Impact of infectious diseases on war

Infect Dis Clin N Am 18 (2004) 341–368

Impact of infectious diseases on war Matthew R. Smallman-Raynor, PhDa,*, Andrew D. Cliff, DScb a

School of Geography, University of Nottingham, University Park, Nottingham, NG7 2RD, UK b Department of Geography, University of Cambridge, Downing Place, Cambridge, CB2 3EN, UK

In his classic book The Epidemics of the Middle Ages, Hecker [1] paints an apocalyptic picture of the association between war and infectious diseases. These ‘‘unfettered powers of nature’’ are ‘‘inscrutable in their dominion; destructive in their effects; stay the course of events; baffle the grandest plans; paralyze 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’’ [1]. The theme is developed by Hirsch [2] who, in the second edition of his Handbook of Geographical and Historical Pathology, 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 to 1831, Hirsch [2] concluded that the ‘‘military operations of the Russo-Polish war contributed materially to its diffusion.’’ Similarly, Hirsch [2] 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,’’ whereas 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.’’ In much earlier times, 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

The work was supported by Leverhulme Trust Grant No. F/753/D and by the award of a Philip Leverhulme Prize to one of the authors (MRS-R). The financial support of the Leverhulme Trust is gratefully acknowledged. * Corresponding author. E-mail address: [email protected] (M.R. Smallman-Raynor). 0891-5520/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.idc.2004.01.009

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Siculus [fl. first century BC] on the Carthaginian Wars) all attest to the antiquity of the link between war and disease [3]. Down the ages, epidemics of infectious diseases have decimated the fighting strength of armies, caused the suspension and cancellation of military operations, and wrought havoc on the civil populations of belligerent and nonbelligerent states (Table 1). A broad range of social, physical, psychologic, and environmental factors contribute to the spread of war epidemics [3–5]. War heightens the mixing of both military and civil populations, thereby increasing the likelihood of the transmission of infectious diseases. The combatants are commonly drawn from a variety of epidemiologic backgrounds, they may be assembled and deployed in disease environments to which they are not acclimatized, and they may carry infections for which the inhabitants of war zones have little or no acquired immunity. For all involved, resistance to infection can be compromised by mental and physical stress, trauma, nutritional deprivation, and the deleterious consequences of rapid exposure to multiple disease agents. Unsanitary conditions, enforced population concentration and overcrowding, the destruction of public health infrastructure, the interruption or cessation of disease control programs, and the collapse of the conventional rules of social behavior further compound the epidemiologic unhealthiness of war. Against this background, this article illuminates aspects of the historical intersection of war and disease. Given the breadth of the war canvas (Kohn’s [8] Dictionary of Wars, for example, details some 2000 wars, revolutions, rebellions, pacifications, and other warlike events over the last four millennia) the approach is to sample from the available evidence. The article is divided into three main sections. First is a brief review of the nature and quality of the data sources available for the study of infectious diseases in wartime. Second is to identify those infectious diseases which, over the centuries, have frequently spread in conjunction with war. An overview of the consequent demographic losses in military and civil populations is provided. Finally, the article moves from the general to the particular. Drawing on the detailed epidemiologic records of one military force (United States Army), the spread of infectious diseases with military mobilization in three major conflicts of the nineteenth and early twentieth centuries is examined: the American Civil War (1861–1865); the Spanish-American War (1898); and the First World War (1914–1918). To underscore the enduring nature of the war-disease association, the article concludes with a brief review of disease activity in high- and low-intensity conflicts during the late twentieth and early twenty-first centuries. Data sources and issues Before the eighteenth century, only fragmentary documentary evidence is available from which military losses in wars can be assessed [3,7]. From about the time of the War of Spanish Succession (1701–1713), however, an

Table 1 Sample epidemic events associated with war, 500

BC

Year

Conflict

Sample afflicted group or location

Disease

Estimated mortality

Persian invasion of Greece (480–479 BC) Great Peloponnesian War (431–404 BC) Second Punic War (218–202 Social War (91–88 BC)

Persian Army in Greece

Plague or dysentery (?)

>300,000 (?)

Athens

Unknown

>100,000 (?)

Russian Army at Siege of Syracuse Army of Octavius in Rome

Influenza (?) ?

? 17,000

Roman colonial wars, Africa Roman-Gothic War (249–270) Hun raids on Roman Empire (c.375–454) Elephant War (569 or 571) Muslim conquest of Persia (634–651)

Roman Army in Utica Africa, Europe, and Near East Hun Army (advance on Constantinople) Abyssinian Army at Siege of Mecca Syrian Army in Amw
as

? Measles or smallpox (?) ?

up to 30,000 up to 5000/d (Rome) ? (epidemic forced retreat)

Bubonic plague with smallpox (?) ?

60,000 (?) 25,000 (in 639)

1010 or 1011 1148

Later Viking raids in England (899–1016) Second Crusade (1147–1149)

Danes in Kent

Dolor viscerum (dysentery) (?)

?

Fifth Crusade (1217–1221) Eighth Crusade (1270) Siege of Kaffa Wars of the Roses (1455–1485) War of Granada (1482–1492) Italian Wars (1494–1495)

Typhoid, dysentery, or bubonic plague (?) Severe scurvy Dysentery Bubonic plague Sweating sickness Typhus fever Syphilis

?

1218 1270 1346 1485 1489–1490 1495 ff.

Army of Louis VII and civilians at Adalia Crusader Army at Damietta Crusader Army at Carthage Tartar Army at Kaffa England Spanish Army in Granada Continental Europe

? ? ? ? ? ?

1518–1520

Wars of Spanish Conquest (1519–1546) 5th War Against Charles V (1552–1559)

Mexico

Smallpox

2–15 million

Army of Charles V at Metz

Typhus fever and dysentery

10,000

430–425

BC

BC

212 BC 88 BC 125 251–266 425

AD

569 or 571 638–639

1552

BC)

AD

2000

(15%–20% of army) (‘‘many deaths’’) (‘‘infinite’ numbers’’) (‘‘most’’ students at Oxford) (up to 17,000 before 1490)

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circa 480

to

344

Table 1 (continued) Conflict

Sample afflicted group or location

Disease

Estimated mortality

1596–1602

Anglo-Spanish War (1587–1604) Thirty Years’ War (1618–1648) English Civil War (1640–1649) Cromwell’s Irish Campaign (1649–1650) Irish War (1689–1691)

Spain

Bubonic plague

0.5–0.6 million

Protestant population, Dresden Parliamentary Army at Reading Garrison at Kilkenny

Bubonic plague Typhus fever Bubonic plague

7714 ? (‘‘great mortality’’) 900 (cavalry and foot soldiers)

1632–1633 1643 1650 1689

Protestant Army (near Dundalk)

