Introduction
The influenza pandemic of 1918–19, popularly known as the ‘Spanish Flu’ or the ‘Spanish Lady’, is considered the most significant global pandemic crisis of the twentieth century, comparable only to the AIDS crisis at the end of the century. The most recent mortality studies estimate that it killed between 50 and 100 million people worldwide in only two years. According to the same studies, at least a third of the world's population became infected with the virus.Footnote 1 In the United States, it is estimated that some 668,000 people died in two years, significantly more than the 423,000 who lost their lives in the two world wars, Vietnam and Korea combined.Footnote 2
The pandemic unfolded in three waves which, generally speaking – with variation in different countries and on different continents – occurred in the spring and autumn of 1918 and the first months of 1919. Recent studies have suggested that a brief fourth wave took place in early 1920.Footnote 3 The first wave was remarkably benign. Those infected generally experienced common flu symptoms and few complications. Conversely, the second wave of the pandemic occurred on a global scale and mortality was extremely high. During this wave, influenza frequently caused pulmonary complications leading to death. The third wave in the first three months of 1919 was the least severe of all. The pandemic of 1918–19 differed from other flu epidemics in that the worst outcomes were generally seen in seemingly healthy young adults aged twenty to forty.Footnote 4 The regions which experienced the highest mortality rates worldwide were Africa and part of Asia, whereas the pandemic had a far lesser impact in Europe and North America. It is estimated that the worldwide mortality rate was at least 2.5 per cent, albeit with significant regional differences, ranging from 1 per cent in China to 6 per cent in India and 9 per cent in South Africa. The pandemic likewise had an unequal impact in different European countries. Denmark's mortality rate of 0.4 per cent was far lower than the average of 1.2 per cent in Spain.Footnote 5
The intense debate on the origin of the virus began at the start of the pandemic and has continued up until the present day. The most noteworthy studies have concluded that it may plausibly be traced to either China or the United States, though there are also hypotheses which point to France.Footnote 6 Regardless of where exactly the virus originated, it is crucial to keep in mind that the emergence and spread of the pandemic were directly tied to the course and end of the Great War. Among other factors, ‘total war’ entailed the widespread movement of travellers, workers and soldiers around the globe. Travel in overcrowded and unhygienic conditions favoured the spread of the virus.Footnote 7
A large number of studies on the flu of 1918 have been published in the last few decades. Researchers have examined the medical, epidemiological and demographic aspects of the pandemic.Footnote 8 The proliferation of studies focused on the impact of the pandemic at the local level, drawing on testimonies and experiences, has helped to provide a more complete picture of this global phenomenon.Footnote 9 However, in the existing literature, only a small number of collective volumes have considered the importance of analysing the relationship between the pandemic, politics and culture.Footnote 10
The short duration of the pandemic has been an obstacle for historians, as it was for doctors at the timeFootnote 11 Despite the global significance of the pandemic and considerable research on its public health, medical and epidemiological aspects, its political and cultural impact has hardly been studied. Most studies on the global impact of the First World War and its aftermath accord little importance to the flu of 1918–19.Footnote 12 Historians have disregarded the possible relationship between the pandemic and the crisis of European liberalism. There are a number of reasons for this historiographical omission. Firstly, it should be mentioned that no process of constructing an official memory from the state of the pandemic occurred after 1919, meaning few references were made to its impact during the 1920s and 1930s.Footnote 13 Secondly, only recently have researchers revised the estimated death toll of the 1918–19 period. In the years immediately following the pandemic, it was estimated that it had killed nearly 21.5 million people. In the 1990s, researchers suggested the higher figure of 30 million, still far lower than current estimates of at least 50 million.Footnote 14 This lack of knowledge of the actual demographic impact of influenza may had lessened its consequences during the following years. Lastly, and most importantly, there has been little research on the flu pandemic because the First World War was such a crucial historical event. The consequences and convulsive aftermath of the war have done much to obscure the political, social and cultural impact of influenza.Footnote 15 A conclusive comparison of interest in these two historical events can be found in the results of a 2017 WorldCat search, which returned some 80,000 books about the Great War and only around 500 with the Spanish flu as the main subject.Footnote 16
The state of the literature on the impact of the flu of 1918–19 in Spain differs little from that in Europe as a whole and worldwide. Excellent overviews of the topic have been published that discuss local political and social dynamics as well as public health, medicine and demography.Footnote 17 From a cultural studies perspective, Ryan A. Davis has examined ‘flu discourse’ in Spain, underscoring the relationship between narratives of the epidemic and the articulation of discourses of Spanish national identity.Footnote 18 In addition, there are noteworthy studies on the impact of influenza at the local and regional level.Footnote 19 Nevertheless, in Spain and in Europe as a whole, existing studies fail to provide a detailed analysis of the impact of flu in the context of the historical period of 1917–23.Footnote 20 This period, that of the crisis of liberalism in Spain – and in Europe – is essential to understanding the calls for authoritarian solutions that led to the establishment of the dictatorship of Miguel de Primo de Rivera.Footnote 21 This article aims to analyse the impact of the epidemic in Spain in this broader historical context, which stretches from the end of the Great War to the establishment of the dictatorship in 1923.
