==== Front Soc Hist Med Soc Hist Med sochis Social History of Medicine 0951-631X 1477-4666 Oxford University Press 10.1093/shm/hkac005 hkac005 Original Article AcademicSubjects/MED00450 Public Health in a Federation: Lessons from the Spanish Influenza in Australia https://orcid.org/0000-0002-3327-998X Holbrook Carolyn Senior Research Fellow, Contemporary Histories Research Group, Deakin University, Geelong, Australia. E-mail: edwardslaura@example.org 09 2 2022 09 2 2022 hkac005© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. 2022 https://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Summary Public health policy has been identified by scholars as a principal means by which the state has expanded its control over human populations. Yet, as the COVID-19 pandemic has shown, public health responses do not necessarily reinforce the authority and prestige of the state, even while governments employ strict measures such as lockdowns and border closures. This article examines arguments about the nation-making effects of public health measures through an examination of the Spanish influenza outbreak in the recently federated Australian nation during 1919. It examines the effort of the central government to co-ordinate quarantine and other public health measures in the face of serious tensions within the Australian federation. In doing so, the article suggests a need to think more subtly about the role of 'bio-political' events such as public health crises in consolidating state control and fostering exclusionary forms of nationalism. These lessons apply particularly to federal nation-states. public health public health and quarantine Spanish influenza in Australia public health and federalism public health and nationalism article-lifecyclePAP ==== Body pmcOne of the many notable phenomena since the COVID-19 pandemic began is the wildly varied capacity among nations to protect their citizens from the virus. Various commentaries have observed the lack of obvious commonalities of governance or affluence among those countries that have achieved low rates of infection and mortality.1 Some democratic nations, such as South Korea, Taiwan, New Zealand and Australia, have kept mortality rates at comparatively low levels. Others, most notably the USA, the UK and India, have been far less effective at preventing loss of life. China's authoritarian government has done markedly better than many democratic nations, but another one-party state, Russia, has fared less well.2 Federalism, according to an article published in the Journal of Health Politics, Policy and Law in late 2020, has hindered the USA's response to the novel coronavirus. The article claimed that the American federation, which disperses sovereignty between the national and state governments, has caused conflict and confusion concerning such crucial matters as physical distancing, testing and the use of masks and ventilators.3 Overall, the authors concluded: 'This fragmented and disjointed response has undoubtedly cost time and lives'.4 A similar argument has been made in the Australian context, where public health powers are also divided between central and state governments. The long-time health adviser Bill Bowtell, who led Australia's lauded policy response to the AIDS/HIV pandemic in the 1980s, blamed 'deep fault lines in the outmoded structures of the Australian federation' for substantial shortcomings in the nation's response to COVID-19. Of greatest concern to Bowtell were the failures of co-ordination between state and federal authorities, which led casual workers to seed a second wave of the virus that raced through Melbourne's aged care homes during the southern hemisphere winter of 2020.5 Bowtell claimed that Australia's federal system (derived from that of the USA) 'has become a dead weight around the neck of Australia's democracy and people'.6 Citizens of Western Australia, Australia's largest and most isolated state, would presumably disagree with Bowtell's assessment. The state's Labor premier, Mark McGowan, took a hard-line approach to pandemic control, closing the interstate border for most of 2020, despite the protestations of the prime minister and other states. While Victorians endured a 3-month lockdown in mid-2020, and New South Wales and Queensland dealt with sporadic outbreaks of COVID-19, the lives of Western Australians continued in relative normality. Premier McGowan was rewarded with an historic election win in March 2021, which reduced the principal opposition Liberal Party to just two seats in the Legislative Assembly. His willingness to close the border and pit Western Australia against the 'eastern states' Goliaths tapped into long-standing and deeply held secessionist sentiment within Western Australia.7 McGowan's actions in 2020–21 recall those of another West Australian premier during the Spanish influenza pandemic 100 years earlier. During that public health emergency, the unity of the newly created Commonwealth of Australia rapidly fragmented as conflicting subnational interests and mismanagement by the central government subverted attempts at a co-ordinated national approach. This article will explore the issue of pandemic disease governance in a federal body politic, using the case study of Australia during the Spanish influenza pandemic of 1918–19. Through an examination of state and central government responses to the pandemic, I will argue that historiographical understanding of the relationship between public health practices and state authority needs to be more sensitive to the nuances of the federal body politic. This argument also has implications for how governments seek to manage the COVID-19 pandemic and future infectious disease outbreaks. Public Health in Early Twentieth-century Australia Public health policy has been identified by scholars as a means by which the state has expanded its control over human populations.8 Over the centuries, the state has responded to outbreaks of bubonic plague, smallpox, cholera and other diseases with a raft of public health measures that include quarantine, cordons sanitaire, lazarettos, sanitoria, urban renewal programmes and vaccination. These measures have, according to the historian Frank M Snowden, 'justified control over the economy and movement of people; they have authorised surveillance and forcible detention; and they sanctioned the invasion of homes and the extinction of civil liberties'.9 Michel Foucault's pioneering work on anatomo politics, bio-power and bio-politics described the role of the modern state and the medical profession in harnessing new technologies to discipline and punish individuals and to control populations.10 Supervision of processes related to the