Disease and Public Health (Ottoman Empire/Middle East)

Introduction↑

For the Ottoman Empire the Balkan Wars (1912-1913) were a logistical disaster, as invisible microbes and bacteria rather than bullets and bombs decimated the empire’s military. Infectious diseases — such as cholera, smallpox, and typhus — caused massive suffering and deaths among its soldiers, exposing the ineptitudes of the Ottoman military in providing the most basic medical services to its troops. To avoid a replay of that catastrophic episode in the future, the Ottoman government initiated significant reforms to its military’s medical services, and articulated new public sanitation regulations in the immediate aftermath of the wars. Despite these reforms, widespread epidemics consumed Ottoman soldiers and civilians alike during the Great War that followed. Typhus, malaria, and relapsing fever, transmitted via disease-infected lice, mosquitoes, and ticks respectively, were the deadliest assailants, followed by bacterial diseases like dysentery and typhoid.^[1] Indeed, typhus was so common among Ottoman soldiers that it was referred to as “military fever.”^[2] Cholera epidemics, although constantly cited as a danger lurking in water and food supplies able to wipe out large segments of the population, were largely avoided. Besides these most fatal diseases, historical sources mention venereal disease (mainly syphilis), trachoma, and occasional cases of smallpox as challenges to the empire’s medical regime. By outlining the causes, and some of the prophylactic and therapeutic measures advocated, legislated, and implemented by military and civilian medical officers, this entry highlights the reality of an overwhelming disease threat in the Ottoman Empire. The goal here is to provide a brief overview, rather than a comprehensive study, bringing out accomplishments and lacunae in the study of diseases and public health in the context of the Ottoman Empire during World War I and to inspire further research on this important subject.

In the last two decades, historians of western countries have increasingly studied the impact of diseases on both soldiers and civilians during World War I. Social and cultural historians in particular have focused on topics such as medicine and public health, and generally agree on three points.^[3] First, the war’s mixed contribution to the medical field was marked by both breakthroughs in terms of medical knowledge and treatments, such as blood transfusions, and setbacks or at least stagnations as in the work of German pathologists.^[4] Second, shifting the provision of medical services to favor soldiers caused disease to spread among civilians. Third, the war exposed certain “inequalities in wartime patterns of health.”^[5] In Ottoman historiography the struggle against epidemics has long been included in a larger discourse on modernity and as part and parcel of Ottoman centralization efforts in the late-18^th and 19^th centuries.^[6] And recently, a new generation of environmental historians has taken up the subject of infectious disease, challenging dominant narratives of religiously dictated fatalism in the face of epidemics in the early modern Ottoman Empire and normative understandings of historical agency.^[7] Another related and expansive field is the history of Ottoman medicine, medical education, and science.^[8] When it comes to the effects of infectious diseases during World War I, Ottoman historians have mainly focused on the military, and experiences with disease on the battlefields have generally overshadowed those on the home front.^[9] Indeed, scholars have examined the Ottoman military records, and have provided detailed accounts of deaths from diseases, as well as military health and sanitations policies. The first publication mentioning the disproportionate mortality of soldiers from disease was Ahmet Emin Yalman’s (1888-1972) Turkey in the World War from 1930.^[10] In the 1980s, Turkish medical historians began to pay greater attention to the typhus epidemic during the war.^[11] More recently historians have outlined the geographic distribution of prevalent diseases, as well as government policies in terms of prophylactic and therapeutic measures, based on Ottoman military archives.^[12] Hikmet Özdemir’s work on the Ottoman army, for example, outlines official military policies and individual soldiers’ and medical officials’ experiences beginning in 1914. He shows the ineffectiveness of Ottoman medical services, but does not account for any progress made in disease regulation. Oya Dağlar - beginning with the Balkan Wars - broadens the frame by including the state’s legal attempts to regulate sanitation and provide medical services to both soldiers and civilians. Both studies are largely empirical and neither addresses larger questions of war, epidemics, modernity, and diseases as social agents; both also ignore civilians’ experiences as well as the deadly contributions of infectious diseases to the state’s genocidal campaign against its Christian minorities.