From the First Outbreaks to the Eruption of the Epidemic
Although Spain did not participate in the First World War, the social, economic and political consequences of the war had been felt intensely since August 1914.Footnote 22 As such, the domestic situation was already considerably complex when influenza reached the country. The months before the arrival of the epidemic were marked by the crisis of 1917,Footnote 23 the impact of the Russian Revolution, social unrest, conflict between the state and peripheral nationalisms – particularly Catalan nationalism – and the conflictive situation in Morocco. Hunger and unemployment contributed to radicalising the population, and 1918 was the year that saw the largest number of workers’ mobilisations during the period of 1914–18.Footnote 24 Violence began to spread to all of Spain. While unrest took a variety of forms, there were shared elements such as food riots and objections to high prices. Assaults on small shops and bakeries, often by women and children, became commonplace. Particularly intense was the series of strikes in rural Andalusia, where revolutionary ideas held considerable sway and the CNT's (National Confederation of Labour; Confederación Nacional del Trabajo)Footnote 25 influence and membership increased.Footnote 26 As a Catalan industrialist was to recall, in 1918, ‘strikes had already increased one hundred per cent in comparison to the previous year and in Catalonia alone there were as many as 331’.Footnote 27 All these factors meant that the majority of Spain's population were severely weakened and living in conditions of poor hygiene and sanitation, particularly in urban working-class neighbourhoods. In Madrid, for instance, public spending had remained unchanged for two decades, despite a significant population increase. Influenza, as well as other diseases like cholera, smallpox and tuberculosis, exposed the lack of hygiene and public health measures and serious nutritional deficiencies among the population.Footnote 28
In 1918, the Spanish government and regional and local administrations had few tools for managing an epidemic. Spain had no Ministry of Health. Rather, the health system was part of the Interior Ministry (Ministerio de la Gobernación), which allocated only a very limited budget to this area. The country's precarious public health system operated under the General Health Law of 1855, which had last been amended in 1904 to lay out regulations governing the Royal Health Council (Real Consejo de Sanidad). In addition to this advisory body to the Spanish government, there were provincial and local boards (juntas). Doctors were precariously employed, as they were paid by municipal governments and had little authority and independence from mayors, who dominated local politics by means of corruption and caciquismo, a form of political bossism. There were scarcely any hospitals, and charitable religious organisations played a key role in caring for the sick. This resulted in a perilous and delicate situation, as the Inspector-General of Health, Dr. Martín Salazar, had denounced in 1913 in the speech he gave on the occasion of his induction into the Royal Academy of Medicine of Madrid.Footnote 29
As Charles E. Rosenberg has written, epidemics ‘constitute a transverse section through society, reflecting in that cross-sectional perspective a particular configuration of institutional forms and cultural assumptions’.Footnote 30 Epidemics therefore serve to expose dysfunction and other problems in society, politics and culture. Spain in 1918–19 was no exception. Restoration Spain's political system, designed by Cánovas de Castillo following the collapse of the First Republic (1873–4), had reached a critical phase by 1918.Footnote 31 Criticism of parliamentary and governmental incompetence from both the right and the left had intensified following the crisis of 1917 and became more pronounced during the epidemic. Criticism was directed at all levels of government: the central Spanish government, provincial authorities (gobiernos civiles), provincial councils (diputaciones) and municipal governments in large cities.
As the crisis of the Restoration system worsened, Spain's first influenza cases occurred in May 1918. This first wave caused relatively few deaths and did not have a particularly significant impact on society, despite the fact that the virus had reached nearly all of Spain by the end of June. The exceptions where the epidemic didn't break out were Galicia, Catalonia and the Balearic Islands. According to official figures, on 1 June approximately 250,000 people were infected in Spain. The flu was popularly dubbed ‘The Soldier from Naples’ (‘El Soldado de Nápoles’) after a song from La canción del olvido, a zarzuela that premiered in Madrid around the same time, ironically suggesting that the catchy tune was as ‘infectious’ as the virus. Other popular names included ‘the three-day fever’, ‘la passa’ – a popular Catalan term referring to stomach problems – and ‘the cockroach’ (‘la cucaracha’).Footnote 32 Nonetheless, outside Spain, the flu was called the ‘Spanish Flu’, the ‘Spanish Lady’ or, in Italy, simply ‘la Spagnola’, for one simple reason: Spain was the first country to officially report the epidemic because military censorship in the belligerent countries of the First World War covered up the presence of influenza. The popularisation of the idea of ‘Spanish flu’ was perceived as detrimental to the nation, and reaction in Spain was quick and vehement.Footnote 33