protection of human life—birth and death, procreation, health and life expectancy 'was effected through an entire series of interventions and regulatory controls: a biopolitics of the population'.11 Foucault linked the emergence of these networks of bodily control at the individual and collective levels in the seventeenth and eighteenth centuries to the rise of modern capitalism. The new discourses and their regulatory apparatus made possible: 'the controlled insertion of bodies into the machinery of production and the adjustment of the phenomena of population to economic processes'.12 Public health can thus be conceived as a 'bio-political' phenomenon, which can be used to control populations and reinforce the demarcation between those who belong within the nation-state and those who must be excluded. As Alison Bashford has summarised, 'health' has become central to modern national identity, through ideals such a healthy population, a nation of healthy citizens, national fitness, national hygiene and the prevention of harms through border control.13 Delineations and identities created in the name of public health have often been drawn in racialised terms. Much of the Australian research has described how social Darwinian and eugenicist concepts of race were used to control Indigenous peoples and non-white migrants.14 In his landmark study, The Cultivation of Whiteness (2002), the historian Warwick Anderson demonstrated the ways that medicine and public health have acted as instruments of British settler colonialism.15 Anderson shows how the Australian tropics became a site through which anxieties about racial fitness were mediated, and how the settler project was enveloped in and legitimated by the exalted rhetoric of science. Using the insights of critical race theory and whiteness, Christopher Mayes has argued that the establishment of the Australian state rested on a pact between democratic liberalism and racism. Mayes argues that whiteness was a norm around which pervasive and enduring epistemological and institution foundations were built.16 Historians have also observed the parallels that were drawn in the early twentieth century between infectious diseases and other external 'threats', such as communism and Asian invasion.17 The Commonwealth of Australia, formed in 1901, responded to these perceived threats in ways that included not only quarantine and other public health measures but also citizens' forces, cadet training and physical fitness programmes.18 Historians of public health have described the categories of race and mental capacity that Australian migration policy imposed in the early twentieth century.19 Of particular relevance to the Spanish influenza is Alison Bashford's work on the nexus between infectious disease control and racialism, part of her larger contribution to understandings of quarantine, racial hygiene and, more recently, population. Bashford conceived the Australian quarantine system, not merely as a practice for excluding disease, but as an act of spatial imagination, which is deeply embedded in the modern process of nation-making: Boundaries are required for the creation of nations in a modern Western sense, and quarantine is in essence the putting of these boundaries to a particular use by the administrative nation-state. Not infrequently, quarantine and national administration produce and monitor the same space: that is, the border of a nation has often been where a quarantine line was drawn. This same border might well have a military, political and economic significance; the place of potential invasion and defence as well as commercial traffic and exchange.20 Bashford argues that Australian quarantine practices have been 'important to the creation of a sense of national boundary'.21 Echoing the nation's White Australia immigration policy, which effectively barred the entry of non-white migrants, quarantine practices defined the racial borders of the nation-state. Bashford claimed that the power over quarantine that was given to the Commonwealth (central) government at the time of Federation in 1901 became the crucible of a larger public health project that defined and administered the Australian nation in racialised terms.22 Though there is a rich Australian historiography of Spanish influenza, it has not addressed directly the thesis advanced by Bashford about the nexus between the quarantine power and racialised nation-making. Much of the research about the Spanish influenza in Australia takes a regional perspective and employs social and oral history methodologies.23 Some scholars have addressed the Spanish influenza as part of the history of quarantine stations, while others have considered its place in the national memory. Where historians do take a national perspective, however, they appear to contradict Bashford's representation of quarantine as a homogenising process. They conceive the pandemic as an event that demonstrated the limits of central power and indicated the brittleness of the compact that was created in 1901 when the six British colonies of New South Wales, Victoria, Queensland, South Australia, Western Australia and Tasmania federated to become the Commonwealth of Australia.24 Humphrey McQueen observed that Australians had embraced the new 'consciousness of nationhood' spurred by their participation at Gallipoli and in other campaigns during the First World War; a sentiment that was expressed in the emerging Anzac legend.25 Indeed, the war was widely heralded as the 'birth of the nation', a moment that Federation in 1901 had conspicuously failed to induce.26 McQueen argued, however, that Australians lacked a civic-minded patriotism that could summon the unity and common purpose required to protect citizens from the influenza virus: In 1915, an external menace had driven Australians together; by 1919, an internal danger revealed yet again how easy it was for Australians to stand apart. If national unity involved loyalty to the Commonwealth as an administrative machine, the Pandemic showed how little of it there was.27 While historians have noted the administrative failures of the Commonwealth and the disunifying effects of the Spanish influenza, there has been no detailed examination of federal relations during the pandemic. Nor has there been consideration of what this fracturing of national sentiment implies for our understanding of public health practices. In what follows, I will outline the attempts of the Commonwealth government to stake a commanding role in Australian public health, and detail how the Spanish influenza pandemic undermined these centralising efforts. Public Health in the Early Australian Commonwealth Europeans in Australia enthusiastically