ruthless “scorched earth warfare” aimed at destroying as much as possible of what remained of Germany, and left behind a landscape in which famine and starvation were equally destructive to civilians. The cost in German lives was horrific, 20% of inhabitants overall, but as high as 50% in and around Pomerania, and 8 million total. Bubonic plague caused outbreaks throughout the war; typhus and dysentery were endemic; and even scurvy caused numerous deaths during the unsuccessful siege of Nuremberg in 1632. Perhaps the only reprieve of the 30 years’ war was the steadily declining role of religion, which had long been a major destabilizing influence in European politics and which led to the Peace of Westphalia, a series of treaties consummated in 1648 that effectively ended the wars of religion and established the sovereign state system [78].
World War I
Concerned Europeans knew something dreadful was going to happen and it finally did: on 28 June 1914, Archduke Franz Ferdinand, heir presumptive to the throne of Austria-Hungary, and his wife Sophie were assassinated by a Bosnian Serb terrorist. Exactly one month later, 28 July 1914, war erupted: Austria-Hungary declared war on Serbia and Russia ordered general mobilization in support of Serbia. A few days later at the beginning of August, Germany invaded neutral Luxembourg and then Belgium on its way to attack France; the next day Great Britain declared war against Germany. At the war’s end, 32 countries were fighting [79].
The initial invasion by the German Army came perilously close to Paris, but the French successfully pushed back. Then, a 3-year trench-warfare stalemate occurred that resulted in relatively small back and forth shifts of occupied territory, but the repeated attacks and counter-attacks led to enormous casualties on both sides: in the early 1916 Battle of Verdun, for example, there were 700,000–975,000 dead and wounded; later the same year, there were more than one million casualties in the Battle of Somme, one of the highest numbers in a single battle ever. The Germans defeated the Russians in 1917, but after a final push by the Germans in 1918, the Central Powers were exhausted and an armistice with Germany was declared on 11 November 1918 [79].
Note that around 1780, and at greatly varying years afterwards, death rates from TB started to decline and they continued declining for well over 100 years. But then suddenly, as illustrated during the 50-year period from 1885 to 1935 (Fig. 5), 5- to 7-year-long never-before observed spikes of TB mortality rose sharply in several countries, beginning on or just before the day WWI was declared in 1914 [80]; equally remarkable was the subsequent brisk drop in mortality after hostilities and the end of the overlapping influenza pandemic were over in about 1921. After both the wartime increase and its accompanying decrease had concluded, the previous downward slope of TB mortality resumed its decline as though the war had never happened, as strikingly illustrated in Figure 5. (See also Fig. 10 in chapter 2.) These remarkable events during WWI prove without doubt the incontrovertible linkage between TB and war.
World War II
Virtually all of this book addresses the specific wartime partnerships – country by country – between TB and WWII and, thus, will be discussed only briefly in this first chapter. The deleterious influences of TB during wartime are typically exacerbated by the coexistence of several acute infectious diseases, including enteric fevers, smallpox, yellow fever, typhus, and measles, all of which served as preludes to and accompaniments of WWI and WWII [81]. In addition, as discussed later, during the majority of 19th century and later wars, there were more civilian than military casualties, an observation that is being repeated today in Syria. An introduction of what readers will find in chapters 5–19 of the book classifies countries according to one of 3 distinct patterns of TB mortality during the war years, 1939–1945: (1) countries in which there was little or no wartime rise; (2) countries in which the mortality rate rose in the first years and fell in the later years of the war; and (3) countries in which death rates rose throughout the war years to a peak after the end of the war [82, 83]. These fundamental differences explain why some wartime and post-war countries fared so much better (or worse) than others.
Biological Warfare
Biological warfare is defined as the use of both infectious agents, such as bacteria, viruses, and fungi, and/or biotoxins, with the intent to kill people, or more inclusively living organisms. The earliest practice of biological warfare, as far as is known, is documented in Hittite records of 1500–1200 BCE [84]. The strategy was simple. Victims of tularemia, presumably including Hitittes themselves, were driven into enemy territory to spread an epidemic of deadly disease. In the Trojan War, both arrow and spear tips were coated with poison; a later refinement of Scythian archers (4th century BCE), introduced tipping of arrows and spears with snake venom, blood, or feces to increase the likelihood of infection. Another early tactic was to hurl clay pots filled with poisonous snakes or scorpions on enemy ships or troops. Corpses of bubonic plague victims have long been used as weapons. Genghis Kahn catapulted dead bodies of infected Mongol warriors to break the siege of Kaffa (Crimea), after which the defending Tartar forces retreated and the Mongols took over the city in 1346.
After more and more European settlers arrived in North America, the broadening association with Native Americans was inevitable, so was the spread of highly contagious smallpox, measles, and other infections to extremely vulnerable, immunologically naïve domestic inhabitants. Fatality rates were enormous. Spontaneously developed smallpox in the 18th century, especially, was a major cause of indigenous American depopulation; plus, there may have been instances of deliberate spread by British forces of contaminated blankets to transmit disease to Native Americans [85].
Little biological warfare occurred during WWI, chiefly by Germans who spread infectious anthrax and glanders. In 1925, the Geneva Protocol outlawed biological weapons, but research, production, and storage were unaffected. During WWII, the Japanese undertook a large-scale program to develop and use biological weapons, which engaged over 5,000 workers and “killed as many as 600 prisoners a year in human experiments” in but a single of its 26 study sites [86]. Widespread testing of pathogenic organisms on prisoners occurred, and on at least one occasion, more than 1,000 water wells were poisoned by the Japanese army in their effort to investigate outbreaks of cholera and typhus in Chinese villages. A few of the epidemics that were launched by the Japanese during the war persisted for several years after the conflict. During the Holocaust, Nazi doctors experimented on Jewish prisoners in various concentration and extermination camps [87]. These experiments often took the form of injecting prisoners with typhus as part of research projects aimed at developing a vaccine. If victims did not die during the experiments, they were killed with injections of phenol into their hearts. Because Jews were targeted for annihilation by their Nazi captors, these typhus experiments were a specific kind of biological warfare.
Beginning in 1949, the US explored the mock warfare value of experiments, studying the spread of bacterial aerosols in over 200 different sites. The author was involved in one such test in September 1950 – along with 800,000 other San Francisco Bay guinea pigs – who were exposed to a “harmless” (i.e., non-infectious)