Typhus fever

6000

Second Northern War (1700–1721) Austro-Turkish War (1716–1718) Russo-Austrian War (1735–1739) Seven Years’ War (1756–1763) Russo-Turkish War (1768–1772) Comuneros’ uprising in New Granada (1781) War of the First Coalition (1792–1797)

Danzig Austrian troops at Siege of Belgrade Russian troops British forces at Siege of Habana Moscow Socorro

Bubonic plague Typhus and dysentery Bubonic plague Yellow fever Bubonic plague Smallpox

32,599 4000 30,000 8000 52,300 6000

Metz

Typhus fever

4870

1801–1803 1808

Haitian-French War (1801–1803) Peninsular War (1808–1814)

Yellow fever Typhus fever

22,000 72,000

1809

Walcheren expedition (1809–1810)

French Army in Haiti Besieged military and civilian population, Saragossa British Army on Walcheren Island

3960

1812–1813

Napoleon’s Russian expedition (1812–1813) Polish insurrection (1830–1831) Crimean War (1853–1856) Austro-Prussian War (1866) Franco-Prussian War (1870–1871) Spanish-American War (1898)

French soldiers and civilians at Vilna

Malaria, typhus, typhoid, and dysentery Typhus fever

55,000

Warsaw Province British and French Armies, Black Sea Austrian Crownlands France and Germany US Volunteer Army, USA

Cholera Cholera Cholera Smallpox Typhoid fever

13,103 circa 18,000 165,000 circa 300,000 circa 1500

1709 1717 1738 1761–1762 1771–1772 1781 1792–1795

1831 1854–1856 1866 1870–1871 1898

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Year

1902–1904

1917–1922 1918–1919 1942–1945

Russian Revolution and Civil War (1917–1921) World War I (1914–1918) World War II (1939–1945)

1942–1943

World War II (1939–1942)

1965–1975 1971 1984–1994 1995–1997 1999 2002

Vietnam War (1964–1973) Pakistan Civil War (1971) Sudanese Civil War (1956–) Burundian Civil War (1993–) Angolan Civil War (1975–) Operation Enduring Freedom

Data from Refs. [4,17,18].

Philippines

Cholera

circa 200,000

Serbian Soldiers and Austrian prisoners of war, Serbia Russia

Typhus and relapsing fevers

30,000

Typhus fever

2.5–3 million

Global pandemic Allied forces in Pacific and Southeast Asia Servicemen and civilians, Malta

Influenza Scrub typhus

20–40 million 636

Poliomyelitis

37

Vietnam East Pakistan refugees in India Upper Nile, Southern Sudan Internally displaced persons Luanda and other provinces British forces at Bagram, Afghanistan

Human plague Cholera Visceral leishmaniasis Louse-borne typhus Poliomyelitis Norwalk-like virus disease

838 (1966–1970) circa 10,000 95,000–112,000 ? circa 80 0 (29 cases)

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1914–1915

Philippine-American War (1899–1902) World War I (1914–1918)

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increasing variety of military dispatches, memoranda, records, and accounts become available on which to base estimates of losses sustained in battles and, in some instances, entire campaigns [7–9]. By the 1820s, principal causes of morbidity and mortality were being routinely recorded for the United States Army, with general returns for United States forces in the Mexican War (1846–1848) appearing in the consolidated Statistical Report for 1839 to 1855 [10]. In Europe, the Crimean War (1853–1856) is widely acknowledged as the first major conflict for which official summary data on cause-specific military losses are available for the entire period of hostilities [7]. Thereafter, the multivolume medical and surgical histories of conflicts, such as the American Civil War (1861–1865) [11], World War I (1914–1918) [12,13], and World War II (1939–1945) [14,15], among many other official and semiofficial publications, provide further windows of opportunity for the study of infectious diseases in military populations. But such sources take one only so far and for detailed records of wartime losses in civil populations, one is largely reliant on the development of civil systems of public health and disease surveillance from the mid-to-late nineteenth century. Data quality For both military and civil populations, the circumstances of war are little conducive to the effective operation of disease surveillance. The destruction of health infrastructure, the redeployment, transfer, or elimination of health resources and personnel, the collapse of communications systems, the lack of diagnostic capabilities, censorship, propaganda, and the intentional falsification of information all conspire to limit the availability and reliability of disease statistics in past conflicts. Under such circumstances, all results presented in this article are subject to the caveat of data quality and focus primarily on the period from 1850.

War pestilences: the epidemiologic toll of war In his historical survey of war epidemics, the German physician and medical statistician Prinzing [4] observed in 1916 how apparently all infectious diseases had the potential to ‘‘spread in consequence of war and develop into epidemics of varying extent.’’ Prinzing [4] reserved the special term ‘‘war pestilences’’ for six diseases (cholera, dysentery, plague, smallpox, typhoid, and typhus fevers) that ‘‘in the course of centuries have usually followed at the heels of belligerent armies.’’ A further war pestilence identified by Prinzing [4] (scurvy) has been excluded from the present discussion on account of its noninfectious etiology. To these war pestilences, Prinzing [4] added a series of other diseases (influenza, malaria, measles, relapsing fever, and yellow fever) that were deemed to have played ‘‘an important role’’ in past wars. Historical examples of war epidemics

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associated with the classical diseases identified by Prinzing [4] along with a sample of other infectious diseases that have periodically flared in association with military conflicts, appear in Table 1. Military populations That infectious diseases exacted a heavy toll in many past wars (frequently outstripping battle and battle wounds as the leading cause of death in military populations) is evidenced in Table 2. For a series of major conflicts from the late eighteenth century, the table provides estimates of the number of deaths in sample combatant forces caused by battle and battle wounds, and disease. The ratio of deaths from disease to battle is also given along with the principal diseases that afflicted the forces. Table 2 shows that, before the twentieth century, deaths from diseases regularly exceeded those arising from the bombs and bullets of the enemy. During the French Revolutionary and Napoleonic Wars (1792–1815), the British Army suffered seven or more disease-related deaths for every one battle-related death. Similar statistics are recorded for American forces in the Mexican War (1846–1848) and the Spanish-American War (1898), whereas across the set of nineteenth century conflicts in Table 2, the aggregate ratio of deaths from disease to battle is approximately 2.5:1. The early years of the twentieth century marked a watershed in the epidemiologic history of war. Caused in part by developments in the firepower of belligerent states and in part by improvements in military hygiene and disease control, the Russo-Japanese War (1904–1905) and World War I (1914–1918) signaled the start of an enduring temporal trend in which more soldiers died in battle than in military lazarets. By the onset of World War II, the specific agents of many bacterial diseases, and some viral diseases, had been identified. Epidemiologic understanding of the most important infectious conditions had accrued, whereas advances in vaccination and chemotherapy contributed significantly to disease prevention, treatment, and control in the major armies and navies of the world [16]. As testimony to these developments, Fig. 1 plots the ratio of deaths caused by disease and battle in the United States armed forces for sample conflicts, 1846 to 1991. As the graph indicates, by the wars of the mid-twentieth century (World War II and the Vietnam War), battle deaths exceeded disease deaths by a factor of five. Civil populations Writing in the midst of World War I, John Bates Clark of the Carnegie Endowment for International Peace was drawn to comment on the severe epidemiologic consequences of war for civil populations. ‘‘An examination of the facts,’’ Clark maintained, ‘‘will indicate that until comparatively recent times, the most serious human cost of war has been not losses in the

