close

Public Health

The State and the Pandemic: Spain and the 1889-1890 Flu

Plaza Mayor Madrid 1890

COVID-19 has brought the so-called Spanish Flu of 1918 sharply into the collective consciousness, but it was not the first worldwide pandemic to be faced by the modern state.

In the winter of 1889, a new type of flu came to Europe. Although it had originated in China, they called it ‘Russian Flu’ because, in November, newspapers – including those in Spain – reported that large numbers of people had fallen ill in St. Petersburg. It would take less than a month to reach Madrid.

With greatly improved transport links, unsurprisingly, it was suspected that the number of people travelling was responsible for its rapid spread. However, recent research has emphasised ‘that the important predictor of the speed of the pandemic is not the absolute numbers of passengers travelling between cities but the “connectedness” of the network of cities.[1] In other words, it only took of a small number of people to spread the flu so quickly across an increasingly interconnected continent.

There had been flu outbreaks in 1836/7 and 1848 but these were little remembered and, in 1889, the Spanish authorities were disastrously slow to react. Despite the press tracking its seemingly inevitable arrival, no preparations had been made. In fact, the flu had probably been circulating undetected for weeks before the government acknowledged it on 17 December. The consequences of this inaction are difficult to establish but, in a recent study, Sara García Ferrero suggests that 65% of all 6,180 deaths in Madrid in the nine weeks that followed can be attributed to the flu.[2] In Barcelona, as many as 52,000 caught the disease.[3]

Understanding of virology was in its infancy and early reports focussed on whether it was in fact flu or, perhaps, dengue fever. Even making allowance for this, official messaging was confused and, initially, the threat was played down. The Provincial Health Board of Madrid met the same afternoon as the government’s acknowledgment to discuss their response; it was remarkably sanguine. La Iberia reported that they had confirmed the presence of ‘a disease, with epidemic characteristics, of the flu or a severe cold, in a very benign form.’ This is particularly surprising considering that, for weeks, the newspapers had been carrying reports of the large numbers taken seriously ill elsewhere. Even more worrying, though, was their contradictory assertion that the ‘disease is not spread by contagion.’[4]

This may have been a deliberate attempt by state functionaries to manage the public reaction to the outbreak and there is further evidence of this phenomenon elsewhere. In Reus, for example, the authorities ordered that church bells no longer be rung for the dead to avoid spreading fear among the population.[5] It was, however, a difficult balance to strike. The endorsement of ‘cures’, such as ¡Pum! (Bang!) – a punch of rum and bitter orange – may have done more harm than good.

Some of the more concrete measures taken were also strikingly modern. Primary schools were closed and the Christmas holiday was extended for older students. A 250-bed field hospital was constructed at the present-day School of Engineering, off the Paseo de la Castellana in Madrid. What is particularly notable about these actions is that they were the same as those that had been taken elsewhere. Then, as now, there appeared to be an international consensus about the contours of state intervention. Nevertheless, although such intervention may have slowed the spread, it failed to stop it completely.

The authorities did nothing the limit public gatherings, perhaps for fear of economic damage, but it still came at a cost. On 22 December, La Correspondencía de España reported that as many as 600 soldiers of the Madrid garrison had fallen ill. Despite this, there were signs that a type of social distancing was happening intuitively. People decided to avoid public spaces; streets, shops and cafés were largely deserted, and theatres closed (though only because of high levels of sickness among the performers.)[6]

The longer-term, chronic impoverishment of the Spanish state meant that its capacity for a more exhaustive response was limited. Even the field hospital had to rely at least in part on private donations.[7]

The effects of the pandemic itself also significantly disrupted the provision of public services. Predictably, doctors were particularly vulnerable to catching the flu, but there were also high sickness rates among state officials. Paradoxically, though, some of this disruption served to limit the spread of the virus. Sickness rates among transport workers, for example, disrupted tram and railway services, involuntarily restricting the movement of people.

While these restrictions and relative wealth helped shield the middle class, the poor were disproportionally affected. Plainly because of overcrowding and poor sanitation, but also because the state’s penetration was weakest in the most deprived areas. The measures the authorities introduced had little effect on the lives of the residents there. In a quandary with sad parallels today, many had little choice but risk their health and continue to go out to work.

The flu of 1889-90 was nothing like as deadly as COVID-19, but there are remarkable similarities in the Spanish state’s response. Despite advances in understanding, most countries made similar early mistakes during the current pandemic to those Spain made then. In both cases, this can partly be explained by a lack of scientific knowledge about the threat, but most decisions are also political ones, with intended and unintended consequences.

