For the past few years, my researchers and I have been examining what happened when pandemic influenza, the so-called Spanish flu, struck Canada in autumn 1918 and remained around with deadly impact until February and March 1919.
What has struck us is that this was a very different type of emergency and that many of the problems that arose in 1918–19 would also arise today, but now might be more difficult to solve.
Current thinking about emergency response is that it starts at the local level, moves up to the regional, then provincial or state level and then, if these resources aren’t sufficient, involves the federal level.
In fact, it doesn’t always work that way. Often the federal government and federal agencies become involved right from the start.
But the real problem with this approach to emergency response is that it’s based on the assumption that upper levels of government will be able to assist. Our research on the 1918–19 pandemic suggests that when a pandemic strikes, that’s a flawed assumption.
A tsunami of disease
In 1918–19 in Canada (and we believe in the United States) the flu struck hundreds, if not thousands, of communities at virtually the same time. Given that, there were simply not enough upper-level government resources to assist.
It’s easy for upper levels of government to assist a few beleaguered communities, even a few states or provinces. It’s impossible, however, for upper-level governments to assist every community in the entire country at the same time, yet that was the challenge in 1918–19.
There are admittedly much better-developed health resources today than then. In Canada, for example, there was no federal health department at that time, and only one of the nine provinces (Newfoundland was not part of Canada in 1918–19) had a health department. Now there are a federal health department and a federal health agency plus health departments in all 10 provinces.
However, those resources would not be sufficient, not even close to sufficient, to provide support to every municipality at the same time.
In Ontario, for example, provincial resources were strained during the 1998 ice storm when 65 communities declared a state of emergency at the same time. But a provincial response was still possible because large parts of the province, including its capital and largest city, Toronto, were untouched.
That would not be the case during a pandemic. The whole province would be under siege, and Toronto would be hard pressed to deal with its own problems.
But that is only part of the difference.
A different time
In 1918 many persons with the flu remained at home, trying to cope on their own because they could not afford the cost of hospital care. Today that situation would probably be very different in Canada, where almost everyone has state-financed medical insurance. It seems likely it would also be different in the United States, even though medical coverage is not universal as in Canada.
However, even in 1918–19 when many persons remained at home, the hospitals were overwhelmed. That would be even more likely today.
In 1918–19, the solution was to turn churches, libraries and other buildings into emergency hospitals. The problem was: How were these facilities to be staffed? The answer was: Issue a call for women volunteers.
In 1918–19 those volunteers did come forward, and they came from four main sources.
* First there were the teachers. Since the schools were closed they were free to volunteer.
* Second, there were women who had stopped working when they married, including many with relevant skills, such as former nurses.
* Third, there were members of women’s organizations like the Imperial Order Daughters of the Empire (similar to the Daughters of the American Revolution).
* Fourth, there were members of religious orders, mainly Roman Catholics.
None of those sources of volunteers would be so readily available today.
* Teachers are no longer mainly single women: many are married with family responsibilities.
* Second, women do not automatically stop working when they marry.
* Third, women’s organizations now consist of working women and women with family obligations.
* Fourth, membership in religious orders is much less than in 1918–19.
There is also another issue.
The women who volunteered in 1918–19 were assigned two tasks. They were asked to nurse patients in hospitals or emergency hospitals. And they were asked to assist in private homes where everyone was too sick to care for themselves or others.
In addition, they were asked to do so with virtually no training. A few attended an hour or two of lectures, but that was it.
The next time
Could we expect the same response today?
It would seem unlikely, for in 1918–19 there was another factor at play. The world was at war, and young male volunteers were dying in horrific numbers in battle. Women wanted to play their part and were prepared to risk their lives to do so. Some did get sick and some died.
Even by 1920, when the flu struck again, the willingness to volunteer in the face of such risks had gone down. It’s hard to imagine large numbers of untrained women putting themselves at risk today, even if such women were available.
The fact that some recent research suggests medical persons would be reluctant to expose themselves to such risks, even though others have challenged those findings, would suggest that doubts about the willingness of untrained women to come forward in large numbers are reasonable.
Of course some things have improved since 1918–19.
Today there is planning at all levels of government.
Today our knowledge of how disease spreads and how to treat it is far advanced as compared to 1918–19.
Today, in contrast to 1918–19, all our medical personnel would be available. (In Canada in 1918, many physicians and nurses were overseas with the Canadian Army Medical Corps.)
Canada’ experience with SARS, however, is not encouraging.
In Toronto where there was a serious outbreak, though the numbers of ill were few compared to 1918–19, there were major response problems. And one of the weaknesses was that municipal governments were overshadowed by upper levels of government.
In 1918–19, the different provinces offered different advice about what was appropriate. Some, for example, stated that placarding homes stricken with the flu was pointless, even counter-productive. Others provinces urged or even required placarding. Our research shows that it really didn’t matter. Municipalities forced to rely on their own resources did what they thought was appropriate.
Of course, there is one other major difference between 1918–19 and now. In 1918–19 there were no plans for pandemics or any other kind of emergency.
In fact, war-related emergency planning didn’t start in Canada until 1939. Disaster planning did not begin until the 1950s. Pandemic planning began even later. The situation in the United States is very similar.
The dilemma is that no plans are going to be very effective unless they are based on reality, that is, unless they are what my colleague Dr. Erik Auf der Heide calls “evidence based.”
The reality, as we see it, is that a future pandemic, one similar to 1918–19, would cause the same kind of problems today, and today, as we see it, some of those problems would be more difficult to solve.
Joseph Scanlon is professor emeritus and director of the Emergency Communications Research Unit at Carleton University in Ottawa, Canada. He has been doing emergency research for 41 years.