Doctors developed and used some of these cures for the flu. Sydney’s chief quarantine officer, Dr Reid, treated patients in March 1919 with 15-grain (1 gram) doses of calcium lactate every four hours, and a “vaccine” containing influenza and pneumococcus bacteria. In 203 cases, he had no deaths.
Nan Taylor, a New Zealand nurse, advocated whisky — lots of it, including gargling and drops up the nose. She also recommended quinine and castor oil.
Nurse Kate Guazzini cared for Spanish flu patients in South Africa in late 1918, and caught the flu there before moving to Sydney. She said:
I was kept alive on brandy and milk for six weeks […] That, with quinine and hot lemon drinks, were found to be the only effective remedies.
Food manufacturers linked themselves to flu cures. In 1919 a brand new beef extract, Bonox, had just hit the Australian market, and the flu epidemic was a great marketing opportunity. Bonox was advertised as a sure way to recover your health and strength after the flu.
Between 1918 and 1920, Australian newspapers were flooded with Spanish flu cures of all kinds.
In October 1918, a journalist at Victoria’s Bendigo Independent lamented:
Cures? My goodness me, the vast amount of cures on the market are positively frightening, and everyone has a favorite cure. I pin my faith to one, you to another. There’s a certain influenza mixture that, taken in the early stages, is regarded as a certain cure by one large section […] Asperin [sic] is the cry of another batch of victims, and they tell you that that drug does the trick. ‘Try whiskey and milk taken hot and taken often,’ is the advice of others who have had it. But one and all end in the same way: ‘Go to bed and stay there till the thing leaves you.’
On Friday we published the following New York cable: — ‘Dr. Charles Duncan, at the Convention of the American Medical Association, said the cure for influenza was one drachm of infected mucus pasteurised and with filtered water injected subcutaneously … Yesterday (says Tuesday’s Tweed ‘Daily’) a youth was seen inquiring for a chemist, having in his hand the above clipping and sixpence, his object being to secure that amount’s worth of the ‘cure.’ Several others, it is understood, have also been inquiring into the same matter, with a view to ‘having it made up’ locally.
Some of these cures lingered
Once the Spanish flu pandemic was over, many of the cures remained. Most of them, like aspirin, incorporated the threat of influenza into regular advertising.
Some, like quinine, have made a reappearance during the COVID-19 pandemic.
Tensions over border closures are in the news again, now states are gradually lifting travel restrictions to allexcept Victorians.
Prime Minister Scott Morrison says singling out Victorians is an overreaction to Melbourne’s coronavirus spike, urging the states “to get some perspective”.
Federal-state tensions over border closures and other pandemic quarantine measures are not new, and not limited to the COVID-19 pandemic.
Our new research shows such measures are entwined in our history and tied to Australia’s identity as a nation. We also show how our experiences during past pandemics guide the plans we now use, and alter, to control the coronavirus.
The health board openly criticised the government for its handling of the quarantine measures, laying the groundwork for quarantine policy in the newly independent Australia.
Quarantine then became essential to a vision of Australia as an island nation where “island” stood for immunity and where non-Australians were viewed as “diseased”.
Public health is mentioned twice in the Australian constitution. Section 51(ix) gives parliament the power to quarantine, and section 69 requires states and territories to transfer quarantine services to the Commonwealth.
Ports then became centres of immigration, trade, biopolitics and biosecurity.
Spanish flu sparked border disputes too
In 1918, at the onset of the Spanish flu, quarantine policy included border closures, quarantine camps (for people stuck at borders) and school closures. These measures initially controlled widespread outbreaks in Australia.
However, Victoria quibbled over whether NSW had accurately diagnosed this as an influenza pandemic. Queensland closed its borders, despite only the Commonwealth having the legal powers to do so.
When World War I ended, many returning soldiers broke quarantine. Quarantine measures were not coordinated at the Commonwealth level; states and territories each went their own way.
There were different policies about state border closures, quarantine camps, mask wearing, school closures and public gatherings. Infection spread and hospitals were overwhelmed.
The legacy? The states and territories ceded quarantine control to the Commonwealth. And in 1921, the Commonwealth created its own health department.
