The artist had witnessed the deaths of his father, brother and sister, and lost his mother and another sister to insanity. Like many famous men and women–and many more who weren’t famous–disease had blighted his life. Nor was he the only one warning the medical profession against hubris in the early twentieth century. In 1906, George Bernard Shaw wrote The Doctor’s Dilemma, in which the eminent doctor Sir Colenso Ridgeon toys godlike with his patients’ destinies (Sir Almroth Wright, on whom the character was based, is said to have walked out of a performance). But in Europe, the cradle of germ theory, they were swimming against the tide. Only after the Spanish flu did the backlash become generalised. On 28 October 1918, The Times of London muttered darkly about neglect and lack of foresight, and looked to make ‘somebody answerable for the nation’s health’. ‘Science has failed to guard us,’ stated the New York Times, a paper that spoke to one of the most enthusiastically scientific nations on earth.2 ‘No more dope!’ clamoured the enemies of western medicine everywhere.
The hubris of the medical community was punished, at least in the industrialised world. The irregulars had all claimed higher cure rates than the regulars, and their followings now grew. Over the next two decades, as scientists argued over what had caused the Spanish flu, they flourished and acquired respectability–including the more respectable label, ‘alternative medicine’. In the 1920s, in some US cities, a third of those who went to conventional doctors also went to alternative practitioners. Chiropractic reached mainland Europe at the beginning of that decade, and by the end of it the only continent where it wasn’t practised was Antarctica. As for homeopathy, the man who had presided over the health of New Yorkers during the pandemic, and who as a surgeon and homeopath had a foot in both camps–Royal S. Copeland–legitimised it when, as a senator for New York, he made sure its pharmacopoeia was approved under the Federal Food, Drug, and Cosmetic Act of 1938.
The irregulars had a fundamentally different conception of health from Ilya Mechnikov. For Pasteur’s lieutenant, nature was essentially disharmonious and in need of a helping hand–notably vaccination–to coax it into health. For them, disease was the result of a disruption of the natural harmony, and so was vaccination, to which they were fiercely opposed. Benedict Lust, the father of naturopathy, called germ theory ‘the most gigantic hoax of modern times’.3 As the irregulars gained in stature, some of their ideas penetrated the popular consciousness and were eventually embraced even by the conventionals. The most important of these was an emphasis on prevention that went beyond hygiene, to sport, body consciousness and diet. These ideas reached the masses with the blessing and encouragement of the elites, who saw in them a convenient way of distracting the lower classes from the dangerous allure of communism. Thus the King of Spain–the same Alfonso XIII whose high-profile case of flu had contributed to the pandemic’s naming–gave his regal imprimatur to the Madrid Football Club in 1920, creating Real (Royal) Madrid FC, and turned football into a national pastime.
Back-to-nature movements had taken off in the nineteenth century, as an antedote to industrialisation, but they had been fairly elitist affairs. In the 1920s, movements such as Lebensreform (life reform) in Germany–which advocated vegetarianism, nudity and homeopathy–widened their remit, drawing in just those sectors of the population that had suffered worst from Spanish flu. In 1918, the Italian-Americans of New York, like the Jews of Odessa, had kept their windows firmly shut, believing that spirits or bad air caused disease. Now sunlight and fresh air became bywords for health, and by 1930 the concepts of nature and cleanliness had become firmly linked in people’s minds. Counter-intuitively, after the war, a once vigorous anti-cigarette movement collapsed. Smoking had been encouraged among the troops as a least-worst substitute for other sins, but it had also been promoted as a prophylactic against Spanish flu. Now associated with positive attributes, it became fashionable. Women took it up.