It was during the second wave that the epidemic in Spain began to have catastrophic consequences throughout the country. This wave was brought to Spain by travellers coming from France and travelled south along two principal routes, from Irun to Medina del Campo and from Portbou to Almería. Spanish workers, summer holidaymakers and Portuguese soldiers returning from the Western Front likely acted as involuntary spreaders.Footnote 34 During the second wave, the virus caused more severe symptoms and killed many more people. It spread throughout Spain, in part because soldiers were sent home when flu ravaged their barracks. The first cases were detected in mid-August 1918, and the wave lasted until late November. The number of cases and deaths peaked in mid-October, coinciding with the final weeks of the war. In most of the country, the second and third waves overlapped in late autumn and early 1919. Morbidity was high, though the exact figures are hard to calculate, and the mortality rate in 1918 increased 50 per cent compared to the previous year. A total of about 270,000 people died in Spain in 1918, which amounted to the largest negative annual natural population growth rate since 1800, twice that which would be seen in the worst years of the Civil War (1936–9).Footnote 35
In mid-September, the Spanish press, government and political parties began to take greater interest in the epidemic. Authorities at both the central and provincial levels urged people to remain calm, as they could trust in ‘well organised’ (‘bien montados’) health services and modern science.Footnote 36 The interior minister wrote to the governors of Spain's border provinces to set up health stations to increase controls at the border, disinfect passengers, perform medical exams and isolate the sick.Footnote 37 In Catalonia, theatres were ordered closed in cities close to the French border, such as Figueres and Girona, though some were of the opinion that there was ‘no reason for such alarming measures’.Footnote 38 In the city of Barcelona, the provincial governor stated that precautions were being taken even though the health situation was ‘satisfactory, for now’.Footnote 39 Nevertheless, as the epidemic progressed, some newspapers began to sound the alarm, accusing authorities of lying about the situation. El Diluvio, a republican newspaper from Barcelona, demanded to know ‘the truth’ and claimed that authorities – and doctors – thought it ‘more patriotic’ to hide what was in fact a truly ‘criminal’ situation.Footnote 40
In October, measures to stop the spread of influenza were extended to all of Spain. Crowding in enclosed spaces was prohibited and universities and schools were closed, as were bars and other leisure establishments. It was recommended that the sick be isolated from others and that homes be well cleaned. The most common measure was spraying streets, public transport and passengers with disinfectant. Although many scientists advised that such disinfection was useless – because flu was spread from person to person through the air – these practices continued throughout the epidemic, in large part in response to criticism in the press that not enough was being done.Footnote 41
Compliance with these measures was limited and far from uniform. As the press complained, the general public had little awareness and education about hygiene and health issues. While establishments had been closed, parties and religious events continued to be held throughout the country. Persistent attempts at educating the public were unsuccessful. The newspaper El Socialista complained that ‘regional Virgins [Marian apparitions] and saints’ were often invoked to ‘fend off the plague that hygiene ought to prevent’.Footnote 42 The bishop of Zamora, a town with one of the highest mortality rates in Spain by the end of the epidemic, organised a novena – nine days of prayer – starting on 30 September in honour of Saint Roch, patron against plagues, to protect the population from evil. At the height of the epidemic, in mid-October, a crowded procession was held in honour of the local Marian apparition, Our Lady of the Dormition (La Virgen del Tránsito). The procession resulted in a high number of infections, but the bishop, far from being blamed, was awarded the Cross for Charitable Works (Cruz de la Beneficiencia) for his actions during the epidemic in late 1919.Footnote 43 Similar events occurred in other cities, including Igualada in Catalonia and Yecla in Murcia.Footnote 44
From the beginning of the epidemic, the spread of influenza was closely tied to the celebration of religious festivities. Madrid's Saint Isidore festivities had helped to spread the virus during the first wave. At the beginning of the second wave, Valladolid went ahead with the annual city festivities, held from 17 to 27 September, despite advice to the contrary from the provincial health inspector, Dr. Román García Durán. He later recalled how, weeks later, a small village in the Tierra de Pinares area experienced a severe outbreak: ‘Our impression upon arriving in the village could not have been bleaker: the church bells were sounding death knells, and the streets were deserted.’ The doctor ended his report with a hard-hitting rhetorical question: ‘Can there be any greater proof of the extent of a people's ignorance about health?’Footnote 45 As Luis Calandre – a renowned cardiologist affiliated with the Free Institution of Education (Institución Libre de Enseñanza) – demonstrated, culturally speaking, the epidemic brought traditional religious values face to face with scientific and liberal values. This confrontation can be seen in the postcards distributed by the Royal Tourism Commission (Comisaría Regia del Turismo), which sought to associate the grandeur of the nation with hygiene. One side depicted Spanish monuments, while the other gave advice on good hygiene according to the recommendation of the doctors. In this way, the idea of the ‘healthy nation’ aimed to challenge the dominance of traditional religious and ‘anti-liberal’ and ‘non-scientific’ values omnipresence in Spanish society.
