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1919. NEW ZEALAND

SAMOAN EPIDEMIC COMMISSION (REPORT OF).

Presented to both Houses of the General Assembly by Command of His Excellency.

COMMISSION. Liv bepool, ( } overnor-Greneral. To all to whom these presents shall come, and to George Elliot, Esquire, 0.8. E., of Auckland ; Thomas Wilson, Esquire, of Wellington ; and Lieutenant-Colonel William Harold Sefton Moorhouse, M.8.E., of Wellington : Greeting. WHEREAS in or about the month of November, one thousand nine hundred and eighteen, an epidemic of pneumonic influenza broke out in the Islands of Western Samoa, then in the military occupation of the Expeditionary Forces of New Zealand : And whereas it is expedient that inquiry should be made as to the circumstances and causes of the introduction of that disease into those islands and its extension there : Now, therefore, I, Arthur William de Brito Savile, Eafl of Liverpool, the Governor-General of the Dominion of New Zealand, in exercise of the powers conferred by the Commissions of Inquiry Act, 1908, and of all other authorities enabling me in this behalf, and acting by and with the advice and consent of the Executive Council of that Dominion, do hereby constitute and appoint you, George Elliot, Thomas Wilson, and William Harold Sefton Moorhouse, to be a Commission to inquire into and report as to the following matters, namely,— 1. The circumstances and causes of the introduction of epidemic pneumonic influenza into the islands of Western Samoa in or about the month of November, one thousand nine hundred anil eighteen, and of its extension in those islands. 2. All matters connected with the departure of the steamship " Talune " from the Port of Auckland on or about the thirtieth day of October, one thousand nine hundred and eighteen, her voyage to the said islands and her arrival there, in respect of the bearing of those matters on the introduction of the said epidemic. 3. Whether the introduction or extension of the said epidemic was caused by any negligence or default on the part of any persons in the service of the Crown, whether in respect of the Executive Government of New Zealand or in respect of the administration of the said Islands of Western Samoa.

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And with the like advice and consent T do further appoint you, George Elliot, to be the Chairman of the said Commission. And you are hereby authorized to conduct any inquiries under these presents at such times and places as you deem expedient, either in the Dominion of New Zealand or in the Islands of Western Samoa now in the military occupation of His Majesty's New Zealand Expeditionary Forces ; with power to adjourn from time to time and place to place as you think fit, and to call before you and examine on oath or otherwise such persons as you think capable of affording you information as to the matters aforesaid, and to call for and examine all such documents as you deem likely to afford you information on any such matters. And, using all due diligence, you are required to report to me under your hands and seals not later than the thirty-first day of July, one thousand nine hundred and nineteen, your opinion on the aforesaid matters. And you are hereby strictly charged and directed that you shall not at any tine publish or otherwise disclose, save to me in pursuance of these presents or by my direction, the contents or purport of any report so made or to be made by you. And it is hereby declared that the powers and authorities conferred on you by these presents may be exercised by any two or more of you. And it is hereby further declared that these presents shall continue in force, although the inquiry is not regularly continued from time to time or from place to place. And you are hereby further authorized to take into consideration for the purposes of your inquiry and report any information which His Excellency the Governor of His Majesty's Colony of Fiji may of his good pleasure cause to be, supplied to you relative to the arrival and departure of the steamship " Talune " at the port of Suva on her said voyage from Auckland to Samoa. And, lastly, it is hereby further declared that these presents are issued under and subject to the provisions of the Commissions of Inquiry Act, 1908. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Member of His Majesty's most Honourable Privy Council, Knight Grand Cross of the Most Distinguished Order of Saint Michael and Saint George ; Knight Grand Cross of the most Excellent Order of the British Empire, Member of the Royal Victorian Order, Knight of Grace of the Order of Saint John of Jerusalem, Governor-General and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies ; and issued under the Seal of the said Dominion at the Government Buildings at Wellington, this seventh day of May, in the year of our Lord one thousand nine hundred and nineteen. J. ALLEN, Approved in Council, Acting Prime Minister. F. W. Eurby, Acting Clerk of the Executive Council. GOD SAVE THE KING !

