The First World War accelerated the spread of the influenza pandemic among soldiers and civilians in the Ottoman Empire. Plague, cholera, typhus and syphilis were rampant in Russia and these contagious diseases were spreading to Anatolia by immigrants and Russian pilgrims between 1914 and 1918. Syphilis, often seen in Galicia Front during the war, was brought by soldiers returning their homes. Furthermore, pilgrims, captives and marine transportation brought flu and cholera to the Middle East and from there to Anatolia. Aforementioned diseases were seen in both Istanbul and Anatolia.[1] In fact, extraordinary conditions of warfare resulted in the spread of pandemics to masses.
Influenza pandemics emerged in the Ottoman Empire just like Europe and other continents before 1918. It was known that these pandemics were potent with cholera pandemics throughout 1890s.[2] The Spanish influenza, emerging in the United State of America (USA) in 1918, was called Spanish disease (İspanyol hastalığı) or Spanish cold (İspanyol nezlesi) in the Ottoman Empire. Yet, its place in the history of flu seems ambiguous since the pandemic broke out in the USA, leading Middle East and Anatolia out of focus from medical historiography in one respect. This paper discusses the impact of the Spanish Influenza on the Ottoman Empire so as to contribute to epidemiological map of this pandemic disease which was one of the most destructive agents in human history. In addition, this paper mainly focuses on the period from 1918 to the early 1920s when the pandemic swept through the Empire.
Emergence of the Pandemic Influenza in the Empire
To begin with, in order to set a framework of epidemiology of the influenza pandemic in the Ottoman Empire, it is necessary to position the spatial and temporal issues in the first place. The geography where the Empire was located promoted the spread of the contagious diseases. In spite of its undeveloped and inadequate transportation, and the long shoreline created strong external connection through the marine transportation. Istanbul, the capital city of the Empire, was not only a center of commercial and cultural relations but also a place where contagious diseases spread intensively from the West to the East and vice versa. Daniel Panzac who studied the plague epidemics in the Ottoman Empire, reasonably claimed the fact that geography of the Empire was vulnerable to pandemic diseases.[3]
Nevertheless, how the Spanish influenza penetrated into the Ottoman Empire is an uncertain issue. This pandemic might have been brought by either passengers from Europe or the British army in Mesopotamia. When primary records on this issue are scrutinized, introduction of the influenza from Europe to the Empire seems to be more possible since the interregional transportation in the Ottoman Empire was undeveloped.[4] Road transportation was in a kind of budding stage. The British domination over the Mediterranean prevented the marine transportation from working efficiently. Railways were almost mainly composed of only one line. Furthermore, the basic railroads between the Arab provinces and Anatolia had not been completed yet. Therefore, firstly, the materials sent by Germany or Austria were entrained in Istanbul. After they were carried by breasts of burden in the places where railway line was absent or incomplete, they were being carried by another train.[5] Thus, the fact that the virus H1N1, which led to the Spanish influenza, might have reached the Ottoman Empire from the European countries has high probability. In other words, it is possible to argue that backwardness in transportation decelerated spread of H1N1. Over the course of the war, since the Central Powers were close to each other spatially, the transportation and communication between Istanbul and Europe were easier. Although the pandemic emerged in the USA, it was considered to have originated in Spain and to have spread to France and Germany from this Iberian country.[6] Those who were close to the network of transportation played prominent role in the spread of influenza. The German physician M. Weinberg, who had a chance for the surveillance of the medical conditions of the soldiers in Istanbul, stated that the soldiers serving in the sections of motor vehicle, communication and railway of German soldiers in the Ottoman Empire were outstanding patients suffering from the influenza.[7]
The Ottoman Empire suffered from three waves of the Spanish influenza. The first wave that spread in the summer of 1918 in Istanbul and other provinces did not experience too much casualty in the Ottoman Empire like other parts of the world. It means that, the second and third waves were more lethal than the first one. Actually, the virus H1N1 did not acquire chance to spread remarkably since both low virulence pathogen of the first wave and hot weather in summer season decreased the mortality and morbidity of the influenza. In July 1918, 4 soldiers caught the influenza and they recovered after receiving medical treatment. Also, 14 soldiers suffered from it in August of the same year.[8]