The 1990s brought new threats
Over the next seven decades, Australia linked quarantine surveillance to national survival. It shifted from prioritising human health to biosecurity and protection of Australia’s flora, fauna and agriculture.
In 2003, severe acute respiratory syndrome (or SARS) emerged in China and Hong Kong. Australia responded by discouraging nonessential travel and started health screening incoming passengers.
The next threat, 2004 H5N1 Avian influenza, was a dry run for future responses. This resulted in the 2008 Australian Health Management Plan for Pandemic Influenza, which included border control and social isolation measures.
Which brings us to today
While lessons learned from past pandemics are with us today, we’ve seen changes to policy mid-pandemic. March saw the formation of the National Cabinet to endorse and coordinate actions across the nation.
Uncertainty over border control continues, especially surrounding the potential for cruise and live-export ships to import coronavirus infections.
In a remarkable coincidence, the first media reports about Spanish flu and COVID-19 in Australia both occurred on January 25 – exactly 101 years apart.
This is not the only similarity between the two pandemics.
Although history does not repeat, it rhymes. The story of how Australia – and particular the NSW government – handled Spanish flu in 1919 provides some clues about how COVID-19 might play out here in 2020.
Spanish flu arrives
Australia’s first case of Spanish flu was likely admitted to hospital in Melbourne on January 9 1919, though it was not diagnosed as such at the time. Ten days later, there were 50 to 100 cases.
Commonwealth and Victorian health authorities initially believed the outbreak was a local variety of influenza prevalent in late 1918.
Consequently, Victoria delayed until January 28 notifying the Commonwealth, as required by a 1918 federal-state agreement designed to coordinate state responses.
Meanwhile, travellers from Melbourne had carried the disease to NSW. On January 25, Sydney’s newspapers reported that a returned soldier from Melbourne was in hospital at Randwick with suspected pneumonic influenza.
Shutdown circa 1919: libraries, theatres, churches close
Acting quickly, in late January, the NSW government ordered “everyone shall wear a mask,” while all libraries, schools, churches, theatres, public halls, and places of indoor public entertainment in metropolitan Sydney were told to close.
It also imposed restrictions on travel from Victoria in breach of the federal-state agreement.
Thereafter, each state went its own way and the Commonwealth, with few powers and little money compared with today, effectively left them to it.
Generally, the restrictions were received with little demur. But inconsistencies led to complaints, especially from churches and the owners of theatres and racecourses.
People were allowed to ride in crowded public transport to thronged beaches. But masked churchgoers, observing physical distancing, were forbidden to assemble outside for worship.
Later, crowds of spectators would be permitted to watch football matches while racecourses were closed.
Spanish flu subsides
Nevertheless, NSW’s prompt and thorough application of restrictions initially proved successful.
During February, Sydney’s hospital admissions were only 139, while total deaths across the state were 15. By contrast, Victoria, which had taken three weeks before introducing more limited restrictions, recorded 489 deaths.
At the end of February, NSW lifted most restrictions.
Even so, the state government did not escape a political attack. The Labor opposition accused it of overreacting and imposing unnecessary economic and social burdens on people. It was particularly critical that the order requiring mask-wearing was not limited to confined spaces, such as public transport.
There was also debate about the usefulness of closing schools, especially in the metropolitan area.
But then it returns
In mid-March, new cases began to rise. Chastened by the criticism of its earlier measures, the government delayed reimposing restrictions until early April, allowing the virus to take hold.
the Ministry fiddled for popularity while the country was threatened with this terrible pestilence.
Sydney’s hospital capacity was exceeded and the state’s death toll for April totalled 1,395. Then the numbers began falling again. After ten weeks the epidemic seemed to have run its course, but as May turned to June, new cases appeared.
After two unsuccessful attempts to defeat the epidemic – at great social and economic cost – the government decided to let it take its course.
It hoped the public by now realised the gravity of the danger and that it should be sufficient to warn them to avoid the chances of infection. The Sydney Morning Herald concurred, declaring
there is a stage at which governmental responsibility for the public health ends.
The second wave’s peak arrived in the first week of July, with 850 deaths across NSW and 2,400 for the month. Sydney’s hospital capacity again was exceeded. Then, as in April, the numbers began to decline. In August the epidemic was officially declared over.
