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The 1918 H1N1 global flu pandemic, commonly known as the “Spanish Flu,” was possibly the deadliest pandemic in human history. It claimed between 50-100 million lives worldwide between 1918-1920. That's almost the equivalent of 200 million people today, and over twice the number of lives lost in WWI. The Spanish Flu in Japan alone took an estimated 390,000 to 450,000 lives.

We don't hear much about its effects in Asian countries, specifically in Japan. However, as a disease that ravaged the world, Japan suffered as much as any other country. How did they handle it? And what can a world currently in the midst of its own global crisis – the COVID-19 epidemic – learn from this history?

A Note About the Term “Spanish Flu”

Please make careful note that despite the name, the “Spanish Flu” did not originate in Spain. Early records indicate the first case was in the United States. Yet not wanting to stir panic or expose a weak point in a time of war, no one involved in the war reported the outbreak. It wasn't until after Spain, who was neutral at the time, reported the first accurate figures that other countries followed suit. However, many were all too eager to shift the blame to Spain. This is what led to the incorrect naming of the virus as the “Spanish Flu.”

We see similarities to recent accounts of people calling today's COVID-19 pandemic the “Chinese virus.” This has lead to a horrible uprise in xenophobia and hate crimes against Asian people in Western countries. We can see that racism stemming from careless reporting is not a new issue; this happened a hundred years ago.

We should be mindful when discussing current events to avoid finger-pointing and “foreignizing” issues clearly affecting the entire world without bias. We should aim to be like this Japanese politician, the governor of Fukushima, who has spoken out to bring awareness to and hopefully stop racism from spreading like a pandemic itself.

Current World Health Organization guidelines strongly discourage naming a disease after a geographic location or culture. The term “Spanish Flu” is specifically listed by WHO as an example to avoid. We use the term here purely for historical and content discoverability reasons. Unseen Japan does not endorse the use of place and cultural names in reference to infectious diseases.

Discovery of the Spanish Flu in Japan

The 1918 Influenza epidemic began in Japan in late August 1918 and became a national epidemic in November. Experts believe it entered Japan through a group of sumo wrestlers returning from Taiwan (a colony of Japan at the time). Because of this, for a while, people in Japan called it the ‘sumo flu.'

The sick wrestlers' initial diagnosis was bronchitis and pneumonia, which didn't raise serious concern at the time. Mortality rate wasn't as high compared to the plague or cholera (which was ten times higher, but less likely to contract). Dubbing it ‘sumo flu,' and later the ‘Spanish cold' (スペイン風邪 supein-kaze in Japanese) shows how they underestimated its severity.

It only became evident later, when it had spread so far and wide it could no longer be ignored. On October 26, 1918, a Japan Times & Mail headline read: “Thousands Dying from Influenza Throughout the World.”

Effects of Spanish Flu in Japan

Though accurate statistics are impossible to acquire due to incomplete records, academics estimate around half-a-million Japanese victims died either directly from the flu or secondary complications.

The time period preceded modern-day technology. Nearly every business was person-to-person. Naturally, the first to contract the virus first were those in contact with many people on a daily basis: reporters, newspaper delivery men, telegraph workers, transportation operators, government officials, and teachers. Workers fell ill left and right. But it wasn't until it hit schools that the government finally took serious action.

Elementary school children developed high fevers and even nosebleeds. Two children in a Tokyo elementary school died. It was then that the city shut down most stores and businesses. By November, the death toll rose, and Spanish Flu was officially classified as an epidemic.

Spread and Severity Varied By Region

Rate of spread varied by region, but in general, no area was spared. The virus swept through urban areas rapidly due to population density. It hit rural areas later, which suffered more devastating consequences due to lack of resources and medical staff. Frigid mountain villages had it the worst due to low temperatures and harsh winter weather. By the end of the epidemic, it had decimated entire villages.

One “lucky” thing was that the virus didn't linger in one spot for very long. It averaged three weeks to a month. Granted, any length of time was bad enough, but the outcome could have been much, much worse.

Reporting on the Spanish Flu in Japan

A Japanese poster from the time period urges people to seek treatment if symptoms of the Spanish Flu developed. (Picture: Wikipedia)

The Ministry of Home Affairs finally issued an official statement across all prefectures in late October. They reported that this deadly disease was none other than the ‘Spanish Flu' currently ravaging the world.

The problem was that nobody, not even government officials, knew what to do next.

The world was very different 100 years ago. Naturally, so too were the way diseases were transmitted, reported, treated, and studied. Nobody knew where influenza came from, nor how to prevent or treat it. There were no vaccines. People could neither self-diagnose nor run to the nearest facility to get tested.

