Learning from forgotten epidemics

A panic had set in and people from the infected area were hurrying to be inoculated. The crush was dreadful and the crowd fought and struggled. [When injected] ... the men shouted and swore and they charged out like mad bulls. The women didn't scream, [but] hung about on one another's necks and wept softly, wondering if they were going to die.

The Bulletin, March 31, 1900

IN THE COOL, early morning of Wednesday, March 21, 1900, a crowd began gathering outside the offices of the Board of Health in Macquarie Street, Sydney. Inside the building, the Secretary of the Board, Clarence Simms, was already anxious. Bubonic plague had broken out in The Rocks three months earlier and the newspapers were full of lurid stories about the "Black Death". People had died and their relatives been marched off in the night to the quarantine station at North Head.

The New South Wales Government had stockpiled Haffkine's serum, the new plague vaccine cultivated in mutton broth. It had a few hundred doses to inoculate front-line health workers, new plague victims and their contacts, but the Sydney newspapers were campaigning for a public vaccination program. Under pressure, and to the dismay of Mr Simms, the government caved in.

The Board of Health's secretary had gone to his office early that morning to make sure all was ready for the first day of the vaccination program. By half past eight, Mr Simms looked out the window of his office and became so alarmed he rang the police. Outside in Macquarie Street were a thousand people.

What happened next stunned him and rocked the New South Wales Government. When the Board of Health finally opened its doors, the crowd surged forward past the police and up the stairs, where people became stuck. The newspapers reported a melee. In the crush, men fought, women fainted and the offices were damaged.

The public inoculation campaign was abandoned. By that stage, the plague had already spread around the colonies, and it was another two decades before Australia was plague free.


FAST FORWARD A centuary and we're being asked to imagine that this could happen again. Not plague, of course, but something possibly as lethal and swift – a human pandemic of avian influenza. Federal Health Minister Tony Abbott has even asked us to imagine tens of thousands of Australians dead.

"Not since World War II have Australians had to cope with very large numbers of premature deaths," Mr Abbott told a pandemic conference a couple of years ago. "Australians are unused to contemplating the possibility of death on a massive scale, especially from natural causes. The competing temptations are 'it won't happen here' complacency, 'there's nothing we can do' fatalism, and 'no precaution is too great' alarmism."

He was articulating a problem doctors and politicians have always had, and which during the plague scare of the late nineteenth century was described by health officials as "fear in the right proportion". They want to scare people just enough to take appropriate action, but not scare them so much that they panic or retreat into denial.

So, at the risk of alarming you or making you scoff, the Australian public's record in handling outbreaks of swift and deadly diseases isn't good. It's probably no better or worse than anywhere else in the world, but it's a cause for concern for the people planning for a bird flu pandemic. In fact, pandemic planners – companies and governments – have been hiring people to tell them how to handle the public should the worst happen. Peter Sandman lives in New Jersey and is a risk consultant who's been hired by American and Australian companies to tell them about the risk they face from their employees, customers and shareholders. "When something is dangerous and people are ignoring it, I get hired to scare them," he says. "When something isn't dangerous and people are freaking out I get hired to calm them down. And when something is dangerous and people are rightly freaking out, I get hired to guide them through it and help them bear it."

The feeling among many people involved in preparing Australia for a new plague is that the public is not scared enough about bird flu, and this could be a problem. Australian governments and many large corporations have already imagined the consequences of a deadly influenza pandemic, and now have pandemic plans in place. Around the country in secret sheds are stockpiles of anti-viral drugs and medical supplies.

But one of the premises of pandemic plans is that the public will cooperate with authorities. Should a deadly human-to-human influenza pandemic break out, there will be strict laws enforced to curtail our movements. How well we co-operate with quarantine and rationing, queuing at surgeries and being ordered to stay at home will determine how well the country copes.

Unfortunately, the history of our behaviour during epidemics isn't encouraging. "Those who cannot remember the past are condemned to repeat it," said American poet and philosopher George Santayana in 1905, when the plague was still burning its way around the world.

In Australia, when it comes to epidemic disease we have a collective amnesia. The terrifying epidemics that have swept through Australia in the past – diseases such as smallpox and plague, tuberculosis and polio, childhood killers such as whooping cough and diphtheria – are not only outside the experience of most people, but the events themselves appear to have been erased from our cultural memory.

The Director of Health Studies at Macquarie University, Peter Curson, has been studying Australian epidemics for some time. "There were extraordinary scenes in parts of Sydney during the 1900 epidemic where people refused to vacate their homes and they were evicted by police and teams of health workers using long poles for obvious reasons," he says. "There were full-scale fights in Sydney. Quarantine and removal worked all right when you could just remove one or two people, but they removed whole populations of hotels – eighty to a hundred people. There were extraordinary scenes. A wave of hysteria panic and aggression and hostility swept right through Sydney. Without doubt, it was the greatest social tragedy of the nineteenth century in Australia."