Cases continued intermittently for months, but by October, admissions and deaths were in single figures. Like its predecessor, the second wave lasted ten weeks. But this time the epidemic did not return.
While Victoria had suffered badly early on compared to NSW, in the end, NSW had more deaths than Victoria – about 6,000 compared to 3,500. The NSW government’s decision not to restore restrictions saw the epidemic “burn out”, but at a terrible cost in lives.
That decision did not cause a ripple of objection. At the NSW state elections in March 1920, Spanish flu was not even a campaign issue.
The lessons of 1919
In many ways we have learned the lessons of 1919.
We have better federal-state coordination, sophisticated testing and contact tracing, staged lifting of restrictions and improved knowledge of virology.
But in other ways we have not learned the lessons.
Yet, we are still to face the most difficult question of all.
The Spanish flu demonstrated that a suppression strategy requires rounds of restrictions and relaxations. And that these involve significant social and economic costs.
With the federal and state governments’ current suppression strategies we are already seeing signs of social and economic stress, and this is just round one.
Would Australians today tolerate a “burn out”?
The Spanish flu experience also showed that a “burn out” strategy is costly in lives – nowadays it would be measured in tens of thousands. Would Australians today abide such an outcome as people did in 1919?
It is not as if Australians back then were more trusting of their political leaders than we are today. In fact, in the wake of the wartime split in the Labor Party and shifting political allegiances, respect for political leaders was at a low ebb in Australia.
A more likely explanation is that people then were prepared to tolerate a death toll that Australians today would find unacceptable. People in 1919 were much more familiar with death from infectious diseases.
Also, they had just emerged from a world war in which 60,000 Australians had died. These days the death of a single soldier in combat prompts national mourning.
Yet, in the absence of an effective vaccine, governments may end up facing a “Sophie’s Choice”: is the community willing and able to sustain repeated and costly disruptions in order to defeat this epidemic or, as the NSW cabinet decided in 1919, is it better to let it run its course notwithstanding the cost in lives?
Should people be forced to wear face masks in public? That’s the question facing governments as more countries unwind their lockdowns. Over 30 countries have made masks compulsory in public, including Germany, Austria and Poland. This is despite the science saying masks do little to protect wearers, and only might prevent them from infecting other people.
Nicola Sturgeon, the Scottish first minister, has nonetheless announced new guidelines advising Scots to wear masks for shopping or on public transport, while the UK government is expected to announce a new stance shortly. Meanwhile, US vice president Mike Pence has controversially refused to mask up.
This all has echoes of the great influenza pandemic, aka the Spanish flu, which killed some 50 million people in 1918-20. It’s a great case study in how people will put up with very tough restrictions, so long as they think they have merit.
The great shutdown
In the US, no disease in history led to such intrusive restrictions as the great influenza. These included closures of schools, churches, soda fountains, theatres, movie houses, department stores and barber shops, and regulations on how much space should be allocated to people in indoor public places.
There were fines against coughing, sneezing, spitting, kissing and even talking outdoors – those the Boston Globe called “big talkers”. Special influenza police were hired to round up children playing on street corners and occasionally even in their own backyards.
Restrictions were similarly tough in Canada, Australia and South Africa, though much less so in the UK and continental Europe. Where there were such restrictions, the public accepted it all with few objections. Unlike the long history of cholera, especially in Europe, or the plague in the Indian subcontinent from 1896 to around 1902, no mass violence erupted and blame was rare – even against Spaniards or minorities.
Face masks came closest to being the measure that people most objected to, even though masks were often popular at first. The Oklahoma City Times in October 1918 described an “army of young women war workers” appearing “on crowded street cars and at their desks with their faces muffled in gauze shields”. From the same month, The Ogden Standard reported that “masks are the vogue”, while the Washington Times told of how they were becoming “general” in Detroit.
There was scientific debate from the beginning about whether the masks were effective, but the game began to change after French bacteriologist Charles Nicolle’s discovered in October 1918 that the influenza was much smaller than any other known bacterium.
The news spread rapidly, even in small-town American newspapers. Cartoons were published that read, “like using barbed wire fences to shut out flies”. Yet this was just at the point that mortality rates were ramping up in the western states of the US and Canada. Despite Nicolle’s discovery, various authorities began making masks compulsory. San Francisco was the first major US city to do so in October 1918, continuing on and off over a three-month period.
