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The effects of strategic bombing of Germany in WWII on health and medical care

Survey Dates:               March-July 1945

Date of Publication:       May 1947

This report summarises the conclusions of the United States Strategic Bombing Survey in their research into the effects of air raids on the health of Germany. The full report can be read here.

Research was conducted in Western Germany during the closing days of the war and for two months after it. It comprises twelve chapters covering different aspects of how aerial attacks impacted the health of the German people during the war.

Summary

  • The exact number of deaths could not be determined but approximately half a million German civilians were killed by aerial bombing over the course of the war.
  • Precise causes of death were unknown in many cases, and depended on the type of bomb dropped, but were more often external injuries (e.g. burial under rubble, injury from shrapnel) than internal injuries (e.g. carbon monoxide poisoning, overheating).
  • Bombing established perfect conditions for the spread of infectious disease but surprisingly few epidemics materialised in the cities attacked.
  • An increase in psychosomatic complaints was evident but was smaller than would have been expected.
  • Despite the German authorities’ efforts to safeguard industry, bombing rendered working conditions dangerous and weakened productivity.
  • It appears that mortality from all causes of death, excluding the actual air raid deaths, increased in line with intensified aerial bombing.
  • Bombing exacerbated the overworking and under-training of medical staff, but standards of care did not significantly deteriorate over the course of the war.
  • A pre-existing decline in the standard of medical education accelerated over the course of the war, partly due to the impact of bombing on universities.
  • German hospital facilities were both directly impacted by bombing and indirectly affected by destruction of water, electricity and transport infrastructure.
  • Bombing had a severe effect on environmental sanitation, particularly to water supplies and waste disposal.
  • The production and distribution of food, medicine, medical equipment and other essentials was badly impacted by bombing.

Chapter One: Introduction
Prior to this report, there had never been such an extensive evaluation of the effects of military operations on an enemy civilian population. While destroying the health of the German people was not a deliberate intention of aerial bombing, raids created conditions which inhibited the maintenance of good health. In effect, “the average inhabitant of the German cities was placed in the same position as the soldier on the battlefield.”

It was thought that it may take years or even decades to get a full picture of the longer-term effects of aerial bombing on civilian health. The report was therefore restricted to the concrete effects observable in the immediate aftermath. It was thought this information could be valuable “in the future planning for the defense of the United States.”

The overarching conclusion of the report is that “a people well trained in personal hygiene, who… know where the dangers to ill health lie, are the strongest bulwark against breakdown of public health when their cities have been destroyed by the enemy.”

Chapter Two: Civilian Deaths from Air Attacks
The most direct effect of bombing on the health of the German population observable was the number killed. Due to the destruction of records and “the utter confusion of defeat,” however, it was impossible to determine these figures precisely.

The death rate rose in proportion to the tonnage of bombs dropped and the number of consecutive months in which raids were carried out. Only rarely did a high death rate accompany a low bomb tonnage (e.g. when bunkers were directly hit). In some cases, however, cities were bombed so heavily there were officially “zero” deaths, reflecting an overwhelmed local bureaucracy incapable of processing death certificates.

A total of 422,000 deaths were officially recorded, however these figures excluded Jews, foreigners, displaced persons, and prisoners of war. Countless more remained missing and unaccounted for at the time of the survey and many were buried without ever being recorded. The number of these unrecovered and unrecorded was estimated at approximately 25% of the official figure, meaning around half a million German civilians were killed by aerial bombing over the course of the war.

Chapter Three: The Nature of Air Raid Casualties
Few postmortems were carried out on bombing victims in the early stages of war. As the question of compensation for victims became more pressing, however, it was deemed appropriate to establish official diagnoses for casualties. Approximately 20,000-30,000 autopsies were performed on air raid victims over the course of the war.

Broadly, incendiary attacks left more dead than wounded and high-explosive bombs more wounded than dead. Injuries could be broadly categorised as either external (including burial and shrapnel injuries, burns, and tetanus as a result of burns) or internal (including carbon monoxide poisoning, overheating, dust inhalation, cardiac arrest from fright or exhaustion, and blast injuries without visible external wounds).

“There is little reason to believe that air raid injuries to civilians are any different from those encountered in ordinary war medicine.”

