HISTORY AND PUBLIC HEALTH. Two pandemics, 100 years apart: Lessons unlearned

* The influenza pandemic — the Spanish flu in popular imagination — launched itself in short, deadly spurts between 1918 and 1920 and claimed “close to or upwards of 20 million lives” in colonial India

* The crisis — then and now — overwhelmed the government, forcing civil society to step in

* Managing a pandemic, Laura Spinney observes, is a marathon, not a sprint

* “If only we had paid more attention to the 1918 pattern … it is amazing how closely the Covid-19 pattern resembles the 1918 one”

* States could learn from the successes and failures of each other while battling the same pandemic

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“The hospitals were choked so that it was impossible to remove the dead quickly enough to make room for the dying; the streets and lanes of the cities were littered with dead and dying people… the burning ghats and burial grounds were literally swamped with corpses, whilst an even greater number awaited removal; the depleted medical staff, itself sorely stricken by the epidemic, was incapable of dealing with more than a minute fraction of the sickness requiring attention; nearly every household was lamenting a death, and everywhere terror and confusion reigned.”

The litany of losses does not refer to the cruel Indian summer of 2021. It could have, though. The devastation of the ongoing second wave of the Covid-19 pandemic — desperate pleas for life-saving oxygen and critical care, tapering queues at crematoriums and burial grounds, abandoned bodies floating on the Ganga hastily buried on its banks, and an overwhelmed medical staff on the brink — puts F Norman White’s words well within the bounds of people’s imagination.

White was the sanitary commissioner in British India and excerpts from his A Preliminary Report on the Influenza Pandemic of 1918 in India are cited by author Chinmay Tumbe in his book The Age of Pandemics published late last year.

Tumbe’s book is without doubt one for the times, but appears prescient when read against the backdrop of the rampaging second wave of Covid-19. An assistant professor of Economics at the Indian Institute of Management, Ahmedabad, Tumbe anchors the discourse around the current pandemic by studying mass infections that hit the subcontinent in the 19th and early 20th centuries. The influenza pandemic — the Spanish flu in popular imagination — launched itself in short, deadly spurts between 1918 and 1920, and according to Tumbe’s research claimed “close to or over 20 million” lives in colonial India. Newer estimates place the death toll of the influenza worldwide between 50 million and 100 million. It erased 6.4 per cent of the population of India at the time, making it one of the deadliest health calamities in recent history.

Ever since the Covid-19 pandemic hit the subcontinent early last year, the novel coronavirus has peaked and ebbed to claim over 300,000 lives in India so far. And it still rages. The month of May has been the harshest so far, often registering a daily death toll of over 4,000. India has battled one of its worst health crises since Independence in the past two months.

The two pandemics — hundred years apart and separated by giant leaps in science and medicine, and altered economic and political statuses — are strikingly similar in the annihilation it left in its wake. However, the influenza pandemic of 1918, a black box of lessons and warnings for contemporary times, has remained a footnote in history. It is the year World War I ended, and little in comparison is said of the pandemic which killed more people than the Great War.

Spectre of death

“A similarity between what we experienced 100 years ago and what we are seeing now is that it was left entirely to the people to take care of themselves,” points out Chandrakant Lahariya, New Delhi-based epidemiologist, public policy and health systems expert.

While the influenza pandemic raged in a British colony, in the intervening century India has transitioned to an independent, democratic country. “We now elect our governments. When people face challenges, the government should be able to support them. In this pandemic, people were left to fend for themselves, be it for medicine, oxygen or even securing vaccines,” Lahariya says.

The hundred years in between ushered in significant changes in medical and scientific understanding. Differences between then and now are substantial: In 1918, the virus which caused the influenza was not identified; laboratory tests were not prevalent and neither were vaccines, he adds. Biological markers such as CT scans were not available. In 2020, most of those boxes are ticked.

“Despite the medical advances, we’re struggling to fight the disease,” laments Lahariya, co-author of Till We Win: India’s Fight Against the Covid-19 Pandemic .

Tumbe concurs. The crisis — then and now — overwhelmed governments, forcing civil society to step in. Social media transformed into a facilitator during Covid-19, patients and their caretakers found leads to hospital beds and oxygen concentrators online. A century ago, people sought help elsewhere.

“During my research, I came across ‘Letters to the Editor’ in which people wrote in requesting the social service team to visit their district. They were bypassing the government, and asking for help locally,” Tumbe says.

The Covid-19 pandemic has turned Facebook posts, Twitter threads and WhatsApp forwards into a timeline of unfolding health crises and virtual obituaries. However, personal accounts on the 1918 influenza are few. A poignant and oft-cited one is the memoir of Hindi poet Suryakant Tripathi ‘Nirala’. The poet lost his wife and one-year-old daughter to the pandemic. The spiral of death wiped out much of his extended family and farmhands.

