Proving that I can write about things other than the Spanish flu …
In the summer and fall of 1883, the newly-installed Anglo-Egyptian government faced its first public health crisis when cases of cholera were reported in the Nile Delta and rapidly spread throughout the country. The government’s response was based in part on long-standing European prejudices about the “Orient” as the origin of plague and pestilence and “Orientals” as people who did not understand health, science, or hygiene, and were unconcerned—even fatalistic—in the face of life-threatening illnesses.
To the contrary, Egypt had, over the course of the 19th century, developed a basic national health system, which had earned praise from European observers prior to the British occupation in 1882. The prejudices expressed by British occupation authorities also elides the British government’s own stance in ongoing debates among European scientists about contagion and the appropriate methods for preventing the spread of diseases like cholera.
The Anglo-Egyptian government’s response was based on imperial policies, racial prejudices, and scientific understandings that failed to adequately deal with the pandemic at the cost of 50,000 Egyptian lives.
It’s been kind of exciting doing this all from the comfort and confines of my home, where I’m quarantined with a chemical engineer and three hyperactive cats (and a fourth who’s just above it all).
I’ve been trying to figure out what brilliant thoughts I could possibly use to follow up on the previous post, but none are immediately forthcoming, and they’re standing in the way of announcing, for those who are interested, this:
On Wednesday, May 6, 2020, at 3 PM U.S. Eastern time (8 PM London / 9 PM Cairo), I will be giving a lecture on “The Spanish Influenza in Egypt” for Harvard’s Islamic Studies program online. The talk will cover much of the material that’s in my forthcoming article–the one that won’t be out until next year–so, if you’re interested, you might want to tune in. (I don’t know if it will be archived).
I’m extremely honored to have been asked — the director of the program actually found me through my blog post! — and even more elated to follow the incomparable and brilliant Nükhet Varlık (Rutgers& U South Carolina), who is speaking on April 30th (also 3 PM Eastern) on “Rethinking the Plague in the Time of Coronavirus.” (You can RSVP for her talk at https://islamicstudies.harvard.edu/plague.)
I haven’t said much lately because I don’t have much to contribute to the ongoing panic/dialog around the COVID-19 pandemic. Since there’s so much noise out there, I’ve decided to adopt–well, on this website anyway–a less is more approach.
Within the last week or so, however, as the pandemic has settled in to different contexts worldwide, I’ve found myself recounting the story of the “Spanish flu” pandemic in Egypt. This has partly been because there has been some criticism of the way the current Egyptian government has handled the pandemic, and this has caused some questions about how, previously, such things have been handled in Egypt.
I’ve written an article on it that’s been accepted by the Journal of World History, but it likely won’t appear until 2021. I do have permission to share the article here and on my academia.edu profile once it’s out, but I feel like there’s a limit to how much of my own research I can discuss in public before it appears. (note: the key word here is in public. I can certainly respond to, say, questions that are posed, either below or by e-mail … )
However, the article is ten thousand words long, and a short blog piece about the pandemic in Egypt that addresses the questions I feel like I’ve been asked several times won’t venture too far into spoiler territory!
What was the “Spanish flu”?
So, first off, let’s all remember that it was called the Spanish flu because Spain’s uncensored press was the first to report on the unusual nature of the virus in the spring of 1918. It didn’t originate in Spain nor, as someone tried to argue with me on Twitter a few weeks ago, did it attract the name because more people died of it in Spain than anywhere else.
The pandemic lasted globally until 1920, and it went around the world in three waves. The second was the most lethal, although all three waves carried the same unusual mortality curve: in addition to the young and elderly, the highest mortality rates were observed in people aged 15-25.
The virus, a mutated strain of the H1N1 avian influenza, frequently caused victims to cough or spit up blood, their faces to turn purple or black, and, in victims with particularly robust immune systems, it caused their lungs to fill up with fluid. This latter was a frequent cause of death–misidentified as pneumonia early on–because the immune system was triggered into an over-response; fluid was produced in an attempt to counter the virus, and victims essentially drowned.