SEVERAL YEARS AGO, when researching my novel Affection, based on an outbreak of plague in Townsville in 1900, I decided to try to find the site of the isolation hospital and plague cemetery that was the factual basis of my story, the place where three heroic doctors were working. I knew it existed and assumed it was common knowledge in Townsville. I had death certificates and the letters from doctors, and even a map. I found that hardly anyone in Townsville knew of the plague, and that virtually no one had heard about the plague cemetery at Three Mile Creek. It seemed extraordinary to me that somewhere, under a tangle of weeds on the banks of Three Mile Creek just north of the city, were the unmarked, lost and forgotten graves of eight or nine people.

If you drive along the coast north of the main business area and head towards the suburb of Pallarenda, you cross Three Mile Creek. There's a nursing home on the left and a park on the right, and the creek runs through Townsville's town common. The common is an interesting relic. It's surprising that it still exists, but it is mainly swamp and prone to flooding, so that may be the reason. It was once used by the locals to keep their horses and cows, but it also quickly became a convenient area for politicians to put things they didn't want placed anywhere else. Because it was public land, it was a convenient place to solve messy problems.

Bits of the Townsville common were carved off for a quarantine station, a dump, sewage treatment, for bombing practice in World War II, and for the German (now Belgian) Gardens cemetery. And in 1900, in the initial plague scare, it was hastily decided to put the plague hospital on the town common.

It turns out that the site was never officially gazetted, but this is also the case with most plague hospitals and their accompanying cemeteries around the country. There's a substantial plague cemetery somewhere on Gibson Island in the Brisbane River.

There's now little evidence left of Australia's plague epidemic. What happened to cause this historical amnesia? When the plague arrived in Australia in 1900, it produced scenes of mass hysteria and panic. Guns were drawn as doctors came to take people away, people were beaten, and in Townsville a vigilance committee was set up to protect the people from the doctors and the terror not of plague, but of quarantine. There were similar scenes in other towns and cities. Plague wasn't a big killer, but it remained in Australia for more than twenty years, it infected twenty-six towns and cities, and it killed – officially – about six hundred people.

There's a human tendency to cover up mistakes and unpleasant experiences, and so our plague cemeteries are gone. The bodies (well, there wouldn't really be much left of people wrapped in sheets soaked in sublimate of lime, screwed into wooden coffins and buried in lime in graves up to seven metres deep) are nominally still there.

As we confront future epidemics, I have a feeling that this collective amnesia isn't healthy. Who remembers the terror of polio in the 1950s, or the hundreds killed by dengue fever outbreaks in Queensland and New South Wales in the 1920s? Who's still alive to describe the bubonic plague outbreaks of the first two decades of the twentieth century, or in fact the Spanish flu epidemic of 1919?

In 1998, ABC radio interviewed one Spanish flu survivor of 1919, Beryl Duthey, who lived in Balmain in Sydney. "They used to have this big cart going around," Mrs Duthey said. "I said to me mother what's that and she said, oh never mind, it's got nothing to do with us. The dirtman I think, with a bell. I was a sticky beak and I went out and had a look and it was a big long fat cart with two horses in all – one horse different days – and they rang a bell and if you had dead people in the house sometimes they had boxes made out of fruit boxes and things like that, and other times they wrapped the bodies up in blankets and put them all on this cart and took them away. I don't know where they took them to or where they buried them or anything. But my aunty had three or four boys, I'm not quite sure, died with it."

The Great Spanish Influenza Pandemic killed twelve thousand Australians, and at least fifty million people worldwide. Imagine January 1919, when the virulent ancestor of bird flu arrived in Grove Street in Sydney, the home of Beryl Duthey. The troops returning from the Great War had marched up Grove Street from the wharves, and the flu spread from there.

"They seemed to go unconscious," said Mrs Duthey. "You know, perspired and went unconscious. They all wanted to get out of bed. I could hear mum saying, you've got to stay there you got to stay there, because they were all perspiring but Terry, the young one, he got out of bed and run around the peppercorn tree and he got pneumonia and he was the first one to die."

Walking down leafy Grove Street today, you pass the same terrace houses and cottages. The street plunges down to Sydney Harbour and people are strolling down to Birchgrove Park. When I was making a radio documentary on avian influenza for ABC Radio National's Background Briefing program in 2006, I spoke to the people who lived in Grove Street. No one was aware of the body carts, and few were aware of the Spanish flu. Everyone had heard of bird flu, but hardly anyone was concerned. The feeling is that the government is developing a vaccine, precautions are being taken, and all will be well. No one in Grove Street, Balmain had read the government's pandemic plan; no one was aware of Australia's history of epidemic diseases, or of the public's poor form when it comes to remaining calm in a crisis. And why should they be?


