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Influenza pandemics throughout Brazilian history

Pandemias de influenza ao longo da história brasileira

Abstract

Brazil has experienced several major epidemics of influenza, and the most destructive was in 1918-1919. This article focuses on mortality, mitigation policies, and the consequences of pandemic influenza during the national period. We provide the first mortality estimates for the 1890-1894 influenza pandemic and correct figures for later epidemics. The 1918-1919 episode cost more lives than assumed, although some cities suffered less, possibly because of public health actions. Influenza caused pandemics in 1957, 1968, 1976, and 2009, but these did not cause unusual outbreaks in Brazil.

influenza; mortality; pandemics; public health; covid-19

Resumo

O Brasil passou por várias epidemias importantes de influenza, a mais letal em 1918-1919. O artigo focaliza a mortalidade, as políticas de mitigação e as consequências das pandemias de influenza no período nacional. Fornecemos as primeiras estimativas de mortalidade para a pandemia de 1890-1894 e corrigimos números de epidemias posteriores. O episódio de 1918-1919 custou mais vidas do que se considerou anteriormente, embora algumas cidades tenham sofrido menos, possivelmente devido a ações de saúde pública. A influenza gerou pandemias em 1957, 1968, 1976 e 2009, mas elas não causaram surtos incomuns no Brasil.

influenza; mortalidade; pandemia; saúde pública; covid-19

Brazil now faces the deadliest pandemic of acute respiratory disease experienced in this century. The cause, a coronavirus, has been part of human history for millennia, but a novel and dangerous viral strain, called SARS-CoV-2, was first detected in central China in 2019 (Wertheim et al., 2013WERTHEIM, Joel O. et al. A case for the ancient origin of coronaviruses. Journal of Virology, v.87, n.12, p.7039-7045, 2013.). The covid-19 pandemic’s trajectory is unique and the virus is highly virulent, prompting the secretary-general of the United Nations to call it “the most challenging crisis we have faced since the Second World War” (UNSG, 2020). Brazil has confronted pandemics before, including several deadly influenza episodes. Covid-19 and influenza should not be confused, but from what scientists know so far, these viral diseases share some characteristics, especially in their modes of transmission (CDC, 2018; Taubenberger, Morens, 2008; WHO, 2020).

Unfortunately, powerful leaders such as Brazilian President Jair Bolsonaro claim Brazilians have special resistance to diseases like covid-19, which he has called a “little flu” (Friedman, 2020FRIEDMAN, Uri. The coronavirus-denial movement now has a leader. The Atlantic, 27 Mar. 2020. Available at: https://www.theatlantic.com/politics/archive/2020/03/bolsonaro-coronavirus-denial-brazil-trump/608926/. Access on: 17 Dec. 2020.
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). This seems to be based on a belief that acute respiratory diseases spare Brazil, perhaps because of the tropical climate or constitution of the Brazilian people, but these ideas are rooted in old myths and historical uncertainty (Read, 2022READ, Ian. Tragedy at the Tropic of Capricorn: nineteenth century globalization and epidemiological change on two sides of the South Atlantic. In: Read, Ian; Patterson, Andrea (ed.). The shapes of epidemic disease: socio-historical, artistic, political, and ecological significance. London: Cambridge Scholars Publishing, 2022.). In fact, epidemiologists and historians have rarely examined respiratory diseases like influenza over a period longer than a single epidemic. Usually, the focus is regional or on a single Brazilian city.

This is the first essay to document the history of influenza starting more than a century ago, when doctors and politicians first acknowledged the disease as a national problem through today. We present archival research – newspapers, government documents, and other original sources – and construct a national story of the 1918-1919 pandemic in Brazil. Our findings are surprising in three ways. First, influenza became a severe but diminishing problem only in the twentieth century, although thousands died across the nation from the flu in the late nineteenth century. Second, Brazil suffered with the rest of the world during the 1918-1919 pandemic, with a death toll higher than historians have estimated. By comparing several cities, we find that mitigation strategies likely saved lives. Third, influenza became pandemic for several years after 1950, killing from Bombay to Bangkok to Boston, but Brazilians were mostly spared during this period. Influenza has declined as a threat, but the greatest fall in mortality across Brazil occurred before widespread access to vaccination. Finally, influenza’s reduced threat, but periodic morbid sensationalizing by the international media, has allowed politicians to underplay the deadly threat of viral respiratory diseases.

Influenza has killed Brazilians for centuries, but the historiography of influenza concentrates on the 1918-1919 pandemic. This focus is somewhat justified since regional and urban studies from the past two decades have helped us better understand the scale of the tragedy of one of Brazil’s worst pandemics. Pioneering research conducted by prominent historians and graduate students describes the 1918-1919 influenza epidemic as it struck and evolved in Brazil’s cities: São Paulo, Rio de Janeiro, Belo Horizonte, Porto Alegre, Recife, Salvador, and Manaus (Goulart, 2003GOULART, Adriana da Costa. Um cenário mefistofélico: gripe espanhola no Rio de Janeiro. Dissertação (Mestrado em História) – Universidade Federal Fluminense, Niterói, 2003., 2005GOULART, Adriana da Costa. Revisitando a espanhola: a gripe pandêmica de 1918 no Rio de Janeiro. História, Ciências, Saúde – Manguinhos, v.12, n.1, p.101-142, 2005.; Bertolli Filho, 2003; Silveira, 2008SILVEIRA, Anny Jackeline Torres. Influenza espanhola e a cidade planejada: Belo Horizonte, 1918. Belo Horizonte: Fino Traço, 2008.; Abrão, 1998ABRÃO, Janete Silveira. Banalização da morte na cidade calada: a hespanhola em Porto Alegre, 1918. Porto Alegre: EDIPUCRS, 1998., 2009ABRÃO, Janete Silveira. A história de uma epidemia: a hespanhola em Porto Alegre, 1918. Boletim de Saúde Pública, v.23, n.1, 2009.; Gama, 2013GAMA, Rosineide de Melo. Dias mefistofélicos: a gripe espanhola nos jornais de Manaus (1918-1919). Dissertação (Mestrado em História) – Universidade Federal do Amazonas, Manaus, 2013.; Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017.; Souza, 2007SOUZA, Christine Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia. Tese (Doutorado em História das Ciências da Saúde) – Casa de Oswaldo Cruz/Fundação Oswaldo Cruz, Rio de Janeiro, 2007.). The most recent of these studies comes from a team of international social scientists and shows that pandemic influenza was deadlier than the Brazilian government recognized (Guimbeau, Menon, Musacchio, 2020). The present essay also builds on a research project that documents the history of epidemics in Brazil (Read, 28 Mar. 2020, 2022).

Taking a broader approach to the history of influenza, we divide this essay into three sections. The first is a historic examination of flu pandemics, including 1890-1891, 1918-1919, and subsequent pandemics, to show that seasonal flu transformed from a common killer to a much rarer risk, at least until now. Special attention is paid to different municipal governments’ varied and often desperate responses during the 1918-1919 pandemic. We then globally contextualize Brazil’s experience and compare it to subsequent pandemics in Brazil, noting that Brazilian epidemics after 1919 did not coincide with global pandemics. The final section compares the government’s reaction to the 1918-1919 pandemic with the current covid-19 response, identifying what historical lessons could be learned and applied to contemporary Brazil.

The “excess deaths” of the 1890-1891 pandemic

In December 1889, fear gripped many Brazilians as a strange malady spread from Russia to western Europe and across the Atlantic to North America (A Influenza, 6 Feb. 1890, p.1; Retrospecto…, 18 Feb. 1890). By January 1890, as the capitals of Argentina and Uruguay reported hundreds of deaths, the disease was poised to strike Brazil. Oddly, over the next two years, Brazilian doctors attributed a tiny number of deaths to influenza, and medical experts denied influenza existed in Brazil (Sessão…, 22 Mar. 1890; Rodrigues, 1891RODRIGUES, Nina. A epidemia de influenza na Bahia em 1890. Gazeta Medica da Bahia, v.22, p.548-557, June 1891.). Even the newly installed republican president, Marshall Deodoro da Fonseca, refused to acknowledge the disease, despite becoming deathly sick (Affairs in Brazil, 20 Dec. 1889). In Brazil’s capital, Rio de Janeiro, the Head of Municipal Statistics reported only five deaths from the disease, in Recife 48, in Porto Alegre one, and in Salvador six. In Salvador, Nina Rodrigues’ interviewed medical colleagues and reviewed newspapers and encountered a common opinion that influenza was “very benign” and took on a local character in Brazil (Rodrigues, 1891, p.556; Academia…, 15 Aug. 1891; Souza, 2007SOUZA, Christine Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia. Tese (Doutorado em História das Ciências da Saúde) – Casa de Oswaldo Cruz/Fundação Oswaldo Cruz, Rio de Janeiro, 2007., p.143, 174).

