DESTITUTION AND DISEASE IN SERBIA - THE RELIEF OF SUFFERING NON-COMBATANTS IN EUROPE - April 28 1915



DESTITUTION AND DISEASE IN SERBIA - THE RELIEF OF SUFFERING NON-COMBATANTS IN EUROPE

THE Rockefeller Foundation War Relief Commission — sent to Europe to recommend the most effective methods of relieving the needs of non-combatants — has reported concerning conditions in Serbia.
Acting upon this report, the Foundation has joined with the American Red Cross in sending to Europe a  Sanitary Commission to help Serbia control the present epidemic of typhus and the threatened epidemic of cholera.
Essential portions of the War Relief Commission's report on conditions in Serbia is published herein.
APRIL 28. 1915

THE ROCKEFELLER FOUNDATION
' ' To promote the Well-being of mankind throughout the World''

OFFICERS
President
JOHN D. ROCKEFELLER, JR.

Secretary
JEROME D. GREENE

Treasurer
LOUIS G. MYERS

Asst. Treasurer
LEFFERTS M. DASHIELL

TRUSTEES
CHARLES W. ELIOT CHARLES O. HEYDT
SIMON FLEXNER HARRY PRATT JUDSON
FREDERICK T. GATES STARR J. MURPHY
JEROME D. GREENE JOHN D. ROCKEFELLER
A BARTON HEPBURN JOHN D. ROCKEFELLER, Jr.
WICKLIFFE ROSE

OFFICES
61 BROADWAY, NEW YORK CITY

Destitution and Disease in Serbia

From Berlin, on March 10th, the Rockefeller Foundation War Relief Commission, after a visit to Serbia, reported concerning conditions in that country as follows:

General Conditions

Area, Population, Products, Manner of Life

Serbia has largely increased her territory and population by the recent Balkan wars, although Macedonia, which is the territory annexed, has not as yet added greatly to her economic or military strength.

  • Population of Old Serbia— about 3,000,000*
  • Population of Macedonian annexations 1,500,000
  • Present total population 4,500,000
  • Area of Old Serbia— 48,000 sq. km.— about. . . 12,000,000 acres
  • Area of Macedonian annexations — 35,000 sq. km. 8,000,000
  • Total present area— 83,000 sq. km.— about 20,000,000 "

* These figures are taken from a little book by Leslie F. Church, "The Story of Serbia.
** The Carnegie report on the Balkans seems also to reckon the total population of Old Serbia at about 3,000,000.

The country is mountainous and the mountains are rocky. In passing along the railway line from Skopje (formerly Uskub) to Belgrade, one sees few cultivated hillsides, such as are typical of Switzerland or Vermont. The tilled land is mostly in the valleys.
Of the 12,000,000 acres in Old Serbia only 4,500,000 are said to be under cultivation. There is some pasturing on the mountain sides, 700,000 acres being given as the extent of pasture land.

Belgium is four times as densely populated and Switzerland is somewhat less than twice as densely populated. There are no large cities. Belgrade normally has about 100,000 inhabitants; Nish, 25,000; and Skopje in Macedonia has 50,000 to 60,000.

Few Industries

Serbia has no manufactures, although there exist a few breweries and distilleries, beet sugar refineries and flour mills, and a carpet industry of a modest sort is spoken of as flourishing at Pirot. We heard a good deal of vague talk about the country's mining wealth — whatever it may be, it is not greatly developed.
The country is essentially agricultural and pastoral. Hogs and cattle have been its pnnicipal products for export. Maize is the staple cereal, and unleavened corncake the bread of the peasant. The produce of cereals in 191 1 is quoted thus:

  • Wheat 410,000 tons
  • Barley 98,730 tons
  • Maize 663,100 tons
  • Oats 72,120 tons
  • Rye 42,760 tons

This production figures out:

  • Wheat 273 lbs. per capita per annum
  • Maize 422 " " " " "
  • Total all grains. 85 7

Within the last ten years prune growing has been encouraged. We saw young plum orchards from one to five years old everywhere.
The houses are usually roofed with red tile, which is perhaps popular because of its coolness in summer. These roofs give the villages a substantial look when seen from a distance.
But the houses are small one-stoned cottages, which are otherwise of cheap construction. Shelters for animals seemed occasionally to be mere structures of wattle and clay, thatched with corn stalks.

