This article appears with the permission of Military Review.
by Lieutenant Colonel Lester W. Grau, US Army, Retired, and Major William A. Jorgensen, US Army Reserve The views expressed in this article are those of the authors and do not purport to reflect the position of the Department of the Army, the Department of Defense or any other government office or agency.-Editor
The US Army has an excellent record of disease prevention, field sanitation and disease control. However, since the United States belongs to several multinational alliances, the Army will support allies whose disease prevention record is not as good. The recent Soviet experience in Afghanistan is an example of a modern force which was seriously hampered by disease and poor field sanitation, further stressing the commander’s role in protecting the force.
Recent US Army deployments have been relatively disease free, thanks to Army medical professionals’ efforts, a solid inoculation program, high standards of field sanitation and small-unit leadership.1 As the Army prepares for future deployments in conjunction with allies or UN forces, US Army medical professionals could find themselves providing medical support to the other nations’ forces whose experience in field sanitation and disease prevention differs from ours. In this situation, our medical team needs to prepare to fight epidemics rather than isolated cases.2
Throughout history, armies and disease have been constant companions. Death from disease often exceeded battlefield deaths. Typhus, plague, cholera, typhoid and dysentery have decided more campaigns than the great generals of history. In the Crimean War (1853 to 1856), the English and French combined forces against Russia. The French deployed 309,000 men into the theater: of these, some 200,000 were hospitalized – 50,000 for wounds and 150,000 from disease.3 English and Russian experience was similar.
Modern medicine and inoculations have significantly decreased wartime deaths due to disease, but disease continues to sap the strength of modern armies. Some armies do a better job of practicing preventative medicine than others. As the Soviet army learned in Afghanistan, strong preventive medicine and field sanitation programs are essential for maintaining forces in foreign climates.4
For the first six years of the war, the Soviet press barely mentioned the war. When they did, it was in terms of happy Soviet soldiers building hospitals and orphanages. The Soviet combat role was not mentioned, nor was the fact that the Soviets filled more hospitals and orphanages then they constructed. When General Secretary Mikhail Gorbachev’s glasnost policy was implemented in the Soviet Union, the true casualty picture slowly began to emerge. Of the 620,000 Soviets who served in Afghanistan, 14,453 were killed or died from wounds, accidents or disease – a modest 2.33 percent of the total who served. However, the rate of hospitalization during Afghanistan service was remarkable. The 469,685 personnel hospitalized represented almost 76 percent of those who served. Of these, 53,753 (11.44 percent) were wounded or injured. Fully 415,932 (88.56 percent) were hospitalized for serious diseases. In other words, 67 percent of those who served in Afghanistan required hospitalization for a serious illness. These illnesses included 115,308 cases of infectious hepatitis and 31,080 cases of typhoid fever.5 The remaining 269,544 cases were split between plague, malaria, cholera, diphtheria, meningitis, heart disease, shigellosis (infectious dysentery), amoebic dysentery, rheumatism, heat stroke, pneumonia, typhus and paratyphus.6
The medical problems confronting the Soviet army in Afghanistan were markedly different from those threatening the World War II Red army. Figure 1 below outlines those differences.7
|Disease Category||Afghanistan 1980 – 1988|
|World War II 1941 – 1945|
|Vitamin deficency and eat disorders||0.09||4.98|
|Growths and tumors||0.26||0.41|
|Nervous and psychological||2.21||4.58|
|Ear, nose & throat||0.97||1.61|
|Blood and blood-producing organs||0.02||0.12|
|Bones, joints & muscles||2.10||1.39|
|Skin and subdermal tissue||9.90||7.67|
Figure 1. Category of diseases treated in Soviet Army hospital.
The figure shows a dramatic increase in hospitalization for infectious disease and noncombat injuries – a result of deployment to a foreign climate where there are new strains of disease and the increased number of Soviet army motorized vehicles in Afghanistan. The chart shows modest hospitalization increases for bones, joints and muscles, as well as skin and subdermal tissue. Most other categories show a decrease, probably due to conscript age differences: Soviet Afghanistan combatants were younger; the World War II Soviet army included many middle-aged men. Figure 2 shows the breakdown of infectious diseases in Afghanistan by type.8
Figure 2. Infectious Disease Percentages Treated by Type in Soviet Army Hospitals.
