19 Mar 2020
Spanish flu lessons can help combat coronavirus
By Anthony Bergin and Jeffrey Feim
History doesn’t repeat itself, but it often rhymes,” Mark Twain observed.
The catastrophic 1918-19 outbreak of influenza was the most virulent pandemic the world had experienced, second only to the Black Death. Like COVID-19 the Spanish flu was an unknown strain of influenza then for which no vaccine or treatment existed.
The most conservative realistic estimate of the number who died in the pandemic is about 20 million. In Australia the outbreak of influenza in Europe wasn’t viewed with alarm. But our complacency vanished when the disease spread to New Zealand, killing over 6,000 people in twelve weeks.
Based on the proceedings of the first Australian pandemic history conference convened some years ago by health security scholar Athol Yates, the stark lesson for today from 1918-19 is that strong leadership involves early action, and early action saves lives.
Every Australian household was provided with education material. A hotline was created to report sickness and request help. Personal hygiene measures were stressed. Border quarantine was introduced to allow more time for preparations and for the virus’s virulence to reduce.
Regulations were introduced which forcibly closed places where people gathered, from theatres to libraries, although not public bars. In NSW open air church services were held with all worshippers required to be masked. A space of three feet was to be kept clear between individuals.
Fever clinics were established where influenza victims would be taken. Hospitals were kept for non-influenza patients. Contact tracing was critical in the early stages of the pandemic to slow the spread. People were forced to stay at home if they became sick during the containment phase of the pandemic.
In her study on NSW and the 1918-19 influenza pandemic, Robyn Arrowsmith points to the great reliance placed on volunteers for services in the community. A Citizens’ Committee established relief depots, organised house-to-house patrols, fed families, visited and cared for helpless people and established travelling kitchens.
The fourteen-point pandemic plan a century ago was developed by the federal government in consultation with state governments and the British Medical Association. Acting Prime Minister William Watt obtained the agreement of all premiers to the plan, with the exception of Queensland.
The first phase of the plan, a maritime quarantine, worked well. It was the largest maritime quarantine the world had ever seen. At each of the eight quarantine stations there was accommodation for large numbers of people that had to be separated from the general public. Within each of the quarantine stations there were eight hospitals.
The quarantine meant that Australia remained pandemic influenza free for many months. While just over 12,000 Australians died in the pandemic of 1919, had there not been maritime quarantine, an additional 10,000 to 15,000 Australians would have perished.
But as soon as the pandemic broke through the quarantine barrier, every state quickly abandoned the plan, leaving a chaotic situation. Victoria proved the weak link. A case travelled by train from Victoria to Sydney. Several days later there were infections among Sydney residents who could be traced to this case. The Victorian government refused to confirm that pandemic influenza was present. In a ludicrous farce NSW closed their border with Victoria and South Australia quickly followed. Detention camps were established at the Victorian border and anyone entering NSW from Victoria was faced with four days’ quarantine.
The closure of the State border presented enormous problems for NSW citizens stranded in Victoria. There were attempts by people to swim across the Murray River to escape border quarantine. Most were brought back by police and placed in an isolation camp at Albury. The federal government considered its authority as being treated with contempt and withdrew from any attempt to control interstate movements.
Social isolation worked. It spread the mortality and morbidity over a longer time frame and allowed the healthcare system to more adequately meet demand. But the rapid explosion in the number of influenza cases quickly overwhelmed resources.
The fever clinic established at Randwick racecourse, for example, had the tents, beds and blankets in place for when the peak period of influenza cases hit. But it didn’t receive one patient: there were insufficient doctors and nurses to staff it.
A number of measures were ineffective such as inhalation chambers (people either inhaled a gas or a powder that was meant to provide some measure of immunity), trying to impose land border quarantines, the required wearing of masks, (the discomfort they caused after prolonged use led to unrest in the community), the forced opening of windows on trains and bans on standing up in a train (trains and trams could only carry the number of passengers that could be seated). People turned to quack medicines.
We must now do the best we can and remove any obstacles standing in the way of a concerted response. The current Australian government pandemic plan should slow the worst phase of the crisis, but the most severe measures that the community can now sustain need to be taken to manage the infection rate. There’s always the risk the national plan of action could be undermined by individual state actions. That could occur if a jurisdiction considers that the federal government isn’t rigorously enforcing parts of the plan, such as home quarantine or if it’s moving too slowly in enforcing border controls. The states may lose trust in the Australian government if there’s any perception that decisions are taken for commercial reasons, rather than community safety.
While our social and political situation is different, the Chinese response (outside of Wuhan City and Hubei province where they had zero warning) has, despite the initial cover-up, worked well. People were ordered to stay indoors at their homes. Most were already together as families, because they were gathered for the Spring Festival.
One member of each household has been permitted to leave the house every two days. Street committees, local party members, volunteers (often retirees) and private municipal service companies have largely managed enforcement and household support during the isolation.
Provincial disease control and prevention centres and departments of health have issued specific rules of compliance for the management of medical cases. Temperatures are being measured at least daily at every contact opportunity. Once an “isolated” person was suspected of being infected, they would be relocated and processed through a fever clinic diagnostic centre and resettled into medical quarantine.
Raw ingredients and prepared meals have been delivered to the doorstep and also purchased under controlled conditions in designated areas.
One advantage that China has leveraged in this lock down situation is the massive individual meal delivery service industry, with innumerable small restaurants and independent deliverers comprising the backbone of this system. The “gig economy” in action. On any “normal” day, hundreds of millions of ready-made meals are delivered on electric motorcycles in every large city, and this has continued through the epidemic.
The Australian public information campaign that has now started should have commenced weeks ago. The only way to reduce fear, uncertainty and the avoidable demand for emergency department services is blanket media information across print, radio, television and social media. And it should provide practical information: the newspaper ads that are now appearing don’t explain the most effective way to wash your hands or what self-isolation requires. There’s no message to the public not to hoard and to think of the elderly and neighbours.
We now need to start planning for the recovery phase and not simply returning to what we had before. As the Australian Strategic Policy Institute’s Michael Shoebridge has argued the virus adds a new set of risks associated with the concentration of global supply chains in China.
Australia stands to benefit here if we take this opportunity: we can be one of the places to which production shifts because of our low sovereign risk, rule of law, educated workforce, developed health system and natural resources.
Our goal should be to use this time to build back better with a focus on an economy based on greater domestic self-sufficiency that significantly reduces China and other low-cost states in our supply chain.