The newspapers published in the capital city wrote that there were many influenza cases but this disease did not have a hazardous character in terms of lethality. In an article published in a newspaper named ‘Âti’ on 14 July 1918, lots of information on symptoms, signs and course of the influenza was given and the fact that no one died of it was emphasized. In addition, the author of this article claimed that another disease other than the influenza might have resulted in this pandemic.[9] What he or she meant by saying another disease was probably complications like pneumonia. The influenza pandemic caused similar symptoms among its victims in the Ottoman Empire, Europe and the USA. Süleyman Numan, who was an inspector general of field, mentioned the basic peculiarities of the disease leading to the pandemic. These are as follows:[10]
• Sudden start of the disease
• 39-40o fever
• Redness without tonsillitis in the throat of the patient
• Difficulty in swallowing, sharp and dry cough
• Backache
• Symptoms similar to meningitis
The signs of the influenza were the same in other countries. In 1918, one of the prominent clinicians of the USA stated that the influenza began suddenly and continued with symptoms such as cough and backache.[11] After a research on the victims of this disease, it was asserted that the influenza had similar aspects with meningitis in Camp Devens, a military camp in Massachusset.[12] From the personal observation of Âkil Muhtar, a physcian in Istanbul in 1918, there was high fever that started suddenly after malaise lasting for one day and reached 39-40o among the patients. Furthermore, the report indicated influenza sufferers had headache with spine and back pain.[13]
The newspapers in the Ottoman Empire neither censored news about the emergence of the pandemic disease, as New York Times did, nor claimed that the disease spread through the external powers to inflict damage on the state.[14] Some of them were aware of the prevalence of the disease even though influenza was a simple malady.[15] These newspapers benefit from the using influenza pandemic for war propaganda.
It was not compulsory to inform about the influenza cases to the official authorities in the Ottoman Empire like many countries. According to the Regulation on Contagious and Epidemic Diseases (Emraz-ı Sariye ve İstilaiye Nizamnamesi), the following diseases were required to be reported: cholera, plague, typhus, smallpox, diphtheria, dysentery, scarlet fever, trachoma, glanders, rabies, puerperal fever, food poisoning and tuberculosis. Moreover, how to inform these diseases to the official authorities and penalize those who would not care about the orders were explained in this regulation.[16] Thus, it is not possible to make a certain comment about the number of influenza cases. Ekrem Bey, the head of Board of the Contagious Diseases (Emraz-ı Sariye Heyeti), said that he had no clear statistical parameters because influenza was not a reportable ill.[17] The Municipality of Istanbul (Istanbul Şehremaneti) and Sıhhiye Mecmuası (Journal of Medicine) kept the records of some cases, but it was inadequate to figure out the impact of the pandemic. What is remarkable to notice from available but inadequate records was high increase in the number of deaths from the influenza at the time when the pathogen had more virulence in the second and third wave of the pandemic influenza.
The second wave of the influenza pandemic began around September 1918. Âkil Muhtar asserted that after the influenza spread tempestuously in summer, it deteriorated and there was no complication in the majority of cases or it rarely led to death. Also, he added the relapse of this disease after a couple of month. He noticed the high fever, difficulty in breathing, pain and fremitus in thorax among the patients. In the first 36 hour, following these symptoms, death might happen. Even worse, the Spanish influenza activated the pathogen of tuberculosis in the lungs of patients in some cases.[18]
The gradual cooling of weather and disbandment of soldiers from theater of the war led to the spread of the influenza. According to the research conducted by Istanbul Health Directorate, the number of the influenza cases in the Empire was going up, as it was the case all over the world.[19] M. Weinberg, in 1919, states that “an intense form of influenza was prevalent in Istanbul, Eurasia, and countries located in the South of Taurus Mountain as in everywhere in Europe. Our soldiers learnt this while withdrawing and they were inflicted by heavy casualty. New vectors of infection came to the camps with every reinforcement, and as a result pandemic disease did not come to an end. Even all of the soldiers in one camp suffered from the influenza due to terrible conditions there”.[20]
The living conditions of many soldiers in the First World War were awful. Some of the soldiers in the Ottoman Empire were staying in indurable tents. In addition to this miserable accommodation, malnutrition and other pandemic diseases like malaria lessened their immunity.[21] These soldiers were agents of pathogen both during the war and in the post-war period. The disbanded soldiers played a leading role in the spread of the pandemic influenza. The pathogens they carried created danger for the public health as they flocked into Istanbul miserably. They had problems of shortage of accommodation and food. Moreover, many soldiers stayed in mosques[22] as they had no place to stay at that time.
