Remember the swine flu? It’s the pandemic that Australia forgot, arguably to our detriment when it came to wrangling COVID-19. In this article, Dr Richard Trembath looks back on the H1N1 swine flu outbreak, and the impact on Australia, and his own family.
During these times, there was a pestilence[i]
On 8 May 2009 the first case of swine flu (H1N1) was identified in Australia. Within a fortnight it was apparent that community transmission was developing in this country. The peak of the illness was in July and by September the main wave had passed. According to the Federal Department of Health and Ageing, during 2009 Australia reported 191 deaths from 35, 537 confirmed cases of swine flu. On the other hand, the Australian Bureau of Statistics stated that there were 77 deaths. For several methodological reasons which I cannot go into here I prefer the former figure for mortality which, if anything, is understated. The most deaths (51) occurred in New South Wales though the virus ‘gained momentum in Victoria before other states of Australia.’[ii] In the end mortality was considerably lower than worst case estimates, and the disease proved to be moderate in its overall effects. Just another ordinary flu season?
In this article I wish to examine some key features of how Australian authorities reacted to the advent of swine flu, concentrating on those which most directly affected the general public. These features included social control, school closures, vaccination and community response to the outbreak, all factors which anticipated measures undertaken during the current COVID pandemic. Despite these similarities, swine flu, which was classified by the World Health Organisation as a pandemic in June 2009, seems to have largely slipped from memory in Australia. To test this thesis, prior to writing this piece, I conducted an outrageously unscientific survey of family members and friends and found ignorance of what occurred in 2009 abounding. There are reasons for this. Swine flu was much less lethal than COVID and its effects on our daily lives relatively minor compared to the current day. But it is useful to revisit 2009 if only to demonstrate that COVID is not quite as ‘unprecedented’ as some might think. Restrictions on everyday activities are not new and journalists, when discussing COVID, do not always have to go back to the Spanish Flu for a comparison. [iii]
One of those who caught swine flu was my wife, Anne Marie, a secondary school teacher in Brunswick where there was a scurry of cases. Generally, I apologise for the personal or the anecdotal in an article such as this, but here I make an exception as some of the features of our family predicament were useful examples of the wider response to swine flu’s presence. For example, Anne Marie, whose main symptoms were fatigue and depression, ‘quarantined’ herself at home which was the state government’s advice. I think I was supposed to observe some form of sympathetic isolation as well. I cannot remember how strictly I adhered to this protocol.
Thirty-three years before, swine flu had made a notorious appearance in the United States which in 1976 was celebrating the 200th anniversary of the Declaration of Independence. Swine flu was an unwelcome guest. An unfortunate soldier at Fort Dix, New Jersey, collapsed with a respiratory complaint and was diagnosed correctly as suffering from swine flu. There was a sprinkle of other cases and the unfortunate first victim died, though he turned out to be the only fatality. However, the scale of the outbreak, and the virulence of the disease, were both seriously exaggerated. Besides that one death, there were only thirteen hospitalised cases. But amidst fears that the swine flu outbreak would turn into a lethal epidemic, President Gerald Ford, who was facing a tricky election, proclaimed a national vaccination program. Between 20%-25% of United States citizens received the vaccine which was pushed as a high priority by the then Center for Disease Control. At first Americans flocked for the injections as many were convinced that the disease would be as deadly as the Spanish Flu. When it became clear that the outbreak was tiny, and mortality non-existent, fear of the disease was transformed into fear of the vaccine as an indeterminate number of people developed Guillain–Barré syndrome following their injections. As a result, the mass immunisation program was halted in December 1976. A recent BBC documentary described the handling of the 1976 American outbreak as a ‘fiasco’.[iv]
According to Seth Mnookin in his study of public panic about the alleged adverse effects of vaccines this development had long term consequences. For a start, it played right into the hands of anti-vaxxers.