IN FACT, BIRD Flu has disappeared from the front pages, almost vanished from our everyday life, although the threat remains as big as it was two years ago. But raise the subject of bird flu now and people think you're being alarmist, irrational, scaremongering or even naïve. We scoff at fear. We don't remember what it was like to be truly scared of a lethal disease.

We're in the middle of a terrible pandemic of HIV/AIDS, of course. But this isn't something you catch by someone coughing on a bus; it is an insidious, slow burner, not easy to catch. It doesn't produce the same widespread terror as, say, plague or smallpox.

So imagine how you would react in an epidemic of a lethal strain of influenza, which you could pick up on your way to work and possibly be dead by tea-time. What would you do if your child was sent to a special influenza hospital, or if you were quarantined at home for weeks, or separated by road blocks from family and friends in a life-and-death crisis?

History shows that we're not good at obeying the law during epidemics. There's a story from the 1881 epidemic of smallpox in Sydney where entire families, healthy and sick, were quarantined at North Head. In one case, a family had come into contact with a smallpox victim and was forced into quarantine. The father was separated from his family. They were housed at the station onshore, and he was put on a ship just offshore.

A few days later, he learned that his daughter had fallen ill with smallpox. His daughter was dying and so, desperate to see her, he jumped overboard and swam ashore. The guards caught him and brought him back, and so he did it again, until they put him in leg irons. His daughter died. Imagine the anguish that drives a father to visit his dying daughter, and imagine that happening across the country.

Our natural instinct is to be with family, to continue earning money or doing business, to visit our daughters during a crisis. Governments may try to stop us doing that for the public good, and may resort to enforcing the laws of quarantine, which have always been Australia's first line of defence against disease. In fact, the federal government's been dusting off the old Quarantine Act of 1908 to prepare for bird flu.

"It's a very interesting law because over the years quarantine has become much more about animals and goods than humans," says Senior Lecturer in Philosophical and Historical Inquiry at the University of Sydney, Alison Bashford. "But the clauses that deal with humans which were there in the original act are still in operation."

It's just a matter of resurrecting them. Interestingly, the Australian 1908 Quarantine Act was twinned with the Immigration Restriction Act to form the legal basis for the "White Australia" policy. The "White Australia" policy was abandoned in the 1950s, but the Quarantine Act of 1908 is still in force and it's remarkably powerful. It can be used to close our borders, ban public gatherings, commandeer a school for use as a fever hospital, and quarantine us.

"And so it's precisely this lesson that needs to be brought to the present," says Professor Bashford, "about how the question of people being bodily and physically removed from family, removed from home, sometimes in the past for very long periods of time. It goes to very deep liberal questions of habeas corpus, questions of detention, questions about what are the legitimate powers by which the state can intervene in an individual body. For the sake of the public. For the sake of the public good."

In fact, quarantine has saved Australia from many terrible epidemics of the past – or at least held them at bay until they were less lethal. There's no doubt it saved lives. The 1919 outbreak of Spanish flu is a good example. It could easily have entered the country a year before, but for quarantine. Quarantine will be our first line of defence in the case of a human-to-human pandemic of bird flu. We'll be asked to give up some very basic individual rights. "Australia's been geographically protected partly by its distance from other places," says Professor Bashford. "But it really has been through this rigid quarantine measure that diseases like cholera have never entered this continent, and in some ways this really is a remarkable historical achievement. At the same time, at an individual level, at a personal level, the implications of quarantine could be very harsh indeed."


IT IS THE social impact of quarantine, on top of the disease itself, that's uncertain and fraught with danger. And that's worrying the people whose job it is to think about a flu pandemic. During the plague, and smallpox, people were more scared of quarantine, of being separated from their families, than they were of the disease itself. People just don't like being incarcerated and separated from their families, especially at a time when family members may be dying.

In 1915, at the start of World War I but several years before the Spanish flu, Sigmund Freud wrote a paper entitled "Thoughts for the Times of War and Death". It said, in part: "Contemporary man, living in a scientific age in which epidemic disease is understood and to a large extent controlled, is apt to lose appreciation of the enormous population losses in past generations and of the prolonged widespread psycho-social and emotional strain produced by such disasters."

So, getting back to the plague, there are lessons to be re-learnt.

Imagine Australia in 1900. Bubonic plague was already in the papers. People were talking about the war in South Africa and the plague. It had been identified in the city of Canton in March 1894, and within weeks killed sixty thousand people.

