War, the Military, and Epidemic Disease

Joseph P Byrne. Encyclopedia of Pestilence, Pandemics, and Plagues. Editor: Joseph P Byrne. Volume 2. Westport, CT: Greenwood Press, 2008.

The relationship between military activity and epidemic disease is an ancient and complicated one. Disease is met with at every stage of an army’s life: its formation from raw recruits, its training, its off-duty pleasures, its encampments, its travel through its own territory and then the enemy’s, its engagements with the enemy, its treatment of the wounded, its advance after victory or retreat after defeat, its ravaging of the enemy’s countryside and towns between battles, its sieges, its transport and housing of prisoners, and its return home and demobilization.

Wars have involved thousands, tens, and even hundreds of thousands of soldiers at a time. Recruits from distinct disease ecologies intermingle and share their diseases and those of their new home until they are “seasoned.” On campaign, soldiers bring their own diseases and encounter new ones. Fatigue, malnutrition, wounds, and stress lower immune responses, whereas camp life in crowded and unsanitary conditions encourages the spread of contagious diseases and creates ideal ecological niches for both native and imported parasites. Civilians also play various roles in these processes as sources of disease, victims of diseased soldiers and their parasites, healers and caregivers, medical researchers and innovators, and refugees. War disrupts societies in manifold ways, from forced quartering to destruction of homes and hospitals, from sparking local and regional epidemics to the voluntary and forcible displacement of large populations whose squalid new living conditions invite wholesale death by disease. This entry presents a few contemporary and historical examples of the many ways in which war and disease intersect.

Mobilization and Training of U.S. Armed Forces

Though an army may be gathered only from among local populations, as when city-states fought one another in ancient Greece or medieval Italy, armies have historically brought men together from near and far. Pathogens of many types arrived at camp with them, and many of these could spread quickly, especially among those who had never encountered them before.

Prior to the U.S.-Mexican War (1846-1848) and Europe’s Crimean War (1853-1856) few armies kept records that fully detail personnel deaths. During America’s Civil War (1861-1865), many Confederate records were lost when Richmond was burned, but Federal (U.S.) records remain intact. They show that recruiting in 1861 and 1862 brought urban and rural men, often from far-flung regions, together in very close quarters for training, and that this led to an immediate spike among them of the typically childhood diseases of smallpox, scarlet fever, erysipelas, and measles. The last was especially contagious, striking a third to a half of recruits in epidemics lasting as long as two months. When African Americans were first inducted in 1863, the effects of congregating were even greater, though the initial high incidence of diseases slid downward very rapidly.

In April and May 1898, 150,000 American men were recruited to serve in the Spanish-American War. Many volunteers battled measles, mumps, and even meningitis, but typhoid fever struck most widely and severely. Because survivors gained immunity, typhoid struck hardest at induction and training camps. Endemic in much of the United States, typhi bacilli were deposited by carriers in their feces. This material was then spread by incidental contact or by houseflies that were attracted to feces, horse manure, and other organic material. Flies walked and fed on contaminated waste, then landed or defecated on people, food, and other objects commonly handled. At a large camp, a million or more flies could hatch daily. Eventually, 24,000 cases resulted in 2,000 deaths, peaking in late August and early September. Men were first brought together in state basic training camps, then concentrated in four so-called national camps that brought men from across America together. The mixing of these men with those from other camps, and the continued routing of the volunteers among camps, served to spread the disease even more widely, accounting for fully half of the typhoid cases.

This experience, the research into typhoid by Walter Reed and the Typhoid Board, and the conclusions made by the Dodge Commission, led to routine typhoid vaccination of U.S. recruits from 1911 and to much greater attention being paid to camp sanitation and personal hygiene. Between America’s entry into World War I (1914-1918) in April 1917 and December 1918, 3,700,000 recruits underwent training in camps that ranged in quality from long-established bases to tent cities. Although only 244 contracted typhoid fever, over 92,000 suffered from mumps, almost 61,000 from measles, 16,236 from tuberculosis, and 15,488 from rubella, scarlet fever, or meningitis. As during the Civil War, most cases occurred early in the mobilization process. The huge exception was the “Spanish” influenza, which struck U.S. camps in September and October 1918 with 327,480 cases.

