The Influence of the Spanish Influenza Upon U.S. Fleet Operations in European Waters, Part 2

A couple of weeks ago, I posted Part 1 of this two part series which is a paper I presented at a recent Army sponsored Symposium on the Medical History of World War I. Held at Fort Sam Houston, Texas and mounted by the Army Medical Department historians over a two day period, the Symposium featured a broad array of papers on a wide range of medical historical topics. It was one of the best meetings I’ve ever attended. Bravo Zulu to Sanders Marble and his San Antonio associates!

And now, Part 2.

Submarines. Seven American “L” boats were stationed on the south Irish coast to patrol for U-boats as they transited south and west of Ireland and later, along the British and western French coasts. Four older and smaller “K” boats and one “E” boat were homeported in the Azores. The machinery in these latter vessels proved to be so unreliable that the boats virtually never put to sea; they played no role in the anti-U boat effort, though Rose argues for a deterrent effect.[1]. In about half a year of operations, American boats, despite regular patrolling, made few contacts and no kills. No mention of influenza appears in the submariners’ operational reports.[2]

Cruiser and Transport Service. Undoubtedly the most significant American naval and maritime contribution to the Allied war effort was the convoy system. As many as twenty four cruisers, in addition to the destroyers reported above, escorted some 45 American troopships and innumerable Allied and neutral commercial vessels in their trips back and forth across the Atlantic. Vice Admiral Albert Gleaves, USN, Commander of the Cruiser and Transport Service mentions the influenza in his history of the Service, mainly to record the number of troops who got sick on the ships, but he makes no mention of any impact on operations.[3] Only once does influenza appear in operational reports from the Cruiser and Transport Service, and that was to transmit an instruction from the Commander, U.S. Navy Forces in France concerning the early transfer of influenza patients to nearby Naval Hospitals.[4] On the other hand, conditions aboard the troopships in seemed dire. On 2 October, Sims wrote to OpNav, “Thompson, Medical Aide, after consultation with General Winter, Chief Surgeon, London Headquarters US Army, reports to me that the health conditions on arrival transports during last week was serious. Over 200 deaths from Influenza-Pneumonia and about 3,000 sick reported. Medical sides [sic; cites?] opinion overcrowding of troops one important cause of spread of contagion.”[5] The troops had caught the virus in training camps, where it spread readily among soldiers living crowded in barracks and being stressed by the rigors of military training. While an occasional transport experienced delay in movement due to influenza amongst her crew[6], no mention is made of operational interruptions due to influenza among the cruisermen.

Battleships. In early December 1917, RADM Hugh Rodman, USN in Command of Battleship Division Nine arrived in British waters with his coal burning dreadnoughts Delaware, Florida, Wyoming and New York. While intended to supplement the British Grand Fleet (as the 6th Battle Squadron) at Scapa Flow in a hoped for decisive battle with the German Hochseeflotte. their crews in actuality spent most of their time engaged in gunnery drills and convoy escort duty. Three more Battleships – Oklahoma, Nevada  and a bit later, Utah – Battleship Division Six – arrived at Berehaven on the Irish coast in August 1918. Their job was to protect iron ore convoys between Scandinavia and Britain against German surface raiders. The first reports of influenza from both American Divisions are dated 26 October. From Battleship Division Six, “During the early part of the week the epidemic of influenza reached rather serious proportions. At the present time the situation is much improved. Deaths from pneumonia during the week have been as follows: UTAH 4, NEVADA 7, OKLAHOMA 4. Admissions to the sick list have been made freely and all practicable precautions taken to limit the spread of disease.” From Battleship Division Nine, “Influenza is epidemic in the GRAND FLEET; the ARKANSAS with over 230 cases, and the WYOMING with less than 10 are in strict quarantine. To date it is of a mild form. Every precaution is being taken to prevent and eradicate it. There is every reason to believe that the ARKANSAS became infected by quartering a draft of men on her, which came from the [troopship] LEVIATHAN, a badly infected ship. These men were … were accommodated on the ARKANSAS, pending the departure of the vessel in which they were to take passage.”[7]

Jerry W. Jones, in his history of U.S. Battleship Operations in World War I[8] notes that the British Grand Fleet was severely affected by the epidemic. He quotes LT John McCrea, aboard the USS New York, “…had the German fleet come out to do battle during the epidemic, many ships of the Grand Fleet would not have been able to give an account of themselves.” Certainly Arkansas, with nearly a quarter of her crew on the sick list at the peak of her epidemic, would have been hard pressed to contribute effectively to any large fleet operation. Fortunately, crewmembers in the German fleet were war tired, and German Vice Admiral Scheer’s planned naval Götterdämerung against the Grand Fleet was aborted by mutiny among his crewmembers in late October.

Results

The most significant contribution of American naval forces to the Allied war effort was its participation in the anti-submarine campaign in its many iterations. Just what was the impact of the Spanish influenza on these activities? The answer is told in the tonnage sunk statistics for the time. Sims, in his history of the naval war effort lists the monthly tonnage sunk from February 1917 through October 1918. These show that sinkings began to decrease markedly in the last quarter of 1917, a decrease that continued into the next year. Most instructive to our consideration are the tons of shipping (British, Allied and neutral merchants and fishing vessels) sunk in 1918 (see graph 1).[9]

Screenshot (19)

Graph 1

Notice the jump in August. It is virtually impossible to attribute this jump solely to the illness that paralyzed NAS St Trojan. In fact, Navy Surgeon General William C Braisted stated that the main onslaught of influenza among our Atlantic naval forces hit in mid-to-late September, that is, in the month following the surge in sinkings.[10] In fact, the downward trend resumed during the month of highest contagion.

Convoy activity similarly shows that the epidemic in September and October did not result in a decrease in sailings. In fact, ship departures (displayed in Graph 2) showed a continuing increase through the period of contagion.

Screenshot (20)

Graph 2

Conclusion

This report really ends up looking like a scientific paper: I started with a thesis – the Spanish influenza had an adverse influence upon U.S. Navy operations in support of the Allied efforts against the Central Powers in World War I. I then did the “experiment” – a search of relevant historical works and official reports of operations in, under and over European waters. I collected and analyzed the data. Result: the Spanish influenza had no operationally significant adverse influence upon U.S. Navy operations in European waters during World War I. My thesis is disproven.

