Book Review -- War Epidemics: An Historical Geography of Infectious Diseases in Military Conflict and Civil Strife, 1850-2000

John S. Marr, MD, MPH

Disclosures

March 21, 2005

By Matthew R. Smallman-Raynor; Andrew D. Cliff
Oxford University Press
Copyright 2004
839 pages
ISBN: 0-19-823364-7
$200 hardcover

One may find the price (US $200), length (839 pages), and title of this book ( War Epidemics: An Historical Geography of Infectious Diseases in Military Conflict and Civil Strife, 1850-2000 ) daunting. The subject is also daunting: an elucidation of synergies between war and pestilence, 2 apocalyptic horsemen. However, War Epidemics is largely successful in discussing the subject in the context of what the authors define as "historical geography." Indeed, this book was not meant to be, nor is it, an encyclopedic account of all war epidemics.

Drs. Matthew Smallman-Raynor and Andrew Cliff are professors of analytical and theoretical geography at The University of Nottingham (Nottingham, United Kingdom) and Oxford University (Oxford, United Kingdom). They define historical geography as an interdisciplinary effort to assess wartime disease impacts that are based on reliable, analyzable, archival, war materials.[1] Smallman-Raynor and Cliff have chosen to examine "modern wars" because reliable information became available largely after 1850. These data allow them to create elaborate modeling that may best explain disease spread (for example, the diffusion of HIV/AIDS in Africa). They are selective in their analyses, and this may limit interest in those who desire complete, one-stop shopping for a definitive book on wartime-associated epidemics.

The authors initially provide definitions, classifications, and trends of "war" (and lesser, allied conflicts), and discuss why civilian and displaced populations must also be considered in these analyses. Using epidemiologic organizational methods and sophisticated biostatistical modeling, they describe and analyze hundreds of major conflicts and their attendant sequelae in meticulous detail. They then offer observations on ancient wars and pestilences in the first 100 or so pages. Additional information on these pre-1850 "qualitative" (but not quantifiable) wars would have been a wonderful additional resource for the infectious disease historian. But, in fairness, the authors do not claim to comprehensively cover all war epidemics, although they may have nearly done so. The early tables, maps, figures, and references to arcane battles in remote history provide an invaluable resource for those who need detailed references and citations.

The authors make comparisons between historical morbidity and mortality trends in peace time vs war. They follow with discussions of massive civilian dislocations. But these are a preamble for the major thrust of the book: time-space analyses of major post-1850 conflicts. The authors' rationale for civilian peacetime-wartime statistical comparisons appears logical, allowing a case-control comparison of disease rates and the discussion of a "third" population affected by war (in situ civilians, refugees, displaced persons, concentration camps, prisoners of war, etc). The authors posit "a basic epidemiological principle": "the geographical dispersal of highly concentrated (urban) populations -- like the geographical concentration of widely dispersed (rural) populations -- serves as an efficient mechanism for the historical propagation of war epidemics in civil populations.[2]" In other words, an army conscripted from urban dwellers who are then marched into new territories will spread disease. At the same time, immunologically naive rural populations, when forced behind besieged walls, fall victim to and spread common communicable diseases. Variants of this principle become a major leitmotif throughout the book, and may be considered a corollary to Crosby's concept of "virgin soil epidemics.[3]"

The format of this impressive book is noteworthy: Four large sections encompass 13 chapters, numerous figures (202), plates (32), and tables (132). This schema, not unlike a strategic battle map, is assembled in an early, full-page figure: Parts and chapters are encased in boxes, and arrowed enfilades demonstrate the marshaled advance of each chapter.[4] Most of the figures and tables are complex and original; and many are worthy of Edward Tufte's consideration as outstanding examples of the visual display of quantitative information.[5] A few approach the brilliance of Charles Joseph Minard's map of Napoleon's Russian campaign.[6] One could linger on the implications of a graph, map, or single table for hours; the same graph, map, or table could also provide information for a lively hour's classroom discussion. For example, Figure 3.7 summarizes combined global mortality trends expressed at standardized mortality ratios over a 75-year time period (1900-1975) from 31 countries, on the basis of 53 of the International Statistical Classification of Diseases, 10th Revision ( ICD-10 ) codes subsumed under 5 disease rubrics.[7] Another map figure (Figure 4.5) displays proportional battle and disease-related death ratios from 23 major American Civil War conflicts between 1861 and 1865.[8]

Part III, the largest portion of the book, is devoted to an in-depth discussion of major conflicts selected from a 5 x 5 matrix of world regions and disease themes. Thus, Pan America, Europe, Asia/Far East, Africa, and Oceania are cross-tabulated against military mobilization, military camps, emerging and re-emerging diseases, sexually transmitted diseases (STDs), and island epidemics. Five chapters are devoted to a discussion of each of these themes; a sixth chapter deals with 4 other unique themes seen in 5 other wars (Table IIIA).[9] A final, brief Part IV ends the book with discussions of the first Gulf War, Bosnia-Herzegovina, Afghanistan, and the Sudan as well as a brief summary of biowarfare and bioterrorism activities and the future war-associated morbidity and mortality projections.

