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História, Ciências, Saúde-Manguinhos

Print version ISSN 0104-5970On-line version ISSN 1678-4758

Hist. cienc. saude-Manguinhos vol.25 no.3 Rio de Janeiro July/Sept. 2018

http://dx.doi.org/10.1590/s0104-59702018000400005 

ANALYSIS

Coimbra’s response to the 1918-1919 influenza epidemic, seen from the viewpoint of a local newspaper

Ana Maria Diamantino Correia1 

1001Doctoral candidate in Contemporary History/Universidade de Coimbra. Coimbra – Distrito de Coimbra – Portugal anamariadcorreia@gmail.com


Abstract

This article investigates the 1918-1919 influenza epidemic in Coimbra using information found in the pages of a local newspaper. Rigorous and systematic analysis of the Gazeta de Coimbra reveals the urban bourgeoisie’s perception of this health disaster, considered the most severe in the twentieth century. Guided by the newspaper’s editor though an unofficial view of the facts, the reader can glimpse reactions to the first news of the epidemic, particularly the population’s fears related to this information, but also the response from authorities and civil society. The newspaper is critical in many aspects, openly censuring inaction by several institutions of the city such as the city council, the medical school at the University of Coimbra, and the Misericórdia charitable institution.

Key words: public health; epidemic; influenza 1918-1919; Gazeta de Coimbra

Resumo

Neste artigo pretende-se compreender a epidemia de gripe pneumónica de 1918-1919 em Coimbra, a partir das informações contidas nas páginas de um periódico local. Por meio da análise rigorosa e sistemática da Gazeta de Coimbra consegue-se inferir a perceção que uma burguesia urbana teve desta catástrofe sanitária, considerada a maior do século XX. Guiados pelo editor do jornal, numa perspetiva não oficial dos fatos, é possível vislumbrar as reações às primeiras notícias da epidemia, nomeadamente os temores da população frente à informação veiculada, mas também a resposta das autoridades e da sociedade civil. Crítico em muitos aspetos, censura abertamente a inércia de várias instituições da cidade, como a Câmara Municipal, a Faculdade de Medicina da Universidade e a Misericórdia.

Palavras-Chave: saúde pública; epidemia; gripe pneumónica 1918-1919; Gazeta de Coimbra

Although it is considered the largest health disaster of the twentieth century, for several decades the 1918-1919 flu epidemic was forgotten by the historiography and only the target of brief references in general texts. Alfred Crosby (1976) was among the first researchers to address the 1918 epidemic, which he would return to again in 1989 (Crosby, 2003). Over the last two decades research on this topic has blossomed in different areas, reinforcing the growing interest within the international scientific community.

It was a catastrophe on a global scale and was directly related to the Great War. The number of people struck down by the influenza epidemic is still debated; while the official statistics may be far from reality and err by default (Phillips, Killingray, 2003), estimates place the number of fatalities between 25 and fifty million (Oldstone, 2000, p.305-314) and between fifty and one hundred million (Johnson, Mueller, 2002).

Consensus is also lacking on the origin of this mutation of the H1N1 virus. However, the hypothesis most favored by the scientific community is that it emerged at Camp Funston, located on the Fort Riley military base in the American state of Kansas; given the intense mobility of the military during World War I, the virus is thought to have arrived in France between April and May 1918. Although an Asian origin for this pandemic has been theorized, the first cases reported in Asia occurred five months after those that emerged in the US (Oxford, 2001). Furthermore, Chinese researchers maintain that the flu arrived in the country’s main ports from Europe (Iijima, 2003, p.101-109). Recently it was also suggested that the focus was Europe, in military camps in the south of England and northern France (Oxford, 2001; Langford, 2005; Erkoreka, 2009).

Studies have shown excess mortality in young adults aged 15 to 40, a group which would be expected to have the best response to the disease (Porras Gallo, 1997, p.65-67; Phillips, Killingray, 2003, p.8; Girão, 2003; Frada, 2005; Bandeira, 2009, p.142-143). This is indeed a characteristic attributed to the 1918 flu which remains to be clarified, since studies of the apparently democratic nature of this epidemic have yet to be completed. While some authors maintain that the extreme virulence of this disease indiscriminately cut down its victims, others argue that greater numbers of the poor perished from this ferocious illness because they were physically less resistant. This was the opinion of the Portuguese Director-General of Health at the time, Ricardo Jorge (1919, p.25), and was corroborated by the case of the Spanish city of Alicante (Bernabeu Mestre, 1991), for example.

In addition to shortcomings of various kinds which came along with wartime, Portugal during this era faced a climate of profound political, economic, and social instability. A succession of governments, the establishment of a presidential regime with the rise of Sidónio Pais to this office, and a lack of jobs combined with strikes and popular uprisings to contribute to a country mired in crisis (Marques, 1980). This is the scenario in which the influenza epidemic developed, a true test of strength for the state machinery, society, and individuals.

According to Portuguese official statistics, 55,780 people died of the flu in 1918 (Portugal, 1922, p.101); as in other countries, this number is far from reality. In a recent study, Mário Leston Bandeira (2009, p.131-154) estimates an excess mortality of 135,257 people in 1918 and early 1919, concluding that statistically, in the district of Coimbra the epidemic generated demographic consequences quite different from those in other districts of the country, including variations in the most affected age groups and a greater reduction in life expectancy.