How the People Live

The peasants make their own clothes. The outer garments of most of the men consist of rough homespun, the wool of which is undyed. The national footwear is a sort of half sandal, half moccasin, which was generally made of rawhide until quite recently. It is not a manufactured shoe.

We were informed that nine-tenths of the cotton and linen cloth made up into under garments and shirts for the men, and into other clothing for the women, are home-woven.
It has been customary for the peasants to buy thread and yarn after the autumn harvest, and in winter the women weave cloth and make clothes.
One now sees plenty of people going about covered with nothing but the raggedest rags. Their number was greater in Skopje, where Turks are still numerous, than farther north.
The Serbian reservists are without uniforms, and can be distinguished from other peasants only by their weapons or sometimes by a military cap.
These facts about clothing are mentioned because they lend credibility to the statements, often made to us, that there are now no stocks of clothing, footwear or blankets to be bought in the country. Such considerable quantities of gift clothing as have been locally forthcoming in other countries are not now to be expected in Serbia.

RELIEF OF SUFFERING IN EUROPE

Since the first Balkan war the male population has neglected the fields and crops and women have done much of the farmwork. They have accordingly done less weaving and spinning than normally, and Serbia's accumulation of clothing has been used up.
If a refugee or soldier, who has had neither clean bed to sleep in nor a change of clothes for weeks, is brought dirty and lousy into a Serbian hospital to-day there will probably be no clean clothes of any kind to be put on him except such as have been imported into the country by relief agencies.

Railways and Roads

One single-track railway passes through the country from north to south. Its roadbed is about 300 miles long, the country being about 250 miles long. Six spur lines branch off from this road, of which two or three at least are narrow gauge tracks.
The speed limit on the main line is twenty-five miles an hour in the best of times. The trains we traveled on did ten or twelve miles an hour. Lately the roadbed and rolling stock have been roughly used and little repaired.
This single-track railway is now transporting military and other importations arriving by sea at Saloniki, and is carrying troops north and south to the limit of its capacity.
We did not see one macadam road. Even in the immediate outskirts of Belgrade, Skopje and Nish we saw "highways" that were almost impassable. Generally speaking, the roads are in such condition that horses cannot be used as draught animals.
Small oxen (about the size of a Jersey cow, or a little larger) do the hauling. They walk somewhat faster than our oxen, and on every road one sees strings of them, hitched one or two yoke to a clumsy cart and hauling light loads.
They are called the "fifth class," in allusion to the four classes into which the Serbian Government divides the citizens capable of bearing arms. Similarly, the roads in which the Austrian horse-drawn artillery got hopelessly bogged are called the "seventh class."
The importance of the roads, difficult for other animals than oxen, in Serbian military strategy is again humorously recognized in the current remark that Serbia repelled the Austrians by the aid of her highway engineers. The difficulties of transport and communication must be remembered when any extensive distribution of relief is discussed.

A Land-Owning People

The Serbian peasant is a land owner, not a serf nor a tenant, and has been a land owner since his first successful insurrection against the Turks one hundred years ago. There is no legally recognized social class between him and the king.
Furthermore, we were told that there are not more than two or three people in Old Serbia who own more than 1 000 hectares (2471 acres), and that on the other hand the Serbian law exempts 2 hectares of land and a certain number of pigs, sheep, oxen, cows and horses from execution for debt or foreclosure under mortgage.
The farm houses are not scattered as in America, but are grouped in little clusters and small villages. Two intelligent lawyers, one of them a former Minister of Justice, said to us: "In Serbia the farm and village are fostered at the expense of the town."
From this brief summary it will be easy to perceive that the Serbian peasant is still isolated and self-sustaining, and that Serbia is economically and socially unevolved and unorganized to a degree unknown in Western Europe or America.