Despite Soviet preventive medicine teams’ best efforts, hospitals, vector control teams and water purification units were never able to control the spread of infectious disease. The main reasons for the high rate of disease among Soviet troops were lack of sufficient clean drinking water supplies; no enforcement of basic field sanitation practices (a historic Soviet problem, partly due to their lack of a professional noncommissioned officer [NCO] corps); failure of cooks to wash their hands after defecation; infestations of lice and rodents; poor diet; and failure to provide soldiers with clean uniforms and underwear on a regular basis.
The Soviet 40th Army was the primary force in Afghanistan. In addition, Soviet KGB and Ministry of Internal Security (MVD) forces served in Afghanistan along with Soviet advisers to the Afghan army and a Soviet civilian work force that supported the Soviet army.9 As Figure 2 illustrates, the Soviet 40th Army had a serious problem with disease prevention. In fact, over one quarter of the troop strength might be unavailable due to disease. Between October and December 1981, the entire 5th Motorized Rifle Division (MRD) was rendered combat ineffective when more than 3,000 of its men were simultaneously stricken with hepatitis. The sick included the division commander, most of his staff and two of four regimental commanders.10 Every year, 33 percent of the entire 40th Army was stricken with some form of serious infectious disease.11
The major causes of hepatitis are viruses and alcohol and drug abuse. Vaccines can protect personnel from hepatitis B, and troops going to Afghanistan received this vaccination. There are no vaccines against hepatitis A and hepatitis nonA-nonB. Hepatitis A accounted for 95 percent of hepatitis infections among Soviet soldiers. The remaining 5 percent was from hepatitis nonA-nonB.12 Hepatitis is a highly infectious disease and is spread by the fecal-oral route, normally from failing to wash one’s hands or drink clean water. The incubation period in Afghanistan was normally 37 days, and recovery took six to eight weeks with relapses.
The combat tour was 18 months for conscripts and two years for officers. First-year soldiers were 2.5 times more likely to contract hepatitis A than second-year soldiers. The greatest number of hepatitis cases were contracted in the fall and winter.13 Epidemiologic analysis showed the following results:
- 31 to 74 percent of infectious hepatitis cases were contracted in base camp.
- 13 to 45 percent were contracted in the field.
- 8 to 15 percent were contracted in outposts.
- 5 to 14 percent were contracted while on convoy duty.14
- This analysis is surprising, because one would expect that the best sanitation prophylaxis would be in the base camps. Instead, most of the hepatitis was contracted where it could have been best prevented.
Upper Respiratory Disease
Pneumonia and bronchitis were serious problems for the Soviet 40th Army, especially during the first four years of the war. Figure 3 depicts the various types of upper respiratory disease by percentage from 1982 to 1984.15
|Acute respiratory infection||10.6||15.0||6.0||11.9||13.0||6.3|
Figure 3. Respiratory Disease Percentages Treated by Type.
Servicemen contracted acute pneumonia throughout the year, but the majority (65 percent) of the more serious and contagious cases occurred in the fall and winter, compared to 35 percent in the spring and summer. Approximately 10 percent of the cases initially diagnosed as acute respiratory infection were actually typhoid fever. Additionally, 82 percent of the soldiers contracted acute pneumonia during their first year of service, compared to only 18 percent the second year.16 Hospitalization time, by percentage, required for pneumonia follows:17
- 1 to 2 days, 42
- 3 to 4 days, 24
- 5 to 7 days, 22
- 8 to 10 days, 4
- Over 10 days, 8
Statistics show that 6 percent of Soviet soldiers in Afghanistan who developed pneumonia also had a digestive tract illness; and 30 percent of these were 10 to 15 percent below ideal body weight. The possibility of troops in Afghanistan contracting a severe or grave case of pneumonia was twice as high as Soviet soldiers serving elsewhere. Incidents of bronchial pneumonia in Afghanistan were also double the armywide average.18 Physicians had difficulty making the correct diagnosis, since the laboratory results and patients’ symptoms varied so widely from the usual results and symptoms. This created a delay in starting the correct treatment and in returning soldiers to duty.19
In Afghanistan, most combat units were spread out in small outposts where hot meals and clean water were not available. Initially, the Soviet soldiers in isolated outposts ate nothing but dry rations.20 The lack of regularly prepared, balanced meals weakened soldiers’ resistance to disease, since their dry rations failed to provide proper nutritional requirements over time. Additionally, the accumulation of ration cans and other trash provided breeding grounds for rats and disease. As the war progressed, an effort was made to serve everyone a hot meal and tea for breakfast and dinner. Isolated units still had dry rations for lunch. To get hot meals to some troops, the Soviets developed air-droppable containers.