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Table 2 Distribution of estimated deaths by cause in military forces, sample wars (1792–1945) Number of deaths (000s) Force

French Revolution and Napoleonic Wars (1792–1815) Walcheren Expedition (1809–1810) Mexican War (1846–1848) Crimean War (1853–1856)

British Army

Battle and wounds (a) Disease (b) 25.6

British Army 0.1 US Army 1.5 Allied Army 24.9 Russian Army 35.7 Italian War (1859) French Army 5.5 American Civil War (1861–1865) Union Army 91–110 Confederate Army 72.3 Danish-Prussian War (1864) Prussian Army 0.7 Danish Army 1.4 Austro-Prussian War (1866) Prussian Army 4.5 Austrian Army 8.9 Franco-Prussian War (1870–1871) German Armies 26.6 Russo-Turkish War (1877–1878) Russian Army 34.7 Cuban and Spanish-American Wars (1895–1898) Cuban forces 5.2 Spanish forces 9.4 US forces 0.7 South African (Great Boer) War (1899–1902) British Army 7.5 Russo-Japanese War (1904–1905) Russian forces 34–52.6 Japanese forces 58.9 World War I (1914–1918) All forces 8000 Revolution and Civil War, Russia (1917–1921) World War II (1939–1945) Data from Refs. [4,17,49].

Red Army All forces

308.1 16,933

193.9 4 11 95.1 37.1 2 184–224.6 120 0.3 0.7 6.4 19 14.6 81.1 3.4 53.4 5.5 14.4 9.3–18.8 27.2 3115

Ratio (b):(a)

Major diseases

7.6:1

Typhus, dysentery, fevers

40:1 7.3:1 3.8:1 1:1 0.4:1 1.7–2.5:1 1.7:1 0.4:1 0.5:1 1.4:1 2.1:1 0.5:1 2.3:1 0.7:1 5.7:1 7.9:1 1.9:1 0.2–0.4:1 0.5:1 0.4:1

Malaria, typhoid, typhus, dysentery Dysentery Cholera, typhus, fevers, scurvy Typhoid, dysentery, malaria Typhoid, malaria, typhus, dysentery, measles, smallpox Typhoid Cholera, typhoid fever Smallpox, dysentery, typhoid, typhus Typhus, typhoid Smallpox, yellow fever, typhoid

Typhoid Typhoid, smallpox, diphtheria, cholera

283.1

0.9:1

Various diseases, including typhus, typhoid, cholera, dysentery, malaria, influenza Typhus

2363 (?)

0.1:1

Various diseases

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War

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Ratio of deaths (disease:battle deaths)

100:1

10:1

SpanishAmerican War (1898)

Mexican War (1846-8)

American Civil War (1861-5)

1:1

0.1:1

World War I (1914-18) Vietnam War (1964-73)

Disease deaths in excess Disease deaths in deficit

World War II (1939-45)

0.01:1

Gulf War (1991)

0.001:1 1

2

3 4 5 6 Temporal sequence of wars

7

8

9

Fig. 1. Temporal trend in the ratio of deaths by cause (disease:battle) in the United States armed forces for sample wars, 1846 to 1991. Note that the vertical axis is drawn on a logarithmic scale. (Data from references [37,48–50]).

field, nor even the losses from disease in the armies, but the losses from epidemics disseminated among the civil populations’’ [4]. Some impression of the magnitude of the losses can be gained from Table 1. The epidemic of cholera that spread with the Austro-Prussian War (1866) is estimated to have claimed 165,000 lives in the Austrian Crownlands [4]. A few years later, some 300,000 French and German citizens died of smallpox during the Franco-Prussian War (1870–1871) and its aftermath [4]. In the twentieth century, the great epidemic of typhus fever that spread in association with the Russian Revolutions and Civil War (1917–1921) resulted in upwards of 2.5 million deaths [17]. Most destructive of all, the 1918 to 1919 pandemic of Spanish influenza (fuelled by military demobilization in the closing stages and immediate aftermath of World War I) was associated with a global death toll variously estimated as between 20 and 40 million [18]. In the beleaguered lands of occupied Europe, Daniels [19] observes how physical destruction and nutritional deprivation underpinned the emergence of tuberculosis as the ‘‘the major health disaster of the Second World War.’’

War, mobilization, and disease in the continental United States: three case studies It is possible to identify a series of repeating themes that, over the centuries, have linked war and infectious disease [3]. These include: 1. Military mobilization, which at the outset of wars has often fuelled the spread of epidemics among unseasoned recruits [20]

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2. Camp epidemics, historically associated with the unhealthy conditions of army field camps, prisoner of war camps, and other forms of temporary and makeshift military settlement system [21] 3. Emerging and re-emerging diseases, reflecting the long-established role of war as a facilitating factor in the appearance of apparently new infections, and the re-appearance of classical infections, in both military and civil populations [22] 4. Sexually transmitted diseases, highlighting one of the great scourges of past military forces and the wars in which they were deployed [23] 5. Population displacement, marking the epidemiologic importance that attaches to the voluntary and forced movements of civil populations (including formal strategies of population reconcentration and evacuation) in consequence of war [24] The present section draws on the detailed epidemiologic records of the United States Army to examine one of these themes (military mobilization) in relation to the wartime spread of infectious diseases in the continental United States. Three wars of the nineteenth and twentieth centuries have been selected for detailed examination, with each case study illustrating the use of a major contemporary source: 1. Case study 1: American Civil War (1861–1865), drawing on The Medical and Surgical History of the War of the Rebellion (1861–65) [11] 2. Case study 2: Spanish-American War (1898), drawing on the Report on the Origin and Spread of Typhoid Fever in US Military Camps During the Spanish War of 1898 [25] 3. Case study 3: World War I (1914–1918), drawing on the SurgeonGeneral’s contribution to the US War Department’s Annual Reports 1919 [26] Military mobilization and disease: nature of the problem Among the factors that have contributed to the wartime spread of infectious diseases, military mobilization has been an especially fertile breeding ground for epidemics [20]. The rapid concentration of large (occasionally vast) numbers of unseasoned recruits, usually under conditions of great urgency, sometimes in the absence of adequate logistic arrangements, and often without sufficient accommodation, supplies, equipage, and medical support, entails a disease risk that has been repeated down the years. The epidemiologic dangers are multiplied by the crowding together of recruits from different disease environments, including rural and urban settings. Even in relatively recent conflicts, pressures to meet draft quotas have sometimes demanded the enlistment of weak, physically unfit, and disease-prone applicants. As part of the broader pattern of heightened population mixing, regular service personnel may also be swept into the disease milieu, while infections may escape the confines of hastily

