By Parker Volk
Edited by Emily DeMichele
Imagine for a moment that you are an American marine, tramping through the jungle and vegetation of some Pacific island (or, an Indian, African, Australian, Briton, or other Allied nationality in some other theatre of the Pacific or Italy). Absentmindedly you look to your exposed arm and see a mosquito. You quickly flick it away, but it has already left its irritating bite. Two weeks later you start to feel chills and your temperature spikes as a fever develops. You find yourself incapable of performing your basic duties and are taken to a field hospital. There the staff diagnoses you with malaria. As you wait in your bed, the doctor comes up to you. “Guess you weren’t taking your atabrine and covering up,” he says, pointing to the posters on the wall. “You’ve got malaria and won’t be going back to your friends for a long, long time.” It was not a German or Japanese bullet or shell that put you here in the hospital for weeks. It was a single-cell parasite, transmitted into your blood from a lowly mosquito. Like thousands of other Allied soldiers, you contracted malaria while fighting in the Second World War.
Infectious diseases have always played a major role in military history. One can imagine that putting a large group of people together in close proximity under immense stress with inadequate sanitation and medical supplies would have this effect, and it is estimated that until the end of the First World War, more soldiers died of diseases contracted from wounds or the environment than directly from the enemy (Holland and Tregoning, 2022). These diseases include malaria, which has influenced campaigns throughout history, hampering with 18th-century Chinese and 19th-century British invasions of Burma (now Myanmar), as well as being one of the many illnesses laying waste to the British Walcheren expedition in the Napoleonic Wars [1] (Howard, 1999; Shanks, 2021). Malaria also posed a major challenge during the Second World War, with military theatres as far afield as Italy, North Africa, China, and the Southeast Pacific having endemic areas of both the causative parasite Plasmodium and its mosquito vector (Ashley et al., 2018; Beevor, 2012; Harrison, 2004; Joy, 2009). Malaria could decimate unprepared and ill-equipped troops, destroying their ability to conduct operations. Many countries therefore tried to limit malaria’s effects on their forces, a long and material-expensive process. Potentially the most successful was the western allies (i.e. the United States, United Kingdom, and commonwealth countries, henceforth referred to as the Allies), who committed vast quantities of time and resources to counter malaria wherever they found it. Here I will discuss how this problem-solving came about, showing how the Allies adapted to the malaria threat, organizing their forces and providing them with appropriate tools to prevent and treat the disease, thereby helping them defeat their Axis opponents.
The fight against malaria began poorly for the Allies. During early campaigns in the Mediterranean and Pacific, Allied forces did not have special malarial control units or set regulations for the use of prophylaxis and other protective methods, and many soldiers treated the malarial threat with indifference (Harrison, 1996; Joy, 1999). This is especially interesting considering many nations’ previous experience with malaria in wartime, with Britain and its empire meeting it in First World War campaigns in Greece, Africa, and the Middle East and during many colonial conflicts, and the United States during its counterinsurgency in the Philippines from 1899 to 1902 [2] (Harrison, 1996; Gillet, 1995; The Editors of Encyclopedia Britannica, 2022). This lack of preparation and training led to tragic casualty levels during early and mid-war campaigns such as the American and Australian efforts to wrest Papua New Guinea from the Japanese between 1942-1943 (Joy, 1999). During the campaign, it is estimated the American yearly infection rate was 718/1000 men, while, and the 21,600 Australian malaria casualties for 1942 outnumbered the 6,154 battle casualties (Joy, 1999). These high rates of malaria in Pacific-based American and Australian troops even triggered concerns by the Australian government about the parasites being introduced to Australia via infected troops on leave. This led to large-scale quarantine measures of incoming troops until they were deemed malaria-free (Condon-Rall, 1991). The situation was similar with British and Imperial forces in Burma, with a high of 1,850 hospital admissions for malaria/1000 men (roughly 2 admissions per man per year) in 1942 (Harrison, 2004). These malarial issues were not limited to the Pacific and Asia though. When Allied troops invaded Sicily in 1943, the commonwealth 8th army suffered 11,590 cases of malaria vs. 7,798 battle casualties and the American 7th army suffered 9,982 cases. The 8th army’s local publication Crusader even commented that “the tiny mosquito has been a more powerful enemy than the Germans.” Malaria control measures were certainly inadequate (Harrison, 2004). Specialist units arrived late in the campaign, 8th army troops kept using their uniform shorts (despite being issued longer clothing), and personal protection measures such as taking chemical prophylaxis were not enforced nor taken seriously by many (Harrison, 1996, 2004). Certain early campaigns were conducted with good anti-malaria measures though, such as those used by the Australians during the Syrian campaign [3] of 1941 that included poisoning mosquito breeding pools and taking protective doses of quinine (Howie-Willis, 2017). Soon these measures, and more, would be in place in all theatres of operations as the Allies mobilized their resources and learned valuable lessons.
