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Locum shortages, fake drugs and demand spikes: Spanish flu in C+D

C+D dives into its archives to reveal the parallels for community pharmacies between the pandemics of Spanish flu and COVID-19

When the Spanish flu reached Britain in 1918, the country was still at war, there was no radio or television, and the main sources of information were the morning and evening newspapers. For community pharmacists, the impact of this pandemic on their profession was spelled out in weekly journals and magazines, particularly The Chemist and Druggist.

Today, pharmacists and their teams have been inundated with extra work caused by the COVID-19 pandemic, which has seen queues snaking out of pharmacists' doors, paracetamol shortages and a rise in patient violence. But how did the Spanish flu pandemic compare with COVID-19?  

The Spanish flu was a wave of deadly influenza that swept across the globe between 1918 and 1920, killing anywhere between 17 million and 50 million people worldwide. With a mortality rate between 5% and 10%, Spanish flu killed 228,000 people in Great Britain alone.

By comparison, the death toll in the UK from COVID-19 was 41,862 at the time of publication. Although the Spanish flu was far more deadly than COVID-19, there are numerous similarities in the impact of the pandemics on community pharmacies.

Locums "scarce as gold"

The Chemist and Druggist was a weekly print publication at the time. It included on-the-ground reports from pharmacy professionals in cities across England. An early hint of something unpleasant happening entered the pages of the magazine in spring of 1918, with an unusually lingering interest in flu remedies. On March 23, 1918, one correspondent said: “Many chemists in Manchester have been suffering from severe colds and influenza.” One of them was obliged to manage as best he could “til a locum could be secured – locums being almost as scarce as gold”.

By April 6, the Liverpool correspondent was reporting that “window displays have consisted largely of influenza remedies”, and a week later that “dull weather with recurring rain keeps influenza remedies to the fore in pharmacy windows”.

The virus began to take an increasing toll on pharmacists themselves. On April 27, the Sheffield correspondent said one pharmacist had “been laid up with a sharp attack of influenza, but is on the way to recovery”. The severe nature of the disease was starting to be appreciated, but it continued to be blamed on the weather. On May 4, the Birmingham correspondent said: “The north-east wind is held accountable for the advent of influenza, which is of a severe type.”  

The severity of the epidemic began to receive extensive coverage in the daily newspapers soon after. On June 26, above an article on importing olive oil, The Chemist and Druggist had a brief article under the subheading “Spanish influenza”.

It said: “This is the name given to the form of influenza which is rife at the present time in London and other parts of the country. The symptoms that are most prominent are the feeling of great weakness, watery eyes, sneezing and coughing.

“The ideal treatment is to go to bed and remain there until all the symptoms have disappeared, but those who are unable to carry out this ideal method are calling on the chemist for quinine or the popular quinine and cinnamon tablets.

“Antiseptic lozenges and the use of a weak solution of Condy’s Fluid as a mouthwash or throat spray are stated by Sir Arthur Newsholme, chief medical officer to the local government board, to be the best prophylactic measures.”

Employee illnesses

The same magazine edition gave an update from Belfast. "The outbreak of influenza shows no sign of abating, the disease having now spread to all parts of the city. A number of national schools and Sunday schools are now closed, and difficulties have arisen in many pharmacies owing to the large number of cases which have occurred among the employees."

The following week, The Chemist and Druggist reported on the impact of the epidemic on dispensing. Under the subheading “Influenza epidemic”, it said: “Chemists, especially those who were working short-handed owing to the war, are having a very busy time. The pressure varies, however, in different districts and in parts of London, but, owing to the scare that is being worked up by the daily papers, many of the public are taking ammoniated tincture of quinine and eucalyptus oil as prophylactics”.

By this stage, the epidemic had already spread to the rest of the UK. The Birmingham correspondent reported that “ammoniated tincture of quinine is at the top of the list of influenza remedies here. The record…for its sale in one shop in one day is six winchesters" (six large bottles).

The Liverpool correspondent said that “a queue awaiting the opening of the doors for anti-influenza draughts was seen outside a central pharmacy this week…owing to the influenza scare and the presence of a few foreign sailors under treatment, pharmacists have had an almost unprecedented demand for ammoniated quinine”.    