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REPOET. To His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Member of Mis Majesty's Most Honourable Privy Council, Knight Grand Cross of the Most Distinguished Order of Saint Michael and Saint George, Knight Grand Cross of the Most Excellent Order of the British Empire, Member of the Royal Victorian Order, Knight of Grace of the Order of Saint John of Jerusalem, Governor-General and Commander-in-Chief in and over His Majesty's Dominion of New Zea'and and its Dependencies. May it please Your Excellency,— We, the Commissioners appointed to inquire into the several matters and tilings referred to in the Commission, a copy of which is attached hereto, have the honour to submit the following report : — We held our first meeting in Auckland on the 14th May, 1919, when it was decided that no evidence be taken prior to our arrival in Samoa,, in the hope that we might thus gain the confidence of both the European and Native population. We also considered it advisable that the question of taking evidence in public or in private (which had been left to the discretion of the Commission) should be settled on the spot by the witnesses themselves. Colonel Logan, Administrator of Western Samoa, who was on furlough in Auckland, asked that his evidence be taken before our departure. The position being explained to him, he then asked to be allowed to hand in a. statement. This statement was received but not read by the Commissioners ; it was sealed up in the presence of Colonel Logan, who swore to the truth of its contents. He understood that if the meeting of witnesses previously mentioned decided that all evidence be taken in public, his statement would be read in open Court. We left Auckland for Apia by the s.s. " Talune "on Saturday, the 17th May, and arrived at our destination on the 30th May, 1.919 (Samoan time). On our arrival, at a meeting of witnesses and persons interested, called by advertisement, it was unanimously decided that all evidence, be taken in public, and that resolution, as far as possible, was carried out during the whole inquiry. Question No. 1. The circumstances ancTcauses'of the introduction of epidemic pneumonic influenza into the .Islands .of Western Samoa in or about the month of November, 1918, and of its extension in those islands. The whole of the evidence goes to prove that there was no epidemic pneumonic influenza in the Islands of Western Samoa, prior to the arrival of the " Talune " from Auckland on Thursday, 7th November, 1918 (Samoan time) ; that the day following its arrival a lady passenger died of pneumonic influenza ; that in two days after its arrival a male passenger by the same steamer died of the same disease ; that in seven days after its arrival pneumonic influenza was epidemic n Upolu ; that it spread with amazing rapidity throughout Upolu, and later throughout Savaii, the other island of Western Samoa, distance from Upolu at the nearest point about twenty miles ; that up to the 31st December, .1.9.18, 7,542 persons died of influenza, or as a consequence of the prevalence of influenza. Particulars are detailed in the following table : — WESTERN SAMOA. PoPULATIOiN. 1902 .. .. .. 32,815 .1906 .. .. 34,962 1911 .. .. .. 34,063 1917 .. .. . . 37,223 1918 (30th September). . . . 38,302 sixteen yours' increase, 5,487. 1918 (31st December) . . . . 30,738—n0w decrease, 2,077.