Newspapers shared basic influenza prevention and treatment advice. Officials distributed posters and fliers around the city. The government and medical professionals encouraged good hygiene and standard illness-prevention protocol: wearing masks in public and gargling often, washing hands, and avoiding crowds, advised people to stand at least 1 meter apart. Green tea consumption increased, as it is high in immunity-aiding vitamin C.

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In some places, transportation operators turned passengers away for not wearing a mask. In one report, a passenger even pushed the emergency stop button when another rider coughed without wearing a mask. (As we can see, masks were a pretty big deal.)

Despite constant warnings, the government had yet to impose any official restrictions. Many public services continued, albeit at a slower, less-frequent pace, and even entertainment facilities were still open. Because so little was known about the virus, many believed that as long as they followed the protocols mentioned above, they would be fine.

Treating and Controlling Spanish Flu in Japan

Once contracted, even experts weren't sure what to do. People who felt ill were advised to stay home, get plenty of sleep, avoid humid environments, and drink lots of water. Patients in serious condition were quarantined. Some medical professionals turned to herbal and traditional remedies.

Medical professionals and scientists believed influenza was caused by bacteria. Much research and treatment centered around this belief. For example, Dr. Gomibuchi Ijiro, a Japanese physician, made many (unsuccessful) efforts to find a cure – or, at the very least, help his own patients.

The Good Doctor: Dr. Gomibuchi's Efforts

Two New Zealand scholars documented Dr. Gomibuchi's efforts in an English article, “A Japanese Physician’s Response to Pandemic Influenza: Ijiro Gomibuchi and the ‘Spanish Flu’ in Yaita-cho, 1918–1919.”

Dr. Gomibuchi recognized that the symptoms in his patients were typical of the flu virus. However, he also believed the cause was a diphtheria type of bacteria. On that basis, he administered what would have been proper treatment had he been correct: an experimental vaccine of diphtheria serum. He treated 99 patients, including himself and his family members.

Of his 99 patients, six sadly died (a whopping 6%). We may consider this treatment irresponsible and ineffective, but at the time, it was as good as any doctor could hope to do. Though unsuccessful, Dr. Gomibuchi showed commitment to his patients, and deserves some credit for doing what he could with his limited information at the time.

Scientifically Researching Spanish Flu in Japan

Properly studying and identifying viruses required highly skilled researchers, and a huge budget. Unfortunately, Japan lacked these resources. And most of their medical research focused on tuberculosis, the national disease at that time.

Doctors and scientists did what they could, but it was all too easy to fall into the trap of touting each latest discovery as the “possible cause” or “probably cure.” Many reports that claimed to have discovered the influenza pathogen had actually identified Pfeiffer’s bacillus (now Haemophilus influenzae), the cause of secondary illnesses such as pneumonia.

The real cause would not be discovered until the 1930s, after the development of the electron microscope and the ability to isolate, cultivate, and research illnesses through virology. This discovery was thanks to American virologist, Richard Shope. Shope was responsible for the isolation of swine influenza virus and the subsequent isolation of human influenza virus by Smith, Andrewes, and Laidlaw.

Spanish Flu in Japan: The Second Wave

Posters in Japan at the time warned, “You can’t live without a mask!” (マスクをかけず命しらず!)

By mid-November and December, the spread of the virus slowed down. Schools began to open, and society struggled to ease back into normalcy. Businesses paid workers special overtime wages to get the economy back on track and compensate for those still out sick. Occasional outbreaks appeared in some areas, but not to the same extent. People who had already contracted it still died of pneumonia and other secondary causes through January. But with fewer new cases, many believed the worst was finally over.

They were wrong.

Around late January/early February of 1919, a new outbreak erupted. It didn't spread as fast but was far more deadly. This is because when a virus evolves, the newer strain is often more powerful than the first. People who hadn't developed immunity to the first strain were at high risk. Though fewer people contracted the flu this time, the mortality rate was five times higher.

Japan turned to the same practices from the first wave. However, as the second wave was much stronger, these practices were less effective. Use of facemasks was encouraged again, as many people saw it as “better than nothing at all”. All people could do was control it to the best of their ability, and wait it out, hoping for the best.

By March, though it subsided in some areas, it began to ravage rural areas. It was a slow, drawn-out process as it cycled through small mountain villages. By the end of the epidemic, some villages were entirely wiped out. It wasn't until June 10 that Japan saw a day with no new cases. At last, they could safely announce: “Epidemic Finally Over.”

After the Pandemic: Vaccines, Life Insurance, and a ‘Mini-Boom'

Japan sought to do whatever it could to prevent future outbreaks after the epidemic. The introduction of vaccines lead the Japanese government to begin mass vaccination for schoolchildren in 1962. Though they discontinued mandatory mass vaccinations in 1994, they remain a highly-encouraged option, especially against pneumonia, the main cause of flu-related deaths.