Pre-War Public Health and Military Reforms↑

There is an inherent danger in linking the study of infectious diseases to war. It implies that states and societies have little reason to deal with epidemics in peacetime.^[13] Instead, rather than being driven by war, historians have shown that in the Ottoman case public health reforms and medical progress often resulted from the desire to create a stable health environment for commerce.^[14] Still, if one looks at the Balkan War and World War I, it is clear that war accelerated state intervention in regulating citizens’ sanitary behavior through organized surveillance, reporting, and education. Following the disastrous experiences of the Balkan Wars, the Ottoman government invited German military advisers to aid in restructuring and improving its military in terms of mobilization and military operations. The German general, Otto Liman von Sanders (1855-1929), named the Inspector General to the Ottoman army, arrived in Istanbul to lead the commission on 14 December of 1913. ^[15] What the commission found was devastating. Liman von Sanders described poor or even non-existing hygiene, vermin infestations, and rampant sicknesses among the troops he inspected. There were no bathing facilities in the barracks and the military hospitals were in an appalling state. A permeating stench and overwhelming dirt met the inspector as he entered overcrowded hospital rooms. There was no separation between patients with physical injuries and those infected with diseases; men slept in the same beds or crowded on the floor; the medical personnel simply inspected the sick from afar and prescribed “mounds” of medications. ^[16] Liman von Sanders reported the misery to the Ottoman military command and issued suggestions to improve the state of affairs. His propositions were ignored, evaded, or met with outright resistance from higher officers of the military, who felt hygiene to be of minor concern. According to Liman von Sanders, it was only after Enver Pasha (1881-1922) became Minister of War that his advice, although at times still reluctantly, was heard. With the help of Dr. Maner, sanitary officer of the German Commission, and Chief of the Health Directorate of the Ottoman military Süleiman Sabri Pasha (1873-1941), Enver and Liman von Sanders worked to improve first sanitation in the military and later to civilians.^[17]

Among other measures, the state created municipal isolation stations and promised mobile disinfection units where needed. The reforms stipulated reporting procedures, the examination and treatment of infectious diseases, and assigned specific responsibilities to municipalities, local administrators, and physicians in case of epidemic outbreaks; it also ordered heads of households to report any suspicious illness afflicting their families.^[18] Epidemic typhus, the most prolific killer during the Balkan Wars, received special attention from Ottoman health officials. The ministries of war and health worked together to publish an instructional manual, listing precautionary measures and sanitary guidelines to educate the public about the transmission and dangers of typhus.^[19]

Using German military manuals as templates, the Ottomans restructured medical and sanitary services in the army, replacing 1,200 permanent physicians and medical personnel with 200 younger medical experts to meet peacetime medical needs. In case of war, personnel would be increased through conscription of civilian physicians.^[20] The military’s Chief of Staff issued small pocket pamphlets in vernacular Turkish to instruct individual soldiers in personal hygiene, but low literacy rendered this a futile effort.^[21] Moreover, the government distributed educational materials to military physicians, emphasizing correct diagnosis through the use of microscopes to analyze blood.^[22] This was important since the initial symptoms of typhus in particular, such as headaches, muscle pain, cough, chills, and high fever, could easily be mistaken for those of the common flu or relapsing fever, and only recognized when the patient began to suffer from severe diarrhea and a dull red rash.^[23]

Wartime Predicaments: Movement, Crowding and Lack of Hygiene↑

Although there seemed to be appropriate mechanisms for prevention, reporting and personnel recruitment in place before the war, the government never fully put them into practice. Health conditions in villages, towns and cities remained unstable, even if by 1914 “municipal laws were perfect on paper.”^[24] The constant threat of epidemics after November 1914 increased pressure on officials to implement these new and other ad hoc regulations. However, this proved far more difficult than anticipated before the war and seemingly impossible during the war.

Disease posed a problem on all Ottoman fronts; their prevalence depended on climate and the particular circumstances at the frontlines. Typhus, for example, played a significant role in decimating the 3^rd Army during the campaign against Russia led by Enver in January of 1915. While the climate in the Caucasus exacerbated the spread of typhus, this “winter disease” posed a problem on all fronts and especially where crowded and unsanitary circumstances facilitated the spread of lice. Malaria was most common in warmer climates and was the most frequent cause of sickness in soldiers stationed in Mesopotamia and Gallipoli. Deaths from bacterial disease, caused by consuming contaminated water or food, or else through oral contact with exposed utensils or drinking vessels, peaked among troops of the 3^rd Army fighting in Palestine during March and April of 1915. The situation at the Gallipoli front was especially bad not only because the surrounding regions’ environment (such as marshes) was a breeding ground for malaria, but also because the soldiers were housed in abhorrent conditions; the barracks had no bunk beds and soldiers slept crowded on the floor. Moreover, a general shortage of water, a lack of water pumps, inadequate field toilets and innumerable flies swarming around them proved to be a deadly combination. Flies easily transmitted microbes and bacteria, contaminating water and food supplies and causing an epidemic outbreak of dysentery in May 1915. The worst were the green ugly “corpse flies” which feasted on the bodies left on the battlefield. The inability to bury fallen soldiers, as fighting was continuous, constituted another problems. The decaying corpses covered in flies quickly became cesspools of diseases.^[25] Being a soldier at Gallipoli, no doubt, meant fighting not only a human enemy, but also an invisible and perhaps more dangerous one. It was an enemy – albeit tiny in appearance – that reigned supreme, as the only weapons against it, i.e. adequate hospital beds, medical staff and medicine, were in short supply.