Indeed, the impression which we gathered in our brief visit to the country is that its political and military organization, stimulated by Turkish oppression and by the frequent interference of the Great Powers in Balkan affairs, is distinctly in advance of the organization of its economic life.
Economically and socially the Serbian seems to be at the opposite extreme from the Belgian. He has never learned to live in congested towns, nor to impose upon his daily doings the restraint and discipline required by present conditions. He has no industrial organizers (such as have even the Russian Poles), and although he has a few military and political leaders (whom the Russian Pole lacks), these leaders are now devoting their energies to the Serbian army.

Present Exhaustion of the Country

The Carnegie report on the Balkans attempts to make the horrors of war vivid to the world, and argues that suffering would be even greater in an industrial community than in the Balkans. Concerning the two last Balkan wars, it says:
"Thus in the Balkan States war has not produced the depths of individual misery which it would cause in a country with an industrial proletariat dependent on a daily wage. Over a large part of Bulgaria, Serbia and Greece, the circumstances under which the family lives and develops are those of peasant proprietorship.
"When the head of the family went to join the army he left his dependents in a homestead, in which there was always a certain supply of provisions on the soil from which food of some sort was always to be gotten. Though there was less comfort, there was no such distress requiring the succor of the
State as would arise where the workers live in large agglomerations.
"Thus, thanks to the preponderance of agriculture, to the system of small estates, and, in Greece, to emigration, Bulgaria, Greece and Serbia were able to bear a long war, which was sometimes painful and cruel, without any pause in their production and without any deep upheaval ; this due to the economic resistance shown by each family firmly established on its own land."
It is very important to remember that a family "firmly established on its own land" can long maintain its economic resistance. But this fact is only one element in the situation.
As soon as it is a question in any given connection whether relief work can be carried on with local resources or only by means of contributions coming from outside, then it must be remembered that conditions recited by the Carnegie report may all exist and that there may still be no means at hand of succoring the wounded, infected or evicted unfortunates who are cut off from their own acres or unfitted for work.
It is the Commission's impression that Serbia has now reached that state of exhaustion in which it has practically nothing to give away to its own unfortunates.

Losses in Balkan Wars

In the Turkish and second Balkan wars, Serbia is said to have mobilized 467,630 men out of 2,945,950 inhabitants, to have lost 31,000 men and to have had 48,000 wounded.
At present the country is mobilizing every one capable of military service, except in Macedonia. The Serbian public debt, which had amounted to 659 million francs, was increased by 500 million by the Balkan wars, and the moratorium was continued until January 3, 1914.
For three years now Serbia has had no opportunity to repair the farm implements which have been wearing out ; to replace the cattle, horses and vehicles which have been used up in the army; to enable its merchants to replenish their depleted stocks and stores; to renew its supplies of homespun textiles, and to repair its roads, railroads and buildings.
It is said that there are almost no more oxen on the farms, and that the army is now using beasts of poor quality. We were told that there are not enough plows to do the spring work, nor enough seed to plant this season's crops. Most of the autumn sowing was left undone, for Serbia was completely upset at the moment when it should have been done. The richest quarter of the country has been invaded and laid waste.
The channels by which aid can be imported are few and difficult. Most of Serbia's dealings are ordinarily with Austria. There is now no trade across the Austrian frontier.
Military stores and supplies contributed by Russia come up the Danube from the Black Sea to the northeastern corner of the country, where a short stretch of the opposite shore belongs to Roumama.
But all ordinary trade on the Danube is at a standstill, and if the Austnans succeed in entering this corner of Serbia the country will have to communicate with Russia by means of the Bulgarian State railways. Bulgaria harbors no love for Serbia.
Serbia's only other workable connection with the outer world is by rail to the Greek port of Saloniki. At present Mediterranean shipping reaches Saloniki; but the Dardanelles are closed, and this shipping all comes from the west or the Suez.
As Bulgaria and Roumania are not manufacturing countries, Serbia has to send for her miscellaneous supplies — like medicaments, machinery, textiles, tools and all sorts and kinds of manufactured specialties — to the markets of Greece, Malta, Alexandria, or to Italy, France or England.
In all these places supplies are being hoarded by the government or are selling at high prices. Further, transport across and from all these countries is subject to serious interruptions and delays.
During the progress of the war between Serbia and Austria- Hungary the military forces of the latter have twice invaded northwestern Serbia and both times have been driven back across the border.
These successive invasions have wasted the land traversed by the contending armies, while the population fled to the southward and found refuge among the towns and villages beyond the invaded territory.
Since the second expulsion of the Austro-Hungarian forces many of the Serbians have returned to their destroyed homes, and are reported to be suffering from want of shelter, clothing and food.