In determining influenza’s impact, we must count “excess deaths,” but also acknowledge mortality from other epidemic diseases and seasonal fluctuations in endemic diseases. Brazilians suffered from many other contagious and epidemic diseases in this time period: tuberculosis, smallpox, yellow fever, bubonic plague, malaria, and typhoid fever. These caused higher death rates and received more attention. In addition, doctors usually attributed the cause of death to comorbid, pre-existing conditions, such as tuberculosis. Some officials, such as Rio’s medical demographer Aureliano Souza Portugal noticed this tendency after looking back at mortality statistics. In the Interior Minister’s 1892 report, he enumerated exceptional levels of deaths from comorbid diseases and concluded “it is well known that influenza does not cause many deaths, but increases the lethality of certain other diseases” (Ministério do Interior, 1892MINISTÉRIO DO INTERIOR. Relatório apresentado ao Vice-Presidente da República dos Estados Unidos do Brazil pelo Dr. Fernando Lobo Leite Pereira, Ministro de Estado dos Negócios do Interior, em Abril de 1892. Rio de Janeiro: Imprensa Nacional, 1892. Available at: http://ddsnext.crl.edu/titles/103?terms=influenza&item_id=1714#?h=influenza&c=4&m=1&s=0&cv=227&r=0&xywh=-937%2C0%2C3297%2C2325. Access on: 28 May 2020.
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, p.85). Souza Portugal’s findings show how influenza “hid” behind comorbid diseases during the colder months of 1891.

Brazil’s first discernable influenza epidemic appears to have been worse in the South. In Porto Alegre, there were around three deaths per thousand in 1891, while São Paulo and Rio de Janeiro counted two and one death per thousand, respectively.1 1 Recife’s estimate is based on influenza deaths plus excess tuberculosis deaths. Since there are no counts of deaths by other respiratory diseases, we extrapolated the excess death rate from tuberculosis (Freitas, 1905). Rio de Janeiro’s and Porto Alegre’s estimates are total influenza deaths plus excess deaths from tuberculosis, bronchitis, pneumonia, and heart disease (Ministério do Interior, 1892, p.85). São Paulo is based on excess deaths from the parishes São Tiago and Santo Amaro. Recife’s rate was similar to Rio de Janeiro, but influenza struck later, in 1894 (Ponzo, 1976PONZO, Umberto. S.O.S Saúde. Diário de Pernambuco, p.2, 28 Mar. 1976. Available at: http://memoria.bn.br/DocReader/029033_15/82711. Access on: 28 May 2020.
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). In Salvador and Recife, between 1890 and 1893, we have no evidence of excess deaths from influenza. Insufficient data hinders the analysis of Salvador; as Rodrigues noted, “we do not have [a] demographic office in this city to evaluate any type of epidemic” (Rodrigues, 1891, p.556). In total, though our estimates are tenuous, we apply the 1-2 per thousand (i.e., 0.1-0.2%) death rate and estimate 14,000-28,000 Brazilians died from influenza during the first recorded pandemic in Brazil (Maia, 1836MAIA, Emílio. Relatório da comissão especial sobre a febre catarral que grassou nos primeiros meses de 1835. Revista Médica Fluminense, p.10-17. Jan. 1836.; A Influenza…, 4 Sep. 1890; Influenza…, 14 July 1890; Leal, 1892LEAL, Oscar. Viagem às terras goyanas: Brazil central. Rio de Janeiro: Typographia Minerva Central, 1892.). An awful death toll, but one dwarfed by other epidemic diseases. For example, nearly 9,000 people died from yellow fever and smallpox in the city of Rio de Janeiro between July 1891 and June 1892 (Boletim da Semana, 22 Aug. 1892). Rio de Janeiro residents may have been more resigned to infectious diseases before the pandemic arrived. In mid-1889, the Rio News derisively wrote, “After the mortal fear [of yellow fever] into which this whole city was thrown only four short months ago, it is incomprehensible that there could be so much apathy now [to the influenza pandemic] … The Brazilian is a tropical creature who easily forgets today what he mortally feared yesterday” (Rio..., 15 July 1889).

Recognition, not apathy, is evident among most doctors. More recognized and diagnosed seasonal influenza after the pandemic. Doctors switched from older categories such as “catarrhal fevers,” and most cities reported influenza deaths after 1890. Nonetheless, few believed that influenza was pandemic in Brazil in 1890-1892, and hardly any doctors worried that a disease associated with colder northern countries could cause a much worse catastrophe.

The 1918 influenza pandemic

It is not clear how the “Spanish flu” (grippe hispaniola) arrived in Brazil. There were no major increases in flu-related symptoms or deaths through most of 1918. The first cases of influenza among Brazilians were reported in early September. They first appeared aboard several ships carrying Brazilians or docked in Brazil, and soon after cases were reported in several Brazilian ports (Bertolli Filho, 2003). Doctors heard the first complaints of influenza-related symptoms in Rio de Janeiro in late September. The Director of Public Health Carlos Seidl, worried about the spread of the disease, thus, opened Ilha do Governador as a quarantine station for arrivals from Africa, though the deadly strain likely came from Europe. On September 14, when The Demerara, a British ship, sailed into Guanabara bay, with stops in Recife and Salvador, some crew members were already sick (Bertolli Filho, 2003, p.74). From these imported cases, or from elsewhere, the disease spread to the interior of Brazil and caused the worst nationwide epidemic of the twentieth century (Cooper, 1975COOPER, Donald B. Brazil’s long fight against epidemic disease, 1849-1917: with special emphasis on yellow fever. Bulletin of the New York Academy of Medicine, v.51, n.5, p.672-696, 1975.).

In this section, we use published and archival sources to examine the steps taken by state and city authorities in 1918 across Brazil. Our archival sources include newspapers, provincial reports, Health Department publications, and photographs, which are further supported by the groundbreaking research of published Brazilian scholars. We find that most sanitary and social distancing measures were lenient and may not explain the virus’s trajectory. Leniency can be attributed to two causes. First, most people were unaware of the risk of influenza transmission through respiratory droplets and aerosol spread. Second, even if such knowledge had been widespread, most Brazilians were unable to isolate themselves when their survival depended on entering public spaces for work and daily necessities like food and fuel. City and state governments across the nation took steps to reduce crowds, disinfect public spaces and homes, and treat the infirm. Some large cities, like São Paulo, attempted to isolate the sick in hospitals and clinics, many of which were built for the emergency. Although influenza caused remarkably few deaths in some cities like Belém, Salvador, and Campinas, there is no strong evidence to suggest that lower mortality rates were caused by specific mitigation efforts.

Canceling public events and public gatherings was an obvious policy to slow down the propagation of the 1918 influenza. Most health authorities knew from past experiences with epidemics that isolating the sick, disinfecting the homes of the deceased, and increasing case monitoring were crucial for reducing infection (Bertolli Filho, 2003, p.156). Yet, in Brazil, various municipal governments did not effectively limit crowds in churches, factories, and schools and did not restrict army officers or sailors from leaving quartered barracks and docks. Street markets partially justified the government’s reluctance to reduce gathering – since many relied on markets for food, closing them would have caused enormous hardship.

Journalists in Recife and São Paulo pleaded with readers to avoid agglomerations – the term used then for social distancing – but state and city authorities published no official position, even as daily deaths doubled, then quadrupled. On October 15, Artur Neiva, director of the São Paulo Sanitary Service, declared a “state of pandemic” and sent all public employees home, furloughed or on vacation. The next day he closed all schools and announced penalties to pharmacies that increased prices for necessary remedies. Neiva promoted self-isolation as a key measure to prevent the spread of influenza, asking the community to stay at home: “All individuals have to avoid agglomerations, mainly at night; avoid attending theatres and cinemas; avoid visiting other people.” He also recommended not visiting sick people as this was the primary way of spreading the disease (Bertolli Filho, 2003, p.157). Perhaps because they were considered “essential,” factories continued to operate, and the São Paulo Sanitary Service used them as case studies for morbidity rates. In Sorocaba, a town about 100km from São Paulo, one large textile factory defied a request by the town’s government to close (Dall’Ava, Mota, 2017, p.439-444). At the end of October, at the pandemic’s peak, Neiva prohibited sports competitions, street performances, and the sale of fruits and candy on the street. Critics saw these efforts as too little, too late.