Hot meals proved to be a mixed blessing, since a primary source of infection was the cooks. Cooks had lice, intestinal pathogens and little officer supervision. In fact, cooks’ personal hygiene was no better, and sometimes worse, than the rest of the Soviet soldiers. The Soviets recognized this and began inspecting the cooks and conducting monthly medical examinations. Laboratory findings of pathogenic intestinal bacteria among cooks were staggering. It only took a few sick cooks to keep the hospital sick bays filled. The Soviets were never able to keep all their cooks clean and sanitary.21
Physical conditioning and acclimatization is very important in disease prevention. Eventually, most soldiers trained for six months in mountain warfare schools before arriving in Afghanistan. Physical conditioning was stressed, as was field craft, first aid and field sanitation. However, physical training in the Soviet Union did not fully prepare soldiers for the rugged realities of field duty in Afghanistan. The average field combat load in Afghanistan was 70.5 pounds. Despite the rigorous physical conditioning program, soldiers were unable to routinely carry that much weight at high altitudes. The Soviets eventually developed special lightweight field gear, but they never produced enough for all their field units. Troops were rapidly debilitated by the harsh field conditions, which left them more prone to disease.
Rats, lice and mosquitos were a constant problem. Garbage was not quickly policed up and properly disposed of. Garbage dumps were often collocated with camps and base camps. Stagnant pools of water were not drained or treated for mosquito larvae. Troops were dusted with DDT, but since clothing and bedding were seldom washed or exchanged, lice were a constant feature of life for the 40th Army. Typhus and malaria were two consequences of inadequate vector control.
The water in Afghanistan has a high bacteria level. Despite warnings and training, Soviet troops often drank untreated water. This was often due to failures in the Soviet logistic system to provide clean water to troops at remote locations. Sometimes, Soviet soldiers drank untreated water because they did not like the taste of treated water and had grown up drinking water from all sources without apparent ill effects. The untreated water often carried typhus and amoebic dysentery. The Soviets began issuing boiled water treated with pantocides to their soldiers, and water purification points were set up at mess halls. Cisterns were installed to store purified water, and large garrisons built pumping stations with chlorination units.22 Despite these efforts, the Soviets were unable to guarantee adequate supplies of clean water to their forces or ensure that troops drank it.
Basic field sanitation remained a Soviet problem throughout the war. Although field latrines were dug and flush latrines were installed in base camps, Soviet soldiers often did not bother to use them and relieved themselves close to the living and dining areas. The troops often did not wash their hands after relieving themselves. Troops could shower (or visit the steam bath) weekly at base camps, but seldom bathed in the field, resulting in hepatitis, shigellosis and other diseases.
The Soviets underestimated the amount of medical support necessary to support the 40th Army. They were well equipped to handle the wounded, but they were unprepared to deal with large numbers of sick soldiers. To relieve overcrowded hospitals, large numbers of their sick and wounded were evacuated to military hospitals in the Soviet Union and in Warsaw Pact countries. They also established an infectious disease hospital at Bagram, Afghanistan, with a rehabilitation center annex for recovering infectious-disease patients. The Bagram Rehabilitation Center consisted of a command element, eight companies, a medical station and a supply element. Each company had six combat arms officers and six warrant officers to administer the program and control the patients. The rehabilitation program included medical treatment, a 2-hour rest after dinner, five meals a day, therapeutic physical training, vitamin therapy, psychotherapy and occupational therapy. Patients were discharged after full recovery.23 Despite these efforts, the Soviet medical establishment was hard-pressed to deal with the patient load resulting from disease.
