JEFF KILDEA. Lessons to be learned from the Spanish flu pandemic of 1919 – Part 2May 11, 2020
By the end of February 1919 the NSW government, by prompt and strict measures, had, in today’s parlance, ‘flattened the curve’. But the worst was still to come.
In mid-March, the number of new cases began to rise into double figures. On 22 March, in what the Sun described as ‘Sydney’s Worst Day’, 51 new cases and 5 deaths were reported. But it was not to be the worst day by a long chalk.
Soon the number of new cases was in triple figures. In the first week of April more than 760 patients were admitted to hospital, the next fortnight it was more than 1000 weekly, resulting in the city’s 2000-bed capacity being exceeded for a fortnight. Deaths in Sydney also rose: 10 in February, 58 in March 1161 in April, with the peak of 315 deaths in the middle week of April.
If some thought the cabinet had acted too hastily in imposing restrictions in February, with the pace of the epidemic accelerating from mid-March, others criticised the government for relaxing them too early. But the truth is the government delayed too long in reimposing them, waiting until early April when once more it prohibited public assemblies and amusements, including race meetings, and ordered schools to close. Perhaps chastened by its earlier experience, church services were not prohibited, but social distancing conditions were imposed.
The government also prohibited travel from Sydney to country areas to protect them from infection, but that also came too late, and restrictions applying in Sydney were soon extended to regional cities and towns.
From the peak in mid-April, the numbers of new cases and deaths began to decline. From early May hospital admissions fell below triple figures, giving rise to hope that the epidemic would soon run its course. Even so, unlike February, the government did not immediately relax restrictions applying in Sydney, though it did so elsewhere case by case. At the end of the second week of May, with hospital admissions and deaths continuing to fall, the government acted, lifting the prohibition on open-air meetings and race meetings. This was a cautious move as the CMC had also recommended the removal of the other restrictions.
Clearly, troubled by the gravity of its responsibilities, the cabinet postponed a decision on the lifting of the remaining restrictions, calling another meeting of the CMC. Finally, on the advice of the CMC, the cabinet decided on 15 May to lift all remaining restrictions across the state, except in areas beyond Sydney declared to be infected. Social and economic life could now return to normal.
After ten weeks the epidemic seemed to have run its course, but as May gave way to June, the number of new cases began to rise again. The increase sparked concern that wet weather and a cold snap might have caused ‘a slight recrudescence of the pandemic’, a fact acknowledged by the Minister for Health, though he added that the disease was less severe than before and there were no grounds for alarm. He was wrong on both counts. The resurgence came with a virulence that soon exceeded the worst days of April.
Despite a mounting death toll, the cabinet at its meeting on 19 June 1919 declined to reinstate the prohibitions and restrictions. After two unsuccessful attempts to defeat the epidemic, at great cost to the community and the treasury, the government decided the better option was to let it take its course.
Consequently, the public were left to impose their own restraints. While some social events were cancelled, other activities including political meetings, sporting competitions and racing continued without restraint, limited only by the loss of participants to the disease. The annual Labor Conference went ahead minus 50 to 60 delegates absent due to influenza. A mid-June report on the weekend’s rugby league competition, after giving the scores for the games, noted that the ‘influenza epidemic played havoc with nearly every team on Saturday’.
The peak of the second wave of the epidemic came in the third week of June with 1315 hospital admissions and 600 deaths, resulting in hospital capacity again being exceeded for a fortnight. A month later the weekly numbers were 292 and 91. By early August, when the epidemic was officially declared over, they were 76 and 28.
Cases continued intermittently for months but by the end of September 1919 admissions and deaths were in single figures. Like its predecessor, the second wave had lasted about ten weeks. But this time the epidemic did not return. More than 12,000 Australians had died, about 6000 in NSW.
There are many lessons we can learn from 1919. Here are just a few:
Lesson 1: Policy needs to be coordinated at the national level.
In 1919 policy differences led to tensions when states unilaterally implemented movement controls to protect themselves. Lacking the powers and financial resources of today, the federal government was a relatively minor player, unable to formulate and coordinate national policy. In 2020 the formation of a national cabinet and the Commonwealth’s willingness to bear a large share of the financial burden has proved successful in suppressing the epidemic and maintaining public morale. Nevertheless, tensions remain. Unilateral border closures and public spats over approaches to school closures have demonstrated the potential for the fragility of the current ad hoc arrangements. More work needs to be done to devise a robust national institutional framework to respond to future epidemics.
Lesson 2: There is a need for a coherent program of measures that the public will embrace with conviction.
This is a lesson which does not seem to have been fully learned. For instance, in 1919 people could ride on crowded public transport, but not attend open-air church services – until a protest campaign forced the government to change the rules. In 2020 people could ride on crowded public transport, but not sit alone on a park bench. These are small matters in the overall context, but minor irritations can undermine confidence that the authorities know what they are doing when they impose restrictions on us.
Lesson 3: Know thine enemy
This is a lesson not well learned. In 1919 they did not even know the pathogen was a virus. In responding to the epidemic they were literally and figuratively just treating the symptoms. Some measures proved harmful such as inhalation chambers; some were ineffective such as prophylactic inoculation and general masking. Nevertheless, even though we now understand far more about virology than they did then, like them, we are thrashing about trying to devise effective treatments on the run. When this crisis passes, more resources will need to be devoted to virological research before the next epidemic arrives.
Lesson 4: When restrictions are lifted be prepared to reimpose them quickly and thoroughly
In 1919 NSW initially suppressed the epidemic by prompt and thorough measures. But it was not as quick to reimpose them when the resurgence occurred in March. Like Victoria in January, NSW gave the virus a chance to take hold so that April turned out to be a shocking month. (July was worse, but in that case, the government made a conscious decision not to attempt to suppress the epidemic.)
Today, with the ability to test for infection (not available in 1919) and advanced methods of contact tracing, including the COVIDSafe app, we are better placed to recognise when the resurgence has begun. Even so, it will be a political decision as to when to reimpose restrictions and to what extent. In doing so, governments will no doubt be mindful of Professor Welsh’s dictum on blame quoted in Part 1.
Lesson 5: Be prepared for the long haul
If SARS-Cov-2 behaves similarly to the influenza virus of 1919 we may face a series of waves. It is instructive to note (1) that although Victoria suffered badly early on compared to NSW, in the end, NSW had more deaths than Victoria, about 6000 to 3500 and (2) that the epidemic died out in NSW only after the government decided not to take any measures to suppress it.
Epidemiologists are the ones to argue the question of cause and effect. But, for governments, a strategy of suppression that successfully limits infections to levels within the healthcare system’s ability to cope might require many rounds of diminished social and economic activity interspersed with periods of relaxation before the epidemic runs its course, assuming that is possible with COVID-19. This will involve significant social costs, including deteriorating mental health, severe economic stress, including the collapse of businesses and whole industries, and a huge financial drain, currently $4 bn a week.
Already we are seeing signs of social and economic stress, and this is just round one. In the absence of a vaccine, the melancholy question will inevitably arise for all governments, federal, state and territory: Is our community still willing and able to sustain the punctuations of normal life required to defeat this virus or is the ultimate lesson of 1919 to be found in the decision of the NSW cabinet on 19 June 1919?