Hunger: The Biology and Politics of Starvation

[10] Why Do Some People Die?

[10] Why Do Some People Die? Humanity has but three great enemies: fever, famine, and war; of these by far the greatest, by far the most terrible, is fever. —Sir William Osler (1849–1919) And I saw when the Lamb opened one of the seals, and I heard, as it were the noise of thunder, one of the four beasts saying, Come and see. And I saw, and behold a white horse: and he that sat on him had a bow; and a crown was given unto him: and he went forth conquering, and to conquer. —Book of Revelation 6:1–2 William Osler is considered to be the father of modern medicine. A humanist , teacher, and extremely astute clinician, he is credited (among other things) with the development of bedside teaching as a critical means of training new physicians. A man of great intelligence and insight, his meaning in the above quote is not intuitively obvious—one would expect most fatalities in war to be due to combat-related injury; most deaths from chronic malnutrition due to organ dysfunction and eventual organ failure. In the quote below, Thomas Malthus seems to have considered the Third Horseman of the Apocalypse, famine, to be the final arbiter of death. Famine seems to be the last, the most dreadful resource of nature. The power of the population is so superior to the power of the earth to produce subsistence for man, that premature death must in some shape or other visit the human race. The vices of mankind are active and able ministers of depopulation. They are the precursors in the great army of destruction; and often finish the dreadful work themselves. But should they fail in this war of extermination, sickly seasons, epidemics, pestilence, and plague, advance in terrific array, and sweep off their thousands and tens of thousands. Should success be still incomplete, gigantic inevitable famine stalks in the rear, and with one mighty blow levels the population with the food of the world.1 Who Had It Right, Osler or Malthus? Death tolls and the causes of death in armed conflicts and famine are notoriously difficult to measure or validate. When one is able to critically evaluate Why Do Some Die? [] 213 the ultimate cause of most deaths due to war or to famine, either associated with armed conflict or not, it turns out that far more people are killed by the infectious diseases associated with the squalid living conditions, lack of safe drinking water and sanitation, and chronic malnutrition associated with armed conflict or poverty in general than have ever been killed by bullets, or directly by starvation per se (in fact, it was not until World War I that more people were killed by bullets than by disease).2 A well-documented example of this is offered by Florence Nightingale’s experience during the Crimean War. During that conflict, Nightingale was one of the first in health care to use direct measurement and statistical analysis to demonstrate that ten times as many soldiers were dying from typhoid, typhus, cholera, and dysentery than from injuries incurred in battle. Appalled at the state of the sanitary conditions in which the wounded soldiers lived, she arranged for these conditions to be improved (she happened to be friends with the Secretary of War). Within six months of her arrival and the improvement in the sanitary conditions, mortality rates dropped from over 40 percent to 2 percent.3 The generally agreed-upon death toll in the American Civil War (which had the highest number of American casualties of any war before or since) was approximately 620,000. Of these, 204,000 deaths are attributed to battle deaths, while 414,000 are considered the direct result of disease (25 percent of these felt to be due to typhoid fever). As an example of causes of mortality in famines unassociated with armed conflict, the Great Irish Famine of the 1840s is estimated to have resulted in the death of 1,000,000 people, but actual death by starvation was uncommon—the majority of these deaths were ultimately due to infectious disease.4 Even in populations not affected by conflict or chronic malnutrition, infectious disease has historically been responsible for the majority of deaths up to and including those in the twentieth century. It is estimated that smallpox alone accounted for 300–500 million deaths worldwide during the twentieth century, more than all of the wars of that century combined. While we are becoming increasingly...