When alarming reports arrived in Salvador, the city canceled all events and improvised multiple hospitals to isolate the sick (Souza, 2009SOUZA, Christiane Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia. Rio de Janeiro: Editora Fiocruz, 2009., p.179). At that time, Salvador’s residents commonly visited docked ships for entertainment. Officials prohibited this pastime, as “almost all ships had been turned into hospitals … as they had a significant number of sick on board” (p.180). Also, in the first weeks of October, when the epidemic was spreading rapidly, health inspectors visited homes and businesses throughout the city, ultimately inspecting 12,311 people with or suspected to have the disease. Inspectors also examined churches, where many Bahians sought refuge and protection, despite warnings from health authorities to avoid crowds (Souza, 2009SOUZA, Christiane Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia. Rio de Janeiro: Editora Fiocruz, 2009.). During these visits, health inspectors in Salvador found 40% of people had influenza (p.181-182). City authorities asked sick individuals to stay home and sent medical corps to their homes, thus avoiding hospital crowds and further contagion. Among the sick, the incidence was highest in sailors (99%), prisoners (82%), and government officials (76%), while factories, schools, and army barracks had morbidity rates of 42-45%. This provides anecdotal evidence regarding why Salvador, which had been strongly affected by previous epidemics of infectious diseases, was relatively spared by the influenza pandemic.

In Recife, Pernambuco, the death toll was more severe, perhaps because public events restarted too early. Initially, authorities responded but did not explicitly impose stringent isolation measures. By October 9, newspapers described how the influenza epidemic “slowed down movement on the streets, cinemas, cafes, and commercial establishments … due to the fact that of the businesses’ employees are sick” (quoted in Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017., p.60). Residents could also request medical attention at their home by leaving their address at (or calling) the Department of Public Health. The municipal government also established temporary hospitals in several districts of the city. By October 15, public offices and businesses operated with limited hours, the postal service restricted operations, most educational institutions closed, and sporting activities also stopped due to the high morbidity rates among athletes. The director of the Department of Public Health, doctor Abelardo Baltar, succumbed to the flu on October 13, before he or any other government official announced stringent measures to mitigate the disease’s spread. Baltar’s successor, doctor Octavio de Freitas, took another approach and imposed social distancing measures. He required cinemas, churches, hospitals, and schools to close (quoted in Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017., p.154). Yet, these measures ended quickly; cinemas reopened on October 28. Death rates and public pharmacy visits decreased significantly per day by late October (p.116-117).

In Manaus, the capital of Amazonas, in the North, the first case of influenza was confirmed later than most state capitals, on October 24, 1918. Residents had followed the alarming news for weeks, and city officials were aware of the measures their counterparts had taken. Most businesses closed by early November, and on November 4 all soccer games were canceled. Nevertheless, the flu quickly became an awful risk for residents. For example, the city lacked the personnel to bury all corpses even with the aid of the state police. In some of the poorest neighborhoods, bodies were found abandoned (Silva, Costa, 2011, p.9-11). Similarly, the general director of Hygiene in Fortaleza, the capital of Ceará, called on residents to avoid dancehalls in late October, but these recommendations may not have been immediately followed (No Ceará…, 29 Oct. 1918).

All major cities restricted funeral gatherings and passed regulations to expedite burials to avoid contagion. In Recife, the Health Department ruled that corpses should not sit in the public morgue, as was traditionally done, but rather should be taken directly to the cemetery (Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017., p.101). In São Paulo, the Sanitary Service centralized funerals to public buildings to prevent gatherings in homes (Bertolli Filho, 2003, p.146). Still, photographs from the time show crowds in cemeteries and funeral processions with agglomerations of people not wearing facial protection (Figure 1).

Figure 1
Funeral procession of José Paulino Nogueira Filho in São Paulo, without social distancing, 1918 (Nascimento, 2020NASCIMENTO, Douglas. Cenas da Gripe Espanhola em São Paulo: São Paulo antiga. 30 Mar. 2020. Available at: https://saopauloantiga.com.br/cenas-da-gripe-espanhola-em-sao-paulo/. Access on: 28 May 2020.
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)

Brazil’s previous epidemics had somewhat prepared authorities. They quickly mobilized public service employees to clean and disinfect public spaces and provide sterilization services for homes afflicted by contagious diseases. In Recife, the Department of Health provided free sterilization services for families with flu deaths (Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017., p.75). The city of São Paulo mobilized the Central Disinfecting Department to sanitize homes with two or more deaths (Bertolli Filho, 2003). By late October, in Salvador, the Central Disinfecting Unit of the State Secretary of Health began disinfecting spaces where people clustered. In Amazonas, the Health inspector of the Port of Manaus, doctor Madureira de Pinho, identified sick sailors and used a powerful pump to spray and disinfect the ships (Silva, Costa, 2011, p.4).

Previous epidemics also taught public health officials how to deal with large, sudden waves of sick people. Thus, all major cities developed capabilities to rapidly build improvised hospitals and ad hoc clinics (pontos de socorro). Moreover, the different health departments or sanitary services quickly created teams of doctors to staff hospitals and home visitation services. In Manaus, authorities set up a floating hospital, called the Santa Barbara, to treat the poor and homeless. They also converted schools, police barracks, and a detention center into hospitals (Silva, Costa, 2011, p.7-8). Across Brazil, doctors provided home visits to avoid crowding at hospitals. In Salvador, because doctors treated patients in their homes, only about 15% of individuals died in the city’s hospitals and asylums (Souza, 2009SOUZA, Christiane Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia. Rio de Janeiro: Editora Fiocruz, 2009., p.235-241).

São Paulo was unique because it relied less on house calls. The municipal chamber passed a rule in mid-October 1918 to convert public buildings into clinics. By November, the Sanitary Service opened 38 improvised hospitals and 44 clinics to provide free treatment, though there were only ten thousand beds for the thirty thousand sick patients. Neiva initially recommended the ill stay at home, but by early November, he urged the sick to hospitalize to avoid delays caused by traveling doctors and nurses (Bertolli Filho, 2003, p.166-168). Health officials in Porto Alegre took the opposite strategy by keeping the sick at home. The municipal government divided the city and its residents into 25 “sanitary districts” (quateirões sanitários) (Abrão, 2009ABRÃO, Janete Silveira. A história de uma epidemia: a hespanhola em Porto Alegre, 1918. Boletim de Saúde Pública, v.23, n.1, 2009.). One doctor and a small team of medical students were assigned to each district or neighborhood. The government required health teams to make daily visits, provide free supplies, and only remove patients who could not receive home care. The Hygiene director received a report of cases each day at noon in October and November 1918. This approach mirrored Salvador’s aggressive and widespread medical house-calls strategy and differed from the attempt to hospitalize the infirm in São Paulo, Recife, and Manaus.

Across Brazil’s cities, governments monitored pharmacies to prevent price hikes and reimbursed the cost of medicines and remedies to the sick. In the state of Espírito Santo, the government distributed free treatments to towns inland (Franco et al., 2016FRANCO, Sebastião Pimentel et al. Gripe espanhola no Espírito Santo (1918-1919): alguns apontamentos. Dimensões, v.36, p.404-426, 2016., p.416). Improvised new pharmacies were operated by the Sanitary Services, usually located near makeshift clinics or hospitals. For instance, on October 15, the Department of Health in Recife began providing free medicines to the local population using five improvised clinics (Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017., p.75). The government also provided small cash transfers to those who could not sustain their families.

Treatments the Sanitary Services recommended and prescribed were ineffective and likely provided false security, which was often recognized: “Doctors themselves admit it is difficult to treat the flu … no drug had the power to stop the flu’s inevitable course” (Silva, Costa, 2011, p.13). In São Paulo, the Sanitary Service officially recommended regular “cleaning of the nasopharynx with inhalations of menthol Vaseline, or regular gargles of saltwater, iodine water, or citric acid.” One very old drug, quinine, was popular, and stocks quickly dwindled, even though it was never proven effective against influenza. In Rio de Janeiro, the government regulated its price, but some pharmacies sold it for upwards of ten times its regular price (Bertolli Filho, 2003, p.157; O Crack, 22 Oct. 1918).2 2 Quinine forms the basis of hydroxychloroquine, a drug which Brazil’s president promotes for covid-19, despite strong evidence of ineffectiveness. In Recife, the director of Public Health promoted the smallpox vaccine (vacina jeneriana) as a remedy, even though there was no scientific evidence to support the vaccine’s effectiveness (Freitas, 1918FREITAS, Octávio de. A influenza epidêmica em Pernambuco em 1918: relatório apresentado ao governador do estado. Recife: Imprensa Industrial, 1918., p.18). Newspapers even wrote that the smallpox vaccine provided “immunity” against influenza (Silva, 2017SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918). Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017., p.110). These newspapers, and others across the country, show how an older paradigm of miasma or “corrupted air” continued to hold ground. In the Minas Gerais countryside, newspapers indicate a total lack of knowledge about disease transmission, associating the flu with cholera: “The terrible disease is contaminated with the greatest ease, through the air, emanations from the earth, dust and water … [so] one must be extremely careful with stagnant waters” (Sales, 2005SALES, José Roberto. A gripe espanhola em Varginha (MG), 1918: memória de uma tragédia. Belo Horizonte: SES/MG, 2005., p.40). Another newspaper, Carioca, promised a cure with “peculiar recipes” invented by journalists. Clearly, “fake news” circulated throughout the 1918 epidemic (Albuquerque, 2020ALBUQUERQUE, Cristiane. Fake news circularam na imprensa na epidemia de 1918. História, Ciências, Saúde – Manguinhos, Mar. 2020. Available at: http://www.revistahcsm.coc.fiocruz.br/fake-news-circularam-na-imprensa-na-gripe-espanhola-em-1918/. Access on: 28 May 2020.
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). In response to this discourse, the medical profession sought to differentiate and establish itself as an authority. While newspapers announced various “cures” based on homeopathic and popular knowledge, the Sanitary Service of São Paulo sought to discover, classify, and control scientific knowledge concerning the flu (Bertucci, 2004BERTUCCI, Liane Maria. Influenza: a medicina enferma. Campinas: Editora Unicamp, 2004., p.173-283). Unfortunately, scientific medicine had little impact on society’s response to the epidemic. Without effective, scientifically-backed treatments, the government distributed quinine to the population (Souza, 2009SOUZA, Christiane Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia. Rio de Janeiro: Editora Fiocruz, 2009., p.245-246).