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Upolu — Men. Women. Children. Total. Before epidemic .. .. .. .. .. 6,828 7,814 9,313 23,955 After epidemic, .. .. .. .. ..4,749 6,094 8,286 19,129 Loss .. .. .. .. .. 2,079 1,720 1,027 4,826 Savaii — Before epidemic .. .. .. .. .. 4,160 4,513 5,550 14,223 After epidemic .. .. .. .. .. 2,974 3,529 5,004 11,507 .. .. .. .. ..1,186 984 546 2,716 3,265 2,704 1,573 7,542 Totals before Totals after Epidemic. Epidemic. Upolu .. .. .. .. .. 23,955 19,129 Savaii .. .. .. .. .. 14,223 11,507 38,178 30,636 30,636 7,542 Total epidemic losses. Percentages of Population. Upolu. Savaii. All Samoa. Before After. Before. [JAfter Before. After. Men .. .. .. 28-503 24826 29-248 25-846 28-876 25-336 Women .. .. .. 32-619 31-857 31-731 30-668 32-175 31-263 Children .. .. .. 38-878 43-317 39-021 43-486 38-949 43-401 Table showing Percentages of Deaths of Men, Women, and Children to Total Deaths. Upolu. Savaii. Men .. .. .. .. .. .. 43-079 43-667 Women] .. .. .. .. .. 35-640 36-229 Children .. .. .. .. .. 21-281 20-104 (Compiled by the Department of Native Affairs, Apia, Samoa, 31st May, 1919.) Table showing Percentages of Deaths to Total Population of Men, Women, and Children respectively. Upolu. Savaii. All Samoa. Men .. .. .. .. .. .. 30-448 28-509 29-478 Women .. ... .. .. .. 22-011 21-803 21-907 Children .. .. .. „ .. 11-027 9-837 10-432 Average .. .. .. .. 21-162 20-049 20-606 Table showing Percentage of Epidemic Deaths to Total Population. Upolu. Savaii. All Samoa. Men .. .. .. .. .. ... 8-678 8-338 8-508 Women .. .. .. .. .. 7-180 6-918 7-049 Children .. .. .. .. .. 4-287 3-838 4-063 Totals .. - .. .. .. 20-145 19-094 19-620 Total loss of population is 19-620 per cent. We would point out that it is asserted, and we believe the assertion to be true, that the death-rate, especially of Natives, subsequent to December, and for the following months, was so abnormally high that it might be safe to assume the total deaths in Samoa attributable to influenza totalled 8,500. In addition to this, many people are even now suffering from the after-effects of the disease, while others are totally or partially incapacitated. In our opinion there is no doubt whatever that epidemic pneumonic influenza was introduced into Western Samoa by the s.s. " Talune " on the 7th November, 1918, Samoan time (Bth November, New Zealand time).

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Question No. 2. —All milters connected with the departure of the steamship " Talune " from the port of Auckland on or about the 30th day of October, 1918, her voyage to the said islands and her arrival there, in respect of the bearing of those matters on the introduction of the said epidemic. On the arrival of the " Talune " from the islands on or about the 21st day oi: October, 191.8, she was berthed at the Auckland wharf alongside or near the " Niagara." She discharged her cargo and proceeded to Lytteiton on the 22nd October, 1918. On her voyage there, while there, and on. her return influenza of an apparently mild character was prevalent outboard. She loaded and took on passengers at Auckland for the islands. Before sailing it was found that two of the crew were unwell. A doctor was sent for, who diagnosed the cases as simple influenza. These men were sent ashore, and two others were substituted in then places. The " Talune " left Auckland on the 30th October, 1918, w.th a clean bill of health, and arrived at Suva on the 4th November, 1918. The passengers and crew were medically examined there, and as a consequence of that examination the ship was placed in quarantine alongside the wharf, but was permitted to unload her cargo with Fijian labour. Captain Mawson in his evidence makes the following statement : "At Suva 1 was inspected by the Port Health odicer, and had cases of illness on board which I surmised to be influenza, and this was subsequently confirmed by the Port Health Officer. I signed the usual report that ttie ship was clear oi infectious diseases, as I did not know that influenza was then an infectious disease. The local passengers landed at Suva, and the ship worked in quarant.ne. This decision was come to by the Chief Health Officer after consulting with, the board.ng. officer and myself as to the conditions in New Zealand on departure." Tne custom at Suva in connection with the " Talune " is that the Union Steamship Company employs about ninety Natives oo discharge and load cargo at that port, and these same Natives proceed on board the snip on the round trip, discharging and loading cargo at the various ports of call, returning do Suva in the course of twelve days, more or less, where they are landed. Tins course was followed in the voyage under review. The " Talune " left Suva on the oth November, and arrived at Levuka the following morning, where she was again quarantined. 