Professor Christopher Coker, War and Disease, Introductory Paper for Conference on Disease and Security

Disease and Security
Villa Monastero, Lake Como, Italy 23 April - 1 May 2004

War and Disease
by Professor Christopher Coker

The acknowledgment that disease has influenced war is a comparatively recent one. Thucydides tells us the importance of the plague in Athens in hastening the collapse of the Athenian empire but it was only in the nineteenth century that there was enough understanding of disease to think seriously about disease not as an ‘act of God’ but a problem that had to be factored into military thinking. This was the first era of medical history proper and historians were soon testing the full impact of disease on war (though curiously, they showed much less interest in the impact of war on disease). Thus writing two years before the outbreak of World War Two, Hans Zinsser advanced the provocative thesis that soldiers have rarely won wars; the microbes have. Typhus, plague, cholera, typhoid and dysentery had decided the campaigns for the generals. “The epidemics get the blame for defeat, the generals the credit for victory”.

Perhaps, the main reason for the reluctance to consider disease in the past is that it has appealed so little to the warrior ethos. As Achilles tells us, every life deserved a good death. Achilles’ frenzied wish to kill, Harold Bloom reminds us, is “a dialectical process against mortality itself”. Achilles is not in love with death. Quite the contrary. What we find in Achilles is a zest for life, not a willingness to throw it away in battle. Even in Hades, when Odysseus visits him on his journey home to Ithaca he find Achilles still resentful of death, even the early death he chose for its fame instead of the obscure but long life he might have enjoyed had he never joined the expedition to Troy. Nevertheless, in choosing the immortality of fame to a long but unmemorable life, death is for Achilles free chosen.

How different from our own age. One of the reasons one suspects why war is found so increasingly disenchanting – even by the warriors themselves – is how little the life of the contemporary soldier now conforms to the Homeric ideal. As Thomas Swofford records in a much acclaimed book Jarhead, there is little that is Homeric about the modern soldier issued with atropine and oxine injectors and PB pill packs, all intended to reduce the likelihood of dying from the nerve agents that he or she might be attacked with in battle. In the first Gulf War the main fear was of biological agents especially anthrax against which soldiers were immunised by the thousand. Swofford also tells us he read the Iliad in the field, in the run up to the first Gulf War. Clearly the biotech battlefield is not one in which Swofford feels at home. In Jarhead we say goodbye to the hope of a civilised intelligence that war might be different from what it is.

War, Disease and History
If we seek to gain a larger purchase on the intimate relationship between war and disease, we might look at the ways in which war has stimulated the spread of communicable diseases. The Mongol invasions of the 13^th century including large parts of East Asia, the Near East and Eastern Europe helped to spread various epidemics of the plague from one end of Eurasia to the other. Within a few decades the Mongols had launched an attack from Japan in the East to Hungary in the West. And travellers followed the same invasion routes. Thus the Christian monk Rabban Sauma, born into a Turkish people living on the northern frontier of China, found his way from Peking to Bordeaux, while the Venetian merchant Marco Polo travelled to China with his father and uncle and found employment in the service of the Mongol ruler there.

To take a later example, a cholera epidemic which emerged from Bengal in 1826, quickened once it reached southern Russia. Military movements connected with the Russian, Persian and Turkish wars (1826-29) and the crushing of the Polish Revolt of 1831 spread the disease to the Baltic and thence to England by ship from whence it went to Ireland and via emigration to Canada and the United States. The early nineteenth century industrialised world produced even greater scope for infectious disease than the Mongol invasions. Indeed the cholera epidemics of the 1830s can be seen as the first globalised manifestation of disease.

Later still, towards the end of the First World War the great influenza pandemic which killed nearly 30 million people was a final, if ironic manifestation of the war ‘fever’ which had gripped Europe in 1914. We still don’t know where it originated, whether along the corridors of the rat-infested trenches of the Western Front or in an overcrowded army camp in Kansas, where thousands of American soldiers were preparing for embarkation to France. What seems certain is that the virus was so devastating because much of the population of the world (not only Europe) was undernourished and protein deficient and in the case of Europe emotionally exhausted as well. For the Europeans the epidemic was a cruel epilogue to the suffering they had endured in four years of fighting. It was (writes one historian) “the gleaner of the war’s harvest”.

At the same time another pattern can be discerned. Medical discoveries in the early twentieth century altered the epidemiology of the European armies profoundly. Perhaps, the most important factor was the discovery at the turn of the twentieth century of the role of the louse in spreading typhus fever. This, together with systematic immunisation programmes against other common infections, made the unprecedented concentration of millions of soldiers at the front possible for the first time. Passing men and clothing through de-lousing stations became part of the ritual of going to and coming from the Front and thus prevented typhus from playing a lethal role on the Western Front that it often did in the East. The outbreak of typhus in Serbia in 1915 proved so virulent that the fighting on both sides stopped for six months. In the course of the Russian Civil War three thousand men from General Ydenich’s White Army died in circumstances of despair, filth and misery so frightful that the New York Times refused to publish a graphic account of the episode by its leading journalist, Walter Duranty. The medical discoveries of the early twentieth century, especially with regard to typhus, saved the mass armies of the twentieth century from mass extinction. In a word, they made the world safe for Total Warfare.

