THERE is much talk about the Spanish flu these days, the last pandemic which swept the world the way the coronavirus has today. The former hit the world during the First World War, which allowed it to spread rapidly through a world which was far less connected than the present times in which air travel, until recently, was pervasive. A century earlier, armies that moved across countries, mostly on ships, carried the virus with them. By the time it ended in 1920, it had claimed around 50 million lives, according to some estimates. Lower estimates place the number around 20m.

Unlike the coronavirus, however, the Spanish flu hit the young and healthy more than the elderly. It appears that it disappeared as suddenly as it came. But as the world deals with the coronavirus, much has been written about the Spanish flu recently, which provides for interesting reading. It was not just the death toll or the way it travelled around the world, many of the preventive measures implemented then sound familiar as we struggle to deal with the current pandemic.

Social distancing was in vogue then too. According to one article, ‘Flu in Washington: A Look Back at the 1918 “Spanish Flu” Pandemic’, a city county in the US ordered that “all places of public gathering, such as schools, churches, dances etc” be closed, while a second county leased a building “for the purpose of establishing same as an Isolation Hospital”. Later, gatherings were banned in “all places where any kind of business is transacted... with the exception of drug stores, meat markets, restaurants, eating places, hotels and fruit ware-houses”. People were also ordered to wear masks in all public places — they had to cover their nose and mouth.

And yet it seems that the authorities struggled everywhere with the same issues that confront those in Pakistan and elsewhere. Consider a health report ‘Lessons Learned from the 1918–1919 Influenza Pandemic in Minneapolis and St. Paul, Minnesota’ on how the two neighbouring cities dealt with the crisis. Much of it can be transposed to our environs; it does not seem as if 100 years have passed since: “At one point, Minneapolis’s City Hospital reported that ‘nearly half of the nursing staff has been ill with influenza in the last three weeks’.” Later, the report cites a hospital official: “[the] hospital was caring for about 150 cases, and had about 70 on the waiting list. It had beds available for that waiting number, but not nurses”.

In the wake of the Spanish flu, healthcare for all became the responsibility of states.

But for us in Pakistan, more familiar still will be the disagreement between the health commissioners on a major step: one wanted to close public places (Minneapolis) while the other (St Paul) felt that isolation was the way to go. In the words of the latter, “If you begin to close, where are you going to stop? When are you going to reopen, and what do you accomplish by opening”?

They also disagreed on closure of schools though both cities opted for this decision as the St Paul health official was overruled by political decision-makers. Social distancing was, however, prevalent: passengers were limited in public transport; windows were kept open on buses; work hours were regulated; and the use of lifts was discouraged.

Americans proved no more disciplined than Pakistanis today; schools refused to shut down as they did not want to pay teachers or miss out on fees. Bars and restaurants flaunted orders. One man had to be arrested because he “insisted on taking his child from the city hospital before the patient was ready to be discharged. The mother and father and the child later were found mingling with other persons in the neighbourhood”. Masks were widely distributed as a preventive measure.

Intriguingly, only one of the two cities practised mandatory isolation (St Paul) — influenza cases were to be reported to a physician who told the patients to isolate at home and notify the authorities. But this also led to hesitation in people consulting doctors and making public their illness. They preferred to hide their condition till they became gravely ill.

St Paul was also the one with a lower death rate (645) by around 100, though its reported cases were 4,399 compared to 14,411 in Minneapolis, which did not enforce isolation. However, the rate of fatality compared to the reported cases was higher in St Paul.

But for the authors of the report, the biggest disadvantage was that officials were trying to “conceive and realise” plans during a health crisis. Had the plan been developed beforehand and measures taken in advance, it might have been easier, they argue. As a result, officials were not decisive which in turn did not translate into a single, comprehensive message for the public.

This is perhaps what we are witnessing in places in Europe, the US, and at home too. The more authoritarian East Asian states were able to manage this better especially as the earlier scares such as that of SARS had also improved their preparedness (it is not just about aggressive testing!).

But these important lessons were not forgotten once the Spanish flu ended — such was its devastation that it had a long-lasting impact on public health.

In its wake, healthcare for all became the responsibility of states, and Russia is said to be one of the first to put together a centralised healthcare system. In addition, public health leaders were given more of a say as the objective was to “study the occupational and social conditions which give rise to illness and not only to cure the illness but to suggest ways to prevent it”. And lastly, it led to an international bureau for fighting epidemics in Austria, which in modern times has come forward as the World Health Organisation.

In other words, the millions of lives lost caused a sea change. No wonder then that many now are predicting that the coronavirus too will force a rethink of public health, even the return of the big state — for example, the welfare states in Europe in the recent past — which has been on the retreat for decades now. This perhaps is what we also need to push for in Pakistan. Public health needs a rethink, and the coronavirus should force those ruling us to work on this once the immediate crisis is over.

The writer is a journalist.

Published in Dawn, March 24th, 2020