Foreign Danger and Domestic Danger
The varied and contradictory responses seen within Spain contrasted with the zeal for preventing ‘evil’ from entering from abroad. The press took a particular interest in the situation at Spain's borders and the control and disinfection of travellers entering the country. As occurred in other countries, the ‘other’, the ‘foreign enemy’, began to be blamed for bringing the virus to Spain. Foreigners were stigmatised and there were constant claims that this ‘other’ carried the virus, which was in fact already widespread throughout Spain. Particular blame was directed at Portuguese soldiers who had to cross Spain to return home after fighting on the Western Front. There were constant calls to close borders to prevent influenza from entering Spain. The MauristFootnote 46 newspaper La Acción demanded ‘radical and very strict’ measures to prevent the entry of foreigners in order to ‘free Spain from the horrors of an epidemic . . . imported from France by Portuguese soldiers’.Footnote 47 La Nación, another conservative newspaper, warned in mid-September that French authorities planned to send a train full of soldiers ill with flu across the border.Footnote 48 In Palencia, the local press reacted with harsh criticism when it became known that a Portuguese convoy had been allowed to travel through town. Critics demanded that trains be prohibited from stopping at stations along the way and that measures be taken to prevent ‘ill soldiers’ from travelling through Palencia.Footnote 49 Medical professionals were among the many who expressed alarm about the dangers posed by Portuguese soldiers in transit throughout the epidemic. The health inspector in Valladolid proposed that trains carrying Portuguese soldiers ‘carry special deposits’ in which their ‘defecations and urine can be sterilised’. He believed it was ‘dangerous for these products to be spilt along the entire route’.Footnote 50 It led the Spanish government to send a telegram ‘categorically’ prohibiting ‘the entry of Portuguese [nationals] and foreigners’. Entry was limited to Spaniards, who were required to undergo a medical examination.Footnote 51
The health stations located at Irun and Portbou – the principal crossing points on the border with France – and at Medina del Campo – one of the principal railway nodes in Spain – were put to the test. Health stations were also built at the other crossing points along the border with France: La Jonquera and Puigcerdà, in the province of Girona; Canfranc and Sallent, in Huesca; Dantxarinea, Bera and Luzaide/Valcarlos in Navarre; and Behobia in Gipuzkoa. Setting up beds for the sick, steam disinfectors and medical examinations was thought to be fundamental to preventing influenza from entering Spain.Footnote 52 Despite such strict measures, tension abounded among the population, ‘alarmed’ by the lack of control of the epidemic. In October 1918, the situation at the French border in Catalonia had worsened: ‘rumours are circulating, not yet confirmed, but very widespread, that the Guardia Civil and the carabineros Footnote 53 have had to use weapons against a large number of immigrants attempting to enter Spanish territory’ outside the authorised crossing points.Footnote 54 In Figueres, the last major city before the French border, the railway station was ‘packed with immigrants’, who were mostly Spanish workers returning from France.Footnote 55 In Barcelona, too, there were growing concerns about the state of the health stations at the border, in addition to the health stations at the Estación de Francia, one of the most important stations in Spain's railway network. In May 1919, the situation was still tense. Residents of Sanlúcar de Barrameda – a city located on the Atlantic coast of Andalusia, not far from the Portuguese border – expressed concern ‘about the arrival of Portuguese workers who might be carriers of the flu bacillus’.Footnote 56
Tensions were also high in port cities. In Torrevieja, in the province of Alicante, in October 1918, ‘residents rose up to prevent the disembarkation’ of a Norwegian vessel with twelve sick sailors on board. A similar situation occurred in July 1919 when the passengers of the steam ship Valbanera, including some infected with flu, disembarked in Barcelona.Footnote 57 Fear of contagion and memory of the severe outbreak of autumn 1918 kept people on the alert, which sometimes led to violent situations. In Santa Cruz de Tenerife in February 1920, ‘a large number of local residents, led by the parish priest, brandishing a revolver, objected to the disembarkation’ of a vessel with sick people on board. Following mediation with local residents, the passengers were disembarked and isolated, but the ship was ‘fired on from the coast’ as it set sail again.Footnote 58
The social and economic consequences of the second wave were particularly harsh and remained fresh in people's memory through the early 1920s. From September to November 1918, the shortage of doctors and medicine and the limited availability of health care made death a part of everyday life in villages and cities. Productivity fell significantly because workers were off sick or had died.Footnote 59 Many children were orphaned and charitable institutions were overwhelmed. In Barcelona, the Barcelona Economic Society of Friends of the Country (Sociedad Económica Barcelonesa de Amigos del País; SEBAP) organised a major charitable drive to raise funds for the most disadvantaged families. The SEBAP's president, Albert Rusiñol, a businessman and a politician who belonged to the Regionalist League (Lliga Regionalista), a conservative Catalan nationalist party, declared that the reason for the drive was that, in the poorest homes, ‘not only has grief entered, but also the most frightful misery’.Footnote 60 The harsh effects of influenza can be seen in hundreds of letters received by the SEBAP, such as one requesting help for María, Pedro and Juan, three children aged eleven, nine and four, who had been orphaned by the epidemic and were being cared for by neighbours. In another letter, a widow called María Figueres requested that her children, Engracia and Juan, aged six and three, be taken in because her husband had died of flu in October 1918 at the age of thirty-two, and she could not support them.Footnote 61 Among the poorest segments of society, three or four families lived under one roof. Children and adults were living with ‘cadavers alongside dying sick people’.Footnote 62 Burial services were overwhelmed. In Barcelona, during the worst days of October, there were not enough coffins and carts to take away the dead, and bodies amassed in cemeteries.Footnote 63 According to Manuel Ribé, a functionary in the Catalan capital, ‘everything was gloomy, everything reeked’.Footnote 64