By that time, Gerald Ford’s fumbling effort to vaccinate everyone in the country against a threat that never materialised was widely viewed as one more example of the federal government’s incompetence, its engagement in nefarious conspiracies, or both. . . . In the coming years, the consequences of losing the public’s trust became all too apparent.[v]
This was one factor influencing the official response to swine flu in Australia decades later. Measures were taken in accordance with the Australian Health Management Plan for Pandemic Influenza (AHMPPI) which had been adopted in 2008. This had six steps or protocols ranging from the initial ALERT through to the ultimate RECOVER. The gradated approach allowed, hopefully, for the introduction of appropriate strategies but not stringent ones unless required.
The public though reacted strongly to media discussion of the potential severity of the outbreak. According to microbiologist and physician, Peter Collignon, ‘[d]isproportionate fear generated by media reports resulted in many people presenting to emergency departments or medical practices when they had mild illness and should have stayed at home to recover on their own.’[vi] General practitioner, Peter Eizenberg, pointed to implementation problems in Victoria, problems found elsewhere in Australia. These implementation issues included lack of antiviral prophylaxis for frontline practitioners, extensive delays in receiving laboratory results and laggard approval to supply the drug oseltamivir to patients. Eizenberg concluded:
It is only due to the low virulence of the virus that this pandemic has merely stressed our local service delivery and not completely paralysed both our and the statewide response.[vii]
The burden on local clinics eased by winter. As it became apparent that swine flu in Australia was not Spanish flu revisited the focus of the national campaign switched in June 2009 to a new stage of the Health Management Plan – one invented ad hoc – called PROTECT, which was intended to concentrate on vulnerable groups in the community such as Indigenous Australians and pregnant women. Hope was pinned on developing a vaccine.
What social controls were put into place?
School closures sound similar to COVID but they were considerably different in scale and application. Instead of the broad brush measures familiar from COVID, in 2009 schools were closed after the event. If a student or students tested positive to swine flu then an interdict was enforced, but this applied only to the school or schools with ill teachers and/or pupils. Sometimes, only an affected class or school year was shut down. In Melbourne there was minor grumbling at this inconvenience, but this was brief.
Back in 2009 protective masks were seen on Australian streets but this seems to have been largely a matter of personal choice and the practice was sporadic. During my wife’s illness I had to go to my doctor for a matter unrelated to swine flu. There I was provided with a mask to wear for the duration of my visit to the surgery. I have no idea if that was a common practice when there were cases in the immediate neighbourhood. Around this period (and afterwards) international students from China, Taiwan, Singapore and Malaysia often wore masks during the ‘normal’ influenza season, or if they were suffering a cold, an instance of both self-protection and social responsibility. I must add they attracted unpleasant comments for so doing from some locals who muttered nasty comments about excessive worry.
As noted previously, what was meant by isolation was a bit vague. Whatever the official recommendations, most seem to have interpreted it as stay at home until better. Nobody was inspecting to see if one complied with that protocol and my sick wife certainly received our children as visitors.
By February 2010, when swine flu was receding quietly into the past, vaccination take up was estimated to be 3.9 million people, 18 % of the population.[viii] This figure stuns me. It just seems so high. I was aware of the vaccination program but did not even contemplate getting the shot myself. In my mini-survey nobody mentioned vaccination, and most could not recall there was such a program despite the fact that this was the biggest roll out in Australia’s history. One clue here is that once the PROTECT stage of the national plan was implemented prophylaxis focussed on the above-mentioned vulnerable groups, Indigenous Australians, pregnant women, those with serious underlying illnesses etc.
Social controls for the purpose of public health existed in Australia long before COVID, though not to the same extent since Spanish Flu. During the swine flu outbreak there were no restrictions on the size of gatherings, sport, or personal movement, just to name a few. Eve Black had no precedent in 2009-2010. This was the young woman who filmed herself whooping with delight as she burst through a COVID checkpoint, despite being pulled over by the police, and who was later arrested noisily in Carlton. The media just loved her for first being revealed as a topless waitress and stripper and then as being domiciled in an Orthodox convent as part of a ‘religious journey’ to ‘re-learn womanhood.’[ix] Despite some people now claiming otherwise, there ‘were no restrictions on domestic travel, and state border closures were not considered in Australia’ during the swine flu outbreak. Border measures were, however, applied at international airports and seaports.[x] Problems with cruise ships were not foreseen and these ended up, as with COVID, being a significant mode of transmitting infection across distance, including to regions of the Pacific such as New Caledonia. Within Australia though, more Australians were probably inconvenienced by the equine influenza epidemic of spring 2007.