Eventually the measures were lifted. But only late in January and only when the death rate had returned to normal. In 1890 the lessons had been learned; it remains to be seen whether they will be in 2020. And if they will be remembered more enduringly this time.

Dan Royle is an historian of nineteenth-century Spain. His PhD at the University of Sheffield is on 1848.

Cover Image: Plaza Mayor (ca. 1890), Memoria de Madrid

[1] Alain-Jacques Valleron, ‘Transmissibility and geographic spread of the 1889 influenza pandemic’, in Proceedings of the National Academy of Science of the U.S.A. 107/19 (2010) pp.8778–8781.

[2] Sara García Ferrero, ‘La gripe de 1889-1890 en Madrid’, Ph.D. thesis (Universidad complutense de Madrid, 2017), p.452.

[3] Bogumiła Kempińska-Mirosławska and Agnieszka Woźniak-Kosek, ‘The influenza epidemic of 1889–90 in selected European cities – a picture based on the reports of two Poznań daily newspapers from the second half of the nineteenth century’, in Medical Science Monitor 19 (2013), pp.1131–1141.

[4] ‘Noticias’, in La Iberia (18 December 1889), p.2.

[5] Quoted in Ferrero, ‘La gripe de 1889-1890’, p.38.

[6] La Correspondencia de España (22 December 1889), p.3; Ferrero, ‘La gripe de 1889-1890’, p.43.

[7] ‘Boletín sanitario’, in El Día (28 December 1889), p.1.

read more

COVID-19, ‘Big Government’, and the Prohibition of Alcohol: Crisis as a Transnational Moment for Social Change

Liquor_bottles_array (1)

Throughout history, crises have often led to enormous social and economic reform as policymakers are forced to come up with new ways to meet unexpected demands. As Walter Scheidel argues in his book, The Great Leveller (2017), mass violence has been the primary impetus for the decline of inequality throughout world history, most recently with the Second World War serving as a watershed in relation to increased government spending on social programmes in many of its participating states. Although a crisis of a very different nature, the current coronavirus pandemic has also brought about similar shifts, with governments running huge budget deficits to protect jobs and counteract the threat of a looming recession caused by travel restrictions and lockdowns.

We also witness cases where governments experiment with creative solutions to crises that stretch across borders, as is the case with the current global pandemic. For a variety of reasons, a small handful of countries have resorted to banning the sale of intoxicants. One of the most debated aspects of South Africa’s lockdown has been their prohibition on the sale of alcohol and cigarettes, intended to reduce hospital admissions and secure beds for COVID-19 patients. Admissions have dropped by two-thirds due to reductions in alcohol-related violence and accidents, but such draconian measures also meant the rise of black-market trade and the near-collapse of the country’s proud wine industry.

The sale of alcohol was also banned in the Caribbean island of Sint Maarten, a constituent country of the Netherlands, and in Nuuk, the capital of Greenland, over its role in exacerbating incidents of domestic violence that came with the lockdown. In Thailand, the prohibition on alcohol was put in place to prevent the spread of the virus in social gatherings. In each setting, such policies were deemed drastic but necessary, carefully implemented for their advantages in tackling a variety of health concerns whilst also considering their clear downsides.

Although instituted under entirely different circumstances, the First World War was also a moment when similarly harsh controls were imposed on the sale of alcohol across the world. France and Russia were the first to institute bans on absinthe and vodka, respectively, due to concerns over their impact on wartime efficiency. Countries in which anti-alcohol temperance movements were already influential also implemented tough restrictions of varying degrees. Although the production and sale of alcohol had already been banned in different local jurisdictions in Canada and the United States, a national prohibition came into fruition in both countries due to the war. Alcohol was not banned in Britain, but the country nevertheless instituted far-reaching controls on the distribution of drink under the Central Control Board (CCB), established in 1915 to enforce higher beverage duties and shorter closing hours in pubs.

In almost every instance, it was the context of the war that spurred the move towards instituting these tough restrictions. Temperance activists in North America had been pushing for a national prohibition for decades, but the conditions of the war, such as the rise of anti-German sentiment directed towards German-American breweries such as Anheuser-Busch, brought the federal implementation of prohibition to the forefront of national politics. In Britain, part of the CCB’s responsibility was the nationalisation of pubs and off-licenses situated in parts of the country that were of strategic importance to the war effort.

