment was largely responsible for the steady deterioration of these patients' condition was clearly demonstrated by their rapid improvement on an adequate diet following the Japanese surrender.

Diphtheria. One case diagnosed as diphtheria occurred late in 1942. The authorities promptly provided anti-toxin. The source of infection could not be traced and it is remarkable that the patient's two children escaped infection, although they were at a very susceptible age, and lived in a small room with her and no protective treatment was given.

Scrub Typhus. There were nine cases of scrub typhus with four deaths. The severity of these cases and the high mortality rate suggest the possibility of Japanese River Fever. Cases occurred in late summer or early autumn and the evidence available indicates transmission by mites. Several cases among troops on manœuvres occurred in Hong Kong in 1941, and it is possible that incidence increased as a result of the Japanese occupation.

Malaria. In the early history of Hong Kong, Stanley Peninsula was notorious for malaria which caused a high mortality rate among British troops and their families. Although the nature and source of the disease were then unknown, its seasonal incidence was noted and it is recorded that troops were frequently billeted on board ships in Hong Kong harbour so as to avoid the deadly disease which attacked them in the autumn and early winter, if they remained ashore. The old cemetery inside Stanley Camp was a grim reminder of the results of uncontrolled malaria. At the time of the Japanese occupation, the area of Stanley Camp and its immediate surroundings were practically free of malaria, but to maintain the position, constant anti-malarial measures were necessary. The dangers of neglect were immediately appreciated but requests for permission to carry out such measures near the camp, repeatedly made to the authorities, were consistently refused until late in 1942, when the position became serious. All mosquito breedinggrounds inside the camp, and there were many as a result of hostilities and neglect, were dealt with early in 1942 and were permanently eliminated or kept under regular control. But the really dangerous anopheline breeding grounds were just outside the camp boundary and near Stanley village, and mosquitoes, unlike internees, could not be forced to respect barbed wire fences. Once permission was given to deal with several of these areas, an anti-malarial gang from the health staff was formed. Thus the work was undertaken by skilled men, all of whom rapidly became familiar with the localities concerned and the control measures required. When work was particularly heavy, the anti-malarial gang was augmented by volunteers and on some occasions it was possible to have as many as thirty men employed at a time. But the regular and systematic performance of this work, which is so essential for success, was never allowed by the Japanese. In one week, three outings might be allowed or it might be only one and more frequently none at all. Similarly, the number of workers allowed might be anything from three to thirty, the limitation in this respect being usually determined by the number of guards available to accompany the party. A working party of three might be escorted by a Chinese supervisor and two Japanese and two Indian armed guards.

During 1942, there were 143 cases of malaria; in 1943, which was the worst year, 331 cases; in 1944, 151 cases and to the end of August 1945, 57 cases, a total of 682. The figures given may not be entirely accurate as lack of stains made microscopic confirmation impossible in the later periods but, taken as a whole, they present a reasonably true picture of the malaria situation. There was a shortage of quinine and relapses were common but there were no deaths. The last quarter of the year showed the highest incidence; A. minimus was the chief vector.

Other Diseases. One case each of cerebro-spinal meningitis and mumps were recorded. A mild epidemic of chickenpox with 57 cases occurred late in 1944 and early in 1945. Fortunately, there were no cases of smallpox or cholera. Internees were vaccinated against smallpox in 1942 and inoculated against cholera annually in early summer. Beriberi was very prevalent; over 200 cases occurred among Europeans before the end of 1942.

CONCLUSION

The period of internment, which lasted three years and eight months was one of difficulty, hardship and anxiety for the population of the camp, but, considering everything, the health of internees was generally more satisfactory than the most optimistic could have expected in the circumstances. Internees never lacked confidence and morale was high. There were occasional waves of depression, and the worst of these occurred shortly after the collapse of Germany, possibly due to an increased sense of frustration and isolation and impatience for an ending to the war which seemed so near and yet so far.

The presence of women and children, however unfortunate it may have been, gave the camp population the semblance of a normal community and may well have been responsible for its mental stability, as only one case of serious mental disorder occurred.

From a health point of view Stanley Camp must be regarded as extremely fortunate.