Across many Brazilian cities, markets and shops remained open, following an old, institutionalized response to avoid famine. Without electricity and refrigerators, Brazilians visited the market most days for essentials, but in mid-October, 1918, the municipal government decreed a three-day “holiday” and fined shops found open (Do Rio, 1 Dec. 1918; O Comércio…, 22 Oct. 1918). By this point, hundreds of people were dying each day from influenza in Rio de Janeiro, and health officials hoped keeping people home would slow infection. However, the measure backfired: influenza continued to spread while food and basic goods became scarcer. Residents in the poor outskirts may have suffered the most (Jacarepaguá…, 30 Oct. 1918; Uma Obra…, 6 Nov. 1918). On October 22, one day after the “holiday,” the Correio de Manhã reported, “where food establishments are not closed, there is a shortage of goods. … Public authorities opened the city for the plague to invade and allowed it to proliferate. They should know now how to relieve their guilt over so many irremediable misfortunes by avoiding even more terrible evils” (O Comércio…, 22 Oct. 1918). That same day, the president of the Republic responded to the famine by calling on stores in Rio de Janeiro to reopen, and food distribution slowly expanded. City officials mandated the procurement of chickens (Brazilians widely view chicken soup as the best palliative for flu and colds) and opened soup kitchens in police stations and other public spaces. The wives of the Brazilian president and a prominent federal minister directed two large food distribution centers. These served more than a thousand people per day (Na Capital… 28 Oct. 1918). Unfortunately, government efforts and philanthropy were not enough to stave off hunger and malnutrition (Bertucci, 2004BERTUCCI, Liane Maria. Influenza: a medicina enferma. Campinas: Editora Unicamp, 2004., 118).

Newspaper correspondents throughout the Brazilian Republic reported that the proud capital of Brazil, Rio de Janeiro, suffered from plague “and” hunger. Officials in other cities acted aggressively to avoid a similar fate. São Paulo’s municipal president reassured residents that the city had a three-month supply of essential foods, perhaps to prevent a run on the stores. Private residents quickly mobilized “food cooperatives” to collect donations, monitor neighbors, and distribute food to the needy. By the end of October, São Paulo’s Catholic archdiocese oversaw around twenty soup kitchens across its parishes, serving nearly three thousand meals per day (O Fornecimento… 30 Oct. 1918). In Porto Algre, milk, chicken, lime, castor oil, quinine, firewood, kerosene, and gasoline became hard to purchase, except for those with the connections and money to afford exorbitant prices. In late November, one popular magazine reported that “the smallest households” – referring to the city’s poor – “were infected and without fuel for light” and families “without the slightest hope for better days” were “multiplying” (Abrão, 1998ABRÃO, Janete Silveira. Banalização da morte na cidade calada: a hespanhola em Porto Alegre, 1918. Porto Alegre: EDIPUCRS, 1998., p.71). Malnutrition probably added to the number of influenza deaths across Brazil. In northeastern Brazil, thousands went hungry in the inland towns of Alagoas, Ceará, and Recife (Garanhuns…, 29 Oct. 1918; A epidemia…, 30 Oct. 1918; A influenza…, 31 Dec. 1918; O Jornal…, 10 Nov. 1918; Fome…, 23 Oct. 1918). When 1918 finally ended, a Pernambucan poet described the year as: “Unrelenting, cruel, tyrannical, / From hunger, from epidemics, / – Bitter, terrible days” (Na ordem…, 31 Dec. 1918).

Problems with famine reveal the thin line the government walked. Many poor Brazilians lacked reliable food supplies before influenza struck, and because most families bought the foods they needed daily, government officials were careful not to impede commerce, transportation, and production. Any attempt to “limit agglomerations” ran the risk of the “more terrible evil:” hunger, unemployment, and destitution of whole families. This helps us better understand why (1) public officials took few steps to enforce social distancing and (2) why the pandemic struck so rapidly and caused a sharp mortality curve in many places.

Besides social distancing, masks and face-coverings were other measures used in the 1918-1919 pandemic, though rare (Taylor, 10 Apr. 2018; Canales, 10 May 2020; Burgess, Horii, 2012). Cloth or gauze face coverings were first promoted to prevent disease transmission in the late nineteenth century but were not employed widely by surgeons in the United States and Germany until the 1920s (Spooner, 1967SPOONER, John. History of surgical face masks: the myths, the masks, and the men and women behind them. AORN Journal, v.5, n.1, p.76-80, 1967.). During the 1918-1919 pandemic, government officials promoted face coverings in a few parts of the world, but no evidence suggests widespread usage. Additionally, many people in the United States resisted mask mandates, arguing that they were uncomfortable, unnecessary, or infringed on civil liberties (Dalgarno, 13 May 2013; Canales, 10 May 2020). In Brazil, we found no evidence of mask mandates or use. One São Paulo newspaper, O Combate, wrote, “In the United States and France, mainly in the battlefield hospitals, the doctors are using masks. This is not the case with us, which is why 38 doctors have already died in Rio” (A pandemia..., 30 Oct. 1918). In numerous photographs taken in Brazil in 1918 and 1919, we find no images of people wearing masks.

Reviewing the many steps taken by governments and individuals, a puzzle remains. Some large cities, like Salvador and Belém, and many smaller towns in São Paulo suffered from influenza at much lower rates. Perhaps historians will find an explanation in mitigation strategies, although influenza, like other viral diseases, may have been influenced by environmental and other factors less dependent on human behavior.

Reassessing the mortality of the 1918-1919 influenza pandemic

A few cities mostly avoided the flu, but it took a terrible toll in most parts of the country. As shown in Figure 2, historical and updated accounts of mortality rates by epidemiologists in the Bulletin of the History of Medicine show rates of 6.8 per thousand in Brazil, comparatively low compared to Mexico, Chile, countries in Africa, and nations in Southern Europe (most above 12 deaths per thousand; cf. Johnson, Mueller, 2002; Patterson, Pyle, 1991). In developing countries, influenza killed at highly varying rates, according to the statistics assembled. Nations and colonies in Africa and the South Pacific had the highest death rates (between 20 and 60 per thousand). Other countries like Mexico (20 per thousand), China (14.2 per thousand), or Chile (11 per thousand) also had double-digit figures, but none as high as South Africa (44 per thousand) or Indonesia (30.4 per thousand). Mortality estimates of influenza in Brazil from 1918-1919 also look low compared to the rates of densely populated cities in the United States, such as Boston (7.93), New Orleans (8.79), New York (10.38), and Pittsburg (10.04) (Crosby, 2003CROSBY, Alfred W. America’s forgotten pandemic: the influenza of 1918. New York: Cambridge University Press, 2003.). The data may have conveyed the message that even during the worst of pandemics, Brazil, with its relatively underfinanced health and sanitation system, somehow avoided the worst.

Figure 2
1918-1920 estimates of influenza death rates per thousand people, by country (Johnson, Mueller, 2002)

Although these figures are highly cited, particularly those of Johnson and Mueller, these calculations are unexplained and likely underestimates. We suspect the figures were extrapolated from only a few of Brazil’s largest cities. According to the official mortality rates, 4.5 per thousand died from influenza in Rio de Janeiro (12,388 deaths), and only 2.69 in the state of São Paulo (12,386 deaths) (Bertolli Filho, 2003, p.74). These rates are relatively low compared to Brazil’s regional neighbors and countries with similar rates of development, but they are calculated using urban rates and at that time Brazil was a predominantly rural country. This is problematic as it misses the severity of the epidemic in the inland towns of Brazil.

