What we can learn from the history of epidemics

This interview provides an enlightening historical perspective of the COVID-19 pandemic, highlighting the similarities and differences to five epidemics that have hit South Africa.

Ingrid Rewitzky

Very relevant and practical hands-on article!

Wiida Fourie-Basson

Illustration by Cayla Basson

Professor Howard Phillips is a well-respected emeritus faculty at the University of Cape Town. History of epidemics/pandemics is one of the areas in which he has worked extensively. His book ‘Plague, Pox And Pandemics : A Jacana Pocket History of Epidemics in South Africa’ traces the history of South Africa and its battle with five epidemics, namely: Smallpox, Spanish flu, Bubonic plague, Polio and HIV-AIDS. In this interview, when the world is in the middle of yet another pandemic, professor Phillips tells us what we can learn from history.

An interview with Professor Howard Phillips, by Sophie Marques.

This historical background is needed to help us understand COVID-19. The five epidemics that he looked at are: Smallpox, Spanish Flu, Bubonic plague, Polio, HIV/AIDS

Part 1: History of the pandemics

Howard Phillips on how pandemics shaped South African history

My original interest was in the 1918 Spanish flu but after I taught a course at UCT on epidemics to history students, I wanted to expand my knowledge. The best way to know something is to teach it and  to write about it, so I wrote a short book, Plague, Pox And Pandemics: A Jacana Pocket History of Epidemics in South Africa, where I looked at five major epidemics in South Africa’s history.

The first one, smallpox, occurred in South Africa at the beginning of the 18th century. It was a devastating disease. It gravely affected not just colonists and slaves, but also the indigenous Khoi community. It was as if a bush fire had swept through the Khoi community. Three major outbreaks in 1713, 1755 and 1767 effectively ended the ability of that component of the indigenous population to survive as a distinct, independent community. They had initially posed a challenge to the Dutch settlers but the disease soon decimated them. The same was true in  the Americas when settlers came there from Europe because they brought with them infectious diseases unknown across the Atlantic. Locals had no immunity to these diseases which  decimated the indigenous population. The question that many historians often ask is, how did a small number of settlers conquer and dominate a much larger local population in Latin America which included the powerful empires of the Incas and Aztec? The main reason is because of  their low immunity to these diseases. In South Africa, a similar process occurred in the 18th century, with the Khoi being the locals who were decimated by diseases like smallpox which, consequently, contributed significantly to shaping the early South African colonial society.

The second epidemic I looked at was bubonic plague. At the end of the 19th century, the  bubonic plague hit South Africa as part of the world-wide pandemic that started in China in 1870. At the beginning of the 20th century, the South African War was underway.  Bubonic plague was carried by fleas on rats in grain brought in to feed horses of the British cavalry. When these rats died, it then spread to the human population via fleas. This disease was not as big a killer as smallpox, but it caused fear across the world because of its association with the Black Death of the 14th century. The authorities responded by asking: “Who is to blame? Who is bringing it here? Who are those that are the carriers?” This search for someone to hold responsible is a pattern true across history at all times, at all places. Fingers are often pointed to  a group of outsiders, a minority, or those who are different. In 1901, that was black Africans in Cape Town. As a consequence, they were forcibly removed from District 6 to a site out on the Cape Flats. That was the beginning of the residential segregation of Africans in Cape Town. This was followed by racial segregation of Africans in Port Elizabeth, in King Williams Town, and in Johannesburg. That epidemic of bubonic plague, even though it was not a big killer,  gave the authorities the opportunity to undertake residential segregation. From that flowed the subsequent creation of separate African townships, on the fringes of South African towns, for Africans. They were forced to settle there by law.