Malaria soon became a major concern to Allied commanders as they saw the danger it posed. General Douglas MacArthur, commander of the Southwest Pacific Area (which included New Guinea) commented in 1943 that “this will be a long war if for every division I have facing the enemy, I must count on a second division in hospital with malaria and a third division convalescing from this debilitating disease” (Joy, 1999). MacArthur later created a combined American-Australian [4] advisory committee on tropical medicine, hygiene, and sanitation in March 1943, reporting directly to his headquarters to help organize and control malaria and other diseases (Condon-Rall, 1991). Similarly, malaria control units were set up in many theatres to control mosquito populations by draining water pools or spraying them with oil or other poisons. Bed netting, long-sleeved clothing, chemical prophylaxis, and associated training were given higher priority, and scientists from many nations were mobilized to find better ways to limit infection (Condon-Rall, 1991; Harrison, 2004; Joy, 1999). One of the main areas of research concerned chemical prophylaxis.
Before the Second World War, the main drug used against malaria was quinine, given both as a treatment and prophylaxis. However, with the capture of the Dutch East Indies (which produced 95% of the world’s quinine) by the Japanese in 1942, alternatives had to be found (Beevor, 2012; Harrison, 1996; Joy, 1999). The main replacement drug was atabrine (also known as mepacrine), originally synthesized in Germany but then produced in the US and Britain. Pre-war trials had shown promise, though questions remained regarding the most effective dose, the severity of side effects, and symptoms of long-term use (Condon-Rall, 1991; Harrison, 1996; Joy, 1999). Eventually, many of these concerns were addressed through clinical trials and experiments in the field, and atabrine was issued to all troops in malarial areas with set regimens [5] (Condon-Rall, 1991; Joy, 1999; Harrison, 1996).Yet, another hurdle remained: convincing the men to actually take it. Atabrine caused the users’ skin to turn yellow, and rumors circulated that its long-term use would make this change permanent (along with causing sexual impotence [6]) (Condon-Rall, 1991; Harrison, 2004). This was in addition to the traditional unpopularity of anti-malarial with soldiers, with quinine causing nausea if taken irregularly and having similar rumors of sexual impotence. Many soldiers were also indifferent to prophylaxis use and simply ignored regulations (Harrison, 2004). Through a combination of education and enforcement of prophylaxis usage, these hurdles were overcome [7] (Harrison, 2004; Joy, 1999). The focus on enforcement was especially prevalent in some theatres. General William Slim [8] attached great importance to fighting malaria and wrote in his memoirs that “If mepacrine was not taken, I sacked the commander. I only had to sack three; by then the rest had got my meaning” (Harrison, 1996). This need to educate and enforce malaria chemical countermeasures also extended to other methods, such as wearing appropriate clothing and using bed netting (Condon-Rall, 1991). New topical mosquito repellents were also issued, though they suffered from users sweating them off (Joy, 1999). Similar to atabrine, they were also disdained and ignored by troops until discipline was tightened (Condon-Rall, 1991; Harrison, 2004). Overall, all of these measures helped to reduce malaria casualties.
