Negative Effects of Famine upon the Public Health of the European Population
After a long period of negative living conditions under the influence of a plurality of negative factors associated with the economic crisis, political tensions and the war, changes in morbidity and mortality were expected to occur. Average life expectancy was probably the more direct and simple long-range index of public health. Under the effect of malnutrition and poor living conditions, resistance and immunity were gradually lowered, morbidity increased, although it took time for individuals to complete the whole cycle of exhaustion and sickness, ending in a deterioration of health standards and in death rates. The cumulative effect of all of the negative factors was estimated to appear relatively slowly, and several years were needed before the damage to health could be estimated in full.
As a consequence of food shortages and the subsequent reduction of calorie and nutrients intake, public health was affected. Food is not the only factor determining the health status of the population, but it is remarkable that during the war most of the determinant variables upon which health depended developed in a negative direction. Most cities had been destroyed by bombing and land warfare, residential construction had come to a practical standstill in belligerent countries and the housing shortage became a general problem. Many families were forced to share narrow quarters, and in many bombed-out areas, the population lived in improvised shelters or in cellars of ruined buildings. The impairment in housing conditions influenced health negatively. Overcrowding had become a generalised problem at the end of the war, even more acute where whole population groups evicted from their home regions had been moved to areas scarcely equipped to receive large numbers of refugees, destitute people, or where the military had requisitioned civilian buildings. The lack of housing affected health in particular, considering the fact that feeding was deficient all over Europe and general hygiene conditions, clothing, bedding and safe water had become scarce resources.
In general, the meagre supplies of pre-war textiles and shoes were used up, and replaced, to some extent, by articles of less quality.
The lack of soap, the almost complete absence of hot water, and the difficulty of finding decent privacy have naturally affected the habits of personal cleanliness. On top of all this, the efficiency of public health services has lessened in many cases owing to the destruction of hospitals or their requisitioning, the mobilization of doctors and nurses for military service, and the gradual exhaustion of the supplies of medicines, drugs and medical equipment.
In this dramatic sentence, John Lindberg summarised the harsh living conditions of most of the European population in the 1940s. In addition to the general degradation of both diet and living conditions, increasing pressure was exerted upon people. Working hours were generally longer and household duties became harder for housewives. Overwork, fatigue, lack of sleep and stress - as well as the psychological pressure that comes with uncertainty, instability and the disruption of previous lives - aroused a negative perception about people’s quality of life. All these factors, moreover, damaged health, influencing bodily wellbeing, organic defences and immunity. Risks to life posed by aerial bombardments, as well as the presence of enemy soldiers in occupied areas, exposed the population to intense nervous and physical strain. During the war and post-war years, civilians were submitted to high levels of anxiety and had to face an uncertain future. Although the real impact of the deterioration of living conditions and the psychological impairment of the health situation were difficult to assess, it seemed evident that all those factors, together with an insufficient diet, did have a negative effect.
Statistical measures on the evolution of public health were mainly based on scarce epidemiological records, principally morbidity and mortality rates, as there existed no direct measures of health, the previously mentioned ones being indirect negative indices pointing to a waning health situation. Neither anthropometric series of records nor clinical data were collected or made available. Even in the case of morbidity and mortality records, it is important to note that the national epidemiologic services were not always reliable to the same extent - this was particularly important for morbidity statistics. Under extraordinary circumstances, such as the war and post-war, they basically included cases of serious diseases, excluding other conditions, and they often related to deaths rather than to incidence or prevalence figures. Reports and surveys on the state of health of the European population at the end of the war could not draw far-reaching conclusions because the available records were partial, unreliable or unrealistic. The overall picture of the evolution of health that those reports showed was expressive enough, but they were short on specific details. Reports usually referred to urban areas, hardly comparable with total national records. In addition, both morbidity and mortality statistics were likely to be less reliable in countries where health was badly deteriorated and the administration disorganised by war or civil strife.
Traditionally, wars were followed by health crises and disastrous epidemics. After World War I the repercussions of war on health were partly stopped due to improved methods of epidemic control. The international quarantine diseases, plague, cholera, yellow fever, smallpox, typhus and relapsing fever, still affected certain geographically circumscribed areas of the planet endemically, but they could still spread with great violence under exceptionally negative health conditions. All these diseases had been stirred up by the war, yet the new outbreaks had been successfully localised. Since some of these epidemics were transmitted to humans by animal vectors, the war had favoured their breeding and spread to such an extent that they continued to constitute a source of potential outbreaks and risks for human health.