"Extraordinarily busy"

The Sheffield correspondent reported that “the influenza scare has reached Sheffield…this and the further demand by the military for men has brought things to very near the breaking point”. The virus had also taken hold in Ireland. The magazine said: “The influenza epidemic has reached Cork, and has brought in its trail a large addition of business…the fact that many assistants have been laid up with influenza has made the carrying on of business in both wholesale and retail houses very difficult during the past few weeks…Belfast is still in the grip of the influenza epidemic, and in consequence the drug trade is reaping a harvest”. 

Scotland was also severely affected. In Edinburgh, a doctor had been prescribing a powder of cinnamon, ginger and cardamom as well as aspirin for the Spanish flu. “An extraordinarily busy weekend has been experienced,” the magazine said. “Quinine, camphor lockets and disinfectants have not been in such demand for years”.

Regular reports continued over the following months. Readers of The Chemist and Druggist were informed of the spread of the epidemic overseas, particularly in the colonies where the magazine was distributed. On September 28, it reported that “India and the far East have been visited by the so-called Spanish flu, and the chemists’ shops in Calcutta and other large cities have been besieged by sufferers. In Singapore it has chiefly affected the Chinese.”

"Brisk demand"

A few months later, the pandemic reached South Africa. On December 7, the journal said: “Spanish influenza made its appearance in Cape Town a few weeks ago, and during the first week of October it suddenly assumed the proportions of a plague…two thirds of the people here having been affected. There were 5,000 deaths in Cape Town alone during the first half of the month. Many doctors are laid up and several have died. Many pharmacies had to close at first as their staff were attacked wholesale, and the medical and pharmaceutical services broke down entirely. But with the establishment of temporary hospitals and standardisation of prescriptions for use by all doctors and chemists’ matters have much improved."

The pandemic swept through Cape Town, before almost vanishing within a fortnight. An update on December 28 said that “the influenza has now almost disappeared from Cape Town. There have been close to 10,000 deaths or about 1 in 16 of the population, while between 60% and 70% have been down with the disease in Cape Town alone…the demands on chemists have almost returned to normal, with the exception of a brisk demand for tonics”.    

Back in Britain, the virus did not depart as quickly. Less scrupulous sellers of remedies were making the most of its prevalence. On October 19, the magazine said: “An epidemic of Spanish Flu is raging at Leicester, and as a consequence the scarcity of drugs has been severely felt. It is reported that one chemist received an order from a local works for 10,000 quinine tablets. It need hardly be said, that the gentlemen who stand in the marketplace…are doing very well. Most of their blood mixtures and kidney pills have suddenly become ‘influenza cures’ man was lately selling ‘influenza mixture’ while obviously suffering from something very like influenza himself”.

For chemists in the UK, the influenza trade continued well into the next winter. On November 2, beneath a chart of figures of British cocaine exports, the magazine said: “Eucalyptus oil has been in quite lively demand, the so-called Spanish influenza having helped matters considerably.” But by the next month the virus was receding fast. On December 14, the magazine said that in Nottingham “pharmacists have felt the effects of the remarkably sudden diminution in the number of victims attacked by influenza”.    

The Chemist and Druggist continued to carry advertisements for remedies, such as for Fumo-Taracine liquid inhalant “recommended for: Spanish influenza” on January 4, 1919.

Medicine shortages 

A week later, the magazine noted that in Nottingham “one effect of the [Spanish] influenza epidemic has been to reduce stocks to an unprecedented degree. There is an extraordinary scarcity of patent medicines, one chemist last week finding himself out of 160 lines, while packed goods are almost as scarce. One firm has been vainly trying for a week to obtain a clinical thermometer”.

The virus retained its grip on parts of Ireland too. On January 25, the magazine said: “The influenza epidemic is still prevalent in Ireland, especially in the country districts, but in the cities, it appears to have disappeared. The chemists in the small towns are just now very busy and have great difficulty in dealing with the largely increased orders.” 

The pandemic boosted patient demand for medicines from pharmacies exponentially. The January 11, 1919 magazine reported that in Sheffield the Spanish influenza caused dispensing volume in the city over June and July to rise 61%, from 56,977 in 1917 to 91,997 in 1918.

Although there was over a century between them, there are many eerie similarities between the Spanish flu and COVID-19. Staffing issues, soaring patient demand and medicine shortages remain urgent issues for community pharmacy. Both pandemics saw community pharmacy rise to assist patients across the UK, and both were documented in forensic detail in the pages of C+D.


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