Deadly encounters: are we prepared?

Six months before the end of the First World War a new and deadly form of influenza emerged and swept across the world. Over the next 12 months more than 500 million people would catch the flu and probably between 50 and 60 million would die.

It was without doubt the deadliest and most destructive pandemic to affect our world since the Black Death. Australia managed to avoid the pandemic until early in 1919 but over the next seven months more than 1.8 million Australians caught the flu and 15,000 died. It was the greatest public health disaster in Australia's history and it affected all aspects of Australian life.

After sweeping through Europe the pandemic reached South Africa in September in 1918 and New Zealand in October. In both these countries it caused an appalling mortality. In South Africa at least 139,471 people died in four months of which 11,726 were Europeans and in New Zealand there were nearly 9,000 deaths in a little over two months in a total population of only 1.16 million. For some countries the pandemic was even more deadly. In Western Samoa, for example, 90% of the population were infected and 23% died in just a few months.

Towards the end of 1918 Australia, conscious of the pandemic raging in Europe and nearby, made provision to quarantine all ships arriving at Australian ports where cases of influenza had occurred on the voyage. From late October 1918 until late January 1919 infected vessels continued to arrive at Sydney and Melbourne many from Europe with returning servicemen. Most vessels were placed in formal quarantine.

Over this period 326 persons were quarantined at the North Head Quarantine Station in Sydney of which 49 died. A number of returned soldiers who had landed in Melbourne made their way to Sydney in January 1919 carrying the flu with them. One in particular was admitted to the Military General Hospital at Randwick on January 23^rd. Two days later, three of the medical staff who had attended him went down with the flu. It was the beginning of what was to be Australia's greatest social and public health disaster.

From February until late August every aspect of Australian society struggled under the impact of the flu. The Commonwealth Government and all the States fought over who should be responsible for pandemic control and how to institute it. States fought other states and many closed their interstate borders.

The medical profession was totally unprepared and ill-equipped to deal with a viral infection and most simply believed that they were dealing with a bacterial disease. Quarantine, isolation, masks, disinfectant sprays, and popular and quack medicines ruled the day. Thousands tried to flee Australia's cities while tens of thousands locked themselves away in their homes and avoided any contact with neighbours or others.

Social distancing and isolation became the order of the day and fear and panic ruled. Essential services, shops and businesses closed due to lack of staff and State Governments had to convert schools, race courses and other public buildings into temporary hospitals. Within seven months more than 34% of all Australians had succumbed to the flu and 3% died from it.

But could it happen again? What lessons have we learnt over the last 100 years and how well prepared are we if it did happen?

There is little doubt that it will happen again and it is not so much a question of "if" as "when". Both the WHO and the CDC believe that we are overdue for another pandemic of influenza and that it is just a matter of time. SARS, Avian Flu and Swine Flu were mere forerunners of what might soon take place. Interestingly more new influenza strains have been identified over the last 20 years than in the entire 20th century.

But are we ready and what have we learned from our past experience?

Well, in the first place there is no doubt that our attempt to overcome infectious disease over the last 100 years has failed. Smallpox is probably the only real triumph of medical science.

Polio, once thought to be well under control and close to disappearing, has re-emerged in a new form. And what about Bubonic Plague? Today Plague is more geographically widespread around our world that ever before and is nurtured in permanent animal reservoirs which defy control or eradication.

Mosquito-borne infections also continue to dominate our world including Australia. Dengue, Ross River Virus and Barmah Forrest virus cause hundreds of cases every so many years. In Australia since 1870 dengue has been responsible for almost 1000 deaths and more than one million cases of illness.

Ebola and Zika also show us just how quickly new viral infections can emerge and wreck human havoc. Finally, a wide range of childhood infections linger on. Measles is a case in point. In 2018 there were at least 41,000 cases of measles in Europe as well as a number in Australia, all presumably originating from people's inability to seek vaccination for their children.

So what have we learned from our past pandemic experience? The answer is in some respects very little.

SARS, Avian and Swine Flu revealed just how devoid our arsenal of response was and how we were forced to reach back into the past for control measures such as quarantine, cleansing, closures, fumigation, isolation and avoidance. Our real problem is that we continue to believe that we are the dominant species in our world and we continue to underestimate the power and significance of the biophysical environment and the role it plays in our lives.