MEDICAL AND HEALTH CONDITIONS IN HONG KONG 
      JANUARY 1, 1942 TO AUGUST 31, 1945 

Below are extracts from a report by the Director of Medical Services, on Medical and Health Conditions in Hong Kong for the period January 1, 1942, to August 31, 1945.

VITAL STATISTICS

Births. It was not found possible to persuade the Japanese to appreciate the value of birth registrations for several months after the surrender. Consequently, the records available for 1942 are very incomplete. In the following table the figures for Hong Kong are for the last six months of the year, whereas those for Kowloon relate to the last three quarters of 1942. The records for 1945 cover the first eight months of that year.

Births

Year Hong Kong Kowloon Combined

1942    5,374    4,696    10,070

1943    10,244    10,488    20,732

1944    7,441    6,246    13,687

1945    1,811    1,901    3,712

In view of the incomplete nature of the records available, there would seem to be little purpose in calculating birth rates.

Assuming that registration in 1943 and 1944 was relatively complete, the marked fall in the number of births registered would more than justify the conclusion that the population fell very markedly in the occupation period.

Deaths. Death registration was also decidedly faulty during the occupation. On the other hand, records of burials were relatively more reliable. Many bodies of Europeans and Indians buried in January 1942 were of persons killed in action in the previous month. Every effort was made to collect and to give decent burial to such bodies after all possible steps had been taken to secure identification marks, which, if found, were handed later to the International Red Cross for transmission to the War Office in London through Tokio and Geneva. No records are available of the number of bodies of persons executed at Big Wave Bay, although these are believed to have numbered over a thousand.

Burials

Year Hong Kong Kowloon Combined

1942    42,770    40.665    83,435

1943    19.301    20.816    40.117

1944    13.113    11,823    24.936

1945 (Jan-Aug.) 12,593    10,505    23,098

The very marked fall in the number of burials in 1943 as compared with that of 1942 is accounted for by a corresponding reduction in the population, resulting from the compulsory evacuation tactics employed by the Japanese. Since no question arises of the return of evacuated persons until after the collapse of Japanese resistance in August 1945, the actual increase in the number of burials in 1945 indicates a sharp rise in the death rate, probably from starvation.

CAUSES OF DEATH

Malnutrition. Abundant evidence was available both in the public mortuaries and in the patients admitted to hospitals that malnutrition, indeed, actual starvation, was the principal cause of death.

Acute Infectious Diseases. Acute infectious diseases were, on the whole, relatively unimportant in the list of causes of death. Records of the actual incidence of these diseases are incomplete, but it is of interest to note that no case of death from smallpox or plague was reported.

As regards cholera, the table given below shows the cases dealt with in the two main infectious diseases hospitals in 1942 and 1943. Apart from the three suspected but not proved cases of cholera admitted to Lai Chi Kok Infectious Diseases Hospital in 1944, no patients were diagnosed as suffering from this disease in 1944 or during the first eight months of 1945.

                                                      1942                                        1943

                                                 Admissions Deaths Admissions Deaths

Kennedy Town Hospital..    275              167             87             62

Lai Chi Kok Hospital ..       439*             247*         100             61

Totals    ..    ..                          714              414            187           123

[* Figures are exclusive of the period January 1, 1942 to February 4, 1943, when Lai Chi Kok Hospital remained closed.]

In 1942, the cholera outbreak was at its worst during February and March, although it continued until October in spite of a very intensive anti-cholera inoculation campaign. About 1,700 cases were known to have occurred. In the following year, no cases were recognised until June, the peak being reached in July and the outbreak ending in September.

The case mortality of cholera patients treated in hospitals amounted to 58 per cent. in 1942 and 66 per cent. in 1943. This compares with a rate of rather under 22 per cent. in 1941 under British administration.

Of the other acute dangerous infectious diseases, typhoid, dysentery, diphtheria and meningitis were represented in that order of importance in the two infectious diseases hospitals. The experience of these diseases calls for no comment except that the case mortality was very high. For example, some 36 deaths took place in 73 typhoid admissions to the Kennedy Town Hospital and 61 deaths in 101 dysentery admissions; the reason, however, is not far to seek, for the patients were suffering from a very advanced stage of malnutrition on admission and the Japanese failed to supply either adequate food or medicines.