Those refugees who remain in the scattered communities to which they fled, when driven southward, have some sort of shelter, but in other particulars are in as much want as their neighbors who have returned to their homes.
The Austrian provinces of Bosnia and Herzegovina are partly occupied by people of Serbian blood, whose sympathies in the present conflict are with Serbia rather than with Austria.
Many of these people are reported to have fled into Serbia to escape enforced service in the Austrian army, or in fear of persecution because of their sympathies. They are distributed among the communities along its western frontier.
The statement was made that 15,000 or 20,000 of these refugees are in destitution.
The difficulties of travel at present are such that several weeks would be required to enable this Commission to make a comprehensive first-hand investigation of the actual living conditions of the people.
The aspect and condition of places and people we did see induces us to accept statements that were made that much need exists among many thousand Serbians — probably 300,000 or more.
Indeed, such opportunities as the Commission had to observe these conditions prepare it to believe that the destitution in Serbia is more extreme than that which we found elsewhere.

The Aggravations of Disease

The plight of those wretched people is aggravated and complicated by the prevalence of epidemic disease among them which, through any efforts of their own, they are quite helpless to control.
It will be possible to illustrate the extremity of the destitution among the refugees by a brief description of the conditions personally observed by the members of the Commission in Nish, the temporary seat of the Serbian Government.
This city, which has a normal population of about 25,000, now shelters a population estimated at about 80,000. The congestion is due in part to the influx of refugees and to the presence of persons connected with the Government, or drawn there by the fact of the Government's temporary occupation of the place.
Most of the refugees at present in the city are scattered among the private homes, but some are in school houses and other public buildings and places.
It will suffice for the present purpose to describe the conditions observed among two of these groups of refugees in public places, one illustrating what may be regarded as the most favorable; the other as the least favorable of such conditions.

Living Conditions of Refugees

1 . A group of about seventy-five refugees occupies the buildings and grounds of an ancient convent. The buildings are very old and are of one story, with low ceilings and small windows. About them are several acres of open grounds and fields.
At the foot of the slope on which the buildings stand a large natural spring issues from the earth. This spring is known as a "holy well," and its waters are supposed to have miraculous healing powers.
The physical conformation of the ground, the nature of the soil and the natural drainage from the buildings suggest that the water is probably contaminated.
The refugees in this camp are densely crowded into the dark rooms of the old buildings at night and in inclement weather, but in good weather they have plenty of open air and exercise.
They appeared, on the whole, to be in fair health and spirits, although they complained that the few cents per day allowed them by the Government was insufficient to buy the simplest necessaries.
The Government makes no distribution of relief in kind, but gives a cash grant of three francs (about 60 cents) per week for each adult and one and one-half francs (about 30 cents) for each child.
As prices of all foods are abnormally high, the refugees are scarcely able to buy enough to keep body and soul together. In fact, it is doubtful whether they could avoid slow starvation were it not possible for them

