COVID-19: 18 Million Indians died due to Spanish Flu in 1918

Biksham Gujja

After four months of fear, death and destruction of the global economy, there is at least feeling of some respite, just respite. Many countries where the Coronavirus attack impact is most, showed some signs of slow down.  Worldwide infections are over 30 lakhs deaths of over 210,000  as on 28th April.  This figure will go up as days pass by. More than the health and panic, globally close to billion people have lost their livelihood, income and some of them are pushed back into poverty and desperation. Millions of people have stuck outside their home while the rest of the global population stuck in their homes. Nothing ever happened, hopefully, will never occur in future.  India, with a population of 1.3 billion reported less than 30,000 infections and close to 1000 deaths. The virus is kind to India, so far. The Only hope is the history of 1918 should not repeat both globally and in India. 

The Great influenza of 1918.

This is not the first time, it happened in 1918. That is popularly known as Spanish flu, originated in Haskell county of Kansas, the USA  travelled to Europe and all parts of the world with young soldiers in warships. Spain then was neutral to world war and free press, reported extensively, thus the name. It is a Spanish press which extensively and openly reported, thus name and still being known with the same name.

There are many books, reports about 1918-19  influenza/ Spanish flue.  Only now experts and some Governments are taking note of the events a century ago. A book “Very, very very dreadful”, by Albert Marrin mentioned “No country suffered worse than India. An astounding 6.1 percent, or 18.6 million, of its 305.6 million people died of influenza. In other words, India lost twice as many civilians as all soldiers killed during the World War”. Globally, the Spanish flu killed an estimated from 50 to 100 million. China, then with a larger population than India, reported 9.5 million. The US deaths were close to a million.  Influenza did not spare any part of the world including Alaska, causing death and destruction of most of the Eskimo population. The native Americans, Pacific islanders whose immune system of not exposed any virus were decimated.

The 1918 Pandemic has remarkable similarities with the current situation in many ways. To mention three a) There was no cure or Vaccine then and now b) lack of coordination between the countries same then and now c) first panic and declaration of a quick victory. The last point is extremely important at the time, a lot of Governments, Including India, are under pressure to re-open and restart the economy. It is better to look at the events then to learn some lessons. By June  1918, the death toll was significant but manageable. Even in the Indian context, it showed up in Bombay on 29th May 1918,  after nearly three months of first incidents, in the US and Europe. From Mumbai,  dockyards, the virus spread along railway lines all to major cities. The death toll was mild and it was not that significant to be taken seriously. 

By late July 1918, both US, British medical experts concluded that influenza “has completely disappeared”. But within a month by August 1918,  influenza struck back with no mercy. It re-appeared simultaneously in many continents travelling by ships. Flu returned to Bombay in September 1918,  and its impact was deadly “Trains left one station with the living. They arrived with the dead and dying, the corpses removed as the trains pulled into the station. British troops, Caucasians, in India suffered a case mortality rate of 9.61 percent. For Indian troops, 21.69 percent of those who caught influenza died. One hospital in Delhi treated 13,190 influenza patients; 7,044 of those patients died.” John Barry in “The Great Influenza” published in 2004. Most of the deaths globally were in “horrendous twelve weeks in the fall of 1918” as one author put it, killing 5% global population, which was then 1.8 billion. 

Current Situation in India is under control, so far.

First, let us look at the current situation of India compare to some of the richest countries in the world.  So far more than 65% infections and 75% deaths are in six developed countries- USA, Spain, Italy, France, Germany and the UK. All these countries have relatively organised, the well-funded medical system and social stability. Just to give perspective on annual per capita spending on health care, USA $11.600, Spain $ 2400, France and Germany close to $4000. whereas  India just around$200. These countries spend fifty to ten times higher on healthcare compare to India. So there is no way India can come closer in the financial and institutional capacity of these countries to address the crisis like this with financial resources. On a population basis, if Coronavirus casualties are the same as the USA, India would have had close 4 million infections and 200,000 deaths. With UK, Italy and Spain those numbers will be much higher. So far coronavirus has shown some “Karuna” on India, in addition to that effort of Governments contributed significantly to lowering the deaths and infections.

