Updated: March 23, 2020 9:28:35 am
Siddharth Chandra is the Director of Asian Studies Center and Professor in Department of Epidemiology and Biostatistics at Michigan State University. His work on the intersection of demography, economics, health and history in Asia is exemplified by his seminal research on the propagation, evolution and the death toll of the 1918 influenza epidemic in India. He spoke to The Indian Express about the parallels between 1918 and current pandemic, and the lessons it holds for India.
- Are there parallels between the outbreak of 1918 influenza and the coronavirus now?
Yes, one parallel is the overwhelming of medical infrastructure to serve patients. In the case of the 1918 outbreak, there were so many patients that buildings not normally used for medical purposes were re-purposed to accommodate patients. We are seeing the same phenomenon today, with hotels being re-purposed to accommodate patients.
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In the case of India in 1918, however, this overwhelming of infrastructure was more extreme than it has been so far with Covid-19. For example, in his 1918 report, the Sanitary Commissioner of India reported that some rivers were becoming clogged with corpses because of the lack of firewood to carry out proper cremations. Fortunately, this has not been the case in 2020, and I hope that the Covid-19 pandemic can be brought under control before it reaches such an extreme stage.
A second parallel is the grinding to a halt of much economic and social activity. As word of the 1918 influenza got around, people started to stay at home and avoid unnecessary contact with others. As a result, many businesses that depended on customer visits, or what we call ‘footfalls’ today, declined steeply during the pandemic wave.
We are seeing a very similar pattern today. For example, restaurants, where groups of people come together under normal circumstances, have seen a steep decline in business. The travel industry, including airlines and hotels, are also seeing declines in seats and beds filled, and airline and railway companies are reducing service on many routes in response to the decrease in demand for their services.
On the bright side, a few sectors that are seeing unprecedented sales. These include online retail, as consumers substitute away from face-to-face transactions that may otherwise place them at risk of contracting Covid-19, as well as specific items such as foodstuffs with a long shelf life, hand sanitizer, toilet paper (in countries where it is widely used), face masks, and household disinfectants. It also appears that meals that people would have eaten at restaurants are now being made up for with increased purchases of food from grocers. So that has added to the volume of business in grocery stores.
A third parallel is the disruption of education as school and university campuses close. Fortunately, Michigan State University, where I work, as well as many other US universities, have been able to transition very rapidly to online instruction, and I have been teaching my students using live-streaming software. So the disruption has been limited. In 1918, however, schools remained completely closed for the duration of the pandemic, depriving young people of the opportunity to attend classes for a number of months.
- How did the 1918 influenza reach/ spread in India and why did it cause so many deaths, more than 14 million?
The 1918 influenza reached India by ship, most likely carried by troops returning from Europe at the end of World War I. If you look at the maps, you will notice that the first place where the wave of deaths peaked was Bombay, which was a major port at the time and a destination for returning soldiers. Madras, another major port and destination for returning soldiers, peaked shortly after Bombay. It is not clear whether this is because the infection entered Madras independently via ship or whether it came down from Bombay via the railway system or around the peninsula by ship.
The other interesting phenomenon is the early peak in a few districts in eastern India near Puri, one of the Char Dham locations. We know that pilgrimage sites are also high-risk areas for the spread of pathogens during an epidemic, and this seems to have happened in the neighborhood of Puri.
India (and Indonesia), were disproportionately affected by the influenza pandemic of 1918. There are at least two reasons why this happened. First, large numbers of people were under-nourished and therefore exceptionally vulnerable to the disease. This problem was repeatedly mentioned by government officials as they reported on what was happening in the areas under their jurisdiction.
Second, it appears that high population density was also a factor. We have shown in our paper that in India, districts with higher population density experienced higher death rates than those with lower population density. Java, an island in Indonesia, which is even more densely populated than much of India, experienced even higher death rates than most districts in India.
- Should we expect or worry about a similarly high number of fatalities even now?
I do not expect that the fatalities from Covid-19 will be comparable to those from the 1918 influenza, but it is difficult at this early stage to predict how the pandemic will unfold. Here are a few reasons to be optimistic. First, populations in India and across the world are better nourished than they were in 1918. This is enabling us to fight off infection more effectively than our ancestors in 1918 were able to do.
Second, we have better technologies available to us today to help severely ill patients recover from respiratory illnesses like influenza and Covid-19. Our ICUs, with their sophisticated ventilation equipment, are saving many lives today that would have been lost under similar circumstances in 1918.
Third, the availability of free and instant communication technology is enabling a process of learning and implementing best practices at all levels of government and public health infrastructure as well as at the individual level that would have been impossible in 1918.
We should also be very thankful that Covid-19 (which the US Centers for Disease Control is reporting has a case fatality rate of 0.25% to 3%) is not as virulent as the MERS-CoV, another novel member of the corona virus family. MERS-CoV, which was first detected in 2012, had a much higher case-fatality of 37%. So all in all, even though we do not have a vaccine or a cure for Covid-19, we are in a much better position to manage a pandemic in 2020 than we were in 1918.