The sales of life insurance also increased, which were not as widely used before the pandemic. Prices of animal products, such as eggs, rose, as many animals also died, having caught the disease from farmers. Finally, there was also a “mini-baby-boom” in 1920, following the severely low fertility rates of 1918-1919.

Parallels Between COVID-19 and Spanish Flu

Women walking with surgical masks in February 2020 in Tokyo in an effort to ward off COVID-19. (Picture: Rodrigo Reyes Marin / Shutterstock)

You may recognize some similarities to the 1918 Pandemic in today's COVID-19 response. While there is much that we have learned, there are many things that didn't work then, and won't work now. Here are some other parallels to note.

The first is the tendency to use politics as a guideline for reporting and handling a pandemic. Because Spanish flu hit during WWI, authorities downplayed its seriousness to avoid mass panic. Officials suppressed reports, insisted it was “no worse than a cold,” and encouraged people to carry on as usual. This recalls recent headlines in the early phase of today's coronavirus. It particular brings to mind the case of Dr. Iwata Kentaro, the disease specialist booted from the Diamond Princess. According to Dr. Iwata, “the bureaucrats were in charge,” and “weren’t trusting the process to actual infectious disease control specialists.”

Another similarity was blaming the consumption of certain animals. Before the Spanish flu became an epidemic in Japan, officials speculated that pigs were the culprit after discovering infected swines in the Kurume Region. In Fukuoka, they discovered a similar illness in chickens. Though the real cause was found much later, they also found that stronger strains could be transmitted from infected humans to animals. (This resulted in the loss of livestock, especially during the second wave.)

Learning From The Past: What Didn't Work

We can also observe the same erratic behavior in the general public both then and now. While Japan remained generally calm in the midst of the chaos, people turned to all sorts of unusual methods. Many took basic home remedies very seriously, especially those who couldn't visit a doctor. Those who did get treatment didn't even receive the right kind, as with Dr. Gomibuchi's experimental serum.

Many more believed in hearsay remedies, turned to spiritual means (such as praying and visiting shrines), and bought protection amulets. A Japanese farmer reputedly even paid a visit to the “Cough-Suppressing Priest” of Kannonji village and was back to good health again only a short time later.

Though less prevalent in Japan than western countries, there was also the appearance of charlatans taking advantage of the confusion with their latest “surefire cures,” and conspiracy theorists offering every suspicion under the sun, but never a solution. This can be seen in the United States today, where the US President, Donald Trump, is constantly encouraging Americans to try untested and unverified medications to treat COVID-19 – a recommendation that's had fatal consequences.

Finally, some took a more serious and sometimes fatal approach, turning to alcohol and drugs, and some taking their own lives, unable to cope with the loss of loved ones.

What Does Work

There is much we can (and have) learned from the past in terms of both what to do and NOT do. Yet while the majority of us are probably smart enough now not to seek the Cough-Suppressing Priest, we should be aware of the irrational things panic often causes people to do.

With the limited knowledge available at the time, it is difficult to know how many people in isolation contracted and recovered from the Spanish Flu without treatment or diagnosis. What may have been most effective in controlling the spread of Spanish flu in Japan was people adhering to social distancing, isolating when sick, and maintaining basic hygiene and illness-prevention protocol.

Hand washing is a good practice, but alone does not prevent infection. Masks don't filter out everything but do reduce droplet spread. (Regardless if a person is sick or not, nobody wants to be coughed or sneezed on!)

There is a reason “mask culture” has become a standard health practice and social etiquette in Japan. You lose nothing in wearing one if available to you, so best practice may be to do both: wear a mask and continue to wash your hands.

The Future is in Our (Washed) Hands

Once contracted, highly infectious illnesses such as the 1918 flu and COVID-19 are difficult to prevent, contain, and treat. However, citizens – both in Japan and around the world – can take steps to minimize long-term effects and ensure a faster bounce-back, both socially and economically. Both policymakers and the general public alike should study the past and learn from it.

For the general public, following government guidance to remain inside as much as possible is the best way individuals can do their part in controlling the spread of COVID-19. Policymakers should aim to employ more effective methods than offering a meager amount of free masks to citizens. The government has an opportunity to revise business policies to allow more flexibility and sick leave so that sick employees don't come to work and spread illness. (Encouraging telework is also an effective strategy that's working well in other countries.)

The biggest takeaway from Japan's handling of the 1918 epidemic is that a strong community effort enabled everyone to do the best with what they had at the time – and, ultimately, to persevere.

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