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The Impact of the Civil War on the Spanish Nutritional Condition

At the end of 1936 the League of Nations, following a proposal by the Spanish Republican Government, adopted a resolution to send a group of experts to survey the health situation of the Spanish population after several months of conflict. The evaluation of the nutritional state of the population and the strategy to guarantee food availability was not only a matter that impacted upon the economy and public health, but it was also an essential aspect in military terms. The technical commission sent to Spain by the League of Nations included: Antoine Lasnet, a medical officer and member of the French Academy of Medicine; Jean Laigret, a member of the Pasteur Institute in Tunis; and C. Wroczynski, Chief Medical Adviser to the Ministry of National Education in

Warsaw. At the beginning of 1937 a report was presented to the Council.[1]

The Commission paid special attention to the dietary condition of refugees as food supply prospects in certain areas were bleak. Its report dealt with four fundamental problems: health organisation, the epidemiological situation, dietary prospects and problems arising from the evacuation of refugees.[2]

During the first year of the war all the available data showed a controlled epidemiological situation without signs of degradation in the level of health. There were no unexpected epidemic outbreaks. The health of the population in the republican zone remained within the usual limits. The stable population had enough supplies, but there were severe shortages among the refugees. This apparent normality came as a surprise to the League of Nations’ experts visiting Spain at the beginning of 1937. But the situation began to worsen, as shown by the evolution of the general mortality rates. In the period 1930-35 the rate was 14.5 per thousand, and in 1937 it was only 15.5. But the rate increased gradually during the war, reaching a peak of 19.2 per thousand in 1938. When the Civil War ended, there was a decrease in general mortality for a three-month period, but in 1940 an increase brought the rate up to 16.6 per thousand. 1941 showed a new increase due, in part, to food shortages and high infant mortality subsequent to the spectacular birth rise in 1940.[3]

The excellent system of recording epidemiological data put in place by Marcelino Pascua[4] during the first republican biennium had been profoundly altered by the war and so the collection of data was deficient. Yet it still permitted the identification of the four principal problems that required attention under those circumstances: typhoid fever, spotted fever, smallpox and bacillary dysentery. All of them were expected problems, given the living conditions during the war.[5]

According to the League of Nations’ 1937 report, typhoid fever had been an endemic problem in Spain before the war due to poor hygiene in water for human consumption. The number of cases at the start of the 1920s oscillated between 15,000 and 20,000 annually, leading to 3,000 to 4,000 deaths. In 1934-35 the number of cases was strongly reduced. But the situation worsened from the start of the war due to the deterioration of sanitary conditions and the movement of refugees, as shown by the data employed by the expert committee, originally from statistics compiled by the National Hospital of Infectious Diseases. In the second half of 1936 there were 358 cases, 42 of which ended in death. At any rate, the experts expressed their reserve and thought that health services had reorganised and that bacteriological water testing was being carried out on a regular basis. There was no fear of an epidemic, and therefore, an intensification of typhoid vaccination was not recommended.

The whole of the epidemiological survey did not detect the appearance of epidemic or even sporadic outbreaks. The measures adopted by the republican government in this matter consisted of recruiting all the medical professionals of the country, coordinating the actions of the civil and military medical authorities, adopting special measures to ensure the proper functioning of medical aid on the front of battle and developing vaccination campaigns whenever convenient. Typhoid and paratyphoid fever vaccination was administered to the army, and quite widespread paratyphoid fever vaccination was extended among the civilian population. Smallpox vaccination was compulsory, yet vaccination against diphtheria was rare, given that this measure had never been that common with the population. There was no other type of preventive vaccination applied to soldiers, not even against tetanus.

From their direct observations and from the official data compiled, the League of Nations’ experts considered the health situation to be satisfactory at the start of 1937, although they feared the spread of typhoid and spotted fevers. They therefore recommended compulsory vaccination and water and food testing. With regard to spotted fever, they laid out recommendations for the improvement of treatment and prevention that included the use of portable de-lousing devices and treatment material, general immunisation against typhus for health workers and improving the availability of vaccines. They thought it necessary to equip municipal and provincial centres with specific areas for the treatment of patients with infectious diseases, provide disinfection devices for health services, these being clearly inadequate. They also isolated contagious patients and improved the system of epidemiological data collection in order to detect any sign of deterioration in the sanitary situation at any time. A central point was the training of doctors specialised in epidemics; these could be specifically assigned to prophylaxis and the fight against infections and be employed in asylums, prisons and other places where large groups of people lived. As a conclusion, let us accept that the international specialists detected neither nutritional problems nor the impairment of health levels in republican Spain.

