Learning (or failing to learn) from the lessons of the 1918 Spanish Flu

The Spanish Flu is estimated to have killed between 21.5 and 50 million people worldwide. This image from the US National Museum of Health and Medicine.

 

On 23 March, President Joko “Jokowi” Widodo said that the government would begin using the 2018 Asian Games athletes’ village as an emergency hospital to treat the rapidly increasing number of Indonesians infected with Covid-19. At the time of writing, Indonesia had confirmed 579 cases of the infection, and 49 people had died. The numbers will continue to increase.

 

Long before the Covid-19 pandemic, about a century ago, the world was struck by the 1918 Spanish Flu. Almost no country was spared, including Indonesia, which at that time was still known as the Dutch East Indies.

 

Experts say about 21.5 to 50 million people were killed as a result of the Spanish Flu. Historian Colin Brown has estimated that at least 1.5 million of these were in the Dutch East Indies. The large number of deaths was caused by a slow government response, ineffective health policy and the impact of irresponsible parties who sought to take advantage of the situation. Sound familiar?

 

The 1918 Spanish Flu occurred in two waves in the Dutch East Indies. The first wave occurred from June to September 1918, with the first reported case in Pangkatan port, North Sumatra, in June 1918. Experts now suspect that the source of the virus was labourers from Singapore who came to work at plantations in Sumatra. In just a few weeks, the Spanish Flu had reached Tanjung Pandan (Belitung) and Waltevreden (Batavia). In June alone, the virus is estimated to have infected 5 per cent of the total population of Surabaya.

 

The second, larger wave occurred from October to December 1918. The virus spread further east and even remained in a few areas until January 1919. In a short period, the virus had spread to almost all of the Dutch East Indies. The 1920 report of the colonial Department of Health (Burgerlijken Geneeskundigen Dienst, BGD) mentioned that almost no region in the Dutch East Indies escaped the pandemic.

Slow response

When it first emerged, the Spanish Flu was considered by the colonial government to be nothing more than an ordinary flu. The BGD seemed to await the arrival of the disease passively, even though advances in communication available at the time meant it surely knew that the pandemic had already killed millions in Europe and the United States.

 

One doctor in Batavia even said that the Spanish Flu was far milder than regular flu, a statement that was widely published in East Indies newspapers. The aim was simple, to safeguard security and order in the colony. With the First World War raging, many countries, including the Netherlands, were desperate to hide their weaknesses.

 

Early on, the BGD considered the Spanish Flu to be a version of cholera. Following the BGD’s recommendation, a mass cholera vaccination campaign was implemented across the Dutch East Indies. But of course this misguided policy did nothing to resolve the problem. Thousands more continued to be affected, and the death rate continued to climb.

 

Low levels of literacy and awareness of health care practices meant that much of the public saw the pandemic as a curse or a punishment from God. This was amplified by the fact that there was no vaccine or medication that could be used to treat the Spanish Flu. Accordingly, many people chose to manage the illness with strategies that were often far from medical best practice, even for the time.

 

In Solo, for example, the population burned incense and flowers while reciting the name “Sunan Lepen” (a local ‘saint’, one of the early Muslim figures credited with introducing Islam to Java), and followed this up by drinking young coconut juice. The ritual was thought to strengthen immunity against Spanish Flu and other diseases. Unsurprisingly, the impact was minimal. In a few weeks, the death toll in Solo continued to climb.

 

Meanwhile, in Kudus (Central Java) and Medan (North Sumatra), hundreds of ethnic Chinese held cultural processions to ward off the spread of the virus. In Medan, this sparked minor clashes with residents who claimed they were annoyed about participants’ use of road space. The Kudus procession had an even worse outcome. Crowds hurled insults at the ethnic Chinese participants, and clashes soon broke out. Ethnic Chinese-owned buildings were burned and dozens of ethnic Chinese were killed. The incident is now known as the Kudus Riots.

 

As the number of victims continued to climb, demand for coffins also increased. Coffin-makers took advantage of the situation and began price gouging. They also started producing coffins in large sizes only, because they were more profitable. Doctors, too, began markedly scaling up their fees.

 

Hospitals and clinics were full of patients. Many were rejected because of lack of available bed spaces. Doctors were confused about what to do because they had never faced anything like it before. They struggled to treat the illness with the drugs they had on hand, like quinine and asprin.

 

The shortage of doctors in the Dutch East Indies forced the colonial government to send student doctors from the Stovia medical school to regional areas to cover the gaps. According to the Koloniaal Weekblad (Colonial Weekly Magazine) (1919) each doctor was handling an average of 800 patients during this crisis phase.