When did the pandemic hit Egypt?
The first wave of the pandemic appeared in Egypt sometime in late spring–around May or June. It attracted little attention, other than commentary on its appearance at an unusual time of year, and the Department of Public Health (a subset of the Ministry of the Interior) recommended that people should stay home if sick.
It wasn’t until the end of October–right around the time that the Treaty of Mudros was signed, ending Ottoman participation in World War I–that the lethal wave hit. The most lethal period of the pandemic persisted until just after Christmas, resulting in a large number of casualties in the last eight weeks of 1918.
The third wave is mentioned very briefly in the press–right after Sa’ad Zaghlul’s arrest in March 1919. Vital statistics–such as they are–seem to indicate that it was fairly mild, but given the fact that the country exploded into open rebellion and most government ministries were effectively shut down until midyear, it’s impossible to know for sure.
How did the Egyptian government deal with the pandemic?
At the time, Egypt was a British protectorate. The system known as the “Veiled Protectorate,” wherein Egypt was administered by the British but there was lip service given to an official fiction that it remained an autonomous Ottoman province had been done away with upon the mutual declaration of war between Britain and the Ottoman Empire in November 1914. Egypt was declared a British protectorate–it would remain so until 1923–and placed under martial law at the beginning of December 1914 (this was cancelled as a gesture of goodwill by General Allenby in May 1919).
The problem in Egypt, as in other colonial settings, is that colonial officials who held military rank were recalled to duty for the war, and many of them had been sent into Palestine with Allenby’s campaign starting in the fall of 1917, and remained there at the time the pandemic’s most lethal wave arrived a year later. This included much of the leadership of the Department of Public Health as well as most of the district medical officials whose job was to oversee health services for the civilian population.
Simply put, for most of the war, civilian medical needs were a far distant second behind military medical needs (and for this, I’ll refer you to my book that’ll be out sometime in the next decade).
Hence, when the pandemic hit Egypt, the Anglo-Egyptian government was caught with its pants down. Hospitals and clinics were overwhelmed. A meeting of the Alexandria municipality in early November turned into an ad hoc grievance session, with citizens angrily demanding that the head of the Municipal Health Department do more to control the pandemic.
It was mid-November before basic guidelines were issued to the public; schools remained open until early December. Markets, courts, and universities were closed. Cities and provincial governments issued directives, but many seemed haphazard in their approaches: in Cairo, cinemas were closed, but not theaters; bars were closed, but not cafes. In both Cairo and Alexandria, people complained about crowding on the city’s tramways, with local governments feebly admitting they could do little to control the environment.
Physicians–who were mostly Egyptians, Greek, or Syrian–were overworked; at one point the press observed that in Asyut doctors were making constant housecalls and working over 15 hours a day. The next week it was reported that all of the city’s doctors had caught the flu themselves and were unable to see patients.
It was reported that in some rural villages there was “no other business other than to bury the dead,” and that agricultural production had ceased. This is extremely important to note, as the entire economy depended on intensive agricultural production, and most peasants had little savings. Stopping work in the fields would only have happened under the most extreme of circumstances.
Were religious services suspended in 1918 like they are now?
Update: if they were, it happened late. Al-Muqattam reported on December 6 (the height of the second, and most lethal wave) that the Alexandria Municipality’s Sanitary Department had asked the Ministry of Awqaf to make sure mosques were properly ventilated during prayer services, and that the floors were being cleaned with purified water before and after.
This question has come up several times, especially with Ramadan looming now (Ramadan didn’t coincide with the worst of the pandemic in 1918). The issue is suspicious by its absence from the press, in fact, but I don’t know what to make of it (if anyone knows, please leave a comment or message me!).
