Further Regional Studies

In Chapters 7 to 11, we have examined a series of recurring themes in the geography of war and disease since 1850 through regional lenses. In this chapter, we conclude our regional–thematic survey by illustrating further prominent themes which, either because of their subject-matter or because of their geographical location, were beyond the immediate scope of the foregoing chapters. In selecting regional case studies for this chapter, we concentrate on wars which have not been examined in depth to this point (the South African War and the Cuban Insurrection) or which, on account of their magnitude and extent, merit examination beyond that afforded in previous sections (World War I and World War II). Four principal issues are addressed: (1) Africa: population reconcentration and disease (Section 12.2), illustrated with reference to civilian concentration camps in the South African War, 1899–1902; (2) Americas: peace, war, and epidemiological integration (Section 12.3), illustrated with reference to the civil settlement system of Cuba, 1888–1902; (3) Asia: prisoners of war, forced labour, and disease (Section 12.4), illustrated with reference to Allied prisoners on the line of the Burma–Thailand Railway, 1942–4; (4) Europe: civilian epidemics and the world wars (Section 12.5), illustrated with reference to the spread of a series of diseases in the civil population of Europe during, and after, the hostilities of 1914–18 and 1939–45. As before, the study sites in (1) to (4) span a broad range of epidemiological environments, from the cool temperate latitudes of northern Europe, through the tropical island and jungle environments of the Caribbean and Southeast Asia, to the warm temperate and subtropical savannah lands of the South African Veld. Diseases have been sampled to reflect this epidemiological range. The South African War (1899–1902) has been described as the last of the ‘typhoid campaigns’ (Curtin, 1998)—a closing chapter on the predominance of disease over battle as a cause of death among soldiers (Pakenham, 1979: 382). From the military perspective, typhoid was indeed the major health issue of the war, accounting for a reported 8,020 deaths in the British Army (Simpson, 1911: 57).

Tracking Epidemics

In studies of past, present, and likely future disease distributions, the ‘added value’ provided by the geographer lies in three main areas: detecting spatial concentrations of disease; isolating the processes (environmental, social, demographic, and pathogenic) which cause these disease hotspots; and in enhancing our understanding of the space–time dynamics of disease spread. This is as true of war-related epidemics as of any others. Within geography, there is a long-standing tradition of mapping disease. In this early history, the incidence maps of yellow fever produced in 1798 are often given pride of place (Robinson, 1982). These were, however, pre-dated by maps of topics as diverse as hospital capacities and the distribution of dressing-stations on a battlefield, through to maps of pestilential swamps and other hostile medical environments. But, so far as most epidemiological reports were concerned, such maps were usually incidental. The breakthrough in disease mapping occurred in the middle of the nineteenth century with the cholera map produced by Dr John Snow to accompany the second edition of his prize-winning essay On the Mode of Communication of Cholera (1855a). What set Snow’s work apart was not the cartography (dot maps, which were a well-established cartographic device, to show the geographical distribution of individual cholera deaths), but his inductive reasoning from the map. By showing what he termed the ‘topography of the outbreak’, Snow was able to draw inferences about the central source of infection. The use of mapping as an important device for suggesting hypotheses of medical interest may be traced through to the present day. For war and disease, the classic example is the Seuchen Atlas. This atlas of epidemic disease (Zeiss, 1942–5; Anderson, 1947) was conceived by the German army as an adjunct to war, enhancing its ability to mount military campaigns. The atlas was produced as separate sheets over the years 1942–5. Its distribution was confined to military institutes and to those German university institutes involved in training medical students. The scope of the atlas was not global but confined largely to those areas where the Army High Command expected to be fighting.