Incendiary bombs “turned whole city blocks into a flaming hell.” Shelters protected civilians from the direct effects of bombing, but crowded conditions inside often led to heat stroke and exhaustion as fires raged outside. Rescue teams were guided to shelters buried under rubble by the smell emanating from them. In some cases these shelters remained “intolerably hot” inside weeks after an attack. Many shelters contained only ash, meaning the numbers of casualties could only be estimated. Casualties found outside were often naked, their clothes incinerated.

Chapter Four: Communicable Diseases and Other Disorders
Aerial bombardment of crowded cities created ideal conditions for the spread of disease. Surprisingly, however, there were no major epidemics. The psychological toll of living under bombardment did, however, lead to a rise in psychosomatic disorders.

Despite damage to water and sewage infrastructure, corpses lying in the streets, and crowding in shelters, a predicted rise in morbidity and mortality from infectious diseases failed to manifest. This is particularly surprising given reports that fire departments frequently used raw sewage to fight fires. Personal habits of a population “known for their devotion to personal hygiene” is offered as an explanation for the lack of major outbreaks of disease. The exception to this was a rise in the spread of venereal diseases, attributed to a desire for “release and excitement” among the population.

The conditions of aerial warfare produced a psychological environment “ideally conducive” to the production and aggravation of psychosomatic disorders. Indeed, increased incidence of peptic ulcers, menstruation disorders and coronary heart disease all suggest rising levels of anxiety. At the same time, the number of cases in mental institutions fell dramatically, likely owing to forced sterilisations and ‘mercy killings’.

Chapter Five: Industrial Health
“The health of the worker will reflect on the health of the nation,” asserted the report. Industrial workers’ health was therefore safeguarded by a socialised health insurance system which, for the most part, worked well. Despite industry being the target for bombing, casualties in factories were no higher than those among the wider population. Nevertheless, irritability and lack of concentration was credited with a rise in accidents. Bombing damage forced many factories to close and created unsanitary working conditions in others, leading to a rise in upper respiratory infections among workers exposed to wind and rain. An increase in levels of heart disease was also observed, suspected to be a result of younger and healthier workers being drafted into the armed forces. In order to combat absenteeism and deterioration in morale, incentives such as food, liquor and tobacco were offered to workers.

Chapter Six: Vital Statistics
Obtaining statistics of the wider health of the nation was made difficult by the widespread destruction of records offices by the end of the war. The birth rate in Germany steadily rose under the Nazis from 1933 to 1939, after which it declined. Some evidence suggested miscarriages and abortions may have increased during periods of heavy bombing but this did not account for the entire fall in births. The evacuation of pregnant women undoubtedly contributed to the declining birth rate in cities. Infant mortality rose gradually throughout the war in bombed and cities that were not bombed, suggesting the cause was likely to be the general hardships of wartime.

It appears there was little relationship between bombing and general mortality rates from causes unconnected to bombing. Some data appeared to suggest suicide rates rose in some cities following periods of bombing, but this was not considered statistically significant.

Chapter Seven: Medical Personnel
The German medical profession faced an unprecedented challenge in the increased demand for physicians and nurses aerial attacks created. At the time, the national medical organisation of Germany was considered “perhaps the most thorough, powerful, closely knit body for the control of a nation’s health that the world has seen.”

By the spring of 1942 there was a critical shortage of physicians because the Armed Forces had drawn so many from the civilian sphere. Combined with the increase in demand posed by aerial bombing, physicians worked approximately twice as much during the war as they did before. By 1943, all physicians with 50% Jewish ancestry were reinstated to medical practice and a year later this was expanded to those with 100% Jewish ancestry. Even still, a 1943 plan for repopulating post-war Germany suggested it might take as long as 25 years to reach the pre-war level of physicians.

The allocation and distribution of nursing staff did not experience the same problems as physicians. While working conditions were made more challenging, their ranks were bolstered by an auxiliary service of approximately 500,000 volunteers. Generally, the problem with staffing was a lack of expertise, not a lack of personnel.

Despite the increased demand for physicians and nurses, combined with challenging working conditions during air raids and a general inadequacy of medical supplies, civilians generally still received adequate medical attention.

Chapter Eight: Medical Education
Medical education experienced many changes during wartime but few were directly related to bombing. A historically-renowned reputation Germany enjoyed in this field began deteriorating during the 1920s and was further eroded by a “disregard for professional and scientific matters” under the Nazis.

Medical education was strained by the Armed Forces’ demand for physicians, resulting in a curriculum prioritising practical subjects over research. The wartime cohort would therefore “never mature to be outstanding physicians.” Like the wider population, students suffered from disruption to electricity and transport infrastructure. Bombing forced many institutions closed and students were overcrowded in the institutions which remained.