Cholera was endemic in India, Burma and China and had gained little ground outside these areas. A minor smallpox epidemic hit Naples in Italy in the spring of 1944, persisting until 1945. Plague and yellow fever did not affect European countries. There had been outbreaks of typhus in Eastern Europe, Italy and in Germany at the end of the war. A few cases had also occurred in Northern and in Western Europe, transmitted by displaced persons. Typhus was initially controlled “due largely to the efficiency of modern delousing techniques, and, after the liberation of Europe, to the liberal use of the new powerful insecticide, DDT”. However, the dangerous consequences of the use of DDT were not evident.
Since the introduction of vaccinations, typhoid fever was no longer the typical war disease, affecting soldiers and the army, but due to the destruction of cities and sanitation systems, and the uprooting of populations, the disease spread to civilians. The destruction of public health care services, together with polluted drinking water and the worsening of the health conditions of the population, were among the main factors of the serious spread of epidemic diseases.
A quite serious epidemic occurred in September 1939 in Warsaw, after the bombardment of the city, and its spread has since been determined by the progress of bombing; it appeared in the United Kingdom in 1940 and 1941, in Germany after 1942, and epidemically in Japan in 1945. But considering Europe alone, reported cases before the end of the war rarely exceeded twice the normal number. In Germany the incidence in 1943 - the peak war year-was 2.3 times normal, as was also true in France. The incidence was low in Scandinavia, the United Kingdom, the Netherlands, Belgium, Switzerland and northern France, increasing progressively as one moved east and south from this area. But with the end of the war, and the upheaval of life in central Europe, the situation rapidly deteriorated, until typhoid fever came to outweigh diphtheria (previously the chief wartime epidemic) both in frequency and severity.31
Typhoid fever cases increased in Switzerland, the Scandinavian countries and in the United Kingdom, although absolute figures remained low. But since the summer of 1944 new heavily infected areas extended from the Baltic Sea and the North Sea to the Danubian countries, becoming one of the main sanitary threats in the geography of disease at the end of the war.
While medical controls contributed to keeping pestilential diseases supervised, certain other epidemics had increased - although influenza, the great killer after the Great War, had not been severe in the months following the end of the conflict. Some epidemic outbreaks were widespread in the winter of 1943, 1944 and 1945, both in Europe and America, but mortality rates remained low. Emerging as a new serious threat, poliomyelitis showed a growing incidence in many European countries, including France, Switzerland, Norway, Sweden and the Netherlands. Meningitis also became more frequent in Europe and Japan.
Diphtheria was the disease that showed a greater increase during the war. It was almost controlled in Sweden, Denmark, Switzerland and the United Kingdom, although it became an increasing problem in Germany from the late 1930s. Total records registered on the European continent rose during the war: there were 173,000 cases registered in 1941; 283,000 in 1943; and the figures grew even more in 1944, all within the pre-Munich territory. Mortality rates were high and the epidemic spread from Germany to the occupied countries. Incidence was greatest in those countries where the level had previously been the lowest. The situation in Norway and the Netherlands became worse than in Germany itself, since incidence increased 112 times in Norway and 40 times in the Netherlands.32
The number of cases in France rose from two thousand in 1939 to 16 thousand in 1943. In all some 630 thousand diphtheria cases were reported in 1943 in such European countries as maintained tolerably efficient registration. Considering non-reported cases, Knud Stowman, chief of the Epidemiological Information Service of the UNRRA, estimates that there were about one million cases in 1943 in Europe (excluding the USSR), and that the figure was at least as high in 1944. This disease involved about 50,000 deaths in 1943, mostly of children. It is reported that in 1945 diphtheria had become the leading epidemic disease in Japan, with a case mortality much higher than that encountered in Europe.33
The war also had very negative consequences in terms of the emergence and spread of several skin diseases linked to very unsatisfactory hygienic conditions. Scabies increased spectacularly all over Europe; official figures showed that in Norway it was seven times as prevalent in 1943 as in 1938 and in Amsterdam 75 times. In some devastated towns of central Italy, such as Aquila province, 85 per cent of the population was infected, and similar tendencies were described in the case of other skin diseases such as impetigo.34
The fight against the spread of tuberculosis was one of the most important sanitary challenges after the war. As has been generally recognised, the expansion of tuberculosis was particularly susceptible to the impairment of social and economic conditions and above all to the state of nutrition, the excess of working and bad hygienic living standards. In the war and post-war period the systems recording disease incidence and prevalence were heterogeneous and incomplete, and therefore mortality figures were the most reliable index for assessing the spread of the disease among the weakened population. From a policy perspective, however, mortality rates offered a slower and delayed perspective of the evolution of the disease and the impact of the changing situations.