A range of immunizations, several of which had been developed by the military, was available to the World War II inductees. Only after the war, however, was a full range of vaccinations developed. The vaccines currently given to U.S. trainees include measles, mumps, rubella; hepatitis A; hepatitis B; influenza vaccine; polio vaccine; diphtheria, acellular pertussis, tetanus; meningococcal conjugate vaccine; and, if warranted, varicella and yellow fever vaccine. Still others are provided if deployment is into disease-ridden environments.

Camp Conditions and Life

A study published in 2005 theorized that the great influenza pandemic of 1918-1919—which killed an estimated 40,000,000 people—had its origin in a huge rear area British military camp in northern France (Etaples) in the winter of 1917-1918. The authors note that this installation contained dangerous toxic gas supplies that were mutagenic, as well as large numbers of swine, fowl, and horses—all associated with animal forms of influenza. Typically 100,000 men were housed here, but turnover was great as they transited to and from the frontlines and back and forth from Britain. Leakage of gas could have altered swine, avian, or equine flu viruses, allowing them to lodge with the hoards of transient soldiers and spread to friend and foe alike. If true, then this is certainly the most egregious example of unsanitary camp conditions affecting the history of human disease.

Troops barracked at home also suffered from the influenza. Fort Riley, Kansas, has the distinction of being the known point of origin of the pandemic in the United States (March 1918), and the flu clearly spread through the network of military bases and camps and to the neighboring communities and beyond. These installations suffered one death per hour at the pandemic’s height, or about 200 per week, whereas British home camps lost 2,000 per week. Despite good sanitation and nutritious food, living conditions were still crowded and allowed the virus free reign. Though an extreme case, this was by no means a unique experience: in 1950, a modern Israeli military facility near Tel Aviv suffered a bout of West Nile Fever, for which 636 of the resident 1,000 soldiers had to undergo treatment.

Before the advent of germ theory and the emphasis on sanitation, military camps, bases, and forts tolerated poor quality food and water, lax standards for waste removal, and substandard personal hygiene—all of which fostered the growth and spread of pathogens and disease. For military personnel, flight was not an option, unless insightful commanders took the lead. When bubonic plague struck the enormous Russian Black Sea fortress of Ochakov in the spring of 1739, the Russian commander eventually decided to relocate the garrison to Ukraine, but not before some 30,000 had fallen victim. Cholera, too, could sweep through military bases, as it did in July1830 at the Russian Caspian Sea port city of Astrakhan. Because of the regular relationships, commercial and otherwise, between soldiers and civilians, the disease spread quickly through the city of 37,320, causing 3,633 cases with a mortality rate of 91 percent. At the same time, Moscow lost 3,102 to cholera, its garrison taking a quarter of the fatalities. But progressive commanders who sought to stanch the epidemic sometimes paid a price, as when Russian Novgorod’s barracks erupted in riot against harsh sanitation measures being implemented at the base.

With the development of European colonialism in the eighteenth and nineteenth centuries, European troops and sailors often found themselves in tropical ports and bases where local diseases could—and did—run rampant. The British military first encountered endemic cholera in the early 1780s in Ganjam, India, when 1,143 soldiers in a garrison of 5,000 fell ill. Another thousand cases soon weakened the Madras garrison, and the disease spread to Britain’s Indian allies. The origins of the first cholera pandemic are also found among the British in northwest India, in 1817. An especially virulent epidemic in 1861 in Delhi and Lahore, in which 457 cases resulted in 261 deaths over 10 days, threatened to topple the regime and prompted the imperial government immediately to establish the Indian Sanitary Commission.

Africa earned its nickname as the white man’s grave. Military occupation of ports and forts always accompanied colonization, and troops sent to serve needed several weeks—sometimes more—to acclimate their bodies to the weather and disease environment. Yet even the best “seasoning” might not prepare a unit, as in 1778 at the Senegalese Fort St. Louis. Apparently Senegal had not known yellow fever, but it arrived with a slave ship from Sierra Leone, where, as elsewhere, it had long been endemic. The British colonists and soldiers as well as local natives dropped from the disease, suffering a mortality rate of 60 percent in what some consider Africa’s first epidemic of yellow fever. It continued to affect colonial armies in much of West Africa, and Sierra Leone itself suffered 15 epidemics between 1815 and 1885. In similar ways, European and U.S. colonial armies in the Caribbean, Southeast Asia, and the Philippines suffered far more from disease than hostile action.

