By Dr. T. Jock Murray
Special to The Advocate
The pandemic of influenza in 1918-1919, known as the Spanish flu, killed 40-50 million people worldwide. Nova Scotia had a low rate of deaths compared to other areas in North America and it is important to look at the factors that may have helped, and the role of Dr. W. H. Hattie, the Provincial Medical Officer of Health. The story of his role has been neglected by historians, but his leadership saved many lives. It is worth examining the issues that were a concern in the pandemic of 1918 as they are similar to those issues we are confronting with COVID-19 today.
William Harop Hattie was born in Pictou on 27 July 1870, and educated at Pictou Academy. He was always called “Will” by his friends. He graduated in medicine from McGill in 1891 and came back to Nova Scotia, where he was appointed a physician at Mount Hope, a mental hospital in Dartmouth. He renamed the hospital The Nova Scotia Hospital when he became superintendent. He lectured at the medical school on mental and neurological diseases, hygiene (public health) and bacteriology. In 1908 he was appointed the Provincial Medical Officer of Health and played a key role on the committee that organized the medical response to the Halifax Explosion in 1917. When the outbreak of Spanish flu came in the fall of 1918, he was in charge of the provincial public health planning and response. His approach and experience have lessons for us today.
In a public health threat, trusted leadership is essential. The two key leaders on this occasion were Dr. Hattie and the mayor of Halifax, Dr. Arthur Hawkins, who also happened to be a physician. Mayor Hawkins was an argumentative man who had trouble getting along with everyone, but he recognized the threat when he heard the stories of Spanish flu ravaging populations in the USA. Both Hawkins and Hattie had been in medical practice during the last influenza pandemic in 1889 so they knew the dangers. They were also aware that there were already cases in their community, the earliest arriving in Halifax with the hospital ship Med 1099 in July. However, few cases occurred over the summer, and some cases were not recognized. Hawkins knew that Boston was dealing with many deaths so he sent a contingent of three physicians to Boston to see what was happening, and to report back with recommendations on managing the threat. Some local doctors and nurses were also volunteering to go to help in Boston.
After a meeting with the group who arrived back from Boston, Dr. Hattie took charge and began a broad plan to protect the population, based on restricting contact between groups in the community. He realized his task was going to be difficult as he had only a small office with secretarial support, few funds, and little general support by the public or medical profession for the role of public health. He also recognized that historically, disease control was mostly seen as marine quarantine, landing ships on Lawlor’s Island when they had infected passengers or crew onboard. In this pandemic a broader approach would be needed in the communities. Local health boards would be important to carry out preventive measures but they were composed of laymen with little understanding of public health.
Public Health perspective
Although the common pattern of health care is the medical model, providing the best care to an individual, the public health philosophy provides the best care for the population. Dr. Hattie began a process of confining person-to-person contact to limit disease spread. Public meetings were prohibited. Places where people tended to gather, such as schools, theaters, community halls, pool halls, bowling alleys, and churches were ordered closed. Other establishments had restricted hours. Funerals had to be private affairs. Attention was paid to street cleaning and garbage collection. Because the cause was not known, cleanliness was an important approach as well. Telephone mouthpieces were washed down with carbolic acid daily. These actions carried out in Halifax influenced other towns and villages across the province and physicians and quarantine officers took charge locally.
Resistance when action
needs to be early
Dr. Hattie knew the key step was to get ahead of the problem, and this had been emphasized by the group Dr. Hawkins had sent to Boston. They knew there would be a public reaction to limiting of public meetings, and they knew there would be resistance from the theatre owners, clerics and business owners who would insist that this was an over-reaction when they had not yet seen the horror of the pulmonary deaths. It takes resolve and courage to persist when even the press is suggesting the problem is “mild” and the inconvenience is major.
Personal isolation is key
Dr. Hattie had to insist that the important approach was to restrict community gatherings, when others were suggesting there were numerous potions and remedies that would address the Spanish flu. Seeking a magic bullet sounds exciting to the public, and is confusing when so many remedies are suggested in newspapers and rumoured in communities. Just staying away from others doesn’t sound like exciting modern medicine, even though it is the key to preventing viral spread. Even today we know that a concept of population health and attention to the determinants of health is the key to population health. People agree intellectually, but they still want all the health dollars and programs to go to more beds, hospitals, MRIs and cures.