2. About two hundred and twenty-five refugees occupied a school building adjoining and in the enclosed grounds of a large church in Nish. Eleven small school rooms were used, with the number of occupants in each ranging from 1 5 to 25.
There were no beds.
Some of the refugees had filthy stacks of straw, others had only thin blankets or ragged quilts. Some lay on the bare floor. The building was under the charge of a janitor and his wife. She was an ignorant peasant, who saw no disgrace or menace in the awful filth of the building and surrounding yard.
Not the slightest attempt was made to clean the place, inside or out. Some rooms were not as dirty as others, because the groups occupying them retained more strength or pride, but no one seemed to heed the condition of the halls or stairways.
It is difficult to describe the condition of the people in this building in the language of restraint. The hall floors and the stairways were foul with human excreta, and grew worse with each day's addition. No water closets were provided in the building.
We were subsequently informed the closets were in the yard, but we had not observed them and the inmates of the place apparently avoided them. In the rooms the people were huddled in family groups on the floor. The ravages of starvation and disease were appalling.

There remains in our minds the picture of a baby, whose drawn face, the skin stretched sharply over the bones, gave an impression of toothless old age, clutching weakly at the breasts of a mother too weak to nourish or care for it.
Other children were whimpering pitifully, too feeble to crawl about. Here a dying woman moaned faintly and there beside a vacant space a candle burned, indicating that on that spot some one had died a few hours before.
Throughout the entire building the conditions were the same. The refugees were too far gone in illness and starvation to make any real effort in their own behalf. The woman in charge said that usually there were three or four deaths every day.
To the members of the Commission it was obvious that several of the sick were dying. Disease and starvation were rapidly settling all problems for that unhappy group.
Widespread as is the destitution reported to us, and serious as is the plight of the refugees whom we saw, we are strongly convinced that the greater and more urgent problem is that of controlling the epidemics.
In truth, the problems of destitution and health are inextricably interwoven, and it is evident that no measures for the relief of destitution, save in individual instances, can be effectual until health conditions are radically bettered. On the other hand, a reduction in the amount of sickness and death will inevitably lighten the burden of present and future destitution.
Consideration of these facts, daily impressed more deeply upon our minds, leads the Commission to the conclusion that any help which the Foundation may be disposed to give in Serbia should first be devoted to the direction and support of a strong, systematic fight upon the epidemics which now prevail and which are swiftly enveloping the entire nation.

Epidemic Disease in Serbia

At the present time, typhus, typhoid and recurrent fever are epidemic in Serbia.
Small-pox and scarlet fever are also present in some communities.
Cholera is expected with the warmer weather of spring.
Serbia knows from experience the terror of these diseases; but with all her energies concentrated on a war for her existence, with her physicians and her men of strength and influence in the army, with her resources exhausted, she is little able to cope with the vast and vital problem which confronts her people.
It is safe to say that the three epidemic diseases are distributed throughout the country. We found all in the communities we visited and in all the larger hospitals. In a number of cases it is probable that recurrent fever is first, typhus second and typhoid third. In mortality typhus is far in the lead.
Recurrent fever is rarely fatal, but it debilitates and weakens its victims. Statistics are lacking, and the best estimates are to be accepted with reserve. The estimates made by government officials are less than those made by foreign physicians and the members of the foreign medical missions who have personally traveled about the country in their professional capacity.
The national sanitary committee, recently created by the Government to cope with the epidemics, has some statistics relating to sickness in military hospitals, but not in other hospitals, or in private homes, or in the army outside the military hospitals, or in the camps in which Austrian prisoners of war are interned.

