Malaria: Sierra Leone’s Other War

by Dr ANDREW STEWART

Although it is now showing signs of finally being brought under control, the 2014 West African Ebola outbreak is the largest in recorded history. With the anniversary approaching of its start, the most recent figures from mid-April 2015 confirm there have been 10,730 deaths and nearly 26,000 reported cases. Although it spread across the region, the former British colony of Sierra Leone was particularly badly hit and has recorded more than 12,000 cases, the highest of any affected country. Whilst the threat presented by this terrible disease very rightly remains the focus of international efforts, as can be witnessed through the on-going deployment by British military personnel to provide medical support as part of Operation ‘Gritrock’, it is not the only health threat to the people of West Africa. In November of last year Queen Elizabeth II was reported as commenting that the devastation caused by Ebola should not mean that the longer term impact of malaria is forgotten. This warning was prescient as the World Health Organisation’s most recent annual report, published the following month, confirmed that in Sierra Leone in 2013 there were more than 1.7 million reported cases and 4,300 deaths.

My research into how the Second World War impacted upon the then imperial colony and protectorate of Sierra Leone, due for publication early next year in my colleague Ashley Jackson’s edited volume The British Empire and the Second World War (Ashgate), makes reference to how disease affected the British troops who were sent to protect what quickly became an important strategic outpost. Earlier work has highlighted how this had long been a posting that offered considerable challenges particularly in regard to the health of those sent to West Africa who were exposed to a combination of harsh climate, prevalent disease and a lack of anything meaningful to keep them occupied. As the European situation worsened and the garrison expanded the first recorded figures confirmed the adverse impact on the health of those who had recently arrived; at the end of May 1940 there were 57 British officers and 237 other ranks stationed in Sierra Leone but nearly ten percent were in hospital with the majority presumably suffering from malaria. As one of those who arrived later in the summer wrote back to his friends in London, “Sierra Leone is beautiful in the extreme but like all Africa there is hidden danger round every corner”. He did not contract the disease during his tour but as the number of troops increased so did those suffering from the disease with the largest increases being amongst those troops manning the beach defence posts around the capital Freetown where the mosquito carriers were found in the greatest numbers; by the middle of October 155 troops, more than 15 percent of the men, in what was referred to as the Fortress Area were sick. The first signs of improvement came later that month with the issue of anti-malarial ointment; the troops of the Essex Regiment who had been sent in August 1940 to strengthen the garrison arrived without any of this or even mosquito nets which had to be sent out in the next available convoy. Whilst these measures appeared to help reduce the malaria threat and highlight the value of preventative action, there were now signs of other dangers. The same month the first cases of dysentery were recorded confirming the range of potential medical issues which also included sleeping sickness and yellow fever.

The risks from malaria remained the greatest cause for concern. The conclusion at the end of December was that “in spite of the most careful selection of sites and rigid precautions, a night out of barracks on training automatically involved an increase” in cases as numbers once again began to rise. The sick list for the Essex Regiment troops now averaged between 17-18 percent of the battalion and a total of 291 men had been admitted to hospital with all but 60 of them having malaria. The onset of the dry season that same month and the arrival of the hot harmattan winds from the Sahara desert once again saw some improvement but this brought with it an increase in skin diseases especially fungal infections of the feet. For the men they actually found the discomfort of athlete’s foot and dried skin elsewhere on their bodies to have the greatest negative impact on their morale. In addition to being very dry, by early January 1941 it was also very hot although without the humidity and strong breezes. After the four months of damp heat they had faced since their arrival the men of the garrison were now sweating much less during their training. There was though an increased risk of bush fires around the camp and extra work needed to be done cutting gaps in the foliage.

Much as has been the case with the response to Ebola, it was soon recognised in London that the situation would require a significant medical deployment. During the first week of January 1941 a much larger general field hospital arrived in Freetown bringing with it “a galaxy of medical talent among its officers”. As a British army observer later wrote “this was going to be the first occasion when large numbers of European soldiers would be exposed to the hard tropical conditions of West Africa” and with the arrival of a second hospital in only a matter of months it was clear that there were seen to be considerable potential for conducting dedicated research into tropical medicine. At the same time the opportunity was also taken to correct pre-war failings when there had been a woeful shortage of facilities and medical care before the war. Before the war’s outbreak there were just 535 hospital beds for Africans and 14 for Europeans with only 22 European and African doctors.

The improvements to the medical care along with the change in the weather did, however, eventually help bring malaria under control and by March 1941 there was a fairly constant figure of 10-12 percent of the troops being affected. By the end of May the figure for hospital admissions was 545 men of which 286 were malarial cases; more than one-third of all those who had boarded the transport ships the previous August in Liverpool had now been treated. Rigorous precautions were enforced to try and bring down the numbers affected, before sunset all ranks were required to change into long trousers with calf length, suede leather wellington boots and long sleeved shirts which were buttoned at the wrist and collars done up. Mosquito nets were in place an hour beforehand and it was a military offence to be found with holes in the nets. Despite knowing that the quinine did not work fully all men were also required to attend a regular morning parade where they swallowed their day’s dose even though it had the side-effect of staining the skin yellow and making the troops look like they had jaundice.

When further reinforcements arrived in September 1941 they brought with them not only additional heavy and light anti-aircraft batteries to protect the increasingly vital harbour but additional medical support including a new dedicated malaria laboratory. That same month the disease was described by a visiting US naval observer as a “scourge”. Although not yet in the war there was an increasing American presence in the region and attempts were being made to gain a better understanding of local conditions. The resulting report confirmed that, despite all the efforts being made, the threat from malaria was far great than that from any potential Axis attack with each person in Freetown calculated as having an incident at least once a year. At any given time one-quarter of the British army were affected – in the bush areas the numbers could be twice as high – and more than one-third of Royal Air Force personnel. Despite all of the evidence to the contrary it was also suggested that very little was being done by the authorities to tackle the problem with not one house visited by the American officer having mosquito screens across the windows and doors. It was more than eighteen months later when the next report was sent back to Washington DC and, by 1943, the situation had improved with improvements to housing, sustained attempts to control the mosquito population and the widespread supply of netting and anti-malarial drugs.

The experience encountered in Sierra Leone was by no means unique nor were the impacts of malaria confined to British military forces. An August 1944 report by a British brigadier and malariologist provided a global overview and noted that in equatorial zones, such as West Africa, casualties from the disease averaged about 10 percent of unit strength. In the South West Pacific after five months of being deployed 25 percent of Australian troops were affected. Overall they experienced five times as many casualties from malaria as actual battles with the Japanese whilst American troops suffered ten times the number; the estimated annual attack rate was an incredible 200 percent. Whilst British troops stationed in the ‘white man’s grave’ of West Africa had been the first to battle the ‘squito’ their experiences were repeated throughout the war that followed – this was a battle that could not be won without anti-malarial discipline and the deployment of dedicated medical support.

Image: British troops receiving instruction regarding the dangers of malaria from Major Carter at the Divisional Training School in the Anzio region of Italy. Photo courtesy of the Imperial War Museum © IWM (NA 13817).

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