Recognize the sources
of the infection
If controls are going to be enacted to prevent a pandemic, it is essential that the potential sources are recognized. In 1918 there were troop ships arriving in Sydney and Halifax from Europe with many sick and dying with the flu. The marine quarantine officer was Dr. Norman McKay, another argumentative surgeon who regularly clashed with Dr. Hawkins in the pages of local newspapers, so co-operation was going to be difficult between these men. There was a lot of travel back and forth from Nova Scotia and “the Boston States”, as they called New England. Most Maritimers had relatives there. New England fishermen plied the waters off Nova Scotia and landed ashore at many ports. A religious congress in Quebec gathered 25,000 people from across the country and the USA, resulting in many coming down with influenza, spreading it further when they returned home. There was very little control over these factors in 1918. Even small villages that thought themselves protected were not always aware of the numbers of travellers and coaches going through every week.
Seek reliable information
Dr. Hattie put out regular information on the numbers of patients coming down with the flu just as Dr. Strang does now, but there were many other competing news reports and rumours, which served only to confuse the public. When Dr. Hattie was indicating the cases were increasing, the local newspapers were regularly downplaying the seriousness and calling the problem “mild”. When the public is asked to co-operate and make sacrifices, they must have reliable information they can trust. In a public health crisis, then and now, people should get their information from the public health officials.
Don’t lift controls too early
Under pressure to lift some restrictions in early November 1918 so that there could be Armistice Day events, some allowances were made, and the number of cases predictably increased. In the United States there is talk of lifting some restrictions before Easter, before there is any evidence that would support this. It is very hard to re-institute controls once they have been taken off, as they learned in 1918.
Even though the public health officials attempt to emphasize clarity, there are loud voices elsewhere offering alternative views and remedies. There were many remedies available over the counter that were rumoured to help. Some contained opium, some cocaine and many had high concentrations of alcohol. Newspaper ads suggested therapies such as Minard’s liniment which was made in Yarmouth, with active ingredients camphor, ammonia water and turpentine, and Johnson’s anodyne liniment from Maine, which contained morphine and alcohol. Other remedies advertised to help with the Spanish flu were Horlick’s malted milk, and pasteurized milk. Local clothes manufacturers advertised that their outfits would protect against the Spanish flu by keeping you warm and dry. A writer to the local newspaper suggested the answer was to burn sulphur at each street corner. As now, the public health message gets muddied by people with uninformed opinions, well-meaning theorizers, and those hoping to make a buck.
Because of the strong leadership of Dr. Hattie and others, Nova Scotia had fewer deaths from the Spanish flu than other areas in North America. Also, the second wave of cases expected in the months when the pandemic was on the wane, didn’t occur in Nova Scotia. There was a return of some cases a year later in January. The number of deaths overall was thought to be 2,230 in a population of 514,484, including the 250 who died in the three-month period of January to March 1920. This was lower than in other areas, and half that of many areas in the USA. There have been pandemics of influenza throughout the centuries, and the most recent were 1889, 1918, 1957, 1968, and 2009. It would seem that we have to relearn lessons each time.
The experience of WW I, the Halifax Explosion and the Spanish Flu convinced the medical establishment that better health care could be a matter of organization. A new respect for public health led to the formation of a Federal Department of Health and a Nova Scotia Department of Health in 1919. Dr. Hattie was on the initial Dominion Council of Health.
After the Spanish flu pandemic the medical school at Dalhousie began to teach courses on public health and developed a program to train public health nurses. When Carnegie and Rockefeller Foundation funds came for the new buildings and programs at Dalhousie Medical School in the 1920s they included support for the construction of a public health clinic, an infectious disease hospital and a TB hospital.
Dr. William Hattie continued as Provincial Medical Officer of Health and a faculty member and then assistant dean at Dalhousie Medical School. He carried out much of the administration of the medical school when Dean Dr. John Stewart, another physician with a Pictou connection, was in failing health. It is interesting that one of Dr. Hattie’s sons was named John Stewart Hattie. Dr. Hattie died in 1931. His contributions to the health of Nova Scotians should be remembered.
Dr. T. Jock Murray grew up in Pictou and attended Pictou Academy. He is a neurologist and medical historian, former Dean of Medicine at Dalhousie Medical School and founder of the Dalhousie MS Research Unit.