Comparisons to the flu pandemic of 1918-1920 were legion during the current COVID-19 pandemic. Despite many similarities, there were also important epidemiological and contextual differences. The flu pandemic occurred at the tail end of a world war, it occurred before scientists understood the transmission mechanisms of the flu, and it occurred before the existence of a major international organization focused on health (read about the impact of the 1918 influenza on inequality here). A final major difference lay in communications and information: we will never know how many tens of millions perished from the flu, while we could follow case counts and death tolls in real time during COVID-19, flawed as those numbers have turned out to be.
Why was COVID-19 a pandemic of statistics and information (Tworek 2021), while the flu pandemic was not? The systems underlying Covid statistics emerged partly because of the flu pandemic. Beyond comparisons, the history matters because it laid the foundations for the communications disseminated by the World Health Organization (WHO).
Epidemics and the need for international health coordination
From the mid-nineteenth century onwards, Western states had tried to coordinate the exchange of information about infectious diseases like cholera to enable swifter quarantines and, hopefully, prevent epidemics. Politics got in the way: even seventy years later, no coordinated information exchange took place during the pandemic of 1918–1920.
An international system emerged in the 1920s within the new League of Nations Health Organization (LNHO), the predecessor of the World Health Organization. The Versailles Treaty of 1919 did not envision a health organization at the League, but two epidemics spurred its creation: influenza and the lesser-known typhus epidemic. The influenza pandemic had killed more people than World War I with estimates ranging from 50 to 100 million deaths. Colonial, indigenous, and aboriginal people were disproportionately affected: approximately fifty percent of residents in the Bombay Presidency contracted the flu and around one million died (Hardiman 2012). Colonial administrators mostly ignored the issue, though some thought that lack of information had exacerbated the problem. One British colonial administrator in India, Norman White, would later become a League official and had been inspired by the flu pandemic to improve epidemiological information.
The more direct experience fostering the LNHO was a typhus epidemic that raged in Eastern Europe and Russia from 1916. Within four years, the region experienced around 30 million cases and 3 million deaths. The terrible typhus epidemic prompted the creation of the LNHO. Ludwik Rajchman, a bacteriologist, coordinated Poland’s response to typhus so impressively that he became the League’s Medical Director from 1921 to 1939.
The first standardized system of international disease reporting
Ludwik Rajchman believed fervently that statistics and information would “demonstrate the practicability and the indispensability of international health work” (cited in Borowy 2009: 96). The LNHO created myriad monthly and annual reports and publications to standardize international reporting and statistics on infectious diseases. The cornerstone of the system became a weekly epidemiological information service on infectious diseases. In the 1920s, this voluntary system came to encompass two-thirds of the world’s population and made information a vital part of epidemic management (see here).
The system relied on the relatively new innovation of wireless technology to send information between territories and moving ships on the sea. The League’s system sought to forestall epidemics by receiving messages from moving ships and informing ports of infected ships before they even arrived. The system was coordinated through Geneva and an LNHO bureau in Singapore, called the Far Eastern Health Bureau, which opened in 1926. As one former League official wrote, the Bureau was “a central fire-station in a municipal system of fire prevention” or “the world’s alarm system” (cited in Tworek 2019: 823). Imperial states were eager to participate for many reasons, but particularly to avoid trade disruptions. Like today, economic incentives were paramount.
While the system achieved apparent success in covering much of the world and standardizing disease reporting, it also contained and continued inherent inequalities. The wireless version focused on three diseases: smallpox, plague, and cholera. Europeans were particularly concerned about these illnesses, but they actually had lower death tolls than more common diseases like tuberculosis. The system also focused on Asia and Africa, perpetuating a problematic imperial tradition of portraying diseases like cholera as “oriental.” So too the COVID-19 pandemic saw a troubling resurgence of anti-Asian racism tied to disease. And during the pandemic, vaccinations against and attention to diseases like tuberculosis also decreased.
The LNHO’s system conveyed statistics, but never managed to coordinate interpretations or reactions to those numbers. The weekly bulletin listed the number of cases without designating a certain number as an epidemic. The bulletin deliberately allowed each country and port to decide the threshold for an epidemic. “Arbitrary standards are adopted in various countries and individual ports,” wrote the head of the Eastern Bureau in 1938, “and it is obvious that no single numerical standard could be applied universally” (cited in Tworek 2019: 835). The definition of epidemics is political, social, economic, and epidemiological (see the classic Rosenberg 1989). But the LNHO’s inability to coordinate action between states has left a legacy that persists for the WHO today.
The legacy of the League of Nations Health Organization
The League’s epidemiological intelligence infrastructure persisted after World War II through its personnel, publications, and philosophy. Many publications continued, now under the imprint of the WHO. Many LNHO officials went on to work for the WHO. For example, Raymond Gautier, the first director of the Eastern Bureau, served as Acting Director of the Health Organization from 1939 until 1942 then Assistant Director-General of the WHO from 1948 until retiring in 1950. Colleagues later described the first director of the Eastern Bureau who had created the wireless epidemiological service as “truly the soul of the World Health Organization” (British Medical Journal 1957). The philosophy of disease prevention still rests on the assumption that communication could eradicate communicable disease. The latest update to WHO rules, the International Health Regulations of 2005, sees risk communication as one of eight main capacities for member states.
All these systems, though, rest on the structural foundations of the interwar period, a time rife with global inequalities. Alas, some of these prejudices and problems have persisted in the present pandemic. When it comes to international epidemiological information, we and the WHO still live in an interwar world.
- Raymond Gautier, M.D. The British Medical Journal 1, no. 5027 (May 11, 1957): 1127.
- Iris Borowy, Coming to Terms with World Health: The League of Nations Health Organisation 1921-1946 (Frankfurt am Main: Peter Lang, 2009).
- David Hardiman, “The Influenza Epidemic of 1918 and the Adivasis of Western India,” Social History of Medicine 25, no. 3 (2012): 644–664.
- Charles Rosenberg, “What Is an Epidemic? AIDS in Historical Perspective,” Daedalus 118, no. 2 (1989): 1–17.
- Heidi J. S. Tworek, “Communicable Disease: Information, Health, and Globalization in the Interwar Period,” American Historical Review 124:3 (2019): 813-842.
- Heidi J. S. Tworek, “Afterword: Competition during Covid-19,” in Daniela Russ and James Stafford (eds.), Competition in World Politics: Knowledge, Practices and Institutions (Bielefeld: Bielefeld University Press, 2021), pp. 289-300.
Canada Research Chair and Associate Professor of History and Public Policy (University of British Columbia, Vancouver, Canada)
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