The First Gulf War (1990-1991): Protecting Coalition Troops against Disease

In the summer and fall of 1990, over half a million Coalition troops from 40 countries shipped out to Saudi Arabia and other friendly nearby states to force Iraqi dictator Saddam Hussein (1937-2006) to abandon his military occupation of Kuwait. Coalition war planners expected to encounter the diseases and perhaps case rates experienced in the region during World War II. The predominant participants—U.S., British, and Canadian soldiers and marines—were carefully vaccinated against childhood diseases such as diphtheria and polio, as well as influenza, yellow fever, hepatitis A, and tetanus, and many were also vaccinated against anthrax and plague. Military planners employed a sophisticated regimen of prophylaxis to insure that serious infectious diseases remained in check. Desert camps and staging areas were kept sanitary, ample potable water was provided, and food was continually inspected for tainting or parasites. Insecticides and repellents were applied lavishly, inspection and surveillance for disease was constant and careful, and an infectious disease diagnostic laboratory was included along with state-of-the-art field medical facilities. Along with standard theater diseases, planners feared Iraqi biological weapons use. During the build up from July 1990 to January 1991, 60 percent of U.S. service personnel experienced predictable and nonacute gastrointestinal ailments such as diarrhea and mild colds and other respiratory ailments that accompany close living quarters. They reported only 32 cases of leishmaniasis (caused by a protozoon carried by sandflies), 7 cases ofmalaria, and 1 of West Nile fever. Only one U.S. serviceman died of an infectious disease, a case of meningococcal meningitis. Very limited contact with local residents and general lack of privacy kept rates of venereal disease far below the norm for troops in theater. Many veterans of the nine-month campaign have long complained of a variety of chronic ailments generically labeled Gulf War Syndrome, though no single cause has been widely accepted. Disease and Military Opportunism.

An outbreak of epidemic disease may so debilitate a military force that its misfortune tempts its enemies. The Plague of Justinian that began in the sixth century CE so weakened both the Persian and Byzantine empires and their armies that the upstart Muslim forces from Arabia had little trouble conquering the first and devouring much of the second in the middle of the seventh century. When the English army positioned in southern Scotland near Selkirk contracted the plague in 1349, the Scots thought that their hour had arrived. In the course of their advance, the clansmen shared the English fate, and before long 5,000 Scots had succumbed to the Black Death. In the Western Hemisphere the diseases that accompanied the Europeans and Africans from the late fifteenth century mowed down the indigenous peoples and opened doors for conquest. The Aztec capital of Tenochtitlán, praised for its size and wealth by the Spaniards who first encountered it, lost half of its population to smallpox and lay prostrate before the victorious Spanish conquistador Hernán Cortés (1485-1547) in 1521. Within only a few years the disease had penetrated to Peru and killed the Inca emperor Huayna Capac (1464-1527) and his wife, an event that precipitated a civil war. The Incan losses to both violence and imported disease opened the door to Spain’s Francisco Pizarro (1471-1541), who smashed the Incan empire in 1532. In 1706 an outbreak of yellow fever in English Charleston, South Carolina, tempted the French and Spanish naval squadron in St. Augustine, Florida, to sail north to make an easy conquest. The colonial militia, which had stayed outside the fevered city, remained healthy and staved off the small fleet, which retired to its base.

