Why The Military Makes Public Health A Priority – Analysis

By Sanders Marble

The military is involved in public health because diseases do not respect a uniform. The mosquito cannot tell whether the arm is in a uniform or not. The military has to protect itself-campaigns have been affected (even lost) because a force was unhealthy due to communicable disease. The military also has to protect the people on its bases or communities. It must keep its forces force healthy, and- when it provides housing- it takes on responsibility that the housing be healthy.

The U.S. government has a responsibility to the population they are overseeing. Specifically, the Army does not want to bring diseases back to the United States and cause a problem. For instance, malaria was brought back to the United States during the Vietnam War because patients had not taken their anti-malarials. When they were flown back to the United States, mosquitoes bit them and then bit other people, spreading malaria.

So the military gets involved with research. Generally, this is identical to civilian research (the medicine is the same, and military-specific work benefits everyone) although there are different interests. For example, malaria is not a major concern in the United States, but the military is definitely interested. Implementation is a very different matter. Civilian public health departments have far fewer tools available-shutting down restaurants, declaring quarantines, denying children access to school for not being vaccinated, but not a great deal more. The military, on the other hand, can order vaccinations, order bug nets/bug spray, order trash removal, and back up initiatives with threats of punishment.

THE HISTORY OF MILITARY MEDICAL RESEARCH

Before the Germ Theory of Disease, there was little understanding of what caused disease. The Army tried to reduce disease, largely through better sanitation. Clean quarters, clean latrines, clean water-these were recommended from the earliest days of the United States. However, these were merely empirical rather than having a strong chain of If-Then.

There were few active measures to take. In January 1777, a multi-colony smallpox epidemic broke out. George Washington had some tough choices: he could hope that it missed his army and do nothing, or hope that inoculation would not cause a general outbreak-and that the British didn’t attack while his troops recuperated. In February (with the epidemic spreading), Washington went ahead with inoculations, deciding that was the lesser risk. It paid off: only 8 per 1,000 died, and the smallpox death rate in the population fell from 160 per 1,000 in 1777 to 3 per 1,000 in 1778.

When Edward Jenner introduced vaccination rather than variolation, the Army seized upon it almost immediately. All troops were ordered to be vaccinated. This measure prevented soldiers from developing smallpox and, consequently, it did not spread around the country.

The first Surgeon General, James Lovell, had a strong interest in reducing disease in the Army. He directed the post surgeons (the physicians in charge of medical care at posts) to record not only what their patients suffered from, but also the weather conditions. He hoped to find what climatic conditions caused particular diseases-an attempt to put science into the miasmatic theory of disease. He also oversaw the (long held) sanitary precautions. But there was nothing more to be done.

By the 1840s, the “Sanitary Reform Movement” was underway. It ran through the Victorian Era, influencing matters as varied as medicine and city planning. It started with Edwin Chadwick’s report on the health conditions of the poor, “General Report on the Sanitary Conditions of the Labouring Population of Great Britain.” Bad housing, bad water, and lack of baths led to bad health results. Chadwick’s findings led to projects for providing clean water, building sewers instead of having cesspools, establishing public baths to let people wash, and tearing down slums to build better housing. All of these ideas were compatible with both miasmatic theory and Germ Theory. And they spread to the United States. Lemuel Shattuck did much the same work in Massachusetts. Though these new ideas took shape before the Civil War, they had little effect because it was too early. Means of cleaning the water were not yet developed and implemented. The Germ Theory developed during the 1860s and 1870s, but it would take a couple of decades to gain wide acceptance.

However, the Army plunged in. Doctors at dusty frontier posts could get microscopes and explore for bugs. As post surgeons, they were also responsible to the Commanding Officer (CO) for overall health on post, e.g. the water supply or adequacy of housing. From 1889 onwards, when the surgeon made a recommendation on health, the post commander had to commit to paper his “yes” or “no.” Now the CO would have to go on record about science and progress. In fact, Henrik Ibsen’s An Enemy of the People is about the issues that civilian physicians faced on these topics.

In 1893, George Sternberg, an excellent researcher, was appointed Surgeon General of the Army. Three weeks later, he established an Army Medical School (AMS) from the belief that “a special education is needful to prepare a military man to undertake the protection of the public health.” It was not a normal medical school; it was a post-graduate (i.e. post-MD) institution that taught some Army topics (uniforms, saluting, and equestrian skills) and some Army medical topics, such as surgery. It also taught public health-because the Army was responsible for it.