Besides unbearable conditions on the fronts, wartime movement, resulting in overcrowding and lack of hygiene, continuously handicapped Ottoman efforts. Even in the military, as we will see, the sanitary improvements crumbled under the pressure of war. Soldiers, deserters, civilian refugees, and deportees on the move often carried with them microbes, bacteria, and typhus-infected lice. The empire’s poor infrastructure contributed to the spread of disease. Limited trains to and from the fronts were often packed to capacity, meaning that common soldiers and microbes were crammed under unsanitary conditions into freight cars over long stretches of time. Passenger train upholstery generally turned into breeding grounds for lice.^[26] The fact that soldiers often had to march to and from the front made it difficult for Ottoman sanitary officials to maintain adequate hygiene. ^[27] It was during these marches that soldiers would at random mingle with civilians, picking up or leaving behind germs and microbes. Military transfer centers were a particular challenge for Ottoman health officials. Here soldiers slept crowded on the floor, making it nearly impossible to prevent louse-borne diseases, such as typhus and relapsing fever. This was made worse by the fact that the chaos of incoming and outgoing troops often caused sanitary precautions to be neglected.^[28] In addition, demobilization and post-battle chaos meant that soldiers were outside of the military’s sanitary regime.^[29] After defeats in the Caucasus, for example, soldiers swept into towns and villages, simultaneously spreading and contracting typhus-infected lice. Once infested, getting rid of lice was nearly impossible, triggering a typhus epidemic of unprecedented proportion. The large number of deserters roaming the countryside and hiding in villages constituted yet another group falling outside the military’s sanitary regime.^[30]

Large numbers of displaced civilians added pressure to the empire’s health concerns. Refugees and deported minority populations not only were exposed to diseases, but also contributed to their dissemination. For instance, refugees from Russian-conquered territories carried cholera into the empire. Although the Ottomans tightened control of their borders, infected refugees continued to slip past. Often civilians followed the defeated Ottoman army as it withdrew from the fronts, creating a post-battle chaos conducive to the spread of diseases. However, the most vulnerable group was the empire’s forcefully deported Christian, mainly Armenians, minorities. Using war as justification, the Committee of Union and Progress (CUP) government - partially driven by its nationalist desire to homogenize Anatolia - sought to rid its eastern provinces of unwanted minorities, launching a full-fledged genocide in April 1915.^[31] The deportation of men, women and children toward the Syrian Desert was part of this process. The marches were dire, as the government neither guaranteed the deportees’ security, nor their adequate hygienic conditions, medical care, or preventative vaccinations. Frequent attacks by armed bands, the extreme climate, and illnesses all but guaranteed death and destruction for the deportees. Eventually, “rotting corpses on the side of the roads” became breeding grounds for disease, posing a great health risk for deportees and local populations alike. For example, local village and town officials wrote complaints to Ottoman officials when a typhus epidemic wreaking havoc among Armenians reached villages along the deportation routes.^[32] To deal with the crisis, officials in the north often threw corpses into the Tigris and Euphrates, thus creating large problems downstream.^[33]

Many of the deportation convoys passed through transit camps, which would immediately turn into hotbeds of epidemic. A German missionary described the deplorable sanitary situation in one of the camps as follows:

Unable to contain diseases in the camps, the Ottomans decided to disband them and sent deportees further south. Still the government made no provisions in terms of proper shelters, clean water, or food supplies for survivors arriving in Syria, resulting in larger numbers of deaths. For example, about fifty to seventy people died daily of typhus and typhoid fever in Aleppo by mid-June 1915.^[35] A German eyewitness recounts the desperate situation among survivors who lived in crowded and filthy makeshift shelters in Aleppo:

