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1918 flu centenary: How to survive a pandemic

Temporary hospitals, like this one in a California theatre, sprang up around the world during the 1918 epidemic.

2018 marks a deadly centenary.

“The bodies were folded up in their bottom bed sheet, and a flap of the sheet was brought over the face and pinned with a safety pin and a label giving their name and address. They were then carried to the morgue and laid out in rows… the whole place reeked with the smell of formalin. Even now, all these years later, that smell brings back to my mind those rows of bodies wrapped in sheets…

“We were so busy that we lost count of the dead from one day to the next, but we occasionally took a breather and stepped outside for a short walk. I can testify that I stood in the middle of Wellington city at 2pm on a weekday afternoon and there was not a soul to be seen: no trams running, no shops open, and the only traffic was a van with a white sheet tied to the side with a big red cross painted on it, serving as an ambulance or hearse. It was really a city of the dead.”  

– Alfred Hollows, a New Zealand Army Medical Corps orderly assigned to a temporary hospital in Abel Smith St, Wellington, in 1918. (extracted from Black FlU 1918, by Geoffrey W. Rice.)

This year marks 100 years since the greatest natural disaster of the 20th century began. It killed between 50 million and 100 million people – some 9000 of them New Zealanders.
The list of victims included the President of Brazil, the Prime Minister of South Africa, a former First Lady of the USA, the Queen dowager of Tonga, the Austrian painter Egon Schiele, the French poet Guillaume Apollinaire, a New York property developer called Frederick Trump (Donald’s grandfather) and Dr Margaret Cruickshank, our first woman GP.

Dr Geoffrey Rice, a retired professor of history from the University of Canterbury, has spent more than a decade researching the 1918 influenza pandemic in New Zealand and Japan. His recently published paperback, Black Flu 1918 (Canterbury University Press), is the condensed version of an earlier book, Black November: The 1918 Influenza Epidemic in New Zealand – not exactly holiday reading, but gripping research into what he calls “the worst public health crisis New Zealand has ever seen”. This is still, he says, the only national-level study of the pandemic in the world based on the painstaking analysis of individual death certificates.

Rice estimates the flu killed 6400 Pakeha and 2500 Maori in just six weeks. He also found that Maori died at eight times the rate of Pakeha.

An earlier and milder influenza “wave”, he says, had tragically duped New Zealand’s Ministry of Health wonks into thinking, despite reports from Europe, that they were dealing with a typical seasonal flu. Their fatal lack of preparation allowed the virus to erupt throughout the country in the spring of 1918.

The virus, which had been cutting a swathe through Europe since April of that year, was peculiar from the start. It was notable for its virulence and an odd preference for victims between 20 and 45. Worldwide, fit men and women were dying in roughly even numbers.

In the last months of World War I, returning troopships began to disgorge infected soldiers into New Zealand’s efficient arterial transit routes, from railways to coastal colliers and passenger boats. From October 17, people began to die in Auckland. From October 30, they began to die in Christchurch; from November 1, in Wellington. On November 4, there were deaths in Whangarei, Gisborne, Napier, Dunedin and Hokitika.

“The whole country seemed to shut down for a fortnight in the middle of November 1918, while communities did their utmost to cope with this killer,” writes Rice. “If a similarly deadly infection were to hit New Zealand today, we could expect over 30,000 deaths.”

In 1918, of course, there were no antibiotics. Although they don’t work against viruses, treatment with antibiotics would have helped patients survive the secondary bacterial pneumonias that killed so many.

“Spanish flu” arose, it is now thought, in January 1918 in a quiet farming backwater of Kansas, a Midwestern state studded with poultry and pig farms, and a major migratory flyway for 17 species of bird.

Many things still puzzle scientists about this virus – but the early association with birds or pigs isn’t one of them.

A virus cannot replicate by itself, so it hijacks the machinery of living, replicating cells. After it infects a cell, it makes tens of thousands of copies of itself. Some viruses, like measles, do this with so much fidelity they change little over time. This makes it possible for your immune system to recognise a measles virus you may have caught decades ago, and it’s why a measles vaccine can confer lifelong immunity.

But the influenza A virus makes so many “typos” when it copies itself, that it is changing, slightly, all the time. It is a shifting, drifting target for our immune system, which is why we need a new flu vaccine every year. And it isn’t just error-prone: if a bird virus and a human virus infect the same pig cell, their genes can shuffle and swap, resulting in the birth of a profoundly new virus, a hybrid that no immune system can recognise – and one with, perhaps, lethal properties.

So 1918’s pandemic really should be called the “American flu”. In Spain, the virus was dubbed the “Naples soldier” after a catchy tune in a hit operetta (catchy – geddit?). To Germans, it was the “blitzkatarrah”. Others called it the “black plague” for its sobering tendency to turn patients bluey-black as their infected lungs deprived their skin of oxygen.

Could a pandemic as deadly as this ever strike New Zealand again?

Influenza tops the list of viruses worrying experts today. It is difficult to contain because victims are contagious almost as soon as they feel sick. “The fundamental difference between the SARS virus [for example] and influenza was the time it took for infected patients to start excreting the virus,” writes Australian infectious disease specialist Frank Bowden in his book Gone Viral. “This is different from the incubation period, which is the time between exposure to infection and development of symptoms. People with SARS did not reach the peak of contagiousness until they had been ill for nearly 10 days. Quarantining sufferers had a powerful effect on reducing transmission to others.”

By the time you quarantine an influenza patient, they are likely to have passed on the virus.

New Zealand, in 1918, did have one advantage over us today – but they squandered it. There was only one way to arrive on our shores. If the government, forewarned, had quarantined ships from October to December 1918, the virus might have been stopped in its tracks.

When the next dangerous strain of influenza walks unwittingly through a New Zealand airport, we will be depending on a number of things: World Health Organisation scientists developing an effective vaccine in time, stocks of antibiotics not running out, bacterial pneumonias not proving resistant to the antibiotics we do have, and intensive-care units’ ability to cope with their increased workload.

Bowden points out that Australia’s ICUs reached capacity during the so-called “mild” swine-flu pandemic of 2009, when 722 patients with H1N1 were admitted into intensive care: 103 of them died, including seven pregnant women and seven children. The director of one unit told Bowden if he’d had to admit any more swine-flu patients, pregnant women and the young would have had to take precedence over older patients. In the same atypical pattern seen in 1918, it has been estimated that 80% of 2009 swine-flu deaths were in under-65-year-olds.

A pandemic in New Zealand could empty supermarkets and close down schools, essential services and transport hubs remarkably quickly. “New Zealand society has changed a great deal since 1918, and we should not assume that communities would cope as well with a new pandemic as they did back then,” writes Rice.

“The big lesson of 1918 is that hospitals and doctors will be swamped by a massive increase in urgent cases, and most people will have to stay at home while they are ill. How many of us know how to nurse an acute case of pneumonia?”   

This was published in the January 2018 issue of North & South.