The third epidemic is the Spanish flu of 1918. The Spanish flu was another disaster for South Africa. In a span of six weeks, South Africa lost 5-6% of its population. It is a stunning figure. About 300 000 to 350 000 people died in the course of 6 to 8 weeks. It was part of a worldwide pandemic. What is particularly unusual is that it killed young adults more than any other section of the population. Usually, influenza is a big threat to the very young and the very old because their immune systems are still developing or beginning to wane. However, in 1918, young adults, between 18-35 years old, died in their thousands, which meant that many parents of young children died, making many children orphans. In a matter of weeks, sometimes days, orphans were created on a scale that was unprecedented. How does a society deal with that? As  a result of the Spanish flu many children lived their lives without one or both parents. To me the most poignant illustration of this came in an interview in 1998 with a man who was born in 1908 and who lost his mother, when he was 10 years old, during the Spanish flu of 1918. I spoke to  him when he was almost 90 years old and he said to me: “My mother died in the Spanish flu of 1918 and I have missed her ever since.” The emotional, psychological effect the Spanish flu had on that man for the rest of his life, as well as on the other millions and millions of orphans created in the world by this epidemic, is  one of its longest lasting consequences. One cannot measure sadness, one cannot measure bereavement, but both clouded the lives of many millions around the world for the rest of the 20th century Another consequence of the 1918 epidemic was that the authorities realized that  South Africa lacked a central public health system that could deal with such an epidemic. As a result, within months, South Africa passed legislation to set up a department of public health. This was established in 1919 and was the beginning of the current public health department.  

The 4th pandemic that I looked at was polio in the 1940s and 1950s. Polio is a very unusual disease. It does not kill in vast numbers, but attacks the nervous system and can cripple people for life, rendering them unable to walk. One of the greatest fears was that young children would be crippled for life. What is very unusual is that, unlike most epidemic diseases,  polio poses the greatest risk to middle-class children who had not been exposed to it before because of the sanitary environment in which they had been reared. For South Africa, in the early apartheid era, this meant it was mainly white children who were infected. This was an enormous source of anxiety to the all-white government as it raised a question about the future of the white race. The fear was that if children were being crippled, it was going to be difficult to  produce a healthy next generation. The threat of polio led to enormous mobilization of resources and collection of funds to find a cure. In the 1950s, teams in the United States developed an effective preventive vaccine. As a consequence, children were automatically vaccinated against polio. In South Africa, from the 1960s onwards you would rarely see any new cases of polio.

Finally, HIV/AIDS began in South Africa from the 1980s and it is still underway today. It is a different type of epidemic. It is not a rapid, sweeping epidemic like coronavirus or the Spanish flu. It is a slow moving pandemic. Unlike other pandemics in which you die quickly after being infected, in the case of HIV/AIDS it can be up to six to eight years between infection and death. People who are infected become a long standing responsibility for their families. Moreover, from 2008 the growing roll-out of antiretroviral therapy began to reduce the number of new infections. For the last 30 years, HIV/AIDS has had a major impact on the population. Like the 1918 Spanish flu, AIDS created many orphans and the implications of that are enormous. Grandparents had to look after their grandchildren because their parents had died from AIDS. In some cases, young children as young as 10 years old had to look after their younger brothers and sisters because their parents had died, which is a disastrous social situation.

Those are the five epidemics looked at in Plague, Pox and Pandemics: A Jacana Pocket History of Epidemics in South Africa. In each case they have been a major shaper of South African society.

Patterns across pandemics

In many cases, the initial response of the government and those involved in the economy is denial: “Don’t worry, this has been exaggerated, it is not so bad”. During the second phase is that it is no longer possible for government to continue denying what is going on because cases are escalating, and people are dying. Therefore, the response is emergency mobilization to  get resources up and running. I think that is where we are in South Africa at the moment with the Covid-19 pandemic. At first, you see if there is something that can actually treat or even cure the disease. Since we have neither a cure nor a preventive vaccine, we have to go to a very old response to infectious pandemics: quarantining and social distancing. You try to keep people away from each other because that is the way you think you are able to protect yourself and your family. We do not really know how widely the South African population is affected, but the virus continues to spread. The majority of South Africans, particularly the urban population, live in overcrowded homes with poor hygiene and living conditions that make social distancing an impossibility. In such conditions the virus can spread easily and quickly. That is one of the reasons why I think the government is so desperately trying to contain the pandemic. We have also seen cooperation and collaboration between individuals and communities.