In Portugal, research on the 1918 epidemic is still scarce. Paulo Girão (2003) studied the effects of the epidemic in the Algarve, and the physician João Frada (2005) examined the incidence of influenza in the municipality of Leiria. In light of the gap in the historiography, a number of researchers from Portugal and beyond met in 2007 and concluded that the topic is far from exhausted (Sobral et al., 2009). Since that time few studies have been published with a principal focus on the flu epidemic in Portugal (Sousa et al., 2008, p.469-500; Esteves, 2014, p.165-181).

This article addresses the influenza epidemic in Coimbra, a city with a university hospital and a top-notch medical class, via systematic analysis of a local newspaper, the Gazeta de Coimbra; although this periodical was close to the political establishment, it did not shy away from reporting the facts it considered pertinent during the crisis. Unlike the national Portuguese newspapers, where the war overshadowed coverage of everything else (Almeida, 2013, p.164-191; Lima et al., 2009, p.255-277), in the Gazeta de Coimbra the main topic was certainly the flu epidemic, especially in the last quarter of 1918.

This periodical ran from 1911 to 1952, and was located in the Pátio da Inquisição in Coimbra. It was distributed to newsstands each week on Tuesdays, Thursdays, and Saturdays, and owned and run by João Ribeiro Arrobas, an experienced journalist from Coimbra who left the newspaper O Conimbricense to found the Notícias de Coimbra in 1907 and the Gazeta de Coimbra in 1911. The latter, in the words of its director, was guided in its mission by “complete impartiality” and focused its entire attention on “the cause of the oppressed and the working classes” (Gazeta de Coimbra, 1 jul. 1911).1 During the period in question, the editor of the Gazeta was Hermano Ribeiro Arrobas.

The press not only plays an important role in transmitting knowledge, but also has the power to create and manipulate public opinion; by analyzing the rich collection of information published in the Gazeta de Coimbra, we attempt to understand the influenza epidemic in Coimbra through an unofficial perspective of the facts guided by the perceptions of an urban bourgeoisie, which in this case was also responsible for publishing this information. This allows us to investigate the importance of the flu as perceived by the editor of this newspaper, as well to determine the response to this epidemic of catastrophic proportions by both the competent authorities and Coimbra society.

The first cases and their repercussions in the Gazeta de Coimbra

The influenza epidemic developed globally in three successive waves. The first and more benign phase occurred in April and May of 1918, a second more severe wave with absolutely devastating effects struck from September to November, and the third came in early 1919. In Portugal, the first cases of influenza were recorded in late May in the border towns of Arronches, Elvas, and Vila Viçosa (Jorge, 1918b). The sick people were agricultural workers coming back from Spain who brought the virus with them.

As in the Spanish press, in Portugal the first news references to influenza emerged during the first wave of the epidemic (Echeverri Dávila, 1993, p.83). At the end of May, the Diário de Notícias and O Comércio do Porto reported further development of the epidemic in Spain (Almeida, 2013, p.166). The Spanish development only appeared in the Gazeta de Coimbra in the June 13, 1918 edition, when the newspaper noted the development of a flu epidemic in the neighboring country which, while not dangerous, was “excessively contagious” with cases already appearing in Portugal (Gazeta de Coimbra, 1918-1919 [13 jun. 1918]). Midway through month, under the title “Spanish disease,” the newspaper informed readers of its symptoms: the sudden invasion of mucus in the upper respiratory system, high fever, prostration, and possible digestive disorders (Gazeta de Coimbra, 1918-1919 [18 jun. 1918]). Although it was considered a mild epidemic flu, only rarely lasting more than three days and as a result often initially diagnosed as being dengue or three-day fever (Jorge, 1918a; 1919), the paper recommended avoiding closed places where many people congregated. It also suggested airing out dwellings and workplaces and using disinfectants in the nasal passages and throat. The treatment was very similar to that of the common flu. The June 18, 1918 issue also contained the first information related to the district of Coimbra, reporting a high number of patients in the village of Lousã, where entire families were ill (Gazeta de Coimbra, 1918-1919 [18 jun. 1918]).

Although the first wave of influenza was not as aggressive as those which followed, the authorities and press paid attention. At the end of June, the disease (which until then had been nicknamed “Spanish”) was identified by Director-General of Health Ricardo Jorge as influenza, which though not severe “is as contagious as all the demons” (Gazeta de Coimbra, 1918-1919 [22 jun. 1918]), and advised readers to avoid kisses and handshakes. In an attempt to avoid an overly dramatic response, the newspaper humorously noted that fear had settled in among Coimbra residents; the slightest stomachache “caused by a bellyful of cherries” led them to take to their beds and call for a doctor, thinking they had influenza (Gazeta de Coimbra, 1918-1919 [22 jun. 1918]).

Even during the second wave of the epidemic, the periodicals repeatedly reported the benign nature of the disease, especially in the cities (Almeida, 2014, p.700; Nunes, 2014, p.62-63), foreseeing possible panic among the population. Along these lines, the October 5, 1918 edition of the O Século newspaper acknowledged that the hospital authorities in Lisbon barred their employees from discussing what happened within these institutions and threatened disciplinary proceedings for those who did, as a way of avoiding anxiety and rumors (Lima et al., 2009, p.275). Also in Coimbra, in late September amid the second wave of the epidemic the Gazeta refuted rumors that influenza was present in the city, at the request of the authorities (Gazeta de Coimbra, 1918-1919 [28 set. 1918]). These rumors began when two groups of soldiers from the 35th Infantry Regiment were transported to the hospital on September 26, with most discharged shortly thereafter. This was allegedly reflected in the fact that the entire staff of the Coimbra University hospital was sick with the flu, but soon resumed their work (Gazeta de Coimbra, 1918-1919 [1 out. 1918]). There were also rampant rumors about the numerous deaths registered, with many of the dead remaining unburied, reportedly leading to increases in cemetery staff. The newspaper discredited all these speculations as unfounded. Even so, the dean of the university postponed the start of classes indefinitely (Gazeta de Coimbra, 1918-1919 [1 out. 1918]), and this was also the case in the city’s other educational institutions (Gazeta de Coimbra, 1918-1919 [3 out. 1918]). That year the university only opened its doors on November 20 for a visit by president Sidónio Pais (Gazeta de Coimbra, 1918-1919 [12 nov. 1918]).