A Cautionary Afterthought

In some units, a significant proportion of U.S. Navy personnel fell ill at some point during the period of contagion (August through October 1918). That operations were not significantly impacted is at least partly because there was a large enough pool of manpower available to supplement crews where necessary and because larger ships were generously crewed. In addition, the war appeared to be winding down as victory in the land war was clearly in view. Moreover, the enemy’s forces were suffering the same contagion – as Gina Kolata  put it, “…the Germans were at least as devastated…” as were Allied armies[11], and the German Navy was in the throes of the mutinous impulses mentioned above.

But what of today? In an online survey of military and civilian writing on the risks of bioterrorism and biowarfare, I found that the entire conversation appears to be around ameliorization of risk (prevention / immunization), training of first responders, diagnosis and treatment. Other than for first responders and the provision of special medical expertise, manning issues are not mentioned at all. We know well that both simple and sophisticated biotechnologies and increasingly sophisticated weaponization techniques, as well as the knowledge to create and apply them, are readily available to both state and non-state actors.  As a result, our military forces face potential exposure to “designer” agents carefully crafted to disable or kill large numbers. In the meanwhile, in an age of cost constraints and rising personnel costs, our military, and in particular our navy, seems to have instituted manning policies and equipment design based on a “minimum numbers necessary” approach. Given the increasing risk of the use of biological weapons in time of war, it would be wise to put an “epidemic manning surge” – that is, having more people than “mission-necessary” in place as back-ups –  into our force planning, lest critical war fighting capability be paralyzed when epidemic strikes.

[1] Lisle, op. cit. P 197.

[2] NARA, RG 45, ON-Submarines-Submarine divisions 3-6; Operation Reports. Entry 520 I-18, Box 420 of 1630.

[3] Gleaves, Vice Admiral Albert: A History of the Transport Service – Adventures and Experiences of United States Transports and Cruisers in the World War (New York, George H Doran Company, 1921), p190, 191), https://archive.org/stream/historyoftranspo00glea#page/190/mode/2up, accessed 15 March 2018.

[4] NARA, RG 45, CR-Cruiser & Transport Service 9/18-6/19, Entry 520 I-18 Box 88 of 1630, Folder CR-Cruiser and Transport Service October 1918 Folder 2, 4 October 1918

[5] NARA, RG 45, IL 6104, K-20 (in pencil, “October 2, 1918”), From: Sims To: OpNav 6104

[6] NARA, RG 45, Box 34 of 1630, File CE Destroyer Escorts 9, DUMMY Oct 24 1918, Class 3, Part 2 CE CO (pencil crossed out and “CU” entered), From Commanding Officer, S/S RE D’ITALIA To: Commander, Naval Forces, Brest, France, Subject: S.S. RE D’ITALIA unprotected in submarine waters; report on Ship unable to maintain position in convoy owing to so many of her crew having influenza

[7] NARA, RG 45, Box 632 pf 1630, Folder November 1918 4, REPORTS FROM BATTLESHIP DIVISION

[8] Jones, Jerry, W.: U.S. Battleship Operations in World War I (Copyright Jerry W. Jones; Published, Annapolis, Naval Institute Press, 1968)

[9] Sims, op. cit., Appendix VIII, Monthly Losses Since February 1917, From Enemy Action

[10] Secretary of the Navy: Annual Reports of the Navy Department for the Fiscal Year 1919 (Bureau of Medicine and Surgery, report of), (Washington, Government Printing Office, 1920), p2438ff, https://babel.hathitrust.org/cgi/pt?id=coo.31924065924502;view=1up;seq=2503, accessed 13 March 2018.

[11] Kolata, op. Cit., p50

©2018 Thomas L Snyder

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The Influence of the Spanish Influenza Upon U.S. Fleet Operations in European Waters, Part 1

Recently, I had opportunity to give a paper at an Army-sponsored Medical History of World War I symposium in San Antonio. The meeting was superb: a two day affair with dual (“competing”) sessions both days. Excellent papers across a wide spectrum of study, given both by historians and by physicians. Here is the first of two parts of my paper, entitled, “The Influence of the Spanish Influenza Upon U.S. Fleet Operations in European Waters”:

In the popular mind (and probably most academic thought as well), the main American contribution to the Allied victory in World War I lies in the 2,000,000 doughboys who helped slug it out with Central Powers armies. As historian Stephen Howarth put it, “Today, imagining Americans in World War I, the doughboys spring at once to mind – young soldiers in their tens of thousands, singing and fighting through the muddy fields of France. Sailors serving under the Stars and Stripes seem scarcely to figure at all.”[1] E. B. Potter, in his authoritative one volume textbook on naval history devotes just two paragraphs of “U.S. [naval] Contributions” in World War I, which briefly describe our convoy operations.[2]

Introduction

Yet the story is more dramatic that the usual depictions would have it. Rear Admiral William Sims arrived in London on 9 April 1917 to study the naval war. While he was in transit, the United States declared war on Germany. As a result, Sims transitioned from naval observer to commander, as Vice Admiral, of the American naval effort. Immediately upon his arrival, Sims discovered that the British situation was precarious. German unrestricted submarine warfare was sinking 600,000 to 800,000 tons of merchant shipping every month. The British Admiralty predicted that if a solution to the submarine threat weren’t found, and quickly, Britain, facing starvation, would have to sue for peace by November. The solution, arrived at despite stout Admiralty resistance, turned out to be the convoy system. This called for destroyers (lots of them), cruisers and aircraft (both heavier than air and lighter than air) to provide antisubmarine escort for groups of ships – merchant transports, hospital ships and troopships –  traversing submarine-infested waters in the Atlantic and the approaches to Britain, and in the Mediterranean. American destroyers played a significant role in that part of the anti-submarine effort by seeking out U-boats as they approached to attack convoys and bombarding them with depth charges.