The Second World War saw further advances along the same trajectory. New chemicals such as DDT and atabrine made formerly formidable diseases easier to cure or prevent. This explains why logistically states were able to sustain armies thousands of miles from home without the fear that they would disintegrate as they had in the past (vide the cholera epidemic which destroyed so much of Napoleon’s army on its way to – not from – Moscow in 1812). If we look at the scope of German military operations from Narvik to Stalingrad, we find soldiers who, with few exceptions, were unconcerned by the breakout of disease – for the first time in history. By the same token, the slave labour camps and POW camps, as well as other places for displaced persons, shared in the ‘benefits’ – to the same degree. Life behind the lines continued too.

If the belligerents of World War Two refrained from using biological (but not chemical weapons) – though Churchill at one point contemplated a devastating anthrax attack on German cities – in the Cold War that followed the bacteriological war centres continued to produce man-made germs, hybrid strains, even more lethal than those produced by nature. On the very eve of that age, in the atomic destruction visited on Hiroshima and Nagasaki in 1945, many Western visitors were reminded of an earlier plague. A British correspondent, reporting on the effects of radiation at Hiroshima – vomiting, diarrhoea, bleeding gums, loss of hair – spoke of “people still dying mysteriously and horribly from an unknown something which I can only describe as an atomic plague”.

We have now entered a biotechnological age in which the possibility of producing a genetic plague, tailored to the genes of a specific race or ethnic group may well be pursued – by governments, or more likely, by terrorists. In a sense, we have been here before. For there was a natural (not man made) genetic gap between peoples even in the pre-modern era, as the New World found to its cost in conflict with the Old. The latter populations, the only ones living in intimate symbiosis with large numbers of domesticated animals, had had to come to terms with the germs these animals carried. With the passage of time the peoples of Africa and Eurasia built up a measure of genetic resistance. The effect was precisely to create two kinds of human beings – those who had this protection, and those who did not. When the two came into contact, the effect of the Old World germs on a genetically unadapted population was devastating.

The fate of the Aztecs was due to two factors: their susceptibility to Old World microbes and the technological gap between Spanish arms and their own technology. Of the two factors, Spanish germs proved more lethal than Spanish arms. Even the Spanish allies, the Thaxcaltecans, suffered massive mortality despite the fact that they had forged a close alliance with the invaders (they had the right to ride a horse and be addressed respectfully as ‘Don’). The demographic collapse that followed the arrival of smallpox ended any possibility of a Spanish/Indian ‘partnership’ in Latin America. Worse, it forced the Europeans to bring in ten million Africans to the New World as economic workers in the transatlantic slave trade. Perhaps, the impact of the symbiotic relationship between war and disease has never had such an unprecedented scope as the ‘Columbian Exchange’ between the Old World and the New. Of course, if smallpox and measles took their toll in Mexico, syphilis went the other way. Historians still dispute whether the origins of syphilis are to be found in the New World but most accept the case. If true the ‘exchange rate value’ of smallpox was far greater than that of syphilis.

Looking back at the history of war and disease, there is a sense in which disease somehow seems to play ironic games on human beings and their aspirations. It would seem that nothing can disturb the microbes waiting to strike when least expected. In Alsace on 6 July 1885 a rabid dog bit the nine-year-old Joseph Meister. Meister was the first patient to be saved by Louis Pasteur with quinine. He was also the first janitor of the Pasteur Institute and he committed suicide fifty years later when, following the French defeat, the Germans occupied the building. As the poet Miloslav Holub later concluded, “only the virus remained above it all”.

Globalisation, War and Disease
Threats from disease in general now account for 26% of all global deaths annually and are the second largest cause of human death. By comparison deaths from war only constitute 0.4% of the global death rate. Even if this figure is imprecise it still remains miniscule compared to the big killers. Death from war is now far less frightening than at any other time in history. Death from disease is much more significant. The upshot is that disease itself has become a security problem of the first order.

Disease has become one of the ‘amplified fluctuations’ that distinguish globalisation: an outbreak of a major epidemic in one end of the world can easily affect a population in another. The threat is two-tiered. The first consists of the immediate danger from the disease itself. Highly contagious deadly diseases can cause the sudden death of thousands or in the worst case millions of persons in a short time, depleting society of vital human resources and risking fatally overloading the health system, sparking major secondary health problems as a result.

The second tier consists of the impact of human reactions to the outbreak of a pandemic disease. Fear and panic following the outbreak of a deadly pandemic could restrict the movement of goods and people. Thus even a relatively mild disease such as SARS – with limited contamination and a low death rate of around 5-15% – had noticeable economic consequences. A 2% drop in GNP for 2003 is forecast in East Asia as a direct result of the cuts in investment and trade. In addition, other global industries notably airlines and tourism dropped sharply. The secondary consequences of truly lethal disease – such as for example weaponised smallpox – could well produce a major global system crash.

Off all the new security challenges thrown up by globalisation none is more grim than HIV-AIDS. At the end of 2000 36 million people were living with this condition (70% of them in sub-Saharan Africa). More than 5 million new people were infected that year. And the death toll is continually rising. Every day the number of people who die is twice that of victims of the World Trade Center attack.