Only in the October 1, 3, and 8 issues did the Gazeta publish some figures on influenza deaths in the city of Coimbra provided by the subdelegation of health; this allows one to suppose that when the number of fatalities began to increase, this information could be suppressed in order to avoid panic among the population.

Along with the second wave of the epidemic came news from other places in the district of Coimbra. For example, rumors that there were many flu victims in Coimbra spread rapidly to reach the city of Figueira da Foz, where the columnist classified them as “nonsense and absurd.” The regular column “Letter from Figueira” reported the deaths of eight people on one of the smaller streets of Bairro Alto in Coimbra, which was surprising since no one aside from the people who died lived on the street in question. Furthermore, an inhabitant of Figueira da Foz stated that forty people had been buried in a single day, that the barracks had been stricken, with “horses dying from the lack of soldiers” and that consequently “the gravediggers have their hands full” (Gazeta de Coimbra, 1918-1919 [3 out. 1918]). Other news reaching the Gazeta from Figueira da Foz included the death of the celebrated conductor from that city, David de Sousa, another victim of influenza (Gazeta de Coimbra, 1918-1919 [3 out. 1918]).

The development of the epidemic

The disease spread at an overwhelming pace, not only because of the ease of contagion, the fact that the etiological agent was unknown, or the lack of effective prophylactic measures, but also due to a wide range of shortages which were exacerbated during wartime. Moreover, the uneven distribution of doctors throughout the country was aggravated by the mobilization of health professionals for the war efforts and greatly contributed to an utter lack of health care for the population, particularly those residing outside the major urban centers. In line with what is known to have happened in other parts of the country (Girão, 2003; Frada, 2005; Esteves, 2014), great distress was also seen in villages in the district of Coimbra, which for the most part were rural and isolated with limited or even non-existent medical assistance.

With respect to the progression of the flu epidemic, the information provided by the Gazeta is fragmented and does not allow the advance of the disease to be tracked with precision, although the published reports show its spread. At the end of September, the situation in the municipality of Góis was described as dramatic. The epidemic raged wildly and the population was entirely lacking medical care and sugar, which was “so necessary at this time” (Gazeta de Coimbra, 1918-1919 [28 set. 1918]); at the request of the municipal administrator, the military physician António Temido was sent to Góis (Gazeta de Coimbra, 1918-1919 [1 out. 1918]). Meanwhile, there were already victims in Penela, including the doctor and pharmacist, and no medications were available (Gazeta de Coimbra, 1918-1919 [10 out. 1918]). The situation was similar in Paradela, in the municipality of Penacova, where the only clinician was responsible for three very populous medical districts and asked the civil governor for rapid intervention (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). In mid-October in Coimbra, the flu appeared with great violence, but none of the boys in the orphan’s school run by the Misericórdia charity exhibited symptoms, although nearly all of the orphan girls were ill (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). Confinement encouraged the spread of the disease, and nearly all the inmates of the Santa Cruz prison fell victim to the flu (Gazeta de Coimbra, 1918-1919 [22 out. 1918]). Casal do Lobo, within the parish of Santo António dos Olivais in the city of Coimbra, faced great distress and pleaded for urgent aid (Gazeta de Coimbra, 1918-1919 [17 out. 1918]). Of the 250 people who lived there, approximately 150 were sick. In the town of Montemor-o-Velho 12 funerals were held in two days, and health care was provided by two physicians aided by a final-year medical student and a military doctor (Gazeta de Coimbra, 1918-1919 [29 out. 1918]).

On October 31, the epidemic had already decreased substantially in the urban area of Coimbra (Gazeta de Coimbra, 1918-1919 [31 out. 1918]), and on November 2 the crowds at pharmacies had decreased, leaving them “almost deserted, which was not the case a few days ago” (Gazeta de Coimbra, 1918-1919 [2 nov. 1918]). In Condeixa, however, the epidemic was still frightening. The clinicians in the health service, with the help of a medical student, faced grueling work. The situation was serious, with two or three people dying each day, but by November 12 the fatal effects of the flu had already decreased substantially (Gazeta de Coimbra, 1918-1919 [12 nov. 1918]). At this time news arrived from Mira, in the north of the district, that eight to ten people were falling victim to the disease every day. The stricken received care in an improvised hospital under the direction of infantry major José Rodrigues Lage, and nursing was provided by 2nd sergeant Brandão of the 2nd Health Company, assisted by a soldier.

An idea (albeit approximate) of the effects of this epidemic can be seen in the news published in the Gazeta on November 16 about the civil parish of Santo António dos Olivais, one of the most populous areas of the municipality in Coimbra; previously three or four months passed without a single death, but 56 people died in October, all victims of influenza (Gazeta de Coimbra, 1918-1919 [16 nov. 1918]).

