Medicine and Public Health During Estonia's War of Independence 1918 - 1920

Looking back some one hundred years ago, building a military medical service and public health system was indeed a difficult task for newly independent Estonia which was amidst a war for its survival and faced with the effects of epidemics and a pandemic which was not only effecting the Baltic region but the entire world. The ability to effectively marshal medical resources was an effective part of the all of society approach to defense of the country and in maintaining internal security and stability of the newly independent state. A leading figure in Estonia’s public health and military medical efforts was Dr. Konstantin Konik, who also had an major role in Estonia’s declaration of independence The beginnings of building a public health system in Estonia perhaps had its start with the institution that would become the City Central Hospital in Estonia’s capital, Tallinn.

The City Central Hospital had its start in 1785 during the time of Tsarist rule over Estonia, by the Social – Welfare Collegium of Harju County. The Collegium was a charitable organization that established a charity hospital in Tallinn then called by its German name - Reval.  In October 1785, the Collegium rented a spacious wooden house which was to house twelve hospital beds. The residents of Tallinn began to call the new hospital – the frei hospidal (in German) or the prii hospidal in the Estonianization of its German name, it known as the free hospital because the institution provided free treatment for the poor. By 1786 the new hospital had two wards, one which could treat fifteen male patients and the other fifteen female patients. In 1804, the maternity ward started operating, which had six beds. By 1847, the hospital staff consisted of a chief doctor and junior doctor, a surgeon, two maids, a midwife, a pharmacist, three or four nurses and about a half dozen administrative staff members. A mental ward was soon added, as well as an autopsy room and hospital library. In 1890 a new stone building was completed in 1872 and the hospital could now accommodate 220 patients and the size of the staff also increased significantly. In 1892, the first formally trained nurses were hired, in 1903 the hospital constructed a brick chapel/morgue which had cooled storage in the basement to preserve the remains of the deceased. It was innovative in design for the time and the facility remained in use for many years into the future. The other major hospital in Tallinn was the Juhkentali naval hospital which was founded near the end of the Great Northern War in 1715 in the and 1730 the army hospital moved from Kalamaja Shore to Juhkentali with institution becoming a single military hospital in the 19th century.[1]

Prii Hospidal

By the late 19th century hospital facilitates needed to expand as Tallinn grew as an industrial center and port. As the Collegium lacked funds to expand, the expanding industries which employees were served by the hospital provided assistance. The Luther Veneer and Furniture Company, Franz Krull Engineering Works, the  Johanson Paper Mill and the Maier Chemical Works provided funds to expand.

To respond to increasing industrial and street accidents on 27 April 1883, Dr. R. Feldhuhn established the first civil ambulance service in Tallinn, known as the Rescue Service for Accident First Aid, on Vene Street. It was the first of such services in the Tsarist Empire, civil ambulance services were established in Warsaw in 1897, Saint Petersburg in 1898 and Moscow in 1899. In 1891, the Tallinn Fire Brigade began providing ambulance  services when it formed a Sanitary Section 1891 which included a surgeon, surgeon’s assistants, and pharmacists. The fire brigade ambulance was initially for fire-fighters injured at the scene of fires but started to transport sick and injured members of the general public. It was a common pattern in many cities around the world beginning the association of fire services in ambulance work. In 1788, Tallinn had been first city in the Russian Empire to organize a volunteer fire brigade. By 1864 with the growth of the city, many saw that a more extensive fire-fighting organization was needed. The concept for the new of organization came from a watchmaker, Carl Theodore Hollandt who had come from Switzerland and settled in Tallinn. As he had been a volunteer firefighter in Switzerland, he drew on his experiences there to develop a new organization for Tallinn. The City Council approved his new organization modeled on Swiss and French volunteer fire brigades. Concurrently with Tallinn’s fire – fighting reorganization on 5 February 1864 the Tartu City Council announced the founding of a volunteer fire brigade. The next year, a fire station was constructed from stone in the center of the city on the banks of the Emaj?e River. Other Estonian towns and districts soon followed in establishing volunteer fire brigades, P?rnu in 1866, Valga in 1867, V?ru, Kuressaare and P?ltsamaa in 1868, Viljandi and Haapsalu in 1872, in Narva in 1873, Paldiski in 1877 and Rakvere in 1879. A number of the brigades also started operating sanitary sections as the Tallinn Fire Brigade did. In 1910, the Tallinn firefighters received two notable pieces of equipment manufactured in Germany a powerful steam pumper Karmas Catherine which had a capacity of pumping 800 liters of water per minute and a motorized Magirus ladder truck with an aerial ladder reaching twenty meters. The Tallinn Fire Brigade was still an all-volunteer organization and considered as modern model of fire brigade organization for the rest of the Tsarist Empire.[2]