The Anglo-Egyptian administration was very wary of stepping on toes that should have been handled by the Ministry of Religious Affairs (most colonial administrators had experience working in India, where the 1857 revolt loomed large in memory, and the British tried not to offend Islamic sensibilities). Hence, when Al-Azhar was ordered to close–which it was–this was ordered in its capacity as an educational institution, not as a place of worship.
Public celebrations of Mawlid an-Nabi, the Prophet’s birthday, were cancelled, as were permits for religious processions as well as funeral processions. I have not seen references to mass graves (this had caused uproar during previous pandemics), but people were encouraged to conduct quiet burials as quickly as possible.
How many people died?
The officially calculated death toll was 138,000 people — over 1% of Egypt’s population according to the census conducted in 1917.
That said, Niall P.A.S. Johnson and Juergen Mueller wrote an article in 2002 to try to compile a more accurate global total of the pandemic’s mortality, and they concluded that the method used in Egypt as elsewhere usually produced estimates that were too low, sometimes by as much as half. Hence, it seems more likely that the death toll would be closer to 170,000; the overwhelming majority of these deaths taking place in the last eight weeks of 1918. (To clarify: Johnson and Mueller have said that the method was inaccurate; the estimate of 170,000 is mine.)
The highest mortality rate in Egypt was observed in people between the ages of 10 and 20, with rural areas more heavily affected than urban areas. (I do have a theory about why this is, but you’ll have to read the article).
To put it in context, this would be the generation of young men and women who were left behind to run farms and keep things going while fathers and older brothers went off to work in the Egyptian Labour Corps, the Egyptian Camel Corps, and other work associated with the war effort, as agricultural wages had remained relatively flat even as inflation sent the cost of basic goods upwards by as much as 300%. They would have gotten through the war, and then perished just as it looked like things might return to normal. Socially, this must have been devastating.
I do think this is one of the reasons why rural residents were angry and ready to express that anger when the 1919 uprising began. (In my book, which I am still working on, I argue that people were hungry for most of the war. The influenza–the worst health crisis during World War I in Egypt–came after the end of the war, and made everything worse.) Political organizers from the Wafd and other parties who went into rural areas probably had their work cut out for them.
The influenza has, oddly, been omitted or ignored in most of the histories of early 20th century Egypt. I’m hoping my forthcoming article can start a conversation about some of the non-political events in early 20th century Egypt that have long been set aside in favor of the political narrative that tends to be emphasized in scholarship of the period.
Talk to me!
Even though I’ve got an article coming out, I’m interested in comparing notes with anyone else who’s working on this or similar topics, just because there isn’t much out there. I’m especially interested in hearing family lore–did someone in your family tell stories about the pandemic? Or can you fill in some holes in the narrative? Leave a comment, or e-mail me!
I wasn’t expecting this post to be so popular! I’m sorry that it’s not longer. I really wanted to just answer some of the usual questions, but I’m glad so many people are interested in the topic.
The Lecture I gave for Harvard on May 6, 2020 is now online:
A number of people on Twitter have said that they wished I’d written more about the political effect of the pandemic. I’m afraid that I just don’t have enough solid data to make stronger claims at this point.
I am still working on this, so if you have ideas please let me know.
1. Johnson, Niall P. A. S., and Juergen Mueller. “Updating the Accounts: Global Mortality of the 1918-1920 ‘Spanish’ Influenza Pandemic.” Bulletin of the History of Medicine 76, no. 1 (2002): 105–15. https://doi.org/10.1353/bhm.2002.0022.
Over the weekend, the Thomas Cook company went bankrupt and shuttered operations, leaving hundreds of thousands of people stranded worldwide and searching for flights home.
A number of us Twitterstorians became particularly concerned about the impending demise of the company a few days ago when Ziad Morsy, a martime archaeologist and Ph.D. candidate at the University of Southampton tweeted that Thomas Cook’s historical archivist had lost his job.