The Spanish influenza hit many cities as well as Istanbul. The pandemic was prevalent in many cities of Anatolia. Especially the numbers of the incidents were significant in Yozgat, one of the central Anatolian cities. According to a correspondence sent to the Ministry of Interior (Dahiliye Nezareti) by Ministry of Justice (Adliye Nezareti), 400-inmate capacity of a prison in Yozgat decreased by half. There were many measures to be taken to fight with it.[23] In this city, pandemic disease had been mistaken to typhus, but later authorities grasped that it was influenza that led the pandemic.[24] In Alaca in Yozgat, approximately 30 people died within a day. In the subsequent days, the number of death was about 10.[25] The worst hit places in Yozgat were two districts named Köhne and Sorgun. Throughout 48 villages in these districts, out of 10,844 people, 9,800 people suffered from the influenza and 1,160 of them passed away.[26] The mortality here was approximately 11 per 1,000 persons and this number was too high. P. O’Donoghue, a possibly British prisoner of the war in Yozgat, claimed that the influenza spread there and 12 people died. He added that their people were confined to houses and being very badly treated, naturally the disease spread very rapidly under this condition of close confinement. Of course this was ordered by Istanbul and we all know was retaliation for 8 officers who have made good their escape. [27] The conditions of the war captives were not satisfying. The shortage of medical staff and drug problems the Turks faced during the war influenced their life conditions adversely. The many problems of the captured soldiers he mentioned were similar to the problems of Ottoman soldiers on duty and civilians.
The pandemic hit Ankara and some surrounding in the autumn of 1918 badly. This city was prominent to land routes and there was a railway line connected to Istanbul and Eskisehir (located in the west of Ankara). H1N1 might have been brought by the soldiers using those land routes or the railway. The disease influenced the village Satılmış[28] in Eskisehir and the district İskilip in Çorum.[29] Eastern Anatolia could not escape from this malady either. When the French army occupied the region, captive soldiers from the enemy troops played significant role in the spread of the influenza. Makru Kusata, a Senegalese soldier recruited by the French army, was captured by the Ottomans and died of influenza in Elazığ.[30] Also, a soldier named Hasan deserted the Ottoman army in Izmir, escaping to Dogu Bayezit in the Eastern Anatolia.[31]He passed away there because of the influenza.
Apart from Anatolia, the Middle East suffered also from the pandemic. Especially, shorelines of today’s Syrian and Lebanon were struck.[32] It can be said that the strong link with the world due to the war, emigration and mobilization was instrumental in the rapid spread of the influenza. The German soldiers who went to Istanbul from Mosul via Samsun were convulsed by the disease. Weinberg attributed 20 % of the death among these soldiers to this disease. In the hospital where he worked, 450 incidents were detected and approximately 45 of them died during October, November and December of 1918.[33] The pandemic disease affected Nusaybin, a district in the South Eastern of Turkey today. An employee of a train passing there might have brought the influenza. In spite of the measures, the pandemic affected the central troops deployed in Mosul on 15 August and it spread to the second legion in Tikrit on 25 August. It was ascertained that the influenza spread there by means of automobiles from Nusaybin, and the transportation branches of the Ottoman army contributed to the spread of the disease.[34]
Mustafa Kemal, the founder of the Republic of Turkey, was one of those who had to deal with this malady. While he was accompanying to the Crown Prince Vahideddin during his visit to Germany in 1917, Mustafa Kemal went to Wien on account of a kidney problem. Yet, he did not stay there and he travelled to Carlsbad from Austria, one of today’s famous spa towns in Czech Republic. Then, soon after resting in this town, he set out for Istanbul via Wien. Nevertheless, he suffered from the influenza, leading to a couple of days delay to Istanbul.[35] He recovered in Wien immediately.