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established assembly and training camps to diffuse widely in civil populations. Case study 1: recruiting fields in the American Civil War (1861–1865) In terms of human casualties, the Civil War (1861–1865) was one of the costliest of American conflicts. Although the exact mortality experienced by the opposing Union and Confederate forces will never be known, the data that are available show that the disease history of the war repeats a central theme of Table 2: greater loss of life from disease than from battle and battle wounds [27]. Although an estimated 200,000 Union and Confederate troops died from injuries sustained on the battlefield, upward of 300,000 died of disease. The geographic distribution of deaths in the American armies is plotted by the state of origin of troops in Fig. 2. As the map shows, losses from disease commonly exceeded 50% of state mortality totals. Recruitment and disease During the war, the link between recruitment and disease became as familiar to soldiers as did the excess of disease over battle as the principal cause of morbidity and mortality [28]. Raw recruits from the countryside comprised classic virgin soil populations exposed to new disease

VT

OR

WA

WI

MN

D

MA MI RI

IA IL

OH

IN

CO

VA

MO

KS

CA

CT NJ DE MD

PA

NE

NV

KY

DC

NC TN NM TOTAL LOSSES Other causes Disease Killed in action 35,000

ME

NH

NY

WV

AR AL TX

MS

GA

LA FL

20,000 10,000 5,000 2,000

Confederate states 0

200 400 600 800

km

Fig. 2. Mortality in the United States armies, American Civil War, 1861 to 1865. Proportional circles show battle deaths and deaths from disease and other causes, 1861 to 1865. (Data from Surgeon-General’s Office. The medical and surgical history of the War of the Rebellion, (1861– 65). Washington: Government Printing Office; 1870–1888.)

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environments. The so-called ‘‘eruptive fevers’’ (smallpox, measles, scarlet fever, and erysipelas), which ordinarily were infections of childhood, were frequently not so among those coming from remote rural areas, and the rural recruits were prime material for the spread of infectious diseases [29]. During the war, the average annual mortality rate for diseases (per 1000 mean strength) among the Union troops was 53.5 (whites) and 143.4 (blacks). Although comparative data are not available for black troops, the transition from peace to war saw a tripling of the death rate from disease among white Union soldiers. For the same group, Barnes estimates the annual excess mortality caused by the war to be 44.15 per 1000 strength [11]. Temporal patterns. The front loading of sickness to the principal periods of recruitment in the early stages of the war is illustrated in Fig. 3. This shows, for the American armies, the monthly morbidity and mortality rates (per 1000 strength) for diseases in white and black troops during and immediately following the war. With the exception of the flat curve for white mortality, the other line traces decline steadily over the duration of the conflict. As the graph shows, the morbidity rate for black troops was highest immediately after their enlistment in 1863, when nearly half of the command was reported as having been taken ill during the months of July, August, and September. In subsequent years, the general health of the black troops improved so markedly that, during the last quarter of the year to June 1866, their morbidity rates were somewhat lower than those of white troops.

Fig. 3. Monthly rate of disease-associated morbidity and mortality (per 1000 strength) for white and colored troops, United States armies, 1861 to 1866. (Data from Surgeon-General’s Office. The medical and surgical history of the War of the Rebellion, (1861–65), vol. 5. Washington: Government Printing Office; 1870–1888. p. 24.)

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Measles and mobilization Of the eruptive fevers, measles was a particularly troublesome disease to the new recruits in the assembly and training camps. Woodward [28], Assistant Surgeon-General during the Civil War, begins his classic wartime account of camp measles by describing it as ‘‘. . . one of the most characteristic diseases of the present war . . . from which few of the new regiments escaped.’’ According to Woodward [28], it was the characteristically severer nature of camp measles that distinguished it from measles in civil populations: As it occurs among troops, measles pursues the same general course, and presents, in the main, the same train of symptoms [as witnessed in civil populations]. Simply it is a much severer affection, and this severity is exhibited chiefly by its assuming a more adynamic character than is usual in private life.

Woodward used the term ‘‘adynamic’’ when describing the most severe cases of measles, the so-called ‘‘black measles’’ (rubeola nigra) characteristic of outbreaks in the valley of the Mississippi and its tributaries.

20 15 10 5 July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July

0

35

C Central region

30 25 20 15 10 5 0 1861

1862

1863

1864

1865

1866

Morbidity rate (per 1,000 strength)

Colored troops White troops

25

35

B Atlantic region

30 25 20 15 10 5 0 July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July

30

Morbidity rate (per 1,000 strength)

A All regions

35

D Pacific region

30 25 20 15 10 5 0 July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July

Morbidity rate (per 1,000 strength)

35

July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July Oct. Jan. Apr. July

Morbidity rate (per 1,000 strength)

Patterns in time. Fig. 4 plots, by major geographic region, the monthly morbidity rate per 1000 strength for measles among white and colored troops

1861

1862

1863

1864

1865

1866

Fig. 4. Monthly rate of measles morbidity (per 1000 strength) in the United States armies, 1861 to 1866. (A) All regions. (B) Atlantic region. (C) Central region. (D) Pacific region. Rates are plotted for white (full line traces) and colored (broken line traces) troops. (Data from SurgeonGeneral’s Office. The medical and surgical history of the War of the Rebellion, (1861–65). Washington: Government Printing Office; 1870–1888.)

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in the American armies, 1861 to 1866. As for the aggregate pattern of diseaseassociated morbidity in Fig. 3, Fig. 4 illustrates the tendency for the highest measles rates to coincide with the initial phases of mobilization in 1861 to 1862 (white troops) and 1863 (black troops). Thereafter, disease rates declined, but with a marked resurgence in 1864. As Smart explains in his contribution to Volume V of the Medical and Surgical History of the War [11]: The diminished sick rate [from 1861–1864] must be attributed to the weeding out by death and discharge for disability of the inferior material necessarily present in all new levies. The term of service of many regiments expired during the third year of the war, when the hardy veterans composing them were in many instances replaced by raw troops who, in becoming inured to active service, swelled the sick rates during the fourth year.

Impact. Despite fragmentary data, Woodward [28] placed the number of reported measles cases during the first year of the conflict at 21,676, with 551 fatalities. At this time, the short-term impact of measles on the strength of a regiment could be dramatic: Frequently from one-third to one-half of the effective strength was attacked [by measles]. . .. The duration of the epidemic in a regiment was usually from one to two months, and the patients continued to suffer from its sequelae for a still longer period. . .. No part of the army escaped. The new levies on the Pacific slope suffered as well as the great armies of the central basin and the Atlantic coast.