Ambulance Wagon

As rescue services modernized so did the Prii Hospidal, an important modernization was the installation of electrical power. With the outbreak of the World War in August 1914, the hospital would have to expand further. As Tallinn was at the entrance of the Gulf of Finland, protecting the approaches to the capital of the Russian Empire Petrograd (Saint Petersburg). Military authorities required the hospital to have 32 additional beds to treat workmen brought into Tallinn to strengthen the naval fortifications and work in the expanding naval shipyards. Being an important support facility, the military district commander took a seat of the hospital’s directing board. The expansion of the workforce, many coming from Russia, and the expansion of the Tallinn garrison and influx of refugees from Latvia greatly increased the danger of infectious disease outbreaks. With the abdication the Tsar and the rise of the Russian provisional government, Estonia became autonomous. On 30 March 1917, the Russian provisional government granted Estonia autonomy as one administrative unit headed by Jaan Poska as provisional commissar. In July 1917, elections established an executive body, the Maap?ev, and this was soon followed by replacement of Russian civil officials by Estonians and Estonian became the official language of government and education. On 1 September  1917, Poska disbanded the Social-Welfare Collegium which the hospital was subordinated, and the hospital and its assets were transferred to the Harju County Government becoming the Estonian Provincial Hospital. Estonia formally declared independence on 24 February 1918, bringing the country to the entente side, however the Estonians had little ability organize military forces. Germans crossed the Muhu Straits from Saaremaa and Muhu, quickly moved to occupy Estonia.[3]

Dr. Konstanin Konik (Estonian National Archive)

An interesting and significant episode on the eve of the German occupation involved the key figure in Estonia’s later public health efforts, Dr. Konstantin Konik. Konik was born in Tartu in 1873 and attended medical school at the University of Tartu. He practiced in the southern Ukraine and had been mobilized to serve in the Imperial Russian Army’s medical corps in Manchuria during the Russo-Japanese War of 1904 – 1905. He had returned to Estonia and in February 1918 became the leader of the Estonian Salvation Committee (Eestimaa P??stekomitee) along with notable social and political figures, Jüri Vilms and Konstantin P?ts. The Salvation Committee enacted the fateful decision to declare national independence. Konik went with a delegation of three, himself and two staff captains – Nikolai Reek and Andres Larka of the Estonian military forces which were still in a formative stage, to try to negotiate with German forces advancing in southern Estonia. Meeting with German representatives, they stated that Estonia was becoming independent and desired to remain neutral in the war.  The Bolshevik had seized power in Petrograd and were cooperating with the Germans, the implications of which were not known yet in Estonia. The mission had no hope for diplomatic success as the Germans had own plans for Estonia, but it bought some time. They secured the agreement that Tallinn would not be occupied before noon on 25 February 1918. The Germans adhered to this agreement. It essentially bought time – the salvation committee declared independence on the 24 February, independence manifestos were plastered on lamp posts and sign boards throughout the capital. Word of Estonia’s declaration of independence spread to the outside world. On the morning of 25 February 1918, Estonian military units and the Tallinn Fire Brigade paraded through the Raekoja Plats (city hall square). Near to noon the military band struck up the Estonian National Anthem Mu isamaa, mu ?nn ja r??m as they finished German cyclists entered the square. The gathered Estonian crowds quietly dispersed. The declaration of independence made Estonia an occupied country, bringing diplomatic support from the allied powers and pre-empted any German efforts to establish a pro-German government under perhaps a German monarch. The Germans occupied Tallinn the most Estonian military forces could was to prevent looting by demoralized Russian garrison and Russian workforce as they evacuated Tallinn starting their movement to Petrograd. The departure of this unruly host simplified public health problems somewhat but, the situation remained acute.[4]

Even before the start of the German occupation, the former Prii Hospidal and other medical institutions in Estonia had a shortage of a variety of material and supplies. On 13 March 1918, the hospital was subordinated to the city of Tallinn, to become the City Central Hospital. The situation supply did not improve significantly, if in fact,  there was a lack treatment materials and soap and hospital linens were increasingly in short supply. Some innovations did come about during the occupation, on 14 June 1918, the Mayor of Tallinn announced that a 24-hour accident and emergency point was open on the 1st floor of the Surgery Department of the City Central Hospital.  On 14 October 1918, an ambulance was stationed there as well. However, treatment of accident victims was not the main public health concern in Estonia in autumn 1918. In the United States, an avian flu morphed to swine and spread to humans when a large pile of manure was set on fire in Fort Riley, Kansas and wind gusts blew a huge cloud of dust and ash over hundreds of US Army personnel. The fine particles of manure spread the flu to inductees undergoing basic training. The flu spread to Europe as American troops deployed to France and spread across frontlines. The flu was known as La Gripp or Spanish Influenza, to maintain morale, censors in the warring powers minimized early reports of the illness. However, newspapers were free to report the epidemic's effects in neutral Spain, such as the grave illness of King Alfonso XIII, and these stories created a false impression of Spain as especially hard-hit leading pandemic to be dubbed the Spanish influenza. During the German occupation, civil hospitals remained in operation, but influenza started spreading through Estonia. Of all the Estonian nationalist activity and organization had gone underground. In August 1918, the German authorities arrested Dr. Konik in Tartu and held him in prison for the duration of the occupation. Occupation regulations perhaps slowed the spread of the flu to the Estonian civilian population as public gatherings and civil travel were restricted.[5]