It would be unwise to try to draw any definite conclusions from the statistics in relation to the incidence of dangerous infectious diseases during the Japanese occupation because reliable epidemiological studies were extremely difficult throughout this period, and the population was undergoing rapid reduction. All that could be fairly claimed would be that, despite the prevailing malnutrition (with its concomitant loss of powers of resistance to infection) and the progressive lowering in the standard of cleanliness, Hong Kong enjoyed relative freedom from epidemics during 1943, 1944 and the portion of 1945 covered by this narrative.

Deficiency Diseases. Beriberi, malnutritional oedema, loss of visual acuity (amounting to actual central nerve blindness in some cases), and other manifestations of dietetic imbalance or deficiency, became increasingly common during the Japanese occupation, so that it is understandable that the incidence in the general population of Hong Kong was very high.

Tuberculosis. Associated with the considerable increase in the incidence of deficiency diseases, the tuberculosis death rate rose steeply during the occupation period. The disease appeared in many who had previously shown no outward sign of infection and, in the absence of adequate diet, the progress of the disease in individual cases was very rapid. Although the Hong Kong Anti-Tuberculosis Association could no longer function openly, it was found possible to rent two wards from the authorities of St. Paul's Hospital for cases of tuberculosis occurring among the wives or dependants of the interned in the various camps.

Venereal Disease. Several factors contributed to produce an increasingly serious situation in relation to venereal disease. The Japanese troops were not content with using common prostitutes, but forced others to their will. The invading forces lacked anti-venereal drugs and closed the civilian social hygiene centres, so that a large proportion of the community became heavily infected. Efforts to combat this state of affairs were limited to the provision of two 'red light' areas on Hong Kong Island, one for Chinese at West Point and the other for Japanese in Wanchai, and one similar area between Shamshuipo, Yaumati and Tsim Sha Tsui. Two clinics were opened in Wanchai and Tsim Sha Tsui, but treatment was limited practically entirely to Japanese, Formosans and Koreans, and even then there appeared to be an obvious shortage of reliable remedies. Already, by the spring of 1943, numerous cases came under notice of advanced granuloma venereum affecting Japanese military and civilians as well as prostitutes. Immediate steps had to be taken at the time of the Japanese collapse to reorganise social hygiene centres in Wanchai and Tsim Sha Tsui.

INVESTIGATION DIVISION

Malaria Branch. Six weeks elapsed after the surrender of Hong Kong in 1941 before the Japanese could be persuaded to allow antimalarial work to be carried out. Even then the malariologist and such of his staff as could be induced to remain in Hong Kong were seriously handicapped owing to the fact that the Japanese made it very difficult for anti-malarial oil or the necessary tools to be secured.

Up to May 1943, when the malariologist was interned in Stanley civilian internment camp at the same time as the skeleton cadres of health officers and inspectors, an appreciable amount of anti-malarial work was carried out. Priority was given to the areas likely to affect the various internment camps and hospitals. The malariologist undertook anti-malarial work in Stanley Camp after his internment and it was largely due to his efforts and those of the health staff in the camp before his internment that the civilian internees were so free from serious outbreak of malaria. After May 1943, although a small handful of the anti-malarial inspectors remained at their posts, they were able to achieve very little because of the failure of the Japanese to supply oil, etc. However, immediately the department was reorganised, the malariologist was able to employ his staff very usefully, aided by the particularly valuable co-operation of the British Naval, Military and Air Force Authorities. By August, 1945, malaria had become a serious menace and many areas on Hong Kong Island which had been rendered entirely free from anopheline breeding before the war were discovered to have become a hyperendemic area. About 70 per cent. of all patients attending the public dispensaries at Aberdeen and Shaukiwan, for example, were found to be suffering from acute malaria. But for the prompt pooling of resources of personnel and materials by the Civil and Crown Forces, it is probable that a very serious epidemic of malaria would have attacked all branches of the community in the last quarter of 1945, owing to the regrettable neglect of this problem by the Japanese.

