Covid 2.0: Pandemic lessons India should have taken from second influenza wave of 1918?

Years after the deadly influenza pandemic of 1918-20, it was estimated that one-third to half the Indian population was infected and 10-20 million people, then 3-6 per cent of the population, had died. The major damage was caused in a short period from June 1918 to early 1919. The second wave of the pandemic lasted for less than three months -- mid-September to early December of 1918 - but was most devastating.?

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India is in the middle of the second Covid wave, which is turning out to be more dangerous than the first. (Photo credit: PTI)

In late 1918, when the second wave of influenza pandemic struck India, Mumbai (Bombay) and Pune (Poona) were among the worst affected cities. The disease had soon spread to other parts of the country, though relatively less in the northeast. The rural areas were also affected and nearly all states and districts were reporting more cases, and a bigger peak than the first wave. The younger age group was also affected now. To control the spread, local authorities ordered major restrictions such as closure of cinema halls and other public spaces. They appealed to people to avoid large gatherings and wear masks.

There was scarcity of health facilities, doctors and other healthcare providers. Newspapers were full of reports about overwhelmed health services and difficulties faced by people in accessing them. In absence of proven and effective treatment, a few companies made extensive profits by promotion and sale of unproven therapies and treatment. Use of traditional remedies also increased. The estimated number of cases was many folds higher than reported by authorities. In some cities, there were reports of burial grounds filling up and crematoriums overburdened. It was being said that absolute number of deaths was being hidden by authorities. Examinations were postponed or cancelled, and students promoted.

Years after the deadly influenza pandemic of 1918-20, it was estimated that one-third to half the Indian population was infected and 10-20 million people, then 3-6 per cent of the population, had died. The major damage was caused in a short period from June 1918 to early 1919. The second wave of the pandemic lasted for less than three months -- mid-September to early December of 1918 - but was most devastating.

Statistics often fail to convey the human impact of diseases, epidemics and pandemics. One such description appeared in a book titled "Kulli Bhat", published in 1939 and authored by noted Hindi poet and writer Suryakant Tripathi 'Nirala'.

"Come back urgently, your wife is seriously ill", read the Telegram message received by Nirala, who was then in Bengal. He took the next train to his hometown of Dalmau at Raebareli in Uttar Pradesh. When Nirala reached Dalmau (on the banks of River Ganges,) he had observed that "the River Ganges was swollen with bodies". By the time he reached home, his teenage wife was already dead. In the days to follow, his cousin and cousin's wife (both were taking care of Nirala's wife), an infant nephew and uncle were all infected and died. Nirala was referring to the year 1918 and the influenza pandemic, which devastated India that year.

Nirala's description cannot be taken as a literary exaggeration. A report from then sanitary commissioner of India had made similar observation that "all rivers across India were clogged with bodies because of shortage of firewood for cremation". It is now estimated that in the 1918 flu pandemic, every citizen was affected, every family had at least one sick and one acquaintance who died.

Fast forward to 2020-21, and another read of the first two paragraphs of this article reveals that nothing much has changed even a century later. India is in the middle of the second Covid wave, which is turning out to be more dangerous than the first. This is concerning as the world believed health services and medical science have progressed in last the 100 years (which actually has) and it should have resulted in better response to a pandemic.

In 1918, when the influenza pandemic broke out, the cause of disease was not even known (the influenza virus was identified in 1933). There was no laboratory test to confirm the disease and no vaccine; the World War I was going on; health services were already overwhelmed due to cholera and plague.

In 2021, scientific progress has ensured that the entire genome of SARS-CoV-2 was known, a highly reliable laboratory test was available, a few highly efficacious vaccines were administered to people; sophisticated equipments and hospitals were available. The advance of medical and public health science has been remarkable, but people faced the most harrowing time in accessing health services. Doctors and other healthcare providers struggled to cope with new infections.

If there is one thing which would be needed soon after the second wave of Covid-19 is over, it is the need to look back and analyse what the Indian healthcare system could have learnt from the past, should have done and should do now, immediately and urgently.

The second wave of Covid-19 has come a few months after the second wave in other countries, which had a similar situation somewhere in the mid- to late 2020. There was no reason to believe it would be any different in India. The 1918 pandemic data shows that the second wave was deadliest, and it affected and killed more people in a short period than other waves during the entire pandemic. Both flu and Covid-19 are respiratory illnesses.

Public health planning should have been strengthened. Though the laxity in people's behaviour was being noted, but from February to April 2021, the government too did not show its resolve to enforce public health measures. While customary guidance on Covid-appropriate behaviour was issued, it was policymakers and elected leaders who tacitly encouraged crowding in festivals (Holi at end March 2021), election rallies in five states (March-April 2021) and religious congregation (Kumbh Mela in Haridwar; March-April 2021).

For policy makers, it was complete disconnect between preaching and practice. If hapless migrants walking on the highway became defining images of India's national lockdown in 2020; millions of people taking holy dip in the Ganges, with no possibility of adherence to Covid-appropriate behaviour on the day India reported its highest ever daily new cases, have become defining images of the pandemic in 2021.

Handling of the Covid pandemic in Indian states, in spite of scientific and public health advances, demands for honest and critical reflections by policymakers and health experts alike. This is needed to respond to the ongoing pandemic and also to prepare India for all future epidemics and pandemics.

The reason Nirala observed swelling rivers was partly unavoidable. But the swelling crowds at election rallies and at holy dips at the height of the pandemic were avoidable and would have been right public health measures. If we would have learnt the lessons from 1918, the impact of the ongoing pandemic could have been mitigated. Now, there are two pandemics to learn from.

(Dr Lahariya is public policy and health systems expert. He is the co-author of "Till We Win: India's Fight Against The COVID-19 Pandemic". Views are personal)