There was a Professor of Military Hygiene (John Billings, already a past president of the American Public Health Association) and a Professor of Bacteriology, one Walter Reed. As the civilian medical world would recognize, the Army had the first preventive medicine/public health school in the country. And that’s because the Army has broader responsibilities: civilian medical schools trained general practitioners who did retail care in both senses of retail. They provided care in small numbers and for money while the Army had an interest in doing it wholesale (for larger numbers).

The Army Medical School also conducted research. Typhoid was a major problem in the Spanish American War. More soldiers died of typhoid in training camps than died from battle, and that was bad for public relations. So Sternberg appointed a Board to investigate. They made important contributions in science- they identified a carrier stage, proved that typhoid was not bad water but an infection (brought by the soldiers from civilian life, such was the state of American water supplies), and showed that flies spread it.

By 1908, the AMS had developed an experimental vaccine, and in 1911 the Army made it mandatory. A few years later, World War I erupted and the Army ramped up vaccine production to 18 million doses, with obvious and excellent results.

THE SPANISH AMERICAN WAR

The United States also faced new tropical medicine problems-it controlled Puerto Rico and the Philippines, and had a major interest in Cuba. Bailey Ashford investigated anemia in Puerto Rico to determine if the Army was at risk. It wasn’t-unless soldiers walked around barefoot and got hookworms. This research, resulting from a concern for soldiers, mainly benefited civilians. Ashford’s work also interested John Rockefeller in public health, and in 1913 that led to the creation of the International Health Commission. Between the world wars, $25 million was spent on schools of public health.

A more famous outcome of the Spanish American War was yellow fever research. Yellow fever was a problem in Cuba during the war, and afterwards. (In 1885 there had also been a devastating yellow fever epidemic in the Mississippi Valley, so yellow fever was America’s problem also.) The initial effort was focused on clean up-the sanitary engineering approach. Sewers, fumigation, hand washing, and better water supplies were implemented, but with no results.

So Sternberg appointed another Board with Walter Reed at the helm. His Board determined how yellow fever spread: mosquitoes. If the relevant mosquitoes were killed, the yellow fever endemic could be controlled. The Army had the tools to compel civilians to change in ways an elected government in the United States could not. Such requirement included: covering and screening water cisterns, implementing anti-mosquito patrols, oiling puddles, and digging ditches to drain marshes-literally draining disease out of the swamp.

William Gorgas had earned enough of a reputation in Cuba- as an implementer of control measures -that he was sent to Panama to head up the medical side of building the Panama Canal. With much labor and political support (he was backed by the President when the overall director of the canal effort wanted to sack him for demanding too many resources), Gorgas accomplished his task.

In 1900, the Army also set up a Tropical Disease Board in Manila. This board lasted until 1933, and was revived in Panama in 1936. It drew in local expertise and experience, but also dealt with a variety of diseases because they were endemic where the Army would be operating. Medical concerns studied included beri-beri (the first deficiency disease, though nobody knew it was a deficiency disease), plague, malaria, dengue, rinderpest (the Army had animals) and surra.

During World War I, the Army faced different problems. Physicians could not undertake all the necessary work so the Army brought in other peri-medical specialists; then created a new organization, the Sanitary Corps. Relevant here are the Sanitation and Laboratory officers. Their employment by the Army gave them more prestige after the war-the Army commissioned these men; their work was serious and professional.

The Army’s biggest public health topic during the war was a disaster: the 1918-19 influenza pandemic. It likely began in Haskell County, KS, and the Army inadvertently spread it around the country. Draftees from Haskell County went to Camp Funston, at Fort Riley, where they were packed into barracks. The Surgeon General had asked for the normal amount of space per man (72 square feet) to put more space between coughs and sneezes. However, the Army needed to mobilize quickly, and the Chief of Staff, accepting the risk, decided to pack the troops into 40 square feet. These conditions helped the flu spread, so that hospitals were equally packed. When crowded troop ships took troops to France they took the virus there, as well.

Given that the first viruses were not isolated until the 1930s, there was no treatment in 1918. Prevention was the only option. All kinds of activities spread the virus-war bonds rallies, working in war factories, packed trains. Many people died, partly because the virus killed the healthy people. A V-shaped graph is more common, with old and young dying, but the immune system over-reacted so the strong, healthy people died, too.