The German occupation ended with the armistice on 11 November 1918 and the Estonian provisional government could once again function openly. The Germans began to withdraw. However, two great dangers invasion from the east and spread of the Spanish Influenza or Gripp. Jaak S?ggel correspondent for the newspaper Postimees wrote on 20 December 1918 “This autumn, all rural municipalities, villages and farms were called upon by influenza. There are few who were left untouched by it, many from the same farms  fell into the grave under this disease. ”[6]  On 28 November 1918 the Bolshevik Russia attacked Estonia invading from northeast along the northern coast and from the southeast from Pihkva (Pskov). Estonia had to quickly organize an armed forces, along the ability to sustain them in the field and the departments civil government to all resources to be organized for defense and the stability of civil society maintained. Dr. Konik was appointed head of Public Health Administration within the Ministry of Labor and Welfare. In the conditions of the Estonia’s War of Independence, this work required great organizational skills. Not only did Konik have to support the treatment of wounded from battlefield and help maintain the health of the armed forces, he had to organize measures to protect the public against the influenza and other infectious disease outbreaks, he also had to organize the regulation of the professional activities of doctors and midwives, establish procedures for controlling sexually transmitted diseases, and much more.

It was not just new government departments that would have to deal with the medical and public health situation, but nearly the whole of Estonian society would have to be mobilized.  On 1 December 1918, a public meeting was held at the Estonia Theater with representatives of the Estonian Provisional Government in attendance and socially and politically active citizens,  could discuss how civilians could support the armed forces in the ongoing struggle to preserve national independence. The idea came about having a support organization largely of the Tallinn’s professors, teachers and high school student to support the government and the war effort. Initially focused on Tallinn’s educational community, but it would soon encompass a far broader segment of Estonian society. Based somewhat the model on voluntary organization civic organizations formed in various municipalities in the Tsarist Empire to support the Russian war effort during the world war, under the leadership of Voldemar P?ts, director of the School of Art and Design and the younger brother of Konstantin P?ts, the ühist?? – the Cooperative Service was formed on 8 December 1918. The ühist?? would undertake a variety of support tasks for the armed forces, including laundry services, clothing repair, and even the care of prisoners of war, but the first and main priority assisting the army in medical care. Initially, the army had tried to carry out these medical care tasks entirely through the Army medical service, but there was the shortage experienced personnel and materiel of all types, evacuation was also a slow process. Hence the ühist?? formed the Casualty Assistance Section under Captain Dr. Boris Voogas. Voogas was from Rapla and had entered medical school at the University of Tartu in 1916, given the wartime situation, he became a medical practitioner after abbreviated study.

Dr. Boris Voogas (Estonian National Archive)

The Casualty Assistance Section and the Army Medical Service delineated responsibilities the army would provide initial treatment and evacuation from the battlefield to the railhead and the ühist?? would handle the movement of hospital trains from the railhead to Tallinn and transfer to hospitals in the city. The ühist?? would also equip hospitals and organize their work, register the wounded, publish casualty lists in newspapers and also operate catering points for soldiers. In addition to this, the ühist?? also cared for war refugees  The first railway hospital cars were found in at the railway junction of Tapa in between freight cars where they were abandoned by retreating Russian forces in February 1918. They underwent some repairs in Tallinn and the first one went into operation on 16 December 1918.

ühist?? Members and Hospital Car (Estonian National Archive)

The first specific task of the ühist?? was to open reception points at Tallinn’s Baltic Station and at the Harbor Station where the sick and wounded arriving on hospital trains were received, registered, fed and, if necessary had their wounds dressed and then transferred by ambulances to the city's hospitals. A few hundred people, mostly high school students, teachers, Defense League (Kaitseliit) members, firefighters, and some trained nurses. All of them were quickly taught how to deal with the wounded, the organization served as a training ground for those being mobilized and serving in the army medical service.