adopted the maritime quarantine practices that had been used for centuries to control the spread of infectious diseases such as bubonic plague and smallpox in other parts of the world.28 New South Wales enacted quarantine legislation in 1832 in response to the threat of European cholera and operated a permanent quarantine station at North Head from 1837.29 Victoria established a quarantine station at Point Nepean in 1852 and other colonies followed suit. The Australian colonies continued to develop and refine their quarantine practices, even while they were falling from favour in Europe and North America.30 Amid the growing belief that quarantine was a blunt instrument with dire economic consequences, in 1825 a British parliamentarian condemned it as 'anti-commercial, anti-social and anti-Christian'.31 Quarantine was further discredited when it failed to prevent the cholera epidemic of 1866–67.32 By 1873, Britain had abandoned quarantine altogether, in favour of sanitary measures and medical surveillance.33 Ships suspected of carrying disease were inspected and those found to be infected were removed to isolation hospitals.34 Other passengers were released but regularly inspected by medical officers until the risk of infection passed.35 The historian Krista Maglen claims that the Australian colonies departed from what became known as the 'British model' of disease prevention for three reasons: their public health infrastructure was less developed, which meant the sanitary approach would be less effective; vaccination was less available as a treatment option, and Australia remained free from some diseases that were endemic in other parts of the world.36 Following the mid-century discovery of gold in Victoria, shipping traffic greatly increased to the Australian colonies, and with it the threat of infectious disease.37 The desire to streamline quarantine practices became an incentive for improved administrative co-operation between the Australian colonies.38 The Medical Adviser to the government of New South Wales, Charles Mackellar, advocated a federal system of quarantine in1883, claiming that consistent practices, jointly administered by the colonies, were vital 'for our common weal'.39 Though a mooted 'Federal Quarantine Act of Australasia' never materialised, quarantine was the single public health power granted to the Commonwealth in 1901.40 The colonies did not contest the transfer of quarantine power to the Commonwealth, though the future Chief Justice of the High Court, R.E. O'Connor, wondered whether the power should be limited to maritime borders, as federal control of internal quarantine might conflict with existing state jurisdiction over matters of public health.41 Several outbreaks of plague in the years after Federation prompted the Commonwealth to enforce its constitutional power over quarantine.42 Following the passage of An Act Relating to Quarantine in 1908 and the establishment of a Federal Quarantine Service in 1909, quarantine powers were transferred from the states to the Commonwealth. These included power over internal quarantine, despite the objections of Western Australia and New South Wales.43 Dr John Howard Lidgett Cumpston, a leading figure in the burgeoning field of public health, became acting director of the Quarantine Service in May 1913 and permanent director a couple of months later. Melbourne-trained Cumpston had observed directly the American physician Victor Heiser's success in eliminating cholera and smallpox in the Philippines and was resolved to protect Australia from 'the contagious diseases of the East'.44 Cumpston was internationally connected; he had earned a Diploma of Public Health in London and had links with leading experts in bacteriology, hygiene and public health in Paris, Brussels and Berlin.45 Cumpston was prominent in the Australian expression of a wider, international push for greater state intervention to combat ill-health. He envisioned that: the proper objective of governmental administration was much greater than the prevention and control of epidemics; that it was, in fact, nothing less than positive health, freedom from all illness and disability for every individual human unit in the community.46 The new Director of Quarantine had a difficult start in his new role. Following an outbreak of smallpox in Sydney in July 1913, he used his authority to restrict the movement of people to and from parts of the city, and to require people leaving Sydney to be vaccinated. Cumpston was criticised by the New South Wales government, health officials and the press, which perceived his actions as unwarranted Commonwealth interference. Cumpston reflected later that the episode taught him 'the impossibility of reconciling dispassionate decisions based upon technical knowledge with impetuous political actions'.47 The historian Michael Roe placed Cumpston in the vanguard of a group of Australian progressives in the early twentieth century for whom 'the notion of improved public health blended with aspirations towards racial perfection and physical excellence'.48 Along with contemporaries such as Dr J.S.C. Elkington and Dr Richard Arthur, Cumpston grafted rapidly emerging scientific knowledge about the causes of ill-health to less rigorous ideas drawn from social Darwinism that encouraged competition among the 'races'.49 As the Queensland Home Secretary announced upon the passage of the Queensland Hospital Act in 1923: 'Today the health of the individual is a matter of community interest'.50 Emphasis was placed on the maintenance of 'racial hygiene' through the measurement and physical education of school children. Workers were conceived as 'industrial units', whose good health contributed to the 'wealth of the State'.51 The British Medical Association of Australia (BMA) and the influential Medical Journal of Australia were sympathetic to expansion of the state's role in public health.52 The BMA was dismayed by the lack of 'a national point of view' on health matters.53 It favoured the 'nationalisation' of medical services—a deliberately nebulous term—and the creation of a position of Federal Minister for Health.54 Such influential support was vital if Cumpston were to successfully flesh out a public health role for the Commonwealth from the bones of its constitutional power over quarantine. The most vexed issue remained how this newly staked out Commonwealth role would complement the responsibility for health policy that was left with the states under the terms of the federal settlement in 1901.55 The First World War had given a great boost to the cause of centrally co-ordinated public health measures.56 For progressive idealists one of the greatest lessons of the First World War