Disease on Campaign

Epidemic outbreaks rarely started or ended conflicts, but, as at Selkirk, they often played roles in determining battles and even campaigns. Debilitating diseases did not have to kill combatants to cripple an army; they could simply take so many off active duty as to blunt its effective force. Early in the American Civil War, the Confederate forces in western Virginia were halted (September 13, 1861) during an otherwise successful campaign when a combination of measles, dysentery, typhoid fever, and pneumonia struck the men with a biblical fury. In 1722 Czar Peter the Great of Russia (1672-1725) was forced to halt his campaign of expansion in the Caucasus during the Russo-Persian War because of ergot-tainted rye bread. It was said he lost 20,000 men to the disease. In the later sixth century CE, the Christian Ethiopian prince Abraha (r. c. 525-553) controlled a considerable portion of the Arabia Peninsula. The prince’s military campaign to convert Arabians to Christianity in 569-571 was halted abruptly when smallpox or measles broke out among his troops as they approached the important trading center of Mecca. So weakened were the Ethiopians that they lost what they had controlled in Arabia, an event celebrated in the Koran’s Sura 105. Had Mecca been converted, the life story of Muhammad (579-632), Prophet of Islam, might have been very different. The Black Death brought hostilities between France and England to a standstill in 1349; in 1691 yellow fever felled 3,100 British sailors on 18 British warships bound from Barbados to French Martinique, forcing the fleet to return to England, and it was probably malaria that forced Attila the Hun (406-453) to halt his horde’s advance through Italy to Rome in 452. Tropical campaigns could be especially deadly before troops could undergo vaccination.

But armies were not merely victims of disease: they were often responsible for spreading it, among enemy as well as friendly populations, and sometimes at long distances. In 1643 English Royalists were engaged in civil war with Parliament’s army, and both were maneuvering across the English landscape. The problem was that both armies were suffering from typhus, and both spread it liberally among the people along their routes. During the cholera pandemic of 1831, the Czar sent Russian troops into Russian Poland from Volhynia to confront revolutionary students and other liberals. The freedom-loving Poles were met not only with Russian bayonets but also with the cholera that accompanied the regiment. The Boer War in South Africa broke out in the early stages of the Third Plague Pandemic. Between 1899 and 1902, British cargo vessels bringing military supplies from ports in South America brought plague to South African ports, and from there, military transport trains carried it inland, where it readily spread among the civilian population. In 1936 smallpox broke out among unvaccinated Ethiopians who were fighting Benito Mussolini’s (1883-1945) Italian army in Somalia. Somali nomad tribes came into contact with the Ethiopians, and over a six-week period 1,142 cases developed among civilians, with 471 fatalities. During the early stages of American involvement in the Vietnam War, bubonic plague broke out in several South China Sea provinces. It moved along the coast and then inland. U.S. military activity in the region disrupted the rodent populations—largely bandicoots—among which the Xenopsylla cheopis flea made its home. Average annual reported cases of plague among the South Vietnamese were 15 from 1956-1960 and 4,000 from 1965-1970. After the U.S. military withdrawal, annual cases dropped to around 2,500. During the War, 25,000 cases of plague were reported, though estimates run as high as 250,000 throughout Vietnam. Unreported cases probably meant untreated cases, which would have meant a very high mortality rate.


Siege warfare entailed one army surrounding a second army or garrison within a city or other well-fortified defensive position. Given the stagnant nature of a siege, living conditions in both the attackers’ camp and the defensive position would deteriorate as weeks and often months would pass. Food and clean water were vital for both parties, and though the besieged were often in the worse position, the attackers were often little better off. Typhus, dysentery, and venereal diseases could run rampant through either or both armies. During the supposedly “bloodless” Glorious Revolution in 1688-1689 King James II’s (1633-1701) troops besieged a Protestant garrison in the northern Irish city of Derry. Troops and civilians numbering 37,000 suffered a 105-day siege and 10,000 deaths largely as a result of typhus and dysentery. James’s Catholic army suffered also, however, from dysentery and typhus as well as syphilis, and the siege was broken. The famous Plague of Athens occurred as the Spartan army hemmed the city in. As was often the case with sieges, many people from the countryside had flooded into the city, putting a greater strain on food supplies and other necessities and creating the kind of crowded conditions in which epidemics can thrive.