Narrow Gauge ühist?? Hospital Train in P?rnu (Estonian National Archive)

Konik visited with Army Medical Service Commander Mikhel Ostrov and members of the ühist??, the Juhkentali Military Hospital in at the end of December which the Germans had used as a barracks during the occupation. According to Konik, “it was completely devastated by the departing occupation forces and the dirt was indescribable. I was accompanied by the ladies of the organization led by Mrs. Lender, who were to see about helping in possible cleaning work. In the operating room, where there was no artificial lighting, snow blew through broken windows into the room. The room temperature usually stood at 2 degrees (36 F) and did not rise above 8 degrees (46 F) even with greatest attempts at heating. The situation made any kind of operational use impossible.”[7] With a great deal of work, ühist?? reopened the Juhkentali military hospital as an infirmary  (laatsaret). As the building was in poor repair and it would require more time to having it functioning again as a general hospital, it dealt mainly with the light casualties, who were brought directly from the reception point at Baltic Station, for treatment of more serious cases, as according to Konik, “I advised Ostrov to concentrate the more severely wounded in the casualty department of the City Central Hospital, where there was a relatively good operating room and was fairly well supplied with instruments and medications.”[8] The casualty ward's 90 beds were filled in a short time of which sixty were serious wounded patients. As soon as the medical conditions allowed, patients were moved to Jukentali or other facilities to make room for new casualties. The wounded military personnel were treated by doctors Bruno Vahtrik, Konstantin Pedussaar and Josef Israelsohn with Konik, actively involved again as a consulting physician. The former chief physician and surgeon of the hospital Renaud von Wistinghausen had left at the end of the German occupation. As the evacuation and hospital organization was rapidly improving, so was the overall military situation.[9]

The Bolshevik invasion columnated in the early January 1919 the Estonian armed forces went on the offensive. Medicine had a role in this as medical care was breaking down for the Bolsheviks and disease ripped through their ranks. On the other hand, Estonian medical care was quickly improving, for the Estonians, this had a positive effect on morale while Bolshevik moral was declining.  On 14 January the city of Tartu was liberated and by the end of the month, the Estonians had liberated all of their territory. However, the war would continue until January 1920. As Estonian troops had to abandon Tartu on 18 December 1918, the ühist?? could not start work there until 14 January 1919. The ühist?? quickly established a number of infirmaries (laatsaret) throughout the city. Tartu, of course, had the Tartu University Hospital which was established in 1804 on Riiam?e and moved to a stone building on Toomem?e on 1804. In the 1875 the hospital the expanded on Toomem?e.  The institution further expanded 1915 – 1917 with two large new buildings just west of the Tartu’s railway station in Maarjam?isa.  It would take some time, before hospital could get up and fully running after the occupation. Casualties were still being moved to Tallinn. As the infirmaries started functioning and hospital services were restored, the ühist?? set up a reception point at Tartu’s railway station and collection points at railway stations as the front moved south and to the east. In Tartu, the Cooperative Service organized the collection of donations of food and clothing. On behalf of the Military Requisition Commission, various consumables and equipment were collected for the army as well. The ühist?? also set up workshops in Tartu  where hundreds of people worked making and repairing uniforms and boots, making saddlery, and repairing small arms and vehicles. They also operated laundry and a tannery. Additionally, the ühist?? established catering points in the city just between the frontlines.[10]

Hospitalized Estonian Military Personnel at the Greiffenhagen Clinic in Tallinn (Estonian National Archive)

While ühist?? continued to provide a wide range of support activities, it soon passed it medical care responsibilities to another organization. Much through the efforts of Colonel Dr. Hans Leesment, senior medical officer of the 1st Estonian Division, Estonian civic leaders formed the Estonian Red Cross on 24 February 1919. The reason for the formation of the Red Cross was to have a specialized organization focused on medical care. Furthermore, a Red Cross Society was one of the institutions of an independent state and Estonian was amidst the diplomatic effort to win de jure recognition of independence from the great powers. As there was cooperation between various Red Cross societies it was a way gaining more international assistance particularly on the humanitarian front. The ühist?? passed the operation hospital trains and their medical care facilities to the Red Cross. The Red Cross with the assistance of the Estonian Railway Administration, quickly put a number of well-appointed hospital trains into operation and a sauna train for disinfection and bathing for troops at the front, an important measure to prevent the spread of typhus.

Red Cross Hospital Train (Estonian National Archive)

The Red Cross would eventually have as many as sixteen of their own hospitals in operation. As according to Colonel Dr. Leesment on the establishment of the Red Cross of which he became head, “I came to the conviction that there needed to be an organization which devoted their full energy to provide primary assistance to the sick and wounded. I talked to some of the most active members of Estonian society who agreed with this.”[11]  The assistance of the American Red Cross was particularly important, Estonian also received assistance from the red cross societies of Great Britain, Denmark, Sweden and Finland. An American Red Cross mission in Estonia would consist of some forty men under Lieutenant Colonel Dr. Edward Ryan consisting of forty men. In the summer of 1919, Danish Red Cross Hospital Valdemar Sejr arrived in Estonia headed by Dr Ludvig Boye Lundstein. In addition to the chief surgeon, there were four other doctors and twelve nurses as part of the hospital compliment. The hospital initially established operations near Valga. Also, in summer 1919, Estonian Red Cross received seven Rover Sunbeam Ambulances from the British Red Cross and the Order of Saint John’s Ambulance Society. As they were highly suitable for operations near the front lines, they were turned over to Estonian Army to transport wounded personnel from forward dressing stations to receiving points at the railhead to be embarked on Red Cross hospital trains to hospitals in Tallinn, Tartu and various other Estonian towns.[12]

