Lessons of the Second World War

Pre-war years
The present century has seen continued progress in conditions of life for the sailor afloat and ashore, and a continued though lesser fall in sickness. Early in the century, however, epidemics of certain infectious diseases gave rise to concern and one in particular was diphtheria, now very rare. At the Royal Hospital School, Greenwich, between 1919 and 1927, there had been no fewer than 385 cases, mostly concentrated in two major epidemics. At that time artificial immunization had not been started and it was Sheldon Dudley, who later became Medical Director-General during the war years, who used the material for initiating his studies of herd immunity. A scheme of immunization resulted in complete disappearance of recognizable diphtheria. It was Dudley's success at Greenwich and the observations made concurrently in fever hospitals and elsewhere that diphtheria could be virtually abolished, even when exposure might be constant and intensive, which undoubtedly influenced the authorities in their decision to introduce the national immunization campaign in 1940. Dudley's work on herd immunity was fundamental and he also contributed much to the epidemiology of typhoid and rheumatic fever, both of which diseases gave rise to concern in the Navy from time to time. For his contribution to national as well as to naval preventive medicine Dudley was elected FRS - the first naval surgeon to receive this honour since T H Huxley in 1851.

The war years
The stimulus of the war years led to major advances in the field of preventive medicine, such as the development of insecticides, suppresive antimalarial drugs, methods of immunization, all of which aided the Navy to maintain fighting efficiency. The role of preventive medicine in war is paramount, when sickness from preventable disease, at any rate in tropical and semi-tropical countries, is always higher than battle casualties. For example, the ratio of preventable diseases to battle casualties in the earlier phases of the Japanese war exceeded 100:1 in some theatres of operations. In Burma, by improvement in malaria discipline and with the advent of DDT, the ratio of sick to wounded dropped from 120:1 in 1943 to less than 20:1 in 1944. The consultant physician to South-East Asia Command estimated that four-fifths of the sickness in that theatre was preventable. He commented:

'One medical officer engaged on hygiene can save the work of ten medical officers in hospital.'

The Navy, by virtue of past experience and the many improvements in life at sea, thought they would be relatively immune from sickness, but had a very rude shock with the introduction of amphibious warfare and the establishment of naval bases and airfields ashore in malarious countries when they had to leave the security of life at sea. Other problems arose from rapid expansion of armaments and gadgets which had to be fitted into the inelastic hull of a ship built many years before. To work these extra machines required a great increase in complement which led to overcrowding. Additional to this, was the necessity for manning and fighting ships for long periods at sea in all climates, under wartime conditions of blackout and damage control. Dudley summed up the problem by posing the question:

'What is the ratio of the space allotted to the human element to the space allotted to the mechanical element of the total fighting machine (ship plus ship's company) which will make it the most efficient engine of war?'

To study this and other problems and to achieve quick results in which mechanics, seamanship, physiology and preventive medicine were all involved, a Royal Naval Personnel Research Committee was set up. This was a Medical Research Council Committee and had as members, civilian physiological and medical experts, representatives of the executive and technical departments of the Navy, as well as of the medical branch. The terms of reference of the committee were:

'To advise the Medical Research Council on such investigations as the Council may be asked to undertake on biological, medical and psychological problems affecting the health and the fighting efficiency of RN personnel, and to suggest investigations with a view to increasing or improving the health, fighting fitness and environment of naval personnel, and to aid and supervise such investigations as expedient.'

