Chronic Diseases Teaching Unit, University Hospital, Internal Medicine Service, Geneva, Swizerland
|In Geneva, Switzerland, the Spanish flu epidemic affected more than 50% of the population. The mortality was higher among those aged between 20–49 years and among men. The socioeconomic impact was very important, as the outbreak led to severe dysfunctions, including in health services. This epidemic shows the socio-economical burden that may be associated with influenza and highlights the need for pandemic preparedness.|
The epidemic of Spanish influenza in 1918, was studied through the analysis of various documents dated 1918 and 1919. These included publications in Swiss and foreign medical journals, Geneva daily newspapers, and district and federal archives. Oral accounts completed the study, which mainly focuses on the situation in Geneva, but some data involve all of Switzerland.
The Spanish flu affected Switzerland in several waves. The first one occurred in July 1918, the second and most severe one in October–November 1918, then the epidemic declined until February–March 1919. Figure 1 shows the number of influenza cases based on mandatory notifications in Switzerland from July 1918 to February 1919. In a context of world war, the first cases were reported in 1918 at the country’s frontiers, and in foreign soldiers camps, then in inland villages (Château-d’Oex) (1,2). Very quickly, the outbreak then spread in the civilian population. It was estimated that over 50% of the population was affected by influenza in 1918, 58% for both pandemic years (3).
Mortality rates were especially high during the October–November wave, which was characterised by an asphyxial form with heliotrope cyanosis leading to death within 24 hours. The highest morbidity and mortality rates were observed in the adult population, in particular in the 20–49 years age group, with increased mortality in men (Figure 2). This could be explained by the living conditions in the army, frequent travels favouring the transmission of the influenza among soldiers who were already weakened. The severity of the disease among adolescents and young adults was associated with overwork, lack of health care, and military crowded conditions (4). Besides, the elder groups could have benefit from a protective effect as they had been exposed to an important influenza outbreak that occurred the previous century (1889–91).
The socioeconomic impact
Disruptions were numerous in both private and public sectors. Schools were closed intermittently. Some companies reported over 80% of their staff affected by influenza (5). The administration was equally much affected by the outbreak. Some postoffices were closed or worked at a slower pace, telephone and telegraph operators could not answer all requests, and a limited timetable was installed (6). Public transport was irregular and the number of journeys was limited thus encouraging transmission in crowded vehicles.
The medical sector was also very disrupted. Overworked doctors imposed restrictions on reception hours (7,8). Numbers of them were also sick or died from influenza. Taxis had to refuse to transport patients to hospitals because of the contagion risks. Only one company was authorised to transport flu patients and was under the obligation to disinfect all vehicles after each ride (9).
During the epidemic peak of October–November 1918, hospitals refused to admit flu patients. Public sites were requisitioned to become emergency hospitals, which become quickly overcrowded too. Announcements were issued in newspapers to call for volunteers to help in overburdened hospitals. A Geneva doctor was condemned by the Health authorities for not having reported flu cases, because the notification at the federal level had become mandatory since the beginning of the outbreak (10–14).
In the press, daily hospital statistics detailed the number of admissions, deaths, refusals or departures of flu patients in hospitals. The list of the deceased grew longer. Mortuary announcements overed two to three pages of daily newspapers. The medical corpus and searchers contradicted each other about the origin, the transmission and the treatments of the disease. For instance, some recommended the consumption of alcohol, others rejected it violently. These divergences were frequently reported in the general press as in medical journals. Each measure proposed by the health authorities triggered polemics amplified by the media (15,16).
‰ Utter fear prevailed throughout the country. Misinformation was frequent in the scientific and daily press. Articles and readers’ letters erroneously explained the origin of the disease, its prevention, its transmission, and its possible treatments. Public and private hygiene recommendations were multiple and varied, including dry cleaning grounds or spraying streets with disinfectants. For example, it was stated that the virus was transmitted through the troops’ dirty laundry, washed by the Red Cross civilian volunteers, and even that it spread through the mail that contaminated soldiers sent to their families. Advertisements for miracle remedies filled newspapers, the recommendations of which varied from eating onions to breathing exercises outdoors.
Both the measures taken and the bans were severe: no leisure activity involving group of people was authorised. In some districts, cafés and restaurants were imposed restrictions on opening hour’s. Theatres, cinemas, dancing halls were temporarily closed, shows and concerts were cancelled. Even the churches were closed. In Lausanne, some religious services were proposed in public parks, but these gatherings were quickly forbidden. In Geneva, two priests were fined for preaching despite the ban on gatherings (17–20). Funerary processions were limited to five persons. Graveyard employees struggled to dig graves and to quickly bury the numerous bodies.
In Switzerland, the lack of consistency in the measures which were implemented, then cancelled and re-implemented (namely the frequent schools closures) contributed to increase the climate of insecurity. The importance of diffusing clear and consistent messages to the population must be stressed. That was the biggest lack during the 1918 Spanish flu outbreak. This study shows the socioeconomic impact that a massive influenza epidemic can have and highlights the need for a optimal preparedness to a potential influenza pandemic.
1. La Suisse, le 5 juillet 1918
2. La Suisse, le 7 juillet 1918
3. L’influenza en Suisse en 1918/1919, Rapport du Service d’Hygiène publique, Rapport du Conseil Fédéral, 1919
4. Revue Médicale de Suisse Romande, Société Vaudoise de Médecine, séance du 28 septembre 1918, pp.47–53
6. La Tribune de Genève, le 28 août 1918
7. La Suisse, le 15 octobre 1918 ; La Feuille, le 23 octobre 1918, La Tribune de Genève, le 26 Octobre 1918
8. Journal de Genève, les 26 et 31 octobre 1918
9. La Suisse, le 25 Octobre 1918
10. La Suisse, le 20 Octobre 1918; Journal de Genève, le 30 octobre 1918; La Tribune de Genève, le 1 novembre 1918
11. La Tribune de Genève, le 23 août 1918
12. A memorandum on Influenza, from the medical research committee, Lancet, 23 nov. 1918, p. 717
13. La Tribune de Genève, le 19 juillet 1918
14. La Tribune de Genève, le 20 août 1918
15. La Tribune de Genève, les 4-5 et 23 août 1918
16. Correspondenz-Blatt für Schweizer Aertze, 52, le 28 décembre 1918, pp. 1729–41
17. Jugement de la Cour de Justice du Canton de Genève (notification par les médecins des cas de grippe soignés par eux), Jugements et recours, 31 mai 1919
18. La Tribune de Genève, les 4/5 août 1919 ; La Suisse, le 5 août 1918
19. La Tribune de Genève, le 19 juillet 1918, La Suisse, le 10 juillet 1918
20. Cottin E. et al, La Grippe de 1918 – Ses formes cliniques, Revue Suisse de Médecine, 1919, 25 :504–22