Among the bitterest enemies of conventional medicine were Christian Scientists, who rejected almost all medical intervention. The pandemic over, they claimed that prayer alone had proved superior to conventional methods, and their following also grew rapidly at this time–both in their native US and abroad. New faith-healing movements were born. Philadelphia had had a particularly severe dose of the flu, and in October 1918–just as the New York Times was trumpeting the failure of science–the mouthpiece of the Philadelphia-based Faith Tabernacle, Sword of the Spirit, published the testimonies of the ‘healed’ of the Spanish flu under the headline ‘God’s witnesses to divine healing’. That year, Faith Tabernacle established itself in Gold Coast (Ghana)–which had also had a bad case, losing an estimated 100,000 people in six months–and quickly spread to Togo and Ivory Coast. Faith Tabernacle was in decline in West Africa by the late 1920s, but it lives on in the African Pentecostal movement, with its emphasis on divine healing and speaking in tongues.
Many Africans underwent a crisis of comprehension in 1918, since neither Christian missionaries–whom they associated with western medicine–nor their traditional healers could account for the scourge.4 A new generation of prophets emerged who offered a different world view. Flu survivor Nontetha Nkwenkwe was one of them, in South Africa, and her story ended tragically in a clash with western medicine. But Africans weren’t the only ones undergoing intellectual crises. ‘Victorian science would have left the world hard and clean and bare, like a landscape in the moon,’ wrote Sir Arthur Conan Doyle in 1921, ‘but this science is in truth but a little light in the darkness, and outside that limited circle of definite knowledge we see the loom and shadow of gigantic and fantastic possibilities around us, throwing themselves continually across our consciousness in such ways that it is difficult to ignore them.’5
Conan Doyle, the British creator of that most scientific of detectives, Sherlock Holmes, stopped writing fiction after he lost his son to the Spanish flu, and devoted himself instead to spiritualism–the belief that the living can communicate with the dead. Spiritualism had been popular in the nineteenth century, but it enjoyed a resurgence after 1918, encouraged in part by Albert Einstein’s description of time as a fourth dimension (if there were four, why couldn’t there be more, some of which harboured restless spirits?). In 1926, Conan Doyle was invited to speak to the members of a scientific society at Cambridge University, who listened politely if sceptically to his description of ectoplasm as the material basis of all psychic phenomena.6
In general, the 1920s were a time of intellectual openness, of testing and trampling of boundaries. With the publication of his general theory of relativity in 1915, Einstein had introduced the notion of the subjectivity of the observer. Niels Bohr and Werner Heisenberg were arguing, within a decade of the Spanish flu, that there is no knowledge without uncertainty. Any scientist who had lived through the pandemic, especially if he remembered Émile Roux’s insightful musings on those êtres de raison (organisms whose existence can be deduced only from their effects), realised that good science demanded open-mindedness, experimental rigour and a healthy dose of humility.
If such ideas were circulating at that time, some credit must go to the Pope. In 1919, nothing remained of the international scientific community that had thrived before the war. If an international science conference had been organised in that year, Germans and Austrians would have been excluded. The Vatican had annoyed both sides by declaring itself neutral in 1914, and in 1921, wanting both to re-establish peace and to re-ingratiate himself, Pope Benedict XV revived the moribund Lincean Academy–a forerunner of the Pontifical Academy of Sciences. He gave it the mission of restoring international scientific relations, seeing the quest for a disinterested truth as the perfect vehicle for dialogue, but he was choosy about his quests. Only ‘pure’ or experimental science qualified–physics, chemistry, physiology. The applied sciences that aimed to solve human problems were, in his view, subjective and thus liable to reproduce the tensions that had led to war in the first place.7
The entente nevertheless extended to all science
s, eventually, and by the 1930s, medical science had redeemed itself, to some extent. Virology was established as a discipline, the first flu vaccines were coming online, and Fleming had discovered penicillin while trying, and failing, to grow Pfeiffer’s bacillus in a dish. By then, however, thanks to his success in publishing nature cure journals, American naturopath and wrestler Jesse Mercer Gehman had accumulated a larger fortune than the press baron William Randolph Hearst (whose mother, Phoebe, had died of Spanish flu). And the Nazis, in power in Germany, had appropriated the notion of nature as clean to legitimate purification of the German population, a project that culminated in the Second World War. As the Schutzstaffel (SS) retreated at the end of that war, they set fire to the Austrian castle where works from Vienna’s Belvedere Museum had been stored for safekeeping, Klimt’s Medicine among them. All that remains of the work today are a few sketches and some poor-quality photos. The artist never discovered its fate, because he died in February 1918. He had suffered a stroke and caught pneumonia while in hospital. Some have suggested that his was an early case of Spanish flu.