Armed Forces, War, and Venereal Diseases

Traditionally all-male organizations, armies have contracted and spread venereal diseases such as syphilis and gonorrhea in numerous ways. During training or while barracked at home, soldiers may have access to prostitutes or other willing sex partners, including one another. “Camp followers,” who included prostitutes (Union Civil War General Joe Hooker’s [1814-1879] “hookers”), often trailed premodern armies on campaign, and while on duty in foreign noncombat zones or on leave from an active zone, military personnel may take advantage of local sex professionals. In cities such as Saigon during the Vietnam War, Paris during World War II, or Tokyo during the Korean War, many sex workers were displaced young women, often from rural areas and with little or no access to health care or physical protection. Although modern armies have long provided “hygiene” education to enlighten the unsophisticated recruit, drugs, alcohol, peer pressure, loneliness, and the stress of battle may override even the most graphic warnings. Finally, venereal diseases may be contracted or spread during rapes, which may occur in the wake of battle or in the depths of boredom accompanying a campaign in or occupation of enemy territory. Rape is far from unknown as a means of degrading a defeated enemy population or venting frustration by brutalizing the enemy’s women sexually. This was especially feared by German civilians as Soviet troops approached Adolf Hitler’s (1889-1945) Reich in early 1945. Before and during World War II the Japanese armed forces compelled thousands of Korean women into sexual service as military prostitutes, effectively institutionalizing their continuous rape.

Napoleon Bonaparte (1769-1821) mandated licensing and medical examination of French prostitutes, and those in British naval ports were subjected to the Contagious Diseases Acts of the1860s, which also required regular screening for venereal diseases. In Australia during World War II, press and civic groups such as the Women’s Christian Temperance Movement and the newly formed Australian Society for the Eradication of Venereal Diseases unduly whipped up popular opinion against women who entered the wartime workforce and the contrived epidemic of sexually transmitted diseases (STDs) that accompanied it. Public voices flatly blamed and stigmatized liberated women—their healthy inhibitions dulled by “strong drink”—for catering to servicemen’s lusts (including those of 1 million transiting American GIs). City governments hired additional policewomen to handle the supposed influx of “promiscuous amateurs” who needed to be screened for disease for the public’s and military’s protection. Though during World War I, 1 in 10 Australian soldiers contracted an STD, in the early 1940s, only 1 percent did.

In the United States, mobilization in 1942 prompted a coordinated state, local, and federal Public Health Service effort to deal with the potential problem. Like the Australian programs, it targeted women. Within two years, 47 “rapid treatment centers” had been established to isolate women (and some men) who had venereal diseases and were thus deemed public health threats. Military authorities also created prostitute-free zones around military bases and training facilities, an activity sanctioned by the May Act of 1941. The War Department pressured mayors and urban police chiefs to close down brothels, but local interests often outweighed federal influence and threats. The military also tried to reduce the demand for commercial sex: films and posters stressed the horrors of STDs, public relations campaigns enlisted celebrities to extol the virtues of sexual abstinence, and the United Service Organization (USO) worked to entertain and distract troops.

Returning Troops and Refugees

There are many cases in the historical record of armies or military units returning home and bringing with them diseases of all kinds. As troops are demobilized, they spread their diseases deep into the population of their home states. The Antonine Plague of the mid-second century CE that struck the Italian peninsula and western Mediterranean was either smallpox or measles carried by Roman troops returning from duty in Mesopotamia. When the novel disease hit the “virgin soil” in the west, it did tremendous damage. In 570 Byzantine troops on campaign near Mecca (Saudi Arabia) contracted a similar disease and, upon return, spread it about the eastern Mediterranean. As the remnants of Napoleon’s Grande Armee completed their retreat from Russia in 1812 and 1813, they carried typhus, dysentery, malaria, and influenza with them. They infected and killed thousands in the German lands they passed through and thousands more in France. At the end of the Crimean War, typhus had been a problem for the British and French armies in the Black Sea region. In 1856 returning French troops were quarantined on an island off the southern French coast, averting any outbreak at home. British troops, on the other hand, returned directly and sparked an outbreak of typhus in the British Isles.