Few months ago Paul Smith, the archives of the Thomas Cook Historical Archives for 23 years lost his job, and now the archives are at risk amid the eminent liquidation of the company https://t.co/HEQC3xng6j
The Thomas Cook company was 178 years old when it collapsed (just over a month before Britain may or may not exit the European Union–coincidences which have been commented upon elsewhere). Some of its history in relation to British imperial history was covered by another colleague in a Twitter thread yesterday:
Thomas Cook began leading tour groups to Egypt and the Holy Land 150 years ago in 1869. He was even present at the opening ceremony of the Suez Canal in November that year. So began the history of modern Western organized tourism in the Middle East. pic.twitter.com/0pQjxNd60H
Inasmuch as it’s easy to point to the Thomas Cook Company’s early days as those of a commercial company essentially making money off of the expansion of the British Empire, there are occasional glimpses at a richer and more complicated role for the company in various contexts (@afzaque covers several of them in his thread, which is worth a read).
It’s these sorts of things that make the potential loss of the company’s archive particularly painful, as it is one of those out-of-the-box sources for material that can shed startling new light on historical periods.
And hence, I present …
The curious case of the Thomas Cook Hospital
I ran across the hospital while writing the first two chapters of my dissertation, which wound up comprising a comprehensive history of public health in Egypt between 1805 and 1914 as one did not already exist. (Wanna publish it? It’s not going to be in the monograph.)
It was located in Luxor, a settlement that is notable mostly for what people were doing there thousands of years ago, as it is built on top of the ruins of what was almost certainly not known to its inhabitants as Thebes, but was one of the New Kingdom capitals of ancient Egypt. Across the Nile River, wide and lazily flowing at this point, is the pyramid-shaped hill that marks the location of the Valley of the Kings.
Given the numerous pharaonic sites that dot the landscape up and down the river from Luxor, Cook had the bright idea to utilize boat travel for wealthy tourists to visit them without the hassle of having to move constantly to new hotels every night. Luxor, at the epicenter, was the site of the train station from which Wagon-Lits and other operators operated sleeper trains to Cairo.
In 1890, Luxor was a small town — perhaps five thousand permanent inhabitants, which could swell as high as twenty thousand during tourist season when there was work to be had.
John Mason Cook–the son referred to in the company’s official name “Thomas Cook & Son” after 1865 — had the idea to open a hospital as early as 1887:
In 1887, he decided, driven by the reactions of rich foreigners–British, American, German–in the face of the unfortunate hygienic conditions of the local population, to construct a hospital. “Accomplished in 1891, inaugurated by the Khedive Tewfik Pacha, it comprised 26 beds (of which 8 were for women, 10 for men)*, the buildings well constructed, each isolated from the other, in a healthy and fortuitous position.”
*(no, this doesn’t equal 26).
Jagailloux, Serge. La Médicalisation de l’Égypte Au XIXe Siècle. Synthèse 25. Paris: Éditions Recherche sur les civilsations, 1986. (translation mine).
The hospital was co-directed by a Syrian doctor and an Englishman (only the latter–a Dr. Saimders–is named). Given that neither were in residence in Luxor in the off season (April to November), a third doctor–an Egyptian–was appointed to see patients in the off-season.
It was estimated that over 120,000 patients were seen, with over 2,000 operational procedures performed, in its first twenty years of operation. The hospital was presumably built primarily for the treatment of visiting foreigners, with Egyptians working in the tourist industry as a secondary priority.
What is interesting is that, with Cook’s blessing, the hospital was opened to the public as well. In 1898, The Lancet enthusiastically reported that people were coming from over two hundred miles away to seek treatment at the facility. (“Egypt.” The Lancet 152, no. 3905 (July 2, 1898): 59.)
After the British occupation in 1882, funding for public health flatlined. Under Lord Cromer, the public health budget never exceeded 100,000 Egyptian pounds (at the time LE 1 = £0.95).
Hospitals in the provinces, which were already run down and developing a bad reputation among patients (most of them had been built in the 1840s), were frequently closed or moved to other, newer buildings that were not purpose-built to serve as hospitals.