The response to the epidemic in Coimbra

The common commitment to fighting the influenza epidemic was a recurring reality (Girão, 2003; Frada, 2005; Sousa et al., 2008; Esteves, 2014), and was also corroborated in the case of Coimbra. The Gazeta clearly shows the concerted effort between the various authorities and institutions of Coimbra (political, health, military, and religious) and civil society, which organized itself on its own as well as with encouragement from the state.

Besides the effects of influenza, the Gazeta published society’s response in order to overcome the disease. The editor favored organization to combat the epidemic, referring several times to greater pooling of efforts between authorities. He was critical of some matters, such as lack of hygiene on the streets, the lack of an isolation hospital, insufficient numbers of clinicians, and speculation in the sale of essential products (milk, for example), but tirelessly praised the institutions and individuals who helped the flu victims in some way.

Following the indications of the General Directorate of Health (Sobral et al., 2009, p.77-80), the newly appointed civil governor of Coimbra Captain Luis Alberto de Oliveira held a special session of the District Assistance Committee in early October to define aid measures for influenza victims. This meeting resulted in the division of the city into zones corresponding to the civil parishes, each with a commission responsible for proper distribution of medication, clothing, bedding, blankets, and essential goods (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). On 15 October “these subcommittees, with the aid of the Central Committee, chaired by the head of the district and constituted by the Assistance Committee, have been extremely tenacious, already starting optimal distribution of donations to households” (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). As of that time, 105 blankets and 95 sets of bedding and sheets had already been delivered. According to the Gazeta, the efforts made by the civil governor were of the utmost importance to combat the epidemic and assist those who most needed help. With the delegate and subdelegate of health also sick with the flu, the civil governor was to address matters within the scope of the health authorities in the district. As a result, it was the civil governor who worked directly with medical entities to create two first aid clinics in the city of Coimbra, which began operations at noon on October 18 (Gazeta de Coimbra, 1918-1919 [19 out. 1918]). One was located in Alta, the upper part of the city, at the police station in Largo da Feira; the other was in Baixa, the lower part, in the Red Cross post on Sofia Street. Each clinic had six paid staff members. The Alta clinic was open from six o’clock in the morning until midnight and served the civil parishes of Sé Nova, Sé Velha, and Santo António dos Olivais. The clinic in Baixa was open 24 hours a day; from six o’clock in the morning to midnight it exclusively served the sick from the civil parishes of Santa Cruz, São Bartolomeu, and Santa Clara. Any citizen could go to these clinics or request a home visit, but free care was only guaranteed to the demonstrably poor. Furthermore, cars allocated to army officers were placed at the disposal of the physicians for them to move about at night (Gazeta de Coimbra, 1918-1919 [15 out. 1918]).

The creation of these two medical clinics attempted to mitigate the enormous lack of clinicians compared to the overwhelming need; this was noted by the newspaper O Comércio do Porto on October 2, which also mentioned that in Coimbra, “the lack of doctors is startling” (Almeida, 2013, p.171). On October 22, it became evident that there were no more than a dozen physicians in Coimbra, and these few were exhausted by overwork, with some sickened themselves (Gazeta de Coimbra, 1918-1919 [22 out. 1918]). This was the widespread reality in Portugal (Girão, 2003; Frada, 2005; Esteves, 2014) as well as in neighboring Spain, for example in the city of Pamplona (Léon-Sanz, 2014, p.158), and in Salvador, Brazil (Souza, 2009, p.409). The situation was so desperate that examinations were moved forward for last-year medical students (Gazeta de Coimbra, 1918-1919 [26 out. 1918]), and these were summoned by the Secretary of War to present themselves at the 2nd Group of Health Companies, a military health unit which had existed in Coimbra since 1911 (Gazeta de Coimbra, 1918-1919 [19 out. 1918]; [22 out. 1918]). Furthermore, military doctors were summoned as reinforcements for their civilian counterparts, with 11 professionals remaining in the Coimbra military hospital (Gazeta de Coimbra, 1918-1919 [10 out. 1918]).

While they were responsible for public health-related issues at the local level, the municipal councils had executive obligations in the event of an epidemic, although they frequently hid their inertia behind the reduced municipal budgets they had to manage. José Manuel Sobral noted the weak efforts of the Lisbon city council during the epidemic, which were limited to maintaining hygiene in public spaces, providing coffins at wholesale cost, taking measures related to the burial of corpses, and financial aid for poor patients (Sobral et. al., 2009, p.86).

In the case of Coimbra, the lack of action by the city council during the epidemic drew the notice of the Gazeta, since this body had not met since the beginning of September and the council members were still absent (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). The council responded to this pressure with a note mentioning the strengthening of the rules for the streets, daily disinfection of the gutters and sewer pipes, and the burning of barrels of tar on the streets every night, as well as disinfection of the homes of influenza victims (Gazeta de Coimbra, 1918-1919 [19 out. 1918]). It should be noted that coal tar was widely burned as a means of disinfection, which the Gazeta also advocated in its pages, given the beneficial results it achieved when a cholera epidemic struck the city in 1856 (Gazeta de Coimbra, 1918-1919 [17 out. 1918]). Ricardo Jorge also referred to this practice and to excessive disinfections with cresol as a senseless waste against influenza, referring to the cost of the six thousand bottles of this disinfectant purchased each day by authorities in Madrid (Jorge, 1919, p.33). In any case, there are several reports attesting to the widespread use of these practices, particularly in Spain (Echeverri Dávila, 1993, p.140), as well as burning eucalyptus, laurel, rosemary, and lavender leaves in the streets or even within homes to purify the air (Esteves, 2014, p.172; Gazeta de Coimbra, 1918-1919 [22 out. 1918]).