In November of 1918, sultan Vahideddin was reported to suffer from the Spanish influenza though he was not. The sultan just acted as if he had had flu. When the deposed grand vizier Ahmed İzzet Pasha visited the sultan, he alleged that he was suffering from the influenza in order to send away the ex-grand vizier. That the sultan was ill was not true. After the ex-grand vizier went, the sultan acted normally as eyewitness accounts of the incident indicated.[36]
The third and final wave of the Spanish influenza, the most virulent one, emerged towards the last months of 1918 and was rampant in many places in 1919. The main peculiarity of the third wave was that it lasted longer. This wave continued so for a long time that many cases of upper respiratory infections were named Spanish influenza throughout 1920s. Latife Hanım, whom Mustafa Kemal divorced in 1925, went to Czechoslovakia so as to receive treatment in a sanatorium there. In a letter sent to Vasıf Bey in 26 October 1927, she mentioned that she was having bed rest for one week and had been having medical therapy for five months owing to the Spanish influenza.[37]
The third wave of the pandemic influenza had more favorable opportunity to spread widely in the borders of the Ottoman Empire. Not only the influenza but also other contagious diseases were common among both soldiers and civilians in the region of Marmara. Gendarmerie garrisons were deployed in Çatalca, a district in the west of Istanbul at that time, and Ayvacık, a township of Çanakkale, were damaged by the pandemic disease. According to the archival documents available, 15 people died there just in a week.[38] Furthermore, the influenza spread to Mudanya where an armistice concluding the Greek occupation of Anatolia (1919-1922) was signed in 1922.[39]
While Mustafa Kemal was in preparation for departure from Samsun in 1919, he has suffered from the influenza for the second time. Therefore, his assistant Cevad Abbas (Gürer) assigned approximately 10 physicians to have him examined. After medical inspections, they realized that Mustafa Kemal was healthy and the influenza did not harm his health.[40] Except for Mustafa Kemal, many other important Ottomans had the influenza. The Turkish author Osman Ziya lost his mother and the famous painter Fikret Mualla was also in the grip of the influenza.[41]
The pandemic influenza was to appear as a theme in Turkish literature. Nazım Hikmet, a well-known poet in Turkey, mentions this disease in one of his poems even though the pandemic is not a central theme in it:[42]
“We are Istanbul city, those who
Went through mobilization:
Caucasia, Galicia, Dardanelles, Palestine
Wagon trade, typhus and Spanish flu
And the Unionists too
Also long leg of the German boot
devoured us from 914 to 1918.”
Measures against the Spanish Influenza
The time when the influenza first struck was summer and the virus was not much virulent. What the Ottoman Empire did to prevent this pandemic was generally carried out in its second and third waves. Yet, over the course of the war, the Ottoman government had several difficulties in taking necessary measures against the influenza like other diseases such as typhus and malaria. There were mainly four reasons why Ottomans failed to provide efficient health care during the war.[43]
The first reason was inadequate sources of the country. Most of the physicians were appointed in the troops and their total number was 2,555.[44] Even this number was unable to meet the needs of soldiers. Also, the striking example of Ottoman’s backwardness was in terms of the transportation. The total area was 1758 km² and the railway line of 5761 kilometers was serving to the state. What are worse were disconnections between lines in the east, the southeast of the Ottoman Empire and Istanbul. These troubles could have been prevented if marine transportation had been appropriate in the Mediterranean, the Aegean and the Black Sea. However, the Allied Powers had strong navy there.[45]
The second reason is that the bureaucracy of the Ottomans was not efficient.[46] Therefore, the state was both unable to meet all demands of people and brought about procrastination of bureaucratic activities.
