Clive Williams: What we can learn from the Spanish flu
Although it occurred over 100 years ago, there are still valuable takeaways from our handling of the Spanish flu that can be used today. Namely, knowing the main problem, writes Professor Clive Williams.
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While the COVID-19 pandemic needs to be taken seriously – being up to 20 times more lethal than seasonal flu and significantly more infectious – it is nowhere near as deadly as the Spanish flu pandemic of 1918-19.
The Spanish flu H1N1 virus spread around the world as soldiers returned home by ship from active service at the end of the First Word War. A quarter of the 1.8 billion global population became infected. About 10 per cent of those who became infected died – some 50 million people. This total far exceeded the 17 million who died during the war.
In Australia, from January 1919 nearly 14,000 people died, mostly young adults between the ages of 15 and 35. However Australia’s death rate of 2.7 per 1,000 of our five million population was one of the lowest recorded of any country.
Today, annual epidemics of seasonal flu result in about three to five million cases of severe illness and about 290,000 to 650,000 deaths globally, according to the World Health Organisation. The top three communicable killers are lower respiratory infections, diarrhoeal diseases and tuberculosis – mostly in developing countries with poor health systems.
For Australia, the three leading causes of death are non-communicable coronary heart disease, dementia/Alzheimer’s, and cerebrovascular disease – mainly in the over 65s.]
The “Spanish flu” did not in fact start in Spain. Spain was neutral during the First World War and the Spanish media reported freely on the flu, while the combatant countries’ wartime censors suppressed news of the deadly flu for morale reasons. Since people in the media blackout countries could only read about the flu from Spanish news sources, they assumed Spain was the pandemic’s source.
The first recorded case of Spanish flu was at a Kansas military base on 11 March 1918. However, a 2014 study suggested that the virus originated in northern China. Previously undiscovered records linked the virus to the transportation of Chinese labourers across Canada in 1917 and 1918 on their way to France to be employed as labourers. In all, over 90,000 Chinese workers were sent to the Western Front.
The Spanish flu came in three waves, starting in March 1918. The first wave resembled a typical annual flu epidemic; those most at risk were the sick and elderly, while younger, healthier people recovered quickly. Those who survived developed immunity to subsequent waves.
By August 1918, the virus had mutated to become much deadlier. It now triggered a cytokine storm immune reaction in young adults that caused severe lung inflammation, and often death. Paradoxically, the weaker immune systems of children and middle-aged adults were less affected, so they had a better chance of survival.
The third wave came in the northern winter of 1919 but was less deadly. By the end of 1919 the pandemic had run its course.
Initial Spanish flu symptoms included a headache and tiredness, followed by a dry, hacking cough, loss of appetite, and stomach problems, then a high temperature and excessive perspiration. After that, the illness affected respiratory organs and pneumonia could develop.
A 2007 analysis of medical journals from the period found that the viral infection was exacerbated by wartime malnourishment, overcrowded medical facilities, and poor hygiene that led to bacterial superinfection – and that’s what apparently killed most of the victims.
There was no agreed medical treatment for patients, so governments’ emphasis was on flu prevention. Health authorities urged people to avoid crowded places and other people. Doctors told people to keep their mouths and noses covered in public. Americans were advised to stop shaking hands, stay indoors, avoid touching items in public places, and wear masks.
Essentially much the same as today with COVID-19.
There were few crematoriums back then and the sheer number of bodies overwhelmed the capacity of undertakers, gravediggers and casket makers to keep pace with burying the dead. As is the case in Italy and Iran now, restrictions on gatherings meant that few people were able to attend funerals for their loved ones.
Although the Spanish flu occurred over 100 years ago, we can still learn some important lessons from the effective Australian response.
The first lesson was to quarantine arrivals. Of the 81,510 people who were checked on arrival, 1,102 were found to be infected and were quarantined.
The second lesson was to establish a consistent response to handling and containing outbreaks in Australia. The Federal Government held a national influenza planning conference in Melbourne on 26–27 November 1918, at which State health ministers, the DGs of all health departments, and British Medical Association representatives met to agree a common strategy.
The Federal Government accepted responsibility for organising maritime and land quarantine camps, while the States agreed to arrange emergency hospitals, vaccination depots, ambulance services, medical staff and public awareness measures.
In 1918, the Commonwealth Serum Laboratories had developed an experimental vaccine in anticipation of the Spanish flu reaching Australia. Researchers did not know what caused the Spanish flu but produced a vaccine that addressed the secondary bacterial infection.
Between 15 October 1918 and 15 March 1919, CSL produced three million free doses of vaccine for Australian troops and civilians. It was later stated that the vaccine was “partially effective” in preventing death in inoculated individuals.
The main problem with pandemics – then and now – is the likelihood they will have run their course before an effective vaccine can be mass-produced; hence the importance of isolation, personal hygiene, and avoiding a spike in cases that would overwhelm health resources and lead to a higher mortality rate.
Unlike the Spanish flu, most COVID-19 deaths are caused by Acute Respiratory Distress Syndrome, which causes damaged lungs to fill with fluid and makes breathing difficult. That’s why not having enough ventilators to go around would be so dangerous.
But one bit of positive news is that children under the age of 18 don’t seem to become very ill with COVID-19.
Clive Williams is a visiting professor at the ANU’s Centre for Security and Military Law and a former CBRN analyst.