On Oct. 26, 1918, just over two weeks before the end of World War I, readers of The Japan Advertiser, as The Japan Times was named at the time, woke up to the headline “Thousands Dying From Influenza Throughout the World,” and an accompanying article detailing the havoc it was wreaking in Japan.

“There is hardly a school in Tokyo but from which dozens or scores of students and teachers are absent, and it is spreading to offices and factories. The disease has become known as the ‘Spanish influenza,'” the report, a small article on page four, said.

That time period marked the arrival in Japan of a global pandemic that would claim the lives of 20 million to 50 million people worldwide between 1918 and 1920. The figures vary wildly due to poor or incomplete records, but the lower one nearly equals modern estimates of the number of people who perished in World War I, which began in 1914.

A century later, the Spanish flu outbreak and Japan’s response, have largely been forgotten. But with public health still a top concern in the early 21st century, both nationally and at multilateral forums like the Group of 20, Japan’s experience with the illness a hundred years earlier offers valuable lessons for health experts and politicians as they discuss international responses to the next potential global pandemic.

Between the autumn of 1918 and the end of 1920, Spanish flu ravaged Japan. Whole villages were wiped out and large parts of the country’s major cities would be shut down as the disease spread, affecting people of all socio-economic levels.

Incomplete record keeping and the passage of time has made it impossible to determine the precise number of deaths.

However, modern scholars estimate that nearly 470,000 people on Japan’s four main islands died either due to the flu or because of secondary cases of pneumonia that followed. At least another 200,000 people are believed to have perished in Korea and Taiwan, which were then under Japanese colonial rule.

Throughout late 1918 and early 1919, in particular, newspapers painted grim pictures of the flu’s spread and rising mortality rates.

The Japan Times’ initial reporting in late October 1918 said there were more than 9,600 influenza patients in Kobe, and 6,000 in Kyoto, where in a single day, Oct. 28, 1918, 51 people died. On Nov. 8, a headline noted that the flu had killed 931 people in Tokyo alone over a four-day period. By Feb. 6 the following year, the paper noted that the Jan. 25-31 period had seen over 2,100 people die in the capital, while nearly 13,000 schoolchildren were sick. In the same edition, based on government figures, the paper reported that there were 362,842 cases of Spanish flu in Osaka, of which 6,329 proved fatal, between October and December 1918. Fresh outbreaks, it said, had also been reported in the cities of Kyoto, Hiroshima, and Fukui.

In one of the few English-language studies of Spanish flu in Japan, a 1993 article by New Zealand-based scholars Geoffrey Rice and Edwina Palmer said that on Feb. 1, 1919, the Japanese government had given advice on basic treatment, but that actually carrying out any treatment had been left to prefectural governments.

In a world before commercial radio and extensive rail transportation networks, and at a time when few people had telephones, local officials, who were at risk of catching the flu themselves, were the main channels of information to communities for how to treat the disease and halt the spread of infection.

A government poster from the Taisho Era (1912-1926) urges the public to wear masks after the Spanish flu pandemic swept through the nation. | THE NATIONAL INSTITUTE OF PUBLIC HEALTH OF JAPAN / VIA KYODO
A government poster from the Taisho Era (1912-1926) urges the public to wear masks after the Spanish flu pandemic swept through the nation. | THE NATIONAL INSTITUTE OF PUBLIC HEALTH OF JAPAN / VIA KYODO

“Masks, gargling, and inoculation were the three primary preventive measures recommended by Japanese health authorities,” the scholars wrote. “The printed word was the main method of communication between health authorities and the population. Notices appeared in newspapers, and a variety of posters and leaflets were printed and distributed through the primary schools.”

In a recent interview with The Japan Times, Rice said Japanese officials took a proactive approach toward sickness and infection.

“There was also advice to go to bed and to drink lots of green tea,” he added. Green tea is high in Vitamin C, which aids in the functions of the immune system.

In an article published last year on the impact of Spanish flu in Japan, health experts Kenichi Ohmi and Akihito Suzuki noted how local populations viewed and responded to the illness and that the central government struggled with the unprecedented pandemic, which was quite different from earlier cholera outbreaks and an influenza pandemic that hit Japan in the late 19th century. Often, local herbal remedies were used to treat patients, due to reasons ranging from tradition and ease of availability to a lack of alternatives.

Ohmi and Suzuki said that, after the Spanish flu pandemic subsided in 1920, preventive measures became more common, including the widespread use of face masks, which are still prevalent today.

But a century later, at a time when global warming has heightened concerns about the appearance of unknown diseases, Rice and Ohmi told The Japan Times there were still lessons from the Spanish flu that governments and the public needed to bear in mind.

“Mass jet travel has made the world a global village of viruses, and a new flu virus would very likely be widespread before anyone suspected its existence,” Rice said. “It would be a brave politician who ordered the grounding of all airliners, or a halt to all trains and public transport” in the event of a crisis in today’s interconnected world.

“Yet these would be the most effective preventative measures in the event of a major new pandemic,” he added.

Rice said that vaccines against pneumonia, which can develop due to the flu, would seem to be a sensible precaution, as the real killer during the Spanish Flu of a century ago was the secondary bacterial infections by various strains of pneumonia.

“But the main lesson from the 1918 flu in Japan … was that the response had to be a widely based community effort,” he added. “The crucial response was at the street and community level. We cannot hope to know everyone on our street, but we should at least know those on either side. Assistance can then overlap down a street, like the overlapping tiles on the roof of a temple.”

For Ohmi, there are several measures the government must take, including a re-evaluation of the mass vaccinations for schoolchildren that took place in the 1970s and 1980s.

“Japan introduced mass vaccination of schoolchildren for influenza in 1962, long before the vaccine’s efficacy was demonstrated almost 40 years ago,” Ohmi said. “But Japan no longer mandates such a program, even as other countries promote mass vaccination programs.”

According to Ohmi, mass vaccinations were discontinued in 1994 and replaced with optional individual vaccinations in 2001 that primarily target the elderly.

Finally, he said, more concern regarding public health activities is needed. There were over 800 public health centers in 1990, but as of 2018, that number had fallen to about 500, with the number of health center staff falling from about 35,000 in 1990 to about 28,000 presently.

When world leaders gather in Osaka at the end of June for a meeting of G20 nations, global health will be one of the agenda items. Finance and health ministers, along with representatives from the World Health Organization and other agencies, will meet to discuss ways to more quickly and effectively respond to diseases in the more vulnerable parts of the world.

And while much of the advice and new policy initiatives that emerge will likely be based on advances in medical technology, Rice and Ohmi say today’s policymakers can take a far more basic step to help enact effective countermeasures in the event of a future epidemic: study the past.

“We must never forget the efforts and the fruits of our predecessor’s labors, including public health experts, during (the Spanish flu epidemic),” Ohmi said.

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