Consistent with the virgin soil model, regiments of troops from rural areas were especially prone to measles, and training programs were thoroughly disrupted by the disease. For example, the Third Tennessee is reported to have had some 650 cases of measles during the first 2 months of training in a strength of 1100 men [27]. In some units, measles resulted in the suspension of drills, whereas in more extreme instances entire companies, battalions, and regiments were temporarily disbanded on account of the disease [27,30]. Measles, in conjunction with other diseases, also had a material impact on the operation of some military campaigns: on September 13, 1861, the Confederate Campaign for Western Virginia was abandoned on account of measles, dysentery and diarrhea, typhoid fever, and pneumonia [27]. Summary Soldiers in the American Civil War experienced substantially higher morbidity and mortality from disease than they had during the preceding two decades of peace, and black troops suffered disproportionately more than white troops. For all troops, there was a much greater chance of dying from disease than in the heat of battle. The excess morbidity and mortality that accompanied the transition from peace to war may be attributed to

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a mixture of factors including poor camp conditions, inadequate food and hygiene, and limited medical treatment. Equally apparent was the way in which the virgin soil populations of the new recruits suffered in particular, leading to especially high rates in the early months of the war and whenever military necessity led to the raising of more men. Case study 2: American volunteers and typhoid in the Spanish-American War (1898) Many of the factors that contribute to the risk of epidemics among newly mobilized forces reconvened on the soil of the United States during the Spanish-American War of 1898. Beginning with a first call for volunteers in late April 1898, and swelled by a second call in late May, over 150,000 new recruits were massed in an interconnected system of state assembly camps and national training camps that extended across the eastern United States. Minor outbreaks of camp diseases (cerebrospinal meningitis, measles, mumps, and pneumonia) followed. But these outbreaks were dwarfed by an epidemic of typhoid fever that spread through the volunteer encampments. As Fig. 5 shows, at the height of the epidemic, some 250 to 350 volunteers were struck down by typhoid fever each day; all told, about 24,000 volunteers contracted the disease, and 2000 died [25]. Spanish-American War (21 Aprl-12 Aug.)

Armistice (12 Aug.-10 Dec.)

Board on Typhoid Fever established

400

50 45

350 Cases

40

300 Volunteer regiments mustered out

30

200 150

35

25

Second call (25 May)

20

First call (23 Apr.)

Treaty of Paris

Deaths

15

100

Typhoid deaths

Typhoid cases

Volunteer regiments assembled

250

10 50

5

0

0 Apr.

May

June

July

Aug.

Sept.

Oct.

Nov.

Dec.

Fig. 5. Daily series of typhoid fever cases (bar chart) and deaths (line trace) in regiments of the US Volunteer Army during the Spanish-American War, May to December 1898. Counts are based on evidence for a sample of 89 regiments (cases) and a subset of 49 regiments (deaths) for which information is included in Reed et al [25]. (From Smallman-Raynor M, Cliff AD. Epidemic diffusion processes in a system of US military camps: transfer diffusion and the spread of typhoid fever in the Spanish-American War, 1898. Ann Assoc Am Geog 2001;91:73; with permission.)

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As a case study in the conjunction of infectious disease and war, the typhoid epidemic of 1898 in the newly raised US Volunteer Army highlights the singular impact of a rapid and ill-planned process of military mobilization on the spatial propagation of an infectious disease [31]. Kreidberg and Henry [31] provide a summary perspective on the planning, organization, and execution of American mobilization during the SpanishAmerican War. Details of the factors that promoted the spread of the epidemic, including graphic descriptions of the overcrowded and unsanitary conditions that prevailed in many state assembly and national training camps, are provided in Smallman-Raynor and Cliff [32]. This section uses the evidence included in the official report on the epidemic [25] to reconstruct the geographic course of the disease in the volunteer camp system. Origins and spread of the epidemic Epidemic origins: state assembly camps. Although cases of typhoid fever had appeared among commands of the regular army soon after the declaration of war on Spain (April 21, 1898), one important feature of the typhoid epidemic in the volunteer regiments was the role of newly enlisted men in the temporally coincident (but apparently independent) introduction of the disease to a plethora of state assembly camps [25]. The first prospectively diagnosed case of typhoid fever in the volunteer forces can be traced to the First Pennsylvania Volunteer Infantry at Camp Hastings, the state assembly camp of Pennsylvania, on May 12th. If Camp Hastings yielded the first clinical evidence of typhoid fever, however, many other camps were actively incubating the disease. By the final week of May 1898, epidemiologic evidence suggests that the causative agent of typhoid fever (Salmonella typhi) had entered, even if it had not yet widely colonized, the state assembly camps of Georgia (Camp Northern); Iowa (Camp McKinley); Mississippi (Camp Patrick Henry); Nebraska (Camp Alvin Saunders); and South Carolina (Camp Ellerbe). Epidemic foci: national training camps. Although the ultimate origins of the epidemic can be traced to a disparate set of state assembly camps, the decision of the US War Department to override the original recommendations of the Commanding General of the Army (on April 26, 1898, the Commanding General of the Army, Maj. Gen. Nelson A. Miles, recommended to the Secretary of War, Russell A. Alger, that the volunteer regiments should be retained in state camps for a period of some 2 months, where they would be equipped, organized, and prepared for active service) and to concentrate the volunteers in a handful of national training camps [31] served not only to focus the epidemic spatially but also to supercharge its spread. Pivotal to this process were four national training camps, variously designated as the initial reception points for the volunteer commands: (1) Camp Thomas (Chickamauga Park, GA); (2) Camp Alger

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(Dunn Loring, VA); (3) Camp Meade (Harrisburg, PA); and (4) Camp Cuba Libre (Jacksonville, FL). The locations of the four camps are mapped in Fig. 6. The dimensions of the typhoid problem in the national training camps can be seen in Table 3. From the first case of the disease at Camp Thomas in mid-May, to the last case at Camp Meade in mid-November, no less than 11,808 typhoid cases (equivalent to a rate of 1121 cases per 10,000 mean strength) were recorded in the four camps. This high incidence was to secure the position of Camps Thomas, Alger, Meade, and Cuba Libre as major staging posts for the onward spread of the epidemic. Subsequent spread patterns. One important feature of American mobilization in the Spanish-American War was the high degree of spatial mobility of the volunteer commands. Although the volunteer regiments were initially dispatched to one of the four national training camps listed in Table 3, their sojourn of several weeks or months was followed by transfer to other camps. In the absence of an effective quarantine strategy, this mobility played a major role in the spatial development of the epidemic. To illustrate this, Fig. 6 charts the camp-wise movements of typhoid-infected regiments in 1898. Taken together, the maps in Fig. 6 illustrate four discrete phases in the spatial transmission of typhoid fever: 1. June to July (Fig. 6A), marked by the easterly spread of the disease from Camp Thomas to the coastal transit camps at Newport News (Virginia) and Charleston (South Carolina). In turn, Charleston formed a staging post for the onward spread of typhoid fever with US Army transports bound for the Caribbean island of Puerto Rico. 2. August (Fig. 6B), marked by the exodus of regiments from the typhoidridden Camps Thomas and Alger, with relocation in camps at Lexington (Kentucky), Knoxville (Tennessee), and Camp Meade (Pennsylvania). 3. September (Fig. 6C), characterized by an overlapping set of transmission cells and reflecting the return of some infected regiments to their home states, eventually to be mustered out of the Army. 4. October to December (Fig. 6D), marked by a southward spread of the disease in association with a wholesale southerly relocation of volunteer regiments to camps in Georgia and onward carriage of the disease from Georgia to post-war Cuba. Regimental morbidity rates Some impression of the drain of typhoid fever on the strength of volunteer units can be gained from Table 4. For the 20 regiments with the largest number of documented typhoid cases to December 31, 1898, the table gives estimates of the typhoid rate (per 1000 mean strength) and the number of days of service lost to the disease. As the table shows, the morbidity rate in each command exceeded 200 per 1000 mean strength, with a combined loss of some 214,000 days of military service.