The Coimbra city council also requested strict compliance with municipal requests, namely not dumping trash, debris, vegetable and fruit waste, paper or other unused objects, and threatened punishment for offenders (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). At the end of October the council staff responsible for disinfecting the streets also fell ill, and it was necessary to ask the firefighters and soldiers to continue this task (Gazeta de Coimbra, 1918-1919 [26 out. 1918]).

Beside the civil government, the District Assistance Committee, and the city council there was also the Red Cross, which played a noteworthy role in combating the flu epidemic, particularly with regard to transporting the sick. As mentioned, one of the two first aid clinics was located at the Coimbra police headquarters. In response, the civil government contributed one hundred escudos to the Red Cross, the District Assistance Committee gave fifty (Gazeta de Coimbra, 1918-1919 [15 out. 1918]), and the city council provided six tram passes so that Red Cross staff could move about and provide aid to victims (Gazeta de Coimbra, 1918-1919 [19 out. 1918]).

The Directorate-General for Health also sought to regulate the sale of medications, decreeing on October 4 that no medical substances could be exported (Portugal, 1918a). It was essential that the pharmacies remain supplied, with prices free from speculation and access open to everyone, including the indigent. With regard to this last point, it was determined that the pharmacies would serve the demonstrably poor for free, with the authorities paying these costs. As for the other two requirements, the situation was more complicated. Several times the Gazeta noted the scarcity of not only sugar, which was essential to prepare syrups, but also linseed and mustard. This was not exclusive to Coimbra. In the towns of Ponte de Lima and Monção within the Minho region, as early as September the pharmacies were lacking medicinal substances to treat the flu, such as quinine, sodium salicylate, syrup of sodium benzoate and ammonium acetate, as well as essential products such as rice, coal, olive oil, petroleum, sugar, and milk (these last two were also used in treating influenza) (Esteves, 2014, p.167). A similar scenario of pharmacy shortages was described in the Algarve (Girão, 2003, p.107). In order to make up for this lack to some extent, distribution of a ton of sugar exclusively to pharmacies in the province was authorized in Coimbra on October 10, and on October 26 it was reported that 1,100 kilos of sugar was directed toward pharmacies and hospitals of the province by the civil government, with any remainder to be distributed among the sick poor (Gazeta de Coimbra, 1918-1919 [10 out. 1918]; [26 out. 1918]). The editor of the Gazeta considered that like doctors, the pharmacies of the city should make the sacrifice of serving the public on Sundays, at least during the outbreak, which he “hoped would not last long” (Gazeta de Coimbra, 1918-1919 [10 out. 1918]). In this sense, the civil governor followed the recommendation of the Directorate-General of Health in requesting that the pharmacies remain open continuously (Gazeta de Coimbra, 1918-1919 [15 out. 1918]; [22 out. 1918]). The idea was for the pharmacies to stay open from eight in the morning to eleven o’clock at night at the minimum, and this could be extended at the discretion of the municipal authorities. From one o’clock in the morning, all requests were to be responded to promptly. Work in pharmacies increased considerably during the epidemic, and their owners were responsible for paying for this overtime service. By the end of October, the staff were exhausted and many had fallen ill, as was the case in the Misericórdia pharmacy in Coimbra (Gazeta de Coimbra, 1918-1919 [22 out. 1918]).

Furthermore, even though price lists for medications were published, some medicinal substances reached values which were prohibitive for some people. The Gazeta reported the case of a pharmacist in the district of Coimbra who bought up mustard seeds and linseed when they were cheap and sold them at excessively high prices when the outbreak was at full force, given widespread shortages of these resources (Gazeta de Coimbra, 1918-1919 [24 out. 1918]); this was also demonstrated by Paulo Girão (2003, p.150) in the Algarve region, where even during the most critical period of the flu outbreak there was economic speculation by a number of agents linked to trade and industry.

As for the role of the religious authorities in Portugal, the existing studies demonstrate the involvement of the Catholic Church, which was particularly important in disseminating hygiene and preventative measures in rural areas (Sousa et al., 2008, p.493; Sobral et al., 2009, p.88; Girão, 2003, p.112). Within this context, on October 8 the bishop of Coimbra issued a “Circular to the clergy of the diocese” which contained indications for the clerics and the faithful and provided general instructions to avoid the disease (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). The bishop refers to the importance that during this scourge, “each person contritely recognize their guilt and submissively accept God’s punishment [and] change all our lives for the better, especially great sinners, and our Lord will have mercy on us.” Nevertheless, the same text included a request to not disregard scientific means of preventing and treating such as serious disease. It suggested disinfection of the body, linens, and especially of outer clothing, which was to be brushed off outdoors and subjected to a very hot iron, and also discouraged alcoholic beverages in excess. Religious spaces were to be kept strictly clean, with the ground sanitized with lime chloride and sprinkled with distilled water, and coal tar was to be burned indoors.