Illustration by Liani Malherbe

Part 2: What can history teach us about Covid-19?

Comparing Covid-19 to other pandemics

The Covid-19 pandemic has some similarities to the Spanish flu but there are also significant differences. The first similarity is the speed with which it has spread. Back in 1918, the Spanish flu spread at the pace of the most modern transport technology of the time, the steam engine, on ships and locomotives. In 2020, it is also via the latest form of transport, the jet airplane. The second similarity, is that both pandemics stem from what is called a spillover of infection from animals to humans. We are told that the novel coronavirus  comes originally from bats and then was spilled over to humans via another animal host. But its natural habitat is in bats; from them it  made a species jump. The same is true for influenza: the natural home of the influenza virus is water birds which are found in freshwater and the sea. From them it also spilled over to humans. In 1997, there was an outbreak of influenza in the chicken markets in Hong Kong, when the virus spread from water birds to chickens. The fear was that it was going to infect humans too and become another pandemic. The authorities went into Hong Kong in 1997 and killed chickens by the million to  prevent a potential  epidemic.

Thirdly, just like in 1918, there is no preventative vaccine. The health facilities and personnel were swamped then by the sick, as they are  currently also overwhelmed.

Fourthly,  a pattern we  see in all epidemics, is humans responding by asking, “Who is to blame? Who is responsible? Who wants to harm us?” You might have heard Donald Trump saying it is a ‘Chinese’ epidemic. In every epidemic, not only in South Africa, but around the world, in all times, it is a very standard response to point a finger, to stigmatize someone or some group or country, to say they are to blame. I think we are wired, when our lives are under threat from a pandemic, to blame others.

On the other hand, there are major differences between Covid-19 and the Spanish flu. Even though both attack the respiratory system, in the former the incubation period is quite long, two to three weeks. It is also often asymptomatic, which is  very dangerous. You could be talking to someone who does not even know that they are infected. In 1918,  the incubation period was only two days. Another difference is that the  coronavirus seem to be  fairly stable. In 1918, there were three waves of the Spanish flu. The first wave was very infectious, but not particularly fatal. It disappeared between June and July 1918. In August 1918, the virus underwent a major mutation. The mutated virus drove  the second wave, which was not only very infectious, but far more lethal. There was a third wave in 1919, but it had very little effect due to the immunity obtained in the previous waves. We can only hope that the coronavirus remains stable and  that it does not undergo any harmful mutations.

Another way they differ enormously, is that in 1918, the people most at risk were young adults. The coronavirus,  it appears at present, is more of a threat to older people. Currently epidemiologists are looking at something called the case fatality rate (i.e. for each hundred cases,  how many people actually die). I do not know how reliable these figures are, but the existing figures (as of 15th April) put the case fatality rate for Italy at 12.9%, the UK at 12.8%, and France at 11.9%. By comparison with the Spanish flu, in 1918, the worst hit territories had a case fatality rate between 23-25%. That means that one-fourth of the inhabitants who contracted the disease, died. We can only hope that Covid-19 never gets near that.

Today we can also be grateful for the existence of an overarching health body such as the World Health Organization, that first sounded the alarm internationally and has tried to get countries to prepare in advance. In 1918, there was no such organization and the first World War was still  underway. Indeed, countries who were still engaged in World War I tried to suppress information of outbreaks of Spanish flu as they did not want the enemy to know that so many of their soldiers were sick. The war also accelerated the epidemic. The very best way to accelerate an epidemic is to put people in overcrowded conditions, which is what happened during the war in military camps, on troopships, troop trains and in prisoner-of-war camps. In the case of South Africa, the second wave of the flu arrived through soldiers returning to the country by sea. After they disembarked, they were not tightly quarantined and were soon allowed to board trains to take them to their homes. This rapidly spread the disease around the country, fuelling an epidemic. During this epidemic, the society was paralyzed for some weeks, but those people who survived the disease then developed  immunity, resulting in the creation of what is called herd immunity. That meant that there were too few people without immunity for the disease to continue at epidemic levels. It is like a bush fire: it rages through the veld until there is nothing left to burn.

