Nursing historian Pamela Wood looks at the near-impossible task facing nurses at the height of the Spanish flu pandemic.

At the heart of nursing is the belief that all those who need medical care should have it, but in many overwhelmed health systems around the world it’s become necessary to triage patient care due to Covid-19. That will be devastating to the nurses who are battling the pandemic. Already exhausted nurses are struggling to keep going and in Britain at least 60 nursing staff have died. As a nursing historian, I wondered if it was any different in the 1918 Spanish flu pandemic. Did nursing collapse or cope?

New Zealand nurses did their utmost for their influenza patients but yes, they struggled in an overwhelmed health system. Their commitment meant that they, too, succumbed to the disease. At the height of the pandemic, three quarters of nurses throughout the country were ill and 41 died.

The pandemic hit New Zealand hard. It struck Auckland in late October, peaked throughout the country in mid-November and waned in early December. In less than eight weeks, the virus infected between a third and a half of New Zealand’s 1.2 million population and killed more than 8000 people. In its severest form, a person could be asymptomatic in the morning, develop virulent symptoms during the day and be dead by nightfall.

Unlike our experience with Covid-19, there was no preparation for the pandemic’s onslaught. Hospitals scrambled to clear wards for the rapid influx of seriously ill patients.

Historian Geoffrey Rice’s exemplary research for his book Black November: The 1918 Influenza Pandemic in New Zealand showed that three quarters of Auckland’s fatal cases had the pneumonic form of the disease. In normal times, a pneumonia patient’s fever peaked at the “crisis” on the seventh day. This was the point when they either died or the fever broke and they started a long recovery. In those days before antibiotics, intensive care units, ventilators and intravenous (IV) drips, the only thing that got patients through the “crisis” was intensive nursing at the bedside. It was the signature of an excellent nurse. But in the pandemic, the pneumonic phase raced through in just a few days. There was little time to address the fever and few nurses left to do it.

When the pandemic struck, nearly a quarter of the country’s 2195 qualified nurses were still overseas on wartime service. Three quarters of those left in New Zealand collapsed with influenza themselves. In any main hospital, 100 nurses could be off sick. The desperate authorities called for volunteers, and New Zealand citizens rapidly responded. Married nurses returned and women, men, girls and boys took on nursing tasks in the existing or new emergency hospitals. But overall there was only one trained nurse for every 70 or 80 patients, not enough to ensure one in every ward or emergency hospital.

Imagine you’re the nurse in a hospital ward. Most of the 12 patients down each side of the long, open ward are seriously ill with pneumonic influenza. The ward sister and two nurses who normally work with you have collapsed with the virus and been admitted to hospital themselves. Untrained volunteers take their place. You quickly teach them basic skills and organise their work. As the only nurse, you’re working 17 hours each day. There’s no let-up. Seven patients have temperatures spiking to 104 or 105 degrees Fahrenheit (around 40 degrees Celsius), making them delirious. Their skin is turning the characteristic purple-blue with cyanosis. You concentrate on patients nearing the “crisis” but you know that if they’re delirious and cyanosed, it’s unlikely your skills can pull them through. You can only ease their last hours. You’re devastated and exhausted. And five more patients have just been stretchered into the ward.

In the community, nurses and volunteers are frantically busy too. The virus can infect whole households at a time. Sometimes a child is the last person left who can attend to the family. Towns are divided into “blocks” and a nurse is assigned to manage its depot or bureau, take the phone calls clamouring for help and organise responses. Citizens who have learnt basic home nursing, untrained volunteers and religious sisters visit homes and provide what care they can or contact the block’s doctor. District nurses continue caring for their regular chronically ill patients and for as many influenza cases as possible – too many to record in their monthly reports. Plunket nurses set up homes for sick mothers’ babies and nurse in emergency hospitals in schools and halls. In rural areas, emergency hospitals are lucky if they have a trained nurse. The nurses working in the Maori health service keep doing the rounds of Maori settlements in their districts, providing or organising care for the sick. Every community does its best to manage the pandemic.

After the pandemic, Hester Maclean, New Zealand’s chief nurse, allocated nurses to different towns to teach home nursing courses, supplementing those run by the St John Ambulance Association and Red Cross. Citizens eagerly attended these but, after just two years, interest and attendance waned and the extra courses ended.

In the current Covid-19 context, personal protective equipment (PPE) has been an issue. In the early 1900s, a nurse caring for a patient with a highly infectious disease such as diphtheria wore a special cap covering all her hair and a gown over her uniform. She wore a face mask only when giving them close personal care. Gloves weren’t worn – the nurse washed her hands and soaked them in a bowl of disinfectant solution. Did hospital volunteers and nurses wear extra protective gear during the pandemic? Community volunteers and some citizens wore home-made masks (sewn from instructions published in local newspapers) but I haven’t yet found evidence of their widespread use in hospitals.

So, did New Zealand nursing cope or collapse in the 1918 pandemic? With stress and exhaustion from unrelenting work with seriously ill patients, it’s no surprise that so many nurses fell sick or that 41 died. Nursing collapsed to the extent that only a quarter of the workforce in New Zealand hospitals was functioning, but the effective alliance between nurses and volunteers ensured that the remnants of the nursing workforce were able to cope.