Another issue the Army encountered for the first time was mental problems. When the United States went to war, the Army had heard about “shell shock” and wanted to do everything possible to avoid it. Prevention is, after all, better than curing. The prevailing idea was that smarter people were more psychologically resilient. So the Army screened recruits for intelligence. Psychologists volunteered their services to the Army, and the Army Medical Department happily accepted them. Since there were many illiterates (immigrants who didn’t know enough English, people who’d left school to work, African-Americans who received a segregated education, and others) the Army developed literacy tests. There were issues with the tests, however, because they were skewed. In some tests, a knowledge of tennis was necessary to identify missing objects. So the data was skewed. (In the 1920s this data was used by others to argue (successfully) for limits on immigration.)

After World War I, there was a slight increase in the number of schools for Public Health. Sternberg, in retirement, established one in Washington, DC, but only 4 or 5 were operational by the 1920s. Jurisdictions start adding Public Health officers–doctors and nurses. But the positions were poorly paid (especially in comparison with private practice) and had few benefits.

The American Medical Association (AMA) lobbied against Public Health. Public Health jobs were typically low-paying (government) jobs, and there was rarely the satisfaction of seeing patients respond to treatment. The AMA also worked to keep instruction out of medical schools. So the Army was one of the few areas where there was long-term growth. The Army expanded its course to 14 weeks and built new facilities. From 1921, the American Journal of Tropical Medicine was edited by various officers in the Army Medical School-the Army was the only organization in the United States that had a long-running interest in tropical medicine.

By World War II, the Army was entering some new areas. Issues, like industrial hygiene and occupational health were studied by the Army because it was running industrial plants and wanted to keep its employees as healthy as possible.

The chief of Preventive Medicine also reached into the civilian world for expertise. Not only would doctors be putting on uniforms, he created a board (ultimately titled the Army Epidemiology Board) that would have 100 eminent civilians on 10 sub-committees. This board helped both the military and the Public Health world. The military profited from the expertise of the medical elite (who were draft exempt), while the Public Health world had the aura of helping national defense. For the boys in uniform, there were plenty of vaccines required, but none helped with malaria. Thanks to the war in the South Pacific, malaria was a huge problem.

A major effort was initiated to find better drugs, and Atabrine was a key. But malaria discipline broke down early in the war. Inadequately equipped troops went into action in the South Pacific, they couldn’t get enough bug dope or bed nets. They wouldn’t take their pills properly-and disease rates skyrocketed. Douglas MacArthur commented that it would be a slow war if he had a division in the hospital and another recuperating for each one in action.

The Army created a School of Malariaology training units in two areas. First, they supervised malaria control, and second, they dug the ditches and sprayed the oil. There were also campaigns directed at encouraging troop compliance, and new tools (the pyrethrum ‘bomb’) to zap bugs in buildings.

In late 1943 an epidemic started in Naples, Italy-refugees, a collapsing local health system, and a crowded and dirty population set the stage. Enter DDT. A five percent powder, puffed out of a duster, killed the lice-and the effects lasted for weeks. The epidemic was quickly broken.

Since DDT was wonderfully effective against other bugs-including mosquitoes that spread malaria and other diseases-it was widely used after the war. The World Health Organization (WHO) initiated a major campaign, thinking that malaria might be eradicated by wiping out the relevant mosquitoes. There were significant -side effects, however.

WARTIME EFFORTS TO CONTROL MALARIA

Malaria was a problem throughout much of the United States; prompting the creation of the Office of Malaria Control in War Areas (OMCWA). Since mosquitoes could fly from off-post to bite soldiers, and the Army lacked authority off post, someone had to coordinate the dozens of local and state health departments with the Army. It involved lots of committee meetings, but it worked. OMCWA was located in Atlanta, because that’s where Third Service Command was based. There was a high volume of malaria in the southeast. After the war, it was one more government program that never went away. In fact, it expanded from covering only malaria to covering other civil-military problems.

America has had a complicated history with sexually transmitted diseases (STDs), and the Army is no different. There are problems with virtually all options (abstinence-only, punishment for contracting disease, treating contraction of diseases as immoral and/or illegal, etc). The Army has vacillated on treatment policy. However, it had always discouraged Venereal Disease (VD) because it kept soldiers from duty. At times, VD was one of the leading causes of medical discharges. For instance, advanced syphilis can kill, and soldiers were discharged once they had nerve damage. Until 1910, mercury was the only effective treatment, and it has massive side effects. There was still nothing to treat gonorrhea, and condoms were not popular a century ago.