Alberta in Canada did likewise, and New South Wales, Australia, followed suit when the disease arrived in January 1919 (the state basing its decision on scientific evidence older than Charles Nicolle’s findings). The only American state to make masks mandatory was (briefly) California, while on the east coast and in other countries including the UK they were merely recommended for most people.
Numerous photographs, like the one above, survive of large crowds wearing masks in the months after Nicolle’s discovery. But many had begun to distrust masks, and saw them as a violation of civil liberties. According to a November 1918 front page report from Utah’s Garland City Globe:
The average man wore the mask slung to the back of his neck until he came in sight of a policeman, and most people had holes cut into them to stick their cigars and cigarettes through.
San Francisco saw the creation of the anti-mask league, as well as protests and civil disobedience. People refused to wear masks in public or flaunted wearing them improperly. Some went to prison for not wearing them or refusing to pay fines.
In Tucson, Arizona, a banker insisted on going to jail instead of paying his fine for not masking up. In other western states, judges regularly refused to wear them in courtrooms. In Alberta, “scores” were fined in police courts for not wearing masks. In New South Wales, reports of violations flooded newspapers immediately after masks were made compulsory. Not even stretcher bearers carrying influenza victims followed the rules.
England was different. Masks were only advised as a precautionary measure in large cities, and then only for certain groups, such as influenza nurses in Manchester and Liverpool. Serious questions about efficacy only arose in March 1919, and only within the scientific community. Most British scientists now united against them, with the Lancet calling masks a “dubious remedy”.
These arguments were steadily being bolstered by statistics from the US. The head of California’s state board of health had presented late 1918 findings from San Francisco’s best run hospital showing that 78% of nurses became infected despite their careful wearing of masks.
Physicians and health authorities also presented statistics comparing San Francisco’s mortality rates with nearby San Mateo, Los Angeles and Chicago, none of which had made masks compulsory. Their mortality rates were either “no worse” or less. By the end of the pandemic in 1919, most scientists and health commissions had come to a consensus not unlike ours about the benefits of wearing masks.
Clearly, many of these details are relevant today. It’s telling that a frivolous requirement became such an issue while more severe rules banned things like talking on street corners, kissing your fiancé or attending religious services – even in the heart of America’s Bible belt.
Perhaps there’s something about masks and human impulses that has yet to be studied properly. If mass resistance to the mask should arise in the months to come, it will be interesting to see if new research will produce any useful findings on phobias about covering the face.
In India, during the 1918 influenza pandemic, a staggering 12 to 13 million people died, the vast majority between the months of September and December. According to an eyewitness, “There was none to remove the dead bodies and the jackals made a feast.”
At the time of the pandemic, India had been under British colonial rule for over 150 years. The fortunes of the British colonizers had always been vastly different from those of the Indian people, and nowhere was the split more stark than during the influenza pandemic, as I discovered while researching my Ph.D. on the subject.
The resulting devastation would eventually lead to huge changes in India – and the British Empire.
During the early months of 1918, the virus incubated throughout the American Midwest, eventually making its way east, where it traveled across the Atlantic Ocean with soldiers deploying for WWI.
Introduced into the trenches on Europe’s Western Front, the virus tore through the already weakened troops. As the war approached its conclusion, the virus followed both commercial shipping routes and military transports to infect almost every corner of the globe. It arrived in Mumbai in late May.
When the first wave of the pandemic arrived, it was not particularly deadly. The only notice British officials took of it was its effect on some workers. A report noted, “As the season for cutting grass began … people were so weak as to be unable to do a full day’s work.”
By September, the story began to change. Mumbai was still the center of infection, likely due to its position as a commercial and civic hub. On Sept. 19, an English-language newspaper reported 293 influenza deaths had occurred there, but assured its readers “The worst is now reached.”
Instead, the virus tore through the subcontinent, following trade and postal routes. Catastrophe and death overwhelmed cities and rural villages alike. Indian newspapers reported that crematoria were receiving between 150 to 200 bodies per day. According to one observer, “The burning ghats and burial grounds were literally swamped with corpses; whilst an even greater number awaited removal.”