Since Aleppo was a major transfer center for Ottoman troops, the epidemic could not be ignored. Consequently, the Commander of the 4^th Army, Cemal Pasha (1872-1922), had no choice but to approve a plan to build a hospital in the city, specially designated for the treatment of Armenian survivors. ^[37]

In addition to population movements and resulting unsanitary conditions, the lack of medical staff both on the battle and the home fronts posed another challenge.^[38] The number of physicians (2,555) serving in the Ottoman army was inadequate to begin with, considering that the number of active soldiers at times reached 1.2 million.^[39] The problem was exacerbated when somewhere between 215 and 349 physicians and pharmacists died while serving in the army; most of them succumbed to the diseases they sought to treat.^[40] Despite efforts to train new physicians, conscript medical students, and call older physicians back from retirement, medical staff shortages continued to be felt throughout the war. In cities like Beirut, the municipal authorities tried to remedy these shortages by asking the remaining physicians to hold additional office hours and ordering pharmacies to operate on a rotating emergency schedule. Still, this did little to ameliorate the situation.

Disease Mortalities↑

The high number of disease mortalities among soldiers and civilians confirm the Ottomans’ incapacity, and in the case of its minority population unwillingness, to deal with wartime exigencies.^[41] A medical report of all nine armies and enlistment stations shows the total number of military casualties of the Ottoman army as 771,844,^[42] 466,759 of whom died of illnesses and 68,378 from battle wounds.^[43] Özdemir provides more detailed information from military hospital records, which partially reveal the geographical distribution of disease mortalities among soldiers. The hospitals close to the Eastern Anatolian fronts reported the largest number of sick admitted, followed by those in Syria. The hospitals in the Balkans and on the Arabian Peninsula reported the lowest numbers of admittances. Deaths from diseases are distributed along similar lines.^[44] Still, these numbers have to be read with caution, since they only reflect the sick and wounded admitted to military hospitals, include multiple admissions, and neither considers the number of deployments nor the duration of campaigns. The types of prevalent diseases at the various fronts (some were more deadly than others), and the availability of medical facilities near the various fronts should also be taken into account. A more detailed study for example would explain why a much larger percentage of men died of diseases during the Arabian and South Arabian campaigns (25 percent) and the Caucasus campaign (18 percent), compared to the relatively smaller number of disease victims in the Syrian and Palestine campaigns (8 percent).^[45] When it comes to civilian deaths we only have vague numbers. These range from 2,000,000^[46] to 2,150,000,^[47] including 1.2 million Armenians.^[48] How many of them died as the direct result of diseases is impossible to determine.

Treatment and Public Health Measures↑

The devastating effects of louse-born epidemics in the eastern provinces among soldiers and civilians forced the Ottoman Interior and Health Ministries to organize an anti-disease campaign. Initially few provisions had been made to deal with hygiene at the front or in training camps. Not only did the military medical corps have limited stationary and mobile sterilization machines, but also quarantining soldiers during battle was simply impractical. Moreover, shortages in microscopes and medication undermined proper diagnosis and treatment.^[49] As the war continued, the Ottoman authorities tried to increase medical services to soldiers, as well as the number of hospitals, and launched a systematic campaign against lice, including regular inspections and disinfection of soldiers’ bodies.^[50] In the absence of a vaccine against typhus, health officials focused on precautionary measures such as cleanliness and frequent disinfection. By 1917, transfer centers, soldiers’ living quarters, and exercise grounds were regularly disinfected, and mobile disinfection units were dispatched to where they were needed. Each unit kept detailed records of illnesses among its troops and forwarded their reports to the military’s Sanitary Office.^[51] Moreover, health officers and medical staff were instructed to educate the public about typhus and the dangers of lice, and to work in collaboration with civilian institutions.

When typhus outbreaks were reported among civilians in Jerusalem, Aleppo, Damascus and Beirut, municipal officials took up the desperate fight against lice. Municipal physicians inspected the houses of infected people and issued certificates of cleanliness, which the police could demand at any given moment.^[52] Officials warned civilians away from visiting hospitals, mixing with soldiers, using congested tramways, and gathering in public places; they published preventative guidelines and urged people to isolate their sick in their homes. To ward off lice officials asked civilians to keep their hair short, carry a tin of naphthalene in their pockets, and apply mercury ointment to collars and places where lice could sneak under people’s clothing. The Istanbul municipal Health Directorate declared admittance to public baths free of charge. ^[53]