After the war, the Soviets (and then the Russians) studied the US Army deployment to the Persian Gulf for Operation Desert Storm. Among the disease prevention measures taken by the Americans which impressed the Russians were the supply of 80 liters of water per person per day, the wide use of bottled water, the ration heating units on US tanks and personnel carriers, the meal ready-to-eat (MRE) ration, the issue desert chocolate bar that can withstand 150-degree Fahrenheit without melting and the issue field clothing and load-bearing equipment.24
In 1994, Russian military doctors recommended the following measures be taken when deploying troops to other regions:25
- Conduct a rate of personnel illness forecast, taking into account the particular environmental factors that will affect soldiers, and then coordinate logistic, engineer and medical support to deal with these potential problems.
- Immunize personnel well in advance of deployments and train them on field sanitation practices for the new region.
- Perform advance reconnaissances of water sources and conduct laboratory analyses of water quality.
- Seize and protect water sources.
- Establish a system to deliver clean water to field sites and maintain water stores on site.
- Routinely repurify any piped water from local city systems.
- Provide units and soldiers with water purification tablets or filters.
- Establish reserves of bottled water.
- Plan for the early delivery of water purification systems, such as filtration systems, boilers and water storage bladders.
- Stock clean water reserves for raiding parties, combat operations, security outposts and guards.
- Train soldiers how to maintain drinking water purity and operate water purification equipment.
- Plan and conduct environmental protection measures; ensure troops use field latrines and dispose of garbage properly; ensure troops bathe regularly; and ensure latrines and garbage dumps are disinfected regularly.
- Ensure troops receive regular hot meals and do not subsist on canned/packaged food for extended periods.
- Supply battalions and companies with enough mermite-type containers to keep food hot until it is delivered.
- Issue multivitamins to troops immediately when redeployment orders are received.
- Supply enough equipment to each mess to store at least 20 liters of water, including 16 liters of hot water, per person per day.
- Provide adequate sites for personnel to wash their mess kits.
- Monitor prepared food portions to ensure that soldiers receive their full ration.26
- Routinely issue clean underwear and bedding.
- Build a steam bath for every battalion, separate company or platoon.
- Enforce scheduled troop bathing.
- Regularly inspect for lice and disinfect when necessary.
- Disinfect the site within 3 hours whenever soldiers with infectious diseases are discovered.
- Immediately isolate soldiers with infectious disease and hospitalize them within 24 hours.
- Maintain sufficient contingency stocks of immunuglobulins, vaccines, anatoxins and antibiotics to protect all personnel prior to deployment, while deploying, during combat and during convalescence.
The Soviet army in the field was never a particularly clean army. However, in a European peacetime environment, this was not much of a problem. Most of the soldiers had natural immunities to many of the local diseases, and the command never had to pay a price for sick soldiers. Soldiers were cheap and plentiful. This was not the case in Afghanistan where every soldier was necessary and in short supply. The Soviet 40th Army began to pay the price for years of neglect and poor field craft and hygiene. The Soviets were unable to logistically support the large army they felt they needed to successfully prosecute the war in Afghanistan. Their inability to effectively control infectious disease drastically cut into their present-for-duty strength. Accordingly, combat units were often understrength by a third of their authorized strength, resulting in two-company battalions and two-battalion regiments due to disease and other problems.
One reason the Soviets could not control infectious disease was their lack of a professional NCO corps. Soviet NCOs were conscripts who had attended a special six-month course. They had no moral or actual power over their fellow soldiers. The business of discipline, inspection and enforcing standards fell on the platoon leader-a junior lieutenant. He personally had to ensure that all his troops were lice-free, washed their hands, drank clean water, disposed of their trash properly, prepared food correctly and dug and used latrines. He was also responsible for maintenance, training and combat. Without NCOs, the lieutenant was unable to accomplish all his duties correctly, resulting in lack of adequate field sanitation.
