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Smart Treatments In A Pandemic; Lessons From The Black Flu

Surviving the Black Flu

It has been interesting for me to look back and investigate the Black Flu pandemic of 1918. The 1918 pandemic is widely regarded to have been the world's worst pandemic since the Black Death of the late 1340s. (It was commonly known as the 'Spanish Flu', but this is misleading because it most likely began in the United States; this American Flu was brought to Europe by American troops, who helped the allied nations to 'win' World War 1, in part by infecting German troops on the western front. Pandemics are pandemics; it's best not to label them in ways that point blame towards specific others, such as Spanish people. In any pandemic, many mistakes are made by many people; and many good – and often very brave – decisions are also made by many people.) The 1918 pandemic was also called the Black Flu because the often-fatal pneumonia brought about by the virus caused cyanosis, which turned many victims black.

A couple of weeks ago I created a Smithometer chart which suggested that, for two weeks in November 1918, New Zealand had ten times the rate of deaths that it would have had in the absence of that lethal influenza outbreak.

Since then I have been reading Geoffrey Rice's 1988 book, 'Black November'. I was struck by the following two passages (pp.49,50), quoted from the private correspondences of two girls caught up in the Wellington outbreak:

"In our apartment house only the lady owner and two girls aged twelve and eleven (one was me) were still standing, to nurse 13 patients.... We didn't lose a single one, but we heard rumours of whole families dying around us. One evening we two girls went down to Lambton Quay and Willis Street for a gulp of formalin spray and to pick up some lemons from the Town Hall. As we passed houses along the way we twice had to pause while the undertakers brought out the dead in coffins.... Some of our patients turned black all over not brown or blue but a smoky sort of black. Some stayed like that for up to three weeks. Those who could swallow were given water and lemon drinks or beef tea, no food. Those who were unconscious had to be given enemas ... to replace fluids. The doctor came when he could.... I often wonder why our patients all survived when so many better cared for died in hospital. We did no housework, no sterilizing or disinfecting. It was just a matter of getting fluids into them and out of them, with a face and hand wash when we had time. While they were very ill, there wasn't much else we could do for them. It seemed more like plague than 'flu'."

And:

"One by one my five sisters and one brother went to bed, until I was the only one helping mother.... I spent long periods of time at our upstairs window watching the funerals go along Aro Street on their way to Karori. Those funerals gave way to trucks loaded with coffins, and the coffins (for a brief period) gave way to wraps of sacking. I used to count the trucks. Sometimes they just passed one after the other .... My eldest sister Elizabeth, in her first pregnancy, was taken to hospital dying in an effort to save the child. Both lived, but my sister completely lost a thick head of hair – was quite bald – and all her toe and finger-nails. My mother and father did not contract the disease, and always maintained it was because they took massive doses of quinine each day 'My baby brother died – he was pronounced dead by Dr Gibb – but as the undertaker was carrying him in his arms to the waiting hearse, he looked down on the terribly discoloured little face, and thought he caught a faint sigh. He did too, and our brother was thus saved from being buried alive."

These are survivors' stories; stories of houses with desperately ill people who survived while people in other places were dying in large numbers. These important stories have only surfaced through the private reminiscences of modest people who would not have been witnesses to official inquiries. It wasn't money that allowed these people to survive; it was doing the basics, and retaining hope.

In the first story, a combination of Vitamin C and fluids helped people who were desperately ill to survive, when people in the hospitals were succumbing. Hospital environments may in many cases have contributed to the deaths; some people in hospitals may not have been getting Vitamin C and fluids. The emphasis in hospitals on the cleaning of surfaces – sterilizing and disinfecting – may not in fact have made much difference to patient outcomes.

In the second story, not only did everyone survive, but the parents did not even get a disease that had severely affected other people in their communities with the same demographics. The parents used intelligent self-medication. They did not see quinine as a panacea. But they did see it as low risk, likely to reduce their chance of contracting the 'black flu', and likely to reduce the severity of the illness if they did get it.

The principal public health clinical measure used in 1918 was the use of 'inhalation chambers'. These were used to internally disinfect people with zinc sulphate. From 'Black November' (pp.97-98):

"At Milton … both local doctors strongly opposed the inhalation method.... The avoidance of the inhalation chamber may have been a contributing factor to Milton's low infection rate and low death toll."

With hindsight, all health emergencies have included treatments that have hindered and treatments that have helped. Finding out as soon as possible which ones are which is all important. That knowledge enables societies to be able to adopt smart treatments; to know what does work and what does not, so that public health measures can be no more costly than necessary. Smart treatments apply to prevention of infection, facilitating recovery from infection, prevention of economic turmoil, and minimisation of the loss of liberty.

