*The following blog post was written by 2013 Margaret Angus Research Fellow Robert Engen.
As we saw in the last blog post, from a medical point of view the two military campaigns to capture the Dutch island of Walcheren – the first in 1809, the second in 1944 – could not have been more different. The 1809 British expedition was ravaged by disease, a lethal combination of malaria, typhus, typhoid fever, and dysentery that infected over 60% of the force, killed over 4,000 soldiers, and left tens of thousands as casualties. But in 1944, the Canadian Army, fighting over the same ground, suffered only a small number of casualties from disease, a negligible number from the specific infectious pathogens of 1809, and virtually no deaths from illness.
What caused such a drastic change? The answers can be found in the domain of public health practices. Surgical practices and technology had improved considerably, nursing had become a major component of medicine, and acute care treatments had advanced, meaning that few people infected with a disease would die from it; but, the critically important change was that in 1944 only a tiny percentage of soldiers were falling ill in the first place.
By 1809 it had been long-established that hygiene and sanitation measures were essential to the protection of military forces. The earliest-known strictures about military hygiene come from the Old Testament, commanding the soldiers and the people of Israel to wash their hands and themselves repeatedly, to shun polluted or dirty garments and objects, quarantine infected individuals, and bury human waste and excrement far from camp. Throughout the eighteenth century in particular a body of useful military-medical knowledge had arisen thanks to pioneers like Sir John Pringle. Pringle’s medical volume Observations on the Diseases of the Army (1752) prescribed most of the principles and preventive medical practices still used today, except of course for those based on a knowledge of the microbial causes of disease: a strict sanitary code involving the proper disposal of waste, construction and care of latrines, quarantine of the sick, the selection of campsites, the policing of hygiene, the avoidance of concentrating diseased soldiers in central hospitals, and close attention to food and drinking water. Pringle and his contemporaries knew, through observation and trial-and-error practice, that prevention of disease was based on hygiene and sanitation; however, good hygiene and sanitation were based upon officers actively enforcing medical discipline.
By the time of the Walcheren Expedition there had been a body of military medical literature describing how to mitigate the worst effects of disease for at least sixty years, yet, this good advice was often disregarded. Military medical practitioners in the eighteenth and early nineteenth centuries were usually treated with exasperation by commanding officers, and their opinions were not always taken in to account. Physicians and surgeons were of low status in the British Army, had few hopes for advancement, and were unable to actually exercise their officer rank and issue orders to soldiers. Knowledge on preventive medicine was available, but that knowledge was frequently ignored by military commanders who felt that they had more pressing concerns. Military casualty lists continued to contain overwhelmingly the names of those who died of disease, not from battle. During the 1809 Walcheren Expedition in particular few of the “best practices” recommended by Pringle and other eighteenth century practitioners were followed. When combined with horrible conditions and bad luck, this created a medical disaster.
The importance of public health measures in the civilian sphere increased significantly during the nineteenth century, as governments and health authorities slowly (and unevenly) began to link unsanitary living conditions with the prevalence of infectious disease. Scientific medicine and bacteriology began to identify microbes as the true source of illness, and these discoveries often reinforced older ,established preventive health measures. Vaccination, which began for smallpox in the eighteenth century, became an emblematic tool of public health campaigns as vaccines were developed against a number of diseases, including typhus and typhoid fever. Both the infection and the death rate from communicable disease fell considerably in the Western world between 1809 and 1944 as a result of the rigorous application of sanitation and hygiene measures, vaccination campaigns, and improvements to living conditions.
Despite the growth of public health and the fact that the essentials of public health had been identified by military medical practitioners significantly before the modern civilian public health movement, armed forces were slow to adapt. At the end of the nineteenth century armies were still losing more soldiers to fatal infectious disease than they were in battle, in part because battlefield conditions rarely contributed to hygiene.
But by the time of the Scheldt Campaign of 1944, a true reversal had taken place. Hygiene and sanitation had become central to army policy. The British War Office had proclaimed that its Army Manual of Hygiene and Sanitation “must be studied by every office, [warrant officer], N.C.O., and man. Every opportunity must be taken, especially at camps of exercise, to study the practical application of the instructions given in this manual.” The principles of preventive medicine were widely known, medical officers had command authority to implement health measures, and commanding officers were sacked for allowing medical discipline to grow slack. Medical practitioners were being brought in to every stage of Allied military planning. Doing so was a necessity: even during the Second World War there were major outbreaks of epidemic disease wherever public health measures began to falter, such as in the German Afrika Korps or the armies battling in Burma and Southeast Asia.