The problems concerned were conditions in submarines, diving, habitability in ships and climatic efficiency, and visual problems. Note how developments in these fields can no longer be achieved by the doctor alone, but are dependent upon a team of experts - engineers, chemists, physiologists, psychologists and physicists. Statisticians must now be added to the list. The results achieved by the RNPRC and the various subcommittees which were appointed under it were considerable, and enormous improvements followed in ventilation, air movement, air conditioning (particularly in submarines), better amenities, and better conditions in ships. Much experimental work was done at Cambridge and the Hospital for Nervous Diseases, Queen Square, London, on environmental warmth and efficiency. This work was continued after the war at the RN Tropical Research Institute at Singapore and later in Cambridge and at the Institute of Naval Medicine at Alverstoke. Short and long-term experimental work was, and still is, undertaken with the object of defining the limits of habitability in which a man can remain 100 per cent fit. Particular problems in connection with aviation medicine and underwater medicine have also been closely studied. Space is always a critical factor. In past years, when the armament of a ship consisted of heavy weapons with a simple form of control, the ship had to be big simply to float and there was plenty of room for the ship's company. Now, with armament consisting of a few high-precision weapons with a large amount of relatively light but bulky control equipment, the space required for the accommodation of the ship's company is a critical factor influencing the design characteristics of a ship and in consequence has a bearing on health. It was fortunate that in the critical war years the medical direction of all these activities was in the hands of so eminent a man as Sheldon Dudley. Perhaps his most outstanding contribution in the war was the advice he gave to Mountbatten on the control of malaria and dysentery, which contributed so much to the success of the Burma campaign. Some of Dudley's axioms were:

'Broadly speaking, naval personnel need not worry about hygiene as long as they remain in their ships, HM ships being self-contained units in which health measures have been so carefully organized over the course of years that naval officers and ratings have come to accept them as a matter of course. Provided the instructions concerning health and sanitation are observed it should be impossible to obtain bad food or water.

For generations the seaman has unwittingly observed the fundamental law of keeping his ingests apart from his egests, by passing his excrement straight over the side of the ship into the sea where it cannot possibly pollute food or flies.

His ship has always been the sailor's home, accompanying him wherever he goes, granting him facilities for cleaning himself and his clothes which are never enjoyed by a soldier in the field, and allowing him changes of clothing which are automatic safeguards against lice and typhus. As long as he remains in his ship the sailor can avoid contact with the primitive countries which are the chief reservoirs of many of the infectious diseases as well as avoiding infection from insects which travel far from shore across water.'

Mention must also be made of the pioneer work of the Navy during the war in the field of mass radiography, with the development - the first in this country - of a static and later a mobile unit. This was one of the great developments of preventive medicine in the Navy during the war, and considerably affected the incidence of pulmonary tuberculosis. Naval tuberculosis is now (apart from unofficial Chinese) controlled. Dudley was a great advocate of mass radiography in the Service.

Co-operation
One of the duties in a ship is to excerise constant vigilance to ensure that health rules and health measures are observed, but the doctor is helpless without the co-operation of the Captain. Unfortunately this co-operation and the realization of executive responsibility in health matters are not always fully appreciated. At an Allied conference on war medicine during the war Dudley stated categorically:

'Executive and combatant officers must be taught that the enforcing of hygienic measures to preserve health, morale and fighting efficiency of their troops is as important as any other military duty.'

One of the most important Fleet Orders issued during the war stated that Flag Officers and commanding officers were responsible for ensuring that protective and preventive measures are undertaken and rigorously enforced. The medical officer can only advise, as he has no executive authority over officers and ratings, except when they are on the sick list. As Gilbert Blane had once said:

'A ship in the middle of the ocean is a little world within itself at the arbitrary disposal of an individual. All seafaring people, especially those employed in war, are exposed to peculiar and unavoidable privations, hardships, and dangers, which ought to be mitigated as far as is practicable by those at whose absolute will they place their lives and limbs.'

Once again it was found necessary to remind commanding officers of their responsibility, as Lind and Blane had had to do in the past. Dudley considered that educating the combatant officer to take hygiene seriously, and the inculcation of malaria and hygiene discipline ia sailors, soldiers and airmen, are the most important duties of the medical officer in war and peace. Again quoting Dudley:

There is a terrible curse on preventative medicine in that no one realizes its necessity till a disaster arises as the result of its neglect.'