Not only did the poorest members of society suffer the worst consequences of the epidemic, but they were blamed for the emergence and propagation of the disease, stigmatised as a ‘domestic danger’. During the first wave, there were calls in the Congress of Deputies for the inspection of some ‘shacks underserving of that name’ on the outskirts of Madrid. These precarious dwellings were called ‘real focal points of infection . . . to go spreading the germs of the disease all over the place’.Footnote 65 The most extreme example of this tendency to blame the poor occurred in Alicante. Las Provincias, one of the poorest neighbourhoods in the city centre, was accused of being the focal point for the spread of the disease. In October 1918, nearly eighty homes were demolished, and the families who lived there were forced to leave. The city council and all political parties, with the exception of the Alliance of the Left (Alianza de Izquierdas), supported this measure. El Correo, the local conservative Maurist newspaper, justified the measure in the name of a ‘battle for health’. While what happened in Alicante was particularly extreme, it was not the only such case in Spain.Footnote 66
That growing social unrest was tied to the influenza epidemic's worsening consequences was evident throughout 1919 and 1920. The end of the war combined with pressing social conflicts, which were exacerbated by the effects of the Allied victory, the Bolshevik Revolution and the economic recession. The number of strikes increased significantly. Beginning in early 1919, the anarcho-syndicalist CNT became a central player in Spanish politics. Unrest occurred principally in Catalonia and in southern Spain, where the so-called ‘Bolshevik Triennium’ took place. In Catalonia, the labour movement's first show of strength was victory in the La Canadiense strike in February 1919, which led to the introduction of the eight-hour work day. In Aragon, a series of mobilisations culminated in the general strike of 29 November to 11 December 1918, in which the principal demands were the eight-hour work day and increased wages. In 1919, 326,000 working hours were lost.Footnote 67 The influenza epidemic occurred at a time of enormous social upheaval, and events in Spain were part of a broader process taking place throughout Europe. The Maurist newspaper La Acción expressed this idea using a metaphor that linked the concepts of ‘virus’ and ‘moral epidemic’ to the decline (decadencia) represented by trade unionism and Bolshevism.Footnote 68
From Criticism of the Epidemic to Criticism of the Regime: Towards a ‘Health Dictatorship’
Generally speaking, the entire Spanish political spectrum saw the inefficiency of the state and regional and local administrations as the cause of the epidemic disaster. Such criticism, which became more frequent starting in late September 1918, was initially aimed at the ineffectiveness of the measures adopted to control the spread of influenza but subsequently evolved into harsh criticism of the poor functioning of the state. The lack of response dissipated the enthusiasm for the government led by the conservative Antonio Maura from March to November 1918.Footnote 69 From November 1918 to May 1920, the Spanish government was led successively by Manuel García Prieto, Álvaro de Figueroa (Count of Romanones), Antonio Maura (again), Joaquín Sánchez de Toca, Manuel Allendesalazar and Eduardo Dato. In this context of political instability, antiliberal ideas gained sway. On the left, antiliberal tendencies included communism, a form of socialism strongly influenced by the war – for which liberal governments in Europe were blamed – and a form of republicanism with a strongly anti-parliamentarian bent. On the other extreme of the political spectrum, the reactionary right was incessantly critical of what it considered excessive liberalism and democracy.Footnote 70 During this period of increasing antiliberalism and political instability, Catalan nationalist demands for regional autonomy played a key role in shaking the foundations of the regime. The project to grant Catalonia a Statute of Autonomy generated heated debate in Parliament and in the press and put the monarchy, the military and Spanish nationalists in Catalonia on edge because they believed the unity of the Spanish nation was in peril.Footnote 71
Criticism was aimed at the government, which was accused of acting too late and making the wrong decisions to avoid the spread of the epidemic. El Globo wrote that ‘with this system and these authorities it is no wonder that epidemics spread; what is surprising is that anyone is left to talk about it’.Footnote 72 Despite the extreme severity of the second wave, the sanitary situation was not discussed in the Congress of Deputies, which was closed until October 1918 because the government wanted to avoid debate. Even after it was reopened, no special session on the epidemic was held, despite the need for reforms.Footnote 73 Nevertheless, members of the Congress and the Senate harshly criticised the lack of modernisation in Spain's health services, as did newspapers and magazines. The lack of medical personnel, medicines, disinfection products and foresight became grounds for decrying the state's lack of modernisation: ‘everything remains to be foreseen and to be done’, stated an article in the magazine Nuevo Mundo.Footnote 74 In this same vein, August Pi i Suñer, a republican member of the Congress of Deputies and a doctor, referred to the ‘embarrassing Spanish health situation’ resulting from the country's ‘odious public administration’.Footnote 75 People were dying ‘due to apathy, due to negligence, due to the neglect of the Government, aided by irresponsible members of parliament’.Footnote 76
Doctors, who had been somewhat discredited as a profession at the beginning of the second wave of the epidemic due to difficulties in identifying the pathogen that caused the disease, played a prominent role afterwards. Adopting a hygienist discourse that had been predominant in Spain since the end of the nineteenth century, they indicated that a lack of education and hygiene, insalubrity and – most importantly – the state's neglect of medical and health services were to blame for the spread of influenza. These demands from the medical profession were also a way to secure the medical ‘class’ standing and expertise.Footnote 77 They had been calling insistently for the creation of a Ministry of Health and a better organised health system for years. Doctors were paid by municipal governments, rather than by the state, meaning their professional independence and authority were entirely dependent on the will of local caciques.Footnote 78 An example of this lack of professional independence had been seen in Pamplona, where local authorities ignored recommendations to cancel the San Fermín festival in summer 1918.Footnote 79