Other anti-submarine activities undertaken by American naval elements included:

  • Laying 50,000 of a 70,000-mine barrage in the North Sea to interfere with U boat passage from their pens along the Belgian coast to the North Sea and the Atlantic;
  • “Chasing” submarines with about 140 quickly produced wooden submarine chasers. These 120 foot boats, officered largely by naval reservists from colleges and universities and armed with depth charges, gradually developed successful tactics in using hydrophones to identify, locate and attack the enemy submerged in the Atlantic and the Mediterranean;
  • Identifying and attacking submarines from the air. Naval and marine aviators, based on the French and Irish coasts, hunted submarines, then bombed them or marked them with smoke bombs so destroyers or subchasers could attack with depth charges;
  • Pursuing U boats from under the surface. American submarines based on the Irish coast performed both escort and submarine hunting missions.

In addition, four battleships were sent to join the British Grand Fleet as the Sixth Battle Squadron to strengthen the Grand Fleet in event of another Mahanian grand battle against the German High Seas Fleet.[3] Later on, another Battleship division was sent to supplement convoy operations.[4]

Finally, and very importantly American navy and commercial ships carried about 46%[5] of those 2,000,000 doughboys, and vast amounts of food, supplies and war materiel to Britain and to the war effort in Europe itself.

Methods and Materials

In preparing to write this paper, I was struck by the absence of any mention of the influenza in any of the broad naval histories I consulted. Lisle A Rose, in his one volume history “America’s Sailors in the Great War”[6] writes only about individual sailors’ afflictions with the disease. Vice Admiral Sims similarly ignored the flu as did Hugh Rodman, the battleship commander.[7] I attributed this lack of information to the usual bias of military figures and historians to emphasize military operations to the exclusion of such “peripheral” – though often decisive – matters as logistics or contagion. Even writers about the epidemic give short shrift to naval operations: Gina Kolata only briefly mentions the Navy in her book on the flu, and John M Barry ignores impact of the influenza upon sailors entirely.[8],[9]

In order to correct this oversight, I consulted relevant naval histories and actual operational correspondence for U.S. Naval Forces Operating in European Waters for this paper.[10] I will review each aspect of the naval antisubmarine effort in the order laid out above.

Data

Destroyers. As for the Destroyers performing convoy escort duties, just one mention of influenza appears, on 22 October 1918: “The Influenza situation is the occasion for some worry, but, really, compared to other organizations, I think we have been rather fortunate. I have found it necessary to use the hotel temporarily for our influenza cases…”[11]

Minelayers. Scant mention of the epidemic is found in reports from the Minelaying Squadron[12]. Commander Mine Force, in his Weekly Report of Operations for the week ending November 2 1918 wrote, “Very few cases of this disease have occurred… among the ships of the Mine Force. In fact the Naval Forces in this section have been remarkably free from this disease, considering the fact that it is prevalent among the civil population in this vicinity.” A week later, he wrote, “The epidemic of influenza among out [sic – “our”?] forces … has apparently disappeared, there having been no cases since 8 November 1918. A total of 50 percent of this detachment have been ill with influenza and transferred to Base Hospital Number Two, in order that they might receive proper care, and in order to prevent the spread of this disease as much as possible.” He made no mention of impact on minelaying operations.[13] Captain Reginald R Belknap, the Minelaying Squadron Commander mentioned the flu but once in his history of American World War I minelaying operations in which he indicated that 113 of the 427 man crew of the squadron flagship, USS San Francisco (C-5) fell ill as the ship prepared to leave British waters after the Armistice.[14] In a report dated 1 November 1918, the Commander of the Sixth Minesweeper Squadron, based in Ireland, reported that one boat (of about 30 in the squadron) was delayed in undertaking a mission because her crew had to transfer one of her officers to a local hospital, and that another did not leave for operations at all for three days “owing to sickness in the crew”.[15]

Subchasers. The most authoritative history of the subchaser war effort mentions “flu” but once, and this describes a preventative quarantine of one unit – after the Armistice.[16] That said, some subchaser crews appear to have suffered heavily from the influenza. The squadron of 36 boats based on Corfu, in a message sent on 6 November, just five days before the Armistice, when the subchasers were trying desperately to bottle German and Austrian subs up in the Adriatic Sea after Austria’s departure from the war, wrote in answer to criticisms of one of their hunting missions, “As to discrepancies disclosed in signals, principally in the preambles, due to the epidemic of influenza in the Sub Chaser Detachment a large number of the radio operators with the hunt were substitute operators from the Base…”[17] On 9 November, Commander Subchaser Detachment Three at Queenstown, Ireland reported that “[o]ne unit at Holyhead is reported as unable to operate on account of 35 men on the sick list from influenza. None of these cases is serious, however, and the medical officer states that all present cases should be returned to duty within a few days.”[18] None of this illness, however, appears to have impacted the subchasers’ performance of their mission to any degree whatever.

Naval Aviation. Naval aviation was in its infancy when the U.S. declared war upon Germany. As a result, American aviators and the sailors who supported them and their aircraft found themselves integrated into French, British, and Italian aviation units where they were trained. Once qualified, the Yanks flew antisubmarine and convoy escort missions and bombed German submarine bases and other targets using mostly Allied equipment. It was only in the late stages of the war that wholly American units were stood up, with American-made aircraft.[19]Neither Rose nor an official online history of naval aviation[20] mention the influenza in aviation units, nor did any of the intel briefings given to Sims preparatory to the daily Admiralty meetings in London.[21] Geoffrey L Rossano, in his comprehensive history of naval aviation mentions influenza 12 times, 3 of them substantive. Of Naval Air Station Dunkirk, he notes that during the period 21 October to 5 November, “as much as 90 percent of the base complement [were] affected more or less seriously. The weakened men spent the period … taking down hangars, cleaning the grounds, and loading trucks and a barge for possible repositioning northward along the coast” in response to the tactical retreat of German forces from coastal areas. The naval air station at St Trojan, on the French Atlantic coast suffered its epidemic at the end of August, “with 6 deaths and 210 men incapacitated to varying degrees. The sickness lasted about three weeks and ‘at times the station was completely unable to carry on operations.’” Naval Air Station Lake Bolsena, Italy experienced a flu outbreak in October, when “flying activities virtually ceased” for a week or two. This was a training base, so this lack of activity would had virtually no impact on the antisubmarine effort being prosecuted in the Mediterranean.[22]

[1] Howarth, Stephen: To Shining Sea – A History of the United States Navy (New York: Random House, 1991)

[2] Potter, E.B., ed.: Sea Power – A Naval History (Annapolis: Naval Institute Press, 1981)

[3] The grand battle of the war, Jutland, was a Mahanian “disaster” in that neither fleet won what Mahan defined as the necessary decisive large-fleet victory. But the British, if fact, had won a strategic victory, because the Hochseeflotte remained bottled up in port until the end of the war.