What is the security aspect of the threat? Some identify the problem of failed regions (not merely failed states), the traditional market for peacekeeping. The problem is that peacekeepers form the highest risk group. Sexually transmitted diseases are five times higher in the military population than they are in the civilian.

The peacekeeping implications of the HIV-AIDS pandemic have been well documented by the United Nations. The UN heavily relies on Nigerian, Indian and other third world peacekeeping forces. Western armies though operationally more effective are small and already overstretched. But what if peacekeepers export AIDS to the countries in which they operate? The Cambodian government certainly holds responsible the UN Transitional Authority for its present AIDS crisis even though there is no epidemiological data to determine its responsibility for introducing AIDS into a country that had no record of it before their arrival.

If we look at its impact on war fighting and the three components of armed conflict: the status of combatants; the way in which conflicts are conducted; and the social significance of war, the picture is equally bleak.

The HIV epidemic has already begun to diminish the operational efficiency of many armed forces. The US National Intelligence Council lists HIV prevalence in the armies of Angola as high as 60%. In Zambia the figure is so high that the authorities no longer disclose it. This may translate into a possible reduction in the manpower of African armies of between 20-50% by 2005. Clearly this could lead to a decrease in the available recruitment pool. Death amongst officers is usually higher than death in the ranks and thus has implications for the chain of command. And the loss and death amongst the specialised members of the armed forces is particularly high, which has obvious implications in itself.

But HIV-AIDS has consequences for international security more generally. Why, for example, are there six armies in the Democratic Republic of Congo? One explanation is that the Zimbabwean army at least is there to pay its health bills. The average health bill with Western medicines for surviving AIDS is $20,000 per annum. And the average African officer receives less than a few thousand dollars per year. Pillaging a neighbouring state is a way of affording drugs. To paraphrase Clausewitz, we may say that war for some countries is becoming ‘the continuation of medicine by other means’.

HIV-AIDS is also a weapon of war. The deliberate targeting of civilians, especially the rape of women, has long been a feature of what Mary Kaldor calls ‘the new wars’. Humans Rights Watch has documented the systematic nature of sexual violence perpetrated against women by the armed forces in societies such as Rwanda where up to 500,000 women may have been raped. In Kigali alone the evidence is that 100% of them were.

There is some disturbing evidence that some soldiers in societies other than Rwanda have used rape as a weapon and AIDS as a psychological weapon of that. It is difficult to know how deliberate this is but according to evidence some rapists tell women ‘we’re not killing you. We’re giving you something worse’. The deliberate transmission of HIV is part of the growing inhumanity of war.

And HIV can be transmitted, of course, independent of rape. South Africa’s Truth and Reconciliation Committee heard testimony in 1998 about how the apartheid regime intended to use infected blood in military operations. And we know of an attempt to use four HIV positive freedom fighters from the ANC (who had switched sides) to infect sex workers in two hotels so that they would spread HIV among their black clients.

These questions are raising doubts about the continued viability of war as an instrument of policy. Today African civilians who survive war may still face the appalling prospect of a slow and painful death in the future. Casualties such as these may outnumber those resulting from military conflict itself. Thus the growing influence of HIV-AIDS in conflicts in Africa, writes Stefan Elbe, may present the same stark choice that Western Europe faced half a century ago: either you abolish war as an instrument for addressing political differences, or you abolish yourself.

HIV-AIDS as a metaphor
Finally, AIDS raises a very specific question about how we conceptualise security. For it raises this question: is the war against AIDS a war against the virus or the people who have it? Is an entire continent, or countries therein most at risk, in danger of being written off? The whole field is increasingly politicised. The language between the normal (which is always normative) and the pathological (between those we hold to be innocent and those we judge to be guilty) is one that predisposes us to see people and even countries in a particularly disparaging light.

AIDS – for many – has already become one of the determinants of the so-called ‘African Condition’, yet another feature of what The Economist calls ‘the hopeless continent’. AIDS, writes Susan Sontag, is a metaphor and that is where the problem lies. For we talk of its long incubation periods as far more dangerous than the virus itself. We see AIDS as a ‘stealth’ virus for that reason. You can live with it for many years without knowing you have contracted the disease.

So it encourages us to think of security not in terms of what ‘is’ but what may yet ‘become’. Instead of trying to confront a danger, we confront ‘dangerousness’, an idea which encourages us to evaluate a threat at the level of its potentiality, rather than the level of its immediacy. Quarantining societies is one way by which we can deal with the virus, as we quarantined people during the SARS epidemic a few months ago. It is a typical example of how a risk society, obsessed with the potentiality of risks, tends to function.

Globalisation, in short, has created a new type of enemy stereotyping. We now have to defend ourselves not so much against threats (the number of tanks/planes/army divisions) but risks, and the best way to tackle risks is to act pre-emptively. The ‘precautionary principle’ of which we know so much in environmental and domestic health matters, is increasingly becoming a favoured principle of security as well. It would appear that pre-emptive strategies now belong not only to the war against terrorism, but also to the war against disease.