6iie left Levuka the same evening for Apia, arriving there on one morning of ttie 7tn Novemoer, 1918 (Samoan time). The anchor was dropped at 9.35 a.m. At least six of the passengers had influenza on arrival at Apia, certain members of the crew were unwell., and a number oi the Fijian labourers were " sick." Three of the passengers were seriously affected. Certain of the passengers considered it doubtful, if they would be allowed to land Without first spending some time in quarantine. We find that no entry was made in the official log of the " Talune " on her voyage to Apia ot any sickness on board as required by section 4, subsection (ijj, of the Statutory provisions relating to official logs. ■ The Port Health Officer, Captain Atkinson, arrived on board shortly after the ship was anchored, and an examination of passengers and crew was made in the manner customary there -that is, each person passed in review before the Medical Officer while his or her name was checked off the list. The evidence shows that the second officer was ill in bed, and went back to bed after examination, while three of the passengers were manifestly unwell. Captain Atkinson advised one of the passengers, Mrs. Chur-ch ward's maid, co go home, promising to visit her later in the day, winch promise lie carried ono. Sue died the following day The stewardess also informed Mrs. Churchward that her maid was dangerously unwell, and should receive iiunied.aoe medical attcnt.on on shore. Another passenger, the Rev. Mr. Cane, after visiting the Bank of New Zealand and calling on a trader on urgent bus.ness, went straight to the hospital in a high state oi fever and was seriously ill there. He ultimately recovered and rendered good service in ministering to the sick both in Upolu and Savaii. Another passenger, Mr. John Ah Sue, died two days aloer leaving the ship. Captain Atknison states that, in reply to a question regarding the health of passengers and crew, Captain Mawson, captain of the ship, informed him that

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the health generally was as usual, except a number seemed to be suffering from colds and seasickness. He made no mention of being quarantined at Suva and Levuka, nor of the decision which was come to there by the Chief Health Officer, after consulting with the boarding officer and himself, as to the conditions in New Zealand on departure of the " Talune." The chief steward incidentally informed Captain Atkinson that they were not a/lowed ashore at Suva, but that " it was all right at Levuka." Under examination, Captain Atkinson, in connection with the steward's remark, stated that he considered the passengers and crew were not allowed ashore at Suva owing to there being " something wrong " in the port ; but as they had a clean bill of health from Levuka, and as the steward had informed him " it was all right " at that port, he concluded he was correct in his judgment. He therefore passed the ship, pratique was granted, passengers proceeded ashore, and the ordinary work of the ship was carried on. It did not seem to be quite understood at Apia that a " bill of health " referred only to the port of departure, and not to the passengers on the ship. In connection with this particular voyage, there are one or two striking points which we would respectfully bring before your notice :— 1. That, notwithstanding the fact that influenza had broken out in a serious form in New Zealand prior to the sailing of the " Talune " for Apia and. wayports, and was prevalent in Auckland, a clean bill of health was given to the ship, and no mention of this was made thereon. It is true influenza was not a notifiable disease at that particular time, but nevertheless we are of opinion that some mention should have been made of the above condition on the bill of health, especially as the " Talune " was bound for the islands. Medical men, at least, should have known the serious susceptibilities of a Native population to even minor diseases which, in the ordinary course, cause little or no mortality amongst Europeans. 2. That the fact that passengers and crew were quarantined at both Suva and Levuka was not mentioned by the captain of the ship to the Health Officer at Apia. 3. That, notwithstanding the fact that influenza in New Zealand became a notifiable disease by Proclamation dated Gth November, 1918, no information whatever, either from, the Health Department or the Defence Department, was radiographed to Samoa. 4. That at that particular time a number of New Zealand soldiers were on duty in Western Samoa. 5. That Captain Atkinson stated that had be known that influenza had become a " notifiable " disease in New Zealand, he would not have passed the ship. 0. That Captain Atkinson had no previous experience in connection with the duties of. Port Health Officer, nor had he received any instructions from the Principal Medical Officer on the matter. 7. That both the Principal Medical Officer, Surgeon-General Skerman, and Capta n Atkinson, on the 7th November, .1.918, were unaware of the existence of any local port regulations, nor had they made any inquiries regarding same. 8. That generally, as far as regulations governing the port are concerned— and .n this report we are anxious to deal only With matters inside the scope of our Commission —the utmost confusion reigned. One Department, carried, out the law as laid down by the Tripartite Government liegulations, 1891-1894 ; another, those brought into force by the Cerman Government; while the Principal Medical Officer considered he was working under New Zealand regulations. We append for Your Excellency's information the Tripartite Covernment's regulat.on setting forth the notifiable diseases at the port of Apia, and also the Cerman regulations on the same subject. We would draw your attention to the fact that, under Tripartite Covernment, influenza was a notifiable disease ; under German rale ft waß not - Section 8 oj Ordinance relative to Quarantine, issued by the Three-Power Government, 1891-1894. Section 8. The following shall be considered to be contagious or infectious diseases within th i meaning of this Ordinance: Cholera, scarlet fever, scarlatina, influenza, diphtheria, croup, typhoid lever, typhus lever, relapsing fever, yellow fever, dengue lever, measles, leprosy, and all other diseases which the Health Ollicer may deem to be dangerous to the public health.