- 32 Ibidem, p. 106.
- 33 Ibidem, pp. 106-107.
- 34 Ibidem, p. 107.
In spite of being one of the main social diseases and a core epidemiological problem, the number of tuberculosis cases had started to fall in most European countries in the Inter-war Period. However, this tendency was reversed by the war, when the disease became more severe, producing an unusual number of acute cases, accompanied and sometimes described as interstitial pneumonia and tuberculous broncho- pneumonia.35
Increases in mortality are noted over most of the Continent, and were marked in Belgium, France and the Netherlands, and also in Eastern Europe, Yugoslavia and Greece. It is significant that in France, for instance, mortality from tuberculosis per 100,000 inhabitants in the Department of the Seine increased from 172 in 1939 to 234 in 1941, falling to 191 in 1943, whilst in Brittany (where food was plentiful) it continued to fall, being, in the Department of Cotes-du-Nord, 257 in 1938 and 148 in 1943. The most seriously threatened areas were Paris, Marseille, Lyon and the cities of the Riviera. In Greece the death rate from tuberculosis in 1942 was 456 per 100,000 inhabitants. The increase in active cases has been accompanied by a large increase of pre-tubercular conditions and latent tuberculosis. Where food conditions remained reasonably good, tuberculosis has on the whole either been fairly stable or has continued to fall. It should be noted, however, that owing to intensified industrial activity the rate has tended to go up in industrial centres, even in the United Kingdom and the United
Similarly, malaria had become more severe in war-stricken areas. In Greece, malaria mortality was usually high, affecting 40 out of every 100,000 inhabitants in 1939, but in the autumn of 1942 an evident increase was developing. In addition to favourable climatic conditions for the reproduction of the carrier of the microbe, the anopheles mosquito, the outbreak was also associated with the displacement of populations, refugees, low resistance and poor immunity in the weakened population due to famine and bad living conditions, as well as the lack of medicine such as quinine and other drugs. Malaria was essentially concentrated in poor rural districts, where people seldom required medical care, and therefore statistics were neither complete nor reliable.
On the other hand, wartime generally resulted in a sharp increase in venereal diseases, not only in war-involved countries but also in neutral ones. The situation was particularly acute in internment camps and occupied regions. Only Scandinavian countries reported specific figures  
about the increment of syphilis cases. For the war period 1941-44, cases increased 7.7 times in Denmark, 6.13 times in Norway and 3.9 times in Sweden.
Fragmentary evidence indicates that, as might be expected, the situation is even less favourable on the Continent. Syphilis was made notifiable in Belgium in 1942, and the incomplete returns show a 70% increase between 1942 and 1944. Records of dispensaries in France indicate a doubling of cases between 1941 and 1942, and again between 1942 and 1943. Unofficial reports from other countries indicate similar developments.37
At the end of World War II the prevalence of specific nutritional deficiency diseases was almost impossible to measure statistically. A generalised loss of body weight had been reported in adults all over Europe and cases of delayed growth amongst children and adolescents were frequent. This evident loss of body weight could be partially attributed to stress, psychological strain and greater physical activity. But it was mainly due to the fact that diets were widely rationed and, even in those cases in which calorie amounts were adequate, rations were uniformly dull and the lack of appetite became a limiting factor. It had been noticed that newborn babies were generally underweight in areas with food shortages. A portion of adolescents and adults also suffered from serious deficiency diseases such as rickets, scurvy, as well as gastro-intestinal problems due to the lack of vitamin B, pellagra, hunger oedema, and other consequences of undernourishment. In any case, reliable statistics were always scarce.
In general terms, the health situation in the United States, the British Commonwealth, Sweden, Switzerland and Denmark was considered to be improving despite the war. In the Netherlands, Norway and Czechoslovakia, and during part of the period in Finland, a serious deterioration in the state of health of the population was averted. In Germany, France and Italy, the situation was less favourable, according to the experts’ reports. Those countries made the political decision of registering mortality increases. The situation in other countries such as Bulgaria, Hungary and Romania did not seem to have deteriorated in a significant manner, something quite different to what was going on in Poland, Yugoslavia and Greece, where the severe impairment of the nutritional condition and the state of health of the population had intensified mortality, infectious diseases and epidemic outbreaks. It is true that the end of hostilities was followed by some improvement in the health indicators in most Western countries, but the positive tendency experienced a drastic retrogression afterwards in Germany, Italy, Austria, Hungary, Romania and Japan.