was the value of expertise and planning. In his hope-filled template for post-war Australia, In Your Hands Australia, Charles Bean wrote: I do not think that anyone who ever saw that vast organisation behind the lines in France will ever again go back to the theory that the nation can muddle through somehow. The lesson of the war was that by organisation you can do anything … if we want to make Australia the greatest and best country, it can be done by planning. If the plan and the scheme is perfect enough; and if the thousands of brains that we can bring to bear on the subject are bright and active and energetic enough, we can make our country as near perfect as it is possible for a country to be. 57 This war-inspired confidence extended to public health reform.58 Cumpston expected men to return from the war with a new maturity, confidence and willingness to work co-operatively to achieve national benefit, because a new-found 'national spirit' had been awakened by the war.59 With the resolute application of planning and expertise, problems such as hospital provision, infant mortality, tuberculosis and venereal disease could be alleviated. There were already examples to draw upon. In 1916, faced with a shortage of diphtheria and tetanus sera, the Hughes government established the Commonwealth Serum Laboratories (CSL) in Melbourne to manufacture and distribute sera not otherwise available. The Commonwealth had committed to subsidising the efforts of state governments in controlling venereal disease and to assisting with an experimental anti-tuberculosis programme in Bendigo.60 Victor Heiser, now working for the Rockefeller Association's International Health Board, negotiated a joint project between the Commonwealth and the Queensland government to assist in the eradication of hookworm, with the hope that such an arrangement would extend to other states. The nation had passed the public health tests raised by an extra-territorial war with flying colours, but the optimism of reformers was soon deflated by bureaucratic hurdles in the domestic arena. Victor Heiser had hoped to unburden more Rockefeller largesse during his 1916 visit but found that the 'Federal authorities were not sufficiently powerful to compose State differences and embark on a national health programme'.61 In his 1936 memoir, Heiser recalled that: 'Warfare of one kind or another was always being waged against a neighbouring city, State, or even the Federal Government. Because each State considered itself autonomous, inter-State jealousy, political and economic, was intense'.62 Just as the war was ending, the Spanish influenza would visit a major health crisis on Australian shores and test the capacity of the restive young Federation in new ways. Maritime Quarantine The source of the 1918–20 Spanish influenza pandemic, as it was most commonly called in Australia, remains a matter of contention. The disease appeared in American military training camps in Kansas in March 1918 and in the French military base of Brest in early April that year.63 Wherever its origin, by June 1918 it had spread over continental Europe and North America, and to Britain, China and India. After the initial surge of infections subsided, a more aggressive second wave devastated Europe, America, parts of Africa and Asia in July–August 1918. This wave was highly infectious with a far higher mortality rate than seasonal flu. And, unlike seasonal flu, which was most dangerous to infants, the elderly and the vulnerable, the Spanish flu disproportionately affected healthy young men and women. The greatest danger to Australia was posed by ships carrying troops returning from Europe. Maritime quarantine—indisputably a matter of Commonwealth prerogative—would be the first line of Australian defence. During the second week of October 1918, there was a severe outbreak in South Africa and, soon after, in New Zealand.64 The Commonwealth responded by requiring that ships that had been in contact with South African or New Zealand ports undergo 7 days in quarantine. As Director of Quarantine, Cumpston sought to reassure the public 'that we are strongly and efficiently equipped right throughout the Commonwealth to deal with the scourge'.65 Sydney and Perth bore the brunt of quarantine operations; by mid-November, New South Wales had quarantined between 2,500 and 3,000 people and Western Australia between 2,000 and 3,000. Victoria had managed between 800 and 900 passengers, South Australia between 500 and 600, and Tasmania, just 50.66 By the time that quarantine restrictions were eased in April 1919, 228 vessels had been detained, 18,697 crew and 55,147 passengers.67 As Richard O'Connor had foreseen during the Federation debates, the Commonwealth's jurisdiction over internal quarantine clashed with state authority over land use and public health. An early point of controversy emerged when Commonwealth officials declined the admission of Catholic priests to the North Head quarantine station to administer last rites to dying patients. When the New South Wales government backed the Catholic Church, the Commonwealth relented. There was also much consternation in New South Wales about the proximity of the North Head quarantine station to the populous suburb of Manly. The doctor and social reformer, Richard Arthur, instigated a motion in the Legislative Assembly in November 1918, arguing that the station should be relocated from the vicinity of a major population centre to Jervis Bay.68 Though located within New South Wales, Jervis Bay had become a Commonwealth territory in 1915. Arthur and others in the New South Wales parliament engaged in acrimonious outpourings against the Commonwealth. One member claimed that federal politicians: 'think themselves superior to the States, and that matters emanating from the State Parliaments should rarely, if ever, be taken notice of'.69 Another complained that: The interests of New South Wales should not be treated as a mere bagatelle. There is a tendency on the part of the Federal authorities to treat our interests as of no concern because we are only a little place 500 miles away from Melbourne, the centre of Government. This question involves the health and lives of the whole of the people in New South Wales, and yet we have to submit to the domination and dictation of a few people in Melbourne.70 Cumpston's allies at the Medical Journal of Australia sprung to his defence. The journal's editorial condemned Arthur's motion that the North Head quarantine station be closed, and called for a national approach to public health: 'It is a great pity, after four years of war, fighting side by side, not as members of detached States, but as citizens of a great Commonwealth, that