Refugees fleeing a victorious enemy can also spread disease. One of the most significant cases was that of French smallpox carriers fleeing the advancing Prussian army in 1870. Conditions in and around Paris were frantic as new troops were being mustered, existing units repositioned, and thousands packing and fleeing. Smallpox had been rampant in the area since 1868, and it began to spread in every direction. Between 60,000 and 90,000 French are thought to have died in 1870-1871. French prisoners of war (723,500) brought the disease to Germany, and by spreading the prisoners around the new country in 78 prisoner facilities, the military authorities spread the disease. In 1871-1872 an estimated 162,000 were reported dead of the disease. Fleeing French carried smallpox into England (42,000 deaths), Belgium (21,315 deaths) Switzerland, and northwestern Italy, prompting outbreaks, and even New York City suffered 3,084 cases and 805 deaths connected with these refugees. The French army of 1 million had 125,000 cases of smallpox, of whom 23,500 died. The German army, on the other hand, had vaccinated its troops every seven years since 1834, and it only recorded 8,500 cases among its 1.5 million soldiers, of whom 460 died. All told, an estimated 500,000 Europeans—mostly children—succumbed to smallpox. This prompted England and Germany to make vaccination compulsory in 1871 and 1874, respectively.

Contemporary conflicts also produce refugee emergencies, especially in war-torn parts of Africa. In 1994 civil war in Rwanda displaced 1.2 million refugees who established camps outside the Eastern Zaire city of Goma. Living in filth with little or no fresh water, these people suffered greatly from cholera as well as malnutrition. In 1999 Mozambique’s civil war sent thousands into northern South Africa, where epidemic malaria quickly broke out. This spread to tourists in the Kruger National Park, and eventually 50,000 cases were reported.

Epidemics in Postwar Conditions

The social, economic, and physical disruptions caused by war, especially among the defeated, have often left openings for serious outbreaks of deadly diseases. Returning soldiers and prisoners of war, displaced and homeless people, refugees, and occupying soldiers all bring with them their various pathogens. Infrastructural elements such as hospitals, suppliers of medicines, and freshwater delivery systems are often simply gone, as are medical specialists and even primary care providers. The attitude of the victor is often key: if vengeful, it may carry off what it can and damage the ability of the defeated society to care for itself for decades; if magnanimous, it may provide extensive resources to repair, rebuild, and restructure.

Between the 1770s and 1918, Poland had been divided among Germany, Austria-Hungary, and Russia. With the defeat of Germany and Austria and the collapse of Russia in the First World War (1914-1918), international treaties reconstituted Poland as a republic. The country’s three regions had been tramped across by armies advancing and retreating, reinforcements traveling to the fronts, prisoners heading to camps, wounded returning for care, demobilized divisions redeploying westward, repatriating Poles, and Russian and Ukrainian refugees first from the War and then from the violent birth pangs of the Soviet state. The new Polish government established a Ministry of Health whose initial duty was to stem the tide of infectious diseases that had been ground into the Polish people. By the summer of 1919, it had established 44 mobile epidemic disease units with 2,400 beds, 103 local hospitals with a total of 4,400 beds, and 35 disinfection units. Twenty-three epidemic medical specialists helped coordinate the efforts of local physicians and other health-care providers. Limited funds, infrastructure, and supplies undermined efforts to tackle the wide array of diseases and huge number of cases encountered.

War and Reemergent Epidemic Disease

From the early 1990s, wars, civil wars, and endemic regional violence in portions of central Africa have created the social disruption, destruction of medical and public health infrastructure, and forced migration on which epidemic diseases thrive. In war-swept villages and overpopulated refugee camps, poor sanitation, malnutrition, tainted water, stress, and unavailability of needed drugs and other medical supplies affect all involved, but especially the most vulnerable, not least the children. Between 1990 and 1993, crude death rates (CDR) of refugees in countries like Kenya, Ethiopia, and Zimbabwe were 5 to 12 times higher than back home before the violence. Those who were displaced and remained in their home countries fared far worse, with CDRs 12 to 20 times higher those before the disruption. Most common were deaths of infants and children from preventable diseases. A study of Lacor Hospital in war-torn Uganda from 1992 to 2002 demonstrated that almost 80 percent of admissions were of infants, children, and women, and that the most common complaints were typical childhood diseases easily preventable under normal circumstances. Ebola, HIV/AIDS, malaria, and tuberculosis came next, with violence-related injuries and wounds fluctuating with the local level of fighting.