[4] Most of this is discussed in Sims’s history of the Naval war cited above. The Sixth Battle Squadron was commanded by RADM Hugh Rodman. Battleship operations are detailed in Jones, Jerry W.: U. S. Battleship Operations in World War I (Annapolis, Naval Institute Press, 1998.)

[5] Rose, Lisle A.: America’s Sailors in the Great War – Seas, Skies, and Submarines (Columbia, Missouri, University of Missouri Press, 2017.), p 100.

[6] Rose, op. cit.

[7] Sims, William Sowden and Burton J Hendrick: The Victory at Sea (ebook verson, Madison & Adams Press, 2017.) Rodman, Rear Admiral Hugh: Yarns of a Kentucky Admiral (Indianapolis, Bobbs-Merrill, 1928.)

[8] Kolata, Gina: Flu – The Story of the Great Influenza Pandemic of 1918 (New York, Farrar, Straus and Giroux, 1999.)

[9] Barry, John M.: The Great Influenza – The Epic Story of the Deadliest Plague in History (New York, Viking/Penguin, 2004.)

[10] National Archives and Records Administration (hereafter “NARA”), RG 45, Records Collection of the Office of Naval Records and Library, File 1911-1927.

[11] NARA, CE-Destroyer Escorts 9/18 – 11/18, Entry 520 I-18 Box 34 of 1630 – Destroyer Escorts 9, File No 3-978-5 U.S. Naval Base 27, 22 October 1918, to Captain R. H. Leigh, U.S.N. in London.

[12] 10 ships, eight of which were purpose built minelayers, two (including the Flagship, USS San Francisco [C-5]) were nineteenth century protected cruisers converted to minelayers in 1910. https://www.history.navy.mil/research/histories/ship-histories/danfs/s/san-francisco-i.html, accessed 2 March 2018.

[13] NARA, RG 45, TA-Force Commanders General Reports-Vice Admiral Sims Reports, Entry 520 I-18 Box 640 of 1630, Folder TA-Vice Adm. Sims’ General Reports Nov 1918 Folder 5 REPORTS FROM MINE BASE.

[14] Belknap, Reginald Rowan: The Yankee Mining Squadron or Laying the North Sea Mine Barrage (Annapolis, U.S. Naval Institute, 1920, facsimile reprint London, Forgotten Books, 2015.), p 94.

[15] NARA, RG 45. OD-U.S. Subchasers – Operations of 9-12/18 – 1919 Halifax Patrol: Flotilla Attached to Subchasers Entry 520 I-18 Box 388 of 1630 File OD U.S. Subchasers, Operations of November-December, 1918  Folder 3 (in pencil: Force Comm S3466) U.S. NAVAL FORCES OPERATING IN EUROPEAN WATERS SUBCHASER DETACHMENT THREE U.S.S.C. 271, FLAGSHIP BASE SIX    1 November 1918

[16] Woofenden, Todd A.: Hunters of the Steel Sharks (Bowdoinham, Maine, Signal Light Books, 2006.), p119.

[17] See footnote 16, File No 8-255-1   6 November 1918.

[18] See footnote 12, REPORT FROM QUEENSTOWN

[19] Rose, op. cit., pp 234ff

[20]http://www.ibiblio.org/pha/USN/Navy/Naval%20Avaition%20in%20World%20War%20I.pdf, accessed 8 March 2018.

[21] NARA, RG 45 TC-Force Commander’s Letters and TD-Admiral Sims Personal File, Entry 510, I-18, Box 643 of 1630, TC-Admiralty Conferences 1918 Folder 1. These are daily “VERY SECRET” Memoranda prepared for Sims relating to daily staff meetings at the Admiralty.

[22] Rossano, Geoffrey L.: Stalking the U-Boat – U.S. Naval Aviation in Europe During World War I (Copyright Geoffrey L Rossano; Published Gainesville, FL, University of Florida Press, 2010.), pp 78, 117, 295.

I’ll post the second half of the paper in a couple of weeks.

©2018 Thomas L Snyder

On Hospitals in Ships Redux

In 2010, I posted a piece on hospital ships. There I wrote that the first purpose-built American hospital ship was USS Relief  (AH-1), laid down in 1917. As it turns out, Relief was the first Navy hospital ship so constructed. The Army was well ahead of the Navy in this particularly nautical undertaking, as I’ll explain below.

The Navy’s first hospital ship was the legendary USS Red Rover, a sidewheeler that served the Confederacy as a barracks ship for a year before she was captured by Union forces. It was the Army that converted her to hospital use and then operated her for about a year until Congressional legislation required the transfer of the “Western Gunboat Fleet” (Red Rover actually mounted a 32 pounder gun and was expected to support military operations on the Mississippi if necessary) to the Navy. She was commissioned into the Navy on 26 December 1862, and her medical staff of doctors and nurses served with distinction until the end of the war.

Now comes the news (to me) that the truly first American purpose-built hospital ship was actually created by the Army! This revelation arrived in my inbox this morning in the form of a pretty comprehensive article in the on-line news feed gCaptainReferred to as a Hospital Transport, the ship – named after the 12th Surgeon General of the Army, J K Barnes – was described at the time as “the best adapted ship for the purpose, ever fitted up in this country” (Medical and Surgical Reporter, Vol X11 [Jan-Jul 1865], p 217). She apparently was put into service in 1864.