But influenza did not strike everyone equally. Most British people in India lived in spacious houses with gardens and yards, compared to the lower classes of city-dwelling Indians, who lived in densely populated areas. Many British also employed household staff to care for them – in times of health and sickness – so they were only lightly touched by the pandemic and were largely unconcerned by the chaos sweeping through the country.
In his official correspondence in early December, the Lieutenant Governor of the United Provinces did not even mention influenza, instead noting “Everything is very dry; but I managed to get two hundred couple of snipe so far this season.”
While the pandemic was of little consequence to many British residents of India, the perception was wildly different among the Indian people, who spoke of universal devastation. A letter published in a periodical lamented, “India perhaps never saw such hard times before. There is wailing on all sides. … There is neither village nor town throughout the length and breadth of the country which has not paid a heavy toll.”
Elsewhere, the Sanitary Commissioner of the Punjab noted, “the streets and lanes of cities were littered with dead and dying people … nearly every household was lamenting a death, and everywhere terror and confusion reigned.”
In the end, areas in the north and west of India saw death rates between 4.5% and 6% of their total populations, while the south and east – where the virus arrived slightly later, as it was waning – generally lost between 1.5% and 3%.
Geography wasn’t the only dividing factor, however. In Mumbai, almost seven-and-a-half times as many lower-caste Indians died as compared to their British counterparts – 61.6 per thousand versus 8.3 per thousand.
Among Indians in Mumbai, socioeconomic disparities in addition to race accounted for these differing mortality rates.
The Health Officer for Calcutta remarked on the stark difference in death rates between British and lower-class Indians: “The excessive mortality in Kidderpore appears to be due mainly to the large coolie population, ignorant and poverty-stricken, living under most insanitary conditions in damp, dark, dirty huts. They are a difficult class to deal with.”
Death tolls across India generally hit their peak in October, with a slow tapering into November and December. A high ranking British official wrote in December, “A good winter rain will put everything right and … things will gradually rectify themselves.”
Normalcy, however, did not quite return to India. The spring of 1919 would see the British atrocities at Amritsar and shortly thereafter the launch of Gandhi’s Non-Cooperation Movement. Influenza became one more example of British injustice that spurred Indian people on in their fight for independence. A periodical published by the human rights activist Mahatma Gandhi stated, “In no other civilized country could a government have left things so much undone as did the Government of India did during the prevalence of such a terrible and catastrophic epidemic.”
The long, slow death of the British Empire had begun.
Perhaps one of the greatest public health legacies to have emerged from the 14th century plague pandemic is the concept of “quarantine”, from the Venetian term “quarantena” meaning forty days.
The 14th century Black Death pandemic is thought to have catalysed enormous societal, economic, artistic and cultural reforms in Medieval Europe. It illustrates how infectious disease pandemics can be major turning points in history, with lasting impacts.
For example, widespread death caused labour shortages across feudal society, and often led to higher wages, cheaper land, better living conditions and increased freedoms for the lower class.
Various authorities lost credibility, since they were seen to have failed to protect communities from the overwhelming devastation of plague. People began to openly question long held certainties around societal structure, traditions, and religious orthodoxy.
This prompted fundamental shifts in peoples’ interactions and experience with religion, philosophy, and politics. The Renaissance period, which encouraged humanism and learning, soon followed.
The Black Death also had profound effects on art and literature, which took on more pessimistic and morbid themes. There were vivid depictions of violence and death in Biblical narratives,
still seen in many Christian places of worship across Europe.
How COVID-19 will reshape our culture, and what unexpected influence it will have for generations to come is unknown. There are already clear economic changes arising from this outbreak, as some industries rise, others fall and some businesses seem likely to disappear forever.
COVID-19 may permanently normalise the use of virtual technologies for socialising, business, education, healthcare, religious worship and even government.
2. Spanish influenza (1918)
The 1918 “Spanish Flu” pandemic’s reputation as one of the deadliest in human history is due to a complex interplay between how the virus works, the immune response and the social context in which it spread.
It arose in a world left vulnerable by the preceding four years of World War I. Malnutrition and overcrowding were common.