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Ordinance Issued, by the German Government, 15th February, 191,3, concerning the Sanitary Control of Sea-vessels in the Wafers of the Protectorate of Samoa. 3. The master or his representative has to lill up n question sheet according to enclosure 1 if the vessel comes from a harbour declared by the, Governor infected or suspected, or if there are cases of cholera, yellow fever, plague, smallpox, petechial fever, leprosy, scarlet, diphtheria, abdominal typhoid, measles, or cases which suspect such a disease on board, or if there be rat-plague on board, or has been there in the port of departure or during the journey, or if rats die in a suspicious way on board, or if they have been dying in the. port of departure or during the journey in such a way Captain Gillespie, Provost-Marshal and Commissioner of Police at Apia, stated that his predecessor worked under the Triparite regulations, and he continued doing so, and that subsequent to the 7th November, 1918, he got convictions under those regulations against four men on a charge of visiting a, ship quarantined in the harbour. On being recalled, he stated that since giving his evidence he had been informed that the German regulations had superseded the Tripartite regulations. The fact remains that the last-mentioned regulations had been used and acted on during the previous four years and a half. In connection with port regulations generally, we take this opportunity of stating that at Suva, on our way to Apia, three passengers for Samoa were permitted to tome on board the " Talune " from the quarantine island before the period of their isolation was completed and two days before they would have been allowed to land at Suva. Such a proceeding must sooner or later lead to serious consequences if it is persisted in. We therefore recommend that a new Samoan port regulation be, issued at once throwing the full responsibility on to the owners, agent, arid captain of any ship who either wilfully or negligently allows any passenger to come on board, their vessel from any quarantine-station, for any purpose whatever, before his or her period of isolation has expired. The " Talune " left Apia on her return journey to Auckland, via Vavau, Haapai, Nukualofa, and Suva, on Friday the Bth November, 1918 (Samoan time). Two days later, and at the first port of call --viz., Vavau —seventy out of the eighty-five Fijian labourers were suffering from influenza. Fifteen of them died after arrival at Suva and while in quarantine. Two soldiers who were returning to Auck'and. from Apia died after leaving Suva, and were buried at sea, while several passengers died after the steamer arrived at Auckland. QUESTION No. 3. — Whether the introduction and extension of the said epidemic was caused by any negligence or default on the part of any persons in the service of the Crown, 'whether in tespect of the Executive Government of New Zealand or in respect of the administration of the said Islands of Western Samoa. Dealing first with the introduction of influenza into Western Samoa :•■■ In view of the fact that influenza was epidemic in the City of Auckland prior to the departure of the "Talune." on the 30th October, 1918, some mention of it should in our opinion, have been endorsed on the bill of health handed to the ship, notwithstanding the fact that influenza was not a notifiable disease, as far as New Zealand was concerned, until the 6th November, 1918. We are strongly of opinion that Samoa should have been informed by wireless immediately influenza was, by regulation, made a notifiable disease in New Zealand ; and that the Public Health Department and [or] the Defence Department failed in its duty in ignoring the fact that New Zealand was, for the time being at least, responsible for the, welfare of the, inhabitants of these islands, both European and Native. On the 7th November, 1918 (Samoan time), New Zealand soldiers were garrisoning Upolu, and they subsequently suffered considerably from pneumonic influenza. At the same time we would point out that the British Government did not, according to evidence taken at Suva, inform the authorities there at any time prior to December, 1918, of the danger of this particular disease, and, according to evidence taken, at Pago Pago, the American Government did not advise the Administration there of the prevalence and seriousnesslof the disease in the United States of America. We have arrived at the, conclusion that an effort should be made by the Government of New Zealand to come to some reciprocal arrangement with all (or with as many as possible) of the civilized Powers throughout the world for immediate cable notification of any and every serious or partially serious disease

