Folatos en Embrión

The spread of the influenza epidemic, including its consequences, was relatively similar throughout Africa as observed by many commentators. Influenza came to Africa in three waves between August 1918 and January 1920. The first wave of influenza pandemic penetrated Africa through ports and harbours and made its way into the interior facilitated further by communication routes, rainy weather, poor sanitation and the chaos following the First World War.

As a growing number of historians have recognised, the disease was introduced to Africa by a series of events. Many commentators have observed that the first appearance of influenza in Africa was observed in Sierra Leone. On 15 August 1918 HMS Mantua arrived in Freetown harbour with a large number of cases of Spanish influenza on board. The introduction of influenza into the colony of Sierra Leone is believed to have originally been shipped from the American ports, where influenza had been prevalent at the time HMS Mantua left the American shore. Others believe that when the Mantua refuelled in Britain, it unquestionably took influenza viruses on board and transported the disease to Sierra Leone.

Whatever the source, heavy mortality stirred the native population deeply. This led to the creoles indulging in a very abusive press campaign against the colonial government for its alleged carelessness and indifference in matters affecting the health of the country. The pandemic in Sierra Leone followed the global epidemiological pattern in its diffusion. In a relatively short period of time, the disease reached Gambia. A report on the epidemic of

influenza in Bathurst, Gambia colony, suggests that the disease was imported from Sierra Leone.

While the Governor of Sierra Leone was aware that Freetown, and particularly the harbour, was affected by an influenza outbreak that was a virulent and dangerous form, he failed to take precaution measures to quarantine the vessel at the harbour. In his correspondence to the Secretary of State at Downing Street, the Governor admitted the lost opportunity to prevent influenza outbreak from spreading had the vessel been quarantined much earlier.¹⁵ The Governor of Sierra Leone could not take any actions on the vessels because sanitary affairs of warships lied outside civil control and influenza was not a notifiable disease.¹⁶ On 25 August, the ship S.S. Prah left Freetown for Bathurst but, owing to bad weather, did not reach the Gambian port until 29August.¹⁷ The ship had 52 passengers who seemed well upon arrival but after a few days a couple of passengers developed symptoms of influenza. From this time onwards, scattered cases of influenza began to appear throughout Gambia until, at the end of the first week of September, the epidemic became general. In the Gold Coast (Ghana), influenza was introduced by the warship S.S. Shonga arriving from Freetown, Sierra Leone.

Influenza reached the Gold Coast on 31 August 1918. It spread north along the trade routes, and by mid-September reached the furthest corners of French Guinea. During the months of September and October, without any warning, influenza reached Lagos, Nigeria after the arrival of the ocean liner S.S. Bida, carrying passengers suffering from the disease who then entered the town without passing sanitary authority checks. Passengers destined for Lagos are believed to have boarded the ship in Accra, Gold Coast. The first shore cases in Nigeria were discovered on 23September 1918 and, a few days later, the disease spread inland following the railway, appearing in Abeokuta on 1 October and Ibadan on 5October 1918.¹⁸ Once the epidemic had penetrated Nigerian seaports, it made its way into the interior following trade

15 PRO, CO 879/118/1, The Governor of Sierra Leone to the Secretary of State, Received 6 November, 1918, Enclosure in no. 61, folio 53257.

16 http://www.ascleiden.nl/Pdf/workingpaper77.pdf (Accessed: July 31, 2013).

17PRO, CO 879/118/1, Report of the epidemic of influenza in Bathurst, Gambia Colony, from September, Enclosure in no 71.

18 PRO, CO 879/118, Report on the Influenza Epidemic in Lagos, October, 1918, Enclosure in no. 129, folio 325; See also Ohadike (1991).

routes, such as railway lines, rivers and motor roads, progressing according to the speed of normal transport prevailing on each highway (Ohadike, 1991).

As the outbreak of influenza progressed, it became certain that no country was safe. The northern part of Africa was riddled with high levels of cases. Early cases of mild influenza were first reported in Egypt at Alexandria in May 1918, while Cairo reported its first case in June 1918; however, the cause of the increased death rate towards the end of that year does not appear in influenza mortality annual reports because influenza was not a notifiable disease in Egypt (Ministry of Health, UK (1920)). Since influenza was observed in Africa as early as May, this contradicts many commentary reports that the first appearance of influenza in Africa was observed in Sierra Leone. The cases observed in September in Egypt were actually second waves of influenza. Just as in Egypt, two other waves of influenza swept over Tunisia and Algeria; although the cases that appeared at the end of May 1918 were very mild while the second waves in September and December caused a large number of deaths (Ministry of Health, UK (1920)).

