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Lessons from the 1918 flu pandemic for Japan and the world: Hyogo U. Chancellor

A U.S. Army base in the state of Kansas is seen filled with Spanish flu patients in around 1918, in this image from the archives of the U.S. National Museum of Health and Medicine.

In the second edition of our series considering the global spread of the novel coronavirus and its implications, Makoto Iokibe, 76, the head of the Asian Affairs Research Council, looks at the lessons from the outbreak of the Spanish flu 100 years ago and how they may be relevant to the world's experience of the new coronavirus today.

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The history of humanity is also a history of encounters with infectious diseases. Among transmissible diseases carried by bacteria, the plague, cholera, tuberculosis (TB) and others have long threatened us. Afflictions from viruses, which are far smaller microorganisms than bacteria, have included smallpox, AIDS and influenza. Many of them came about from zoonotic infections from animals that lived near humans.

For example, when the plague ravaged European society to near destruction in the 14th century, infections in humans originated from flea bites; the parasitic insects would transmit bacteria from their rat hosts into us. Some types of influenza, too, have come from birds and pigs, and the 2002 outbreak of SARS out of Guangdong province, China, is said to have been transmitted from bats via masked palm civets into humans.

But by the 20th century, treatments and vaccines had been developed for many of the infectious diseases that caused upheavals for humanity, and today a large number of them have been suppressed. But in the midst of all this, some stubborn viruses persist. Among influenza types A, B and C, A mutates easily, and many existing vaccines and treatments are not effective against it.

Ebola hemorrhagic fever (EHF), which emerged from Africa in 1976, the previously mentioned SARS, and 2012's MERS are all new types of powerful viruses for which there was no treatment. But if a powerful virus maintains a terrifying mortality rate and slaughters many people, it loses its hosts and goes down a path of localized self-annihilation.

In comparison, the 1918 influenza that has come to be known as the Spanish flu, and the novel coronavirus we face today; both avoided the folly of a suicide attack and started off as viruses exhibiting light symptoms while they infiltrated human society.

The Spanish flu went on to end the lives of 25 million people. In an interview with the Yomiuri Shimbun daily published on April 10, UCLA professor Jared Diamond, an authority on infectious diseases in human history, said that because the world's population is four times its number during the 1918 influenza pandemic, and because globalization has enabled a marked acceleration in the spread of infections, he expects the death toll from the novel coronavirus to exceed the Spanish flu. It's a frightening thought. From here, I wish to take into consideration analysis including that provided by Akira Hayami in his 2006 book "The Influenza Pandemic in Japan, 1918-1920: The First World War between Humankind and a Virus," and examine the two pandemics.

In March 1918, the final months of World War I, infections from a new strain of influenza began at an army base in the U.S. state of Kansas. The year before, President Woodrow Wilson had decided America would join the war, enabling the virus to hitch a ride to Europe by boat. There is no environment more ideal for viral transmission than an army barracks; soldiers were cramped like sardines, and orders were exchanged at close pointblank range in loud voices. Their conditions were what we refer to today as the "three Cs" of confined spaces, crowded places, and close contact.

But the first wave of infections taking place in 1918 over the spring and beginning of summer saw many develop only light symptoms, and it wasn't treated as a matter of great importance. But after briefly dying down, the second wave emerged in the summer. The virus had successfully mutated, and attacked with greater potency.

There were many cases of people between their 20s and 40s, in the prime of their health, drawing their final breaths around two days after developing symptoms. Incidentally, it's said that many older people had greater immunity due to the influenza outbreaks of the previous century.

The virus flourished among soldiers, and it traveled from port towns along the main arteries of Europe to engulf the Eurasian continental landmass. There was a huge amount of death, with 600,000 in North America, 2.3 million in Europe, 12.5 million in India, 1.5 million in Indonesia, and 390,000 in Japan, among others. In all 25 million people are said to have died, but others assert that it was closer to 50 million or 100 million.

But this was all going on in the middle of a huge war, when the number of deaths is a state secret that countries don't want their enemies to know. All sides worked to conceal the figures to prevent exposing their weaknesses. So Spain, a neutral country, ended up getting its name slapped onto the disease spreading everywhere.

In all, around 9 million people died fighting in WWI, with the younger generation who were to be in charge of the future of society killed indiscriminately. On top of that was the threat from the virus. What a mess. In November 1918, the ceasefire came. Perhaps the countries caught up in the war's frenzied slaughter were being punished further by the infectious disease, which, ironically, fulfilled a role in pushing the combatants toward peace.