How Typhus Started

The presence of typhus and recurrent fever in Serbia is explained by the Serbian authorities as follows:
When the Austrian army invaded Serbian territory it brought with it these diseases. Many of its soldiers died of typhus while with the army of occupation, and in this way Serbian houses, in which Austrians were quartered, became infected.
The Serbians have captured about 60,000 Austrian prisoners. The burden of maintaining and guarding these prisoners was so heavy that the Serbian Government found it necessary to distribute the load.
Accordingly, detachments of prisoners were sent to all the important cities and towns in the country, where they were quartered in public buildings.
In this way, it is said, the seeds of typhus were widely scattered. Then the Serbian soldiers who guarded the prisoners and the civilian employes about the prison camps contracted the disease, and through them it spread into both  homes and barracks.
Soldiers are constantly being transported from point to point by rail. They carry upon their persons the lice which are the medium of the dissemination of typhus, and some of these insects remain in the cushions and upholstery and crevices of the cars.
When civilians occupy the same cars a few hours later they are likely to carry away some of the lice upon their bodies or clothing. A more efficient means of introducing infectious diseases into every section of a country and into every home cannot easily be imagined.

Extent of Infection in Certain Places

In Bulgaria a smaller outbreak of typhus is similarly traced to Macedonian ex-soldiers in the Serbian army, held prisoners by the Austrians and infected while among them, and later escaping into Bulgaria at the time of the Austrian rout.
In Nish an English physician stated that it was his belief that a hundred patients were dying of typhus daily.
One day during the visit of this Commission it was reported that the cemetery at Nish contained 250 unbuned bodies. The force of grave diggers was entirely unable to keep up with the work.
Nish, with its congestion of population, its unsanitary conditions — such as lack of water and drainage imply — and with an almost total lack of physicians outside those attached to the army, offers a rich field for the spread of infectious disease.

In Belgrade, whose normal population is near 1 00,000, but whose present population is estimated at 15,000, are to be found all the facilities for cleanliness. As is to be expected, the epidemics have been least destructive here. Yet in one hospital were 1 65 cases of typhus, with a larger aggregate number in several other hospitals.
The city of Skopje, with a normal population of 50,000, now is estimated to have probably 70,000, including refugees and soldiers. An English physician who has had previous experience in treating typhus and who has been in Skopje several months with a British medical mission estimated the number of typhus cases in Skopje on February 24th at 2000.
At the time of our visit the sanitary committee in Skopje, of which this British doctor is the active member, had just been given the use of a group of buildings on high ground near the city for use as an isolation hospital.
The committee estimates that with the rapid spread of typhus this hospital will soon be compelled to increase its capacity to 2000 beds.

Conditions in Skopje

The buildings to be occupied have been used as a military school for the training of officers and non-commissioned officers. The Commission visited the place with the doctor on the day before the young officers were to depart.
Several hundred good-looking students were about the buildings and grounds, apparently in good health and spirits, but we were informed that typhus had broken out among them.
We were then conducted into the basement of one of the buildings, where we saw, lying on the floor, the bodies of eight young men who had died in the school on the preceding day.
No guard or other person was in or about the room, and the door stood wide open while the bodies lay in the full glare of daylight. No effort had been made to prepare the bodies for burial or even to compose the distorted limbs, which, drawn and stark and naked, half concealed beneath carelessly placed, soiled blankets, presented a grewsome and shocking sight.
This is told as illustrating the fact that death from the epidemic, because of its frequency, already had become a commonplace.
Every community on main lines of travel is infected with typhus. Into the mountain places and the villages distant from the railroads the disease is being carried by the moving troops and bullock drivers and by the straw-lined carts in which the sick and well are transported, and it is said to be prevalent in most of them already.
These instances might be indefinitely multiplied. In the extreme southern territory, recently acquired by Serbia from Turkey, are communities into which the epidemic probably has not yet penetrated, but this statement is made of no other section of the country. The Commission had opportunity to observe conditions in Nish, Belgrade and Skopje. Statements regarding other points are based on reports believed to be reliable.