The role of the media  

Some Indies newspapers made efforts to report on the situation objectively, regardless of their own political persuasion. But there were many others that inflamed the situation by publishing rumours and hearsay. De Sumatra Post urged all newspapers in the Dutch East Indies to routinely publish articles informing the public how to prevent and manage the illness. The Bataviaasch Nieuwsblad, Bromartani and Oetoesan Hindia published several articles about herbal remedies to treat the flu. The spike in the use of herbal remedies was no doubt connected to the fact that the BGD had no idea how to manage the disease.

 

Two advertisements for “anti-influenza” medication in the Sin Po daily. The newspaper also published information on the clinical signs of the illness. Sin Po, 28 October 1918 and 30 October 1918.

 

At the time of the outbreak, newspapers played an important role in disseminating new information that authorities had tried to withhold. Karel Zaalberg, the editor of Bataviaasch Nieuwsblad, wrote that the government had not acted quickly enough to respond to the outbreak and had attempted to cover up the facts. Meanwhile, Pewarta Soerabaia said that BGD had no concrete solution for the outbreak and didn’t appear to be doing anything to get on top of the disease spread.

 

Responding to this criticism, rather than acknowledging its shortcomings, the colonial government instead blamed the poor hygiene practices of the indigenous population. According to the government, malnutrition, unhealthy lifestyles and a reluctance to use western medicine made the indigenous population particularly susceptible to disease. The unusual clinical signs of Spanish Flu, which was also often accompanied by pneumonia, added to the BGD’s confusion about the correct medical steps that should have been taken to respond to the disease.

 

At a meeting at the Volksraad (People’s Council), only Dr Abdoel Rivai criticised the government’s slow response. He spoke of how people were dying like rats (nog sterft als ratten) because of the sluggish government response. Abdoel mentioned that the death rate in the East Indies, especially in Java, had spiked. It was not acceptable, he said, that 900,000 people had died in the Dutch East Indies in the four months from August to November 1918.

 

Abdoel pointed to Pasuruan, where from 1-14 November 1918, some 5,187 people died, compared to just 496 in the same period the year before. At the same time, he said, many poor patients were not able to access medicines from government pharmacies, due to a lack of supply or expense. Abdoel suggested the colonial government look to the governments of Ceylon (Sri Lanka) and the Straits Settlements (Penang, Malaka and Singapore) which had managed to handle the Spanish Flu in their regions.

Too little, too late

The BGD made its first serious efforts toward tackling the Spanish Flu on 16 November 1918 by forming an “Influenza Commission”, consisting largely of prominent Dutch physicians and researchers. The commission aimed to investigate the illness and provide recommendations for managing the outbreak. In May 1919, the commission provided a list of seven recommendations, one of which was to publish pamphlets and posters in local languages to be distributed to villages across the East Indies.

 

In 1920, the colonial government published two guidebooks on prevention and management of influenza, “Lelara Influenza” and “Awas! Penyakit Influenza”. The first book was written in informal Javanese (ngoko), with the wayang clowns punokawan as the main characters. The second was written in low Malay and was accompanied by attractive illustrations. With their light and engaging language, the books attracted many readers.

 

Cover and contents of Lelara Influenza, published by the Bureau of Literature (Balai Poestaka) in 1920.

 

On 20 October 1920, the colonial government also issued the Influenza Ordinance (Influenza Ordonnantie) which regulated the entry and exit of ships in East Indies ports, as well as the steps to be taken if a person was suspected of contracting Spanish Flu. But by the time both books and the legislation had been released, the Spanish Flu had already begun to recede. Meanwhile, some 1.5 million people had died in the preceding two years.

 

The Dutch East Indies government failed to respond adequately to the 1918 Spanish Flu. It made almost no efforts at prevention, even though newspapers had been warning of the pandemic from July 1918. The outcome of this lack of preparedness was clear. When the Spanish Flu attacked the Indies, the government didn’t know how to respond.

 

The colonial government’s failures in 1918-1919 are important lessons for the Indonesian government as it faces the rapidly escalating threats of Covid-19. Sadly, it looks to have made many of the same mistakes that the colonial government made some 100 years ago.

 

 

This article was first published in Bahasa Indonesia in Kompas daily on 21 March 2020 as “Belajar Dari Pandemi Flu Spanyol 1918”, and has been republished with permission of the Kompas editorial team as part of efforts to prevent further spread of Covid-19.

 

Ravando Lie is a PhD candidate in the School of Historical and Philosophical Studies at the University of Melbourne. His thesis examines a Chinese-Indonesian newspaper called Sin Po (1910-1965) as a lens to explore the political movements and transnational connections of Chinese-Indonesian society in the Dutch East Indies.