Bacterial diseases like dysentery, typhoid and cholera called for a different set of preventative measures. When a sizable cholera outbreak affected a number of Anatolian cities in November 1915, health officials took immediate measures, including the review of vaccines, evacuation of unsanitary barracks, isolation of cholera patients, travel moratoriums, strict food supply controls, and border controls.^[54] Since water was easily contaminated, health officials regularly tested water supplies.^[55] Improperly disposed feces of sick individuals could mean that bacteria would leak into the ground water, spoiling wells, or that flies could transfer bacteria onto food and water supplies. Hence, officials trained troops in the building and maintenance of proper field toilets. The municipal health directorates instructed civilians to cover up their cisterns, drain stagnant water, boil it before use, isolate infected individuals, disinfect their utensils and drinking vessels, bury the excrements of patients far from water sources, and not to eat raw vegetables. To prevent the spread of malaria health officials urged that nets be hung in front of doors and windows, and that manure be burned to keep mosquitoes at bay.^[56]

Faced with the constant threat of disease, Ottoman health officials organized an empire-wide vaccination campaign. Vaccination had been a regular practice before the war. The Imperial Medical School in Istanbul had a vaccination office, and its laboratory produced vaccines against cholera, smallpox, typhoid fever, and dysentery. The laboratory was equipped to analyze and diagnose infectious diseases and experts gave regular lessons in bacteriology. As the demand for serums increased during the war, the government opened additional laboratories and distributed vaccines free of charge to hospitals and vaccination stations throughout the empire.^[57] The Imperial Health Directory ordered soldiers to be vaccinated against smallpox, cholera, and typhoid fever, and to carry vaccination cards at all times.^[58] Moreover, the government made an effort to offer vaccinations to civilians, and, through local municipal agents, regularly announced the hours and locations of government-sponsored vaccination stations.^[59] Even so, vaccinations were often administered improperly or not recorded on soldiers’ identity cards. As I mentioned above however, medical treatments against diseases like malaria were limited. Quinine, the only anti-Malarial medicine known at the time, was in short supply due to the maritime blockade, and pharmacies were often overwhelmed with orders.^[60] Still soldiers in high-risk areas received tablets twice a week.^[61]

The government worked to increase the number of hospitals and absorbed some existing health institutions with the goal of expanding services to the military. The military leadership, for example, arranged for mobile hospital units for every Corps situated near the battlefronts (at least on paper) and expanded existing hospitals near the fronts.^[62] At times the Red Crescent Society supported these official efforts by adding significant numbers of hospital beds to those provided by the government, opening convalescent units, producing and distributing vaccinations, and treating wounded and sick soldiers and civilians, and assisting refugees as much as they could.^[63] In addition, the German and the American Red Cross sent physicians to work in Ottoman hospitals, providing bacteriology laboratories and aiding the Ottomans in providing medical services to civilians.^[64]

Conclusion↑

Overall, faced with an onslaught of infectious diseases, the Ottoman state sought to improve sanitary conditions and expand its medical services to both civilians and military personnel. Wartime predicaments such as the massive movements of human bodies, chaos, and overcrowding, made it difficult to implement precautionary measures. The outcome was a vast number of deaths. Still, some campaigns like the anti-lice measures, after which typhus cases decreased in the military records, and the fact that large-scale cholera and smallpox epidemics were avoided, both account for some - albeit minimal - success in state intervention.

To understand the full extent of epidemics in the Ottoman Empire during World War I, future study will need to move beyond the confines of the military, the experiences of the individual soldiers, and official legal measures, and include Ottoman civilians’ encounters with epidemic. After all, disease vectors - lice, rats, mosquitoes - and various microbes and bacteria made no distinctions between soldiers and civilians. Studying the civilian experiences across the large territorial span of the empire is not an easy task and perhaps warrants a collective effort, as sources are fragmented and scattered. It will also necessitate a clear methodological shift away from military archives, and toward memoirs, diaries, diplomatic and missionary correspondence, the local press, the reports of local civilian officials, and municipal and local hospital records wherever available.^[65] Furthermore, such studies would greatly benefit from taking into account the historical agency of microbes, bacteria and insects. There is no doubt that such organisms competed with humans for living space, crossing the invisible boundaries between battle and home fronts, and rendering human action simply reactionary and defensive. Indeed there is no area where the totalizing character of World War I is more evident.

Melanie Schulze-Tanielian, University of Michigan, Ann Arbor

Section Editors: Elizabeth Thompson; Mustafa Aksakal