The report presented by J.A. Palanca to the League of Nations in 1939 on the Francoist side commented on the main health problems in the nationalist sector regarding the army but also the health situation of the civil population.[6] The report was rather unrealistic in trying to show that the actions taken before the war allowed a controlled epidemiological situation during the war in the nationalist zone. The completion of Palanca’s report coincided with the end of the war, a time at which the necessary reconstruction of health care for the population was already underway.[7]

The evacuation of refugees fleeing the front to neighbouring areas was a fundamental aspect regarding the health and nutritional state of the population. The report of the League of Nations showed that 250,000 refugees from Extremadura lived in Jaen, Ciudad Real and Toledo; and Catalonia had received a large quantity of refugees from Aragon. The flow of refugees aroused spontaneous solidarity in the families living in the hosting zones, but there was a clear need to set up a National Committee for War Refugees. The provincial and local delegations of this committee were in charge of the evacuation, distribution and fostering of the refugees.[8] The money for their care came from private sources and from the national budget.

The magnitude of the problems posed by the evacuation of the population from the front was enormous. At the end of 1936 they numbered more than one million. Of those, 350,000 were fostered in Catalonia and 250,000 in Valencia.[9] The refugees accounted for 14% of the whole population of the country. The capacity to foster new refugees was on the verge of saturation and food shortages appeared in some areas. The evacuation of the capital, Madrid, which was under siege, was extremely hard and the experts predicted the dramatic worsening of the health and nutritional status of the population in this area. In fact, most of the research on the nutritional impairment of the Spanish population regards the dramatic situation of the capital exclusively.[10] However, historians have not taken into consideration the fact that feeding conditions in the principal cities of republican Spain were radically different, as well as access to food. The case of Madrid cannot be absolutely generalised, as unfortunately has been done by a significant part of historiography, simply because medical reports were slanted and focused on a city under siege. Food supplies became a problem affecting more than 1,200,000 inhabitants during the siege of Madrid. It worsened during the first months of the war, with more than 300,000 refugees.

The military front divided the country into two sides. The east was under Republican control and the rebels took the west and the north. The Republican zone produced wheat, rice, vegetables, fruit and wine. The area controlled by Franco’s troops produced cereals but mainly for grazing.[11] The experts from the League of Nations predicted that the inhabitants of Madrid would go short of meat and milk. The supply of flour, olive oil, fruit, pulses, and vegetables was guaranteed if the republican authorities were able to defend the transport infrastructure. Although the shortage of milk and meat was alleviated by using other products, shipping difficulties meant serious problems in the distribution of food.[12]

From the second half of 1937 severe food problems hit the Spanish population, comparatively worse than the shortages in central Europe during the First World War.[12] Madrid saw a decrease in the caloric value of its diet as compared with the first winter of the war and this led to nutritional deficiencies and progressive malnutrition in the whole population.[14]

The state of war changed the social and political dimension of food availability and nutrition, which now became a military tool. Following international recommendations, the Spanish Government established an Instituto Nacional de Higiene de la Alimentacion [National Institute for Food Hygiene], where experts in physiology of nutrition aimed to coordinate nutritional policies both for the civil population and the military forces under the direction of Jose Puche, a Professor of Physiology, Rector of the University of Valencia and an expert on nutrition. The Spanish experts knew about the latest developments in nutrition physiology and the research work discussed and published by the technical committee of the League of Nations.[15] From January 1937 scientific criteria were used to implement a system on the basis of family or personal food rationing and special norms for the sick.[16]

At the beginning of 1937 Spanish health officers advised that the demand for basic products had almost been covered by domestic agricultural production. Nevertheless, in anticipation of future shortages, 120 tons of potatoes were imported from Holland. The main problem, however, was related to transport. In 1937 the food supply had not yet led to critical problems of hunger, deficiency diseases, or malnutrition, but experts expressed their concern: “If we consider the hundreds of thousands of women and children who live in Madrid, we can only conclude that it will be necessary to evacuate them as soon as possible... as food deficiency is a big threat”.[17]

Nutrition had become central to the war. In mid-1939 the Technical Commission on Nutrition of the League of Nations presented a report of the work done between June 1938 and April 1939, including a section on the critical situation of the feeding of refugees in Spain and the need to take emergency measures to avoid starvation.