The press largely ceased to question the trustworthiness of doctors and instead turned its attention to the failure of governmental policies, a widespread phenomenon seen in both conservative and left-wing publications. El Socialista, which had pointed to the omnipresence of religious practices as contrary to modernising the health system, did not hesitate to link corruption and caciquismo to the insufficient response to influenza.Footnote 80 A news story from July 1915, the murder of the local cacique in El Pobo, in the province of Teruel, at the hands of the local doctor, Alfredo Alegre, was again discussed in the press.Footnote 81 This murder case was used to argue that violence appeared to be the only means to do away with political obstacles to taking action against influenza. Corrupt local politics was incompatible with the adoption of policies based on scientific knowledge. The Restoration system in Spain appeared to be irreconcilable with the democracy and modernity that were emerging from Europe's battlefields. As Victoria Blacik has pointed out, like the ‘iron surgeon’ theorised by Joaquín Costa in 1902, the El Pobo doctor was portrayed in the press as Spain's civic saviour.Footnote 82 Doctors were at the forefront of the fight between civilisation and barbarism, which had re-emerged in Spain.Footnote 83 As the doctor and liberal politician José Francos Rodríguez contended, modernising Spain meant professionalising its health system.Footnote 84 Intellectuals and medical professionals – doctors, but also pharmacists and veterinarians – thought that the epidemic had only brought to the forefront a national problem dating back to the loss of Spain's last colonies in 1898. This national problem took the form of a fight between the ‘two Spains’ defined by José Ortega y Gasset in March 1914.Footnote 85 It was a conflict between the old and corrupt Restoration regime and the new nation, full of life, which was to be reborn at the hands of intellectuals and professionals untainted by old politics.Footnote 86 As noted by Ryan A. Davis, the tale of the ‘two Spains’ is closely related to the flu discourse distinction between the ‘epidemic Spain’ and the ‘sanitary Spain’.Footnote 87
Influenza made the profound crisis of the Restoration state readily apparent. Neither clientelist networks nor the bureaucracy were working. Spain's ‘national disease’ – a term that clearly came from the Regenerationist tradition – had again become evident in the inefficiency in both politics and health policy of the governments that followed the concentration government led by Maura. National decline went hand in hand with physical and psychological decline. The journalist José Ortega y Munilla, father of José Ortega y Gasset, wrote that influenza was the ‘fatal ailment’ from which Spain was suffering.Footnote 88 The government's lack of action at Spain's borders and inability to deal with the growing strength of Catalan nationalism further emphasised the ‘national apathy’ that had been reflected in neutrality during the war: ‘Despair – a microbe that destroys the soul – has taken over Hispanic psychology’. Ortega y Munilla's ideas were not far from those of Miguel de Unamuno, who referred to the Catalan question as ‘the real national flu’.Footnote 89
The question was, once again, how to regenerate the nation. Some proposed technocratic solutions: given the political incompetence laid bare by the poor management of the epidemic, continual government crises, Catalan demands for autonomy and growing social unrest on the streets, decision-making ought to be left to experts. In this regard, José Ortega y Gasset suggested during the second wave that ‘cultured Spaniards’ ought to take charge of the situation: ‘doctors, engineers, lawyers, artists, industrialists, et cetera’.Footnote 90 In a similar vein, the socialist Luis Araquistáin – editor of the magazine España, which Ortega y Gasset had founded in 1915 – asserted that the Restoration regime was not working due to ‘intellectual inferiority’ and ‘technical incapacity’. The crisis of the regime meant Spain had to choose between ‘revolution’ and ‘an antidemocratic and antiliberal dictatorship’.Footnote 91
The fight against national decline was directly tied to the need to develop a modern health system, which could only be achieved once the corrupt and ineffective Restoration system had been profoundly reformed. The journalist Julio Camba said as much in January 1920: ‘Medicine does not yet exist in Spain, where it is still mixed up with politics . . . Do you want to fight the disease that afflicts you? Then start a violent opposition campaign against it.’Footnote 92
There began to be calls for a ‘health dictatorship’ (‘dictadura sanitaria’). Much of the press and most political parties and intellectuals shared the belief that the government ought to act with a firm hand in matters of health. The idea was to establish a programme imposed from above to contain the epidemic. The second wave had made such a move necessary. The interior minister (ministro de la Gobernación) referred to the policies adopted by the government since the beginning of the epidemic using this concept.Footnote 93 So, too, did the newspaper El Liberal, in an editorial that supported controlling and censuring the dissemination of information and strictly enforcing the measures put in place.Footnote 94 Calls for imposing such measures were a reaction to the Spanish government's failure to do so due to the local caciques’ control over doctors.Footnote 95
These ideas, which tied criticism of parliamentary and governmental inaction to national decline, continued to develop after the epidemic. Continued references to a ‘health dictatorship’ underscored how authoritarianism could be suggested as the most effective form of government for Spain. In July 1921, Dr. Martín Salazar, head of the General Inspectorate of Health (Inspección General de Sanidad del Reino) – which remained under the Interior Ministry – was still remarking on the public's lack of awareness about hygiene and the underdeveloped state of health legislation in Spain. Given that infectious disease might again strike the country at any moment, the solution was to ‘strengthen health authority’ by means of a ‘health dictatorship’.Footnote 96 A few days later, there were calls for a ‘health dictatorship’ at an assembly held at the Radical Republican Party's People's House (Casa del Pueblo) in Madrid.Footnote 97 In this same vein, Antonio Maura declared that ‘the health dictatorship can be found in current legislation; what is not present is the will to exercise it’. This ‘blessed dictatorship’ needed to be ‘exercised’ because ‘nowhere has this been remedied but by dictatorship’.Footnote 98 Most parties represented in Parliament came to see this ‘health dictatorship’ as the best possible option.
