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1Independent consultant in health Development: firstname.lastname@example.org
2Department of preventive medicine, school of public health, Addis Ababa University: email@example.com
A Century after Yehedar Besheta (The Spanish Flu in
Ethiopia): Are We Prepared for the Next Pandemic?
Yayehyirad Kitaw1, Mirgissa Kaba2
One hundred years after the most devastating pandemic
in human history (1, 2, 3), and in view of the growing
concerns from emerging and re-emerging
communicable diseases such as SARS, Avian Flu,
Ebola and other fevers) it is appropriate to reflect on
the Yehedar Besheta [the Spanish Flu 1918-1919. Even
though it might have started in USA (1 2), the
pandemic was “an ominous warning to public health”
(4, 5). Worldwide, it is estimated to have killed one
third of the then estimated 1.8 billion population (2)
just in two years which is much more than what
HIV/AIDS has killed in 40 years). Sub-Saharan Africa
suffered the most where 2% of Africa’s population was
wiped out by the pandemic (3). In Ethiopia, the
pandemic has not only killed scores of people but ahs
also threatened the fabrics of the society (6).
Related to war, famine and other complex disasters and
the subsequent population movements, epidemics have
repeatedly ravaged Ethiopia (6,7,8). Public health
legislations, by Emperors Yohannes and Menelik were
inspired by such epidemics particularly smallpox in
particular (9). Fates of war and conquest, recurring
themes in Ethiopian history, have been triggered by
epidemics and/or drought/famine, some of which were
characteristically international outbreaks (6).
The 1918 pandemic, Yehedar Besheta
the murderous 2nd wave of pandemic (3), is believed to
have reached the Ethiopian interior through the Gulf of
Eden by train. It is estimated to have killed about
50,000 people throughout the country and 10,000 from
Addis Ababa alone. No particular group of society was
spared since priests and educated ‘national leaders’ of
the population were all killed by the disease. A number
of high political dignitaries died, threatening the
stability of the country. The havoc was unprecedented
since among the small medical profession in the capital
4 out of 8 have died. One of the missionaries
documented that, “God first took the doctors… and
then swept away the people” (7). Most public leaders
run away from the town for fear of death or isolated
themselves in their houses that routine government
functions were disrupted.
The epidemic was so devastating that its memory still
lingers. Every year, on the 12th of Hedar (21
Novemebr), all household rubbishes are collected at
one point in the neighborhood and ritually burned –
Besheta/Disease of the month of Hedar, name of the
month in Amharic, most of November and early
December, of the heaviest mortality
Hedar Sitaten (smoked Hidar) – in commemoration
and presumably to ward off future pandemics. It has
left, as in many other countries (1), its marks on the
folklore and literature of the country. It has inspired a
recent film by Yemane Dessie; “and Then Rains
Currently, parallels are being drawn with the Avian
Flu, “the global threat that most occupies world
business leaders’, but H5N1 could be even more
devastating with growing urbanization and expanding
slums, facilitated global travel, cross border migration,
poor preparedness ( 11, 12).
The Next Pandemic
It is now time to reflect and draw lessons since
“Pandemic influenza is not a theoretical threat; rather,
it is a recurring threat” (10). However, it is difficult to
predict when the next pandemic will occur, or how
severe it will be (10). Some in fact, believe the next
pandemic, the antimicrobial resistant one is already on
us (13). Major influenza epidemics show no
predictable periodicity or pattern, and all differ from
one another as exemplified by the three influenza
pandemics of the 20th century, a the Spanish (1918),
Asian (1957), and Hong Kong (1968) influenza. So, as
the World Bank (13) clarified that,, “It is not a question
of if, but when we will face the next major pandemic --
yet we are still stuck in an unsustainable cycle of panic
and neglect” (13). Current geopolitical circumstances
are very different from those of 1918 (2). However,
prevailing instability in the different coroners of the
world particularly in the Middle East and Africa;
crowded way of living and mobility offers fertile
grounds for a new wave of pandemic (14). What
prevails in the world of during the last few years is
nothing but a warning bell.
The virus is now endemic in bird populations and could
mutate and pass to humans at any time. With advanced
globalization (14,15) and urbanization (16), more rapid
spread of any pandemic with potentially greater impact
is imminent. The challenge is huge for Africa. An
estimate shows that of the 62 million deaths from new
influenza, 96% were from developing countries (5).
While influenza is the major threat, there are a number
of other possible candidates including Crimean-Congo
haemorrhagic fever (CCHF), Nipah virus, Middle East
Respiratory Syndrome (MERS)” (17) and many other
emerging or reemerging infections (18). There could as
well be a lot more lurking out there as contacts
between humans and wild animals has also intensified
(19). The need for preparedness is patent and
endeavors are underway worldwide for the next “big
one”, a disease that could kill tens of millions (17).
A century after Yehedar Besheta 69
Ethiop. J. Health Dev. 2018;32(1)
As illustrated above, influenza pandemics have
historically taken the world by surprise and
overwhelmed health services challenging all other
coping mechanisms (19). Vaccines, available for the
1957 and 1968 pandemics were not distributed in time
to ward off the high level of mortality from the
pandemic and contain consequent social and economic
challenges. Preparedness implies spotting outbreaks
early and identifying warning sites so as to take action
before it spirals out of control (17). It is unreasonable
to believe that we can count on prophylaxis with
antiviral agents to protect a large, vulnerable
population for more than a few days at a time, and that
is not long enough” (20).