The Army briefly operated a hospital ship (USAHS Relief) in the Spanish American War, but none in support of the 2,000,000 doughboys who fought and served in Europe in World War I, though troops clearly were transported across the English Channel in large numbers. Navy hospital ships and Army and commercial transports brought the soldiers home. In World War II, however, the Army Transport Service had responsibility for 25 hospital ships – used mainly to transport sick and wounded troops from in-theater to rear-area hospitals or to the United States. Since then, only the Navy has operated hospital ships for the U.S. All Navy hospital ships are fully equipped to care for major surgical cases rather than as transporters – that function having been absorbed by Air Force flying ICUs and air transporters.

Worth pondering: a Navy insider tells me, though I’ve not confirmed this, that officials would like to get rid of  T-AH-19 USNS Mercy and T-AH-20 USNS Comfort with their 8 fully equipped operating suites and 1000 bed capacities, even as Mercy embarks on Pacific Partnership 18, a soft power / medical diplomacy mission to several nations in the Indo-Asia-Pacific region. In this day and age of dangerous outlaw non-state and state actors, are big white ships with red crosses simply too tempting as targets?

(c) 2018 Thomas L Snyder

Medical Diplomacy Redux

This popped up in my U.S. Naval Institute newsfeed this morning:

Hospital Ship USNS Mercy Kicks Off Pacific Partnership Mission” – https://news.usni.org/2018/02/22/hospital-ship-usns-mercy-kicks-off-pacific-partnership-mission?utm_source=USNI+News&utm_campaign=407ad5e226-USNI_NEWS_DAILY&utm_medium=email&utm_term=0_0dd4a1450b-407ad5e226-230375425&mc_cid=407ad5e226&mc_eid=318d84df80

From the USNI news article:

This year’s Pacific Partnership marks the 13th year of the multinational mission that was prompted by the massive destruction following a 2004 earthquake and tsunami that devastated the Indian Ocean and Southeast Asia regions. With a heavy focus on humanitarian assistance and disaster response, the annual multilateral missions are seen as building and strengthening relationships with both allies and fledgling partners in a vast, global region regularly affected by natural disasters and civil unrest.

It looks like medical diplomacy, American style, is alive and well.

PEs (Physiological Events) in Navy Jets

On 5 April 2017 Navy authorities grounded its fleet of T-45 training jets, after instructor pilots vigorously expressed concerns about an apparent rise in the number of PEs (“Physiological Episodes”) experienced in that fleet of aircraft.

It turns out that the Navy has experienced a “sharp increase in hypoxia-like physiological events in the last decade” in its entire combat fleet of airplanes and T-45s, according to an article in Aviation Week’s Aerospace Weekly online. These episodes appear to take two forms: those mimicking true hypoxia – “oxygen starvation” or decreased oxygen in the blood – euphoria and loss of judgement, headache, nausea, light-headedness or dizziness, paresthesias (pins-and-needles sensations), breathlessness; and decompression sickness – from exposure to low barometric pressure, in aviation typically the result of loss of cabin pressure, which results in formation of tiny nitrogen bubbles in tissues (think what happens when you pop the top off a bottle of ginger ale) – joint pain in shoulders, elbows, knees or ankles (“the bends”), headache, confusion, dizziness, nausea, breathlessness and chest pain, paresthesias. Except for the bends, the similarity of symptoms of hypoxia and decompression sickness is striking.

Most recent data for the Navy’s operational aircraft fleet report 101.42 PEs per 100,000 flight hours in F/A-18AD aircraft, 66.52 (down from 90.83 a year earlier) in EA-19Gs and 30.37 in F/A-18EF series planes. Pilots of F-35s (from all services), the new “joint fighter”, have reported 27 PEs since the aircraft began entering service in 2011. I couldn’t find statistics for the T-45s. Since 2010, four aviator deaths have been attributed to PEs.

The Navy (and the Air Force and NASA, and Boeing, manufacturer of the F/A-18 series) are vigorously studying the matter using what’s described in a 5 April Navy release as an “unconstrained resources” approach. Investigators include aviation medicine types, flight physiologists and, of course, a plethora of engineers. It appears that, in the F/A-18 series, 75% of PEs are decompression sickness episodes are caused by the aircrafts’ Environmental Control System (“ECS”) while the remainder are hypoxia episodes attributed to the On Board Oxygen Generating System (“OBOGS”).

Finding the causes and solving the problems have not been easy, in part because of the very complicated interrelatedness of onboard aircraft systems – themselves being intricate – and the human pilot’s physiology and psychology. Slowly, however, the problems are being teased out, and they are multiple and often interrelated.

Regarding the ECS, NASA researchers think the problem – especially in the older F/A-18 AB series aircraft – is due to the fact that the system is designed to “service” the avionics, radars and other electronic systems preferentially. The amount of electronics has increased markedly over the years while key components including even the ductwork and the software haven’t really changed since the 1980s. Because the ECS is programmed to feed the electronics first, the OBOGS gets fed with air last. And that is the system that generates oxygen for the pilots.

NAVAIR is installing modifications to the equipment and software with urgency as causes are identified. So far, this has produced the previously noted short drop in PEs in the especially electronics-heavy EA-18G series. Results in the others remains to be seen. Says RADM Sarah Joyner, who heads up the PE team, “PEs are not going to go away, but we are going to try to do our best to mitigate them and make them milder in nature as best we can”.

This doesn’t sound very optimistic. Stand by for future reports.

Hat tip to my high school classmate Price Bingham, Lt Col, USAF, Retired, who has been keeping abreast of news on OBOGS and EXS.

Articles I consulted, thanks to Lt Col Bingham, include:

https://aviationweek.com/awindefense/us-navy-turning-corner-fa-18-hypoxia-crisis

http://www.navy.mil/submit/display.asp?story_id=99760

https://breakingdefense.com/2017/09/jpo-fixing-f-35-oxygen-carrier-landing-software-glitches-vadm-winter/

https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/dcs.pdf

https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/hypoxia.pdf

Health / Medical Diplomacy and Navy Medicine

We are quite used to seeing big white ships festooned with large red crosses much in evidence after natural disasters. Our Navy’s hospital ships Comfort and Mercy, and the Chinese ship Peace Ark create very dramatic visual representations of their nations’ outreach to provide humanitarian assistance and to help build local medical infrastructure through advice and training.