Bacteriological Institute. The Bacteriological Institute remained open during the whole period of the Japanese occupation. In fact, the Japanese took over a teaching institution at 103, Austin Road, Kowloon, and established a second laboratory in the former maternity ward of the Kowloon Hospital. Although the institute rendered valuable assistance in the earlier months of 1942 by carrying out special tests for Tweed Bay Hospital, Stanley Civilian Internment Camp, St. Paul's and other hospitals, its activities were very largely devoted to the preparation of anti-cholera vaccine and the examinations of rectal swabs from would-be immigrants or contacts with cases of cholera and typhoid. The invading authorities refused to make any provision for the care and feeding of laboratory animals and the large majority of these had died before the retaking of Hong Kong despite the devoted sacrifices made by the staff of the institute. This state of affairs had a very depressing effect on Professor R. C. Robertson, M.C., formerly lecturer in pathology to the University of Hong Kong and medical officer in charge of the Victoria mortuary. After putting up a courageous fight, he found the situation too difficult and died in tragic circumstances in the summer of 1942.

Much of the cholera vaccine produced by the Japanese, especially in Kowloon, proved to be heavily contaminated and had to be condemned owing to its very serious effects in those inoculated with it. The antismallpox vaccine also proved to be without any potency whatever and had to be destroyed.

Chemical Laboratory. The chemical laboratory was taken over by the Japanese Military Authorities soon after the surrender in 1941, and ceased to be available for the examination of water samples, food, drugs or biochemical work. Since the Japanese Military Authorities refused any co-operation, a duplicate laboratory was fitted out in the same building and at considerable expense, although the bulk of the actual chemicals and apparatus had been seized from ‘enemy' sources in the town. In view of the high prices charged for drugs (the importation of which ceased when the Colony was captured, with the exception of a relatively small quantity of Japanese origin), the counterfeiting of drugs like atebrine, quinine, sulphanilamide and vitamins became prevalent. To give examples: eight out of ten samples of sulphapyridine needed for outbreaks of dysentery proved to be inert or heavily adulterated; ampoules of vitamin B1 prepared by a reputable local Chinese firm of manufacturing chemists during the occupation contained only 6 milligrammes of thiamin hydrochloride instead of 10 milligrammes per cubic centimetre. The testing of powder, tablets and solutions purporting to contain thiamin chloride was of particular importance in view of the tendency to beriberi induced by a high proportion of broken rice in the rations issued to the internment camps and to the rapid increase in vitamin B deficiency among the general population.

Valuable work was also carried out by the senior Chinese member of the Government chemists' staff, under a very able and pro-British research chemist appointed by the Japanese. Both the officer concerned (David Louie) and his wife, who had been in the Government Nursing Service, were arrested by the Gendarmerie and later were executed.

Owing to the prompt action taken by the research chemist referred to above to prevent looting, both chemical laboratories were handed over practically complete when the Medical Department resumed control once more in August 1945.

HOSPITALS, OUT-PATIENTS' DEPARTMENTS, ETC.

Hospitals. Almost immediately after their entry into Kowloon, the Japanese took over the Kowloon Hospital and the Central British School Hospital. St. Theresa's Hospital was also taken over by the Japanese in December 1941, but was used as a military hospital for British troops for a few months in 1942-3. In 1944, the hospital was occupied by Japanese patients, mostly suffering from venereal disease. Finally, in August 1945 it reverted to the use of British (Indian) sick pending their evacuation by hospital ship to India. The Central British School Hospital was utilised for Japanese troops until the late spring of 1945 when it was handed over to the R.A.M.C. in place of Bowen Road Military Hospital on Hong Kong Island, which remained closed until the re-occupation of Hong Kong. The Kwong Wah Hospital with 200 to 300 beds was the only general hospital available for all sections of the community on the Kowloon peninsula. The Medical Superintendent and his staff laboured under exceptional difficulties as regards food and medical supplies, and the attitude of the Japanese was generally unfavourable. By exemplary courage, the Superintendent and his Matron kept the staff of the hospital together and the hospital rendered invaluable service throughout the occupation.