The Soviets received brutal lessons in Afghanistan on the importance of diet, physical conditioning, pure water, field sanitation, vector control and adequate medical support. Yet, the heir to the Soviet army – the Russian army has not learned these lessons or taken them to heart. In 1988, Soviet soldiers were rushed into Armenia to provide earthquake relief. Their poor food and lack of field sanitation and clean clothing resulted in mass illnesses that required “rescuing many of the rescuers.” In 1989, the Soviet Kostroma Airborne Regiment, the Akhalkalaki Motorized Rifle Regiment and the Kutaisi Air Assault Brigade moved into Tbilisi, Georgia, to put down rioting. The troops had one or no changes of underwear for an extended tour.27
In 1992, the Russian 14th Army fought in Tirasapol, Moldova. Only the brevity of the combat prevented a serious outbreak of disease from a lack of clean water for drinking and cooking. In 1992, the Russian 201st MRD deployed to the border between Afghanistan and Tadjikistan to help guard the border of this newly independent republic against the mujahidin. In the rush to get forces forward to the border, the command again neglected to establish sanitary mess halls and field mess facilities and to provide adequate, pure water for drinking and washing. As a result, viral hepatitis, intestinal infections and malaria mowed down the 201st MRD and filled hospital wards with entire squads and gun crews.28 Reports from Chechnya indicate that disease is again a limiting factor in the number of troops the Russians can deploy.
In recent years, the US Army has had an excellent record of disease prevention, field sanitation and disease control. However, as the United States conducts foreign policy by membership in multinational alliances, the chances increase that the US Army will have allies whose record in field sanitation and disease prevention is similar to the Soviets. US Army medical professionals could find themselves providing medical support to these allied forces. If so, the US Army medical community will need to prepare to fight epidemics, not isolated cases. MR
1. The overall health of US Armed Forces in Somalia was excellent. The endemic diseases in Somalia were high, yet the weekly rate of disease and nonbattle injuries was approximately 11.5 percent, with a 0.5 percent hospitalization rate. Expected medical problems with diarrhea and heat injuries were minimal. Only 72 cases of Malaria were recorded. This excellent health record can be attributed to food and water control, command emphasis on heat injury prevention, aggressive field sanitation, a program for protecting personnel from mosquitos and disease surveillance, rapid diagnosis and early treatment. US Army Medical Department Archives, Somalia-Operation Restore Hope D +70 (Summary), http://126.96.36.199/lessons/Archived/11002139.htm. 2. This article is an adaption of “Medical Support in Counter-Guerrilla War: Epidemiologic Lessons Learned in the Soviet-Afghan War,” U.S. Army Medical Department Journal (March-April 1995). 3. Hans Zinsser, Rats, Lice and History (Boston, MA: Little, Brown and Company, 1934), 165. 4. The Soviet Afghanistan invasion on 25 December 1979, thrust Soviet ground forces into the middle of a civil war to fight a guerrilla enemy on some of the roughest terrain on earth. Their vain attempt to prop up an unpopular Marxist regime ended with complete withdrawal by 15 February 1989. Discontent with the Soviet leadership’s handling of the Afghanistan War was a major cause leading to the disintegration of the Soviet Union. In Afghanistan, the fighting continues but no longer between Afghan communists and Afghan Muslims. Now, the various Afghan resistance groups are fighting one another for control of this dry, mountainous South Asian land. 5. G.F. Krivosheev, Grif sekretnosti snyat [The secret seal is removed] (Moscow: Voyenizdat, 1993), 401-5. In the original, the figures are given as 415,932 hospitalized for disease, including 115,308 cases of infectious hepatitis, 31,080 cases of typhoid fever and 140,665 cases of other disease. This leaves 128,889 cases or 39.99 percent of the total unaccounted for. We added the 128,889 to the 140,665 figure. 6. V.S. Perepelkin, V.F. Korol’kov, V.F. Kolkov, V.A. Mandrik and P.N. Ogarkov, “Uroki bor’by s kishechnymi infektsiyami v period voyny v Afganistane” [Lessons in the struggle with intestinal infections during the war in Afghanistan], Voenno-meditsinskiy zhurnal [Military medical journal, hereafter VMZ] (July 1991), 27-31. 7. V.T. Ivashkin, “Opyt organizatsii meditsinskoy pomoshchi bol’nym 40-i armii v Afganistane” [The experience of the medical care to the sick servicemen of the 40th Army in Afghanistan], VMZ (November 1992), 13. 