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Fig. 6. Movements of typhoid-infected regiments of the First, Second, Third and Seventh US Army Corps, June to December 1898. The solid vectors trace the camp-wise movements of typhoid-infected regiments in (A) June and July, (B) August, (C) September, and (D) October to December. Vector widths are drawn proportional to the number of infected regiments that linked a pair of camps. National training camps from which typhoid fever ultimately spread (Camps Thomas, Alger, Meade and Cuba Libre) are denoted by squares; all other camps are marked with open circles. On each map, the black circles plot the weekly position of the mean geographic center of typhoid morbidity. (From Smallman-Raynor M, Cliff AD. Epidemic diffusion processes in a system of US military camps: transfer diffusion and the spread of typhoid fever in the Spanish-American War, 1898. Ann Assoc Am Geog 2001;91:81; with permission.)

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Table 3 Cases of typhoid fever in camps occupied by volunteer regiments of the US Army in the Spanish-American War, 1898 Camp

Typhoid cases

First case

Last case

Epidemic peaka

National training campsb Camp Thomas Camp Alger Camp Cuba Libre Camp Meade Other campsc or unknown

5437 727 3400 2244 6882

17 May 21 May 25 May 10 Aug 8 May

14 Sept 8 Sept 6 Nov 18 Nov 29 Dec

16 25 13 19 30

Aug Aug Sept Sept Aug

a

Date of peak typhoid morbidity. National training camps that served as the initial rendezvous for volunteer regiments of the First, Second, Third, and Seventh Army Corps. c Includes state assembly camps; national training camps (other than Camps Thomas, Alger, Meade, and Cuba Libre); transit camps; and camps in Cuba and Puerto Rico. Data from Reed W, Vaughan VC, Shakespeare EO. Report on the origin and spread of typhoid fever in US military camps during the Spanish War of 1898, vols. 1 and 2. Washington: Government Printing Office; 1904, and Smallman-Raynor M, Cliff AD. Epidemic diffusion processes in a system of US military camps: transfer diffusion and the spread of typhoid fever in the Spanish-American War, 1898. Ann Assoc Am Geog 2001;91:71–91. b

Ramifications of the epidemic The typhoid epidemic of 1898 was a defining event in the development of hygiene and sanitation in the United States Army [33,34]. Spurred by the investigations of the Dodge Commission into the conduct of the War Department during the conflict of 1898, the early years of the twentieth century were associated with a major reorganization and strengthening of the Army Medical Department. Not least, with the establishment of the Department of Military Hygiene within the Military Academy at West Point, military hygiene was effectively promoted to the core curriculum of American military science [34]. With a broadened skills and knowledge base, and equipped with developments in vector control, water purification, and vaccination (antityphoid vaccination was made compulsory for the Army in 1911), the Army Medical Department had attained a new level of competence in preventive medicine by World War I [33]. Case study 3: home camps in World War I (1917–1918) According to Kreidberg and Henry [31], American mobilization in World War I was hampered by ‘‘lack of preparation, faulty organization, and failure of military leaders to appreciate the importance of economic mobilization in the early part of the war.’’ Troop housing lay at the forefront of the logistic difficulties. At the time of the American declaration of war (April 6, 1917), the Army had accommodation for just 124,000 officers and men, for a force that, within a year, would swell to several millions. As a remedial response, 32 National Guard (tent) camps and National Army (wooden) cantonments, with a maximum troop capacity of

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Table 4 Top 20 volunteer regiments as ranked by the number of reported typhoid fever cases, May to December 1898

Rank

Regiment

Army Corps

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

49th Iowa 203rd New York 12th New York 15th Minnesota 12th Minnesota 2nd Ohio 1st Mississippi 35th Michigan 8th New York 3rd Wisconsin 52nd Iowa 2nd Illinois 2nd Wisconsin 9th New York 2nd New Jersey 10th Ohio 1st Wisconsin 6th Ohio 69th New York 1st New Hampshire

Seventh Second First Second First First Third Second Third First Third Seventh First Third Seventh Second Seventh First Third First

Mean strength

Typhoid casesa

Estimated days of service lost to typhoidb

1236 1047 1302 1280 1299 1297 1029 1150 1301 1313 1304 1095 1326 1292 1153 1228 1232 1299 1026 1296

608 (491.9) 508 (485.2) 490 (376.3) 464 (362.5) 433 (333.3) 401 (309.2) 397 (385.8) 383 (333) 379 (291.3) 378 (287.9) 345 (264.6) 338 (308.7) 329 (248.1) 323 (250) 321 (278.4) 316 (257.3) 312 (253.2) 311 (239.4) 299 (291.4) 297 (229.2)

17,024 14,224 13,720 12,992 12,124 11,228 11,116 10,724 10,612 10,584 9660 9464 9212 9044 8988 8848 8736 8708 8372 8316

a

Rate (per 1000 mean strength) in parentheses. Estimate based on the duration of a bout of average severity (28 d). Data from Reed W, Vaughn VC, Shakespeare EO. Report on the origin and spread of typhoid fever in US military camps during the Spanish War of 1898, vols. 1 and 2. Washington: Government Printing Office; 1904. b

almost 1.5 million, were hurriedly constructed during the summer and early autumn of 1917. Capacity was further augmented by the establishment of special camps with functions for embarkation, the housing of coast and field artillery, tank and signal corps, and the like. Disease patterns Between April 1917 and December 1918, some 3.7 million recruits passed through the system of US Army cantonments and camps [33]. For 39 of the principal cantonments and camps,1 Fig. 7 is based on information included in the US War Department’s Annual Reports 1919 [26] and charts the 1 National Guard camps: Beauregard, LA; Bowie, TX; Cody, NM; Doniphan, OK; Fremont, CA; Greene, NC; Hancock, GA; Kearney, CA; Logan, TX; MacArthur, TX; McClellan, AL; Sevier, SC; Shelby, MI; Sheridan, AL; Wadsworth, SC; and Wheeler, GA. National Army cantonments: Custer, MI; Devens, MA; Dix, NJ; Dodge, IA; Funston, KA; Gordon, GA; Grant, IL; Jackson, SC; Lee, VA; Lewis, WA; Meade, MD; Pike, AR; Sherman, OH; Taylor, KY; Travis, TX; and Upton, NY. Special or other camps: Eustis, VA; Forrest, GA; Greenleaf, GA; Humphreys, GA; Johnston, FL; Mills, NY; and Syracuse, NY.