a prominent politician should exhibit signs of such desperation', it read.71 The journal accused state politicians of seeking to resist the legitimate authority being exercised by the Commonwealth: It is not unnatural that those who realize the inevitable superseding of the Federal control for State control in matters of communal interests, and who have failed to grasp the real significance of an Australian nation, should manifest jealousy at the complete success of the quarantine measures adopted by the Federal authorities …72 West Australians were equally dissatisfied with Commonwealth quarantine arrangements. Following outbreaks of Spanish flu on returning troop ships, there had been public outcry about the poor conditions endured by both the soldiers and the nurses who tended them at Woodman's Point, south of Fremantle.73 Feelings intensified when 600 soldiers were forced to remain on the highly infected Boonah because Woodman's Point was overcrowded. At public meetings and in newspaper correspondence, West Australians condemned the treatment of the soldiers, who had been 'willing to sacrifice so much' in the war.74 Protesters delineated between the state and federal spheres, and directed their ire at a Commonwealth government that was ill prepared for the influx of ships. The state Minister for Public Health, Hal Colebatch, made sure to emphasise that quarantine was a matter for the federal government: 'Every day makes more clear the futility of control from Melbourne in a matter of this kind', he told the press. 'The exact local knowledge and prompt decision founded thereon are the two essentials. With control from Melbourne we have neither of these.'75 Despite clashes between the Commonwealth and the states, there was also admiration for Cumpston's maritime quarantine programme. It appeared that the disaster that had unfolded in South Africa and New Zealand had been averted in Australia. By December 1918 Cumpston felt confident to pronounce that 'the period of greatest danger was certainly over, though constant watchfulness would continue to be exercised'.76 A correspondent to the Medical Journal of Australia offered his 'warm congratulations' to the director and officials of the Quarantine Department: 'While we were threatened with this dire epidemic, they saved the whole of Australia', he wrote.77 The Medical Journal of Australia judged that: 'The Federal authorities [had] attacked this problem of excluding a highly infectious disease from the Commonwealth with energy, skill and intelligence'. Not missing a chance to push its case, the editorial noted that 'the thoroughness of their work must be regarded as one of the strongest arguments in favour of the abolition of State control, and the substitution of Federal control in all matters concerning the public health'.78 The November Agreement and the Premiers' Conference Though the maritime defence remained intact, the Commonwealth decided in November 1918 to devise a plan of action with the states in the event that the disease escaped quarantine. State ministers of health, directors of state health departments and branch presidents of the British Medical Association were invited to confer with the Minister for Trade and Customs, Walter Massy-Greene and the Director of Quarantine in Melbourne. The location prickled New South Wales sensitivities; the acting premier requested that proceedings be moved northwards to the 'storm centre' of the disease.79 The meeting proceeded as planned in Melbourne on 26 November, where the disease was officially designated 'pneumonic influenza', in light of its capacity to cause severe secondary infection of the lungs.80 The conference produced a 13-point plan of action. Each state agreed to establish an advisory committee consisting of the chief health officer and members of the British Medical Association. Other preparatory measures included the establishment of vaccine depots and special hospitals and arrangement for ambulance transport, respirators and medical and nursing assistance in the event of an outbreak. The states agreed to provide advice to local authorities through the press and by circular.81 Massy-Greene and Cumpston were sceptical of the value of border quarantine within mainland Australia—except in the case of Western Australia, which was sufficiently isolated for the strategy to have some merit.82 The premiers insisted, however, that movement be checked as far as possible in the event of an outbreak.83 Restrictions on travel would buy neighbouring states time to complete their preparations and 'afford a delay which may result in some diminution of the virulence of the epidemic'.84 Delegates agreed a clear procedure in the event of pneumonic influenza breaching quarantine. When a case was recognised, the chief health officer of the state would notify the Commonwealth Director of Quarantine. The Commonwealth would then proclaim the state to be infected with pneumonic influenza and close its borders with clean states. Public places such as theatres, musical halls, picture shows, race meetings, churches and schools would be closed. Upon the proclamation of a state as infected, the federal government would take complete control of all interstate traffic by land and sea in order to enforce the quarantine. Under this arrangement, the states were required to 'render to the Commonwealth every possible aid and cooperate in the effective carrying out of the Regulations'.85 Cumpston later characterised the Commonwealth's assumption of border control with state co-operation as 'a general affirmation of acceptance of dominant Commonwealth authority'.86 If influenza was discovered in a neighbouring state, the border would be reopened. The power to repeal a proclamation that a state was infected would also rest with the Commonwealth. Special dispensation to travel to an infected state could be granted via a permit issued by the Commonwealth government. As the new year dawned, it looked increasingly likely that the November agreement would be redundant. The pandemic that was claiming millions of lives around the world had not penetrated Australia's maritime border. The Premiers' Conference that was scheduled for 22–27 January was due to proceed. Prime Minister Billy Hughes had left Australia in April 1918 to call on American President Woodrow Wilson before sailing to Britain, where he attended meetings of the Imperial War Cabinet. The prime minister remained in Europe to attend the Versailles Peace Conference in early 1919 and didn't return to Australia until August that year. Hughes had left the Treasurer William Watt in charge. Watt had previously been premier of Victoria and was considered highly capable and a likely successor