Rover Sunbeam Ambulance just behind front lines - Geneva Crosses are Covered as the Bolsheviks often did not respect the protected status of medical personnel (Estonian National Archives)

Overseeing the entire medical system was Dr. Konik who, in addition to serving as the head of the Public Health Administration, oversaw military hospitals and practically assisted in treatment served as a consulting surgeon to the Central Military Hospital or Juhkentali Hospital. General Jonathan Laidoner, Commander-in-Chief of the Estonian Armed Forces, informed Konik than Ostrov was leaving as head of army medical service, Laidoner offered that Konik take over Ostrov’s duties. Konik told Laidoner that it would benefit the armed forces more if he stayed in his present capacity. However, there was a very suitable candidate to take Ostrov's place, Arthur-Aleksander Lossmann had recently returned to Estonia. Originally from P?rnu County, Lossmann had graduated from the Tsarist Military Medical Academy in 1904 and had both surgical and medical administrative experience from the Russo-Japanese War and the World War. Lossmann was appointed head of the medical service on 29 March 1919. As according to Lossmann,   "The first task I had was to create a practical military medical administrative apparatus that would allow the smooth, accurate and fast execution of medical tasks. I divided the work between the various departments, where everyone had their clearly delineated roles and responsibilities.”[13] As Lossmann led the military medical effort, Konik coordinated overall Estonian public health effort committing civilian medical resources where and when necessary.  

Konik had seen that City Central Hospital facilities were needed to treat the wounded military personnel. Some ninety beds were used for military personnel out of total number hospital beds which were 280, divided into five wards. The hospital still had to serve the civil population as well. On 5 June 1919 Dr. Karl-Eduard Sibul became the chief physician of the City Central Hospital, he was the first Estonian to be chief physician of the institution as previous ones had all been Baltic Germans.

Dr. Karl-Eduard Sibul (Estonian National Archive)

Like Konik, Sibul was from Tartu County and had attended the University of Tartu and started his medical career as a veterinarian. During the Russo-Japanese War of 1904 – 1905, he was mobilized into Tsarist Army and sent to care for horses in Manchuria. On return to Estonia, he completed a medical degree and practiced medicine in Tartu for time and then worked as a bacteriologist in Tallinn. He was mobilized into the Tsarist Army with the outbreak of the war in 1914, but he returned to Tallinn in 1917 and resumed his career as a bacteriologist becoming head of the city medical laboratory. In addition to serving as the chief physician and director of the City Central Hospital, he served as director of the Red Cross Nursing School which was located at the City Central Hospital as the Red Cross did not have their own full hospital in Tallinn. Sibul was a great asset for Konik given his laboratory experience and his background as bacteriologist as Konik had to contend with containing infectious diseases in wartime conditions.[14]  

As mentioned, the Konik had to contend with Spanish influenza but there was other threat of other infectious diseases such as dysentery,  cholera, and typhus. For the Public Health Administration information was the key to controlling outbreaks. From local governments, military authorities, and medical institutions Konik established a reporting system throughout the country tracking cases, deaths, etc. Local authorities sent statistics in a timely manner to the Public Health Administration, so outbreaks could be isolated and dealt with. From the Public Health Administration detailed instructions were sent to schoolteachers on how to prevent in infectious diseases in schools and what actions to take when an infectious disease was found in a school. To military forces in the field, leaflets with instructions were widely distributed on how to prevent to dysentery and typhus and how to maintain hygiene. Spanish influenza has seemed have been most serious in autumn 1918 with perhaps as many as 5000 deaths in Estonia, while deaths were reported in 1919, influenza seemed to have already run its course and with the effective reporting and openness of information allowed authorities to enact quarantines and take other measures where necessary. In 1918 - 1919 there were 25,000 deaths in Finland from influenza and in Russia influenza raged from 1918 well into 1920 resulting hundreds of thousands of deaths. Konik was open with information on the conditions in military hospitals writing about the difficult situation in newspapers as well to ensure that adequate attention was paid to the treatment of the wounded and that enough resources available for effective medical care. To him it was a terrible phenomenon if a minor wound became a serious case in hospitals due to inadequate attention or resources. This was also an important issue of morale, ensuring that comrades in arms knew that their cohorts were receiving good medical care, this applied to family members of the wounded as well. In maintaining morale, transparency was an important element. The national leadership had to maintain a trusting relationship with the public and the ranks of country's military forces. As the war continued into summer and autumn 1919, though the medical system was relative efficient and sanitary situation was improving, the Public Health Administration still had great concerns about the spread of disease, as according to Konik,  “Towards the end of the summer, the activities of the Public Health Administration increased. Our doctors were notably raising concern that as continuing hostilities diseases were being spread across front lines and when rearward from front to population centers by soldiers on leave. However, things went relatively well from the beginning of summer and into autumn.”[15]