However, there are many unknowns as well. For example, in July and August 1918, India experienced what epidemiologists now refer to as a ‘herald wave.’ During this herald wave, death rates in many locations, including Bombay, Madras, and Calcutta, doubled or even tripled, causing panic. Fortunately, this herald wave soon subsided and people went back to business as usual in late August. Little did they know what was in store for them in October, when the truly lethal wave of the pandemic arrived in India.
So we do not know whether this wave of Covid-19 cases is a one-time wave that will subside or whether there will be more to come, and whether what comes next will be more or less harmful. For those of us who have studied the 1918 influenza, this is cause for concern. Like the people of India – and much of the rest of the world – who had just recovered from the herald wave in 1918, we do not know what lies ahead. We can hope that this is a one-wave disease, but we should be prepared for the possibility of future, possibly more dangerous waves as well.
- What are the big lessons from 1918 that can be applied today by India as a pandemic controlling strategy?
There are many big lessons. First, we need a completely new mindset. This disease is potentially lethal, and infections spread from people who are not showing any symptoms. Our research on 1918 has shown that population density was a factor in the harm that the 1918 influenza caused in India. So lesson number one is to imagine how you would behave if you knew that everybody around you was infected and act accordingly. This means keeping a safe distance from everybody and assuming that surfaces that others have recently touched are contaminated. It is best to stay at home and have little to no contact with others.
Second, the public health system needs to prepare for a surge in emergency cases, many of whom will need ventilation. The public health infrastructure in India was completely overrun in 1918, and there was little doctors could do to save many lives that might have been saved with greater surge capacity and better health infrastructure. Surge capacity in our hospitals is going to be of critical value. There is still time to prepare and improvise as best we can.
Third, going forward, the recommendations of the 2003 Government of India paper prepared by the then-Deputy National Security Advisor of India, which warned against such an outcome way back in 2003 during the brief and thankfully limited SARS epidemic, should be implemented without delay. These include enhancing public health infrastructure (see above) while also creating capacity in the pharmaceutical production and vaccine research and testing sectors. As was the case with the 1918 influenza pandemic, there is a chance that there will be successive waves of Covid-19, and more pandemic-causing novel viruses will almost surely emerge in the future. If we did not learn from the 1918 influenza or SARS, let us use the Covid-19 pandemic as a learning experience to prevent such crises from occurring in the future.
Fourth, nutrition was an important factor in determining outcomes for people infected with the 1918 influenza virus. It will very likely be a factor in outcomes for Covid-19. Continued focus on and improvements in nutrition for poorer sections of society will be a determining factor in how India deals with the current pandemic.
Fifth, the 1918 influenza exacted a disproportionately heavy toll on doctors and nurses. Every effort must be made to ensure that they are given adequate protections and support to continue their crucially important work. They are at the front lines of our fight against Covid-19.
Sixth, the 1918 influenza had a severe impact on pregnancies and births. At the time that deaths were peaking, there was a parallel peak in stillbirths, preterm births, and maternal mortality. These effects continued in the months after the mortality peak. While there is no hard evidence yet – it is too early to make such determinations – to show similar effects for Covid-19, it is known that a number of viruses are harmful for pregnant women and their unborn babies. So, out of an abundance of caution, pregnant women should take extreme precautions to avoid infection.
- Most of us tend to think of 1918 as from an era when medical science was still not so developed. Despite developments in medical science and improvements in modelling, forecast and research, why is the world struggling even today?
The world is struggling today because, while there have been many developments in medical science and improvements in modelling, forecasting, and research, we still do not have the capability to come up with quick and effective vaccines and cures for novel viruses. Our technologies and regulatory processes are slow enough that, in many cases, solutions will only be ready after significant damage has been done.
I hope and believe that the time will come when we have this capability. Perhaps our experience with the Covid-19 pandemic will spur governments to make a concerted effort to invest in research that can get us to that point before a more virulent novel virus attacks human populations on a large scale.
However, we have come a long way since 1918. For much of 1918, there were ongoing debates about the cause of the influenza; many scientists did not even know what was making people sick. Today we can quickly identify the cause of an illness. We already have a good idea about the structure of the virus that causes Covid-19 and, therefore, possible ways in which we can prevent or counter infection.
In addition, the speed and ease of communication means that large populations can quickly be made aware of the state of the art when it comes to prevention of a disease. This rapid dissemination of best practices at a policy and personal level has benefited us greatly. I think that things would have been much worse today had we not had the internet.
Third, the nutritional status of people today, especially in countries like India, is far better than it was in 1918. We know from reports by Indian health officials at the time that poor nutrition was strongly associated with a higher likelihood of mortality from the 1918 influenza. With large countries like China, India, and Indonesia pulling millions of people out of poverty over the past several decades, human populations as a whole are fitter and better able to cope with novel pathogens today than they were in 1918.
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