to Hughes. He had opposed Labor's referendum proposals to increase Commonwealth powers in a range of social and economic areas in 1911 and 1913 and was regarded as an advocate of states' rights.87 The principal purpose of the conference was to consider the financial discontents that had bedevilled the Federation since its foundation. The most contentious issue remained, as ever, the amount of customs and excise duty returned by the Commonwealth to the states. The states had ceded their right to collect these taxes to the Commonwealth government at Federation in 1901. Faced with massive war debt, the Commonwealth proposed a graduated reduction over 6 years from the current per capita payment of £25 to £10. Watt also wanted to streamline taxation collection and overseas loan raising within the Federation. Soldier repatriation and employment opportunities for returned men were also on the agenda, including a scheme to settle soldiers on the land. On the back of his quarantine success, Cumpston seized the Premier's Conference as the moment to press for the establishment of a federal health department. Cumpston's innocuous-sounding agenda item concerned the co-ordination of Commonwealth and state powers with respect to quarantinable and other diseases.88 The Director of Quarantine made a strong case for the Commonwealth to take a more assertive role in health care. Management of the health of soldiers returning with conditions such as venereal disease and tuberculosis could not fairly be left to the states, he argued. The Commonwealth was responsible for the administration of the Northern Territory, Federal Capital Territory and Papua, with New Guinea likely to be added to the list as a result of peace deliberations at Versailles, Cumpston pointed out.89 Advances in medical science permitted many of the diseases occurring in these areas of Commonwealth jurisdiction to be successfully treated. The Commonwealth could also co-ordinate responses to diseases such as diphtheria, typhoid, tuberculosis, venereal disease and heart disease among the states: 'Disease knows no State boundaries, and the efforts of one State may be nullified by the neglect of another', he wrote.90 It was the role of the Commonwealth simultaneously to safeguard citizens from danger and maximise their capacity to contribute to the common good: Human health controls the defence capabilities of the Commonwealth, determines the working efficiency and therefore the national wealth of the Commonwealth and as, in the final test, all national emergencies are matters for the Commonwealth as a whole human population which determines the capability of the Commonwealth to meet these emergencies should surely be a matter for the earnest attention of the Commonwealth Government.91 Cumpston advised his minister to proceed with caution in his dealings with premiers jealous of their constitutional prerogative in matters of public health. Mindful of his bruising experience during the Sydney smallpox outbreak in 1913, he reminded Massy-Greene that: 'The adjustment of relationships between Commonwealth and States in these matters will require intelligent and careful handling if satisfactory results are to be obtained, and if friction is at the same time to be avoided.'92 As the Premiers' Conference began in the temporary Commonwealth Parliament House on Monday 22 January, rumours spread of an outbreak of pneumonic influenza in Melbourne. These reports had been circulating in medical and political circles for a couple of weeks, only to be stonewalled by the chief health officer, Edward Robertson.93 By the third week of January, the superintendent of Royal Melbourne Hospital, Ralph McMeekin, had no doubt that the disease affecting an increasing number of his patients was pneumonic influenza. Growing frustrated by the attitude of health officials, on the evening of 22 January McMeekin announced to the press that there were 27 cases of the disease in the Royal Melbourne Hospital and 'a good many cases of similar character' at the Alfred Hospital.94 It was not possible to say if this strain was identical to those occurring in New Zealand and in quarantine in Sydney, McMeekin admitted, but 'Bacteriological examinations' were being carried out and the Health authorities had arranged for Dr Penfold from the CSL to assist, if required. McMeekin expected to have the results in a day or two.95 Cumpston convened an informal conference the following day with McMeekin, Robertson, Penfold, Elkington, who was temporarily in charge of quarantine in Sydney, and another Sydney quarantine doctor, Paul Mitchell.96 Cumpston made various claims later in his life about what happened at the meeting on 23 January. In one account he writes that 'it was recognized and admitted that definite cases of this new form of influenza' existed at the Melbourne hospital.97 In another, he claims that state health authorities acknowledged the presence of the disease after he urged the reluctant Robertson to make an official admission.98 For reasons Cumpston does not clarify, this admission did not extend to an official declaration, which would have triggered the arrangements of the November agreement and allowed the Commonwealth to close and control Victorian borders.99 But Cumpston's correspondence and public statements from the time do not match his later versions of events. Far from urging Robertson to confirm an outbreak, Cumpston argued that there was 'no justification for any alarm' and that 'no definite statement' could be made on the subject until diagnoses were made of the cases under observation.100 Cumpston went even further in a statement published in the Age on 24 January 1919, claiming the Melbourne cases were not Spanish influenza, but a milder version that had been circulating for some time: The cases reported from various sources have been considered in the light of all the available evidence. It has been decided that, while the cases present an appearance generally similar to some cases that have been dealt with in quarantine, they do not present the same severity of toxaemia, and are not inconsistent with the occurrence of pneumonia, following after influenza of the kind which has been prevalent in Australia for nearly a year.101 Robertson, the state's Chief Health Officer, had a similar message. He told the press on 23 January that there was 'no proof that the disease was the overseas type' and that it was 'premature to enter into any discussion … as nothing definite would be known until late this afternoon'.102 Robertson deferred to the results of tests on 'bacteriological cultures' drawn from infected patients. To an inquiry from the New South Wales chief medical officer Dr Paton about reports