On Hong Kong Island the Japanese took over the Queen Mary Hospital a month after the surrender. During hostilities, some four hundred naval and military, and rather more than twice that number of civilian casualties, were attended by the surgical unit in this hospital. Many of these patients were on extensions and fracture boards when the Japanese ordered the Director of Medical Services to evacuate the hospital. The removal was carried out (after ineffectual protests) to the R.N. Hospital, Bowen Road Military Hospital, University and St. Stephen's Relief Hospitals and to the Tung Wah Hospital.

Thereafter, the Queen Mary Hospital became an institution for Japanese wounded. It was finally evacuated by the invading forces early in September 1945. For some time before this, the hospital had been used largely as a barracks. The condition in which it was left beggared description. Much of the hospital equipment had been removed or destroyed and not one sheet was to be found. After a skeleton staff of doctors and sisters transferred from Stanley Internment Camp had worked hard for a period of four weeks, it was possible to re-open one floor (about 200 beds) of the hospital in October 1945.

The Japanese Naval Forces took over the Tung Wah Eastern Hospital from the British Military Authorities shortly after the surrender and Indian sick and wounded troops were moved to St. Albert's Military Hospital and later to Bowen Road Military Hospital. The Tung Wah Eastern Hospital was used chiefly for Japanese patients suffering from venereal diseases. After the transfer of Japanese to the Kowloon peninsula, the hospital was cleared and re-equipped.

During January, February and March 1942, the Matilda, War Memorial, University, St. Stephen's and Sai Ying Pun hospitals were evacuated. In April 1942, the Director of Medical Services obtained permission for the Sai Ying Pun Hospital to be re-opened for patients since the Tung Wah, Nethersole, St. Paul's and St. Francis hospitals proved inadequate to meet the needs of the population on the Island. Later, the Sai Ying Pun (General) and the Tsan Yuk (Maternity) hospitals were closed by the Japanese, allegedly owing to lack of funds available to the Japanese Medical Department. The Mental Hospital remained open throughout the occupation, although the rations made available by the Japanese were not enough to prevent most of the patients dying of malnutrition within a short time of admission.

The Infectious Diseases Hospital at Kennedy Town was maintained until 1944 when it was replaced by a group of private residences at Pokfulam. The whole of the hospital buildings and much of the Leper Settlement adjoining became ruinous and the former were eventually razed to the ground. Apart from the hospitals referred to in the foregoing paragraphs, small camp hospitals were established in the Shamshuipo, Argyle and Ma Tau Chung Military Internment Camps, and in Stanley Civilian Internment Camp (Tweed Bay Hospital).

Out-patients' Departments. Out-patient departments continued to function on a much reduced basis at St. Paul's Hospital until the staff quarters and other premises suffered serious damage from Allied air bombardment in January 1945, and at the Nethersole, Tung Wah, Kwong Wah and, for limited periods, the Sai Ying Pun Hospitals. Outpatient activities at Queens Road, and in the out-patients' department at the Queen Mary and Kowloon Hospitals were restarted in September 1945, before the hospitals were actually ready to receive in-patients.

Public Dispensaries. The Japanese adopted the attitude that public dispensaries, like civilian hospitals, were unlikely to contribute to the Japanese war effort and so were unworthy of assistance. As a result, many of the public dispensaries closed down. The Kowloon City Dispensary, one of the best of its kind, was demolished during the widening of an airfield and the Hung Hom Dispensary was damaged during the successful bombing of Kowloon Docks by Allied aircraft. Chinese doctors were permitted to carry on private practice and were occasionally (and at irregular intervals) given a few medical supplies by the Japanese.

Welfare Centres. Although the staffs of the welfare centres were kept together in the hope that the Japanese would permit them to be reopened, all such requests were refused.

SCHOOL HYGIENE

All schools were closed at the commencement of hostilities in Hong Kong in order to obviate loss of life from concentrations struck by shells or bombs, and because some of the schools were needed as relief hospitals, first-aid posts, medical stores and the like. For several months after the surrender, the Japanese refused to allow schools to re-open. Later, a small number were permitted on undertaking to teach the Japanese language. Little scope existed for school medical work with the possible exception of that carried out by the Hong Kong Informal Welfare Committee in premises hired from St. Paul's Hospital and loaned in Kowloon for the children of those interned in the military and civilian camps.