The construction of private facilities was encouraged by the Anglo-Egyptian government; the government would not open new hospitals or dispensaries (a combination pharmacy/clinic used to supplement hospitals in smaller settlements) in towns that had “good” private facilities. Many of the hospitals were funded by local European communities to serve their own–Austro-Hungarians, French, Greeks, Italians, and Anglo-Americans all had their own facilities in Cairo and/or Alexandria, most of which referred their Egyptian patients to government facilities.
Hence, it is a point of curiosity for me as to what inspired John Mason Cook to open his hospital to the general public, especially given that his company did not lack for wealthy clientele to fill its beds.
It suggests that, even at the height of imperialism, with a company that can (and has) be considered an agent of an imperial power, things are never quite as simple as they might seem.
As I was writing this, Ziad tweeted me this tantalizing entry from the archival catalog:
FYI, all the info you would need about the Hospital in Luxor could be found in Black Box #3
And here is more about what’s inside, if the Archive is ever opened again! 🤷🏽♂️ pic.twitter.com/VZbIlTaewV
Hence, the answer to my questions may lie in this box, whose future is now in doubt.
What you can do to help
If you’re one of us history types who has benefitted, or could benefit, from consulting the Thomas Cook archives, this thread has specific action items you can take to let people know that there is interest in saving the archive and not letting its contents be dispersed or destroyed.
People: you’ve seen the bad news about Thomas Cook. We *urgently* need to secure the archives, hugely important in the history of transport & mobility.
If you’ve used the archives, or have an interest, please help! Letters of support needed – pls contact Mike Anson: @BAC_Chair
I know, not the best title for my first blog entry, right?
A couple of months back, I presented some of initial findings on epidemic and epizootic disease in Egypt during the first World War at a symposium. (Ok, I’ll tell you the symposium was at Oxford. Yes, you may touch me.) I was flattered to be asked, especially since, as an ABD candidate, I got to be part of a two-panel session with speakers like Khaled Fahmy and Marilyn Booth (I’m still not entirely convinced I didn’t embarrass myself and everyone else, but that’s impostor syndrome for you).
The paper–which you can read here–is a short synopsis of human suffering during the war, especially among the poor, rural classes in Egypt, which are largely undocumented. It’s a works-in-progress presentation, very much based in preliminary findings, as one does at this stage in writing.
My dissertation focuses on breakdowns in public health during the war–the topic sentence could be summed up as “1918 was a deadly year for the Egyptian populace.” Even if one heeds Roger Cooter’s warning about reifying a positivist relationship between war and disease –and I’ve compiled statistics for nearly a decade before and after the war–the demographic anomalies in Egypt between 1914 and 1918 are unmistakable. Four times as many Egyptians died of disease during the war than from military actions.
1918 also saw the birth rate decline to its lowest rate in a quarter century.
I described a number of issues: food shortages that were documented as early as 1916. As residents complained about shortages of soap, eggs, cheese, and meat the Anglo-Egyptian administration, concerned with keeping the protectorate profitable, maintained a positive trade balance, exporting goods that were dearly needed at home. The cost of some basic household items rose over 200% between 1914 and 1918.
Likewise, relapsing fever and typhus cases increased substantially — both are louse-borne diseases, which can likely be tied to the increased movement of troops and support staff (including the men of the Egyptian Labour Corps). The war ended with the “Spanish flu” outbreak, which killed almost 140,000 Egyptians in just under three months.
There were also epizootics of both cattle plague (rinderpest) and foot-and-mouth disease that lasted over 18 months in large swaths of the country. Is there a relation between this and the soaring price of meat? It’s almost certainly the source of much of the protein that was sold on the black market in major cities.
As I said. Cheerful stuff.
During the break that followed my panel, a member of the audience approached me, identifying himself as a member of the landholding class from the Sharqiyya province in the Nile Delta (for the record, he is not an academic).