Building international goodwill through medical assistance is a relatively new arrival in diplomacy, which started out as efforts to manage interdynastic or international communication. The earliest “diplomats” likely were relatives of monarchs sent to foreign capitals as hostages to assure honest fulfillment of treaty agreements. Because such hostages were of high social station, they likely had ready access to their “host”‘s leadership, and thus could report to the folks back home on a variety of matters of interest. From this simple expediency evolved the system of information gathering, representation and negotiation by state-designated agents (and non-state actors, too) that we call diplomacy today. There is evidence of such (City) State – to (City) State representation as early as the Sumerian civilization around 2400 BCE.

“Diplomacy” around health matters no doubt accompanied the health policies instituted by Mediterranean states in the 14th century, as commercial ships and their crews were held in quarantine, sometimes for weeks, without compensation. As international trade and travel increased, quarantine and other local policies failed to prevent the rapid spread of diseases. The mid-19th century saw the institution of a wave of international sanitary conferences that sought to create synchronized policies for the control of diseases like cholera, yellow fever and plague and to regulate trade and traffic in alcohol and drugs. These efforts were supplanted in the 20th century first by the League of Nations Health Office, and later by the World Health Organization. Other health-oriented organizations like the Pan American Health Organization also were created by governments to promote policy synchronization and technical interchange on a more regional basis.

The current status of health diplomacy is captured in this graphic from the National Defense University Press:

This document categorizes various types of “medical engagement” according to their benefit to local populations. In a tone of realpolitik, it also attempts to assess “U.S. Gains” from said engagements.

So, what are some examples of each “Mission Type”; and in particular, what roles has U.S. Navy medicine played?

As I mentioned at the top, very visible examples of Types I & 2 missions include big white ship (and other large naval unit) participation in efforts of humanitarian relief, training and technical exchanges. According to Navy publicity, the most recent international deployments of Mercy and Comfort, in Pacific Partnership and Continuing Promise operations respectively, saw visits throughout the Indo-Asia-Pacific and Central- & South-America and the Caribbean over the past several years. In 20 port visits the ships’ medical staffs cared for more than 140,000 patients and performed nearly 2000 surgical operations. Medical personnel of this joint operation also provided disaster relief trainings, and offered such technical assistance as monitoring for mosquito larvae near schools. The most recent purely international disaster response that I could find was the very visible attendance of Comfort to provide humanitarian relief after the devastating Haitian earthquake in 2010. Immediately upon arriving her medical staff of 300 began caring for the sickest and most severely injured earthquake victims.

According to a 20 November 2017 China Daily article, the People’s Liberation Army Navy’s sole purpose-built big white ship (and one only 4 or five hospital ships in the world), Peace Ark most recently participated in a multinational medical mission in Africa. The ship’s 115 medical workers, “mostly from the Naval Medical University” provided “carry out free medical services, humanitarian assistance, and conduct medical training to consolidate and promote friendly relations and deepen professional exchanges between China and (several nations on both coasts of the African continent).” Peace Ark carried out a similar mission in 2015.

Such short term endeavors seem to me to have great humanitarian merit, but as “diplomacy”, I think they miss the mark, because they by and large fail the definition of diplomacy I offered at the top: information gathering, representation and negotiation. Certainly, except for temporary “feel good” relationships, it’s hard to imagine many meaningful nation-to-nation policy changes emerging from Mission Types I & II. Think of it this way: do you remember the name of the doctor who set your child’s broken bone 20 years ago? Did you even remember that she broke her arm? Apply that thought to people who benefit from temporary humanitarian relief and one-week medical visits to rural communities.

The U.S. Navy has long been engaged in Type III missions. Navy medical historian André Sobocinski has pointed out that the Navy was fortunate to have a world class expert in tropical diseases – Edward Stitt, MD – in its ranks at the turn of the 19th to 20th centuries. His interest was piqued by the “new” medical problems he saw as a result of our Navy’s engagement during and after the Spanish American War (1898) and our resulting acquisition of tropical territories in the Pacific and Caribbean. Under the leadership of Stitt and others, Navy doctors, corpsmen and nurses soon were engaged in research, diagnosis, treatment and prevention of diseases exotic and common in those areas. Between 1911 and 1918 Navy nurses established schools in American Samoa, Guam and Haiti to teach basic health knowledge and skills to native women. Navy personnel vaccinated the people of American Samoa and Guam against the scourge of smallpox in the early years of the 20th century. In the 1940s, Navy experts stood up a series of Navy Medical Research Units in places like Addis Ababa, Ethiopia and Jakarta, Indonesia. Today, NAMRUs in Cairo, Egypt, Lima, Peru and Honolulu continue their missions of monitoring disease activity, performing ongoing research (with particular emphasis on infectious diseases), and – medical diplomacy.

in 2012, Public Health England, the UK’s public health agency responded to requests for assistance during a cholera outbreak in Sierra Leone by sending a microbiologist with special skills in identifying enteric pathogens to work with local personnel to set up a national enteric bacteria diagnostic and reference lab. While there, he trained four local staff members on cholera identification and on laboratory safety and quality assurance. This Type III Mission also has Type IV (see below) implications, as the laboratory was to become part of Sierra Leone’s national cholera control program.

As can be seen by these example, Type III medical missions add a new element to medical diplomatic missions, the element of time. U.S. NAMRUs have been deployed for decades, and in the British example, direct involvement lasted for several weeks. The time element offers opportunity for plenty of professional-to-professional interaction that provides for education, and conceivably over time, will have international policy impact. Certainly the longer term goodwill created by these interactions can have a salutary effect on nation-to-nation relations.

While the U.S. Navy created physical and human infrastructure (Type IV missions) in territories “adopted” after the Spanish American War and World War I, such efforts are quite limited today. Interestingly, Cuba has become a major force in this form of medical diplomacy – especially in developing human infrastructure throughout the developing world. Originally an initiative of Che Guevara, himself medically trained, Cuba has sent more that 130,000 medical personnel to the world’s poorest areas to treat the sick and educate local providers. Even in today’s economic hard times in Cuba, something like 37,000 Cubans provide care in rural Venezuela; in return, Venezuela sends oil to Cuba. That’s medical diplomacy with a nice quid pro quo.