The virus came to Japan a little late. In May 1918, a group of sumo wrestlers on tour in Taiwan were infected, and some cases in Yokohama that originated on a military vessel docked at the Port of Yokosuka were reported, but Japan effectively avoided the first wave.

But then came the more virulent second wave. For Japan, there were two peaks: one in November 1918, the other in January 1920. Primarily during 1919, the virus spread to every corner of the country, and 388,000 people lost their lives. The figures, compiled by the Ministry of Home Affairs which oversaw the police and health departments, are accurate in comparison to international numbers.

Even in today's Japan, we are still some way away from having a medical system that can cope with the number of patients with heavy symptoms that were seen during the influenza outbreak. Then, most had no choice but to stay home on the verge between life and death. People who asked to be hospitalized were refused, and it was apparently not uncommon for bodies to be seen in front of hospitals. It was a completely horrendous time.

Avoid gatherings, move away from people who are sneezing, always wash your hands and gargle, cover the face with a mask or cloth. All of these directives come from the Home Affairs Ministry's messages to the public at the time. It's grimly amusing to see how little has changed between now and 100 years ago.

Humanity finally saw a virus for itself under an electronic microscope in 1933, and research after that identified the so-called Spanish flu as Influenza A virus subtype H1N1. As mentioned before, type A mutates easily, and there are suspicions that the novel coronavirus could resemble it in that way. H1N1 disappeared from our world after that, but the new strain of influenza that emerged in 2009 was its return.

In December 2019, pneumonia cases of unknown origin began taking place in Wuhan, China. But in China, the leaders of the ruling party must be made aware of a situation, and political implication must be cleared before even making an announcement. Finally, on Jan. 9, a public statement was made that a new coronavirus had emerged one month prior. The virus continued to spread explosively, and the Chinese government locked down Wuhan on Jan. 23. It was two days before start of the Spring Festival to celebrate the Lunar New Year.

Among the countries and regions in China's vicinity, Hong Kong, Taiwan and Vietnam took immediate, decisive action in response to the virus. They quickly cut off travel links to Wuhan, and entered state of emergency measures against the infectious disease. These three places have two things in common. One is that they all keep a close watch on China's movements due to its enormous influence on the region. The other is that they all suffered under the 2002 SARS outbreak.

SARS spread from Guangdong to Taiwan, Hong Kong, Vietnam and Singapore, bringing with it a mortality rate of 10%. They didn't forget the lessons learned from that experience, and established systems to deal with infectious diseases. It made them victors in the early stages of the battle with the novel coronavirus. Even now they continue to hold that position, with incredible results showing just six deaths in Taiwan, four in Hong Kong and none in Vietnam as of April 25, according to data compiled by Johns Hopkins University in the U.S.

In an unexpected development, the new coronavirus instead traveled from Wuhan along the course of countries in China's "Belt and Road Initiative" to cause explosive outbreaks in Iran, Italy and Spain. In a reverse of the events of 100 years ago, the virus then traveled from Europe into North America, where the United States then became the country with the greatest number of infections.

There have also been claims that places where anti-TB Bacille Calmette-Guerin (BCG) vaccinations are not carried out have seen a greater spread of the novel coronavirus, but it's unquestionable now that whether people are in East Asia or Europe or the United States, if they come together unguarded, they run the risk of cluster infections.

And so we come to Japan.

The government of Prime Minister Shinzo Abe used its good relations with Chinese President Xi Jinping to have Japanese nationals in the Wuhan area come home quickly on chartered planes. It was an early diplomatic success. But Japan faltered on two points. It didn't stop Spring Festival travelers from China visiting the country, and it could not get the situation on the Diamond Princess cruise ship under control.

Compared to the three places mentioned earlier that had experience of the SARS outbreak, Japan was lax about the threat. I understand that it didn't want to lose inbound tourists and that with a state visit from Xi on the calendar, it didn't want to be the one to pull the trigger on worsening relations between the countries.

But these were all considerations to be taken under ordinary circumstances, and Japan lacked a sense that it was facing another of human history's terrible infectious diseases. In the same way, the attitude of treating the chaos on the cruise ship as an unavoidable result of complications over who has the right of jurisdiction over what goes on inside it was a symptom of being stuck in an ordinary, peacetime way of thinking. In the emergency they found themselves in, it was necessary to insist to the vessel's owner and its captain that Japan be given full authority so far as fighting against infectious disease, or that the ship leave the port.

I think that what saved Japan from a dangerous situation was its distinguished infectious disease experts. From the end of January, the Ministry of Health, Labor and Welfare established a prevention headquarters that included experts in their fields. On Feb. 14, the government created its panel of experts that falls under the headquarters, and a plan to stop the virus based on their advice was drawn up.

