Lessons from Irish history underline the vital importance of leadership, decisiveness, clarity of communication and effective co-ordination when dealing with public health crises, along with co-operation from the public.
We should not think of our health history as just a journey from darkness to enlightenment or primitiveness to modernity. The historian Oliver MacDonagh has pointed out, for example, that by the mid-19th century, Ireland had “one of the most advanced health services in Europe” which was “to a large degree state-supported, uniform and centralised”.
Nonetheless, there were always regional disparities and accessibility issues, and care at home was imperative for many, while the Edwardian era generated new administrative issues relating to public health and – correspondingly – a more extensive role for local authorities.
As a result, potential public health disasters were avoided or lessened. As pointed out by historian Ciarán Wallace, a serious outbreak of smallpox in 1902-3 “threatened Dublin’s overcrowded population and its proverbially inefficient Dublin City Council”. According to Wallace, “how this looming catastrophe was averted illustrates the growing importance of local councils in safeguarding public health.” The city had become its own sanitary authority and, in rising to the challenge, its council became vital in confronting the outbreak.
In February 1902 a visitor from Glasgow became ill while staying at a lodging house in the tenement district of Townsend Street; he was removed to a fever hospital and the occupants of the lodging house were moved to an isolation unit. Three “contact” cases occurred but the patients recovered in isolation.
The mediating role of the city, equipped with modern powers and state funds, was essential
Smallpox entered the city again in March 1903 and, within five months, 255 cases across a densely populated north inner city emerged, and 33 people died. The outbreak lasted until July but what was most notable was the decisiveness shown, especially by the impressive Charles Cameron, Dublin’s medical superintendent of health, through identifying the chain of original infection and then moving quickly to isolate and disinfect.
Smallpox hospital
Crucially, new isolation beds were needed, and so a smallpox hospital was rapidly constructed at the Pigeon House Fort on an isolated sea wall at the mouth of the River Liffey – a 50-bed wood-and-iron unit constructed in just 21 days at a cost of £939. This state intervention, via the local authority, proved to be the vital initiative. There were also 1,400 “contacts” housed in a refuge in St Nicholas Street for two weeks at a time. As Dublin cabmen were loath to take passengers there, the city council bought a 12-person omnibus to ferry people to and from the refuge. A campaign to get people to present themselves for vaccination was also initiated, with vaccination centres set up in various parts of the city. Vaccination against smallpox was compulsory in Ireland and the local authority was responsible for enforcing the regulations.
There was also a search for concealed cases of smallpox along with incineration of patients’ clothing and bedding and disinfection of their dwellings. Voluntary effort – or indeed central government – could not have handled all this, and the powers the local authority exercised were crucial. As Wallace concludes, “the mediating role of the city... equipped with modern powers and state funds, was essential.”
The great influenza pandemic of 1918-19 was of course on a terrifyingly vaster scale and the greatest threat since the cholera epidemic of the famine era. In three waves it killed well over 20,000 and infected an estimated 800,000 in Ireland. The leading historian of this calamity, Ida Milne, has observed it “placed an enormous strain on the underfunded, overstretched and awkwardly structured health system”.
Complication
But another complication was that the Local Government Board (LGB) – often regarded as the public face of government in Ireland due to its reach and multiple responsibilities – “was widely perceived as being either unwilling or unable to devise a plan of action to deal with the epidemic”. There was thus an absence of a “centralised crisis management strategy emerging from the LGB”, while a range of voluntary healthcare providers “devised localised strategies to feed and nurse the ill”.
Once again Charles Cameron, who was now aged 80, delivered public advice in a clear and practical way
There were many complaints about poor communications from the authorities, though given the scale and rapidity of the spread, this was a common accusation internationally. The LGB’s doctors worked tirelessly but inevitably struggled to cope.
Milne also records that commerce was hugely disrupted and “entire towns were silenced as the flu passed through... court sittings and public meetings were postponed, libraries and other public buildings were closed and sports fixtures and concerts cancelled.” In many cases whole families were incapacitated and there was little point in them going to hospital as the capacity was not there. Once again Charles Cameron, who was now aged 80, delivered public advice in a clear and practical way, emphasising the need for disinfection, ventilation and minimal contact until recovery.
As The Irish Times put it at the time, “Disinfection and purification are the watchwords just now.”
And now too.