One important type of restrictive treatment is quarantine, and its cousin, physical distancing. Both were used, successfully, to varying extents in 1918 and 1919. Australia applied strict quarantines, and faced a much less severe flu epidemic, in 1919 rather than 1918. American Samoa had a quarantine, and had zero cases. Western Samoa, controlled by New Zealand, had among the world's most severe outbreaks of the Black Flu. Coromandel town had no cases, thanks to an effective quarantine. Generally, these barrier measures were lifted promptly when no longer required.

In New Zealand, Māori experienced double the mortality from Black Flu, compared to Pakeha, for a variety of reasons; one being to less immunity acquired from a prior but similar strain few months earlier. But the Māori from Te Araroa escaped 'the flu' entirely (ref. Rice p.96):

"At Te Araroa, near East Cape, the locals set up a road block guarded by men armed with shotguns to make sure nobody went out or came in."

The Black Flu was only similar to Covid19 in that both were viral, both led to pneumonia, and both were highly infectious. Today, we cannot learn precise lessons from 1918. But we can learn from the kind of mistakes that were made then, and we can learn that the most effective treatments – medical and social treatments – are not necessarily those involving the latest medical technology. Local initiatives could make a huge difference, for the better.

Low Tech 'Treatments' for Covid19

A 'treatment' is an intervention, be it a clinical intervention or a public policy intervention. The best treatments are those that give plenty of 'bang' (ie are effective) for relatively little 'buck' (ie no more costly than necessary).

I was stuck by this story Senegal's $1 COVID-19 test kit from Al Jazeera's 'Counting the Cost' a couple of weeks ago.

Senegal is a proud and innovative West African country. It's had its past tragedies – the North Atlantic slave trade, European colonisation, World War 1 losses at Gallipoli, the ebola epidemic in 2014.

Senegalese troops fought alongside New Zealand troops at the disastrous Second Battle of Krithia on 8 May 1915. New Zealand troops were British reinforcements; Senegal's finest were France's reinforcements. It was a battle with huge allied casualties that went under the radar of our WW1 memory.

Countries like New Zealand tend not to look at countries like Senegal for modern solutions to modern problems, despite some shared history. For the most part ethnic Europeans have a condescending pity towards Africa, in line with the first-world narrative that the whole African continent is impoverished, dangerous and (implicitly) pathetic.

While Senegal has had quite a few new cases of Covid19 since the cited story (though its case rate and death rate remain much lower than New Zealand's), it still seems that Covid19 is well under control there, thanks to cheap low technology testing and tracing. We can learn from Senegal, which is using smart solutions to deal with Covid19. Indeed, Africa is by and large finding its own solutions to Covid19. All the evidence so far suggests that Africa will end up the continent least affected by Covid19 illness.

Chile has also developed cheap low technology sniff testing (Al Jazeera news today). Low tech tests are not necessarily low quality or unsophisticated. They may not be perfect (just as high technology methods are not perfect), but they are easily done and can be done repeatedly, as a way to check the spread (or non-spread) of Covid19, and can give the necessary information very quickly when new outbreaks occur.

The first-world can learn much from poorer countries, if only it deigns to look.

Targeted Restrictions

The best treatments are smart treatments, not costly treatments. Restrictions on our freedoms are policy treatments.

People all over the world have faced severe restrictions, all over the world, these past two months. Most have been necessary, in light of our substantial ignorance about the problem we are facing. We need to know, with urgency, which of those restrictions have been important, and which have not. Just as we need to know which clinical treatments are effective, and which ones are not.

We are already learning much about the infection cycle of Covid19, and about the demographics of which people are most at risk of being infected, and most at risk of becoming critically ill or worse.

We need to do more to understand which environments are substantially safe, and which are not. Aeroplanes may be safe, but airports not. Cruise ships are not safe. Relatively open food halls may be safe, while enclosed restaurants may not be. Outdoor spaces may be much safer than indoor spaces. Ventilation using windows may be safer than spaces with minimal indoor-outdoor flow.

Are indoor spaces like modern offices among the most dangerous of environments? Could the single most effective public health treatment be to substantially reduce the density of workers in these spaces, in large part by having such people work from home? This one measure may mean we no longer need to have blanket physical distancing imposed on us.

Further, by attempting to minimise our exposure to a single virus, we may also be substantially underexposing ourselves to the microbes in the environment that fine-tune our immune systems. In particular, over-the-top disinfecting may be setting ourselves (and especially our children) up for other major public health crises in the future. We cannot expect to be able to vaccinate ourselves against everything. Past pandemics have been more lethal when people have less life-acquired immunity. Senegalese (and other African) 'labourers' in America's past were so effective because they were relatively immune to the diseases that Europeans brought to America; diseases that killed so many native Americans.

In the coming long tail of Covid19, we need smart policies that maximise the protection from immediate threats, while minimising the losses to our freedoms. We need to live good socially enriched lives, without losing the incidental freedom to expose ourselves to nature, dirt and all.

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