The panel compiled its basic policies against the new coronavirus about 10 days later, but there were many problematic issues and long-winded sections. In response, Prime Minister Abe announced at the end of February that all of the country's elementary, junior high and high schools should be temporarily closed from the start of March. Although it was late, it signaled that Japan was beginning an all-out war with the novel coronavirus.

There were criticisms reminiscent of more ordinary times that the Abe government did not consult the Ministry of Education, Culture, Sports, Science and Technology or those in positions connected to schools, but those evaluations are evidence of a lack of understanding regarding the crisis ahead. Even in democratic societies, leaders act quickly and decisively in an emergency, but there is a greater demand for structures of governance in which the leadership seeks the understanding of the public and provides appropriate financial relief.

With the panel's deputy chair Shigeru Omi and professor Hitoshi Oshitani of Tohoku University, both of whom worked for many years combatting infectious diseases at the World Health Organization (WHO), and Hokkaido University professor Hiroshi Nishiura's mathematical analysis to try out policy decisions at the center of their proposals, the team put together a package of measures for Japan's version of the coronavirus fight.

In it, their tactics would focus first on quickly apprehending cluster infections, which serve as the base for further infections, and keep them from spreading. Additionally, to protect the health system's limited capabilities and stop people coming to hospitals in overwhelming numbers, they suggested a policy of having individuals with mild symptoms stay home and see how their condition develops. Next, the concept of the "three Cs" was put forward as a way to reduce all residents' instances of contact. The countermeasure package also provided a mathematical model showing that if people's interactions were reduced by 80% of normal levels, then the virus could be brought under control. It was then that Tokyo, Osaka and the rest of Japan's governors were put in a front position of taking emergency measures.

Japan's government does not fully control with an iron fist all aspects of citizens' lives in the way that China does. But even in democracies, there are cases of cities being locked down, and citizens being punished for going outside. In the middle of all that, Japan's national and regional governments have based their approach on requests to the populace, and in the name of the safety of society as a whole while being careful not to stop economic activity or excessively remove people's freedoms. It is a very lenient society that places its faith in high cultural standards.

But despite that, the explosion in cases in Japan that was warned about by experts abroad has yet to materialize. The death toll in Japan by late April 2020 was around 500 people, a modest number compared to that of European countries. As a lesson from the experience of this time, the reconstruction of legislative and medical systems should become a very important issue.

Primarily there are two things that could influence what happens after our present situation. One is whether, like the Spanish flu, the novel coronavirus returns in a second wave with a more virulent strain. Whether that happens is largely dependent on our opponent, but if we think of mutation as something that occurs among a large number of viral infections, then whether or not human societies avoid the three Cs becomes a factor. The other thing is the progression of medical science. Without successful development of new medicines or vaccines, then our battle could end up not so different from the one we faced 100 years ago.

A century ago the world was embroiled in a major war, and it could not afford to face down a virus. Today, the largest concern among the world's people is this pandemic, but international society is no less fragmented than it was 100 years ago. The United States is rushing to pin responsibility on the WHO and China, while China itself is strengthening its hold on the seas around it. Cooperative work to resolve the pandemic and rebuild the post-pandemic world will certainly face persistent difficulties.

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Viral mutation

The influenza virus, which initially posed no threat to humans, became able to infect them, and then passed from person to person. In the case of the Spanish flu, it became an especially virulent pathogen that claimed the lives of 25 million people. The influenza virus is slowly altering its genetic configuration by mutating for its own survival. The H1N1 influenza virus mutated significantly as it passed between large numbers of people.

SARS

SARS, which stands for Severe Acute Respiratory Syndrome, emerged from Guangdong province in China, and spread internationally as a new infectious disease. It was contained in around half a year due to measures by the WHO and others, but over 8,000 people in 32 countries and regions were reportedly infected, with 774 people known to have died from it. It causes a sudden fever of over 38 degrees Celsius, a persistent cough and shortness of breath, among other symptoms.

Makoto Iokibe

Born in 1943, Iokibe specializes in the history of Japanese political diplomacy. He has served as a professor at Kobe University, the president of the National Defense Academy, chancellor of the Prefectural University of Kumamoto in southwest Japan, and is now chancellor of the University of Hyogo in west Japan. He was also chairman of the government's Reconstruction Design Council in response to the March 2011 Great East Japan Earthquake, among other roles.

(Japanese original by Makoto Iokibe, Chancellor of the University of Hyogo)

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