The National Academies' matrix of conditions contributing to disease emergence mentions over 2-dozen contributing factors,[10] with "war" being one. War Epidemics goes much further in explaining exactly how war rapidly produces ecologic change, population displacement, and environmental disruption, fostering new, unnatural nidalities for rapid diffusion of these diseases.[11] For example, Chapter 9 ("Asia and the Far East: Emerging and Re-emerging Diseases") deals with more recent events (World War II, Korea, and Vietnam), offering fascinating historical details to the emergence of scrub typhus, Korean hemorrhagic fever (KHF), and pneumonic plague, respectively. The map of scrub typhus outbreaks in India and Burma in 1943-1945 is a labor of love, demonstrating both qualitatively and quantitatively the concept of mite island nidalities.

A similar series of maps and graphs of KHF cases in 1952-1953, with an attendant discussion, focuses on how the displacement of organized farming near the battlefront fostered the emergence of hantaviral disease from burgeoning mouse populations in the central plains of Korea. Figures 9.12 through 9.14 are a series of graphs, maps, and histograms documenting the incidence of plague in Vietnam from 1906 and its spread in the years 1951-1970. The authors discuss the reversal of rice delivery from rural areas to cities during the Vietnam War that caused infected rodents to "follow the rice" into the interior. Chapter 10 ("Africa, STDs and War") discusses traditional STDs in various parts of Africa during wars, but is primarily a vehicle to promote the authors' previously published civil war hypothesis as being superior to the truck down and migrant labor hypotheses in explaining the spread of HIV/AIDS from the late 1970s through the 1990s.[12] Again, superbly drawn maps, intriguing figures, and methodical statistical analyses are fascinating and overwhelmingly convincing.

Experts in infectious disease epidemiology and military history may be knowledgeable about many of the major historical consequences of disease and war. They will certainly appreciate the synergies created when many new accounts of wartime diseases are juxtaposed. This work provides countless new facts and observations, and a wide array of tables, figures, and commentaries. For example, the authors offer a fresh look at the dispersion of the 1918 influenza pandemic and a discussion of mitigating results of a massive maritime quarantine imposed by Australia on its returning troop ships.[13] Numerous epiphanies, the value-added intellectual candy of this book, are quite common, arguing for more interdisciplinary works within the social sciences.

Unfortunately, the book gives only a relative nod to pre-1850 war epidemics, because the authors argue that their formulas are not amenable to qualitative data. Yet, with minimal effort Smallman-Raynor and Cliff could have easily supplemented Part I with fuller discussions of many historic qualitative accounts of pre-1850 conflicts. These might include the historic consequences of yellow fever epidemic in Napoleonic Hispaniola.[14] The post-1850 analyses omit a discussion of the emergence of Schistosoma japonica as a significant cause of morbidity in the conquest of Leyte,[15] whereas the obscure outbreak of Bullis fever[16] receives more space than a concurrent 1942-1943 epidemic (28,505 cases) of hepatitis B in US Forces from contaminated yellow fever vaccine.[17] The dramatic effect of tetanus prophylaxis in Allied troops during World War II is also not mentioned. (The Axis powers were controls.) Although not communicable, tetanus has to have been a major historical wartime problem: "tetanus among U.S. troops declined from a rate of 200/100,000 in the Civil War to 0.6/100,000 in World War II.[18]" Surprisingly, there is no mention of disease in World War II German concentration camps (of which the data are presumably available), although analyses of the diaspora of postwar refugees and other more recently displaced populations are quite detailed.[19]

Visually presented statistical analyses are the métier of the authors; many are sculptured masterpieces of data. Their inferences, based on sophisticated formulas, are used to explain the preferential vulnerability of troops (and civilians), spread (diffusion) of disease, outcomes of battles, etc. However, some conclusions appear intuitively obvious, and many formulations and their rationales are distracting, and might have better been placed as end-chapter appendices.

Smallman-Raynor and Cliff allude to John Keegan, an eminent war historian. Keegan exudes enthusiastic warmth in his writings, which seems lacking in War Epidemics . It is clear by many internal references that the authors envision this book as a work in progress. Had they chosen to write their book on the basis of all the data that they have amassed, it would have been unwieldy, and probably tripled its length and expense. Yet, War Epidemics is a most beautiful, ongoing project, and we should hope that the next addition will add even more flesh, mind, heart, and soul to what is already a seminal work on war and infectious diseases.

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