A Cerebrospinal meningitis 7 6 5 4 3

Upper quartile

Embarkations

Median

3,000

2,500

2,000

2,500

2,000

1,500

2,000

500 Lower quartile

0

1,500 200 1,000 500 0

0 O N D J F M AM J J A S ON D 1917 1918

2,000 1,500 1,000 500 0 O N D J F M AM J J A S ON D 1917 1918

F Scarlet fever

E Rubella 60

2,500

20

50

2,000

15

40

2,500

350 300 250 200 150 100 50 0

2,500 2,000 1,500

1,500 10

30

1,000

1,000

20

500

10

0

0

5

G Tuberculosis

H Typhoid fever 2,500 2,000

30

0 O N D J F M AM J J A S ON D 1917 1918

O N D J F M AM J J A S ON D 1917 1918

40

500

0

2,500

2.0

2,000

1.5

1,500 20 1,000 10

500 0

0 O N D J F M AM J J A S ON D 1917 1918

Cumulative number of personnel embarked (thousands)

2,000

100

0

0

D Mumps 2,500

300

500

500 O N D J F M AM J J A S ON D 1917 1918

C Measles 400

1,000

1,000

O N D J F M AM J J A S ON D 1917 1918

Admissions rate (per 1,000)

1,500

1,500 1,000

2 1 0

B Influenza

2,500

1,500 1.0 1,000 0.5

500 0

0 O N D J F M AM J J A S ON D 1917 1918

Fig. 7. Infectious diseases in military camps, continental United States, World War I. Graphs plot, as a heavy line trace, the median value of the monthly admission rate (per 1000 strength) for sample diseases in 39 military camps. On each graph the shaded area forms an envelope, which delimits the interquartile range of the corresponding admission rates. (A) Cerebrospinal meningitis. (B) Influenza. (C) Measles. (D) Mumps. (E) Rubella. (F) Scarlet fever. (G) Tuberculosis. (H) Typhoid fever. The broken line trace on each graph plots the cumulative monthly count of Army personnel embarked for Europe. (Data from US War Department. Annual reports 1919, vol. 1. Part II: Report of the Surgeon-General. Washington: Government Printing Office; 1920; and Kreidberg MA, Henry MG. History of military mobilization in the United States Army, 1775–1945. Westport, CT: Greenwood Press; 1975.)

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Table 5 Admissions for sample infectious diseases among enlisted men in the continental United States, October 1917 to December 1918 National Guard camps Maximum troop capacity Disease Cerebrospinal meningitis Influenza Measles Mumps Rubella Scarlet fever Tuberculosis Typhoid fever TOTAL

National Army cantonments

683,887

769,047

693 103,564 25,774 34,472 3914 1135 7314 112 176,978

1123 201,710 32,880 54,529 5356 2965 8371 127 307,061

Special or other campsa

Total

b

73,515

75 22,206 2318 3387 126 101 551 5 28,769

1891 327,480 60,972 92,388 9396 4201 16,236 244 512,808

117,156

a Eustis, VA; Forrest, GA; Greenleaf, GA; Humphreys, VA; Johnston, FL; Mills, NY; and Syracuse, NY. b Capacity data not available for two camps (Greenleaf, GA, and Syracuse, NY). Data from US War Department. Annual reports 1919, vol. 1. Part II: Report of the Surgeon-General. Washington: Government Printing Office; 1920, and Kreidberg MA, Henry MG. History of military mobilization in the United States Army, 1775–1945. Westport, CT: Greenwood Press; 1975.

pattern of monthly admissions (per 1000 strength) for eight sample infectious diseases, October 1917 to December 1918. For reference, Table 5 gives the absolute count of disease admissions over the observation period. As Table 5 shows, the eight sample diseases caused 512,808 admissions during the 15-month observation period, with the overall pattern dominated by influenza (327,480 admissions); mumps (92,388 admissions); measles (60,972); and tuberculosis (16,236). Rubella, cerebrospinal meningitis, and scarlet fever were each associated with less than 10,000 admissions, whereas compared with the experience of the Spanish-American War, the extremely low incidence of typhoid fever attests to the success of the Army’s program of compulsory vaccination against this disease. Epidemic sequences With the exceptions of influenza (chart B) and typhoid fever (chart H), the diseases in Fig. 7 repeat a familiar epidemiologic feature of the mobilization process: the tendency for disease incidence to peak in the early months of hostilities. It is also apparent from Fig. 7, however, that the diseases differed in terms of the exact timing and the duration of their main epidemic phases. To examine the epidemic sequence more closely, the vectors in Fig. 8 identify months of unusually high activity (epidemic months) for each of the eight diseases. Taken together, the vectors show an overlapping, time-ordered, sequence of epidemic events of greater or lesser magnitude and duration. By May 1918, Fig. 8 shows that epidemic activity

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180

Influenza

Admissions (thousands)

160

Typhoid Scarlet fever

140

Mumps

120

Tuberculosis

100 80 60 40

363

CSM Rubella Measles Typhoid

20 0

Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec. 1917 1918 Admissions (epidemic phase) 10,000-100,000

>100,000

1,000-10,000

<1,000

Fig. 8. Epidemic sequence in military camps of the continental United States during World War I, October 1917 to December 1918. The bar chart plots the aggregate monthly count of medical admissions for eight infectious diseases (cerebrospinal meningitis, influenza, measles, mumps, rubella, scarlet fever, tuberculosis, and typhoid fever) in 39 United States military camps. To identify the epidemic phases associated with the constituent diseases, disease-specific monthly admissions rates (per 1000 strength) were reduced to standard Normal score form; months with scores in excess of 0.5 standard deviations above the mean (defined as epidemic months) are indicated by arrows. Arrow widths have been drawn to indicate the number of admissions associated with the epidemic months for a given disease. CSM, cerebrospinal meningitis. (Data from US War Department. Annual reports 1919, vol. 1. Part II: Report of the Surgeon-General. Washington: Government Printing Office; 1920.)

associated with the sample diseases had all but ceased. Thereafter, a minor upsurge in typhoid fever during July and August 1918 (see Figs. 7H and 8) was followed, in September and October, by the devastating autumn wave of Spanish influenza (see Figs. 7B and 8). Spanish influenza: evidence from the mobilization camps The Spanish influenza pandemic of 1918 to 1919 diffused around the globe as three temporally distinct waves of infection: spring and early summer 1918 (wave 1); autumn 1918 (wave 2); and winter 1918 to 1919 (wave 3). Although the source of the virus that caused the pandemic has been the subject of considerable research and debate in recent years [18], Army training camps in the continental United States provided some of the earliest clinical evidence for the first, and least severe, influenza wave [35]. The relatively mild nature of this first influenza wave is reflected in the modest increase in the admissions rate in Fig. 7B, peaking in April 1918.

