Health historian Warwick Brunton imagines how Dr Joseph Frengley, acting head of the Department of Public Health, Hospitals and Charitable Institutions in 1918 might have compared New Zealand’s responses to the Influenza Pandemic of 1918 and the Covid-19 Pandemic of 2020. He does so in the way of a letter from Dr Frengley to his successor, Dr Ashley Bloomfield.
Dear Dr Bloomfield,
I write to offer collegial understanding, encouragement and reflections as New Zealand and the world grapple with the Covid-19 pandemic. I have long wondered whether lessons from the devastating 1918 influenza pandemic, coinciding as it did with the end of the war to end all wars, had got lost, with institutional memory amid the multiple reorganisations of the health system and state sector since the 1980s.
You sit in the same hot seat that I occupied, albeit in an acting capacity and with a much longer title than yours, from April to November 1918. My use of the letterhead stationery of my era above symbolises professional and official solidarity at this very challenging time.
I was left in charge when the other two departmental top brass were seconded elsewhere to help the war effort. With only eight staff, our head office was hardly a bloated bureaucracy. Six district offices (public health units) shrank to four. The only professional assistance I could call on was Wellington’s hard-pressed district health officer (medical officer of health). When the epidemic spread rapidly in November 1918, I did what I could but it was impossible to lead and direct national-scale operations by remote control. I was already fully stretched having been sent north to control the Auckland outbreak.
People said that I did not wait for red tape or instructions before taking action there and only consulted Wellington afterwards! Some of my local actions upset our prickly and overbearing Minister of Health, George Russell, who, in my absence, assumed the role of de facto chief executive for some weeks. Our departmental head was then recalled from the Defence Department to take charge shortly after the epidemic peaked.
The scale of that awful tragedy haunts me. Forty percent of all New Zealanders were infected. Nearly 8,600 people died, including at least 2,160 Māori. Little wonder the department and minister faced the inevitable inquiry as if on trial. There was a sting in the inquiry’s censure: ‘a strong policy of definite initiative on the part of the head office and of all district centres is essential.’
There’s a lesson there. Strong and sustained political backing for public health as a national priority is imperative. ‘Were there active public opinions upon health questions many of the evils that now exist could not long remain,’ the inquiry concluded. Tokenism and lip service to the principle of public health do not suffice. Sadly, public health lacks the resource-pulling power and political clout of treatment services. Russell described the 1909 merger of separate government departments of public health and hospitals as false economy. Hospital boards took their public health responsibilities lightly. ‘Public health in this fair Dominion has been starved,’ I wrote.
How far have we come? Sir David Skegg says public health capacity has been run down for years and seriously weakened our ability to respond to pandemics. He moots a separate public health agency as a strong impartial advocate for public health. So demand the extra staff, resources and dedicated public health organisation and infrastructure we all need. Always keep clamouring!
Swift and decisive
Priority telegrams, cables and toll calls were the fastest ways to communicate in 1918. Daily press cables reported the steady wave of a more virulent and deadly strain of influenza from the northern to the southern hemisphere. Our overworked staff had no time to study events outside New Zealand, the full impact of which was only realised when British and overseas professional journals reached New Zealand after the Armistice. Knowing that rail and inter-island steamers facilitated travel from Auckland to Invercargill in two days, the lead-time could have been used to close the border and impose cautionary travel restrictions or internal borders. I had some doubts about the value of quarantine.
The inquiry found the department lacked foresight and preparedness. More than five weeks after the first deaths, Russell had influenza declared a ‘dangerous infectious disease’ – on my advice. That opened the armoury of ‘special powers’ for each district health officer [DHO] to deal with the emergency regionally.
The authorities initiated action much sooner in 2020 – less than four weeks after the first confirmed case of Covid-19. The declaration of a state of national emergency at 12.21pm on March 25, 2020, activated the use of still extant special powers. Thank heavens those powers survived the health reforms of the early 1990s, when some Cabinet ministers were surprised they had not been purged from the statute book. Fortunately, the fashion for contracts did not undermine the ongoing necessity for a national chain of command.
This pandemic differs from influenza in 1918 in several respects, but you have wisely anticipated a similar national threat. I am greatly heartened that New Zealand can draw upon comprehensive and updated plans for an influenza pandemic (2017) or a national health emergency (2015). These plans clearly set out roles, responsibilities and expectations of different agencies. I am so relieved the influenza plan acknowledges the invaluable contribution of historian Geoff Rice, New Zealand’s authority on the 1918 epidemic.
We had no national plan in 1918. The promulgation of special powers anticipated a regional approach and lacked graduated levels of lock-down. We muddled through by sharing practical ideas and by influencing our district networks. The Influenza Commission of Inquiry was right: ‘confusion and overlapping’ prevailed. I had to work through 40 hospital and charitable aid boards, 154 urban and 125 rural local authorities and myriad independent doctors and pharmacists. Count yourself lucky with only 19 district health boards, 12 public health units, 78 local authorities and growing links with primary care practitioners and services.