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which may break out from time to time in any particular country within the Convent'on. It seems to be a fact that prior to the arrival of the " Talune " at Apia the Medical Department and the public generally there had no particular knowledge of the ravages of this scourge, which broke out in Europe last year, and it was only when the mail brought by the " Talune, " was distributed on the 7th November (that is the Bth in New Zealand) that recipients of letters and papers were made aware of the state of affairs in New Zealand and the outside world. The fact that any and every Native population is liable, to be seriously affected by what to Europeans seem mild diseases should, now that New Zealand is extending her sphere of influence over such populations, arouse in the members of its Health Department a lively sense of the grave responsibility which rests upon them. Tt is no doubt common knowledge that some years ago when measles broke out in these Pacific islands the death-rate was enormous. In our opinion it is incumbent and essential that any Government having jurisdiction over tropical countries and Native populations should be alive to the necessity of seeing that the medical staff of such tropical countries is thoroughly organized and efficient. It seems to us that Captain Atkinson failed in his duty as Port Health Officer in granting, or allowing the Harbourmaster to grant, practique to the "Talune" under the circumstances. Assuming his evidence to be true in every particular, he admits that the chief steward informed him, perhaps inadvertently, that the passengers were not allowed to land at Suva but were " all right " at Levuka ; and assuming that he did remember, as he says he did, coming to the conclusion that there must be something wrong in connection with the public health of Suva and not with the ship, it seems peculiar that, he made no inquiries as to what was the disease which made it necessary for the Health Officer there to quarantine the passengers. Having got so much information, his natural course would have been to question the captain of the ship closely on the point. At least one would conclude that, thinking as he did, he would closely examine the passengers who got on board at Suva, but he did not do so. According to his evidence, Captain Atkinson did examine several mem bens of the ship's company who complained of illness, and found their temperatures normal. Apart from the admission of the chief steward, there appears to have been a complete silence, or, at least, a want of frankness, on the part of the officers, crew, and passengers on board the " Talune " in regard to the subject, of influenza specially, and the question of health generally. While it was natural that the officers did not welcome the idea of quarantine, with its vexatious delays and consequent disorganization of the service, and while the passengers of course desired to get off the ship at the earliest possible moment, still we are of opinion that Captain Mawson alsoffailed in his duty in not informing the Health Officer that he had been quarantined both at Suva and Levuka, and giving the reason for such quarantine. To prevent, as far as possible, a recurrence of such a state of affairs, we, suggest that a declaration should be signed by the captain of every ship calling at Samoan ports, and handed to the Health Officer when he boards the, vessel, and that it should be made a penal offence if any captain is found guilty of wilfully falsifying such declaration. This declaration should deal with the health of passengers and crew on the voyage ; which ports were touched at; whether clean bills of health had been received at all ports —if not, what was the nature of the disease at that particular port; whether the ship or passengers had been quarantined, and, if so, why ? We also consider that great benefit would result in the appointment under the Department of Public Health of a Quarantine Officer for New Zealand and its dependencies, who should have control of all matters connected with quarantine, inoluding' , Vontrolling and advising Port Health Officers, the clearance of inward and "outward "shipping, the issue of billsof health, &c. We find that at present bills of health are procured by shipping companies without any reference to the Department of Public Health. Such a course is open to serious abuse. We strongly recommend that in future all bills of health should be issued only by the Health Department, and that the incidental expenses thereof be paid by or through 1 his Department.