As for the rituals celebrated, the bishop of Coimbra ordered the substitution of the Ad petendam pluvium mass with Pro vitanda morbilitate vel tempore pestilentiae, which was also requested in the Brazilian city of Salvador (Souza, 2010, p.55) and in Spain (Echeverri Dávila, 1993, p.146). The prelate also recommended that the sacraments be administered to the sick and spiritual assistance to the dying, but also introduced measures of caution for these practices. When visiting the sick, clergymen were to take a smaller quantity of holy oil soaked in a piece of cotton that could be burned immediately after use, and the vessel which carried it was to be purified. Bell-ringing was to be suspended or at least abbreviated, and the priests were to cooperate with the authorities as much as possible in efforts directed at public and individual health. Furthermore, the circular authorized the celebration of public prayers, which the Gazeta reported with regard to the church of São Salvador in Coimbra, where these efforts called for the “end of the horrible scourge that plagues us” (Gazeta de Coimbra, 1918-1919 [22 out. 1918]). This also occurred in Vil de Matos, a municipality of Coimbra, where a crowded procession of penitents “implored Divine Providence to cease the terrible epidemic of ‘pneumonic influenza’” (Gazeta de Coimbra, 1918-1919 [23 nov. 1918]). It should be noted, however, that large gatherings of people were strongly discouraged as a prophylactic measure by the health authorities (Jorge, 1919), which did not stop people from seeking comfort in these religious rituals when faced with a situation beyond their control which left the health authorities essentially impotent. These processions were a common practice, not only in Portugal. Beatriz Echeverri Dávila (1993, p.146) mentions religious events thronged with participants (to the delight of their organizers) in the Spanish cities of Zamora, Valladolid, and Covadonga, which forced the health authorities to take measures which in some cases were poorly received. Christiane Maria Cruz de Souza (2010, p.62) concluded that in Salvador, religious practice intensified during the epidemic.

Through a decree issued on October 2, 1918, the Directorate-General of Health expressed its intention to create relief committees in each municipality to raise funds which could be distributed to the sick poor, thus appealing to civil society for intervention (Portugal, 1918b).

As mentioned, subcommittees were initially created in Coimbra under the tutelage of a Central Committee chaired by the civil governor, and comprised by the District Assistance Committee. For the Central Committee, the civil governor contributed with 1000 escudos and the District Assistance Committee provided 3000 escudos (Gazeta de Coimbra, 1918-1919 [15 out. 1918]). On October 24, this committee was replaced with another, which was appointed at a meeting held at the headquarters of the Society of Defense and Propaganda [Sociedade de Defesa e Propaganda].2 The central objective of the new committee continued to be the collection of donations to help needy families which had fallen victim to the epidemic. It was comprised of representatives from organizations including the Municipal Administrative Committee, the Society of Defense and Propaganda, the Trade Association, the District Assistance Committee, the Misericórdia charity institution, the rector of the University, the Chief of Staff of the Division, and the judge of the Sisterhood of the Holy Queen [Irmandade da Rainha Santa].

Public pledges were sought immediately, and the corresponding donations were sent to the headquarters of the Society of Defense and Propaganda where the committee met each day (Gazeta de Coimbra, 1918-1919 [24 out. 1918]). Here blankets and bedding were distributed each day to those who presented a supply chit, and financial aid was also given. This aid money was essentially meant to be used for late rent payments and to recover important objects that had been pawned (clothing, for example). At a certain point, so many people appeared that “at times one cannot enter [the headquarters of the Society of Defense and Propaganda] because so many needy people are gathered there from all points of the city and surrounding areas” (Gazeta de Coimbra, 1918-1919 [31 dez. 1918]).

The Gazeta de Coimbra was always supportive of this cause, appealing to everyone to participate, particularly the “wealthy classes of Coimbra [that] will prove in this most agonizing and truly tragic moment for so many unfortunate [people] just how great and noble their feelings of humanity and pious charity are” (Gazeta de Coimbra, 1918-1919 [28 nov. 1918]). The paper published the names of those who pledged support during a period of just over two months; these included members of the city’s fraternal organizations, university professors, judges, justices and officials of the Coimbra Court of Appeal, members of the Municipal Administrative Committee, the District Assistance Committee, civil government officials, and many individuals from Coimbra society. President Sidónio Pais also contributed 100 escudos (Gazeta de Coimbra, 1919 [3 dez. 1918]).

The Central Committee raised 6691 escudos and 20 centavos, “far superior to all other [pledge campaigns] in this city, where such a large number of needy people had never been assisted at the same time” (Gazeta de Coimbra, 1919 [7 jan. 1919]). All in all, the Gazeta reported, a total of 1,162 families were assisted and 407 sets of bedding, 715 blankets, and 130 beds were distributed (Gazeta de Coimbra, 1918-1919 [22 fev. 1919]). To support the valuable services they provided, the Committee allocated 150 escudos to the Coimbra Red Cross delegation, 50 escudos to the December 8 Soup for the Poor organization [Sopa dos Pobres 8 de Dezembro], and 50 escudos to the Children’s Fund [Patronato da Infância] (Gazeta de Coimbra, 1918-1919 [7 jan. 1919]). Furthermore, after all the accounts were settled, 1203 escudos and 63,5 centavos remained; during the last session, held on February 19, 1919, it was decided to distribute this amount among the city’s main assistance institutions, namely the Coimbra Artists Mutual Aid Association [Associação de Socorros Mútuos dos Artistas de Coimbra], Montepio Martins de Carvalho, the Child Care Association [Associação das Creches], the Olímpio Ruy Fernandes Coimbra Women’s Association [Associação Conimbricense do Sexo Feminino Olímpio Ruy Fernandes], the Beggars’ Home [Asilo da Mendicidade], the Poor Children’s home [Asilo da Infância Desvalida], the Home for the Blind and the Lame [Asilo dos Cegos e Aleijados], December 8 Soup for the Poor, the Red Cross, João de Deus School [Jardim-Escola João de Deus], and the Santa Casa da Misericórdia charity hospital (Gazeta de Coimbra, 1918-1919 [22 fev. 1919]).