Today’s plans fit within the over-arching framework and procedures of 21st Century epidemic preparedness and Civil Defence emergency management legislation. The Ministry of Health rightly takes the lead role, but in the context of wider social and economic impacts of a pandemic. That all-of-government response, as your generation terms it, is rightly led by the Prime Minister. I admire your joint daily briefings, complemented as necessary by the Minister of Finance, other ministers and leading officials. These convey a clear picture of national inter-sectoral coordination within government. I also appreciate the decision to maintain Parliamentary scrutiny during the lockdown through a specially constituted select committee. That is a decided improvement over limping through the 1918 Parliamentary Session.
As your decisive preventive interventions take effect, you will all face pressure to relax restrictions prematurely. Commercial interests weigh up economic and human suffering differently from public health officials. What a relief the Prime Minister adopts proper caution and says we should stay the course. I faced similar pressures and told carping critics that ‘you cannot write a balance sheet for a Public Health Department.’
People expect regular up-front and authoritative briefings from a real public health doctor. We worked differently in 1918, with vital communications being dispatched in confidence. In 1918, the minister, a former newspaper-man, took the lead. He suppressed daily death figures to avoid alarm or, more likely, political backlash.
How right you are to take the country into your confidence with daily briefings. TV and radio are making you a household name and a member of every bubble. Your unflappable style conveys clarity, competence, a command of the facts, an alert listening ear and readiness to provide more information. Continuing high levels of public trust in the exercise of huge power by the Government and officialdom at this time are the glue that binds bold initiatives together and makes way for a new normal when restrictions are eased.
Mind you, you do look tired at times! I can empathise with you there, remembering the exacting and time-consuming responsibility that falls upon unseen departmental and health service workers to feed and convey information and advice.
In my day, daily newspapers advertised our advice and instructions. Although informative, they were unimaginatively official. Ten thousand posters contained formal directions issued ‘by [my] order.’ The only light touch I engendered came after a list of healthy hints to Aucklanders: ‘Don’t worry. Be cheery.’
Mobile phones, emails and social media are fantastic tools for instant communication. How different is the saturation multimedia advertising with its slick colour-coded messages. Today’s message also calls on every citizen to be a public health worker by adopting simple health practices. They are us. Perhaps we have heeded the 1919 inquiry’s insight that ‘we, as a people, have been too much disposed to regard affairs relating to public health as being almost exclusively the province of the medical expert and the specialist, instead of being the concern of the general body of citizens, as it should be.’
Looking back, our tiny department muddled through the epidemic guided by professional experience, textbooks, and relying on goodwill and co-operation from the disparate elements of the health care system and local government. How different things are for you. I believe you have technical and advisory mechanisms to draw in the significant mainstream public health community of informed professionals and interest groups. Academic freedom should provide good allies.The public health community is well versed in chivvying officialdom. How different from 1918 when New Zealand had only one professor of public health and bacteriology.
Luckily, too, today’s sophisticated and instant global communications technology plugs New Zealand into the latest international intelligence and ideas from the World Health Organisation, which you are following. Members of the 1919 inquiry would have been so pleased. They recommended an ‘International Bureau’ to collect and disseminate public health information. The importance of international action to prevent and control global pandemics kick-started specialised agencies of the League of Nations and the United Nations. It is a pity that narrow national and political agendas in one country threaten to undermine the potentially enormous benefits of international collaboration through WHO.
So much for the meandering memories of an ancient public health veteran. Keep safe and well and don’t be afraid to demand loudly the skilled people, resources and organisation you need for a strong public health priority. Rely on your collegial, professional and specialised support networks and the general goodwill of the public. You are not alone.
There will almost certainly be some form of public debriefing or inquiry to learn the lessons from this pandemic. So, please try to find time to keep a personal notebook as an aide memoire about what works or not and why, and how the whole public health system might be improved.
In taking my leave, may I offer you the wise counsel of the American public health advocate, Milton Terris:
‘The health departments which were established to control infectious diseases encountered many difficulties, but they learned by doing, by making errors and correcting them. Health departments will have to do the same today; they will compare notes, and from their dithering collective experiences, the blueprints will emerge. We are at the beginning of an era. It will be our burden and our opportunity to be pioneers.’
I remain &c., from my time capsule,
Dr Frengley was passionate about public health and spent 22 years and held senior positions in New Zealand’s public health service. He died in office at the relatively young age of 53. He was remembered for his wide range of scientific knowledge and for the painstaking care he took over even the smallest details. His administrative style was laced with a quiet brand of Irish humour and a kindly nature.
Warwick Brunton is an honorary senior lecturer in the Department of Preventive and Social Medicine at the University of Otago, a health historian and former public health administrator and policy-maker in the Department / Ministry of Health (1972-96).