19
Healthcare for all
If health authorities had learnt anything from the pandemic, it was that it was no longer reasonable to blame an individual for catching an infectious disease, nor to treat him or her in isolation. The 1920s saw many governments embracing the concept of socialised medicine–healthcare for all, free at the point of delivery.
You don’t put a universal healthcare system in place in one fell swoop. Such a system takes time to develop, and to become truly universal. The first and most important step is to work out how you are going to pay for it. Germany was a pioneer in this, Chancellor Otto von Bismarck having set up a national medical insurance programme in 1883. Under this state-funded, centrally administered scheme–which lives on in spirit in the country’s modern healthcare system–Germans could expect to receive treatment and sick pay for up to thirteen weeks. Britain and Russia established insurance systems in the 1910s, but it wasn’t until the following decade that most countries in western and central Europe followed suit.
Once you have your funding in place, the next step is to reorganise the way you provide your healthcare. In Germany at the time of the Spanish flu, healthcare was fragmented. There was no national health policy, though the idea had been floated in 1914, and doctors worked either on their own account, or were funded by charities or religious institutions–a pattern repeated all over the industrialised world. In 1920, a social hygienist in Baden named Ernst Künz suggested a root-and-branch reform, whereby the government would train and fund district physicians, and health councils would be elected at every level of the country’s administration.1 Künz’s proposal was ignored–perhaps, some have suggested, because if they had acknowledged the need for change, German physicians would have been admitting to their failure to manage the Spanish flu, and they weren’t yet ready to do that.
In 1920, therefore, Russia was the first to implement a centralised, fully public healthcare system. It wasn’t universal, because it didn’t cover rural populations (they would finally be included in 1969), but it was a huge achievement nevertheless, and the driving force behind it was Vladimir Lenin. He was well aware that, although the revolution had succeeded, it had done so at the cost of the near annihilation–due to famine, epidemics and civil war–of the working class. Doctors feared persecution under the new regime (the Bolsheviks weren’t fond of intellectuals), but Lenin surprised them by soliciting their involvement at every level of the new health administration, and in the early days, this placed particular emphasis on the prevention of epidemics and famine.
The official Soviet vision of the physician of the future was spelled out in 1924, when the government called on medical schools to produce doctors who had, among other things, ‘the ability to study the occupational and social conditions which give rise to illness and not only to cure the illness, but to suggest ways to prevent it’.2 Lenin realised that medicine should be not only biological and experimental, but also sociological, and it was around the same time that epidemiology–the science of patterns, causes and effects in disease, that is the cornerstone of public health–received full recognition as a science.
Epidemiology requires data, and in the years following the pandemic the reporting of health data became more systematic. By 1925, all US states were participating in a national morbidity reporting system. The early warning apparatus that had been so lamentably lacking in 1918 started to take shape, and public health officials also began to show more interest in a population’s ‘baseline’ health. The first national health survey was carried out in America in 1935–eighteen years after the ‘horrible example’, when the mass examination of army draftees had revealed shocking levels of preventable or curable illness and deformity.