PORT HEALTH WORK

A general scuttling of shipping was most effectively carried out at the beginning of the Pacific War. From this date, port health work ceased and was only carried out in a perfunctory fashion by the Japanese Forces during their occupation and then only in cases where ships were reported to be infected with cholera.

SUMMARY

The period January 1942 to August 1945 was without doubt the blackest in the whole history of Hong Kong. Although the deaths from war injuries during the actual period of hostilities in December 1941, were comparatively few (1,400 Service personnel and more than 2,000 civilians) the deaths from violence and from starvation, particularly in 1942, rose to appalling heights. During the Japanese occupation, the population fell from rather over one and a half millions to about half a million. The invading forces made it clear that they intended to bring about a reduction in the population to this figure. They achieved their object, but at what toll of pain and suffering!

The systematic starving of the bulk of the population over such an extended period-over three and a half years—may exercise a serious effect on the health of the community for many years to come, including an increase in the incidence of and deaths from tuberculosis. Hundreds of dwellings were destroyed by bomb, shell and fire during hostilities in 1941 and as the result of aerial bombings, but thousands of dwellings, and many valuable educational establishments (e.g., the University of Hong Kong, Kings and Queens Colleges, etc.) were irreparably damaged by looters whose activities could have been stayed by the Japanese.

General hygiene (including water purification plants) suffered marked deterioration during the occupation of the Colony by a race which claimed to possess a higher standard of hygiene than any other in the world. The community was deprived of most of its medical and health services, its chief hospitals being taken for Japanese troops, its maternal, child welfare and social hygiene clinics closed and vital preventive work against malaria neglected. There is, however, another side to an otherwise sorely depressing picture. The ruthless invaders have given the British an opportunity of proving to young China the sincerity of their belief in the policy not of so-called trusteeship (with its implication of superiority and patronage over an indefinite period) but of co-partnership in the reconstruction of a new and better Hong Kong.

LESSONS LEARNED

Just as in the United Kingdom so in Hong Kong, a serious miscalculation was made in the number of potential casualties from enemy air action.* [* See Emergency Medical Services, Vol. I, in this series.] The figure on which estimates were drawn up for bomb casualties was 50 per ton of bombs and it was assumed that the enemy might drop between 20 and 40 tons of bombs per day. It is not difficult to calculate that at this rate every available hospital bed in Hong Kong would be needed for bomb casualties in a few days, leaving no accommodation for persons wounded by rifle, machine gun, mortar and shell fire. In fact, such formulae were discarded during the preparation of the medical defence of the Colony, and the Medical Defence Committee worked on the basis of arranging as many beds for casualties as buildings, staff and equipment permitted.

The provision of beds proved to be quite adequate, but delay occurred at times in bearing seriously wounded to first-aid posts or mobile firstaid units and to the casualty clearing hospitals owing to lack of a sufficient pool of reliable St. John Ambulance stretcher bearers. Apart from this minor criticism, it can be said that the civil defence medical services functioned without a hitch, all branches working harmoniously and with complete disregard of safety or personal comfort.

Mention has been made of the plan evolved to encourage the dispersal of population. It was assumed that several hundred thousand Chinese would be willing to leave the overcrowded areas and install themselves in 'camps' in the hills. The idea arose from the example offered by Chungking and certain other cities in China where the population went to air raid shelters excavated in the hillsides or to tunnels and caves they themselves had dug out. The salient difference, of course, lay in the fact that the people of Chungking and such cities had a considerable time to reach shelters owing to the distance of Japanese airfields and the relatively long warning, and they would return to their normal home life (if their house escaped bombing) after the raid was over. In Hong Kong the potential airfields were within a minute or two of the city. It would have required far more provision of actual shelter and other amenities than was ever made in these dispersal camps to make them sufficiently attractive to induce the community to use them. Certain camps on precipitous hill slopes were never occupied and there were never as many as ten thousand persons in the whole of the dispersal areas which had been designed to hold between 300,000 and 400,000. In other words the Defence authorities failed adequately to appreciate the psychological make-up of the average Chinese who showed just as much reluctance to leave his daily haunts and to take to the almost bare hillsides as was the case with the average French and Belgian peasant in 1914-18 and the London cockney of 1939-45.

