when sneeze kills

When Sneeze Kills:

Indonesia's Influenza Pandemic of 1918

by Arie Rukmantara

Influenza pandemic in 1918 was probably the greatest single natural disaster ever to hit this earth. The impact of the pandemic made a catastrophe to every country, including Indonesia, then the Netherlands Indies.

In the midst of World War I, a deadly flu hit Southeast Asia. Historical records said the Dutch colonial authority believed that the disease originated from China. In early 1918, some patients were detected to have influenza in Hong Kong port. These people were on their way to Southeast Asia.

Another historical source said it was generally believed that Influenza pandemic of 1918 started in the United States of America in March 1918, and spread to Europe along with the arrival of the US troops sent there. Few weeks later, the disease started to spread to other parts of the world. In June, the flu reached Bombay, India, and in the same month, it reached Pankattan, in the east coast of Sumatra. The place is now known as Pangkatan District in North Sumatra. It is suspected that the disease came from the Straits Settlements (Singapore or Malay Peninsula).

The Dutch consulate in Singapore saw the threat and warned Batavia about possible arrival of people with flu symptoms. It advised Batavia to ban arrivals of ships from influenza-affected areas. The Batavia authority managed to prevent the advent of influenza, but other ports in the archipelago failed to apply the same measures. The Dutch flagship carrier was reported to have carried flu patients with them to the Netherlands Indies. Ports in Banjarmasin, Makassar and Buleleng in Bali soon reported emerging influenza cases.

From Buleleng, Bali, the virus spread to East Java, also through sea. Within two weeks, the deadly flu arrived in Surabaya. According to Dutch Colonial Health Office, the city recorded tens of thousands of influenza patients.

In early 1919, the flu spreads to Central Java and then entered West Java. The Batavia administration was shocked to see the flock of new flu patients, outnumbering patients of pest, which had severely hit Central and East Java in the previous year.

The administration decided to apply anti-malarial drug, known locally as “ pil kina”, as prophylaxis. To minimize possible complications among people with underlying and other chronic diseases, the administration also advised certain patients to consume opium.

Another historical record said that on July 1st 1918, residents of Tanjong Pandan in the eastern part of Sumatra, were infected by passengers on a ship arriving from Singapore. Soon afterwards, the disease was reported to have infected people in Weltevreden (popularly known as Batavia), Medan, and Borneo, Bandjermasin and Stagen (Pulu Laut) in Kalimantan, also known as Borneo. From those places, it spread to the rest of the archipelago. In July, several epicenters had been reported: one in Bandung, West Java, one in Central Java: Purworedjo and Kudus, and one in East Java: Kertosono, Surabaya, and Djatiroto. By the end of July, major outbreaks of the disease had been recorded in most parts of Java and Kalimantan.

During this initial attack, the disease seemed to have penetrated no further east than Java: Bali, Sulawesi, and the islands to the east were, for the time, untouched. And although high levels of morbidity were recorded, mortality was generally quite low.

The Netherlands Indies colonial government’s health agency, the Netherlands Indies Public Health Service (Burgerlijken Geneeskundigen Dienst) made an investigation and came up with some conclusions on the characteristics of the new infectious disease. The BGD concluded that the influenza was imported to the Netherlands Indies from the Straits Settlements. The quick spread of the disease was carried by travelers. The health agency also concluded that the high morbidity of the flu was caused by factors such as the susceptibility of the population to infection by influenza; the short period of incubation; the fact that the virus can cause severe health impacts between 2 and 5 days; the transmission’s mode was that the virus spread from the respiratory organs from a patient to another through speaking, coughing, sneezing; and the fact that many who were slightly ill remained working and continued to socialize with others including those who worked in schools, factories, mosques, and churches that helped spread the virus.

Historical records showed that there was a time gap between the first influenza case and the later cases. The first period lasted for 14 days. After this period the flu epidemic developed rapidly and within two weeks it reached its peak. This height of the flu epidemic remained for two weeks. For a few weeks afterward, the Netherlands Indies recorded a decline in cases and fatalities. Another wave then reemerged. Each of the flu epidemic waves lasted four to six weeks.

The occurrence of the influenza in Netherlands Indies in the year 1918 is divided into two waves. The first and more benign one took place during July-August, and the beginning of September, principally in the western part of the Archipelago. The second, the very malignant one, occurred from the end of the October until December in the eastern part of the Netherlands Indies. At the end of the year, the deadly flu has spread over the whole archipelago.

Historians said the July epidemic wave was not such a great deal compared that of November. The first chiefly attacked places in Java and Sumatra, whilst Celebes, the Moluccas and the Little Sunda Islands remained free from it. In the first epidemic, the source of infections can still be traced. The July epidemic burst out explosively and thus showed a great morbidity during a very short time; the persons attacked generally did not show serious symptoms. This was without exception unanimously reported by all observers. The mortality in the first epidemic was low.

The November epidemic covered a much larger territory; there were few areas in Netherlands East Indies which were not infected by the influenza.

As to the morbidity of the second wave vary in different places. No complete record is available to show the numbers of patients or the fatalities during the pandemic. The November wave was characterized by its maliciousness; the flu symptoms were much more severe.

The disease showed an inclination to complications, through which the duration of the disease generally was much longer. For example, while in the first epidemic the attack had an average duration of five days, this became eight and a half days during November.

At the same time, the Netherlands Indies had also suffered attacks of other infectious diseases, making the government figures on mortality surge in the year 1918.

Some records said in the year of 1918 in Java and Madura almost 10,000 people died of cholera, more than 900 from smallpox and some 700 from other plagues. Altogether more than 11,000 people died from these contagious diseases. This number dwindles to nothing in comparison with more than 400,000 deaths due to influenza in November 1918 alone. Statistics are scarce and it is hard to gain a sense of what truly happened. Records showed that most fatalities occurred in the young adult age bracket.

In the 1980s, a historian published a paper titled The Influenza Pandemic of 1918 in Indonesia, which gives an idea of what happened during the period. The estimation was that around 1.5 million people died in Dutch East Indies, which was then home to just some 30 million people. These deaths were recorded in the Dutch’s Kolonial Verslaag (Colonial Journal).

Historians showed the horror of the pandemic situation. In Southeast Sulawesi, a Catholic missionary was quoted as saying that "deaths are everywhere". According to the report, in one Sulawesi village, a third of its population died in a period of just three weeks.

In Tana Toraja, 10 percent of the population reportedly died from the flu. Some Toraja tribe leaders still pass the stories of the outbreak through oral tradition, read out during traditional ceremonies. The mysterious outbreak, dubbed locally as Raa’ba Biang (loosely translated as fallen threes), killed hundreds of people in the hilly areas of Tana Toraja.

In early 1920, the Dutch Colonial government issued an “Influenza Ordinance” to ensure that response and mitigation measures were carried out promptly and correctly and that any future outbreaks in the archipelago could be rapidly detected and contained. It also set up a commission to investigate the cause of the pandemic. The law consists of information of influenza symptoms, response and prevention measures for people and administrations across the nation.

The government also took into account risk communication measures by instructing its information office to spread information on pandemic influenza. A brochure was printed to promote awareness on influenza prevention habits among the public.