In the developed world, major efforts are being made
to prepare for the next pandemics. WHO and Member
States “have committed, within the framework of the
International Health Regulations (2005) (IHR), to
detect, verify, assess and report events that may pose a
risk to international public health” (21,22).
Preparedness may have different components.
According to a recent document from the US,
preparedness such domains as: Surveillance,
Epidemiology, and Laboratory Activities; Community
Mitigation Measures; Medical Countermeasures:
Diagnostic Devices, Vaccines, Therapeutics, and
Respiratory Devices; Health Care System Preparedness
and Response Activities; Communications and Public
Outreach; Scientific Infrastructure and Preparedness;
and Domestic and International Response Policy,
Incident Management, and Global Partnerships and
Capacity Building (10). However, questions on
countries’ readiness to respond and global capacity to
coordinate remains questionable (10, 18). Some
promising initiatives such as the United States Global
Health Security Agenda (GHSA) toward “a world safe
and secure from infectious disease threats” launched in
2014 (23) seem to have faltered (24).
In Ethiopia, a high-risk country for avian human
influenza, there was no surveillance system until
October 2005 when an emergency national task force
on AI was established. . A 3-year (2006-2008)
Preparedness and Response Plan was developed and
the Ministry of Agriculture and Rural Development
started AI surveillance targeting wild and domestic
birds. Formal Influenza Sentinel Surveillance (ISS)
Activities were launched in September 2008 with the
establishment of a National Influenza Laboratory under
umbrella of Virology & Rickettsiology Research
Group of the Infectious & Non Infectious Diseases
Research Directorate of EHNRI (25-27).
This was strengthened during the Health Sector
Development Program IV (HSDP IV 2010-2015)
which aimed to improve health risk identification, early
warning, response and recovery from disasters using an
effective early warning, preparedness, response,
recovery and rehabilitation system (28). The strategic
objective was to improve health system’s copeing with
existing and emerging disease epidemics, acute
malnutrition, and natural disasters of national and
During HSDP IV, the Ethiopian Public Health Institute
(EPHI, the former EHNRI), a lead institution for
epidemic control, undertook several activities in terms
of establishing Public Health emergency management
surveillance system (21). This system is responsible to
identify major public health risks and assessment of
vulnerability; verification and timely response to
outbreak rumors; strengthening of public health
surveillance and database management system;
resource mobilization, coordination and collaboration
with partners; and preparation, revision, and
distribution of guidelines including Global Health
Security Agenda (GHSA) Roadmap, 2015-2019 for
Ethiopia. In the early years of HSDP IV (2011/12),
18,543 government health facilities including 15,327
health posts, 3,096 health centers and 120 hospitals
were reporting on epidemic outbreak and
The Public Health Emergency Management
surveillance system under EPHI collects weekly and
daily reportable diseases. The weekly reportable
diseases include measles, acute watery diarrhoea
(AWD), poliomyelitis, rabies, dysentery,
meningococcal meningitis, relapsing fever, typhoid
fever, anthrax and pandemic influenza. EPHI received
several rumors every day. For example, it received
2,217 public health emergency rumors in 2013/14 and
assessed them within 3 hours, with only 31 (1.4%) of
the rumors found to be real public health emergencies.
In 2014/15, about 35 cases of 65 rumors received were
confirmed. EPHI also prepared weekly
epidemiological bulletin and distributed them to
concerned stakeholders for possible action. However,
the bulletins were prepared for all weeks only in
The reporting completeness has satisfied the WHO
80% minimum requirement. The system has been able
to detect, among others, a yellow fever outbreak (30)
and the first cases of dengue fever in Ethiopia (31).
Cases of swine flu have also been reported since 2010
with increasing trend since 2015 (32). During HSDP
IV, Ethiopia had also to prepare for the threat of Ebola
virus which originated in West African countries. The
EPHI undertook the necessary preparedness training of
about 1000 health workers from all regions and two
medical centers were established and equipped with the
necessary equipment in order to prevent and control
potential epidemics. However, there is no place for
complacency as even the most endowed systems
consider themselves unprepared for future pandemics
(33,34) and Ethiopia is known to harbor several deadly
virus with a lot more yet to be identified and yet to be
developed surveillance system..
70 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2018;32(1)
Ethiopia is not new to devastating pandemics as
illustrated by Yehedar Besheta. Growing urbanization,
growing interaction with countries in the globe, poor
preparedness etc poses challenges to responses. In view
of this, the impacts of the next pandemic could spell
havoc of unprecedented magnitude. The need to build
resilient health system with capable health actors,
institutions, and populations to effectively respond to
emerging pandemic is critical. Perspectives on
preparedness greatly vary. However, attempts to
forestall epidemics and bring speed and justice to
global responses in case of outbreaks ultimately depend
on a combination factors related to political will,
human and financial resources, and public health”..
Preparedness even in the best system is tenuous;
therefore the need to strengthen IPC including renewed
political commitment, review of policy and
implementation modalities, increased availability of
resources (both human and infrastructure) etc are key
considerations now than latter.
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