Like other nationally-circulating newspapers such as the Diário de Notícias, which in the space of two weeks gathered 12 contos de réis to assist the victims of the epidemic (Almeida, 2014, p.701), the Gazeta also started a fundraising campaign, in this case “for the orphans [of the flu] of Coimbra, those unfortunates without a father or mother, who tomorrow will have to beg for public charity if no one can save them with their spare pennies” (Gazeta de Coimbra, 1918-1919 [24 out. 1918]). The paper’s emotional appeal reaped 96 escudos and 50 centavos, which were symbolically distributed at its headquarters on Christmas Day (Gazeta de Coimbra, 1918-1919 [31 dez. 1918]).

Criticism of action by various agents

The response to the epidemic was not immune from criticism, particularly in the Gazeta de Coimbra. The newspaper frequently decried points in the city where it identified violations of the most basic rules of hygiene which damaged public health, often establishing a direct relationship between the focuses of illness and the influenza epidemic and calling for attention from the authorities.

The publication did not hesitate to criticize the inertia seen in some of the city’s institutions, for example in the School of Medicine at the University of Coimbra. The paper stated that some “unpleasant comments which had been directed at the school” were circulating, asking for the publication of useful advice “intended to overcome the terrible scourge ... advised by medical science” (Gazeta de Coimbra, 1918-1919 [8 out. 1918]). It questioned the silence from the school, whose teaching body was absent from the hospitals where their presence was needed (Gazeta de Coimbra, 1918-1919 [26 out. 1918]). When the epidemic began to claim its first victims, the Gazeta stated that it was still the vacation period, which was why rapid actions corresponding to the gravity of the situation were not taken. For this reason,

most of the members of the Municipal Administrative Committee, the teachers at the medical school, doctors from the hospitals and other clinics, and several staff from the Santa Casa da Misericórdia etc., were absent, and not willing or able to abandon their own tranquility and well-being, stayed where they were without wanting to know what was happening here with the epidemic. ... There are many responsibilities on the part of all those who refrained from promptly offering their services in the fight against this evil. The consequences are quite visible (Gazeta de Coimbra, 1918-1919 [29 out. 1918]).

With very uniform distribution throughout the country, and administration mostly drawn from the country’s hospitals, the Misericórdia charities seem to have taken an active role in assisting flu victims (Esteves, 2014). Conscious analysis of the Gazeta’s partiality is necessary during reading, although this does not make its descriptions any less important. In the words of its editor, the total neglect of the local Misericórdia charity can be seen, which during the epidemic did nothing beyond its normal activities (Gazeta de Coimbra, 1918-1919 [26 out. 1918]). In other words, the institution is accused of not making any additional efforts (which some of its counterparts did) to create and run isolation hospitals, although these were financially supported by the Directorate-General for Health, as in the case in the Misericórdia charities in Caminha and Viana do Castelo (Esteves, 2014, p.171-172). With regard to the actions of Misericórdia in Coimbra before the flu outbreak, the institution’s lack of commitment and scarcity of resources can be seen. At this time, its Santa Casa charity hospital had three clinicians on duty; one was ill, and for this reason some daily clinic visits were not offered as they should have been. Furthermore, alms were not increased, no new clinic was opened, and the institution did not provide “clothes or means of subsistence to the unfortunate people who live in poverty and have died from a lack of aid” (Gazeta de Coimbra, 1918-1919 [26 out. 1918]). The newspaper acknowledged the budget challenges faced by the institution, but insisted that “nobody will look askance if the budget is unbalanced because of the calamity that is punishing our land” (Gazeta de Coimbra, 1918-1919 [26 out. 1918]).

Isolation hospitals and care of the sick in their homes were among the measures set forth to avoid contagion, although these were not implemented consistently or rigorously by the authorities in Portugal (Sousa et al., 2008, p.479) or in Spain (Echeverri Dávila, 1993, p.140). Given the need to isolate the infected, or simply to urgently accommodate an excessive number of sick people, it was often necessary to create (or improvise) spaces to provide medical aid. Note that because of the significant increase in the number of ill people in Lisbon, derelict hospitals such as the one in Arroios were used and other buildings were converted into infirmaries, as was the case in the Camões School [Liceu de Camões] and the Trinas Convent [Convento das Trinas] (Sousa et al., 2008, p.479). The Central School of João de Deus [Liceu Central João de Deus] was similarly converted to serve the sick in the city of Faro in the Algarve (Girão, 2003, p.108). A makeshift hospital was also established in Mira, in the north of the district of Coimbra, under the orders of a military physician (Gazeta de Coimbra, 1918-1919 [12 nov. 1918]). But the Gazeta regularly noted that there was no isolation hospital within the city of Coimbra during the influenza epidemic. In early October a building outside the city in the hills of Chão do Bispo was suggested to the authorities for this purpose (Gazeta de Coimbra, 1918-1919 [8 out. 1918]), given the urgent need to create a hospital of this kind as in previous epidemics of other diseases.

