INFLUENZA 1918 – 1919:
The state of epidemiology and the effects of war and censorship, in the Western world
It is 95 years since the worst influenza pandemic the world has ever known began killing people in the latter stages of the Great War. Even today we ask ourselves how such a trivial disease could kill so many people. We question its rapid spread, why people were so unable to fight it, and the effects war and censorship had on it.
Part of the answer lies with its timing. The influenza pandemic arrived in three waves, each of which coincided with major movements of troops during the war; the deployment of American troops, the end of the war, and the demobilisation of troops. This movement provided the disease with access to many more people than would have been possible in peacetime.
The war had demanded censorship which greatly affected the information available to the developing medical communities of the era. Censorship hid the disease in a cloud of secrecy. This prevented warring nations from warning both their own people and those of neighbouring countries of the danger posed by the outbreak. Even between allies the influenza pandemic was kept secret. There was no unity between nations. This secrecy not only hid the fact that people were getting sick, but also forestalled treatments that might have helped.
The 1918 outbreak was not trivial. This deadly variant of the influenza virus as well as causing the ordinary fever, sneezing, coughing, running noses and headaches associated with the flu, caused bleeding from mouth, nose and eyes, and cyanosis. This cyanosis or blue colouring occurred as patients’ lungs filled with fluid, depriving them of air. While the first wave was milder, it was extremely infectious leaving its victims susceptible to its return in the more virulent form.
In Britain the Royal College of Physicians had identified the method of transmission as the fine spray of droplets issuing from people’s mouths in sneezes, coughs and speech. However, antiquated notions of miasma, or poisonous air still caused contention. The doctors of the time did not know what a virus was, and had no way to fight it. Viruses were identified in 1933. The 1918 flu virus was identified in 1995. The use of antiseptic-soaked masks prevented secondary infections but could not stop influenza spreading.
The best course of action would have been to quarantine patients. Quarantine was first established in the fourteenth century and was in general use since the eighteenth century. However, these procedures were not used effectively in Europe where the focus was the war. Some countries including Australia did employ effective quarantines and, as a result suffered fewer deaths from influenza than countries which had not implemented them.
The movement of troops required by the war effort contributed to the spread of influenza. Those who were infected but not yet sick delivered it to friend and foe alike. There was a war to fight and the troops were necessary. Troops were transported on ships, whose close confines provided the highly infectious influenza virus with fresh victims. In the first wave few died. The latter two waves were deadly. The hospitalization of flu-infected troops infected the doctors and nurses who treated them. In the course of their work they then infected others before falling ill themselves.
By the end of the war in November 1918 it was too late to apply quarantine. Hundreds of millions of people had been exposed and millions had already died. Medical authorities did what they could. In Britain doctors were hampered by red tape as public health was spread between innumerable services and authorities. In 1919 Britain made influenza a notifiable disease, as Australia had done in 1918. When the League of Nations Health Organisation (now the World Health Organisation) was established in 1920 it too listed influenza as a notifiable disease.
The recognition that people were dying of influenza in large numbers became obvious but the actual death toll was not known. On December 12, 1918 the Sydney Morning Herald reported that six million people had died of influenza. That incomplete figure was conservative. Medical researchers began investigating the pandemic. We now know that over 21 million people died with some estimates exceeding 100 million people. The true figures will never be known.
There was no cure in 1918, and there is still no cure now. The idea that a pandemic similar to that of 1918 – 19 could happen again is alarming. While the 1918 pandemic took six to nine months to circle the earth, today with rapid air travel it could take as many weeks. With a similar death rate, up to a billion people could lose their lives. Medical researchers continue to search for cures to this fast-changing virus and countries stockpile anti-viral agents.