When the plague reached Hong Kong in the same year, it killed tens of thousands more. From Hong Kong, it jumped aboard that modern transport system the steamship, and for several years went around the world with the ships' rats. The danger was well anticipated in the more developed countries. There was an international conference in Germany and another conference in Melbourne well before the plague arrived in Europe and Australia.

And this was a fairly optimistic and exciting time in medical history because for the first time doctors could see their enemy under a microscope, and they had developed anti-toxins. Rabies, diphtheria and plague, for the first time, could be tackled reasonably successfully with vaccines. There was real hope that all disease could be conquered.

Australia had six years to prepare for plague, but when it arrived in January 1900 it infected thousands, killed hundreds, and stayed for more than twenty years. And it wasn't very contagious. You had to be bitten by a flea carrying the bacterium, although in Townsville one man apparently caught it chasing a rat around the hotel bar: every rat had a sixpence bounty on its head. This is another curious response to a crisis. Many people panicked, and others – including some doctors – denied it was plague at all.

The bubonic plague that swept around the world in the late nineteenth century was the third great plague pandemic, and it killed around twelve million people. That pandemic is still killing people. The plague that reached California in 1900 infected local rodents and became endemic. Plague also gained a foothold in Africa and South East Asia. People still die from plague in Africa, Asia and the USA.

The plague wasn't all bad. Even though it wasn't eradicated until the 1920s, it had a profound effect on Australia's healthcare systems. It revealed widespread conditions of filth; it resulted in the creation of a national quarantine service; and more money was spent on public health systems (which hardly existed then). In fact, the plague helped create the public health systems we know today. Public health commissioners replaced the boards of health and public health officers who went out into the towns and suburbs.

But it had taken deaths from plague to change the health systems. The mere threat of death has, historically, rarely been enough to cause the changes necessary to prevent death. Even today, when it comes to public health, people usually have to die before the system changes. Look at what's happened in Queensland in recent years with the Bundaberg hospital scandal, and funding for anti-venin research into irrukandji jellyfish stings.

The plague was by no means the worst epidemic Australia has experienced, and if it wasn't actually theplague I doubt any people would have worried too much about it. Typhoid killed more people in 1900 and hardly rated a mention in the newspapers. Plague, on the other hand, arrived in Australia with all of its historical baggage: its terror, and its ability to bring out the worst and best of human behaviour. It's something we should remember, but don't.


LAST YEAR, THERE was a program on television  about Auschwitz and the documentary-makers were surprised that most of the current generation of young Britons had never heard of Auschwitz. So why is it important to remember the things that killed us in droves?

Louis Pasteur, the man after whom the plague was first named (Pasteurella pestis was later renamedYersinia pestis), said: "In the field of observation, chance only favours the prepared mind." Observing the history of how humans behave during epidemics can help us all stay alive. But studying history has been out of fashion for some time. It seems we really should take a close look at what human beings are capable of doing in times of crisis. We need to focus not only on the damage disease can cause, but on our own potential for behaving badly, because we're all potential cowards. We celebrate mateship and the Anzac spirit, but it's worth reminding ourselves that, under pressure, any one of us could run, desert our mates, ignore the law, flee an isolation hospital, break quarantine to visit a loved one.

The other thing about the 1900 outbreak of plague that struck me when I was looking at it was its destruction of public confidence in authority, particularly in all levels of governments. We yearn for governments that are accountable and transparent, but during emergencies governments and administrators clam up, or dither, or resort to spin. They fear the public more than the disease, probably with good reason. During war, we accept a level of secrecy. During an epidemic, the attitude appears to be different. When a member of our family is at risk, we'll be demanding the awful truth.

The plague in that initial outbreak in 1900 also revealed a dangerous flaw in governments: how badly levels of government tend to co-operate with each other. It has to be said that an enormous amount of good, hard work has been done to prepare Australia for a pandemic. I don't believe, though, that we – the public – are as prepared for the consequences as we could be. I'm not sure how to achieve this, but a look at history would be helpful.

In Australia and other Western countries, we're several generations removed from those terrible epidemics that swept swiftly and indiscriminately through communities, killing and maiming the people we loved. We've forgotten what it's like, and in forgetting this aspect of history we may be making mistakes. As Professor Alison Bashford says: "I think that there's a lot more work to be done, especially now that there's this huge security juggernaut, if you like, this massive investment in disease and security questions, and I think that the people who are involved in Australian security questions around this issue of disease would do well to look at past experiences of government, of people, of popular opinion, of ways in which the government has successfully or unsuccessfully brought people on board around questions of extremely difficult critical life and death decisions."

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