From a mortality perspective, the death rate continued its pre-war downward trend in a significant number of European countries: Denmark, Sweden, the United Kingdom, Switzerland (except in 1944), Ireland and Bulgaria, in the last country until 1943. This tendency persisted probably until the end of the war, except in the case of Bulgaria. The lowest death rate was that of the Netherlands in 1938, amounting to only 8.5 per cent, an indicator that increased to 11.5 per cent in 1944. A similar trend was noticed in Norway, Germany, Italy, France and most other European countries. If birth rates were on the decline, absolute numbers of infant deaths would also fall, reducing the general death rate as a consequence. However, birth rates went up in the Netherlands, Norway, Czechoslovakia and Finland and, due to this widespread increase in the birth rate, the population did not generally drop in the European context; only Belgium and France were the exception.
Infant mortality remained on a considerably lower level during World War II compared with the Great War. Most countries succeeded in safeguarding the nutritional intake of children, although a difficult challenge was to protect children from the negative impact of displacement and the breakdown of public services. In Sweden, Switzerland, the United Kingdom and Denmark, infant mortality continued to fall, reaching new record lows, notwithstanding the impairment of the nutritional problems. The situation was similar to the pre-war period in Czechoslovakia, Bulgaria and Norway, and also for Finland, except during specific acute warfare and aggressive moments. In the Netherlands, infant mortality rates rose but were still very low when compared with other European countries; something similar happened in Belgium and France, a sharp increase between 1938 and 1940 was followed by a recovery.
At the end of the war, infant mortality rates were less favourable than in the preceding war years and nutritional deficiencies were considered to be one of the contributing factors. “The deterioration was partly connected with the sweeping land warfare, the heavy aerial bombardments and the consequent breakdown of public services, communications and administration, as well as the displacement of populations; but it reflects also, no doubt, the further deterioration in the supply situation over wide areas”.38
At the end of the war official reports regarding the health situation of the European population by the League of Nations, the Food and Agriculture Organisation and the World Health Organisation indicated that it was methodologically convenient to analyse the war years and the period after the end of the conflict separately. During the war period the health status and the nutritional condition of the population became widely diversified. The United Kingdom, Sweden, Switzerland and Denmark succeeded to a great extent in preventing the deterioration of health, even improving their pre-war health and nutritional standards. Other countries, such as the Netherlands, Norway and Czechoslovakia, and also Finland during certain periods, succeeded in avoiding serious impairment, although pre-war gains were partially lost or at least not improved upon. In Germany, France and Italy, the situation was more serious, as morbidity and infant mortality went up and large groups of the population had lived under such negative conditions that it would have lasting effects on their future health. On the other hand, Eastern and Southern European countries formed an area ordinarily characterised by high mortality rates and low life expectancy, although general conditions did not deteriorate greatly during the war in countries such as Bulgaria, Hungary and Romania, and it would even improve in others. For Poland, Yugoslavia and the Soviet Union the international agencies did not have statistics, although in some regions in these countries the health and nutritional conditions were as bad as in Greece during the famine of 1942. In Greece, all indices of morbidity and mortality indicated a serious deterioration of health and high rates of mortality. The situation was considered to be a sanitary emergency.
In 1946 the world health situation as a whole, apart from the specific areas of deep crisis already mentioned, was better than expected. This was largely due to the absence of serious epidemics of the type occurring after the Great War, but also, without doubt, to the relative success of the rationing systems and distribution schemes. The experts emphasised that the full effects of malnutrition, starvation and a deficient diet would take a long time to become evident. But the situation in the early post-war years was extremely fragile and uncertain and a general assessment of the impact of the war and rationing over public health could not be undertaken in a consistent way.
-  [Lindberg, J.], 1946, p. 92.
-  Ibidem, p. 104.
-  Ibidem, pp. 104-105. The main surveys on epidemiologic records of the Europeanpopulation during and after WWII come from the Weekly Epidemiological Record ofthe Bulletin of the Health Organisation. The 4th issue of volume 10 was devoted to“Health in Europe”.
-  Ibidem.
-  Ibidem. pp. 107-108.