Two big questions are still hanging on –

  • a) what might happen in the next 30 days, specifically by the end of  May
  • b) what could be the situation once this current wave/peak ends, hopefully by the middle of June. 

No one on this planet can give answers to these questions. However, policymakers have to make certain decisions. In order to get to some understanding for the first question, the following assumptions have to be made about India

Lucknow: Medics collect a swab sample of a young boy for the test at Sadar, one of the hotspots for COVID-19 during a nationwide lockdown in the wake of coronavirus pandemic, in Lucknow, Monday, April 13 2020. (PTI Photo/Nand Kumar)
  • a) far fewer virus-positive cases are being reported due to lack of testing
  • b) number of deaths reported are more or less accurate
  • c) virus is similar to elsewhere
  • d) Indian deaths are like to surge, if not at European, US level, but certainly will go up.

Even if India escapes below 10,000 deaths it is a remarkable achievement. Of course, one death is far too many, but in times of this global Pandemic, we need to be pragmatic and realistic.

Will this be it or will we see a second wave?

There are some troubling trends globally, the day China reported no deaths that is the day Spain and Italy reported the largest deaths. Then in January, the world expected to have massive causalities in China now looking like small incident compared to the USA and Europe. Europe has declared the situation is “stabilising” and some countries including Spain and Italy where carnage is massive, slowly opening the shops and economy. But on the other side, within days of opening Wuhan where all this has begun, China reported the highest number of new cases and it is continuing. This is a different region bordering Russia. This has raised alarm bells and panic in Russia. The situation is the same in South Korea, some extent in Singapore. Is there a second wave?

India is in rather a peculiar situation. It has not yet fully peaked as was the case in other countries. Similar situation in Africa and many developing countries. Therefore it is difficult to say if this end or beginning  COVID-19 for India. Even globally, is its end of a first wave or likely to get back. Unfortunately, we have to look at the pattern of 1918-19 influenza. That is too frightening, we can choose to ignore,  doing so will be too disastrous. Only we can hope that 1918 will not repeat. If it does, we should have a strategy to reduce the toll.

Until the end of May 2020 is crucial for India. Extending lockdown by then might be too much on the economy to get back on track. But if required India should be prepared to extend until May end, that is a safer option. Yes, it is tough, massive economic and social consequences. But not doing so could be even worse.  The other options India seems to be going is selective lockdowns where the situation is worse. This is a risky strategy. It could go either way. Governments and civil society have to work together.

Dharavi
A doctor takes a swab sample of a resident at a COVID-19 coronavirus testing drive inside the Dharavi slums during a government-imposed nationwide lockdown as a preventive measure against the spread of the COVID-19 coronavirus, in Mumbai on April 16, 2020. (Photo by INDRANIL MUKHERJEE / AFP)

India’s main strategy should be

  • a) To minimise the death toll now and prepare for the second wave if that occurs. 
  • b) gradual opening of the economy, particularly the rural economy while taking all precautions. This is possible, at a cluster level, identifying and empowering local areas to where the virus is not there yet.
  • c) India with its size and complexity, one policy does not fit everywhere, showing flexibility for states to design their suitable measures
  • d) a balance between economic activity in these difficult times and health concerns 

In addition to that, we need to do anything to avoid September 1918. One colonial physician working then in Punjab wrote that hospitals “choked that it was impossible to remove the dead quickly enough to make room for the dying.” Not just India, world came so close that “Civilisation could have disappeared within few more weeks” wrote a Victor Vaughan, dean of Michigan medical school, who was one of the powerful member the crisis team then.

Yes, surely situation is lot different now, we have a lot more mobility, internet, technology, Scientific development, a stronger economy, all are true. But unfortunately, when it comes to fighting Pandemics, we are not that different from 1918. That is the bitter truth. The world in general and India, in particular, may have to be more cautious than declaring early victory over the virus. 

Dr. Biksham Gujja is Scientist, worked with WWF-International as a Policy advisor and based in Gland, Switzerland, Gmail:gujjab@gmail.com