War and Disease: Recent Trends and Future Threats

In the foregoing chapters, we have focused on the intersection of war and infectious disease over the 140-year period from 1850. We have examined long-term trends in disease activity in civil, military, and displaced populations (Chs. 3–5), outlined some of the analytical approaches used to describe the spread of war epidemics (Ch. 6), and we have explored in a regional context recurring themes at the interface of war and infectious disease (Chs. 7–12). In this concluding chapter, we examine the epidemiological consequences of wars and war-like events in the years since 1990.We begin in Section 13.2 by reviewing the empirical evidence for the spread of diseases in association with three recent conflicts: the Gulf War (1990–1); the Bosnian Civil War (1992–5); and Afghanistan and the ‘War on Terrorism’ (2001–). In Section 13.3, we examine the role of war both as an obstacle to disease eradication and to disease-control strategies while, in Section 13.4, we focus on biological weapons as one of the foremost threats to global security in the modern world. Finally, in Section 13.5, we isolate a series of further war-related issues (militarism; economic sanctions; international peacekeeping; disease re-emergence; and post-combat syndromes) that—given the balance of probabilities—are likely to be of continuing epidemiological significance in the current century. As we enter a new millennium, there is an undercurrent of academic thought that nuclear weaponary and the end of the Cold War have rendered war obsolete; that war is, and will be, increasingly supplanted by economic competition between states and regions (see e.g. Black, 2000).Yet it is clear from Figure 13.1 that wars—of greater or lesser intensity—have continued to increase, rather than decrease, in number over the last few decades. This increase has remained largely focused in the less developed regions of the world (van der Wusten, 1985; Brogan, 1992; Arnold, 1995). By way of illustration, Figure 13.2 delimits the global pattern of conflict in the year 2000. As the map shows, levels of conflict intensity were highest in some of the poorest of the world’s regions—in Sub-Saharan Africa, Central and South Asia (Murray et al., 2002).

Pan America: Military Mobilization and Disease in the United States

In the previous chapter, we outlined a number of methods employed by geographers to study time–space patterns of disease incidence and spread. In this and the next four chapters we use these methods to explore five linked themes in the epidemiological history of war since 1850. We begin here with Theme 1, military mobilization, taking the United States as our geographical reference point. Military mobilization at the outset of wars has always been a fertile breeding ground for epidemics. The rapid concentration of large—occasionally vast—numbers of unseasoned recruits, usually under conditions of great urgency, sometimes in the absence of adequate logisitic arrangements, and often without sufficient accommodation, supplies, equipage, and medical support, entails a disease risk that has been repeated down the years. The epidemiological dangers are multiplied by the crowding together of recruits from different disease environments (including rural rather than urban settings) while, even in relatively recent conflicts, pressures to meet draft quotas have sometimes demanded the enlistment of weak, physically unfit, and sometimes disease-prone applicants. The testimony of Major Samuel D. Hubbard, surgeon to the Ninth New York Volunteer Infantry, US Army, during the Spanish–American War (1898) is illustrative: . . . I examined all the recruits for this regiment . . . Practically all the men belonged to one class . . . They were whisky-soaked, homeless wanderers, the majority of whom gave Bowery lodging houses as their places of residence . . . Certainly the regiment was composed of a class of men likely to be susceptible to disease . . . The regiment was hastily recruited, and while the greatest care was used to get the best, the best had to be selected from the worst. (Hubbard, cited in Reed et al., 1904, i. 223) . . . But the problem of mobilization and disease is not restricted to new recruits. As part of the broader pattern of heightened population mixing, regular service personnel may also be swept into the disease milieu while, occasionally, infections may escape the confines of hastily established assembly and training camps to diffuse widely in civil populations.