In fact, the 1918-1919 pandemic was deadlier than previously assumed. We compile new estimates of mortality rates for 1918 in Brazil’s largest cities. Our estimates of average deaths per thousand in cities with more than thirty thousand people fluctuate between 8.7 and 9.2 per thousand (Table 1). Additionally, previously published mortality rates often exclude the majority of the country’s population. In 1920, about 80% of Brazil’s population lived in small towns and rural municipalities.3 3 The combined population of Brazil’s capitals, which included its largest cities, was 3.2 million in 1920. This urban population composed 11.7% of Brazil’s total population (27,500,000) (IBGE, 2011). Outside of the big cities, we discover higher mortality rates. Hundreds of towns and rural municipalities in São Paulo and Mato Grosso with accessible data show a weighted average death rate of 20.4 per thousand, an alarmingly large number. Our refined estimates of death rates, based on a broader base of historical sources that include urban populations and the higher toll of rural areas, demonstrate that only the most conservative estimates of total deaths align with our calculations. Thus, based on mortality rates, we calculate that in 1918, influenza killed 23,000-31,000 in the largest cities. At that time, Brazil’s total population was about thirty million. In smaller towns and rural municipalities, another 183,000-556,000 died from the Spanish flu. In sum, we posit 266,000-587,000 deaths during this pandemic.4 4 These estimates are generated from mortality rates and the 1920 census. Please contact the authors for detailed methodology. This was Brazil’s deadliest pandemic yet. But when measured by the percentage of deaths, Brazil’s battles with cholera and smallpox were likely worse (Cooper, 1975COOPER, Donald B. Brazil’s long fight against epidemic disease, 1849-1917: with special emphasis on yellow fever. Bulletin of the New York Academy of Medicine, v.51, n.5, p.672-696, 1975.).

Table 1
Average death rates due to influenza in various cities in Brazil, 1918

Influenza in the twentieth and twenty-first centuries

By 1921, Brazilians were looking toward a new decade, one free of pandemics. They got their wish, temporarily. Though influenza no longer killed hundreds or thousands daily, it remained a serious problem. It was a top cause of death until the 1950s, especially for young children and the elderly. However, by 1977, mortality rates had fallen and deaths from influenza became so rare that the federal government stopped reporting them (Pantoja, 1969PANTOJA, Woodrow P. A saúde no Brasil. Revista de Administração Pública, v.3, n.1, p.119-146, 1969., p.123). More surprisingly, as the world suffered other influenza pandemics, these did not align with Brazilian epidemics.

We turn first to mortality rates in the 1920s across Brazil. In twelve cities, in 1921 and 1922, doctors recorded about 0.7 death per a thousand residents. Rates were also lower in Rio de Janeiro (0.6), Curitiba (0.4), and São Paulo (0.28) (Rio de Janeiro, 1923). Though less prevalent than years before, the disease remained dangerous.

São Paulo’s experience with influenza reflects national trends in wealthier regions, as shown in Table 2. Death rates from seasonal flu were reasonably stable in the 1920s and 1930s but fell quickly in southern and southeastern Brazil. The poorer northern and western regions also saw lower rates, but with a decade lag. The reason for lower rates is unapparent, but with the rise of chronic and degenerative diseases, influenza and other infectious diseases declined in Brazil and other parts of the world. Historians debate the primary cause of this transition (the “third epidemiological transition”), including nutrition, sanitation, and public health measures (Omran, 1971OMRAN, Abdel. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Quarterly, v.49, n.4, p.509-538, 1971.; Colgrove, 2002COLGROVE, James. The McKeown thesis: a historical controversy and its enduring influence. American Journal of Public Health, v.92, n.5, p.725-729, 2002. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447153/. Access on: 28 May 2020.
https://www.ncbi.nlm.nih.gov/pmc/article...
; Armelagos, Harper, 2005). For influenza, the discovery of penicillin in 1945 likely caused a sharp decline in the 1940s and 1950s. While flu is unaffected by antibiotics like penicillin, some of its common comorbid diseases, like bacterial pneumonia, could be treated. Indeed, pneumonia also killed far fewer residents of the state of São Paulo after 1950 than just a decade before (Taxa…, July 1960).

Table 2
Mortality rates of influenza and pneumonia in São Paulo, 1894-1979 (per 1,000)

Influenza also became less lethal in Brazil’s cities, but rates fluctuated year to year. For example, influenza appeared to be epidemic in Natal from 1963-1964, then spread to Recife, Maceió, and Cuiabá in 1965. These patterns do not align well with the two pandemics that historians often describe during this period, including the 1957-1958 “Asian flu,” and 1968-1969 “Hong Kong Flu.” Brazilians were well aware of the pandemics during these years, and they caused public fear (A asiática…, 20 Aug. 1957; Viana, 30 Aug. 1957; Cantarino da Costa, Merchan-Hamann, 2016, p.16-17). Nonetheless, the mortality patterns of influenza did not follow the global trends, except in the nation’s capital (by then, Brasília) in 1968. In some cases, journalists frightened their readers with news of the flu’s “inevitable” arrival, only to report several months later that the disease caused no unusual increase in deaths (O surto…, 4 Feb. 1933; Medidas…, 11 Aug. 1957; Vigilancia…, 15 Jan. 1960; Previna-se…, 2 Dec. 1968; Gripe…, 28 Mar. 1976). In Rio de Janeiro, some journalists speculated that the warmer climate prevented the disease from becoming epidemic (Gripe…, 11 Dec. 1969).

By the late 1970s, the government recorded relatively few influenza deaths in Brazil. Vaccination helped, as safer “split” vaccines were mass-produced and distributed by the end of the 1970s (Barberis et al., 2016BARBERIS, I. et al. History and evolution of influenza control through vaccination: from the first monovalent vaccine to universal vaccines. Journal of Preventive Medicine and Hygiene, v.57, n.3, p.115-120, 2016.). In 1978, the Anuário Estatístico do Brasil, which published regional and municipal mortality rates from across Brazil for much of the twentieth century, stopped publishing influenza death rates (Brasil, 1962-1984).

After 1970, influenza’s ferocity declined, though journalists continued to sensationalize the disease. In 2009, newspapers warned of an influenza pandemic rumored to have emerged among drifts of pigs in Mexico (Cantarino da Costa, Merchan-Hamann, 2016, p.17-19). Again, headlines suggested inevitable mass casualties, claiming the disease could affect 67 million Brazilians in only eight weeks (Schwartsman, 2009SCHWARTSMAN, H. Gripe pode afetar até 67 milhões no Brazil. Folha de S. Paulo, 19 July 2009, p.C5. Available at: https://www1.folha.uol.com.br/fsp/cotidian/ff1907200907.htm. Access on: 28 May 2020.
https://www1.folha.uol.com.br/fsp/cotidi...
). Many Brazilians braced for the worst, some pharmacies sold out of hand sanitizer, and hospitals prepared contingency plans. Yet, once again, mortality from the 2009 “Swine Flu” in Brazil was only slightly worse than the general flu. Experts estimated influenza killed about 0.011 people per a thousand, a rate similar to that of Argentina (0.0153), Uruguay (0.010), Costa Rica (0.029), and Chile (0.006) (Balanzat et al., 2012BALANZAT, Ana M. et al. An analysis of 332 fatalities infected with pandemic 2009 influenza A (H1N1) in Argentina. Plos One, v.7, n.4, e33670, 2012. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033670. Access on: 20 Sep. 2020.
https://journals.plos.org/plosone/articl...
; Confirmam 33…, 9 Sep. 2013; Saborío et al., 2014SABORÍO, Guiselle G. et al. Influenza-associated hospitalizations and deaths: Costa Rica, 2009-2012. Emerging Infectious Diseases, v.20, n.5, p.878-881, 2014.; Maquilón et al., 2018MAQUILÓN, César O. et al. Adultos con influenza: evolución clínica, costos y grupos relacionados por el diagnóstico: resultados de 4 años, Clínica Dávila. Santiago de Chile. Revista Chilena de Enfermedades Respiratórias, v.34, n.2, p.102-110, 2018.).

The decline of influenza in the late twentieth century and Brazil’s misalignment with other infamous pandemics help explain why covid-19 was discounted and derided. The Brazilian media reported the risk of influenza pandemics with high alarm in 1957, 1968, 1976, and 2009, but like the old fable of the boy who cried wolf, Brazil was not struck by destructive epidemics those years.

Final considerations

Our research shows that Brazil periodically experiences influenza pandemics and epidemics. During the 1890-1891 and 1918-1919 pandemics, death rates were high, and the authorities were often unwilling to recognize the scale of the problem. During the 1918 influenza pandemic, death rates in Brazil’s cities varied based on whether treatment was centralized in public and emergency hospitals or if the infirm were treated by visiting doctors. Politicians were concerned about the economic impact, hunger, mass unemployment, and a loss of individual autonomy. Face masks and coverings were only beginning to be used in some parts of the world, but we found no evidence of their use in Brazil. After 1919, the world’s pandemics did not align well with Brazil’s mortality rates. By the middle of the twentieth century, antibiotics, vaccines, and antiviral medications considerably lowered the risk of influenza among Brazilians. The perception that a new and very deadly pandemic would arrive appears to have faded more than the actual risk of infectious, acute, and viral respiratory disorders.