Influenza reached Southern Africa at about the same time as most countries in West and East Africa. South Africa was first to be affected in September; three weeks later in October, Bechuanaland (now Botswana) and Southern Rhodesia (now Zimbabwe) became infected.¹⁹ Nyasaland (now Malawi) was affected in early November. In Southern Africa, just as in West Africa, the disease began at ports and then spread inland to the high commission territories.

The earliest outbreak in the Union of South Africa occurred in the vicinity of the harbour area in Durban on 14 September 1918 (Ministry of Health, UK (1920)). It spread to the central Rand area, where numerous cases were observed around 18 September, chiefly among the natives working in mines (Ministry of Health, UK (1920)). Basutoland (now Lesotho) was severely hit by the influenza pandemic. The disease was very prevalent during the months of October and November. Deaths are not registered as attributable to influenza, but information gleaned from the observation of medical staff, native chiefs and statistics recorded by the medical missionaries indicate that a lot of people died from this disease (Ministry of Health, UK (1920)).

19 PRO, CO 626, Annual Medical Report on the Health and Sanitary Condition on the Nyasaland Protectorate, 1918.

Influenza reached Swaziland at the same time as the Union of South Africa although it was a less severe type than in most parts of South Africa. Influenza broke out in Bechuanaland in October and spread rapidly across the whole territory, except the Western Kalahari and the Ngami littoral (Ministry of Health, UK (1920)). Influenza reached Southern Rhodesia along the railway line from the south, with its first case detected in Bulawayo on 9 October. Within days the disease broke out with extraordinary virulence at Que Que Umona and Salisbury (Ministry of Health, UK (1920)).

In East Africa, influenza was prevalent in Uganda during the last week of October 1918; the first case was reported at Entebbe. Mombasa was hit by 23 September. A few days later, Kampala and Jinja were also affected. The epidemic reached its peak in Uganda during the third week of November 1918 (Ministry of Health, UK (1920)). The epidemic spread throughout the protectorate causing thousands of deaths by the end of December. Meanwhile, Zanzibar was attacked between October and December 1918. Cases had already occurred in British East Africa in October following the arrival of two ships from Bombay in Mombasa (Ministry of Health, UK (1920)). The disease was reported at Portuguese East Africa (now Mozambique) by 20 October and southern Nyasaland by 5 November.

Diffusion of influenza is an important concept rarely examined in Africa. The above account is an attempt to profile the diffusion patterns and the transmission dynamics of the spread of influenza in time and space. The relevance of diffusion patterns in Africa provides the basis to understand how the disease speed and spread, and this can inform the development of policies that are able to control the disease. The 1918 pandemic in Africa ran its course smoothly without much interruption and took a number of countries by surprise with its death toll. This suggests that most countries were not prepared since they did not identify the causative agent or know how to confront it.

While most countries in Europe were aware of the source and diffusion mechanism of the disease through communication routes (roads, rivers), these determinants were relatively unguarded. There are lessons to be learned from the way the disease diffuses, especially now with an increase in cross-border and cross-continental movement. The demographic spread of influenza is relevant for current debates especially when flagging up issues about where the focus should be when planning (the borders or the centres of cities) and how fast responses can be implemented.

3.4.0. History of Pandemic Influenza in the Gold Coast (Ghana) 3.4.1. Diffusion of the Pandemic Influenza in the Gold Coast