China provides another example of long term medical commitment to care, training and infrastructure. She started sending medical missions overseas in the late 1960s. Since then, in Africa alone, she has established a long term medical presence in 25 nations. China has constructed more than 100 hospitals worldwide, 54 of which are in Africa. She runs or participates in several medical training programs. When I visited my son in Mozambique a couple of years ago, the lovely 1950s Portuguese-built Central Hospital Of Maputo was undergoing renovations sponsored by the Chinese (they are not just putting up new structures). And they’ve built pharmaceutical production facilities in 3 countries abroad.

With Type IV missions – infrastructure building – the longer term political and diplomatic benefits become more clearly discernible. There are two reasons for this. First, the longer term person-to-person relationships that develop can produce, as the people involved move up in their national medical establishments, meaningful impacts on nations’ health and international policies. Second, the infrastructures developed – both human and and especially physical (hospitals, clinics, labs, schools) – provide a continuing remainder of the medical missions for the citizens of recipient nations. Generation after generation of goodwill and support can result. Think of it this way: if you’ve developed a good relationship with your GP, or your therapist, now, 20 years on, office visits are more likely to be taken up with conversations about the now adult kids in your families, or about politics… Thus it might be with populations, and especially thought leaders who’ve developed long term relationships with medical workers from abroad.

The National Defense University source for this post’s graphic gives no specific examples of Type V medical diplomacy missions. Perhaps examples of this level of medical diplomacy would include G7 and G20 health ministers meetings and other minister-level interactions and engagements. Besides producing high-sounding declarations of principle, they must provide “top down” direction for ongoing international health policy cooperation and execution.

One final note. I did a word search (“medical” and “health”) in the new National Security Strategy document released by President Trump in December 2017. I found no instance where either term was conjoined with “diplomacy”, and but one instance where “health” was used in an international context: “REDUCE HUMAN SUFFERING: The United States will continue to lead the world in humanitarian assistance. Even as we expect others to share responsibility, the United States will continue to catalyze international responses to man-made and natural disasters and provide our expertise and capabilities to those in need. We will support food security and health [italics mine] programs that save lives and address the root cause of hunger and disease. We will support displaced people close to their homes to help meet their needs until they can safely and voluntarily return.” But American medical diplomacy is not quiescent. HHS announced in December (the document was signed by Ambassador Deborah L Birx, MD) [bolding mine] that PEPFAR (George W Bush’s “President’s Emergency Plan for AIDS Relief” has seen remarkable success in controlling that scourge in Africa. (During my Mozambique visit, mentioned above, I met a Maputo-based Brazilian infectious disease specialist at an American 4th of July party. He told me that when he first came to the country, he saw people dying in the streets of AIDS / complications. “Today,” he said, “I see none of that. PEPFAR is a miracle for these people. President Bush is a revered hero because of it.”) The HHS announcement stated that President Trump had committed his support of the program, “noting both its importance and it as an example of doing more each year by finding more efficiencies and ensuring we continue to drive forward with impact and clear value for each dollar invested.”


Here are the sources I used for this post (in no particular order). I accessed all of them during the period of preparation for this post: 11 – 16 January 2018. I did not write at the weekend.

https://www.scribd.com/document/125263073/Black-j-2010-a-History-of-Diplomacy

http://ndupress.ndu.edu/Media/News/Article/577539/medical-diplomacy-in-achieving-us-global-strategic-objectives/

https://thediplomat.com/2016/04/chinas-medical-diplomacy/

https://csis-prod.s3.amazonaws.com/s3fs-public/legacy_files/files/publication/111122_Freeman_ChinaEmergingGlobalHealth_Web.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331141/#!po=4.16667 I didn’t actually use any material from this article, but it’s quirky comparison of doctors and diplomats is enlightening and informative.

http://summit.sfu.ca/system/files/iritems1/10865/ghg-ghd-lee-smith-12-07-11.pdf

http://navymedicine.navylive.dodlive.mil/archives/3881

http://www.who.int/bulletin/archives/79(9)842.pdf

https://pdfs.semanticscholar.org/96a9/2f8d24383480e0a1f90842a4734972c0a535.pdf

https://health.mil/News/Articles/2018/01/11/Joint-efforts-in-search-of-a-cure-for-tropical-diseases

http://www.paho.org/hq/index.php?option=com_content&view=article&id=91

https://www.navy.com/about/equipment/vessels/hospital-ships.html

http://navylive.dodlive.mil/2015/10/01/by-the-numbers-pacific-partnership-and-continuing-promise/

http://www.chinadaily.com.cn/world/2017-11/20/content_34757172.htm

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354156/Global_Health_Strategy_final_version_for_publication_12_09_14.pdf

http://www.coha.org/cuban-medical-diplomacy-a-developmental-paradox/

https://www.ft.com/content/debaad0c-5d6e-11df-8373-00144feab49a

https://www.scribd.com/document/8057665/Medical-Diplomacy-a-Brief-Outline “Medical Diplomacy – A Brief Outline” from Aesisgroup.com was a late find. It offers a different “system” for considering this topic, and carefully differentiates between “medical diplomacy” (by which medical resources are used to encourage positive relations between nations and / or to exchange specific benefits between nations) and “health diplomacy” (diplomatic efforts to enact international health measures). Aesis is a “network for advancing and evaluating the societal impact of science” – http://aesisnet.com/

http://www.g7italy.it/sites/default/files/documents/FINAL_G7_Health_Communiqu%C3%A8_Milan_2017_0.pdf Eric Hargan took office as Acting Secretary of Health and Human Services on 10 October 2017. I could not identify his face in the photo of ministers attending this November 2017 meeting. The HHS website is similarly unrevealing.

https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/G20-Gesundheitsministertreffen/G20_Health_Ministers_Declaration_engl.pdf I think I can identify then-HHS Secretary Tom Price at this May 2017 meeting.

https://www.whitehouse.gov/wp-content/uploads/2017/12/NSS-Final-12-18-2017-0905-2.pdf

https://www.whitehouse.gov/articles/american-leadership-brink-controlling-aids/

(c)2018 Thomas L Snyder

Happy New Year!