Asia and the Far East: Emerging and Re-emerging Diseases

In the last chapter, our consideration of camp epidemics ended with an examination of a strange and debilitating illness that, prior to World War II, was hardly known to medical science—Q fever or ‘Balkan grippe’. Historically, Q fever is one of many seemingly ‘new’ diseases that have suddenly and unexpectedly erupted into military conciousness. In Chapter 2, for example, we saw how maladies such as the mysterious English sweating sickness, along with venereal syphilis, typhus fever, and yellow fever, appeared—ostensibly for the first time—in association with wars of the fifteenth, sixteenth, and seventeenth centuries. More recently, trench fever (World War I, 1914–18), scrub typhus (World War II, 1939–45) and Korean haemorrhagic fever (Korean War, 1950–3) provide twentieth-century examples of the emergence phenomenon (Macpherson et al., 1922–3; Philip, 1948; Gajdusek, 1956). At the same time, wars have also served to fuel the epidemic re-emergence of many classical diseases, of which human plague (Vietnam War, 1964–73), visceral leishmaniasis (Sudanese Civil War, 1956–), and diphtheria (Tajikistan Civil War, 1992–) are recent instances (Velimirovic, 1972; Seaman et al., 1996; Keshavjee and Becerra, 2000). In the present chapter, we develop the theme of war and disease emergence and re-emergence, taking selected conflicts and diseases in the Asian and Far Eastern theatres to provide examples. We begin in Sect. 9.2 by locating war within the broader conceptual framework of emerging and re-emerging diseases. Subsequent sections examine the wartime emergence of three zoonoses which, on their novel appearance in deployed western troops, prompted a series of landmark epidemiological investigations into the diseases concerned: scrub typhus among Allied forces in Burma–India during World War II (Sect. 9.3) and Japanese encephalitis and Korean haemorrhagic fever in the UN Command during the Korean War (Sect. 9.4). We then turn to the wartime re-emergence of classical diseases, illustrating the theme with reference to US troops (malaria) and Vietnamese civilians (human plague) during the Vietnam War (Sect. 9.5). The chapter is concluded in Section 9.6.

Wars and War Epidemics

Disease is a head of the Hydra, War. In his classic book, The Epidemics of the Middle Ages, J. F. C. Hecker (1859) paints an apocalyptic picture of the war–disease association. For Hecker, infectious diseases, the ‘unfettered powers of nature . . . inscrutable in their dominion, destructive in their effects, stay the course of events, baffle the grandest plans, paralyse the boldest flights of the mind, and when victory seemed within their grasp, have often annihilated embattled hosts with the flaming sword of the angel of death’ (Hecker, 1859: 212). The theme is developed by August Hirsch who, in the second edition of his Handbook of Geographical and Historical Pathology (1883), was repeatedly moved to comment on the manner in which wars fuelled the spread of infectious diseases. Writing of Asiatic cholera in the Baltic provinces and Poland in 1830–1, Hirsch concluded that the ‘military operations of the Russo-Polish war contributed materially to its diffusion’ (i. 398). Similarly, Hirsch traced one of the last ‘considerable’ outbreaks of bubonic plague in nineteenth-century Europe to ‘1828–29, when the Russian and Turkish forces came into collision in Wallachia’ (i. 503–4), while the waves of typhus fever that rolled around early-modern Europe were attributed to ‘the turmoil of great wars, which . . . shook the whole framework of European society to its foundations’ (i. 549). In much earlier times, Book I of Homer’s epic poem the Iliad—which may well be based on historical fact—tells of a mysterious epidemic that smote the camp of the Greek Army outside Troy around 1200 BC. According to Homer, the fate of King Agamemnon’s legions was sealed thus: . . . Say then, what God the fatal strife provoked? Jove’s and Latona’s son; he filled with wrath Against the King, with deadly pestilence The camp afflicted,—and the people died,— For Chryses’ sake . . . . . . Elsewhere, the celebrated works of ancient Greek historians—Herodotus (?484–?425 BC) on the later Assyrian Wars, Thucydides (?460–?395 BC) on the Great Peloponnesian War and Diodorus Siculus ( fl. first century BC) on the Carthaginian Wars—all attest to the antiquity of the war–disease association. Of ancient Rome, Bruce-Chwatt notes that ‘Foreign invaders . . . found that the deadly fevers of the Compagna Romana protected the Eternal City better than any man-made weapons’ (cited in Beadle and Hoffman, 1993: 320).

