MG - Historical geography of war and disease

Why do wars facilitate the spread of disease?

• Unusual congregations of troops drawn from different epidemiological environments
• Various hardships may lower resistace to diseases
• Poor sanitary conditions
• High levels of psychological stress
• 'Normal' rules of social behaviour break down in war time

• Spanish war: for every 1 death on the battlefield: 3 deaths from diseases
• Early 20th century: start to see more people die from battle than diseases
• Vacinators cannot get to the people that need vaccinating 
• Increase in sexually transmitted diseases

Nature of Typhoid Fever

• Transmission occurs via ingestion of faecally contaminated food, water and other fluids.
• Thrives in unsanitary conditions
• 10-20% mortality in untreated cases

Background to the Spanish-American War

• USA declared war on spain in April 1898
• Each USA state assembly camp tended to contain a few thousand men and the national camps contained even more, around 50 thousand
• Sanitary conditions were dire
• Rain washes faeses from uphill to downhill to where people were camped
• 1000 deaths

How did it spread

• Tried to march the disease off when it got too bad in Camp Thomas - but this just spread the disease round more

• France declared war on Prussia on 17 July 1870
• War lasted until 28 January 1871
• Culminated in a Prussian victory
• War associated with vast movements of troops (~1.5 million troops crossed the France-Prussian border)
• Large number of French troops taken prisioner (~260,000 carried to Prussia as prisioners of war)
• At the time of the war, a huge outbreak of smallpox was occuring in France
• Hierarchical spread of smallpox from large POW camps to smaller camps
• Each prisoner of war camp is connected to a town, so smallpox eventually started to seep out into the Prussian population  

Epidemic diffusion processes in a system of US military camps: transfer diffusion and the spread of typhoid fever in the Spanish-American War, 1898

• 24,000 army volunteers contracted typhoid fever
• Camp conditions: overcrowding, inadequate or nonexistent drainage and sewerage systems, poor or contaminated water supplies, and the failure to institute or to maintain rigid sanitary pre-cautions. 
• Troops resistance to disease may be compromised by fatigue, trama, mental and physical stres and poor diet.
• 2000 left for dead
• Thin topsoil in Camp Thomas (a national training camp) meant flooding and flowing of faecal matter into the camp
• Incompletely data for the cases of the disease
• The national training camps supercharged the spread
• Neither contagious or hierachical diffusion can describe this, so the model of tranfer diffusion is used (the wholesale movement of regiments from one encampment to another drove the spatial course of the epidemic)
• Each spread process contributed to the diffusion of Typhoid - just at different stages of the epidemic
• 2Trand the failure to institute or to maintain rigid sanitary pre- cautions. sewerage systems, poor or contaminated water supplies, and the failure to institute or to maintain rigid sanitary pre- cautions. sewerage systems, poor or contaminated water supplies, and the failure to institute or to maintain rigid sanitary pre- cautions.

The geographical transmission of smallpox in the Franco-Prussian War: Prisoner of war camps and their impact upon epidemic diffusion processes in the civil settlement system of Prussia, 1870-71

• 500,000 soliders and civilians dead throughout Europe due to the outbreak
• Smallpox first appeared in Paris on New years day of 1870
• The Prussian army had immunity to the disease due to a compulsory programme of smallpox vaccination and revaccination that dated from 1834, but the Prussian civilians were not
• Hierachical diffusion in POW: Large prisoner of war populations were infected at an early stage of the epidemic and small POW populations were infected at a later stage
• Because the number of POWrelated facilities expanded during the course of the war to include locations with increasingly smaller holdings of prisoners, the hierarchical spread of smallpox was, itself, driven by the evolution of the POW settlement system.
• The POW camps structured the spatial course of the state-wide epidemic

• The end of wars is associated with the widespread disemination of diseases

Spanish influenza pandemic

• Wave 1: May/June 1918 - low death rate
• Wave 2: September/December - caused most mortality, fuelled by demobilization in the wake of World War 1. 50% mortality in ages 20-40 - these people put up the most vigorus responce which may have actually killed them.
• Wave 3: March 1919

World wide diffusion of influenza

• Origin: US recruits in Kansas - spread to other military camps in the USA 
• May/June - spread to South Asia and Brazil
• Critical move: Transatlantic crossing in April by military transport ships - to western france and then spread out from there (West to East across Europe). Second introduction into Portugal and spread outwards into Spain. Wave stopped short of russia. Direction of spread is usually from East to West in Europe

• Evidence of virus in France in August, then spread to italy and rest of europe. By October spread to Russia.
• August - also in West Africa
• September - transatlantic crossing to USA and hospital ships carrying troops back to America
• November - Australia 
• driving force of spread - troops returning home from europe after the first world war
• Transport ships carrying Australian troops back home after the war: Devon ship = Suez --> Fremantle via Colombo - 8 per cent cases, 8 deaths
• Medic = 31 percent cases - 22 deaths
• Quarintine in Australia was relatively successful
• The rapid spread of influenza was a reflection of the dramatic changes in connectivity that occured at that time. Troop movements were critical to the spread of the disease.
• Patterson and Pyle (1991) argue that the spread was so quick that any heirachical component was swamped out by the contagious spread.