The most serious threat to public health came in late autumn 1919 when the War of Independence nearly over. The Estonians were successfully holding its borders but in November 1919, after General Nikolai Yudenitch's White Russian Northwest Army failed in its offensive against Petrograd, about 100,000 former soldiers and hunger-stricken refugees crossed over the Luuga and Narva Rivers into Estonia. A major typhus outbreak started at Iisaku-Illuka-M?etaguse just south of Narva where former soldiers of the Northwest Army were temporary encamped. Soon hospitals in the Narva area were overwhelmed. Patients from the Northwest Army were brought to Tallinn, where a hospital was established in the buildings of the Russian – Baltic Shipyard on Kopli Peninsula for about 2,000 patients. The epidemic spread to Tallinn and at the end of 1919 it was already there 1,500 new typhoid patients, in early February 1920 the average of ten new cases in Tallinn. The War of Independence had formally ended with the signing of the Treaty of Tartu on 2 February 1920, but a new crisis was just beginning. The workload of the General Health Administration quickly went up, staff in Tallinn coordinating efforts when upwards to 120 staff members, they were joined by some 74 staffers of army medical service. With the support of the American Red Cross, the Estonian Army and American Red Cross enacted strict quarantine measures, Narva and all of surrounding were Viru County quarantined as well as the Kopli Peninsula which was effectively isolated from the rest of Tallinn, the area around Russian hospitals was declared a danger zone and access was allowed only with written permission from military and Red Cross authorities. In Kopli, the hospital grounds were bounded by barbed wire and any kind of movement between the Kopli Peninsula and the rest of Tallinn was prohibited from 9 pm to 6 am. The Estonians mobilized thousands of volunteers who disinfected schools, churches and private homes to rid them of plague-spreading insects. A series of sanitary stations were established on the Russian border to inspect and delouse refugees coming in from Russia. The ühist?? supported the effort with paid employees who produced new clothing for the American Red Cross. The American Red Cross provided some 40,000 items of new clothing to the former soldiers on the Northwest Army and the civilian refugees replacing their lice infested old uniforms and civilian clothing they had worn crossing into Estonia. The combined efforts to stem the outbreak began to pay off.[16] 

Within twenty days of beginning of the anti-typhus campaign the backbone of the epidemic had been broken and the emergency passed as the outbreak was localized. Unfortunately, there were multiple thousands of deaths among former soldiers of the Northwest Army but many survived as they were bathed and given clean clothing and returned to disinfected hospital wards. The epidemic was localized and prevented from spreading further to the Estonian population or to other countries. Dr. Konik in his later remembrances noted that at the time, he realized the potential danger and that the situation could have been worse, “The more difficult days in the field of public health began the failure of Yudenitch's campaign and the masses of Russian refugees that came with the end of the campaign. There was a terrible outbreak of louse-borne typhus which caused medical care to break down in Viru County. The plans and policy of the Public Health Administration were fully supported by the frontline commanders Generals [Alksander] T?nisson and [Ernst] P?dder and thanks to their assistance we escaped into the clear.”[17]

Despite the difficult situation of country building and an armed forces nearly from scratch as well as all support elements while at war, the Estonians were very successful building a military medical system which truly sustained the combat power of the Estonian armed forces, as according to military historian Hannes Walter, “ In May 1919, the number of hospital beds reached 5,000 and remained there until the end of the war. In general, the treatment of the wounded was on an exemplary level. Thus, the mortality rate of casualties evacuated from the battlefield was only 3.1%. The corresponding figure for the German Army during the First World War was a 3.0% mortality. The fight against disease was more difficult at the beginning of the War of Independence. Due to insufficient winter clothing, there were treatment of 3,000 men for cold weather injuries and the due to insufficient winter clothing, nearly 1800 cases of pneumonia from which 17% of the afflicted died.”[18]

The success of the military medical effort as well as the overall public health effort, were both vital to preserving Estonia’s independence. After all of stable and healthy society was vital in supporting the war effort, especially for a small country that had to use all of its available resources to the fullest extent. A coordinated effort of all organizations, government, military, and social like the ühist?? was necessary. The ühist?? continued to work until 1921 raising money to help the local destitute population and engaging in fundraising to erect monuments for the War of Independence.