These contexts directly parallel what we’re seeing in South Africa and Thailand, where extraordinary circumstances necessitated extraordinary countermeasures. However, there is also an important difference that must be stressed: while current lockdown prohibitions are merely temporary, most advocates of prohibitions and controls a century ago believed that such measures were to be permanent, based on their view that there were no advantages to permitting the existence of ‘demon drink’ in society. The ban on the distillation of vodka instituted under Imperial Russia in 1914 was maintained after the October Revolution and was not scrapped until after Lenin, himself an ardent prohibitionist, died in 1924. Yet, within the British context, the First World War effectively reshaped alcohol licensing for several generations, as high beverage duties and shorter opening hours were mostly preserved into the interwar and postwar eras.

These cases highlight the broader implications of social and economic reforms that are being implemented today. Right-wing governments in both Britain and Japan have approved record levels of government spending in the form of economic aid and stimulus. As Bernie Sanders ended his bid for the Democratic nomination in April 2020, politicians of both the left and the right debated the federal implementation of universal healthcare and paid sick leave in light of the public health crisis. Most recently, the Spanish government announced a €3-billion-euro universal basic income scheme to stimulate the pandemic-hit economy through increased consumer spending. A columnist for The Washington Post was clearly onto something when he declared that ‘there are no libertarians in foxholes’.

It is, however, decidedly too early to predict the long-term impacts of COVID-19 and whether these will lead to what many hope to be a reversal of neoliberal reforms that have dominated economics since the 1970s. One cannot forget that the ‘Keynesian Resurgence’ in stimulus spending during the Financial Crisis of 2007-08 was immediately followed by the tragedy of the Eurozone Crisis and the traumas of austerity measures that devastated the public sectors of Greece, Spain, Italy, Britain, and so on. Despite that, the impact of abrupt changes in undermining the status quo cannot be underestimated, as we saw with the global ‘wave’ of alcohol prohibitions a century before. History, therefore, is an apt reminder of how crises are moments when ‘radical’ reforms that were previously only imagined can eventually become reality.

Ryosuke Yokoe is a historian of medicine, science, and public health, presently affiliated with the University of Sheffield as an honorary research fellow. He recently completed a PhD on the medical understandings of alcohol and liver disease in twentieth-century Britain. You can find him on Twitter @RyoYokoe1.

Cover image: Array of liquor bottles, courtesy of Angie Garrett, https://www.flickr.com/photos/smoorenburg/3312808594/ [accessed 28 May 2020].

read more

Dawson’s ‘Big Idea’: The Enduring Appeal of the Primary Healthcare Centre in Britain

Retford

May 2020 marks the centenary of the publication of the Interim Report of the Consultative Council on the Future of Medical and Allied Services, popularly known as the Dawson report after its principal author, Lord Dawson of Penn.[i] The report, commissioned in 1919 by the newly established Ministry of Health, outlined a plan to bring together existing services funded by national health insurance, local authorities, and voluntary bodies in a coherent and comprehensive healthcare system. The final report was never published, being consigned to oblivion by a worsening economy and changed political climate. Though cautiously welcomed by professional leaders, Dawson’s plan was condemned by a hostile press as grandiose and unaffordable.[ii] However, recent NHS policy directives regarding Integrated Care Systems show that the principal task which Dawson’s group had set itself, that of successfully integrating primary, secondary and ‘allied’ health services, is one with which NHS leaders are still grappling today.[iii]

Lord Dawson of Penn, courtesy of the British Medical Association archive

Central to Dawson’s plan, and its most revolutionary idea, was the creation of a network of ‘primary health centres’ (PHCs) in each district in which general practitioners (GPs) could access diagnostic, surgical, and laboratory facilities for their patients and which would also house infant welfare and maternity services, facilities to promote physical health, and space for administration, records, and postgraduate education. GPs and other professionals would see and treat patients at PHCs, referring only complex cases to specialists at secondary care centres (essentially district hospitals) located in large towns, while patients needing the most specialized treatment would be referred to regional teaching hospitals with attached medical schools. This ‘hub and spoke’ model is one to which recent generations of NHS health planners have returned time and again, seemingly unaware of its antecedents.