The third reason was the war-induced burden in terms of economy. Participation in a war against the big powers such as Great Britain and France meant a challenge for the Ottomans. Furthermore, Balkan Wars (1912-13) exhausted them and they could not bear up a worldwide conflict due to the material shortages. What exacerbated this condition were the misguided military plans prepared to attack against the enemy from distant fronts simultaneously.[47]
The fourth and final reason is that the wartime corruptions and irregularities prevented the Ottomans from conducting health system efficiently. Acceptance of bribery or demanding it was an ordinary behavior among officers.[48] Throughout the war, inflation peaked and cost of living quadrupled in Istanbul. In addition, different extraordinary levies were imposed, which were subtracted consecutively from the salaries: 25% war fund; 5% Red Crescent fund; 5% aviation fund and 5% defense and the faith fund.[49]
Initial steps for protection of public health were to meet physician deficit and provision of required medical supplies, since the appointment of many medical staff in military troops left civilians vulnerable to contagious disease. For instance, in order to fight with the Spanish influenza, the municipality of Istanbul (Istanbul Şehremaneti) demanded 30 physicians from the Ministry of Interior (Osmanlı Dahiliye Nezareti). This demand was not welcomed because most of the physicians were in the services of the army. Yet, the appointment of medical staff on the battlefield could not meet even the need of soldiers.[50] Another medical problem was the drug shortage. Upon beginning of the war, importation of many drugs from the Allied powers stopped and thus the number of available drugs sold in market decreased dramatically. The Ottomans had to import necessary drugs from friendly countries. The prices of drugs went up sharply and incredibly and profiteering became extremely widespread while the Spanish influenza was striking. The Ottoman Ministry of Interior reported that it was not possible to find drugs and physicians in even affluent neighborhood.[51]
The treatments used for the people suffering from the influenza severely failed. Drugs like antifebrile were not workable remedies. Neither Quinine for the cure of malaria nor Salvarsan (Arsphenamine) for syphilis were of use. Basically, there were two reasons for the usage of these drugs. First, they served to healing malaria and syphilis successfully as many medical staff assumed that they could be helpful for the influenza patients. Second, some of the influenza sufferers had to face up with many diseases such as tuberculosis and malaria. Any decrease in the body resistance eased the emergence of these diseases. Owing to the medical shortage, it was not possible to perform autopsy on the bodies of people who died of the influenza. Nevertheless, Weinberg demanded autopsy and after performing it, he noticed that this respiratory tract infection was the influenza.[52] It can be asserted that carrying out autopsy and therapeutic approaches were helpful in taking precautions.
Despite the shortage of medical staff and equipment, the Ottoman Empire developed an idea on what to be done in terms of preventive health services against contagious diseases. Medical staff figured out that pathogen spread through coughing and sneezing. Thus, one of the preliminary measures was to prevent people from gathering. Short after the second wave of the pandemic, deaths became widespread and closing some public spaces was one of the best courses of action. Ottoman Ministry of Education (Maarif Nezareti) tried to get the opinion of General Directorate of Health (Sıhhiye Müdüriyet-i Umumiyesi) on whether schools had to be closed or not.[53] The ministry took the pandemic seriously and closed all the official and non-official schools until further notice. Yet, some of the Armenian and Greek schools disobeyed the order of the ministry.[54] An investigation about why these schools did not abide by measures for public health and did not close their institutions was demanded.[55] Also, the newspaper Âti confirmed that the schools had been closed for a while on account of the influenza pandemic.[56] How many schools took the order of the ministry into consideration was not certain. When the impact of the pandemic was lessened, the schools reopened.[57]
During the war, it was not only the ministries that had initiatives to take preventive medical precautions. Local administration in the provinces also tried to cope with the pandemic influenza. In 1918, the district governorship of Bandırma ordered the closure of a kindergarten and cinema. In doing so, the governor tried to keep people healthy.[58] People were informed about the epidemiology of the influenza, theatres were closed and many activities like conferences were postponed.[59]
The municipality of Istanbul issued a declaration consisting of ten articles in order to struggle against the influenza. According to this document, people were warned about the following.[60]
1. The germ carriers of this disease are those who suffered from it. Therefore, the first thing to do is to avoid contact and unnecessary visits.