He insisted that I was completely wrong about nearly everything that I had said.
“We had hygiene!” he declared. “People didn’t die from these diseases in the 20th century!”
He suggested that I extend the dates of my study by decades in each direction; for example, he inquired if I had I looked at the number of deaths incurred through the construction work on the Suez Canal (1863-69), or knew how many more people died of disease in Egypt in the 18th century.
I won’t lie. This was my first outing with this material, and this was … not the sort of feedback I had hoped to get. The more I tried to explain the nuance of my argument, the more pushback I got. Having spent 3 months mapping the country from cataract to Delta, I tried to change the subject and ask where he was from–meaning where, specifically, in Sharqiyya. He looked at me as if I might just be the stupidest man on earth and responded, “Egypt?!”
As you can tell, I’ve let this episode roll right off my back.
However, I think there is something significant in the greater picture about his defensiveness, one that pushed me to think about the puzzling collective silence in nearly every history book about what I’m looking at. Even the Spanish flu is described in only two medical reports from the time; I’ve seen it mentioned nowhere else.
The notion of Egyptians dying in elevated numbers from disease was clearly distasteful to him–largely, I suspect, for the reason that it was undignified. People—at least not those of his class—did not die from disease in high numbers in the early 20th century.
In short, Egypt was modern. If it had not ascended, as the Khedive Ismāᶜīl had optimistically pronounced in 1869, to being among the ranks of countries which should be considered European, it had developed more rapidly than much of the Arab east, which languished in such a state that one scholar discussing the “Spanish flu” influenza pandemic in the Arabian peninsula (1919) could legitimately wonder whether medical officials in central Arabia were capable of distinguishing the influenza apart from other diseases with similar symptoms, such as typhoid.
Indeed, my interlocutor is correct about that hygiene and medical care had been introduced under Muhammad Ali Pasha in the mid-19th century as part of a national campaign to improve public health. This has been described by LaVerne Kuhnke and Hibba Abuguideri (although the project had peaked in the 1850s and all but vanished under British administration).
I struggled to explain in my response that afternoon that my interest was the significance of the war’s anomalous blip in the statistical record. The public health scheme in Egypt had, to a certain degree, brought epidemic disease under control, which is why the fact that infection and death rates soared during the war comprise a factor of interest. So, too, do the numbers of registered prostitutes in Egyptian cities, as well as the number of reported cases of venereal diseases, both of which increased substantially during the war and comprised their own crises in both medical and social health
During the first world war, Egypt was a nation at war. Its citizens were recruited into the war effort, and many of those citizens faced bodily harm and death fighting for the Union Jack in far-off lands. Those who remained at home suffered from shortages of basic supplies–although production rates decreased slightly, they dropped nowhere near as much as consumption rates. They were forced to eat tainted meat that they purchased at high prices. They died of disease whose effects were exacerbated by malnutrition. Some turned to prostitution or other illicit activity to make ends meet.
There is nothing heroic about the fight against a virus, perhaps. As the first World War and the 1919 uprising became enmeshed together in the national historiographic project celebrating the nationalist movement and Egypt’s strive for self-determination, there was no space for sympathetic portrayal of poor women desperate to feed starving children and elderly relatives, and those who, in sheer desperation, turned to extreme measures to support themselves.
The commemorations held in Egypt from 2013 onward to celebrate the nation’s contribution to the First World War recognize only one of these groups.
I’m hoping to recognize the second.
 Roger Cooter. “Of War and Epidemics: Unnatural Couplings, Problematic Conceptions.” The Journal of the Society for the Social History of Medicine 16, no. 2 (2003): 283–302
 LaVerne Kuhnke. Lives at Risk. Vol. no. 24. Comparative Studies of Health Systems and Medical Care. Berkeley and Los Angeles: University of California Press, 1990; Hibba Abugideiri. Gender and the Making of Modern Medicine in Colonial Egypt. Ashgate Publishing, Ltd., 2013.