While influenza and covid-19 are different diseases, their impact and lethality may be compared. During the 1918-1919 influenza pandemic, Brazil battled twin problems: infection and hunger. More than a century later, covid-19 again brought forth these unconnected problems. Though Brazil is now a dramatically different country – notably being more urban, educated, and wealthy – the government’s reaction is eerily similar to that of twentieth century Brazil. In this new epidemic, the Brazilian government continues to struggle to balance disease mitigation policies with efforts to avoid destitution and hunger. Millions of Brazilians depend on daily work and living conditions that are not conducive to social distancing, work-from-home, and “lockdowns,” which forces the government to walk the line when implementing policies. These policy risks also continue to be politically charged.

The 2020 covid-19 pandemic is unmatched in magnitude in modern Brazil, but it is unlikely to be as mortal as the 1918-1919 pandemic, although we face the same detection problem as influenza: both diseases “hide” behind other comorbid illnesses. Although less severe, covid-19 reminds the world that acute respiratory diseases remain a serious threat, as do the consequences of the policies – or lack thereof – to combat them. The lessons learned from previous pandemics and covid-19 may make the world more prepared for the next influenza pandemic.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the expert research assistance of Kennah Watts, André Lanza, Tayná Baptista and Carol Hasheda. The project was funded by the Brazil Initiative, Brandeis International Business School and Academic Affairs, Soka University of America.