Oceania:War Epidemics in South Pacific Islands

So far, the geographical foci of our regional–thematic examination of the linkages between war and disease have been the great continental land masses of the Americas, Europe, Asia, and Africa. We now turn our attention to a different stage for the geographical spread of war epidemics—oceanic islands. As well as the particular interest which attaches to islands as natural laboratories for the study of epidemiological processes (Cliff et al., 1981, 2000), island epidemics also hold a special place in war history. For example, we saw in Chapter 2 how the islands of the Caribbean became staging posts for the spread of wave upon wave of Old World ‘eruptive fevers’ (especially measles, plague, smallpox, and typhus) brought by the Spanish conquistadores to the Americas during the sixteenth century. Much later, the mysterious fever that broke out on the island of Walcheren in 1809 ranks as one of the greatest medical disasters to have befallen the British Army. In this chapter, we examine the theme of island epidemics with special reference to the military engagements of Australia, New Zealand, and the neighbouring islands of the South Pacific since 1850. Figure 11.1 serves as a location map for the discussion, while sample conflicts—exclusive of tribal feuds, skirmishes, and other minor events for which little or no documentary evidence exists—are listed in Table 11.1. Our analysis begins in Section 11.2. There we provide a brief review of the initial introduction and spread of some of the Old World diseases which occurred in association with South Pacific colonization and conflicts during the last half of the nineteenth century. In Sections 11.3 and 11.4, we move on to the twentieth century. In the Great War, Australia and New Zealand made a relatively larger contribution to military manpower than any other allied country. At the end of the conflict, the return of many tens of thousands of antipodean troops from the battlefields of Europe fuelled the extension of the 1918–19 ‘Spanish’ influenza pandemic into the South Pacific region (Cumpston, 1919). In Section 11.3, we examine the spread of influenza on board returning troopships and subsequently within Australia, New Zealand, and the neighbouring islands of the region.

Africa: Soldiers, Sexually Transmitted Diseases, and War

As we observed in Chapter 4, from time immemorial, sexually transmitted diseases (STDs) have been a scourge of military personnel and of the wars in which they were deployed. So, in her excellent historical review, Venereal Diseases in the Major Armies and Navies of the World, Josephine Hinrichsen (1944, 1945a, 1945b) traces the military problem of female prostitution—and, by implication, the associated spread of STDs—to the great army camps of classical Greece and Rome. In more recent times, the Italian War of Charles VIII (1494–5) provides one of the most dramatic instances of the intersection of armies, STDs, and war—the pan-European dissemination of venereal syphilis by the disbanded mercenary troops of France, Germany, and Italy (see Sect. 2.3.3). Thereafter, epidemics of syphilis and other venereal diseases followed wave-like on wars in Europe and elsewhere (Prinzing, 1916: 18). In Sweden, the syphilis epidemics of 1762 and 1792 were sparked by military returnees from the Seven Years’ (1756–63) and the Russo-Swedish (1788–90) Wars. In the nineteenth century, the Russo-Turkish Wars (1806–12, 1828–9) contributed materially to the spread of the disease in the Balkans (Hinrichsen, 1944). Elsewhere, in World War II (1939–45), the high-level transmission of gonorrhoea, chancroid, and syphilis among Allied personnel in the Burma–India, Africa–Middle East, and Mediterranean Theatres provides a twentieth-century example of the war-related problem of STDs (Sternberg et al., 1960). As Berg (1984: 90) notes, the historical concern of the military wth STDs was eminently a practical one. Prior to the era of antibiotics (penicillin was first used in the military treatment of syphilis and gonorrhoea in 1943), STDs were associated with extended periods of hospital treatment with correspondingly high economic and medical manpower costs to the armed forces. Some impression of the dimensions of the STD problem for one army (US Army) and war (World War I) can be gained from Table 10.1. During a 21-month period of military engagement, April 1917–December 1918, three STDs (chancroid, gonorrhoea, and syphilis) accounted for over 6.8 million days of lost service in the US Army.