A firm believer in teamwork, Dawson hoped that collaborative use of PHCs by GPs would encourage group practice and multi-disciplinary working. But the individualistic nature of general practice at that time meant GPs remained wary of his ideas, despite the fact that examples of PHCs already existed in Gloucestershire and in Scotland and many of the facilities they were meant to comprise could be found in GP-run cottage hospitals and Poor Law infirmaries.[iv] Experiments with architect-designed health centres in the 1920s and 1930s failed to elicit a major change in professional or governmental attitudes.[v] In 1948 the NHS brought public, voluntary and local authority hospitals under state control but in its early years the promise of new PHCs remained largely unrealised.[vi] Proprietorial traditions and fear of local government control led to a mushrooming of purpose- built, GP-owned practice premises between the late 1960s and 1990s independently of local authority-owned health centres, for which there was a major building programme in the 1970s.[vii]

Illustration of a Primary Health Centre, from the Dawson Report, courtesy of the BMA archive

Although by the late twentieth century the Dawson report had largely been forgotten, interest in PHCs resurfaced in the early 2000s with a major investment in primary healthcare facilities through the establishment of Local Improvement Finance Trusts (LIFT). These were a form of private finance initiative designed to provide state of the art community health and social care hubs housing GP practices and other services. Unfortunately, LIFT buildings proved more expensive than anticipated and their facilities, intended to promote the transfer of work from secondary to primary care, were often underutilised.[viii] While these were being constructed, the Labour health minister, Lord Ara Darzi, announced the establishment of a number of ‘polyclinics’, bearing a close resemblance to Dawson’s PHC idea. However, the Darzi Centres that were established were either mothballed or repurposed, being condemned as an expensive ‘white elephant’ by professional leaders.[ix]

In the last few years a ‘quiet revolution’ has been taking place in the NHS in England involving attempts to dismantle the financial and institutional barriers between primary, secondary and community care created by the internal market. Its byword, ‘Integration’, echoes Dawson’s overriding goal and the ‘hub and spoke model’ he advocated is now well established. Meanwhile, the pressures of unending demand have forced GPs to collaborate as healthcare providers in locality groups called Primary Care Networks (PCNs). Though guidance on these is not prescriptive, some PCNs have adopted the idea of a community ‘hub’ housing shared diagnostic and treatment facilities much as Dawson had envisaged.[x]

While the full impact of COVID-19 on our struggling health services is still unknown, the abiding necessity for all parts of the NHS to collaborate, communicate and mutually support each other during this crisis underlines the value and relevance of Dawson’s vision of integrated services. It remains to be seen if, in its aftermath, his ‘big idea’ of ubiquitous multi-purpose PHCs will come any closer to being realised.

Chris Locke is a fourth year PhD student in the History Department at the University of Sheffield. His research is focused on the political consciousness of British GPs and their struggle for professional self-determination in the early Twentieth Century.

Cover image: LIFT -built Primary Care Centre, Retford, Nottinghamshire, photographed by the author.

[i] Interim Report of the Consultative Council on the Future of Medical and Allied Services, Cmd 693 HMSO  1920. For an account of the origins and significance of the report see Frank Honigsbaum, The Division in British Medicine (London, 1979) chapters 6-12.

[ii] The British Medical Association’s blueprint for health services reform, A General Medical Service for the Nation (1930) and the report by Political and Economic Planning, The British Health Services (1937) both referenced the Dawson report, and it clearly influenced the Beveridge report, Social Insurance and Allied Services (1942).

[iii] https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems (last accessed 3 April 2020)

[iv] The report referenced the hub and spoke model of healthcare facilities overseen by Gloucestershire County Council’s Medical Officer of Health, Dr J Middleton Martin. Commentators also noted similarities with Sir James McKenzie’s Primary Care Clinic in St Andrews and Trade Union-run Medical Aid Institutes in South Wales.

[v] Jane Lewis and Barbara Brookes, ‘A Reassessment of the Work of the Peckham Health Centre 1926-1951’, Health and Society vol 61, 2, 1983 pp.307-350; For Finsbury Health Centre see A B Stewart, ‘Health Centres of Today’, The Lancet, 16 March 1946 pp. 392-393.

[vi] For one exception see R H Parry et al, ‘The William Budd Health Centre: the First Year’, British Medical Journal, 15 March 1954 pp.388-392.

[vii] BMA General Practitioners Committee guidance: The Future of GP Practice Premises (Revised 2010)

[viii] Nottinghamshire Local Medical Committee, NHS LIFT in Nottinghamshire (Nottingham,1997)

[ix] Peter Davies, ‘Darzi Centres: an expensive luxury the UK can no longer afford?’, British Medical Journal, 13 November 2010, 341; c6237.

[x] https://www.england.nhs.uk/primary-care/primary-care-networks/ (last accessed 3 April 2020)

 

read more