From November 1936, as a result of the siege of the city by rebel troops, a period of dietary restrictions started for the population of Madrid, worsening over time and finally affecting the majority of citizens. The City Council introduced a Family supply card and placed a ban on the free traffic of foodstuffs. As a consequence, most of the inhabitants were given the same ration for much of the war and Madrid’s society was turned into a laboratory to analyse the effects of a prolonged lack of food, since the period of famine and scarcity lasted more than two years. A group of experts from the National Institute of Food Hygiene completed a study of the diet of Madrid’s population during the 19-month siege, from August 1937 to February 1939.[18]

The average calorie value of the diets provided in the 19-month period came down to 1,060 calories a day, representing 49.7% of the minimum acceptable level. In the last year of the war the average was 944 calories or 43.3% of the minimum daily intake. The calorie value of the diet dropped steadily, from 1,514 daily calories in August 1937 to 852 in February 1939, a leap downward from 70% to 36% of the minimum diet. From an energy point of view, it was definitely a poor diet; besides, the main foodstuffs were bread, oil, rice, legumes and sugar, with animal products accounting for just 4.7% of the total calorie value. While the approximate protein need was estimated at 60 g per day, the average figure for the 19 months was 34 g, i.e. 56% per cent lower. In fact, the diet on the Cartilla de Racionamiento represented an average value of 25 g per day.[19]

The diet was deficient in fats (41% of the minimum diet) and carbohydrates (53 % of the minimum daily intake) but also in minerals and vitamins. Group A and C vitamins were below the minimum threshold, group B vitamins were highly deficient and only the good weather of the city made up for the shortage of vitamin D. All these records placed the population of Madrid in a more negative position than that of Germany in the First World War, whose calorie coefficient ranged between 1,400 and 1,800 calories per person per day. It is worth insisting on the exceptionality of the situation in Madrid, not at all equivalent to that of many other cities and rural areas, which certainly suffered from shortages.

In the study of deficiency diseases associated with malnutrition, the Spanish experts F. Jimenez and F. Grande Covian, who worked at the Instituto Nacional de Higiene de la Alimentacion during the war, estimated the average caloric value of the diet of the Madrid population


to be 2,130 calories daily before the conflict. In August 1937 that figure had been halved.[20] The feeding of the population reached a critical point in October 1938 when only 150 g of bread per person could be allocated and the daily diet of a great deal of people was limited to a cup of Malta coffee with or without sugar for breakfast, a plate of lentil soup with a little bread for lunch and some rice with a little bread for dinner. That type of diet only provided between 800 and 1,000 calories and caused a very significant loss in body weight. Surveys developed by nutritionists at the end of the war indicated that the average loss of weight of the population in Madrid as a result of deficiency diseases represented approximately 30% of their weight before the war.[12]

The Spanish group of experts began to detect simple, non-specific malnutrition signs and several deficiency diseases, which attracted the attention of physiologists, nutritionists and clinicians. There were neither reliable nor comprehensive statistics. Only data on mortality in the first year of the war were available, but they were inaccurate due to an inefficient system of recording epidemiological data. From the research published by nutritional experts we know that the main deficiency illnesses in Madrid were pellagra - the so-called pellagra sine pellagra - neuropathies associated with nutritional deficiencies, optic and acoustic neuritis, simple glossitis and hunger oedema.[22] Most of these conditions were associated with avitaminoses or with a deficiency of proteins. The situation worsened in the post-war period.[23]

In the early 1940s Jimenez Garcia and Grande Covian published a series of research articles in the Revista Clinica Espanola, including plenty of records on the deficiency illnesses suffered by the inhabitants of Madrid during the war and the early post-war period.[24] Notwithstanding the dramatic nutritional status of the population, avitaminoses A, C and D were very infrequent, exceptionally causing haemeralopia, scurvy and rickets. In 1943 and 1944 deficiency illnesses similar to the ones described in Madrid began to appear in some European countries as a consequence of the Second World War.[25]

The situation of the Spanish population hardly improved in the first years after the conflict. In fact, in several ways, the nutritional status of the Spaniards worsened during the post-war period, as reflected in 1943 by Yves Biraud, an expert form the League of Nations, in his assessment of nutrition in Europe.[26]