Governments beefed up their epidemic preparedness. Nowhere was this feat more remarkable than in China, where–in the years since the Manchurian plague outbreak of 1911–Wu Lien-teh had, almost singlehandedly, put in place the foundations of a modern health system. In 1912 he had set up the North Manchurian Plague Prevention Service. The following year, dissection was legalised in medical schools, and in 1915, the National Medical Association was created to promote western medicine in China, with him as its first secretary. After Chiang Kai-shek seized power from the warlords, his regime centralised the collection of health data, and in 1930 a National Quarantine Service was set up in China. Under its first director, Wu, this organisation oversaw quarantine arrangements at all China’s major ports, and sent regular epidemiological reports back to the League of Nations in Geneva. Within two years of crowning himself Shah of Persia, meanwhile, General Reza Khan had snatched back quarantine services on the Persian Gulf from the British–though not without a struggle–and between 1923 and 1936, his government increased fiscal allocations to the country’s sanitary infrastructure twenty-five-fold.3
As more disease data became available, and as more people were drawn into the universal healthcare ‘net’, epidemiology’s scope broadened. To begin with, it had been narrowly focused on infectious disease, but it soon encompassed non-communicable or chronic diseases too, and by 1970 epidemiologists were interested in any health-related outcome–even homicide. That evolution reflected both scientific progress and demographic change, as heart disease, cancer–and more recently the dementias–overtook infectious diseases as the biggest killers.
When Britain set up its National Health Service in 1948, pneumonia, TB, polio and venereal disease still killed large numbers of people, and one in twenty babies died before the age of one (tenfold more than today). Medical science wasn’t what it is now, but it had nevertheless made great strides since 1918: there were modern antibiotics, and from 1955, a polio vaccine. This is why the NHS and similar systems were so transformative. Poor people who had previously received no medical care at all, who had relied on their own, sometimes dangerous folk medicine or on the charity of doctors, could now be cured of many of their illnesses. The elderly were among those who saw the biggest change, since many of them had been condemned to ending their lives in neglected ‘back wards’ or workhouses. The NHS pioneered the development of geriatric medicine in Britain.
Many of us take free healthcare for granted today, so it’s easy to forget that the concept was extremely unpopular in some quarters, in the 1940s. Doctors tried to block the NHS for two years prior to its birth, considering it a threat to their income and their independence. It was seen as synonymous with socialism–a ‘socialist plot’–and at one point Winston Churchill of the Conservative Party attacked the Labour health minister Aneurin Bevan in the House of Commons, calling him ‘a curse to his country’. Indeed, fears of a ‘socialist plot’ are the reason Americans still don’t have a universal healthcare system today. Instead, employer-based insurance systems began to proliferate in that country from the 1930s on.
Many countries created or reorganised health ministries in the 1920s. This was a direct result of the pandemic,
during which public health leaders had been either left out of Cabinet meetings completely, or reduced to pleading for funds and powers from other departments. Now they had a seat at the high table, and thus, increasingly, public health became the responsibility of the state. At the same time, politicians realised that public health measures gave them a means of extending their influence over populations. Health became political, and nowhere more so than in Germany.
Though Ernst Künz’s proposal of reform was ignored, the emphasis in German healthcare did gradually shift from private practice to public health under the Weimar Republic (1919–33), and by the time the Nazi Party came to power German doctors were used to cooperating with the government in the provision of medical care. Eugenics, of course, had long been a powerful current of thought, but in 1930s Germany, eugenic theory–as promulgated by the Nazis–became mainstream medical practice.
One of the first Nazi laws to be passed, in 1933, was the Law for the Prevention of Offspring with Hereditary Diseases–also known as the ‘sterilisation law’–whose aim was to prohibit persons defined as genetically inferior from reproducing. ‘Genetic health courts’ made up of judges and doctors–with the doctors acting as ‘advocates of the state’–made decisions about the forcible sterilisation of such individuals, in sessions from which the public was barred, and sometimes in less than ten minutes. A subsequent expansion of the law allowed them to order abortions up to the sixth month of pregnancy.4
Pale Rider: The Spanish Flu of 1918 and How It Changed the World Page 23