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Fig. 9. Spread of the autumn wave of the Spanish influenza pandemic in sample US Army camps, September to October 1918. Formed relative to the putative start of the main phase of the epidemic wave at Camp Devens (Thursday 12 September, coded day 1), the circles identify those camps in which influenza was first recognized in week 1 (days 1–7); week 2 (days 8–14); week 3 (days 15–21); and weeks 4 to 5 (days 22–35). Camps infected in weeks 1 to 3 are identified by numerical code. (Data from Soper GA. The pandemic in the army camps. JAMA 1918;71:1899–909.)

Thereafter, influenza abated in the Army camps to reappear catastrophically in the autumn of 1918. Spread of autumn wave. According to Soper [35], Camp Devens, Massachusetts, was the first Army camp to report the occurrence of a severe epidemic of influenza in autumn 1918. On September 16th, the camp surgeon informed the Surgeon-General of the Army that, as part of a general epidemic in Massachusetts and neighboring states, influenza had now appeared among the troops. Whatever the source of influenza at Camp Devens, other military camps were afflicted by the disease in the remainder of September and early October. The camp-wise sequence of attack is mapped in Fig. 9. Consistent with a postulated introduction of the disease by troopships and other vessels from infected European locations [35], Fig. 9 shows that

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the first camps to be attacked by influenza were positioned close to the Atlantic seaboard. In addition to the putative index camp (Devens), other camps infected in week 1 of the epidemic included Camp Upton (New York) on September 13th, Camp Lee (Virginia) on September 17th, and Camps Dix (New Jersey) and Jackson (South Carolina) on September 18th. From these locations, the disease followed a rapid westward advance such that, by the end of week 3, most Army camps of the United States had been infiltrated by the influenza virus. Military versus civil settlement systems. As for the process by which the virus spread to units of the Army camp system, Soper [35] observed how the first appearance of influenza in a given camp (see Fig. 9) usually lagged the appearance of the disease in proximal towns and cities of the civil settlement system by a week or more. Although any interpretation of the evidence must proceed with caution, Soper [35] noted that such a lag effect is consistent with the hypothesis that ‘‘the camps derived their infection not from one another but from their immediate [civil] environment.’’ If this interpretation is correct, one may infer that the rapid, high-level, spread of influenza in the civil population of the United States effectively served to short-circuit any epidemiologic integration of the Army camp system in the autumn of 1918. Epidemic severity in camps. Regardless of the source of influenza in the individual camps, available evidence suggests that the epidemic took a more severe course among recruits than among their civilian counterparts. Writing in the Journal of the American Medical Association in early December 1918, Heiser [36] summarized the evidence in the following manner: From the statistics so far available, the death rate in the military camps is higher than among the civil population, even in similar age groups. The mortality in New York and Chicago, for instance, shows that the death rate in the Army is more than double that of the civil population of the same age group. There is also the possibility that when allowances are made for the fact that defectives have been eliminated from the Army, and that these poor ‘‘risks’’ swell the civil death list, the corrected margin will be still further increased in favor of the civil population.

The reason for the difference between camps and cities, Heiser postulated, rested with the living conditions in camps and, in particular, the epidemiologic risks afforded by high-density accommodation, sleeping, and messing. The cramped quarters of the barrack camps (National Army cantonments), in contrast to the relatively airy lodgings of the tent camps (National Guard camps), seemed to afford a special danger of pneumonia in influenza patients [35,36]. ‘‘It would seem well,’’ Heiser [36] recommended, ‘‘to consider plans for ÔdebarrackingÕ aggregations of men throughout the country.’’ ‘‘As matters stand,’’ he added, ‘‘those responsible for retaining men in barracks are assuming a heavy responsibility.’’

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Summary Globally, no less than 350 wars, revolutions, and coups d’e´tat have been staged in the six decades since World War II [6]. Such conflicts, like their pre1945 counterparts, have typically been accompanied by a pronounced increase in the occurrence of infectious diseases. For example, among UN forces in the Korean War (1950–1953), Japanese encephalitis and Korean hemorrhagic fever spread in epidemic form, while malaria, dysentery, and respiratory tract infections contributed significantly to an average annual disease rate of 611 per 1000 strength [37]. During the main phase of American combat activity in Vietnam (1965–1969), 69% of US Army-based hospital admissions were attributable to disease [37]. In more recent conflicts, outbreaks of dengue fever, respiratory tract infections, and enteric diseases have operated as a drain on international peacekeeping forces in Haiti, Somalia, Namibia, and Bosnia [3]. Beginning in mid-May 2002, an outbreak of Norwalk-like virus disease among British troops at Bagram, Afghanistan, provides a twenty-first century example of a camp epidemic [38]. Similarly in civil populations, wars of the late twentieth and early twentyfirst centuries have continued to be associated with a marked increase in epidemic activity. War-related outbreaks of enteric disease in Bosnia in 1993 [39], diphtheria in Tajikistan in 1993 to 1995 [40], cholera in eastern Zaire in 1994 [41], louse-borne typhus in Burundi in 1996 to 1997 [42], and epidemic poliomyelitis in Angola in 1999 [43] all attest to the enduring importance of the association of war with disease. The natural occurrence of infectious diseases is just one dimension of the war-disease complex. Looking to the future, the strategic military use of biologic agents is anticipated to represent a major threat to global security in the twenty-first century [44]. Once the secret preserve of a handful of states, advanced bioweapons technology is increasingly finding its way to lesser state powers, nonstate organizations, and others who have been attracted by the potential destructiveness of such weapons [45]. Recent bioterrorist activities in Japan [46] and the United States [47] serve to warn the global community that, someday, advanced bioweapons technologies may well be exploited.

References [1] Hecker JFC. The epidemics of the Middle Ages, 3rd edition. London: Tru¨bner & Co; 1859. [Babington BG, Trans.]. [2] Hirsch A. Handbook of geographical and historical pathology, vol. 1. Acute infective diseases. London: New Sydenham Society; 1883. [Creighton C, Trans.] [3] Smallman-Raynor M, Cliff AD. War epidemics: an historical geography of infectious diseases in military conflict and civil strife, 1850–2000. Oxford: Oxford University Press; 2004. [4] Prinzing F. Epidemics resulting from wars. Oxford: Clarendon Press; 1916.

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