General Incidence of Disease

No comprehensive or reliable statistics of the extent or virulence of the epidemic have been collected.
The Serbian Government is absorbed in the conduct of the war; its usual staff of civil employes is too much depleted by the demands of the military service for it to turn attention to the gathering of statistics.
In fact, the degree to which all the strength and resource of the nation are concentrated in the military struggle against the Austrian enemy precludes the hope that Serbia will give that attention to the epidemic which its deadly importance demands.
The National Committee on Sanitation has reports indicating that in the military hospitals alone are 33,000 sick patients, of whom 1 1 ,000 are suffering from epidemic diseases.
This report does not include the non-combatant hospitals, the sick in private homes or the sick among the Austrian prisoners.
Estimates which are based on inadequate information place the total number of typhus cases in Serbia at 25,000 to 30,000, and while these figures must not be regarded as other than largely conjectural, we heard no one express an opinion that they are seriously in excess of the truth.
It is to be remembered that no serious effort to check the epidemic has been made up to March 1 0th, with the exception of the establishment of an isolation hospital at Skopje, not yet in operation.
Without separation of the sick from the well among the refugees or in prison camps or homes, and without measures of disinfection or sanitation, typhus continues to spread at an ever-increasing rate.

Mortality Among Physicians and Nurses

Perhaps nothing more strikingly illustrates the universality of the typhus infection and the difficulty of escaping it than the inroads which it has made upon doctors and nurses.
Doctors and nurses, to be sure, are particularly exposed, but a good deal depends — even for them — on the conditions under which they work. In a well-manned and properly equipped hospital the risk is reduced to a minimum. Where the sick he on straw on the floor of a tobacco factory without change of clothes it is impossible to work among them without being infected. Many of the foreign missions were equipped for surgical work and were unprepared for an epidemic.
Normally Serbia has had not more than 400 physicians, a very small number for a population of four and a half millions.
In the two months of January and February sixty of these physicians died of typhus, and during our stay in Serbia we were told daily of the striking down of others. Medical missions from foreign countries, sent by Red Cross societies and other agencies, have suffered severely.
Three missions or groups have been sent to Serbia from the United States by the American Red Cross. Two of these missions were combined, with a total personnel of six doctors and twelve nurses, and were placed in charge of a hospital containing 1000 patients at the town of Djevdjeh.
Three of the doctors and nine of the nurses contracted typhus. One doctor was dead from the disease when we were in Serbia, and several nurses were very low.
A British Red Cross medical mission of eighteen members was stationed at Skopje. Three died with typhus and all the others were down with the disease except three when we were in that city. We were told of other deaths among medical missions from Russia, Greece and elsewhere.
Two American doctors were sent to Serbia by a group of Americans in Paris. They went together to Valjevo. Both contracted typhus, and while we were in Serbia one died and the other contracted the disease.
It is to be noted that this great mortality among the already inadequate force of doctors is rapidly reducing Serbia's ability to grapple with the epidemic herself. More than half of the total number are with the army at the front or in the military hospitals.
Trained nurses, as we know them in the United States, are unknown in Serbia, except as a few have been brought in by the medical missions from other countries.
An outbreak of cholera is fully expected with the warm weather of spring. This we heard from sources which seemedbest able to speak from knowledge and experience, but we could not discover that any adequate steps are being taken toward preventing or arresting it.

III What Can and Cannot Be Done in Serbia

The conditions which have been described as existing at Nish (where the Government is fully cognizant of the situation and where the members of the Government themselves are not only in danger, but are undoubtedly aware of their danger) call for emergency measures and indicate that it would be vain to try now to do anything beyond controlling the epidemic.
In other words, there can be no question for the moment of:
1. The best treatment of the sick; or of
2. The maintenance in hospitals of any European standards, except those of cleanliness.
It is more important to safeguard those not yet infected, by isolating the sick, than it is to give every care to those whoare already infected. The work of isolation cannot wait until really comfortable hospitals or fever camps are set up; because in Serbia it might take weeks or months to set them up.
It may, therefore, be said that the establishment of isolation units should go forward, quite regardless of other things, as fast as :
1 . There is a physician competent to enter patients on a good diagnosis.
2. The material facilities are assembled, which will make it possible to keep the premises clear of vermin and to give thepatients clean food and water and a clean place in which to lie.
3. There is a sufficient staff, properly supervised, to clean the patients before admitting them, to distribute food and water to them, and to render to them a few essential services.
4. Facilities are provided for washing and disinfecting blankets and other supplies which one cannot afford to burn.
The tremendous demands of the war for men and supplies have absorbed the nation's strength and interest so fully that it is likely that a campaign against disease, by Serbia herself, must fail for lack of leadership and support. Even if she possesses the will, she is without the material facilities and aids needed for the work. Foreign aid will have to supply these.
Recognizing the menace to the health not only of the Serbian people, but of the whole world, presented by this terrible condition in Serbia, but appreciating that questions of neutrality and international relations might be involved, the Rockefeller Foundation took the matter up with the American Red Cross.