2. Even though some people fell ill, they continue their daily life, being unaware of the danger. This situation plays leading role in the contribution of the spread of disease into masses. As a result, miscellaneous administrative actions are put into effect for the closure of public spaces such as cinemas and theatres.
3. Common cold increases in the emergence of the influenza. Thus, medical actions have to be taken against it.
4. Since the germ of the Spanish influenza spread through oral ways, people often have to wash their mouths and take care of their teeth.
5. While coughing, everyone has to use a handkerchief and even those who are close to the person coughing are responsible to protect their mouths and noses with handkerchiefs from their germs.
6. In case of indisposition, fever, common cold, headache, and cough, patients need convalescence deterioration of these symptoms.
7. If there is a patient in a house, he or she has to be taken to a separate room and only one person has to look after the patient. Also, other members of the household have to keep themselves away from this room. A kind of isolation is capable of decreasing the possibility of the contagion of the pandemic.
8. Those who have contact with the patients have to wash their mouths and hands well with disinfecting substances after touching the patient so that germ-carriers can prevent both exacerbation and the spread of their illness.
9. The patients have to spit into a pot to prevent the spread of the germ. Their belongings which contact with excretion like exudation have to be scalded to kill the germ.
10. It is crucial for the municipality of Istanbul to take the aforementioned measures so that it can maintain the public health.
In fact, it can be asserted that the municipality tried to put the most efficient steps into action. One of the first things was the implementation of preventive measures. The closure of public spaces such as schools and theatres was a right decision even though all of the educational institutions did not obey this decision. The primary cares for the patients at that time were isolation, high quality patient care, obedience to hygienic rules, and bed rest. In an era when the Ottomans were in drug shortage and had no adequate medical staff, the municipality of Istanbul did the best thing. Moreover, with relief efforts of the Ottoman Red Crescent, Red Cross, Allied Commission of City and Quarantine, the influence of the contagious disease decreased a little, and according to available records fight with the pandemic influenza was successful to certain extent.[61] The reliefs of these organizations reduced the responsibilities of the Ottoman medical staff at least. As Istanbul was of significance for both the Ottomans and the occupation forces, this city caught the attention over the course of the First World War and post-war era.[62] After the occupation of Istanbul, Allied States established nine commissions to control the city easily and one of these commissions dealt with the health issues there.[63] Health commission kept some of the hospitals in Istanbul under their control and they occasionally intervened in medical services and measures against infectious diseases.[64] The commissions of Allied States imposed strict control on maritime traffic.[65]
The physicians in the Ottoman army tried their best in order to get rid of the influenza pandemic. Compared with the civilian doctors they were both fortunate and unfortunate. The reason why they were lucky was that majority of medical staff were under the service of troops. In fact, they had more opportunity to make their plans work since during the war, the utmost goal of the state was to win the war, a matter of life and death. Thus, it paid more attention to medical units to enhance the ability of the army. On the other hand, they had difficulty in healing the patients on grounds that measures like isolation of patients could not be taken easily in military barracks and trenches, which were well-known for their crowdedness and dirtiness. Fighting efficiency of the Ottoman army decreased dramatically due to the contagious diseases, including the influenza. Gendarmeries did not perform their duties in Iskilip efficiently.[66]
Ottoman Ministry of War (Osmanlı Harbiye Nezareti) issued a Memorandum on the Diagnosis, Protection against and Treatment of the Epidemic Diseases during Campaigns (Seferde Bulaşıcı Hastalıkların Teşhis, Korunma ve Tedavisi Hakkında Muhtıra) in which the ways to prevent the spread of diseases and what to do in case of the outbreaking of any epidemic disease were explained in detail. Medical services the Ottoman soldiers needed during the war were planned from head to foot, but the disruption and inadequacy in medical services prevented the practice of what were commanded in the memorandum completely. [67] During the Spanish Influenza, observation reports and tables on morbidity and mortality were prepared by military physicians.[68] Inspector Süleyman Numan in the Ottoman army sent a document about medical examination of influenza cases to the troops. In this document, he explained the symptoms of the influenza and underlined the types of treatment. Furthermore, in case of death from this pandemic disease, he ordered military physicians to perform autopsy.[69] Influenza sufferers in the Ottoman army were sent to hospitals for treatment and as soon as they recovered, they were discharged from the hospitals to go to their military units.[70]
Consequences of the Pandemic
After the time when the pandemic started in July 1918, its impact emerged. Yet, as the lethality of the first wave was not severe, there was no tragic result. The early impact of the influenza was the disruption of public utilities led by the increase in deaths. The closure of schools interrupted continuity of education. Owing to the deaths among military and civil staff, the relative interruption of state affairs was inevitable. For instance, one of the members of the administrative board of Ottoman Red Crescent Society (Osmanlı Hilal-ı Ahmer Cemiyeti) quit the membership due to the influenza.[71] Osman Ziya, who was bacteriological expert on serum in Istanbul, passed away during the pandemic.[72] Medical staff had more risk to catch the influenza than civilians and other officers since they had to deal with germ-carriers directly. According to the information provided by Ahmed Emin, the total number of the civilian and military physicians was 2,555.[73] 292 of them died through contagious diseases.[74] It can be inferred from these numbers that approximately 18 % of physicians lost their life.