Pall of gloom: Bodies buried on the banks of the Ganga in the wake of a deadly second wave of Covid-19

“In whichever direction I turned, I saw darkness,” he writes in A Life Misspent , translated into English by Satti Khanna. He buries his cousin’s dead daughter on the banks of the Ganga. Soon, his uncle succumbs: “One more corpse to cart to the Ganga.”

A telegram intimating him of his wife’s illness had brought the poet to Dalmau in Uttar Pradesh. “I travelled to the riverbank in Dalmau and waited. The Ganga was swollen with dead bodies,” he observes.

Nirala’s woes find mention in Paris-based British journalist and science writer Laura Spinney’s article and book Pale Rider: The Spanish flu of 1918 and how it changed the world . “The imagery is shockingly similar at the moment. ‘Nirala’ could be speaking of today,” Spinney tells BL ink .

Familial loses were widespread. MK Gandhi, for instance, lost his daughter-in-law and grandson to the pandemic. Both Spinney and Tumbe put forward the argument that the pandemic played a part in consolidating Gandhi’s stature as a mass leader.

“Grassroot networks were mobilised during the pandemic. It is interesting to see how pandemics affect social movements that are underway,” Spinney says. Gandhi really came to the fore in 1918-19, adds Tumbe. The massacre of Jallianwala Bagh in 1919 was the tipping point, but the seeds of discontent could have been sown earlier, by the pandemic that killed millions.

Influenza of 1918

The influenza pandemic hit India in two predominant waves. The first was between April and June, 1918, and the deadlier second wave between August and December that year. World War I had just ended. Indian troops were returning home. Parts of India were battling drought.

“It really exploded in India in the middle of September. The entire wave just takes a month or so, but in that one month it could take millions of lives back then,” Tumbe says.

The pandemic decimated the Indian population, though the British rulers largely remained inured to it. “The best way to characterise the official British response to the 1918 pandemic in India is disorganised at best, negligent at worst, and in either case entirely focused on the wrong problem,” points out Maura Chhun, faculty at the department of History at the Metropolitan State University in Minnesota, US.

Chhun’s doctoral thesis studies the influenza pandemic in India and the official British response to it. The monsoons had failed that summer, and the British were bracing for a famine. The feared “massive, widespread starvation” did not happen, but prices of essentials shot up, leaving the vulnerable malnourished when the deadly virus struck.

“Many British doctors noted a clear link between malnutrition and high death rates from influenza. This did not stop British officials from claiming victory in the case of the famine, however,” Chhun says.

The pandemic spurred little discussion among the high-ranking British officials, she notes. They were focused on the impending famine or the war in Europe. While the British doctors in India wrote in contemporary journals about treatments, theories and even vaccines, it did not evolve into a coherent public health response. The crisis, Chhun says, hardly pushed forward any meaningful ramp up of the health system.

“The death rates for Europeans in India were relatively low overall, so to most of them it was almost certainly a distant problem,” she observes.

Lessons for future

The deadliest health crisis in 20th century India, however, quietly disappeared from public memory. “There appears to be something about pandemics that makes them forgettable,” Spinney notes.

A revisit, though, to the forgotten chapter was necessitated by the novel coronavirus. And in that experience, author Tumbe points out, lie clues that should have aided in managing the current crisis better. He talks of the complacency that had set in after the first wave of Covid-19 in India. The lull that followed should instead have set off alarm bells.

“Be it cholera, plague and influenza, no pandemic has just come and gone. It has stayed for a few years and the first lesson from the flu of 1918 is that it comes in waves. India experienced two waves; the first was mild,” he says.

The argument that a second Coivid-19 wave could not have been anticipated doesn’t hold. “History lesson out there says it could be,” he adds.

Pandemics hit in waves, and they could be steep, sudden and devastating, throwing life out of gear — another takeaway from 1918. Tumbe draws a parallel between the second waves of the influenza and Covid-19. “The 1918 experience tells you that between the first and second wave things can go completely haywire and very quickly, within a week cases can shoot up exponentially. If only we had paid more attention to the 1918 pattern … it is amazing how closely the Covid-19 pattern resembles the 1918 one.”

The influenza pandemic had devastated rural India. Though Covid-19, in its early days, was largely dubbed an urban illness, it changed with the second wave when the virus made deep inroads into the countryside. Health infrastructure in rural areas is typically weaker.

“The 1918 experience showed us that if a pandemic really gets to rural India, then you’re gone. You don’t know the extent of the crisis at the tehsil and district levels,” Tumbe notes. After a virus works itself into the rural landscape, discerning its impact takes longer. “We will get to know in a few years the toll of this pandemic and a huge chunk of that is going to be rural India… The numbers are not showing that yet,” warns Tumbe.

The death toll of the influenza pandemic left deep economic scars too. The peak mortality was in the age group of 20-40 years, which wiped out a considerable part of the workforce.

“India’s biggest supply shock was in 1918. GDP growth was minus 10 per cent, and inflation at about 30 per cent per annum. India was an agrarian economy at the time; prices went up partly because of the drought and partly as there were nobody to work the fields,” Tumbe observes.