The biophysical environment is a powerful, ever-changing force and we have severely under-estimated the role it plays in our lives and in particular its significance with respect to infectious disease. We need to appreciate that the microbial world reveals a dynamism that confirms the strength of evolution and adaptation.

Many infectious diseases continually change and mutate in ways that make it difficult for our immune system to adapt or for medical science to provide a satisfactory cure. We are also living in a highly mobile world where tens of millions of people move across national borders most by air in journeys that are far less than the incubation time of most infectious diseases.

Infections now recognise no borders and move at will around our world. Add this to the way we continue to modify our natural environment and intrude on natural disease reservoirs such as Plague and Ebola continually placing ourselves at risk.

There are some things that we have learned however.

Firstly, that pandemics of flu behave unpredictably with some being far more virulent than others generally targeting the very young and the old, although not in the case of the 1918-19 pandemic where people aged between 20 and 39 were most at risk. The reasons why this was the case still remain unclear.

Secondly, that pandemics follow what is known as an "epidemic curve" with a gradual onset, followed by a surge of cases and then a gradual decline.

Thirdly, that flu pandemics tend to unfold in a series of waves, with the second wave often being far more virulent than the first. The 1918-19 flu pandemic came in three or four waves with the first being moderately mild.

Fourthly, once a pandemic gets underway it is extremely difficult, often impossible to control its spread. Quarantine, travel restrictions, closure and isolation have little effect.

Fifthly, we now understand that Influenza is permanently maintained in natural reservoirs among migratory aquatic birds in parts of South Asia and that epizootics or epidemics occur frequently among such hosts often allowing the virus to invade nearby domestic birds and animals. Finally, our search for a vaccine to confront major influenza outbreaks struggles against the ability of flu viruses to adapt, change and mutate.

So how should we prepare for the next pandemic?

In the first place we need to recognise the significance of the biophysical environment and the significance of zoonotic or animal infections.

To this end we need better surveillance of animal diseases at home and abroad.

Secondly, we also need to glance back at the history of how we responded to past epidemics and pandemics and the wrangling and disputes and lack of cooperation that characterised the relationship between the Commonwealth and the States as they struggled with finding a way to address the crisis.

Thirdly, we need to carefully reassess the containment measures advanced to try and control past pandemics, and in particular how successful such measures were and how they impacted upon ordinary people.

Fourthly, there is little doubt that we require a rapid diagnostic and surveillance system that quickly identifies the threatening disease agent and what might be done to contain it. To this end we need to stockpile relevant anti-viral and antibiotic drugs always recognising the ability of the flu virus to mutate and change every year.

Fifthly we need to have in place an emergency hospital and healthcare arrangement that can be activated in times of crisis. A continuing problem which marks all epidemic and pandemic encounters in Australia is the failure of Governments and medical authorities to recognise that epidemics and pandemics have a significant human dimension and are as much psycho-social events as epidemiological ones.

Critically we need to acknowledge the importance of understanding how ordinary people regard risk in their lives. There is a failure to recognise the dissonance that exists between how "experts" and "ordinary" people view risk. Risk for "experts" and governments is a definable measurable phenomenon.

For most of us, however, risk is, the way we view the world and the people around us. It is a social phenomenon, emotionally constructed. People harbour deep-seated fears about contagion which are a mix of rational and irrational fears about exposure, infection and "outsiders". Fear is also highly contagious and considerably influenced by the way governments respond to pandemics as well as by the way the media often presents sensational stories and imagery. We need to understand that containment and management procedures such as quarantine, isolation, surveillance, restrictions on movement and closures of public places may aggravate fear, hysteria and panic and that during times of pandemic crisis people have little confidence in the Government and medical profession's power to protect them.

Finally we also need to encourage people to embrace "old fashioned" concepts of personal hygiene and preventive strategies as well as show concern for vaccinating their children against common childhood infections.

In the final analysis if we do not learn from the past we run the risk of repeating the mistakes made. As Ashburton-Thompson, possibly Australia's greatest Public Health practitioner remarked in 1899 -  "The brilliancy of modern discoveries blinds incautious eyes to old truths and often endangers sound practice".