REFERENCES

  • A ASIÁTICA não é bicho de sete cabeças. A Noite, p.7, 20 Aug. 1957. Available at: http://memoria.bn.br/DocReader/348970_05/43336 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/348970_05/43336
  • A EPIDEMIA na segunda região militar. Jornal do Recife, 30 Oct. 1918. Available at: http://memoria.bn.br/DocReader/705110/75833 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/705110/75833
  • A INFLUENZA. Gazeta de Notícias, p.1, 6 Feb. 1890. Available at: http://memoria.bn.br/DocReader/103730_03/171 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/103730_03/171
  • A INFLUENZA hespanhola em bom conselho. A Província, p.3, 31 Dec. 1918. Available at: http://memoria.bn.br/DocReader/128066_01/40653 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/128066_01/40653
  • A INFLUENZA: relatório apresentado ao cidadão governador pela inspectoria de hygiene destado de Goyaz em 28 de agosto de 1890. Goyaz, p.3, 4 Sep. 1890. Available at: http://memoria.bn.br/DocReader/246590/986 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/246590/986
  • A PANDEMIA da hespanhola. O Combate, p.1, 30 Oct. 1918.
  • ABRÃO, Janete Silveira. A história de uma epidemia: a hespanhola em Porto Alegre, 1918. Boletim de Saúde Pública, v.23, n.1, 2009.
  • ABRÃO, Janete Silveira. Banalização da morte na cidade calada: a hespanhola em Porto Alegre, 1918 Porto Alegre: EDIPUCRS, 1998.
  • ACADEMIA Nacional de Medicina. O Brazil-Médico: Revista Semanal de Medicina e Cirurgia, p.240, 15 Aug. 1891. Available at: http://memoria.bn.br/DocReader/081272/2172 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/081272/2172
  • AFFAIRS in Brazil. Greenfield Republican, p.2, 20 Dec. 1889. Available at: https://newspapers.library.in.gov/?a=d&d=GR18891227&e=-------en-20--1--txt-txIN-------. Access on: 28 May 2020.
    » https://newspapers.library.in.gov/?a=d&d=GR18891227&e=-------en-20--1--txt-txIN-------
  • ALBUQUERQUE, Cristiane. Fake news circularam na imprensa na epidemia de 1918. História, Ciências, Saúde – Manguinhos, Mar. 2020. Available at: http://www.revistahcsm.coc.fiocruz.br/fake-news-circularam-na-imprensa-na-gripe-espanhola-em-1918/ Access on: 28 May 2020.
    » http://www.revistahcsm.coc.fiocruz.br/fake-news-circularam-na-imprensa-na-gripe-espanhola-em-1918/
  • ALONSO, Waldimir J. et al. The 1918 influenza pandemic in Florianopolis: a subtropical city in Brazil. Vaccine, n.29, B16-B20, July 2011.
  • ARMELAGOS, George J.; HARPER, Kristin N. Disease globalization in the third epidemiological transition. In: Guest, Greg (ed.). Globalization, health, and the environment: an integrated perspective New York: AltaMira Press, 2005. p.27-54.
  • BALANZAT, Ana M. et al. An analysis of 332 fatalities infected with pandemic 2009 influenza A (H1N1) in Argentina. Plos One, v.7, n.4, e33670, 2012. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033670 Access on: 20 Sep. 2020.
    » https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033670
  • BARBERIS, I. et al. History and evolution of influenza control through vaccination: from the first monovalent vaccine to universal vaccines. Journal of Preventive Medicine and Hygiene, v.57, n.3, p.115-120, 2016.
  • BERTOLLI FILHO, Claudio. A gripe espanhola em São Paulo, 1918: epidemia e sociedade São Paulo: Paz e Terra, 2003.
  • BERTUCCI, Liane Maria. Influenza: a medicina enferma Campinas: Editora Unicamp, 2004.
  • BOLETIM da semana: mortalidade da cidade do Rio de Janeiro. O Brazil-Médico: Revista Semanal de Medicina e Cirurgia, v.6, n.31, p.246, 22 Aug. 1892. Available at: http://memoria.bn.br/docreader/081272/2613 Access on: 28 May 2020.
    » http://memoria.bn.br/docreader/081272/2613
  • BRASIL. Anuário estatístico do Brasil Rio de Janeiro: IBGE, 1962-1984.
  • BURGESS, Adam; HORII, Mitsutoshi. Risk, ritual and health responsibilisation: Japan’s safety blanket of surgical face mask-wearing. Sociology of Health and Illness, v.34, n.8, 2012. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01466.x Access on: 28 May 2020.
    » https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01466.x
  • CANALES, Katie. These surprisingly relevant vintage ads show how officials tried to convince people to wear masks after many refused during the 1918 flu pandemic. Business Insider, 10 May 2020. Available at: https://www.businessinsider.com/people-vintage-mask-ads-spanish-flu-1918-pandemic-2020-5 Access on: 28 May 2020.
    » https://www.businessinsider.com/people-vintage-mask-ads-spanish-flu-1918-pandemic-2020-5
  • CANTARINO DA COSTA, Ligia Maria; MERCHAN-HAMANN, Edgar. Pandemias de influenza e a estrutura sanitária brasileira: breve histórico e caracterização dos cenários. Revista Pan-Amazônica de Saúde, v.7, n.1, 2016.
  • CDC, Center For Disease Control and Prevention. Influenza (flu): how flu spreads. 27 Aug. 2018. Available at: https://www.cdc.gov/flu/about/disease/spread.htm Access on: 28 May 2020.
    » https://www.cdc.gov/flu/about/disease/spread.htm
  • CEARÁ. Anuários Estatísticos do Ceará Fortaleza: Departamento Estadual de Estatística, 1918.
  • CEARÁ. Anuário Estatístico do Ceará Fortaleza: Departamento Estadual de Estatística, 1917.
  • COLGROVE, James. The McKeown thesis: a historical controversy and its enduring influence. American Journal of Public Health, v.92, n.5, p.725-729, 2002. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447153/ Access on: 28 May 2020.
    » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447153/
  • CONFIRMAN 33 muertos em Uruguay por gripe A H1N1. Hoy, Sep. 9, 2009.
  • COOPER, Donald B. Brazil’s long fight against epidemic disease, 1849-1917: with special emphasis on yellow fever. Bulletin of the New York Academy of Medicine, v.51, n.5, p.672-696, 1975.
  • CROSBY, Alfred W. America’s forgotten pandemic: the influenza of 1918 New York: Cambridge University Press, 2003.
  • DALGARNO, Paul. The Conversation podcast – 13/05/13. The conversation, 13 May 2013. Available at: https://theconversation.com/the-conversation-podcast-13-05-13-14168 Access on: 4 Sep. 2020.
    » https://theconversation.com/the-conversation-podcast-13-05-13-14168
  • DALL’AVA, João Paulo; MOTA, André. A gripe espanhola em Sorocaba e o caso da fábrica Santa Rosália, 1918: contribuições da história local ao estudo das epidemias no Brasil. História, Ciências, Saúde – Manguinhos, v.24, n.2, p.429-446, 2017.
  • DO RIO. O Exemplo, p.1, 1 Dec. 1918. Available at: http://memoria.bn.br/docreader/843717/668 Access on: 4 June 2020.
    » http://memoria.bn.br/docreader/843717/668
  • FOME. A Lucta, p.1, 23 Oct. 1918. Avaliable at: http://memoria.bn.br/DocReader/720763/561 Access on: 4 June 2020.
    » http://memoria.bn.br/DocReader/720763/561
  • FRANCO, Sebastião Pimentel et al. Gripe espanhola no Espírito Santo (1918-1919): alguns apontamentos. Dimensões, v.36, p.404-426, 2016.
  • FREITAS, Octávio de. A influenza epidêmica em Pernambuco em 1918: relatório apresentado ao governador do estado Recife: Imprensa Industrial, 1918.
  • FREITAS, Octávio de. O clima e mortalidade da cidade do Recife Recife: Imprensa Industrial, 1905.
  • FRIEDMAN, Uri. The coronavirus-denial movement now has a leader. The Atlantic, 27 Mar. 2020. Available at: https://www.theatlantic.com/politics/archive/2020/03/bolsonaro-coronavirus-denial-brazil-trump/608926/ Access on: 17 Dec. 2020.
    » https://www.theatlantic.com/politics/archive/2020/03/bolsonaro-coronavirus-denial-brazil-trump/608926/
  • GAMA, Rosineide de Melo. Dias mefistofélicos: a gripe espanhola nos jornais de Manaus (1918-1919) Dissertação (Mestrado em História) – Universidade Federal do Amazonas, Manaus, 2013.
  • GARANHUNS. Jornal do Recife, p.3, 29 Oct. 1918. Available at: http://memoria.bn.br/DocReader/705110/75827 Access on: 4 June 2020.
    » http://memoria.bn.br/DocReader/705110/75827
  • GOULART, Adriana da Costa. Revisitando a espanhola: a gripe pandêmica de 1918 no Rio de Janeiro. História, Ciências, Saúde – Manguinhos, v.12, n.1, p.101-142, 2005.
  • GOULART, Adriana da Costa. Um cenário mefistofélico: gripe espanhola no Rio de Janeiro Dissertação (Mestrado em História) – Universidade Federal Fluminense, Niterói, 2003.
  • GRIPE nova ameaça a população do Recife. Diário de Pernambuco, p.2, 28 Mar. 1976.
  • GRIPE: Brasil preparado. Diário da Noite, p.11, 11 Dec. 1969.
  • GUIMBEAU, Amanda; MENON, Nidhiya; MUSACCHIO, Aldo. The Brazilian bombshell? the long-term impact of the 1918 influenza pandemic the South American way. National Bureau of Economic Research: Working Paper Series, w26929, Apr. 2020.
  • IBGE, Instituto Brasileiro de Geografia e Estatística. Tabela 1.6: população nos censos demográficos segundo os municípios das capitais, 1872/2010. Sinopse do Censo Demográfico 2010 [S.l.]: IBGE, 2011. Available at: https://censo2010.ibge.gov.br/sinopse/index.php?dados=6 Access on: 28 May 2020.
    » https://censo2010.ibge.gov.br/sinopse/index.php?dados=6
  • INFLUENZA. Jornal do Commercio, p.1, 14 July 1890. Available at: http://memoria.bn.br/docreader/364568_08/1385 Access on: 28 May 2020.
    » http://memoria.bn.br/docreader/364568_08/1385
  • JACAREPAGUÁ em completo abandono. O Paiz, p.3, 30 Oct. 1918. Available at: http://memoria.bn.br/docreader/178691_04/40797 Access on: 4 June 2020.
    » http://memoria.bn.br/docreader/178691_04/40797
  • JOHNSON, Niall Pas; MUELLER, Juergen. Updating the accounts: global mortality of the 1918-1920: Spanish influenza pandemic. Bulletin of the History of Medicine, v.76, n.1, p.105-115, 2002.
  • LEAL, Oscar. Viagem às terras goyanas: Brazil central Rio de Janeiro: Typographia Minerva Central, 1892.
  • MAIA, Emílio. Relatório da comissão especial sobre a febre catarral que grassou nos primeiros meses de 1835. Revista Médica Fluminense, p.10-17. Jan. 1836.
  • MAQUILÓN, César O. et al. Adultos con influenza: evolución clínica, costos y grupos relacionados por el diagnóstico: resultados de 4 años, Clínica Dávila. Santiago de Chile. Revista Chilena de Enfermedades Respiratórias, v.34, n.2, p.102-110, 2018.
  • MEDIDAS de defesa contra a gripe asiática em Congonhas. O Correio Paulistano, p.2, 11 Aug. 1957.
  • MINISTÉRIO DO INTERIOR. Relatório apresentado ao Vice-Presidente da República dos Estados Unidos do Brazil pelo Dr. Fernando Lobo Leite Pereira, Ministro de Estado dos Negócios do Interior, em Abril de 1892 Rio de Janeiro: Imprensa Nacional, 1892. Available at: http://ddsnext.crl.edu/titles/103?terms=influenza&item_id=1714#?h=influenza&c=4&m=1&s=0&cv=227&r=0&xywh=-937%2C0%2C3297%2C2325. Access on: 28 May 2020.
    » http://ddsnext.crl.edu/titles/103?terms=influenza&item_id=1714#?h=influenza&c=4&m=1&s=0&cv=227&r=0&xywh=-937%2C0%2C3297%2C2325
  • NA CAPITAL da República. Correio Paulistano, p.2, 28 Oct. 1918.
  • NA ORDEM do dia. A Província, p.1, 31 Dec. 1918. Available at: http://memoria.bn.br/docreader/128066_01/40652 Access on: 28 May 2020.
    » http://memoria.bn.br/docreader/128066_01/40652
  • NASCIMENTO, Douglas. Cenas da Gripe Espanhola em São Paulo: São Paulo antiga. 30 Mar. 2020. Available at: https://saopauloantiga.com.br/cenas-da-gripe-espanhola-em-sao-paulo/ Access on: 28 May 2020.
    » https://saopauloantiga.com.br/cenas-da-gripe-espanhola-em-sao-paulo/
  • NO CEARÁ. O Paiz, p.4, 29 Oct. 1918. Available at: http://memoria.bn.br/docreader/178691_04/40782 Access on: 4 June 2020.
    » http://memoria.bn.br/docreader/178691_04/40782
  • O COMÉRCIO pode abrir. Correio da Manhã, p.1, 22 Oct. 1918. Available at: http://memoria.bn.br/docreader/089842_02/37094 Access on: 4 June 2020.
    » http://memoria.bn.br/docreader/089842_02/37094
  • O CRACK da tabela. Correio da Manhã, p.1, 22 Oct. 1918. Available at: http://memoria.bn.br/docreader/089842_02/37094, Access on: 4 June 2020.
    » http://memoria.bn.br/docreader/089842_02/37094
  • O FORNECIMENTO de sopa aos pobres. Coreio Paulistano, p.2, 30 Oct. 1918.
  • O JORNAL da Parahyba. Jornal do Recife, p.1, 10 Nov. 1918. Available at: http://memoria.bn.br/DocReader/705110/75907 Access on: 4 June 2020.
    » http://memoria.bn.br/DocReader/705110/75907
  • O SURTO epidêmico de gripe na Europa e na América do Norte. Diário de Pernambuco, p.1, 4 Feb. 1933.
  • OMRAN, Abdel. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Quarterly, v.49, n.4, p.509-538, 1971.
  • PANTOJA, Woodrow P. A saúde no Brasil. Revista de Administração Pública, v.3, n.1, p.119-146, 1969.
  • PATTERSON, K. David; PYLE, Gerald F. The geography and mortality of the 1918 influenza pandemic. Bulletin of the History of Medicine, v.65, n.1, p.4-21, 1991.
  • PONZO, Umberto. S.O.S Saúde. Diário de Pernambuco, p.2, 28 Mar. 1976. Available at: http://memoria.bn.br/DocReader/029033_15/82711 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/029033_15/82711
  • PREVINA-SE, a gripe vem aí. Diário da Noite, p.2, 2 Dec. 1968.
  • READ, Ian. Tragedy at the Tropic of Capricorn: nineteenth century globalization and epidemiological change on two sides of the South Atlantic. In: Read, Ian; Patterson, Andrea (ed.). The shapes of epidemic disease: socio-historical, artistic, political, and ecological significance London: Cambridge Scholars Publishing, 2022.
  • READ, Ian. A change very perceptible and very oppressive: climate, epidemics, and race in Brazil. Luso-Brazilian Review, v.58, n.2, p.81-117, 2021.
  • READ, Ian. Como epidemias moldaram o Brasil e legaram marcas profundas à sociedade. Folha de S. Paulo, Ilustríssima, 28 Mar. 2020. Available at: https://www1.folha.uol.com.br/ilustrissima/2020/03/como-epidemias-moldaram-o-brasil-e-legaram-marcas-profundas-a-sociedade.shtml, Access on: May 28, 2020.
    » https://www1.folha.uol.com.br/ilustrissima/2020/03/como-epidemias-moldaram-o-brasil-e-legaram-marcas-profundas-a-sociedade.shtml
  • RETROSPECTO da Semana. O Apóstolo, p.2, 18 Feb. 1890. Available at: http://memoria.bn.br/DocReader/343951/12162 Access on: 4 June 2020.
    » http://memoria.bn.br/DocReader/343951/12162
  • RIO DE JANEIRO. Anuário de estatística demografo-sanitária, 1922 Rio de Janeiro: Oficina Gráfica da Inspetoria de Demografia Sanitária, 1923.
  • RIO de Janeiro. The Rio News, p.2, 15 July 1889. Available at: http://memoria.bn.br/DocReader/349070/2174 Access on: 4 June 2020.
    » http://memoria.bn.br/DocReader/349070/2174
  • RODRIGUES, Nina. A epidemia de influenza na Bahia em 1890. Gazeta Medica da Bahia, v.22, p.548-557, June 1891.
  • SABORÍO, Guiselle G. et al. Influenza-associated hospitalizations and deaths: Costa Rica, 2009-2012. Emerging Infectious Diseases, v.20, n.5, p.878-881, 2014.
  • SALES, José Roberto. A gripe espanhola em Varginha (MG), 1918: memória de uma tragédia Belo Horizonte: SES/MG, 2005.
  • SÃO PAULO. Anuário demográfico. São Paulo: Serviço Sanitário do Estado de São Paulo, 1918.
  • SCHMID, Ary Walter. Alguns dados epidemiológicos sobre a mortalidade por doenças transmissíveis respiratórias agudas no município de São Paulo: com uma crítica sucinta a respeito da morbidade e da letalidade. Arquivos da Faculdade de Higiene e Saúde Pública da Universidade de São Paulo, v.13, n.2, p.263-370, 1959.
  • SCHWARTSMAN, H. Gripe pode afetar até 67 milhões no Brazil. Folha de S. Paulo, 19 July 2009, p.C5. Available at: https://www1.folha.uol.com.br/fsp/cotidian/ff1907200907.htm Access on: 28 May 2020.
    » https://www1.folha.uol.com.br/fsp/cotidian/ff1907200907.htm
  • SESSÃO da Sociedade de Medicina e Cirurgia de 11 de fevereiro de 1890. O Brazil-Médico: Revista Semanal de Medicina e Cirurgia, ano 4, n.11, p.86, 22 Mar. 1890. Available at: http://memoria.bn.br/docreader/081272/1512 Access on: 28 May 2020.
    » http://memoria.bn.br/docreader/081272/1512
  • SILVA, Alexandre Caetano da. Recife, uma cidade doente: a gripe espanhola no espaço urbano recifense (1918) Dissertação (Mestrado em História) – Universidade Federal de Pernambuco, Recife, 2017.
  • SILVA, Julio Santos da; COSTA, Hideraldo Lima da. A desolação, o pavor e o luto: a história da gripe espanhola em Manaus (1918-1919). In: Simpósio Nacional de História, 26., 2011, São Paulo. Anais… São Paulo: ANPUH, 2011.
  • SILVEIRA, Anny Jackeline Torres. Influenza espanhola e a cidade planejada: Belo Horizonte, 1918 Belo Horizonte: Fino Traço, 2008.
  • SOUZA, Christiane Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia Rio de Janeiro: Editora Fiocruz, 2009.
  • SOUZA, Christine Maria Cruz de. A gripe espanhola na Bahia: saúde, política e medicina em tempos de epidemia Tese (Doutorado em História das Ciências da Saúde) – Casa de Oswaldo Cruz/Fundação Oswaldo Cruz, Rio de Janeiro, 2007.
  • SPOONER, John. History of surgical face masks: the myths, the masks, and the men and women behind them. AORN Journal, v.5, n.1, p.76-80, 1967.
  • TAUBENBERGER, Jeffery K.; MORENS, David M. The pathology of influenza virus infections. Annual Review of Pathology: Mechanisms of Disease, v.3, p.499-522, 2008.
  • TAXA reduzida de mortes por pneumonia. A Gazeta da Pharmacia, p.18, July 1960. Available at: http://memoria.bn.br/DocReader/029548/5929 Access on: 28 May 2020.
    » http://memoria.bn.br/DocReader/029548/5929
  • TAYLOR, Alan. Photos of the 1918 flu pandemic. The Atlantic, 10 Apr. 2018. Available at: https://www.theatlantic.com/photo/2018/04/photos-the-1918-flu-pandemic/557663/ Access on: 28 May 2020.
    » https://www.theatlantic.com/photo/2018/04/photos-the-1918-flu-pandemic/557663/
  • UMA OBRA benemérita em Nova Iguassu. O Paiz, p.4, 6 Nov. 1918. Available at: http://memoria.bn.br/DocReader/178691_04/40840 Access on: 4 June 2020.
    » http://memoria.bn.br/DocReader/178691_04/40840
  • UNSG, United Nations Secretary-General. Transcript of UN Secretary-General’s virtual press encounter to launch the report on the socio-economic impacts of covid-19. United Nations. 31 Mar. 2020. Available at: https://www.un.org/sg/en/content/sg/press-encounter/2020-03-31/transcript-of-un-secretary-general’s-virtual-press-encounter-launch-the-report-the-socio-economic-impacts-of-covid-19 Access on: 27 Sep. 2022.
    » https://www.un.org/sg/en/content/sg/press-encounter/2020-03-31/transcript-of-un-secretary-general’s-virtual-press-encounter-launch-the-report-the-socio-economic-impacts-of-covid-19
  • VIANA, Ruy. Erlindo Salzano: sobre a asiática: excesso de zelo causa pânico. A Noite, p.2, 30 Aug. 1957. Available at: http://memoria.bn.br/DocReader/348970_05/44079 Access on: 28 May 28 2020.
    » http://memoria.bn.br/DocReader/348970_05/44079
  • VIGILÂNCIA para evitar a entrada do vírus M. Diário da noite, p.2, 15 Jan. 1960.
  • WERTHEIM, Joel O. et al. A case for the ancient origin of coronaviruses. Journal of Virology, v.87, n.12, p.7039-7045, 2013.
  • WHO, World Health Organization. Q and A: Similarities and differences: covid-19 and influenza. Available at: https://www.who.int/news-room/q-a-detail/q-a-similarities-and-differences-covid-19-and-influenza Access on: 28 May 2020.
    » https://www.who.int/news-room/q-a-detail/q-a-similarities-and-differences-covid-19-and-influenza