  • [1] Rapport sur la mission sanitaire en Espagne (28 decembre 1936-15 janvier 1937),Geneve, Societe des Nations, 1937.
  • [2] Anguera A., “Servicios sanitarios con motivo de la inmigracion durante la guerra”,Revista de Sanidad eHigiene Publica, Vol. 1, 1938/1939, pp. 25-42; Garcia Luquero,“Aspectos sanitarios de la evacuacion de refugiados en Santander”, Revista deSanidad e Higiene Publica, Vol. 1, 1938-1939, pp. 68-81.
  • [3] Barona, 2007b.
  • [4] Marcelino Pascua was a former pensionate of the Rockefeller Foundation at theJohns Hopkins School of Public Health and General Director for Health in thesocialist government 1931-1933. After the war he went into exile, becoming head ofthe statistics office of the World Health Organisation.
  • [5] Rapport sur la mission sanitaire, 1937, pp. 72-73.
  • [6] Palanca y Martinez Fortun, J.A. Les services sanitaires espagnols pendant la guerrecivile, Geneve, Societe de Nations, 1939. Palanca was a conservative hygienistbelonging to the group of experts in public health leading reforms in Spain during theprevious decade; he was an intern of the Rockefeller Foundation. After the start ofthe Civil War he became the head of health policies on the nationalist side.
  • [7] Ibidem, 1939.
  • [8] Rapport sur la mission sanitaire, 1937, pp. 73-74
  • [9] Ibidem, p. 86
  • [10] Del Cura, M.I. del, Huertas, R., Alimentacion y enfermedad en tiempos de hambre.Espana, 1937-1947, Madrid, CSIC, 2007; Del Cura, I., Huertas, R., “The siege ofMadrid (1937-1939). Nutritional and clinical studies during the Spanish civil war”,Food & History, Vol. 6, 2008, pp. 193-214; Del Cura, I., Huertas, R., “Estudiosnutricionales en Madrid durante la Guerra Civil espanyola”, in Bernabeu-Mestre, J.,Barona, J.L. (eds.), Nutricion, saludy Sociedad. Espana y Europa en los siglos XIX-XX, Valencia, SEC/PUV, 2011.
  • [11] Rapport sur la mission sanitaire, 1937.
  • [12] Ibidem.
  • [13] Ibidem.
  • [14] Grande Covian, F., La alimentacion en Madrid durante la Guerra. (Estudio de ladieta suministrada a la poblacion civil madrilena durante diecinueve meses de
  • [15] guerra: Agosto 1937 a Febrero 1939). Madrid, Publication de la Revista de Sanidade Higiene Phblica, 1939. The Technical Commission on Nutrition was presided in March 1937 by EdwardMellanby, and composed of 16 members. Teofilo Hernando, a Professor ofPharmacology in Madrid, Enrique Suner, a Professor of Pediatry and Jose Murillo,director of the Spanish Institute for Food and Medicines were Spanishrepresentatives.
  • [16] Jimenez Garcia, F., Grande Covian, F., “Sobre los trastornos carenciales observadosen Madrid durante la Guerra. I. Los cuadros cllnicos presentados con mas frecuenciay su clasificacion”, Revista Clinica Espanola, Vol. 1, 1940a, pp. 313-318; JimenezGarcia, F., Grande Covian, F., “Algunas observaciones sobre las dietas consumidaspor los enfermos carenciales de Madrid”, Revista Clinica Espanola, Vol. 1, No. 1,1940b.
  • [17] Rapport sur la mission sanitaire, 1937, p. 89.
  • [18] Grande Covian, 1939.
  • [19] Ibidem, pp. 45-46.
  • [20] Jimenez Garcia, Grande Covian, 1940a, 313-318; Jimenez Garcia, Grande Covian,“Algunas observaciones sobre las dietas consumidas por los enfermos carenciales deMadrid”, 1940b.
  • [21] Ibidem.
  • [22] For a broader analysis see Barona, 2010, pp. 105-118; Barona, Perdiguero, 2007,pp. 115-122; Huertas, R., Del Cura, I., “Deficiency Neuropathy in Wartime: The“Paraesthetic-Causalgic Syndrome” described by Manuel Peraita during the SpanishCivil War”, Journal of the History of the Neurosciences, No. 19, 2010, 173-181; DelCura, M.I. del, Huertas, R., Alimentacion y enfermedaden tiempos de hambre, 2007.
  • [23] Garcia-Albea Ristol E., “Las neuropatias carenciales en Madrid durante la GuerraCivil”, Neurologia, Vol. 14, 1999, pp. 122-9.
  • [24] This research has been partially analysed by Del Cura, Huertas Garcia-Alejo, 2006,pp. 50-89; Barona, 2007b, pp. 31-34; Garcia-Albea Ristol, 1999, pp. 122-129.
  • [25] Barona, 2007b.
  • [26] Biraud, 1943-1944.
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