The imposition of restriction on public spaces for the sake of preventive health measures exacerbated the social life crippled by the war. In this awful situation, the spread of the influenza took the lead in carrying out medical studies about the disease. In spite of the fact that the influenza was considered mild, the medical investigation of its treatment was inevitable when it left remarkable impact on social life. It shows that although many shortages were available in medicine, these problems did not prevent scientific studies. Refik Bey, the director of the bacteriological room (Bakteriyolojihane) in Istanbul, generated influenza vaccine, but later it was seen that this vaccine was inefficient in curing the disease. The reason for his failure was that the pathogen of the influenza, H1N1, was not discovered until 1933. If a retrospective evaluation is made, the pathogen needed to be found in order to generate a vaccine. Refik Bey might have attributed the influenza cases to bacteria called “haemophilus influenzae”, which was acknowledged as the reason of this disease by Richard Pfeiffer, a well-known German physician and bacteriologist.
One of the controversial issues about the Spanish influenza was the uncertain number of people who died of it. It was the same for the Ottoman Empire. The influenza was not required by law to be reported to official authorities, while keeping the records of cases was hampered because of the detrimental effects of the outcomes of the war on the medical infrastructure. Therefore, it seems like exact number of the mortality and morbidity cannot be put forth. However, in light of primary and secondary sources, it is possible to make prediction about one of the most destructive pandemics of history despite providing precise quantitative information on this issue.
According to the Ottoman Ministry of Education (Maarif Nezâreti), approximately 400 deaths took place only in Istanbul in October 1918 a week.[75] Based on this number, it is presumable that the most lethal wave of the pandemic led to the death of about 1600 people in Istanbul. Nevertheless, what is really important is the inability to consider the mortality of the contagious disease in a simple way. There are many independent variables having effect on morbidity and mortality which can range from time to time.
According to a newspaper, 190 people caught the influenza between December 15 and 22, 1918 and 48 of them passed away. Furthermore, 349 people died of pneumonia.[76] By 1921, probably the number of those who suffered from pandemic reached 30,000.[77]
By looking at the figure above, it is possible to make an analysis of the flu in Istanbul. What was remarkable is the majority of young people among deaths. The information on the figure seems to belong to 1918 since according to Sıhhiye Mecmuası the influenza and pneumonia led to 6,835 deaths in Istanbul in 1918 and 3,139 ones in 1919.[79] In fact, two death tolls provided by the municipality and this journal are close to each other in terms of the deaths of year 1918. When the numbers given by Ahmed Emin on the figure 2 are examined, total loss of life of civilians rose by 60 % compared with that of previous years. This increase is possible to be related to the deaths brought by the influenza.