NOTES

  • 1
    Recife’s estimate is based on influenza deaths plus excess tuberculosis deaths. Since there are no counts of deaths by other respiratory diseases, we extrapolated the excess death rate from tuberculosis (Freitas, 1905FREITAS, Octávio de. O clima e mortalidade da cidade do Recife. Recife: Imprensa Industrial, 1905.). Rio de Janeiro’s and Porto Alegre’s estimates are total influenza deaths plus excess deaths from tuberculosis, bronchitis, pneumonia, and heart disease (Ministério do Interior, 1892MINISTÉRIO DO INTERIOR. Relatório apresentado ao Vice-Presidente da República dos Estados Unidos do Brazil pelo Dr. Fernando Lobo Leite Pereira, Ministro de Estado dos Negócios do Interior, em Abril de 1892. Rio de Janeiro: Imprensa Nacional, 1892. Available at: http://ddsnext.crl.edu/titles/103?terms=influenza&item_id=1714#?h=influenza&c=4&m=1&s=0&cv=227&r=0&xywh=-937%2C0%2C3297%2C2325. Access on: 28 May 2020.
    http://ddsnext.crl.edu/titles/103?terms=...
    , p.85). São Paulo is based on excess deaths from the parishes São Tiago and Santo Amaro.
  • 2
    Quinine forms the basis of hydroxychloroquine, a drug which Brazil’s president promotes for covid-19, despite strong evidence of ineffectiveness.
  • 3
    The combined population of Brazil’s capitals, which included its largest cities, was 3.2 million in 1920. This urban population composed 11.7% of Brazil’s total population (27,500,000) (IBGE, 2011).
  • 4
    These estimates are generated from mortality rates and the 1920 census. Please contact the authors for detailed methodology.

Publication Dates

  • Publication in this collection
    19 Dec 2022
  • Date of issue
    Oct-Dec 2022

History

  • Received
    1 Feb 2021
  • Accepted
    3 June 2021
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