What did the Canadian Army do right in the Scheldt to keep their disease casualties so low? It began with mandatory and regular vaccinations starting at the time of enlistment; vaccinations and regular boosters were given for smallpox, typhus, typhoid and paratyphoid.
Furthermore, dedicated Field Hygiene Sections were attached to every formation from the division level up, serving as front-line sanitation inspectors and enforcers and advising senior medical officers on matters of preventive medicine. The hygiene section personnel assessed the state of accommodations, water supplies, rations and messing arrangements, personal hygiene, deinfestation, sanitation, waste disposal, the state of training in hygiene and sanitation, and the prevalent diseases in the army at the time, as well as carrying out bacteriological and chemical analysis of the water supplies being drawn upon. They were also to guard against laziness and the deprioritization of basic hygiene and sanitation, which tend to happen in the field, and their reports were circulated at a high level.
Finally, aggressive measures were taken to ensure that parasite-borne diseases such as malaria and typhus were eliminated. Chemical agents like D.D.T. were used extensively for mosquito habitat destruction and delousing procedures. D.D.T. powder canisters were provided to soldiers so that they could treat their own clothing and possessions for lice, and all clothes were impregnated, after washing, with a solution that left a low dosage of D.D.T. in the fabric fibres. Combined with vaccination, these measures explain why the typhus bacterium, historically the greatest danger faced by armies in the field, did not appear at all in the Scheldt.
All of the above public health measures seem simple; but, they required a tremendous amount of work, discipline, and support from all levels of the military in order to succeed .A military culture willing to accept the expertise and importance of medical authorities was also key. Today’s military forces can still suffer debilitating problems with infectious disease if basic public health procedures and lessons are not treated with sufficient gravity. It takes only a small amount of laxness, disobedience, or indiscipline for a modern military force to wind up back on Walcheren Island in 1809.
Robert Engen is pursing his PhD in military history at Queen’s University. He also teaches at Queen’s and writes extensively about Canadian military history (http://www.mqup.ca/canadians-under-fire-products-9780773536265.php?page_id=73&).
UK Parliamentary Papers 1810 (14(2)) Military – Supplementary – A – No. 26, 1.
 Weekly Summaries of Sick, Injured & Dead (by disease and formation), LAC RG 24, vol. 12565, 11/AEF HYG
 Holy Bible, King James Version, Book of Numbers, chapter 5, verses 1-2; Book of Deuteronomy, chapter 23, verses 10-14.
 Sir John Pringle, Observations on the diseases of the army, by Sir John Pringle, President of the Royal Society, and Physician to Their Majesties (London: 1775).
 A. Peterkin, Commissioned Officers in the Medical Services of the British Army, 1660-1960, vol. 1 (London: The Wellcome Historical Medical Library, 1968), xxv-xxvii.
 For a more detailed account of Walcheren, see: Robert Engen, “Half the Battle: Public Health and the Scheldt Campaigns of 1809 and 1944,” (Kingston, ON: Museum of Health Care at Kingston, 2013).
 Paul Weindling, “From Germ Theory to Social Medicine: Public Health, 1880-1930,” in: Deboarh Brunton (Ed.), Medicine Transformed: Health, Disease, and Society in Europe, 1800-1930 (Manchester: ManchesterUniversity Press, 2003), 239.
 UK War Office, Royal Army Medical Corps Training 1935 (London: His Majesty’s Stationery Office, 1940), 11.
 In the Burma campaign in 1943, for every British soldier evacuated with wounds, there were 120 evacuated sick. The army also had an annual malaria rate of 84%, and struggled with high rates of dysentery and scrub typhus. See: Field Marshal the Viscount Slim, Defeat into Victory (New York: David McKay Company, 1961), 150-4.
 William Feasby (Ed.), Official History of the Canadian Medical Services, 1939-45, Vol. 2: Clinical Subjects (Ottawa: Edmond Cloutier, 1953), 134.
 Ibid., 133.
 No. 14 Canadian Field Hygiene Section, Hygiene Report – October 1944, LAC RG 24, vol. 12565, 11/AEF HYG REPORTS/2.
 Feasby, Official History, 143.
 Mark Harrison, “Medicine and the Culture of Command: the Case of Malaria Control in the British Army during
the two World Wars,” Medical History 40, no. 4 (1996).