Red Cross Ambulance

After the Independence war the Red Cross also continued its service. The Estonian Army returned the seven Rover Sunbeam ambulances to the Estonian Red Cross, which underwent extensive repairs and were repainted from subdued green to brilliant white. Experience from the independence war was readily applied to civilian emergency medicine. As according medical doctor and historian Raul Adlas, “civil ambulance work began in earnest after the War of Independence, when highly experienced doctors returned from the front."[19] Dr. Voogas, was appointed head of the Red Cross Transport Section. On 1 September 1922 the Red Cross established an ambulance headquarters in Tallinn at 12 Niguliste Street which received emergency calls and dispatched ambulances. Three years later the facility was expanded as an emergency clinic providing pre-hospital care before patients were transported to a hospital. Red Cross ambulances responded to accidents free of charge to the patient, but a donation to the organization could always be made. The Red Cross provided non-emergency medical transport on a metered basis. Ambulance services soon were established in Tartu and other Estonian towns. In Tartu, the fire brigade continued to operate its own ambulance as well. The Rover Sunbeams were wide and squat being purpose built as military ambulances, thus the citizens of Tallinn baptized them the mardikaks or the beetles. Soon the ambulances were well regarded in Tallinn, they were described in the tenth anniversary album of the Estonian Red Cross, “Who in the Tallinn does not know these fast-running white cars? The mighty siren of which can be heard on and around the streets of the capital in the early morning, during the day, and during the deep night! Always running at speed, because somewhere there is danger, trouble and gloomy death!”[20] As a gift of the American Red Cross in summer 1922, the City Central Hospital also received it own ambulance, a Ford which was  busily employed in medical transport work. In a few years the Red Cross ambulance fleet was supplemented with newer and more modern machines, the bodies of which were built at home, only chassis and drive train were imported from abroad.  Much of the construction of the ambulances was done locally to save costs and support domestic industry. The Rover Sunbeams or mardikaks were soon all replaced by modernly equipped ambulances with special suspension systems and all kinds of amenities to treat patients.[21] Clearly, the civil ambulance system the developed greatly in a short span of time after the War of Independence.

Auto Accident outside of Tallinn in June 1924, traffic accidents were an increasing hazard in Estonia in the 1920s requiring ambulance response (Estonian National Archive)

The Estonian War of Independence lasted 402 days, during which the Estonians often had to fight outnumbered 5 to 3 to 1. Maintaining the health of the armed forces, sustaining of the fighting strength was of critically importance. The Estonians had 75,000 men within the armed forces at the peak of mobilization in late 1919. The total number of forces would perhaps equal to 119,000 if the rear-area forces of the Kaitseliit – the Defence League are put into the total. In estimated total, the civil and military health system in total during could provide 8,000 hospital beds as peak. Estonian military medicine had to the develop quickly where casualties received immediate treatment on basic unit level and were quickly moved on to the appropriate civil or military hospital. In sum, the armed forces had twenty-seven hospitals available at the height of the conflict as well as forty-six pieces of hospital train rolling stock. As the typhus threat increased the Estonian Railway Administration quickly constructed eight more sauna trains. The armed forces established two sanatoriums at Haapsalu and Kuresaare for convalescent care. At height, the military medical system had some 250 doctors, sixty pharmacists, over 300 nurses, nearly 700 medical assistants (velskers)  and several thousand medical corpsmen. The War of Independence cost Estonia, 3,588 dead and 13,775 wounded, of the dead, some 1,388 Estonian military personnel died of disease.[22] This sacrifice was not in vain, as it was a war of necessity for national survival. It could have been far worse. Epidemics raged out of control within Russia as public health had broken down there, the importance of the Estonian military medical and public health efforts cannot be understated. Estonia was truly a cordon sanitaire. In the words of historian Walter Hannes the medical and public health victory "maybe for the Estonian people and for Europe as a whole, the greatest victory in the Estonian War of Independence.”[23]

.

[1] Arne-Lembit K??p, “Ida-Tallinna keskhaigla 20. sajandi s?dade keerises,” [East Tallinn Central Hospital in the whirlwind of wars in the 20th century] Postimees (18 October 2015) [https://arvamus.postimees.ee/3366463/arne-lembit-koop-ida-tallinna-keskhaigla-20-sajandi-sodade-keerises] (Accessed 24 April 2020)

[2]Eesti üleriiklise Tulet?rje Liidu 10. a. juubelialbum : 1919-1929 [10th anniversary of the Estonian National Fire Brigade jubilee album: 1919-1929] (Tallinn: Eesti üleriiklise Tulet?rje Liidu Kirjastus. 1929):7,  Priit Jaan Parmask. Eesti tulet?rje ja tsiviilkaitse.[Estonian Firefighting and Civil Defense] (Tallinn: AS Kupar. 1995}; 42,  Veiko Pesur, “Tallinna kiirabi sai 120-aastaseks.” [Tallinn’s Ambulances are 120 Years Old] Eesti P?evaleht (28 April 2003) [ https://epl.delfi.ee/eesti/tallinna-kiirabi-sai-120-aastaseks?id=50953222&url=%2Fnews%2Feesti%2Farticle.php] (Accessed 23 April 2020)

[3]Ivo Karlep “Tallinna esimene haigla ravis vaeseid tasuta,” [Tallinn's First Hospital Treated the Poor for Free] Pealinn (19 October 2015) [https://www.pealinn.ee/koik-uudised/tallinna-esimene-haigla-ravis-vaeseid-tasuta-n154893] (Accessed 23 April 2020)

[4] Küllo Arjakas, “Saaga Konstantin Konikust,” [Saga of Konstantin Konik] Horisont 2 (2003) [https://vana.loodusajakiri.ee/horisont/artikkel60_41.html] (Accessed 24 April 2020)

[5] Arjakas, “Saaga Konstantin Konikust.”