The medical profession continued to suggest the need for profound political change. Many liberal doctors appealed to ‘health dictatorship’. Gustavo Pittaluga,Footnote 99 a doctor specialising in endemic diseases, denounced that his profession had not been taken into account during the influenza epidemic and that the situation had not changed despite this recent experience. The fight against the corrupt Restoration system seen months earlier, in which a ‘new race of politicians’ faced off against corrupt caciques, re-emerged. The goal was not to ‘free the rural doctor for the cacique's claws’ but to ‘exterminate the cacique’.Footnote 100 Politicians and experts were shown to be on opposite sides. This was precisely the idea that a manifesto published in January 1922 sought to advance. The manifesto, which resulted from First National Health System Reorganisation Conference (Primer Congreso Nacional de Reorganización Sanitaria), declared that Spain was a ‘country without a pulse’ because it was ‘a country of weakened and sick people’. The solution was to give the country ‘health’ so that Spain could provide ‘universal civilisation the strength of its arms, the courage of its will and the shine of its intelligence’. José Verdes Montenegro, who signed the manifesto as president of the commission that had written it, would go on to serve as General Director of Health under the Second Republic in 1933.Footnote 101
On 1 September 1923, twelve days before the coup d’état that would bring Miguel Primo de Rivera to power, an article published in the newspaper El Imparcial again called for the establishment of a ‘health dictatorship’ in response to a public health crisis stemming from a problem with the supply of basic foodstuffs in Madrid. This was yet another example of demands to replace ineffective municipal management with effective centralised policies, as seen in ‘all nations that care about the health [sanidad] of their people and the vigour of their race’.Footnote 102
Calls for a ‘health dictatorship’ appeared across the Spanish political spectrum following the influenza epidemic. The idea of a dichotomy between doctors and politicians was likewise widespread. Nevertheless, only the right came to call for the combination of political authoritarianism and technocracy, with increasingly insistent claims that the crisis of the regime was directly related to ‘the excess of politics’. In this context, they developed approaches which often confounded health policy with a particular type of political regime. Calls for a ‘health dictatorship’ were thus closely linked to the calls for a stricto sensu dictatorship which emerged in 1919, at a time of acute political crisis and uncontrolled violence on the streets, particularly in Barcelona.Footnote 103 Many of the principal demands that had been made during the epidemic of 1918 were met during the dictatorship. During the epidemic, Primo de Rivera himself wrote that he was fighting ‘between flus and exams’ in the face of a ‘national body ill with laxity and weakness’.Footnote 104 Five years later, he stated that the goal of the coup d’état was to heal ‘the sick body of the nation’ and eliminate the ‘cancer’ of oligarchic power.Footnote 105 The Provincial Health Regulations, enacted in 1925, created Provincial Institutes of Hygiene led by provincial health inspectors. The following year, the Municipal Health Regulations created the Corps of Municipal Health Inspectors, who were to work independently of local authorities. Charles A. Bayle's 1926 report, which resulted from an agreement between Spain and the Rockefeller Foundation, showed that some significant improvements had been made in the country's health system.Footnote 106
Official propaganda insistently underscored the work done in the area of health policy, particularly during the Civil Directory period, which began in December 1925. This can be seen in the regime's principal publications. For instance, in November 1927, Unión Patriótica, the official organ of the single state party, contrasted the work of the current director general of health, Dr. Francisco Murillo, with poor management of the health system in the past: ‘Our leaders realised that the only effective policy is that which is based on defending health, saving the race and preparing strong and vigorous generations’. The dictatorship was portrayed as the only solution able to put an end to the dysfunction and ineptitude of liberal parliamentarianism: ‘The form of Government we have has also prevented the excesses of parliamentarianism, political diatribes and delaying corruption to which the Cortes were party’, which had always created ‘difficulties and obstacles’ in dealing with matters of health. Dr. Murillo's work had been successful because responsibility for the health system had fallen ‘not to a conniver, a politician, [someone] improvised or a shyster, but simply to a man of science’.Footnote 107 The healing of the nation, Regenerationism and the end of caciquismo justified the proclamation of the dictatorship, and these elements continued to be central to the regime's rhetoric in its final days. Regime propaganda likewise aimed to put an end to the debate about ‘politicians’ versus ‘technicians’. The dictatorship, led by ‘technicians’, had brought about the advancement and regeneration of the patria (Fatherland). One of the regime's key propagandists, Emilio Rodríguez Tarduchy, asserted that the dictatorship had always requested ‘the advice of technicians [hombres técnicos] of competence and prestige’. This was its guiding principle in managing the construction of ‘the new Spain’.Footnote 108