In brief, while the intention was excellent, and every possible step was taken to implement the plan by arranging for conducted parties to be transported by motor convoy and trams from congested districts to pre-arranged dispersal areas, the result by no means justified the time, trouble and expense devoted to this aspect of the civil defence scheme.

A serious problem arose as the result of the temporary eclipse of British influence in Hong Kong. It had always been assumed that the Forces of the Crown would be able to defend Kowloon and the Island of Hong Kong for a period of at least 130 days, by which time the United States Pacific Fleet based upon the Hawaian Islands, assisted by units of the British Fleet based in Singapore, would have arrived on the scene to lift the siege, with Generalissimo Chiang-Kai-shek engaging the Japanese Army in Southern Kwangtung. The story of Pearl Harbour and the fatal air attacks on our capital ships put an end to these hopes. It was never contemplated that the Colony would be compelled to surrender unconditionally after eighteen days' fighting, and no policy had been evolved to meet this eventuality. A few days after the Japanese landing on Hong Kong Island on December 18-19, the Defence Secretary (who bravely met his death in Stanley Prison in 1943, trying to shield others involved in alleged espionage) did issue instructions to heads of departments to destroy all secret and confidential papers, but no general principles had been laid down for the guidance of Government officers or heads of the essential services as to what policy to adopt should the enemy prevail. It might be argued that any such guidance, even if restricted to departmental heads and heads of essential services, might savour of a defeatist policy if issued before surrender.

The Governor was closely confined soon after the surrender to the Japanese and the Colonial Secretary was under close detention, unable to move more than a few blocks distance from the quarters assigned to him, before his admission to the Stanley Civilian Internment Camp. Neither was therefore in a position to be able to issue instructions of any kind. In the absence of any previous instructions or set plan to meet the peculiar circumstances of this period, it was left to departmental heads of services to carry out such work for the benefit of the community as might be permitted by the restrictions on movement, etc., laid down by the Japanese Military Commander.

The problem was relatively simple in so far as the head of the medical and health services was concerned, for wounded had to be collected, dead to be buried, water, food, fuel and light supplies to be arranged, household and human waste to be removed, and so on. He obtained covering sanction for these activities subsequently from the Colonial Secretary. But a serious situation arose later when pressure was brought to bear by British and Chinese Authorities in Free China upon members of the medical and health staffs to leave Hong Kong, or to remain at their peril with the possibility of a charge of collaboration with the Japanese being levelled against them when the Colony was recaptured by the British troops.

In order to maintain a staff in the hospitals to prevent them from being looted and destroyed (as was the fate of many educational establishments), so that they might serve the general community, the widows and orphans of volunteers, the wives and dependants of prisoners-ofwar and interned civilians, and that the health conditions in the town might not deteriorate so much as to foster epidemics of cholera, etc., nor adversely affect the various camps in which British troops and civilians were incarcerated, the Director of Medical Services adopted the line of persuading a skeleton medical and health staff to remain in Hong Kong. In these circumstances, he was enabled to assist the prisoner-of-war and civilian camps with supplies of food, drugs, vitamins, instruments, apparatus, clothes, shoes, bedding, seeds, crockery, cutlery and cooking utensils, gardening implements, etc., until arrested and imprisoned by the Japanese sixteen months later and charged with espionage.

In spite of the obviously necessary nature of this work, the Director of Medical Services did not escape charges of collaboration by the uninformed particularly in Free China. How much more serious might such charges have been in the case of those not taking part in work of a humanitarian character! It would appear, therefore, that clear directives might have been given to heads of departments and of essential services before the outbreak of hostilities with Japan, in order that they might be in a position to direct their staffs appropriately in the unhappy event of the enemy prevailing.

Finally, the hostilities and subsequent lengthy period of Japanese occupation of Hong Kong gave opportunities for the best and worst traits in the human character to be manifested. That most of the members of the medical and ancillary services in Hong Kong carried on the proud tradition of the profession under conditions of exceptional stress and more often than not ill-fed, ill-housed and ill-clothed and subjected to frequent humiliations and sometimes to ill-treatment, imprisonment, and even death, will always remain a source of justifiable pride to those who had the honour to work with and for them.