In Coimbra, the editor of the Gazeta noted the Terceira Order hospital as a viable possibility, as well as the great hall of the Ursuline School, the José Falcão School [Liceu José Falcão], and the Quinta Agrícola (Gazeta de Coimbra, 1918-1919 [22 out. 1918]; [24 out. 1918]). Indignation seeped into the paper’s reporting on this topic, “in a land where things of this nature should not be lacking” (Gazeta de Coimbra, 1918-1919 [22 out. 1918]), where the existence of a medical class linked to the university and to the university hospitals should not ignore such circumstances. According to the editor, initially little importance was given to the virulence of the disease, and the necessary measures were not taken. As an example, he describes the typhus exanthematicus epidemic; when the first cases were reported in Porto at the end of December 1917, the country was in an uproar, and the Coimbra Municipal Administrative Committee quickly brought together the authorities to take rapid measures in response. This was quite different from the influenza epidemic. The only two cases of typhus exanthematicus which the paper cited were sent by the Coimbra Health Delegate to an isolation hospital set up in Arregaça (Gazeta de Coimbra, 1918-1919 [29 out. 1918]; [2 nov. 1918]). Everything indicated that typhus exanthematicus did not make significant progress in Coimbra, but it should be noted that in this case the etiology of the disease was identified.

Careful reading of the Gazeta de Coimbra allows us to conclude that the city was not prepared to combat an epidemic as ferocious as influenza. In this respect, the editor of the journal says that “it is not when the epidemic is already having an impact within the localities that places, homes, staff, furniture, clothes, and so on that is necessary to establish this hospital should be sought ... the city is unprepared, without an isolation hospital” (Gazeta de Coimbra, 1918-1919 [22 out. 1918]).

When at the end of November the cases of influenza appeared to be waning, smallpox began to appear (Gazeta de Coimbra, 1918-1919 [5 nov. 1918]; [21 nov. 1918]), and the newspaper continued to express disbelief that there was still no hospital to isolate the sick. It stated that if the city had a hospital for epidemic diseases, there would have been fewer cases of influenza, since many patients lacked medical and pharmaceutical care (Gazeta de Coimbra, 1918-1919 [5 nov. 1918]; [21 nov. 1918]). The responsibility was assigned to the entities which did not insist on this measure which the paper considered fundamental: civil government, the District Health Board, the medical college, the Delegation of Health, the city council, and the university hospitals.

Final considerations

We conclude that the influenza epidemic occupied a central role in the pages of the Gazeta de Coimbra, which largely reflected the daily life in the city and served as the main source of its news. The Gazeta consequently provides a wealth of important information that allows readers today to perceive the uneasiness felt by the population during the epidemic, not only because of the aggressive virus but also because of the authorities’ demonstrated impotence with regard to progress using the means available at the time. The situation in Coimbra seems very similar to other cities in Portugal and abroad, where the measures adopted were always insufficient in comparison with the easy spread of the disease. A concerted effort between the various entities is clearly seen, as are the mobilization and cooperation of civil society; even though this latter involvement only resulted from prodding by the state, the response was active and organized in a wide variety of ways.

In this case, the voice of the Gazeta gives us an unofficial version of the facts, allowing access to the flu epidemic in Coimbra through the eyes of a member of the urban bourgeoisie who did not spare words when describing what he thought of the failures by authorities when faced with this severe epidemic.

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1 In this and other citations of text from Portuguese, a free translation has been provided.

2 The Society of Defense and Propaganda was founded in 1909 to protect the heritage of the city of Coimbra.

1 A Sociedade de Defesa e Propaganda, fundada em 1909, tinha como objetivo a defesa do património da cidade de Coimbra.

ERRATA

Na Carta do Editor Convidado (DOI 10.1590/S0104-59702018000400002) publicada em História, Ciências, Saúde – Manguinhos, v.25, n.3, jul.-set. 2018:

  • Na página 631, no título “Jean Gayon: historiador y filósofo de la biologia (Saint-Maur-des-Fossés, 15/6/1940 – Paris, 28/4/2018)”, onde se lê “1940”, leia-se “1949”.

  • Na página 631, terceiro parágrafo, primeira linha, onde se lê “1940”, leia-se “1949”.

  • Na página 634, no título “Jean Gayon: historian and philosopher of biology (Saint-Maur-des-Fossés, June 15, 1940 – Paris, April 28, 2018)”, onde se lê “1940”, leia-se “1949”.

  • Na página 634, terceiro parágrafo, primeira linha, onde se lê “1940”, leia-se “1949”.

No artigo “A resposta em Coimbra à epidemia de pneumónica de 1918-1919 sob o olhar de um periódico local” (DOI 10.1590/S0104-59702018000400005), de Ana Maria Diamantino Correia, publicado em História, Ciências, Saúde – Manguinhos, v.25, n.3, jul.-set. 2018:

  • Na página 693, acima de “NOTA”, leia-se “AGRADECIMENTO O trabalho foi realizado com apoio da Fundação para a Ciência e a Tecnologia (SFRH/BD/130169/2017).”

  • Na página 693, nas Referências, na primeira e na sexta linhas, onde se lê “ALMEIDA, Maria José Pires de”, leia-se “ALMEIDA, Maria Antónia Pires de”.

  • No artigo “Coimbra’s response to the 1918-1919 influenza epidemic, seen from the viewpoint of a local newspaper” (DOI 10.1590/S0104-59702018000400005), de Ana Maria Diamantino Correia, publicado em História, Ciências, Saúde – Manguinhos, v.25, n.3, jul.-set. 2018 (disponível em: https://goo.gl/PkuWqQ):

  • Na página 14, acima de “NOTES”, leia-se “ACKNOWLEDGMENTS The Fundação para a Ciência e a Tecnologia (SFRH/BD/130169/2017) supported research for this article”.

  • Na página 15, nas Referências, na primeira e na sexta linhas, onde se lê “ALMEIDA, Maria José Pires de”, leia-se “ALMEIDA, Maria Antónia Pires de”.

Received: February 14, 2017; Accepted: February 7, 2018

Translated by Tracy Miyake.

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