[6] Quoted in Tiit K?ndler, “Eesti t?histab juubelit ühes Hispaania gripiga,” [Estonia’s Anniversary of the Spanish Influnza] Maaleht (14 February 2018) [ https://maaleht.delfi.ee/tasubteada/eesti-tahistab-juubelit-uhes-hispaania-gripiga?id=81079767 ] (Accessed 4 April 2020)

[7]Konstantin Konik, “M?lestuste katkendid,” [Excerpts from Memoirs] in Eduard Laaman (ed) M?lestused iseseisvuse v?itlusp?evilt ; I k?ide : revolutsioon ja okupatsioon 1917-1918 [Memoirs of the days of the struggle for independence; Volume I: Revolution and Occupation 1917–1918] (Tallinn: Waba Maa. 1927):29

[8] Ibid.

[9] K??p, “Ida-Tallinna keskhaigla 20. sajandi s?dade keerises.”

[10] Kadri Bark, "Vabatahtlik ühist??" [Volunteer Cooperative Service]  Ajalugu 11 (2017): 30 – 31, Jaan Maide. ülevaade Eesti Vabaduss?jast 1918–1920 [Overview of the Estonian War of Independence 1918 – 1920] (Tallinn: Kaitseliit. 1933): 128

[11] Maido Sikk, “81 aastat Eesti Punast Risti,” [81 Years of the Estonian Red Cross] Tervisleht (2 August 2008): 1

(https://www.terviseleht.ee/200009/9_punastristi.php ) [accessed 20 February 2011]

[12] Kuulo Kutsar, “Eesti Punase Risti asutamisest 100 aastat. Eesti Punase Risti tegevuse k?rgperiood 1919–1940,” [

100 years since the establishment of the Estonian Red Cross. Activities of the Estonian Red Cross peak period 1919–1940] Eesti Arst 98 (2019): 121 -123, Pesur, “Tallinna kiirabi sai 120-aastaseks.”   

[13] Maido Sikk, “Eesti s?jameditsiini rajaja meditsiinidoktor Arthur-Aleksander Lossmann,” [Medical Doctor Arthur-Aleksander Lossmann, Father of Estonian Military Medicine] Eesti Arst 87 (2008): 150

[14] Sirje Maasikam?e, “100 aastat tagasi astus ametisse esimene eestlasest haiglajuht, kes oli ka Tammsaare ihuarst,” [100 years ago, the first Estonian Hospital Chief was Appointed , He was also Tammsaare's physician] ?htuleht (5 June 2019) [https://tervis.ohtuleht.ee/965938/malestuspink-teenekale-tohtrile-100-aastat-tagasi-astus-ametisse-esimene-eestlasest-haiglajuht-kes-oli-ka-tammsaare-ihuarst] (Accessed 24 April 2020)

[15] Konik, “M?lestuste katkendid,” 30

[16] Küllo Arjakas, “Konstantin Konik 1918.–1919. Aastal.” [Konstantin Konik in the Years 1918 – 1919] Eesti Arst 87 (2009):147, George W. Baer (ed) The Origins of U.S.-Soviet Diplomatic Relations : The Memoirs of Loy W. Henderson (Stanford CA: Hoover Institution Press. 1986): 75 -76

[17] Konik, “M?lestuste katkendid,” 30

[18] Quoted in Arjakas, “Konstantin Konik 1918.–1919. Aastal,” 146 – 147

[19] Pesur, “Tallinna kiirabi sai 120-aastaseks.”  

[20] Quoted in Ivo Karlep, “Vabaduss?da treenis ?pilastest halastaja?ed ja t?ukas kiirabi looma,” [The War of Independence experience trained student nurses and spawned the development of ambulance service] Pealinn (30 April 2018) [https://www.pealinn.ee/arhiiv/vabadussoda-treenis-opilastest-halastajaoed-ja-toukas-kiirabi-looma-n220080] (Accessed 30 March 2020)

[21] Ibid.

[22]United Kingdom National Archives, FO 608 22652 "Goode to Bosanque 19 May 1919," Estonian War of Independence, 1918 – 1920 Reprint of a Summary of prepared in 1938 – 1939. (New York. Eesti Vabadusv?ltlejate Litt. 1968): 44, K?ndler, “Eesti t?histab juubelit ühes Hispaania gripiga.”  Sikk “  Eesti s?jameditsiini rajajavmeditsiinidoktor Arthur-Aleksander Lossmann,” 151

[23] Arjakas, “Konstantin Konik 1918.–1919. Aastal,” 147