By World War II, penicillin could quickly cure most VD. Just before D-Day, the Army was accused, by civilians, of hoarding penicillin for VD cases. However, it was actually stockpiling it for anticipated invasion casualties. The Army was unable to say anything for fear that the Germans would hear about it.

The occupation of Germany and Japan after WWII proved a major public health problem for the Army. Food was short, there were millions of displaced persons (refugees); Prisoners of War, Recovered Allied Military Personnel; and concentration camp survivors. In both countries, infrastructure was badly damaged and sanitation was a mess.

The “former regime elements” had to be removed from office while the Army attempted to run as many public health programs as possible through locals. The Army did not want to get involved with retail patient care. The objective was to get the locals back on their feet and brought to good standards. The problems were daunting-and took years to fully solve. The efforts were helped by: identifying the problem early (before occupation of enemy soil); the front gradually advancing rather than having to do everything at once, and by bringing in civilian sector experts (public health officers and nurses from civilian life). The efforts were also aided by the lack of resistance. In other words, the Italians, Germans, and Japanese accepted their defeat.

After the war, public health was accepted by the medical community-with a board established in 1948, and state recognition quickly spreading. The Army’s role during the war-training doctors in public health and persuading medical schools to teach some public health (and tropical medicine)-probably nudged the AMA towards accepting public health.

The Army Medical School became the Walter Reed Army Institute of Research and continued doing good work. Joe Smadel discovered what chloramphenicol could do against scrub typhus, the first specific treatment for a rickettsial disease. Ed Buescher and Maurice Hillman isolated the Asian influenza virus and another team isolated rubella. Both led to new vaccines. But civilians were also providing marvelous research. Jonas Salk and Albert Sabin found ways to prevent polio. The focus had changed from the environment (getting rid of mosquitoes, for instance) to protecting the individual. Vaccination was still the preferred route, but taking pills proved easier and was cheaper for the United States in foreign countries. Whether the results were lasting for the locals was not necessarily the Army’s problem.

Vietnam created a different dynamic than that of Germany or Japan. The United States was trying to build up an allied government, not impose American ways of doing things. This was in part because that could have been grounds for anti-imperialist rhetoric. But there were lots of endemic diseases, and the indigenous standards of sanitation and health were not high. But the Army’s focus was on individual protection and treatment (whether it was insect repellant against mosquitoes, or treatments for skin diseases and plague), rather than on collective protection.

PUBLIC HEALTH TODAY

In recent decades, public health (at least in the United States) has changed to education. This education includes diet and exercise, risk awareness, and trying to steer people away from high-risk endeavors. And of course the United States, generally, has the infrastructure (sewers, water supplies, etc.) for good public health.

In many ways, the Army now runs a pretty normal public health campaign. Yet, there are still military-specific problems. The military mostly operates outside the United States, so tropical diseases such as malaria need research. While organizations like the National Institute of Health (NIH) research AIDS in the United States, the Army is involved in clinical trials of a multi-strain HIV vaccine in Thailand. And the military faces biological weapons threats.

In summary, the Army has been interested in public health because it needs to be healthy to do its job, and to protect those for whom it is responsible. It played a useful role in advancing public health, in general, when the general medical community was not interested; it has made key advances at times, but has also taken advantage of civilian advances. The Army’s requirements are different than those of American society, and so are the military’s tools. But science and command authority have to come together to prevent disease.

Sanders Marble holds degrees in history from William & Mary and King’s College, University of London. He has worked at the Smithsonian’s National Museum of American History and since 2003 has been an Army medical historian, including at the Surgeon General’s Office and Walter Reed Army Medical Center.

This essay is based on a talk given at a History Institute for Teachers on The Role of the Military in America’s Domestic History, sponsored by FPRI’s Wachman Center and by the Cantigny First Division Foundation, and held at Cantigny’s First Division Museum in Wheaton, Illinois, April 10-11, 2010. This is part on an ongoing focus on U.S. military history; for video files, texts and lesson plans from previous programs in this series, visit: www.fpri.org/education/militaryhistory.

The views expressed in this essay are the author’s alone and do not necessarily reflect those of the U.S. government.