Sleeping sickness is endemic in most of Africa between the Sahara and the southernmost regions and was brought under control by successful efforts to control the tsetse fly vector and livestock infections. These efforts flagged as political turmoil turned to open conflict in Uganda in the mid-1970s. As a result, sleeping sickness rebounded, leading to a reported 40,000 cases over two decades and a suspected number 10 times as high. Treatment is expensive and complicated, but without it, the disease is virtually always fatal. In Sudan, civil war led to sleeping sickness’s reemergence in 1997, and soon its prevalence rates in some areas rose to between 20 and 50 percent. By 2007 it ranked beside AIDS as the top regional killer. In Uganda the epidemic occurred when war disrupted living conditions, increased the likelihood of human exposure to the infected tsetse fly, decreased the likelihood that victims would have access to treatment. The cessation of insect control efforts and the movement of displaced people into swampy, fly-infested areas increased transmission rates, while the closure of clinics and blocking of relief efforts denied access to lifesaving services. The Sudanese civil war effectively halted the medical surveillance of populations, especially of refugees, in which the disease was rampant. But even if needful populations had been identified, poor and dangerous transportation infrastructure, roadblocks, official corruption, and the desire of each faction to murder its enemies would have seriously hampered relief efforts.

Military Research on Infectious Disease, Prophylaxis, and Treatment

During World War II, German units serving along the Metaxis Line in Greece and in the southwestern USSR suffered heavily from malaria. Hitler’s Army Medical Academy, as well as pharmaceutical companies such as Bayer and I. G. Farben, searched for new malaria drugs and a vaccine and for new means of insect control. Correct dosing of Plasmochine and Atabrine, the two standard drugs, remained elusive, and ruthless experimentation on prisoners and the mentally disabled took many lives. Armies have always had a huge stake in developing the ability to curb the effects of disease, but only since the development of smallpox inoculation in the eighteenth century could they effectively do so. Military researchers, often under combat conditions, have worked diligently to defeat disease, and the ranks of the disease fighters are rife with military careerists. They include the work of Walter Reed and William Gorgas in fighting yellow fever, as well as the efforts of Alphonse Laveran and Ronald Ross to understand malaria and its transmission. The current protocols for treating malaria were developed and tested by U.S. military researchers in Vietnam

Biological or Germ Warfare

From at least 1347, when Mongol warriors hurled bubonic plague corpses into the Christian outpost of Kaffa hoping to spread the pestilence, belligerents have sought to use disease as a means of weakening the enemy forces. Advances in germ theory and microbiology in the later nineteenth and early twentieth century unlocked the secrets of dangerous pathogens, allowing scientists to “weaponize” a range of biological agents. The second Gulf War ignited when Iraqi dictator Saddam Hussein (1937-2006) refused to disavow or allow inspection of biological weapons development sites, and these remain a grave concern to diplomats and military planners worldwide.

In the early 1930s, the Empire of Japan began a concerted effort to develop effective weapons using a score of different pathogens. Though outlawed by the Geneva Convention of 1925 (not ratified by Japan), the program was initiated and led by the racialist microbiologist Dr. Shiro Ishii (1892-1959). As Japanese militarists gained power and influence in the government during the 1930s, they saw the value of germ warfare, and Ishii was provided with laboratory facilities first in Tokyo and then in Manchuria. At Pingfan, near Harbin, Ishii’s infamous Unit 731 built a research city housing some 400 human laboratory subjects, including political and military prisoners. By the end of World War II, 20,000 Japanese military and personnel had worked for Unit 731’s facilities at Pingfan and scattered across the Empire. Inmates were given many diseases, including anthrax, dysentery, diphtheria, hemorrhagic fevers, smallpox, typhoid, and yellow fever. Autopsies and vivisections were performed, vaccines tested, and the remaining corpses incinerated in crematoria. An estimated 20,000 people died under these conditions. Pathogens in powder form were placed in bombs and shells, and in August of 1942, 80 victims in Jiangshan Province, China, died of purposely cholera-tainted fruits, rice cakes, and well water. At the same time, an estimated 200,000 died of weaponized cholera in Shangdon Province, and an equal number succumbed to the same in Yunnan Province. By the end of 1942, 1,700 Japanese soldiers who had entered contaminated zones had died of these diseases. Between medical experiments and “field tests” perhaps as many as half a million people perished at the hands of Ishii and his scientists.