However, the impact of Covid-19 on the economy may be muted, he believes. “There will be some inflationary pressures. Farmers may be affected in two ways: One, a direct impact of deaths means a part of the labour force vanishes. Secondly, they will stay out of the labour force to grieve.”

Covid-19 missteps

Epidemiologist Lahariya narrows down the sheer scale of Covid-19 infections in India to people’s refusal to learn from 1918 and other epidemics. “If we had, the outcomes would have been very different.” Countries that have learned from the past have worked to strengthen their public healthcare systems, he notes.

Primary care: Only a robust public healthcare system can fight a pandemic, experts stress

Fighting a pandemic is impossible without a robust public healthcare system, the experts stress. Lahariya draws attention to Nobel Prize-winning economist Angus Deaton’s The Great Escape where he analyses the economic and social development of European countries against the backdrop of their investment in health.

“Those countries too have struggled with Covid-19. But their struggles were different from ours. They could manage it,” Lahariya says. The efficacy of India’s future pandemic battles will be dictated by its attention to healthcare. The policy and health expert calls for nodal centres at district levels to track epidemics and pandemics.

Emerging viruses, he adds, are a reality. “This is not the first virus we’ve tackled; we’ve had chikungunya, dengue, Ebola, acute encephalitis syndrome and others. Yet, there isn’t enough investment on public health areas of surveillance, laboratory testing, human resources, or even epidemiology units at the district level. These are basic requirements while tackling diseases,” he points out. States with better public healthcare systems have fared better than those without in the fight against Covid-19, Lahariya observes.

A recent petition filed in the Supreme Court urged that India’s vaccine PSUs, instrumental in keeping epidemics and pandemics in check, be revived. The units were meant to ensure self-sufficiency in vaccine production, but their numbers have drastically dwindled in recent decades.

A new virus is always a challenge. “But the idea of a health service is to minimise its effect. The key difference between India and the other countries is that, in our case, the impact has not been minimised, rather we are under-counting numbers and showing that as a success,” Lahariya adds.

The learning, he stresses, need not be from a pandemic a hundred years ago. States could learn from the successes and failures of each other while battling the same pandemic. “Parts of the country experienced oxygen shortage in April. Yet, weeks later, Goa reports oxygen scarcity and, even deaths, allegedly due to the shortage. It shows that we don’t learn from contemporary challenges even,” he rues.

Way ahead

Author-journalist Spinney has studied the 1918 influenza closely for her book and reported extensively on the ongoing Covid-19 pandemic. She puts the nature of pandemics in perspective. “As soon as the health system is overwhelmed, one gets to see the same phenomena — queues [at hospitals], people developing complications that otherwise could have been avoided, and the problem of disposing of the dead. Once you get to that saturation point, the consequences are, at the general level, predictable.”

Though the imagery of suffering evoked by the two pandemics are similar, Spinney is careful to point out differences. “Even if the three million plus Covid-19 deaths in the world turn out to be an underestimation, as it is most likely to be, we are not in the same ballpark when the dead were between 50-100 million people.”

Spinney believes lessons have been learnt from past experiences and draws attention to the quick responses to Covid-19 world over. The pathogens were identified within weeks of its emergence, sequencing of the genome happened weeks after that, and vaccines rolled before the year was out. “We do learn. Perhaps we could argue that we don’t learn fast enough or completely enough.”

Managing a pandemic, she observes, is a marathon, not a sprint. “Rare is a country that has scored well all along.”

Spinney, however, underscores the parameters by which a country’s response to a pandemic can be judged. Countries that have done well are those which have taken it very seriously from the beginning. “Their efforts have been full scale and absolutely transparent. They shared information and mobilised people at every level in the community. That is clearly the right thing. Where countries have not done that or been slow to react or hidden information then that is criticisable,” she adds.

The novel coronavirus has not run its course as yet. And whenever it is done, a chief takeaway could be keeping the collective memory of it alive. It is the first pandemic to hit after the internet revolution, and there’s a surfeit of pandemic reminders — virtual and elsewhere.

Will that be enough to keep Covid-19 from slipping out of collective consciousness? Or will it go the influenza way, forgotten until the next pandemic?

“Despite the digital footprints we’re leaving behind, it’s completely possible that in 2120, India will see a pandemic the way we have seen this one,” warns Chinmay Tumbe. He suggests systematic documentation of this crisis — books, reports et al — to ensure it doesn’t disappear from collective memory. “We need a non-partisan government committee to look at what happened,” he says.

Historically, Spinney points out, societies have bounced back from a pandemic quicker than, say, a war. “Wars destroy infrastructure as well as people. Pandemics destroy ‘just’ people. People bounce back,” she adds.

But questions remain. “How do we keep ourselves more protected from future pandemics, make health systems more robust and societies less unequal. The pandemic is a reminder to get things right,” Spinney says.

And it begins by not forgetting. “If we were to remember it better,” she adds, “we would be more prepared for the next.”

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