Pandemic Politics

How the Spanish flu changed our approach to public health

When Canadians contemplate the potential for another pandemic after experiencing severe acute respiratory syndrome in 2003 and novel H1N1 influenza in 2009, they generally turn to the Public Health Agency of Canada website for information about the most effective ways to protect themselves and their families. But why do we expect the federal government to provide this information and to coordinate a national pandemic plan? Have Canadians always been able to rely on the federal government to fight disease and protect citizens’ health?

The Last Plague: Spanish Influenza and the Politics of Public Health in Canada by Mark Osborne Humphries, a military historian at Memorial University, is an ambitious attempt to examine the history of public health governance from 1832 to 1939 using the influenza pandemic of 1918 as the pivotal event that prompted the creation of a national health department in 1919. This study challenges existing scholarship on the pandemic and charges that “Canadian historians have been reluctant to present the influenza as an important actor in the national narrative.” Humphries’s objective is to explain how the 1918 outbreak changed existing health policy and reflected popular and official responses to the disease, social issues and the rising expectations that accompanied the end of World War One. His reinterpretation offers historians, policy makers and the public an opportunity to learn how a society challenged by war and epidemic disease musters the resources to cope, survive and build on the experience.

In dense but readable prose, Humphries presents his narrative of the outbreak. Vivid descriptions of individuals suffering and dying from the 1918 influenza are balanced by tables and figures that quantify the human cost of the pandemic. But his central focus is the chaos that resulted from the lack of central direction and the conflict between civilian and military officials during the outbreak. (Ironically, as we know, the SARS outbreak of 2003 generated the same calls for unified action, but instead of internal requests, the World Health Organization imposed a travel advisory on Toronto because it was unable to get accurate information from the federal government. Political conflict between Ernie Eves’s government in Ontario and Jean Chrétien’s government illustrated the continuing divide between federal and provincial authorities even in the face of a new and deadly enemy.)

The Last Plague begins with an introductory overview of the 1918 influenza pandemic and an analysis of the current state of the historical literature. Humphries correctly notes that most recent studies focus on specific Canadian cities or regions and that there are inaccuracies and gaps in our understanding of the timing of the outbreak and the factors that contributed to its virulence. He therefore proposes to examine the way in which Canadian authorities and citizens understood the disease, used traditional quarantine and non-therapeutic measures to try to stop the spread, and ultimately turned to community action to care for the sick in the midst of the final push to win the war. He begins with two introductory chapters that establish the historical context for the practices and problems discussed in the following five chapters, all of which focus on the 1889–90 and 1918 influenza epidemics. In Chapter 9, he examines the politics underpinning the creation of the first federal health department, and then the final chapter examines the work of the new department and demonstrates the extent to which the pre-war emphasis on immigrant inspection and quarantine as the first line of defence against communicable diseases was altered by the implementation of modern public health theories and programs. His conclusion reiterates the importance of the outbreak in causing a paradigm shift in public health policy.

The Last Plague raises many important issues about national health policy and the deeply rooted beliefs that influenced its evolution. Using broad strokes, Humphries outlines the impact of 19th-century cholera, typhus and smallpox epidemics in shaping both state action and public attitudes. Using a Foucauldian theoretical frame stressing the “medical gaze” and governmentality, he defines public health governance as “attempts to encompass all practices, social activities, and economic exchanges that threaten to spread disease or undermine collective health.” As he indicates, all of these are negotiated actions that are “constrained by dominant political ideologies and popular attitudes toward disease, the state, and medical science.” One important result of the belief that disease was imported to healthy colonies and provinces through immigration was the assurance that federal authorities were made responsible for the inspection and quarantine of newcomers while provinces and their municipalities were assigned hospitals, charities, and property and civil rights in the British North America Act, 1867. Given Canada’s relatively slow progress in terms of urbanization and industrialization after 1867, the alternate vision that posited environmental causes for “filth” diseases had limited political support. It was far more popular to blame the strangers at the gate than to ask the general population to embrace cleaner habits. Nevertheless, dedicated sanitarians called on federal and provincial governments to emulate British and American policies and shift attention from border security to national health standards. Their calls for a federal health department met resistance from politicians who did not see the need to interfere in a field left to provincial jurisdiction.

As a result, when the influenza broke out in 1889–90, Canadian quarantine authorities continued to examine newcomers and quarantine the sick as they entered the country, but since the epidemic was relatively limited, no further policy changes resulted. This contrasted with British and American approaches, which adapted to the discoveries of the bacterial causes of communicable diseases by creating stronger local or state health departments and establishing central agencies to coordinate action. Was Canada so dilatory in spite of pressure from the medical profession because the pandemic was mild or because the federal government lacked money and interest in expanding its oversight?