Europe: Camp Epidemics

One recurring theme of the previous chapter was the role of military assembly and training camps as sites for explosive outbreaks of infectious diseases during periods of wartime mobilization. Historically, however, the general problem of camp epidemics has extended beyond the initial massing of unseasoned recruits in barrack and tent camps on home soil to include the field camps, siege camps, and bivouacs of deployed armies, as well as temporary and makeshift military settlements such as prisoner of war (POW) and concentration camps. In this chapter, we examine the broader issue of camp epidemics (Theme 2 in Table III.A) with reference to sample wars in the European theatre. The social, physical, and environmental conditions that fuelled the spread of diseases in the military encampments of past wars, and which remain a potent threat in modern conflicts, are well known (Prinzing, 1916; Major, 1940; Bayne-Jones, 1968; Cantlie, 1974; Shepherd, 1991). As illustrated in Chapter 7 by the mobilization camps of the United States, military encampments of all kinds—often hastily erected and densely populated—provide a setting for intense population mixing, thereby increasing the likelihood of the transmission of infectious diseases. The epidemiological hazard is exacerbated by the injudicious selection of campsites and by the deleterious consequences of overcrowding, inadequate or non-existent drainage and sewerage systems, poor or contaminated water supplies, and by the failure to institute or to maintain rigid sanitary precautions. As for the occupants, they may be drawn from a variety of epidemiological backgrounds, they may possess different patterns of disease immunity, and their resistance to infection may be compromised by fatigue, trauma, mental and physical stress, exposure to the elements, and poor or inadequate diets. That there is often a high degree of spatial mobility between the constituent units of a camp system adds a powerful geographical component to the spread of camp epidemics. Against this background, the case studies presented in this chapter have been selected to illustrate different aspects of the geographical spread of camp epidemics.

Mortality and Morbidity in Modern Wars, III: Displaced Populations

As a threat to life and liberty, wars and political upheavals have served to precipitate the flight of populations since biblical times (Marrus, 1985; Zolberg et al., 1989; UNHCR, 2000). Historically, the basic mechanism of flight, sometimes across national boundaries, and with no surety of safety or asylum in the new land, has operated as a device for the carriage of infectious diseases from one geographical location to another. In Chapter 2, for example, we encountered numerous instances of wartime fugitives who spread bubonic plague, typhus fever, and other war pestilences to their local ‘host’ populations. At the same time, however, fleeing populations may be forced to enter epidemiological environments to which they are unacclimatized, with the attendant risk of exposure to diseases for which they have little or no acquired immunity. The intensive mixing of the populations in refugee camps or other makeshift forms of shelter, often with poor levels of hygiene, with little or no medical provision, and under conditions of stress and malnutrition, further add to the disease risks of displacement (Prothero, 1994; Kalipeni and Oppong, 1998; UNHCR, 2000). The epidemiological dimensions of wartime population displacement—variously manifesting in the movements of refugees, evacuees, and other persons who abandon their homes as a consequence of conflict—form the theme of the present chapter. We begin, in Section 5.2, with a brief overview of international developments in the recognition and management of war-displaced populations, the legal meaning which attaches to such classifications as refugee and internally displaced person (IDP), and theoretical frameworks that have been developed for the study of such groups. International refugees, along with certain other categories of displaced person, have fallen within the mandate of the Office of the United Nations High Commissioner for Refugees (UNHCR) since its inception in January 1951. Drawing on this source, Section 5.3 examines global trends in refugees and other UNHCR-recognized populations of concern during the latter half of the twentieth century, while Section 5.4 reviews epidemiological aspects of the associated population movements. The remainder of the chapter follows a regional-thematic structure.