Siddharth Chandra
Pieter Bastiaan van Steenis’ insightful article in the Geneeskundig Tijdschrift Voor Nederlandsch-Indië is a rare and detailed account by a colonial health official who experienced first-hand the horrors of the 1918 influenza pandemic in Java. A second-class health officer with the Royal Dutch East Indies Army (KNIL) at the time, he was able to visit and interact with victims and survivors of the pandemic and unusually, given the scarcity of such reports from that time, put pen to paper to record his findings. Later in his career, van Steenis was to become a leading light in the field of tropical medicine in the Netherlands.
The first part of van Steenis’ report characterises influenza as a disease and explores its causes based on a robust literature review and his own experiences as a bacteriologist and public health professional. While we take for granted today the knowledge that influenza is caused by a virus, in 1918 the question of influenza’s causative agent was the subject of a vigorous debate. Many scientists at the time believed that Pfeiffer’s Bacillus (now known as Haemophilus influenzae, henceforth Hi) caused the flu. Van Steenis’ account, written 15 years before the definitive discovery and isolation of the influenza virus, illustrates the many doubts scientists and public health officials across the globe were beginning to have about the role of Hi in causing influenza.
The second part of van Steenis’ report focuses on how the pandemic unfolded in Magelang in Central Java. The 1918 influenza pandemic struck Java with great severity. With estimates of population loss ranging as high as 4.26 to 4.37 million, or approximately 10 per cent of the population, Java was one of the worst-affected regions of the world. Van Steenis made several observations that aligned with what was being observed in other parts of the world at the time. For example, he emphasised the disproportionate impact the pandemic had on pregnant women, noting a spike in deaths among women between 20 and 40 years of age and ‘extremely frequent influenza-associated deaths during childbirth (at term or premature)’. Drawing the reader’s attention to the important role of nutrition in determining individual outcomes of infection, observed in many other locations including British India and the USA, he pointed out the ‘paramount importance’ of a good supply of food in areas affected by the influenza. On the timing of the pandemic, he noted that Java experienced a so-called ‘Herald Wave’ of infections and excess mortality in mid-1918 that preceded and was later dwarfed by the massive wave of late 1918. A similar spring or early summer wave had been observed in many locations around the world.
Van Steenis’ account also gives us a unique week-by-week account of the spread of the pandemic across Magelang. Here he emphasises the importance of the roads from Yogyakarta to the southeast and Temanggung to the northwest as important routes for the spread of the infection to Magelang. Importantly, he highlights the role of the crowded markets (see the above image) as locations of what we might today call ‘super spreader’ events:
‘with a few exceptions, the outbreaks appear to start close to the large bazaars and to develop around them. This is very important. Everybody knows the bazaars, where thousands of natives appear twice a week, swarming together. One could not create a better opportunity for the infection to spread rapidly.’
The public health implications of this observation, with all the challenges they entailed, were as clear to him then as they were to officials during the recent COVID-19 pandemic:
‘Domestic Administration officials I spoke to considered it impossible to close a large bazaar for two to three weeks - that would cause famine - but in any case, measures should be taken to mitigate the dangers of these bazaars; closely monitoring and removing feverish patients would help somewhat, but how long the recovered influenza patients remain infectious, and what is the status of healthy bacilli carriers, these are unanswerable questions.’
While van Steenis’ report mentions maps, they were not included in the digital scan of the article used for this translation. Therefore, a cartographic version of his account, rendered using ArcGIS, is included as an appendix to illustrate how the pandemic progressed from the main thoroughfares and markets of the regency to more remote locations, often at higher altitudes.
Van Steenis’ account of the pandemic also provides an important, contemporary, and authentic insight into the magnitude of the devastation of the pandemic. For example, ‘…dessa Tindomojo met 822 inwoners stierven in de week 22-28 November 60 personen’ (van Steenis, p.909), which translates to ‘60 people died in the week of 22-28 November in village Tindomojo (population 822)’. This translates to a staggering seven per cent mortality rate in a single week for a pandemic that dragged on for many months and appeared and reappeared in multiple waves across Java.
Van Steenis’ account is backed by reports from other sources, for example ‘Nu er bijna 2 millioen Inlanders aan die ziekte gestorven zijn, komt men pas tot de ontdekking, dat die groote sterfte te wijten is aan onvoldoende voiding’ (‘Persoverzicht’, Koloniaal Tijdschrift of 1919, first half-year, p.482), translated as ‘Now that almost 2 million Natives have died of that disease, it is only discovered that this large death is due to insufficient feeding’.
Notably, the synopsis in the Koloniaal Tijdschrift referred to a newspaper article published in December 1918, that quoted a notification by the Civil Medical Service of the Netherlands Indies long before the pandemic had worked its way through all of Java, let alone the other islands of the Netherlands East Indies. The published two million figure is (like van Steenis’ account) based on truncated information, pointing to an even higher death toll for the entire duration of the pandemic. These descriptions are important because a recent estimate of deaths places the toll for Java at an optimistic 1.47 million (or about 3.9 per cent of the population; see the unpublished working paper by van der Eng (2023)). This calculation is based on Boomgaard and Gooszen’s (1991) underestimate of early 20th century population growth in Java. They ignore the impact of the one-time drop in population during the pandemic on the slope of the population growth trajectory, thereby deriving a much lower growth rate of population than would otherwise be obtained. This introduces a logical contradiction into the van der Eng analysis. It attempts to estimate the effect of a historical event based on underlying data that assumes that the event never occurred.
The final section of van Steenis’ report speculates on modes by which influenza was transmitted in Magelang. While he rightly identifies ‘droplet infection at a short distance’ as a key mode, his statement, ‘In the high, humid mountain regions I consider it likely that long-lived germs of infection blow through the air during the early morning or evening hours from village to village over greater distances’, is intriguing and likely would not pass muster among modern-day epidemiologists.
While there exist a few reports on the 1918 influenza pandemic in the Netherlands East Indies, most describe the pandemic at a high level of spatial aggregation (such as ‘Rapport over de Influenza-epidemie in Nederlandsch-Indië 1918’ [Report on the influenza epidemic in the Netherlands Indies 1918], Mededeelingen van den Burgerlijken Geneeskundigen Dienst in Nederlandsch-Indië [Reports of the Civil Medical Service in the Dutch East Indies] 1920;10:77–157); or provide very brief snapshots of the pandemic in specific locations (for example, the Koloniaal Tijdschrift article described above). By virtue of its thoughtfulness and degree of detail, the van Steenis report on the pandemic in Magelang is a unique and valuable resource that stands apart by providing rich scientific, social, and spatial context on how this devastating event unfolded in one of the most densely populated regions of the world.
van Steenis, P.B. ‘Some epidemiological remarks about the flu in the Magelang Division, 1918’, Medical Journal for the Netherlands Indies, LIX:901-20.
Siddharth Chandra (chandr45@msu.edu) is Director, Asian Studies Center and Professor of Economics, James Madison College and Professor (by courtesy), Department of Epidemiology and Biostatistics, Michigan State University.