To my readers, I know there’s been a drought of my scribblings over the past some time. But now I’ve passed most of my Naval Order responsibilities off to an energetic and capable successor, and already this ancient brain is beginning to swirl with ideas for new posts. Let’s hope some mental alchemy yields nuggets of gold from the lead that’s been mouldering in the depths and is just now getting some agitation!

My older son James gave me as a holiday gift Admiral Jim Stavridis’s 2017 book, Sea Power (New York, Penguin Press). In what I see as the Admiral’s combination memoir and strategic reflection, I encountered (for the first time in my consciousness) the term “medical diplomacy”.

Bingo! The subject of my next post – in a few days.

For now, my standard New Years mantra: may 2018 meet or exceed your expectations!

Thanksgiving 2012

I wrote this greeting 5 years ago. I still like it. Best wishes to my historical friends.

Of Ships & Surgeons

The cornucopia – horn of plenty – symbolizing the abundance of a good harvest, comes down to us from the ancient Romans. Americans have traditionally associated the symbol with Thanksgiving.

We have the great good fortune to live in a nation that is wealthy enough to be able to support a robust historical establishment. University programs and fellowships produce their own cornucopiae of newly minted historians each year. Many if not most cities and communities sponsor or at least encourage local historians to accession and preserve their communities’ stories. Some corporations have historians on staff (I retired from Kaiser-Permanente, a company that does this). Even our popular culture embraces – and purchases – the works of excellent historians who have plumbed the far reaches, and the nooks and crannies of our national history. The instant popularity of Jon Meacham’s biography of Thomas Jefferson is but the most recent example of this.

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Navy Medicine in Araby (Episode 8, the Final)

In seven previous episodes, I’ve told the story of combat casualty and general medical care given our sailors in conflicts in “Araby”, starting with 19th century battles against the Barbary States and finishing with our current military activities in Iraq and Afghanistan. Herewith is the final episode, in which I describe the truly innovative aerial ICUs of the U.S. Air Force.

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The final 21st century iteration of an earlier concept is the Air Force’s Critical Care Air Transport Team. The first reported aeromedical evacuation was during the Franco-Prussian War of 1870-71, when 160 French casualties were evacuated by observation balloons from Paris, then under siege. Fixed wing aircraft soon followed, and by the end of WW I, the British were using aircraft specifically modified for medical applications. The United States Army Air Corps created Medical Air Ambulance Squadrons starting in 1942, and by the end of WW II more than a million patients from both theaters of war had been evacuated by these means. The concept of critical care evacuation – that is, transporting medically unstable patients requiring such support as respirators and intensive physiological support (IVs, transfusions and blood pressure sustaining drugs and the like) – evolved quickly after Operation Desert Storm, when it was discovered that such a capability simply did not exist. This lack of capability at the time forced the Army and Navy to utilize huge and semi-permanent Field Hospitals in or near the theater of operations. Prior to 1994, aeromedical transport teams typically consisted of two or more nurses, sometimes with critical care training, and several medical technicians. In 1994, the Air Force launched a formal Critical Care Air Transport Team program. These teams include critical care physicians, critical care nurses, respiratory therapists and the required medical supplies to support what are essentially flying ICUs. This concept has permitted medical planners to reduce the size of in-theater medical facilities while enhancing their flexibility and mobility to keep them as close as possible to zones of combat. [1],[2] Once wounded warriors receive emergency stabilizing surgeries, they can be rapidly evacuated to more definitive care settings in Kandahar & Bagram in Afghanistan, or to Landstuhl Germany or even to the specialty care facilities like the Brooke in San Antonio.

flying ICU.jpg

Intensive Care Unit in an Airplane (Credit: http://www.dodlive.mil)

In conclusion, there really is no comparison between the medical care offered our sailors in the Barbary Wars and that provided today. Hippocrates, the Greek father of western medicine wrote in ‘On the Surgery”, “He who desires to practice surgery must go to war”, and it is cliché’ nowadays to say that the surgical art and science advance with every war. The evolution of that art is clearly seen in this story of Navy medicine across three centuries. From bleeding and purging to antibiotics and transfusions, from amputations in the cockpit to damage control surgery in the field and intensive care in airplanes, the sophistication of knowledge and the resources brought to bear for the care of combat casualties are beyond comparison.

The one common thread throughout this story, however, is the dedication of medical people to the care of their sick and wounded military compatriots.

[1] Air Transport of the Critical Care Patient, http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=57ab806b-df57-42d7-85b4-5f96907faf92, accessed 5 October 2016.

[2] U.S. Air Force Website, Gulf War Created Need for Better Critical Care, http://www.af.mil/News/ArticleDisplay/tabid/223/Article/643126/gulf-war-created-need-for-better-critical-care.aspx?source=GovD, accessed 5 October 2016.

Veterans’ Day Greeting

Today, I wrote this to Naval Order Companions of the San Francisco and Continental Commanderies, and the members of the Albany Medical College – Military Affinity Group. I send the greeting now to followers of Of Ships and Surgeons, with my best wishes:

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The word “service” comes to us from the Latin servus / servitium, meaning “slave” and “slavery”. By the 13th century, the old French servise had come to mean “labor undertaken for or at the direction of another”. The Roman and “Scholastic” notion of work with body or hands as dishonorable servitude underwent further modification under the influence of the Enlightenment so by the early 1700s, the association of “service” with military duty, at least for higher ranks, was seen as completely honorable. The need for larger “citizen” militaries probably completed the transition to a view of “honorable” service being performed by all ranks.
 
Let us salute each other on this day set aside especially to honor the service and sacrifice of the Veterans among us. 
Very Respectfully,
Tom S
Tom Snyder MD ’69

Captain, Medical Corps, US Navy (Ret​.​)
Commander, San Francisco and Continental Commanderies,
Naval Order of the United States
Founder / Coordinator
Albany Medical College – Military Affinity Group