As a result of the damage done, the report declared that “the facilities of the Allies will have to be called upon to render [medical] assistance” until education could be re-established and locally-trained medical workers were trained.

Chapter Nine: Hospitalisation
“In total war, hospitals are not spared,” declared the report. “The red cross on the brilliant white background is no longer a shield of safety on the roof of a hospital but a pinpoint for orienting pilots over a blackened city on a moonlit night.”

Bombing had a serious impact on hospital capacity which was “barely adequate” at the start of the war. Approximately 90% of hospital beds were occupied during the war, leaving little leeway for emergencies. A drop in the population of larger cities as a result of evacuation was concomitant with the destruction of hospitals, so levels of capacity did not vary greatly.

Hospitals were equipped with shelters during the war that patients could be moved in and out of. As bombing intensified, however, vulnerable patients were kept inside the shelters at all times and the shelter operating rooms came to be used by default. In some cases, medical facilities inside the shelters were more modern than the hospitals themselves. Still, hospitals suffered from a loss of power and water like everywhere else and some even had to resort to candlelight and well-pumping.

A number of strategically-located “Brandt” hospitals were purpose-built in wooded areas far from cities for dealing with air raid victims. In many cases, however, the patients and staff in these facilities felt isolated and resented being distanced from their homes, families and communities.

The evacuation of such huge numbers of children and elderly people placed a strain on rural medical services, one which was handled “by working extra hours and by discharging patients… a little sooner than they ordinarily might.” This was the story for hospitals across wartime Germany, which were strained but nevertheless managed to maintain minimum standards of care.

Chapter Ten: Environmental Sanitation
An adequate supply of potable water and disposal of sewage and refuse were greatly strained by aerial bombing. Only one city, Hamburg, was left without water entirely for any length of time as a result of air raids (three weeks). Most others had contingency plans in the event of pumps being wiped out, such as private wells. Nevertheless, people were encouraged to fill bathtubs and other containers and to boil all water before drinking. As a result, although water supplies were frequently disrupted, the diligence of sanitary engineers meant there were no major epidemics among bombed cities that could be traced to dirty water. Similarly, although sewage systems were badly disrupted and fire services were known to use raw sewage for extinguishing fires, there were amazingly few cases of disease directly attributable to this. Waste collection, on the other hand, broke down entirely in the final months of the war. At the time of writing, the report suspected that as many as 80,000 bodies were still decomposing under rubble.

Chapter Eleven: Food Supply and Nutrition
Germany’s agricultural economy was previously incapable of adequately feeding its population without imports, so the effect of naval blockades necessitated tight control of domestic supply.

Feeding the nation depended on the supply, storage and even distribution of food. Aerial bombing, through damage to fertiliser industries, lowered agricultural output by 150kg per hectare and eliminated as much as 35% of total cold storage capacity. An elaborate rationing system designed to distribute food evenly was badly impacted by bombing damage to railways and canals. By February 1945, transport was so disrupted that distribution was effectively abandoned in favour of letting provinces produce and distribute their own food. ”Despite these serious difficulties,” it was observed, “fortuitous circumstances appear to have staved off a more rapid deterioration” in the German civilian’s diet. As rations were allocated by weight rather than content, it seems nutritional adequacy was maintained largely by chance.

Chapter Twelve: Medical Supplies, Development, Production and Distribution
The quality of medical care provided is as dependent on a reliable supply of materials and medicines as it is on physicians. Aerial bombing had a significant impact on the industries manufacturing these supplies and their means of distribution. The pharmaceutical industry was largely concentrated in a few cities, rendering it highly vulnerable to attacks on railways and canals. In many instances, even when factories were untouched, the destruction of supply centres and transportation effectively halted their production. Certain resources grew scarce, such as insulin, and by the end of the war 88 drugs were rationed.

Aerial bombing aside, the loss of foreign supplies from Iran and Turkey prompted Germany to hire children to cultivate poppies for opiates. Similarly, surgical instruments and dressings were badly affected by the loss of coal and coke from Silesian mines, forcing some surgeons to use dressings made of paper and moss.

The Brandt reserve plan sought to mitigate these shortages in the supply of medical essentials by stockpiling critical items. Sound in theory but late in execution, it had a limited effect.

The report can be read here.