of an outbreak in Melbourne, Robertson replied on 24 January that 'Bacteriological findings [were] not identical with Sydney cases' and concluded there was 'no apparent connection'.103 It is tempting to conclude that Cumpston was using the authority of his office and his formidable personality to obtain Robertson's acquiescence in his tactics of obfuscation and delay—prompted by Cumpston's own unwillingness to believe that his lauded maritime boundary had been breached. Further, an official notification would trigger the internal border controls, under Commonwealth direction, about which Cumpston and Massy-Greene had expressed disdain. While Cumpston reiterated that official notification remained a Victorian matter, as per the November agreement, he was simultaneously martialling the resources of the Commonwealth to prevent it. Dr Penfold was conducting tests at the CSL, which Cumpston was 'hopeful' would indicate the disease circulating in Melbourne was not the strain from overseas.104 It was a 'fortunate coincidence', Cumpston added, that the Commonwealth officer who had overseen the Sydney quarantine station 'throughout the whole of the active phase of the true pneumonic influenza there', was in Melbourne to lend his expertise.105 McMeekin was increasingly alarmed by the circumstances at the Royal Melbourne Hospital, which had admitted 14 new cases on Thursday 23 January and was now treating 40 patients.106 Others were sent to the Fairfield Infectious Diseases Hospital, when the Royal Melbourne ran out of beds.107 On 23 January, McMeekin 'was emphatic in declaring that the disease was epidemic influenza pneumonia'.108 He warned that 'Every precaution must be taken by the country to prevent the spread of the infection', including avoiding crowded halls and theatres and forbidding people visiting houses with infected people.109 McMeekin equivocated on the question of the disease's relationship to Spanish influenza; 'No definite relationship' could be established, he admitted, but added that the origin of the disease was 'immaterial from the public standpoint'.110 On Friday 24 January 1919, Cumpston and Robertson were summoned to Parliament House by Acting Prime Minister Watt to brief the premiers on the influenza cases in Melbourne.111 Cumpston later claimed that he told the premiers that there was 'no doubt' the Melbourne Hospital cases were the 'new disease', but that he could not act until Victorian authorities made an official notification.112 Contemporaneous sources show that his message was unchanged from the day before; it was too early to ascertain whether this was the overseas strain of the disease but that seemed unlikely, he told the premiers.113 On the back of this reassurance, the West Australian premier wrote to his deputy in Perth that reports of the outbreak were 'disquieting' but he trusted the diagnosis would not prove complaint to be the virulent type.114 The New South Wales premier, William Holman, was less mollified, perhaps because he had received a telegram about the Melbourne outbreak from concerned colleagues in Sydney who had convened an urgent meeting of Cabinet. The message reminded Holman of the November agreement and advised that he urge Watt to act on its terms.115 When delegates gathered on Saturday morning, Holman's seat was empty. Fearing that he would be detained in Melbourne if the borders were closed, the New South Wales premier had booked a special train back to Sydney at 10 o'clock that morning. Cumpston's bid for an increased Commonwealth role in public health would have to proceed in the absence of the party representing the most populous state. Prime Minister Watt read Cumpston's memorandum, which outlined two options—the Commonwealth would seek to extend its constitutional authority in order to take a greater role in public health, or it would use existing powers and seek to co-operate with the states and provide expert and financial assistance.116 The acting prime minister informed the remaining premiers that he was seeking an indication of their attitudes before circulating details to the federal Cabinet. The premiers were not satisfied by this approach. They told Watt that they wished to know whether there was unanimity within the Commonwealth government before they considered such a proposal.117 In the face of this procedural stalemate, Watt undertook to distribute copies of Cumpston's memorandum to the states and to convene a special health conference at an unspecified time in the future.118 The failure to advance Cumpston's ambitious scheme for public health characterised a disappointing conference.119 Not only had the public health proposal stumbled at its first hurdle, but leaders had been unable to reach agreement on per capita payments, uniform tax collection and loan-raising measures. Cooperation was proving difficult in a system of dual sovereignty in which the federal government was increasingly flexing its financial and administrative muscle. The influenza wave was cresting behind the nation's political leaders as the Premiers' Conference concluded on Monday 27 January. The pending epidemic would test the federation in ways that suggested the Commonwealth had not yet learned to yield its expanding authority wisely. The Influenza Escapes Quarantine On Sunday 26 January 1919, Chief Health Officer Robertson, consulted with his advisory committee and reaffirmed his judgement of previous days that the disease afflicting Melburnians was not the same one that was rampant in New Zealand.120 Meanwhile, in Sydney a returned soldier who had travelled by train from Melbourne on Tuesday 21 January was displaying 'suspicious symptoms of pneumonic influenza' at Number 4 Military Hospital in Randwick.121 New South Wales authorities acted quickly. On 27 January, the state declared itself infected, with approximately 20 cases at, and connected to, the Randwick Military Hospital.122 The Victorian advisory committee convened again on 28 January and decided that pneumonic influenza did indeed exist in Melbourne.123 Victoria declared itself infected on 28 January, the day after New South Wales. The Victorian government ordered the closure of all picture shows, theatres and public halls within 15 miles of the General Post Office, throwing 2,200 men out of employment at a loss of 8,800 pounds weekly in wages.124 The consequences of Victoria's delayed declaration were quickly apparent. By the time that New South Wales declared itself to be infected, there were 420 cases nationally.125 Four hundred of those were in Victoria, of which 35 were fatal. All of the 20 or so cases in New South Wales could be traced to people who had recently arrived from Victoria, or their close contacts.126 