At the moment, it is much debated whether a bout of  Covid-19 will give you immunity or not. There are cases reported in Wuhan of people who had recovered from the virus but who are now showing symptoms again. It is not clear if the disease was only temporarily damped down in them and coming out again or whether they did not gain immunity from the first attack. It was very noticeable that after the second wave of the flu rampaged through South Africa in 1918, the third wave in 1919 had only a limited impact as so many people had developed immunity because of the second wave.

Living the outbreak as an historian specializing in the study of pandemic

Having worked on the influenza epidemics for a very long time, I was always aware of what the medical experts were telling me, that another flu pandemic would be coming sooner or later There have been several pandemics in recent years and each time I wondered if it would be the big one virologists have been warning us about for a long time? When I heard  about Covid-19, even though it was not caused by an influenza virus, I wondered if this is the pandemic that we have been dreading for so long. I watched it with a sense of déjà vu. I saw this disease spreading rapidly. In a sense, I have one foot in the past and one in the present and the future, trying to understand what is playing out in front of me as I constantly have in my mind what happened just over 100 years ago.

I now have a better understanding of the fear and anxiety that were very common back in 1918. When I did my  research about the 1918 pandemic over 40 years ago, I was able to interview a lot of people who had  lived through it. They were then in their 70s, 80s and 90s; all  have since died. One of them told me: “You know what caused the greatest fear back in 1918? It was walking down the street and hearing someone sneeze or cough”. Now I can understand very personally what she was referring to. If you stand in a queue today, or are in a bus, or in a shop and you hear someone sneeze, you immediately  think,  “Have I been  infected?”

How prepared is South Africa for the COVID-19 pandemic?

I am not in a position to give an answer to that as a specialist in public health would be. But, it seems to me that the world was caught wholly unprepared by the outbreak in China and for the speed with which it has spread around the globe. If we had this conversation two months ago, we would have said, “It is in China but it is unlikely to spread here rapidly”. But, it has spread at an enormously fast pace, which has been a surprise. It would seem to me that the South African authorities, with their limited resources, are trying their best to get ahead of the game. If we can rely on the statistics which they have given, it seems that, at the moment, we are holding the line. Mark Twain said: “There are lies, damn lies and statistics”. It would be a boost of confidence if we were sure that the statistics we are given were the actual numbers. I really do not know. The figures might be misleading us, not necessarily willfully, but it might be that those figures are just not an accurate marker of what is happening on the ground. 

Advice from an historian used to looking backwards and thinking ahead

As difficult as it is, if we do not want a catastrophe of the same magnitude as in 1918, we need to balance lives and livelihoods today. We have to evaluate the needs of the economy and employment, the need for schooling, against the potential threat to life. It is not that one choice is 100% right and the other 100%  wrong; we have to find something which is the “least bad option”. Whoever cannot maintain social distance should be given the necessary protection equipment:  masks, visors, gloves and hand sanitizer, especially for those on the front line.

Prof. Howard Philips

Emeritus Professor Howard Phillips is a graduate of the University of Cape Town and the University of London. He specializes in two areas, viz. the social history of medicine (especially epidemics and pandemics, medical education, and hospitals) and the history of universities. In 2012 he wrote a book [1], that provides the first look into the history of epidemics in South Africa, probing five lethal episodes which significantly shaped this society over three centuries.

[1] Plague, Pox And Pandemics : A Jacana Pocket History of Epidemics in South Africa (an eBook version is available from Take-a-lot.)

Meme by Nandan Malhotra

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