Malaria control also extended to large-scale efforts via poisoning mosquito breeding pools, digging drainage ditches, and the large-scale use of insecticide (Harrison, 2004; Joy, 1999). The use of insecticides by Allied forces also provides an example of enemy operations forcing new compounds to be found like quinine and atabrine. Pre-war the preferred pesticides used pyrethrum, a compound isolated from flowers found mainly in Dalmatia and Japan (Harrison, 1996). As Japan was an enemy nation and Dalmatia was occupied by Axis forces, alternatives needed to be found (Beevor, 2012; Harrison, 1996). Enter the infamous dichlorodiphenyltrichloroethane (DDT), originally synthesized in 1874 but only used as an insecticide beginning in 1939. By 1944 the highly effective DDT [9] was used in many theatres of operations (Harrison, 1996). In Italy it was used against both mosquitoes and typhus-carrying lice, being sprayed over marshland, cities, and even people (Hall, 2009; Outterside, 2017). In Burma, it was sprayed by special aircraft in front of advancing troops (Harrison, 2004). Pyrethrum was still used though, with the US army creating the 1-pound “bug bomb” capable of treating 150,000 cubic feet of enclosed space with pyrethrum insecticide. Approximately 35 million bug bombs were made throughout the war (Joy, 1999). Finally, another insecticide used was the pre-war Paris Green, though it was considered inferior to DDT (Outterside, 2017). Large-scale measures therefore also helped the Allies in their fight against malaria’s mosquito vector.
A final major tool against malaria was the rapid treatment of malaria cases as they developed. During early campaigns many soldiers had to be transported to rear area hospitals for effective treatment, taking them from the front for long periods of time. For example, in Burma troops were absent for 25 days in the hospital for treatment, in addition to the time spent traveling the tortuous route to Chittagong or further back in India (with patients sometimes getting re-infected during the trip). Eventually, forward treatment centers were set up to better care for malaria casualties and return men to the front quicker. In Burma, the 14th army set up Malaria Forward Treatment Units closer to the front which could provide the full spread of treatments at most 24 hours after a case was detected, significantly lowering the time men were away from their units (Harrison, 2004).
With all these advances, Allied forces slowly won the fight against malaria and cases dropped significantly. For instance, in MacArthur’s South-West Pacific area in February 1944 cases were 179/1000, down from February 794/1000 the year before (Joy, 1999). This focus on battling malaria also allowed Allied forces to operate in otherwise inhospitable climates. In 1944, strict malaria measures allowed Slim’s 14th army to operate in the malaria-heavy monsoon season of Burma and continue to battle and pursue their Japanese opponents (Harrison, 1996; Shanks, 2021). Therefore, the vast investment and deployment of malaria prevention and treatment played a key role in keeping Allied forces healthy and capable of winning the Second World War.
[1] Sent in 1809 to disrupt French naval operations in the Netherlands, though the expedition was an utter failure as troops were ravaged by disease (Howard, 1999).
[2] Fought after the Philippines were taken from the Spanish during the Spanish-American War (The Editors of Encyclopedia Britannica, 2022).
[3] Fought against the Vichy French regime in one of the more complicated features of the war (Beevor, 2012)
[4] As American and Australian forces were the predominant nationalities in MacArthur’s theatre (Beevor, 2012; Condon-Rall, 1991).
[5] One wonders if the American tested atabrine and Coca Cola, an American gin and tonic if you will.
[6] A fear also played upon by German and Japanese propaganda (Harrison, 2004).
[7] It should also be noted that prophylaxis and treatments were also given to civilians. Interestingly, in Italy quinine chocolate was used to treat malaria in children (Outterside, 2017).
[8] In command of the British-Imperial 14th Army in the India/Burma theatre for much of the war (Beevor, 2012).
[9] Described as “the war’s greatest contribution to the future health of the world” in January 1945 (Outterside, 2017).
References
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