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HISTORY CHECK: Did 1918 Spanish flu ‘decimate more than 300,000’ South Africans in just two years?

Dr Nkosazana Dlamini-Zuma, South Africa’s cooperative governance minister, recently compared the Covid-19 pandemic to another deadly outbreak a century ago. 

“The world, and our nation, have not been faced by such a potentially daunting challenge since the 1918 Spanish Flu and the 1932 Great Depression,” she said on national TV in April. 

“You will recall that the Spanish flu decimated more than 300,000 South Africans over a two-year period.”

Did this many South Africans die? We checked.  

The 1918 Influenza Pandemic

According to the US Centers for Disease Control (CDC), the 1918 influenza pandemic was the deadliest pandemic of the 20th century. It was caused by the H1N1 virus which is thought to have come from wild birds.

The CDC has since sequenced and reconstructed the virus so it can be better understood.

A number of countries have been suggested as ground zero for the pandemic, including France, Britain, China and the US. The CDC says that “although there is not universal consensus regarding where the virus originated, it spread worldwide during 1918-1919”.

Some 500 million people, or a third of the world’s population, were infected, and 20 to 50 million died. About 675,000 deaths were in the US. But the true figures remain unknown.   

It is known as the Spanish flu, but did not start in Spain, as many people believe. Spain was neutral during the first world war, so the media there could report freely on the pandemic while other countries had a media blackout, leading many to think it originated there.

The highly infectious virus attacked the respiratory system and had a high mortality rate. Unusually, this was mainly among healthy adults aged 15 to 34.  

Global death toll difficult to calculate

Dr Alexander Navarro is the assistant director of the Center for the History of Medicine at the University of Michigan. He told Africa Check that global statistics for Spanish flu deaths were affected by inaccurate reporting. This is, in part, due to an absence of laboratory testing and uniform death certificates at the time.

“The truth is, we simply do not have the data to be able to determine the true morbidity or mortality figures, or the resulting case fatality rate,” he said.  

“If a victim did not see a physician, they were not counted.  If they did see a physician, there was still a chance they might not have been counted.” 

Pandemic devastated South Africa

According to the not-for-profit South African History Online, South Africa’s participation in the first world war was key to the onset of the virus in the country in 1918, due to the movement of soldiers.  

It was also spread by infected migrant workers leaving gold and diamond mines for the rural areas on the country’s train system, taking the virus with them. 

Writing in the Conversation Africa in March 2020, emeritus professor Howard Philips, a historian at the University of Cape Town, said South Africa was estimated to have been “one of the five worst hit parts” of the world.

Philips specialises in the social history of medicine and has written two books on the Spanish flu’s effects on South Africa. He told Africa Check that the official death toll released by the government in 1919 was 140,000 to 142,000. This was for 1918 and 1919.

But the unreliable way the figures were calculated meant this toll was probably low, Philips said.

“There was no comprehensive death registration system in South Africa in 1918. There was supposedly for whites, but for Africans in [the Cape province and Transvaal] there was no requirement to register deaths,” he said. 

“In many rural areas where there was a requirement, they were overwhelmed by the huge number of deaths that they needed to count.”

After 1993 the Cape was divided into the Western Cape, Northern Cape and Eastern Cape. The Transvaal was split into today’s Gauteng, North West, Limpopo and Mpumalanga. 

Figure calculated using census

To get around these shortcomings, Philips studied the country’s 1921 census. He found that statisticians at the time flagged a significant shortfall of half a million people in the general population. He compared the number of Spanish flu deaths to the estimated shortfalls in key areas and calculated that the actual death toll was likely between 200,000 and 350,000 people. 

“The influenza was very, very rapid indeed. It really swept through the country in a space of six or eight weeks. So the number of [non-influenza deaths] that occurred in those six or eight weeks would not have been a very significant number,” he told Africa Check.

Other scientists have noted that “the manner in which deaths occurred was also unusual”. “During the ‘Spanish flu’ epidemic, many people died within just a few days from acute respiratory distress syndrome.” 

John Barry is professor at the Tulane University School of Public Health and Tropical Medicine. In a recent interview, he pointed out that the Spanish flu had a shorter incubation period than Covid-19. 

“Influenza in 1918 to 1920 would burn through a community in six to 10 weeks, and then you forget about it,” he told the Center for Infectious Disease Research and Policy at the University of Minnesota. 

Barry, author of The Great Influenza: The Story of the Deadliest Pandemic in History, told Africa Check that any country would have experienced this rapid toll. 

South Africa did seem “very hard hit”, he said in an email.  

Accurate figures for the 1918 pandemic are difficult to obtain because of the reporting deficiencies of the time, but Dlamini-Zuma would be in the ballpark with her estimate.

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