• War time: there are often simultaneous epidemic events
• Feb/march 1895 - cuban revolutionists rose up against the spanish authorities. This revolution again spanish rule continued until 1898. Cuban insurrection and spanish american war were very close to each other.
• Mortality very high in 1896-7. Dip in mortality associated with the spanish amercian war but this is not accurate. Data from public health personel in cuba, which were drawn to america during the S-A war so therefore data would not be accurate
• At the end of the CI the mortality increases again due to return of personel
• 3 infectious diseases - Yellow fever, Smallpox and Typhoid fever
• During the war: highly integrated epidemiological system - same pattern with every disease
• All diseases have a small incubation period

• Bacterial disease
• Incubation period: months/years/lifetime
• Not easily transmitted - need sustained contact
• War: 1. environmental conditions enhance transmission (overcrowding) - refugee camps and overcrowded working conditions
• 2: Social conditions reduce resistance to infected individuals (protien - calorie malnutrition). Severing of food supply lines, refugee camps and concentration camps not having the correct diet. Franco-Prussian war - Prussia cut off food supply lines into Paris and protien calorie malnutrition increased greatly.
• Large spike in mortality during the first world war
• Cuban Insurrection - Epidemics of tuberculosis. Before CI: 100/150 deaths per month from T. After CL: 300 deaths per month from T. (Havana)
• Why? during the CI, the cuban revolutionary army were getting supplies (food) from the rural population on the island. To stop this support the spanish army issued a reconcentration of the rural population into urban centers so they could be more easily controlled 
• First use of population reconcentration as a military strategy. 
• With bacterial diseases there is a steady rise in cases due to the long incubation periods and with viruses there is a peak at the start of the war and decline there after (short incubation periods)

The spatial anatomy of an epidemic: influenza in London and the county boroughs of England and Wales, 1918-19

• In 1918 a new variant of influenza spread throughout the world, infecting half a billion and killing around 40 million people. 
• Influenza activity in England and Wales are largely dependent upon the influenza mortality statistics collated by the General Register Office
• Influenza appeared in britian in the early summer of 1918
• Origin of the 1918-19 pandemic is largely unknown
• There were three waves in which the epidemic occured and there is variations in data as to the times of these
• Because of the war there was a shortage in medical personnel
• Birmingham was the first provincial city to display a sudden and sustained increase in recorded influenza mortality
• Disease spread was viewed as irregular. The country was virgin soil for the new virus strain on wave 1 and the virus spread north to south. Wave 2: south to north. Wave 3: North to south
• The spread was driven by the differential patterns of popualtion mixing associated with the phases of war (wave 1), demobilization (wave 2), and peace (wave 3)
• Contagious diffusion
• High levels of influenza in Cambridge due to high proportion of young people. 400 junior naval officers were sent to residence at Cambridge in 1919. Within a week 90 had been admitted to hospital. Closure of school and abandonment of meetings as a quarantine device.

• Emerging and re-emerging diseases are “disease that have newly appeared in the population, or which have existed but are rapidly increasing in incidence or geographic range” (S. S. Morse, 1995)
• During war time: heightened exposure to zoonotic pool. Zoonoses - diseases naturally transmissible from animals to man. Historically ecologcal changes associated with war fare such as forest fires and alteration of animal habitats. Brings humans into close contact with animals

Historical examples – pre-20^th century

Plague of Athens

• Unknown disease
• Broke out in 430 BC and continued until 426 BC
• Broke out during the Great Peloponnesian War - therefore directly associated with the war
• Estimated mortality = 25%

English sweating sickness

• Broke out at the end of the wars of the roses
• Population floods after the war
• Uncertainty as to what the disease was

• Typhus fever - Spanish Christian-Muslim War. First time this disease appears in the historical record

World war 2 - Scrub Typhus, allied forces in Burma-India

• Acute febrile disease that occurs when humans are bitten by mites
• Human invasion of ecological niche of larval trombiculid mite
• Mortality 3-40%
• 5 clear outbreaks
• Outbreaks occured when the troops were in active combat or training 
• Non-combat troops experienced very little of the disease

Korean War - Korean haemorrhagic fever in UN troops

• Hantaan virus. Natural reservour - Striped field mouse
• Accidental exposure to contaminated mouse excreta

Drug-resistant malaria in US combat troops

• Caused by infection with protozoan parasites, genus Plasmodium 
• Transmitted from human to human 
• Relative inexperience of line officers with regard to malaria and malaria discipline in high-risk locations
• Combat exposure of troops to drug resistant stains of P.falciparum