As Humphries clearly explains, influenza is a complex disease that mutates with great frequency. This genetic drift and shift means that it is regarded as a minor nuisance until it assumes pandemic form and turns into a killer. Pandemics that are worldwide epidemics are crucial moments in individuals’ and states’ lives. The Spanish influenza of 1918 was a turning point in Canadian life because it revealed the limitations of the current approach to disease control, the power of the military to override civilian authorities and the determination of social reformers to achieve the changes that would justify four years of sacrifice and respond to well-known urban problems.

The heart of this study is an analysis of the complex nature of the 1918 outbreak in Canada. Through diligent research in military and civilian records, Humphries has concluded that there was a “herald” wave of the epidemic in Canada during the winter/spring of 1918. He suggests that this occurred because the British authorities had 94,000 Chinese labourers, some of whom were sick, shipped east across Canada for travel to the Western Front. Further complicating the situation, the recently elected Unionist government, a Conservative and Liberal coalition that had campaigned on a platform of promising to win the war and transform Canadians’ lives in peace, had agreed to provide troops for a Siberian Expeditionary Force, embarking in Vancouver, and at the same time military authorities were attempting to round up conscripts for training and shipment to England. As a result, provincial and municipal efforts to control the spread of the second and much more virulent wave of influenza were negated as troop ships sailed east to Europe and troop trains travelled west en route to Siberia spreading the disease. For news editors, parents and government critics, the deaths of soldiers from influenza was a preventable event and they wanted to know why federal quarantine officers and provincial and municipal officials had failed to coordinate their efforts. For the middle and upper class women who ventured into the homes of the poor to provide nursing care and food, fuel, clothing and rent money, the epidemic provided an opportunity to cross class lines and led the National Council of Women to redouble its efforts to achieve social change. The 1918 influenza thus became both a symbol of dedication and community spirit as doctors, nurses and gallant volunteers nursed the sick and tried to keep the war effort functioning, and a catalyst for demands for a national health policy.

While granting the central role of the pandemic in highlighting the deficiencies of divided jurisdiction, the realpolitik behind the creation of the federal health department also merits somewhat more attention than it receives in this study. Important as the NCW was in pushing for a federal health department, the work of the Canadian Medical Association and the Canadian Public Health Association should also be recognized. The leaders of these organizations were engaged in war work and were well aware that between 30 percent and 50 percent of volunteers had failed their physicals, that venereal disease was a significant problem in the Canadian Expeditionary Force and that wounded and tubercular soldiers would require care when they returned home. The leaders of the CPHA were closely linked to their American counterparts during the war and the pandemic, and had long been advocates of a national health department. Medical professionalization and the increasing emphasis on medical research and scientific advances were factors that also contributed to public support for central direction in spite of the ineffectiveness of most medical efforts during the outbreak.

But perhaps the most interesting unanswered (and possibly unanswerable) question is why did the CMA, the sanitarians, the NCW, leftist intellectuals such as William Irvine and social reformers/politicians such as Newton Rowell believe that a national health department was necessary. Is it possible in a country as geographically diverse and dispersed as Canada to create national health policies? The social reformers clearly accepted the view that society’s problems required expert solutions. Were they convinced that only the federal government had the power and funds to achieve national standards in health and welfare? Did they see the new federal department as a way to achieve social change? As Humphries demonstrates, the new department found itself developing shared-cost programs to deal with infant mortality, venereal disease, food and drug quality, and housing. It also continued to provide immigrant inspection and quarantine and was charged with examining civil servants for employment, illness, disability and pensions. And by the end of the 1920s, it was being asked to look into the question of health insurance. Cuts by first the King and later the Bennett government blighted the promise that had seemed so evident in 1919. But with the creation of the Dominion Council of Health as an advisory group of provincial deputy ministers and representatives of women’s, farmers’ and labour organizations who met twice a year to discuss pressing health issues, the question of Canada’s pandemic preparedness was finally addressed. At the first meeting in October 1919, a pandemic protocol was worked out; it was designed to ensure that the approximately 50,000 deaths in 1918 would not occur again.

The Last Plague is a valuable addition to the scholarship on World War One and the Spanish influenza pandemic. By focusing on both the military and civilian experience, Humphries illustrates how the chaos of conflicting priorities and lack of central direction may well have added to the morbidity and mortality rates. But does he pay sufficient attention to the zeitgeist? Were the NCW and other reform groups simply in the right place at the right time? Or was it cold political calculation about the number of women voters and their role in future elections that truly prompted the creation of the federal health department? For all their emphasis on collective good, did the social reformers really understand the dynamic underpinning the federal bureaucracy? Were they aware of the impact of the Civil Service Reform Act? And had they and the Unionist politicians thought about the inevitable backlash against centralization that would result once the war had ended? One of the ironies of achieving a longstanding objective is surely the realization that despite one’s faith in planning and expertise, the never-ending contest inherent in federal, provincial and now territorial relations still lies at the heart of national policies. This question was pertinent in 19th- and early 20th-century Canada and continues to challenge policy makers today. The relevance of Humphries’s work is that it demonstrates the contingent nature of policy making and the difficulty in maintaining reform momentum during periods of retrenchment. These lessons from the past still resonate today.