Fear, Flight, Frustration and Dedicated Service: A Brief History of International Disease Control Activities, 1918-2008

MacDougall, Heather, Forum on Public Policy: A Journal of the Oxford Round Table

Introduction

What role does studying the history of epidemics play in enhancing our understanding of nations and empires? Similarly, how do health threats fit in traditional diplomatic history or policy making? Is health security a national or an international priority? And in the 21st century with its opportunities for the rapid transmission of communicable diseases will the agencies and approaches that were so slowly crafted during preceding centuries continue to suffice? Will nation states willingly participate in supranational efforts to stem the tide of disease? And even if they do, does humanity have the capacity to meet the challenge posed by ever-mutating microorganisms?

To answer these questions, a comparative review of the 1918-1919 flu pandemic and the 2003 SARS epidemic will be used to demonstrate the many factors which influence nations as they grapple with severe outbreaks of infectious disease. In general as many historians have argued, local and national responses to epidemics from the Black Death to the present reflect existing scientific knowledge, cultural beliefs and practices and the power of the state to impose preventive or curative measures such as quarantine or isolation. (1) But were influenza and SARS imported or endemic? Should nations regard them with the same fear that was felt for cholera, plague and yellow fever in preceding centuries? What best practices would ensure that limited human and institutional resources were used to greatest effect since the 1918-19 pandemic coincided with the final months of the First World War while SARS was coterminous with the war in Iraq?

The similarities and difference between the two outbreaks reveal the importance of historical understanding of local, national and regional approaches to controlling communicable disease in a global context. Although efforts to establish international regulations had occurred prior to 1914, the First World War effectively prevented cooperation among the combatants. As a result, each nation or colony had to rely on local laws and existing health personnel for action to contain the outbreak and care for sufferers and their families. In contrast, the SARS epidemic occurred in a world linked through air travel and the Internet which enabled the World Health Organization (WHO) to take a leadership role on behalf of its 193 members to assist those countries who were suffering disease outbreaks. What changes in international diplomacy, biomedical knowledge and public attitudes had occurred to legitimize global action against a communicable disease? Does this portend a new definition of global health as a public good that must be available to all? By comparing and contrasting the international dimensions of the 19181919 influenza pandemic with the SARS outbreak in 2003, we will see how various nations and their peoples responded to the challenge of controlling communicable disease and the impact of these experiences on biomedical science, national health systems and international order. Starting first with the influenza pandemic, we will then examine the contested interwar attempts to create effective disease monitoring and control efforts, the discovery of the flu virus and its frightening ability to mutate, the creation and disease fighting function of the World Health Organization, and end with a discussion of the SARS outbreak and the way that it has affected global health.

Pandemic Influenza, 1918-1919

The historiography of the 1918-19 pandemic focuses on national, regional and local responses to the disease, the scientific challenges which it posed, the difficulty of determining the worldwide death toll and the surprising absence of discussions of the outbreak's impact on the peace talks in 1919, and in long term collective memory. (2) To date little attention has been paid to its role as a catalyst for the expansion of international sanitary regulations during the 1920s beyond the limited group of European and American nations who had formed organizations such as the Pan American Sanitary Bureau (1902) and the Office international d'hygiene publique (1907). (3) In part this is likely due to the overwhelming nature of the crisis and the inability of states and the medical profession to determine whether the policies and practices which had evolved during the 19th century and been codified into the Sanitary Convention of 1912 were applicable to a disease such as influenza. The war was also a significant factor because trade and migration were disrupted and the sanitary regulations had been designed primarily to facilitate trade and to protect western nations from the threat of imported 'Asiatic' diseases such as cholera and plague. (4) As the discussion of the pandemic will illustrate, influenza in the fall of 1918 challenged all the experience and standard disease control measures which both military and civilian authorities around the world had traditionally used to combat outbreaks.

As John Barry and Carol Byerly indicate in their respective studies, influenza emerged in American military camps in Kansas in spring 1918. (5) Although the outbreak was generally mild, some victims suffered from a pneumonic form which turned their extremities blue (cyanosis) and produced massive nose bleeds and other hemorrhages. When this phase of the outbreak subsided, there had not been much spread of the flu to the civilian population in the US but overseas, Allied troops and their enemies all began to suffer from the disease. During the summer of 1918, the virus increased in virulence and during the fall explosive outbreaks occurred in military camps in North America and overseas and quickly spread to the adjacent population. Beginning at Camp Devens outside Boston, the epidemic moved down the eastern seaboard to New York, Philadelphia and Washington before turning inland and moving north into Canada, (6) south to Texas and west through Chicago all the way to California. The disease struck so swiftly that available hospital space and health care personnel were overwhelmed. The military searched desperately for nurses, doctors, and orderlies while using the healthy and survivors for the grim task of attempting to bury the dead. (7) In major cities, local health departments were expected to control outbreaks of disease and they responded by implementing existing laws regarding quarantine and isolation, recommending that people wear gauze masks and avoid crowds, and in some instances closing schools, churches, theatres and other public gathering places, shortening hours of opening for businesses and urging the public to volunteer to help the ill. As the disease proved more and more deadly, local, state and provincial authorities created temporary hospitals, and used voluntary groups to prepare food in soup kitchens, deliver supplies to stricken households, drive the limited number of civilian doctors and nurses from patient to patient, and to raise funds for the poor and wage workers who were unable to work while they were ill. (8) Many also turned to groups such as their national Red Cross Societies for assistance and these non-governmental agencies responded although much of their attention was focused on suffering soldiers.

To countries immersed in total war, the influenza pandemic was an additional blow because not only did it affect recruitment and training but it also had a severe impact on war industries and the provision of food and other supplies for combatants and their allies. As the disease spread throughout the world, carried by troop ships taking casualties home or bringing new recruits to the western front, Africa and the Pacific nations were infected. Like the Europeans and North Americans, the mortality rate was striking. Normally influenza kills the elderly and the young but this pandemic strain showed a marked preference for men and women aged 20-40. The carnage of the war is estimated to have killed nine million but the flu epidemic is now thought to have destroyed 50-100 million people between 1918 and 1920. While acknowledging the sustained underreporting of influenza deaths, Niall Johnson and Juergen Mueller have calculated regional mortality based on material provided by recent scholarship which has broadened our understanding of the impact of the disease. In Africa, the death toll is estimated at 2,375,000 for a mortality rate of 18.20 per 1,000 but this hides the contrast between countries such as Cameroon with a population of 561,000 where 250,000 died as opposed to Kenya which lost 150,000 from a population of 2,596,000. (9) In India 18 million are thought to have perished and in China 4-9.5 million while in Europe, more that 2,300,646 succumbed for a death rate of more than 4.80 per 1000. (10) But as Johnson and Mueller remind us, these figures represent existing records and do not cover all communities. Equally important, since there was no standard nomenclature and agreed upon definition of what constituted a death from influenza, existing statistics may contain deaths from pneumonia and other sequelae or may simply be underreported because health care and military personnel were too …

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Publication information: Article title: Fear, Flight, Frustration and Dedicated Service: A Brief History of International Disease Control Activities, 1918-2008. Contributors: MacDougall, Heather - Author. Journal title: Forum on Public Policy: A Journal of the Oxford Round Table. Publication date: Summer 2008. Page number: Not available. © 2008 Forum on Public Policy. COPYRIGHT 2008 Gale Group.

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