Around 500 million people were infected – a third of the global population at the time – leading to 50-100 million deaths.
A unique characteristic of infection was its tendency to kill healthy adults between the ages of 20 and 40.
Clearly, our medical and scientific understanding of the ‘flu in 1918 made it difficult to combat. However, public health interventions, including quarantine, the use of face masks and bans on mass gatherings helped limit the spread in some areas, building on prior successes in controlling tuberculosis, cholera and other infectious diseases.
Australia imposed maritime quarantine, requiring all arriving ships to be cleared by Commonwealth Quarantine Officials before disembarkation. That likely delayed and reduced the Spanish flu impact on Australia, and had secondary effects on the other Pacific Islands.
The effect of maritime quarantine was most striking in Western and American Samoa, with the latter enforcing strict quarantine and experiencing no deaths. By contrast, 25% of Western Samoans died, after influenza was introduced by a ship from New Zealand.
In some cities, mass gatherings were banned, and schools, churches, theatres, dance and pool halls closed.
In the United States, cities that committed earlier, longer and more aggressively to social distancing interventions, not only saved lives, but also emerged economically stronger than those that didn’t.
Face masks and hand hygiene were popularised and sometimes enforced in cities.
In San Francisco, a Red Cross-led public education campaign was combined with mandatory mask-wearing outside the home.
This was tightly enforced in some jurisdictions by police officers issuing fines, and at times using weapons.
3. HIV/AIDS (20th century)
The first reported cases of HIV/AIDS in the Western world emerged in 1981.
Since then, around 75 million people have become infected with HIV, and about 32 million people have died.
Many readers may remember how baffling and frightening the HIV/AIDs pandemic was in the early days (and still is in many parts of the developing world).
We now understand that people living with HIV infection who are on treatment are far less likely to develop serious complications.
These treatments, known as antiretrovirals stop HIV from replicating. This can lead to an “undetectable viral load” in a person’s blood. Evidence shows that people with an undetectable viral load can’t pass the virus on to others during sex.
Condoms and PrEP (short for “pre-exposure prophylaxis,” where people take an oral antiretroviral pill once a day), can be used by people who don’t have HIV infection to reduce the risk of acquiring the virus.
Unfortunately, there are currently no proven antivirals available for the prevention or treatment of COVID-19, though research is ongoing.
The HIV pandemic taught us about the value of a well-designed public health campaign, and the importance of contact tracing. Broad testing in appropriate people is fundamental to this, to understand the extent of infection in the community and allow appropriately targeted individual and population-level interventions.
It also demonstrated that words and stigma matter; people need to feel they can test safely and be supported, rather than ostracised. Stigmatising language can fuel misconceptions, discrimination and discourage testing.
4. Severe Acute Respiratory Syndrome (SARS) (2002-2003)
The current pandemic is the third coronavirus outbreak in the past two decades.
The first was in 2002, when SARS emerged from horseshoe bats in China and spread to at least 29 countries around the world, causing 8,098 cases and 774 deaths.
SARS was finally contained in July, 2003. SARS-CoV-2, however, appears much more easily spread than the original SARS coronavirus.
To some extent SARS was a practice run for COVID-19. Researchers focused on SARS and MERS (Middle Eastern Respiratory Syndrome, another coronavirus that remains a problem in selected regions), are providing important foundational research for potential vaccines against SARS-CoV-2.
Knowledge gleaned from SARS may also lead to antiviral drugs to treat the current virus.
SARS also emphasised the importance of communication in a pandemic, and the need for frank, honest and timely information sharing.
Certainly, SARS was a catalyst for change in China; the government invested in enhanced surveillance systems, that facilitate the real time collection and communication of infectious diseases and syndromes from emergency departments back to a centralised government database.
Advances in science, information technology and knowledge gained from SARS, allowed us to quickly isolate, sequence and share SARS-CoV-2 data globally. Likewise, important clinical information was distributed early to the medical community.
Few infectious disease researchers were surprised when another coronavirus pandemic broke out. A globalised world, with overcrowded, well connected people and cities, where humans and animals live in close proximity, provides fertile conditions for infectious diseases.
We must be ever prepared for the emergence of another pandemic, and learn the lessons of history to navigate the next threat.