After swine flu passed Australia kept a careful eye on two more lethal illnesses in avian flu and Middle East Respiratory Syndrome (MERS) but these did not become world events or affect this country. But epidemiologists and infectious diseases experts were aware that in a globalised world, new viruses not only leap from species to species but they can also catch planes and travel on ships. Swine flu might only be a footnote in history but it gave this country a foretaste of how our lives might be affected by a pandemic. Perhaps it had a negative effect too, persuading some people that ‘we’ve seen this before, it’s never as bad as you think.’ Possibly the best known example of this state of mind is Boris Johnson who was recently disparaged by his former adviser, Dominic Cummings:
Among the most damning assertions is that while nations like Taiwan were locking down in early 2020, Boris Johnson was dismissing coronavirus as a scare story, no more serious than swine flu. According to his former adviser he’d even go on live television and be injected with COVID-19 to prove the point.[xi]
Of course, Johnson was almost terminally wrong in his prediction.
Funny old Boris, you might say, but in March 2020 there were those in this country, influential people who could write (with no authority) that ‘we (and the rest of the world) are making so much fuss about it mainly because it’s new.’[xii] It may be just like swine flu.
Don’t be fooled by history.
[i] Procopius, cited in William Rosen, Justinian’s Flea: The First Great Plague and the End of the Roman Empire, Penguin, New York, 2008, p.9. The great historian is describing the first appearance of bubonic plague in the Mediterranean world in 542..
[ii] Australian Government, Department of Health and Ageing, Review of Australia’s Health Sector response to Pandemic (H1N1) 2009: Lessons Identified, Department of Health and Ageing, Canberra, p. vii.
[iii] For an example of reviewing previous epidemics for possible guides to dealing with COVID see ‘As coronavirus spreads, what can we learn from the last five epidemics to hit Australia?’, SBS News, https://www.sbs.com.au/news/as-coronvirus-spreads-what-can-we-learn-from-the-last-five-pandemics-to-hit-Australia, accessed 1 June 2021. The five pandemics are Spanish flu, Asian flu, Hong Kong flu, HIV/AIDs and Swine flu.
[iv] ‘The fiasco of the 1976 “swine flu affair” ’, BBC Future, 22 September 2020, https://www.bbc.com/future/article/20200918-the-fiasco-of-the-us-swine-flu-affair-of-1976, accessed 15 June 2021.
[v] Seth Mnookin, The Panic Virus: Fear, Myth and the Vaccination Debate, Black Inc., Melbourne, 2011, p. 66.
[vi] Peter J Collignon, ’Swine flu – lessons learnt in Australia’, Medical Journal of Australia, Volume 192, No. 7, 5 April 2010, pp. 364-365.
[vii] Peter Eizenberg, ‘The general practice experience of the swine flu epidemic in Victoria – lessons from the front line’, Medical Journal of Australia, Volume 191, No. 3, August 2009, pp. 151-153.
[viii] Review of Australia’s Health Sector response to Pandemic (H1N1) 2009, p. 63.
[ix] See Daily Mail Australia, 19 June 2021, https://www.dailymail.co.uk/news/article-8579387/Coronavirus-conspiracy-theorist-Eve-Black-outed-topless-waitress-raunchy-stripper.html , accessed 19 June 2021. Also see 7News.com.au, 19 June 2021, https://7news.com.au/lifestyle/health-wellbeing/conspiracy-theorist-eve-black-has-been-living-with-nuns-as-part-of-journey-to-re-learn-womanhood-c-2091632, accessed 19 June 2021.
[x] Review of Australia’s Health Sector response to Pandemic (H1N1) 2009, p. vii.
[xii] Ross Gittins, ‘Virus overreaction big fear’, Age, 11 March 2020, p.18.