The Gold Coast, once a British colony, lies a few degrees north of the equator and covers an area of almost 240.000 sq. km. It is bordered by the Ivory Coast to the west, Upper Volta (now Burkina Faso) to the north, Togo Land (now Togo) to the east and the Gulf of Guinea to the south. In the Gold Coast (now Ghana), the influenza was introduced into the country by the warship S.S. Shonga, arriving from Freetown, Sierra Leone. Figure 1 illustrates the spreed and diffusion of influenza in the Gold Coast. Influenza reached the Gold Coast on 31 August 1918. It is believed that the earliest influenza signs were seen at Cape Coast in a mail officer who alighted from the S.S. Shonga on 31 August 1918. The S.S. Shonga moved away from the coast and proceeded eastwards towards Accra with influenza patients on board; upon arrival on 3 September 1918, the vessel and the crewmen of the S.S Shonga were quarantined as an immediate precautionary measure in the hope of controlling influenza. However, 16 patients had to be hospitalised overland.²⁰ Within just two weeks of the landing, influenza was widespread. According to Patterson (1983), the disease spread rapidly along the Cape Coast into the interior of the country. It is uncertain whether the Cape Coast may have been infected before the S.S. Shonga reached it.

On 5 September 1918, the disease had already established itself at the port of Sekondi and the surrounding towns. In Kofuridua, the first case was a schoolgirl from Accra who is believed to have arrived in town with the disease on 19 September; her brother who lived in the same house was struck down the next day.²¹ Ten days later, Kofuridua and the surrounding towns had changed drastically: places of business were closed and markets deserted.²² Axim was not affected until 25 September, when boat-boys (sailors) arrived from Sekondi and introduced the disease.²³ From 27 September to 2 October the infection spread slowly, but from 3 to 7 October it spread quickly.

The first case in Saltpond was recorded on 21 September and the outbreak reached its peak in the first week of October (Patterson, 1983). All native medical professionals had the disease and within a fortnight the town was deserted and markets practically empty. Yeji had its first

20 PRO, CO 879/118, Government of Gold Coast, Medical and Sanitary Report, 1918.

21 CO 98/30, MSR, 1918 pp7; See Patterson (1983).

22 ibid., pp 7.

23 ibid., pp 8; See Patterson (1983).

case on 8 October, while Bole and Salaga became infected on 26 October and 5 November 1918 respectively (Patterson and Pyle, 1983). In the north-western part of the country, the outbreak hit Wa and Lawra between 7 and 15 November and spread from there, reaching Tamu on 16 November. Tamale was affected on 12 November and by 27 November, outbreaks had occurred in every major settlement in the northern territories, including Zuarungu, Navrongo, Paga, Bawku and Gambaga (Grischow, 2006). Indeed, influenza spread over the entire Gold Coast in about three months (Patterson, 1983). In a state of disbelief and shock, the Governor is recorded to have said: “the disease spread with devastating rapidity and in three waves, disorganizing everything. Almost everybody was attacked almost at once during the first wave”.²⁴

The diffusion of the disease in the Gold Coast reveals that influenza spread is not only global but that the disease can extensively manifest itself at a national and local level. The rapid diffusion of influenza in the Gold Coast, apart from being facilitated by communication routes, was also supported by social and economic conditions such as unsanitary conditions and poverty. In addition, influenza was not a notifiable disease under the quarantine ordinance, making it hard for the medical authorities to take action. Understanding diffusion patterns has great relevance in understanding the early stages of a pandemic outbreak. While it is difficult to establish the pattern of waves that swept the Gold Coast as this differed from place to place, two and three waves were observed.

The first wave was short, about six weeks beginning at the end of August and reaching its summit by 30 September. Areas that had reported early cases observed a steady decline until mid October when most reported their last cases. The second wave ran its course for about 8-12 weeks beginning in the early part of November, remaining slow in formulation and more destructive in terms of mortality at its peak. The third wave was also slow and partially reverted to mild influenza as observed in north-eastern provinces in April 1919 and Ashanti in November, 1919.²⁵

24 PRO, CO 879/118, Government of Gold Coast, Medical and Sanitary Report, 1918.

25PRO, CO 98/32, Northern Territories Annual Report For 1919, Gold Coast, Government Press, Accra, 1920.

Figure 1: Map of Influenza Speed – Gold Coast (Patterson, 1983).

These observations are interesting for planning assumptions (see planning assumptions for Ghana in appendix 14) especially when determining appropriate interventions necessary for each wave of the pandemic period. Timing the duration of the pandemic through waves is necessary not only to predict how the pandemic will develop but also to ensure that planning against the reasonable worst case scenario is smooth and able to adjust as it is implemented.

Historical diffusion of influenza is useful for understanding social history but also when studying the 2009 H1N1 planning for, and response to, pandemic preparedness.