Cumpston was quick to recast his role in the Victorian debacle. He briefed Watt in early February that he had emphasised to Dr Robertson the urgency of obtaining an 'early and definite decision' about the nature of the cases, but neglected to mention his own pattern of obfuscation and diversion.127 The terms of the November agreement determined that the border between Victoria and New South Wales should remain open because both states were infected. If Victoria had dealt the first blow to the November agreement by delaying its notification, New South Wales landed the second. Correctly perceiving that the southern state was more severely infected, New South Wales issued a proclamation under its own Quarantine Act on 29 January, which prevented Victorians from entering New South Wales.128 Both Watt and Cumpston expressed 'the greatest surprise' at New South Wales' decision to close the border, while the Victorian premier Harry Lawson called Holman's action 'unneighbourly'.129 New South Wales began medically inspecting incoming vessels and imposed 4 days of quarantine in addition to the Commonwealth period.130 The acting New South Wales premier, George Fuller, exchanged terse messages with Watt about the state's determination to quarantine ships arriving from Melbourne.131 In response to a journalist's query about whether the Commonwealth was in negotiations with the New South Wales premier, a federal minister replied: 'I don't know about negotiations. Perhaps there are recriminations.'132 Lawson insisted to Holman that his state had adhered to the 'spirit and letter' of the November agreement and suggested that New South Wales, not Victoria, was the source of the influenza outbreak.133 Such a claim defied the evidence: by 5 February, Victoria reported 1,452 cases and 79 deaths, while New South Wales had only 56 cases and 1 death. And yet, Holman argued, Victoria claimed the right 'to send any number of her widely infected population into this State, in which, so far, we have been successful in keeping the disease within small bounds'.134 In the absence of Commonwealth action, two quarantine camps were eventually established at the Victorian border, at which land travellers were required to spend 4 days.135 Goodwill within the Federation continued to fray as premiers from 'clean' states moved to preserve their status. On the afternoon of Monday 27 January, 350 passengers boarded the overnight mail train from Sydney to Brisbane.136 At around 10 o'clock that evening, a special issue of the Commonwealth Gazette declared New South Wales to be a quarantined area.137 Queensland responded by closing its border completely with New South Wales, ignoring an exemption to residents within 10 miles of the border under the November agreement.138 The Brisbane-bound passengers were disembarked at Tenterfield, 20 km south of the Queensland border. Two more trains disgorged their passengers at Tenterfield, swelling the local population by 800 and stretching its amenities to near-breaking. According to the November agreement, the only means by which these travellers could reach Brisbane was by returning to Sydney and proceeding by sea, subject to maritime quarantine measures operated by the Commonwealth. Acting Prime Minister Watt offered the stranded passengers free train travel back to infected Sydney, from where they would need to find accommodation until an infrequent and expensive steamship fare became available.139 Despite the representations of the Queensland government, and newspaper columns filled with tales of hardship from displaced Queenslanders living in basic conditions, the Commonwealth refused to countenance a quarantine station on the state border.140 The refusal probably reflected Cumpston's scepticism about the value of land quarantine, as well as the Commonwealth's reluctance to bear responsibility for an operation that would be run day-to-day by the Queensland authorities; if the quarantine programme failed, the federal government would wear the blame.141 Watt wrote to the premiers in early February about the 'Practical difficulties attending' quarantine stations: the risks involved in the event of an outbreak of the epidemic in a hastily established and ill-equipped quarantine station at the border presents such difficulties of tragic results that the Commonwealth does not in any circumstances feel justified in running the risk of establishing border stations, which would necessarily have no proper sanitary or hospital conveniences.142 In the absence of Commonwealth support, the Queensland premier announced on 1 February that the border with New South Wales would be subject to strict quarantine procedures.143 Quarantine camps were established at Wallangarra, Mugindi, Goondiwindi and Coolangatta, at which travellers were required to spend 7 days.144 Queensland also intervened in maritime quarantine processes for both interstate and overseas vessels, much to the irritation of the Commonwealth Director of Quarantine.145 'Constitutional Crisis' was the headline of an article in the Brisbane Telegraph about the conflicting public health powers of state and federal governments.146 Like Victoria, South Australia was laggard in declaring itself infected. A large number of cases of pneumonic influenza had been reported by the medical superintendent of the Adelaide Hospital in late January.147 By the time the state gave official notification on 5 February 1919, the disease had been circulating for some time.148 South Australia closed its land border to Victoria, until a delegation of Victorian and Commonwealth officials, including Cumpston and Robertson, negotiated an agreement wherein restricted travel could resume.149 Tasmania and New South Wales both responded to the South Australian outbreak without waiting for the state's official notification. On 31 January, Tasmania began controlling the entry of small sailing vessels from South Australia and New South Wales prohibited entry of South Australians.150 Cumpston criticised these measures on the basis that South Australia had not officially declared itself to be infected.151 The Trans-Continental Train Western Australia's geographical isolation from the rest of continental Australia and its sparse population afforded it greater opportunity of preventing infection altogether.152 At the same time, the state's ambivalence about the Federation found expression in this new threat from the east. The always-opiniated Sunday Times warned its readers that the 'danger that menaces this State resides in the Eastern States'.153 Unlike in the other mainland states and Tasmania, it was a train line that became the medium for federal dispute in
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