8. Perepelkin, 28. What is missing from Figure 2 is typhoid fever. According to official statistics, typhoid fever accounted for 7.47 percent of infectious cases, yet it is not reflected in this figure. It is probably included in the upper respiratory category. 9. KGB was the Committee for Government Security. Their duties included intelligence, counterintelligence, prison camp administration and border guards. They also fielded a potent field force. The KGB role in Afghanistan was supporting the Afghan equivalent-the KHAD-and manning border guard posts within Afghanistan. The Ministry of Internal Security (MVD) was a large armed force that ran prison camps, provided crowd control and antiriot forces and performed rear-area security in wartime. The Soviets advised the Afghan Combat Police-the Sarandoy. 10. Boris V. Gromov, Ogranichennyy kontingent [Limited contingent] (Moscow: Progress Publishers, 1994), 275. Figure 2 only shows hospitalized personnel with hepatitis, so those confined to quarters with the disease are not shown. The 5th Motorized Rifle Division, roughly one-fifth of the Soviet 40th Army’s total strength, exceeded the annual rate for hepatitis in two months. Thus, the official statistics, although staggering, are on the low side. 11. E.A. Nechaev, “Meditsinskaya reabilitatsiya uchastnikov voyn i lokal’nykh vooruzhennykh konfliktov” [Medical rehabilitation of veterans of wars and local conflicts], VMZ (February 1994), 5. 12. Perepelkin, 29. 13. V.F. Korol’kov, P.I. Ogarkov, and V.A. Mandrik, “Profilaktika kishechnykh antroponozov sredi lichnogo sostava” [Prophylaxis of intestinal anthroponoses in servicemen], VMZ (April-May 1992), 73. 14. Perepelkin, 29. 15. V.V. Zakurdaev, “Kharakter patologii organov dykhaniya u voennoclyzhashchikh v usloviyak Afganistana” [Traits of respiratory system pathology in servicemen in Afghanistan], VMZ (June 1992), 39. 16. Ibid. 17. Ibid. 18. Ibid. 19. Ibid, 40. 20. Dry rations are similar to the old US Army C ration. There were three types of dry rations: a can of meat, crackers or toast, jam and a tea bag; two cans of meat mixed with oatmeal; or a can of meat and a can of vegetables or fruit. 21. Perepelkin, 30. 22. I. Konyshev and A. Grib, “Opyt, kotoryy nichemu ne uchit” [Experience which teaches nothing], Armeyskiy sbornik [Army assembly] (August 1994), 36. 23. Y.V. Nemytin and V.V. Boldyrev, “Organizatsiya reabilitatsii infektsionnykh bol’nykh pri mnogokratnoy peregruzke gospitaley” [Rehabilitation management of infectious patients in overcrowded hospitals], VMZ (April-May 1992), 38-39. 24. Ibid, 38. 25. Ibid, 39. 26. Theft and resale of soldiers’ food has a long history in the Russian and Soviet armies. 27. The Soviet (and Russian) army issues three sets of underwear per soldier. Theoretically, the soldier wears one set, one set is held in regimental stores and one set is at the division laundry point. Underwear is supposed to be changed once a week, but due to shortages, losses and breakdowns in the supply system, the soldier often wears his single set of underwear for months at a time. The situation with uniforms is not much better. The soldier has one field/work uniform and pair of boots. He wears these continually for six months. When he washes his uniform, he wears it damp the next day. 28. Konyshev, 36-37. Lieutenant Colonel Lester W. Grau, US Army, Retired, is a military analyst in the Foreign Military Studies Office, Fort Leavenworth, Kansas. He received a B.A. from the University of Texas at El Paso and an M.A. from Kent State University. He is a graduate of the US Army Command and General Staff College (CGSC), the US Army Russian Institute, the Defense Language Institute and the US Air Force War College. He held a variety of command and staff positions in the Continental United States (CONUS), Europe and Vietnam, including deputy director, Center for Army Tactics, and chief, Soviet Tactics Instruction Branch, CGSC; political and economic adviser, Headquarters, Allied Forces, Central Europe, Brunssum, the Netherlands; and diplomatic courier, Moscow. His article “Bashing the Laser Range Finder With a Rock” appeared in the May-June 1997 issue of Military Review.
Major William A. Jorgensen, US Army Reserve, is assistant professor of Clinical Medicine, State University of New York College of Health Sciences, Syracuse, New York. He received a B.S. from Saint Bonaventure University and a D.O. from the University of Health Sciences College of Osteopathic Medicine. After completing his family medicine residency at Womack Army Hospital, Fort Bragg, North Carolina, he served as the Primary Care and Community Medicine department chief at Munson Army Community Hospital, Fort Leavenworth, Kansas.