Conclusion
The influenza pandemic of 1918–19 had a major impact worldwide, including in Spain. The lack of a properly organised health system and a population weakened by the food crisis and rising prices significantly reduced the Spanish governements’ capacity to respond to the epidemic. At the same time, the consequences of the Great War, the impact of the Russian Revolution, social unrest and the crisis of the Restoration political regime intersected with the eruption of the influenza epidemic, particularly during the most difficult months in autumn 1918. Influenza became politically relevant, as the association between ‘epidemic’ and ‘evil’ permeated all areas of political life.Footnote 109
The measures adopted proved far from satisfactory in reducing the spread of influenza. Implementation and compliance were uneven, limited and sometimes contradictory. In this regard, as was also expressed in Portugal,Footnote 110 there was an evident disparity between state policy and the understanding of the epidemic from a religious perspective, as demonstrated by the case of the bishop of Zamora. These measures also show that concerns about ‘foreign danger’ were widespread in Spain, in the context of a continent marked by war, as can be seen in the constant claims that Portuguese and French nationals were responsible for spreading the virus. This ‘national defence’ discourse occurred alongside the stigmatisation of the poorest segments of Spanish society, who were considered a ‘domestic danger’, as in the case of Alicante.
Influenza brought death and misery to all of Spain. The ineffectiveness of authorities in dealing with the epidemic was quickly denounced by politicians, the press and intellectuals. Criticism of the Spanish governments’ insufficient response to the epidemic itself evolved into criticism of the poor functioning of the state and the existing political system. Doctors and intellectuals criticised the political system and linked its shortcomings to the moral decline of the nation. They interpreted the influenza epidemic as being part of a much broader process dating back to 1898. Most of the political spectrum came to argue that the solution to the ineffectiveness of the state and national decline was to put experts in charge, rather than corrupt politicians. In this context, calls for a ‘health dictatorship’ began to emerge during the second wave of the influenza epidemic, in late 1918. This is earlier than the date of early 1919 given by many historians for the emergence of support for a dictatorship in Spain.
Calls for firm and energetic action to improve the country's health system continued after the end of the epidemic. Calls for a ‘health dictatorship’ became intertwined with right-wing proposals for an authoritarian political system capable of correcting the country's health and moral disfunction. The concept of a ‘health dictatorship’ thus anticipated the Primo de Rivera dictatorship's discourse, in which the rhetorical use of medical language was tied to authoritarian regenerationism. In this sense, both the political impact of the epidemic and the dictatorship were nourished by a medicalised rhetoric inherited from Regenerationism and the debates on political modernisation expressed since the end of the nineteenth century in Spain. In this regard, the dictatorship was part of a long process. However, the influence of the pandemic and the radicalised political context of the First World War gave shape to an ‘authoritarian regenerationism’ that showed resemblances to political movements elsewhere in Europe.Footnote 111
The demands for a ‘health dictatorship’ which had emerged during the epidemic were closely linked to the dictatorship's rhetorical use of scientific and medical language. Despite the fact that references to the influenza epidemic from the period of the dictatorship are hard to come by, the Primo de Rivera regime put considerable effort into improving health system. Many of the policies developed by the dictatorship responded to the demands expressed both in political and sanitary senses during the pandemic. It was clear for José Pemartín, one of the main intellectuals of the regime, who stressed the links between political and national conceptions and health system improvements in a book published in 1929 with a prologue by the dictator.Footnote 112 Public health, modernisation and the ‘national disease’ were clearly linked. Five years after the second wave of influenza, General Miguel Primo de Rivera emerged as the nation's saviour with the aim of putting an end to the excess of politics which hampered Spain's progress. Policies and discourses developed by the dictatorship were careful to establish a clear continuity between the criticism which had emerged during the epidemic and the ‘sanitisation’ (‘saneamiento’) of the nation.
Acknowledgements
Maximiliano Fuentes Codera has received grants from the BBVA Foundation (‘Ayudas a Equipos de investigación científica SARS-COV-2 y COVID-19') within the project ‘From the 1918 Flu to COVID-19: A Historical Analysis in Europe and Latin America’ and the Spanish Ministry of Science and Innovation within the project ‘Democracy and Its Enemies (1918–1931): Spain, the First Post-War Period, the dictatorship of Primo de Rivera and its links with Italy, Portugal and Argentina’ (PID2020-112800GB-C22).