These numbers of the municipality and the journal allow us to estimate the human destruction by the pandemic. However, a problem arises here: the population of Istanbul was continuously variable during the war. In addition to the social mobility, the capital city exceeded one million in population.[81] Zafer Toprak claims that its wartime population was 1,129,655.[82] If this number is accepted as the population of Istanbul in 1918, one could reach the conclusion that the death rate in influenza cases in Istanbul at the time would be around 5,6 per 1000 persons according to Municipality and 6 per 1000 persons according to the Sıhhıye Mecmuası. These numbers are over the world average between 2,5 and 5 as claimed by Johnson and Mueller.[83] If all the death cases had been recorded, these rates have been certainly higher. In Izmir, the records kept by municipality in 1919 shows that 35 deaths occurred there. Nonetheless, this number seems low, but if all deaths of the influenza and its complications like pneumonia are included in the total amount, the number of the death of respiratory tract diseases in İzmir reaches to 663. Proportion of this number among all of the deaths in 1919 in this province is approximately 29 %, but the lack of records of the year 1918 is a hindrance to make an accurate estimate. Besides Istanbul and İzmir, deaths occurred in other provinces. Since only deaths from the influenza rather than its complications were recorded, the death toll was 3,226 while it was 85 during previous year.[84] This total number contains death cases from some parts of the provinces Aleppo, Beirut, Syria, Sivas and Trabzon. It does not contain the deaths in the provinces Basra, Bagdad, Hijaz, Van, Yemen and sanjak of Asir, Jerusalem and Medina. However, it is not a reliable enough to estimate the total loss of life by using these 3,226 death cases since medical units probably did not keep the records of other than capital city. While 6,835 people died from the influenza only in Istanbul, claiming 3,226 deaths occurred in the provinces is incoherent in a sense.
Weinberg examined 500 soldiers suffering from the influenza and 42 of them passed away. It means that death rate was 84 per 1,000 persons. In the light of the information he provided, the mortality of soldiers was too high compared with that of civilians.[85] Also, the physician Abdulkadir Noyan revealed that 35 of 1,000 soldiers catching the influenza died from the flu or the complications engendered by it.[86] Bringing about physical exhaustion that the long-lasting war weakened their immunity and the H1N1 caused more death among the youngers answer why the rate of death among the soldiers were much higher.
Following the weakening of the immunity of soldiers, the cases of encephalitis lethargica increased remarkably in the Ottoman Empire as elsewhere in the world. Right after the end of the war, this disease was common among the slaves coming from Egypt to Istanbul. The nervous system of soldiers got severe harm owing to this disease. Its most tragic result was Parkinson’s disease.[87]
Because the sources about the impact of the influenza on the Ottoman Empire are inadequate and scattered, it is compulsory to give rough and estimated information apart from the capital city. Actually, the best way to reach the unknown is to use known.[88] Therefore, the optimum option to do here is to refer to the mortality of Istanbul in order to estimate prevalence of the influenza in the Ottoman Empire, population of which was about 18,500,00 in 1918. If the mortality is 5 % per 1,000 persons, it means 92,500 deaths occurred because of the Spanish Influenza throughout the Empire. This result can be deceptive but, it is fruitful to predict overall statistical information.
Conclusion
As the pandemic influenza was widespread all over the world, the Ottoman Empire, having large territory, was inevitable to escape from this disaster. Located between Asia and Europe, it was a kind of transition point of pathogens just like that of commerce and culture. Ottoman’s active participation in the First World War corroborates the possibility that virus H1N1 was brought by soldiers of the allied powers or soldiers captured on battlefield.
All three waves of the pandemic hit the empire, but its spread was slower compared to other countries because undeveloped means of transportation and inadequate network were hindrance to the spread of the germ into Anatolia quickly. Like all over the world, the most lethal wave of the pandemic was the second one. At the beginning, the influenza spread but its mortality was slight. The effect of the pandemic accelerated in the second wave. Cold weather and noticeable increase in the lethality might have caused the death toll to rise sharply.
When the pandemic broke out in the world and it spread into the Empire, many measures were taken by the civil and military authorities. People did not adopt an attitude that epidemics were work of God and fought with the pandemic influenza despite the war-induced poverty. Attempts to prevent influenza or dilute its impact were beneficial at least. In order to make the impact of the influenza on the Ottoman Empire clear, there must be further studies in the history and medicine.