Inquiry by the Red Cross brought a cable from the Serbian Government inviting the presence of an American Sanitary Commission which — the Red Cross was assured — would be fully empowered to institute vigorous measures to cope with the epidemic.

* * *

The American Sanitary Commission

The American Sanitary Commission was accordingly constituted under the leadership of Dr. Richard P. Strong, professor of tropical diseases in Harvard Medical School, and probably the foremost plague expert in the United States.
Dr. Strong is especially well known for his work in aiding in the suppression of the Manchunan pneumonic plague in 1911. He started abroad, ahead of his American associates, accompanied by the disbursing officer, and taking with him an initial supply of 10,000 anti-cholera treatments.
The chief sanitary inspector for the Commission is Dr. Thomas W. Jackson, of Philadelphia; bacteriologist, Dr. HansZinsser, professor of bacteriology, Columbia University; clinical laboratory assistant, Dr. Andrew W. Sellards, of Harvard Medical School; clinical assistant, Dr. George C. Shattuck, of Harvard Medical School ; assistant sanitary inspector, Dr. Francis B. Grinnell, of Harvard Medical School. Dr. Nicolle, the French expert on typhus, has been invited to cooperate with the Commission.
Charles S. Eby, of Washington, lately connected with the United States Immigration Service, is disbursing officer and secretary for the Commission.
For the use of this Commission the Red Cross sent a great quantity of supplies, especially for disinfecting work — sulphur, iron pans, Dutch ovens, alcohol, tons of paper for sealing buildings for fumigation, whitewash brushes, flour for paste, bichloride tablets, formalin, soap, bathtubs, petroleum, mercurial ointment, phinoteus oil, permanganate of potassium, etc.
The American Sanitary Commission sailed from New York for Naples on the Italian liner Duca d'Aosta on April 3d. From Naples it was planned to proceed to Serbia via Saloniki.
Satisfactory arrangements have been made in Paris for full co-operation between this Commission and commissions sent by Great Britain and France.

THE AMERICAN AGENCY FOR SERBIAN RELIEF

THE Serbian Agricultural Relief Committee of America has formed a special organization of noted physicians and surgeons from all parts of the United States to have charge of the typhus situation.
At the head of this is Dr. T. Tileston Wells, Chairman of the Executive Committee of the General Committee. On this Committee for Sanitary Relief in Serbia are Drs. Walter B. James, W. Kinnicut Draper, Samuel Lambert, Eugene H. Pool, and John Van Der Pool, of New York City; William H. Welch and Howard A. Kelly, of Johns Hopkins University, Baltimore; Frank Billings, of Chicago, and H. C. Moffat, of San Francisco, and Michael Idvorsky Pupin, Consul General of Serbia; Dr. Trowbridge, Murray H. Coggeshall, George A. Plimpton, Theodore L. Van Norden, John W. Frothingham, and Willard D. Straight, of New York.
Co-operating with this committee are the National Red Cross and the Rockefeller Foundation. Mrs. W. K. Draper, Secretary of the Red Cross Chapter of this city, has charge of this branch of the work for her organization.
Contributions for the Sanitary Commission should be sent to J. P. Morgan & Co., marked " Serbian Sanitary Relief," or to Murray H. Coggeshall, 70 Fifth Avenue, with an indication that they are intended for the support of the Sanitary Com mission in Serbia.

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