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We attach specimens of declarations which captains of ships are required to sign and hand to the Health Officer at Suva and American Samoa. In our opinion, however, and in the light of the experiences at Samoa, neither of these declarations is full enough. We would also suggest that with regard to all passengers, officers, and crews of all ships leaving any port of New Zealand for a tropical destination, the temperature and pulse of every person on board should be taken before sailing, and registered. This register should be open, to inspection at all ports of call and at the ship's final destination ; and we recommend that, as far as Samoa is concerned, it should be obligatory on the part of the Port Heaith Officer to examine such register and to take all temperatures there and compare them with those taken at the port of departure. All passengers joining the ship at way-ports should be similarly treated. Captain Atkinson in his evidence stated that the time spent in carrying out such an arrangement would delay the ship for days. We do not agree with this statement. We find the time expended in taking the temperatures and pulse-beats of all passengers, officers, and crew of the " Niagara " or " Makura " averages from two to three hours, according to the number of passengers on board. With a sufficient number of thermometers we venture to state that a ship, say, the size of the " Talune," visiting these islands, could be medically examined in the way we suggest in one hour —surely not a large price to pay for the additional safety which would be thereby obtained. We are of opinion that had the temperatures of all the passengers and crew been taken when the " Talune " arrived in the Apia Harbour on the 7th November last no qualified Port Health Officer could have granted immediate pratique without being guilty of criminal carelessness. With reference to the extension of the epidemic : As pointed out, the disease spread with startling rapidity, and with appalling results. On the 20th November the much-discussed radiogram arrived from the United States Governor at Pago Pago for the American Consul at Apia. It reads as follows : — Government American Consul, Apia. Greatly regret to learn of severity of epidemic, and extend sympathy and hopes speedy recovery for Mrs. Mitchell (stop). No cases here yet (stop). To avoid risk of contagion here will recpiire all vessels from Apia to undergo five days' absolute quarantine before discharging or taking on board any mail, or cargo (stop). Request you to inform authorities of this decision (stop). Please inform me if we can bo of any service or assistance. Poyer. Colonel Logan in his examination in Auckland stated that he did not understand the message to be an offer of medical assistance as far as Western Samoa was concerned, but rather assistance for Mrs. Mitchell, who was then ill with influenza. Further, as a rule all messages, other than commercial, dealing with Samoan matters came direct to him and not through the Consul, and he replied direct to the Governor at Pago Pago. When this particular radiogram was handed to him in the post-office he concluded that the only matter of interest to him in it was that relating to the quarantine of vessels before discharging or taking on board any mail or cargo. We think Colonel Logan might easily have taken that view of the matter, as the message, without the light of after-events being thrown upon it, was somewhat ambiguous. We would ask you, however, to look at the position for moment as it existed then in Samoa. Practically all the Natives were down with influenza or fright, and they either could not or would not do anything to help themselves or others ; the whole burden or nursing, feeding, and burying was therefore thrown on the military and European civilian population who were fit, as well as on many who were unfit. The people, especially the Natives, were dying at a startling rate, and the call for assistance, medical or otherwise, was totally beyond the power of the handful of Europeans to respond to, when some one suggested to Colonel Logan that outside aid should be sought. The quicker assistance could be obtained the more lives would be saved ; even two or three additional doctors with qualified attendants would have been of immense assistance. The nearest place was Pago Pago, within ten hours' steam of Apia, occupied by friends and allies, having at least three fully qualified medical naval officers, with many trained orderlies, and yet assistance was not sought in this direction. Indeed, instead of asking for. muchneeded assistance from Pago Pago —as we think he should have done, apart altogether from the wireless message referred to —Colonel Logan, incensed, no doubt,

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by the refusal of the American authorities at Pago Pago to accept mail-matter from Apia until the vessel carrying it had undergone strict quarantine for five days, by a written order dated 28th November, closed down all wireless communication with Pago Pago, without informing the authorities there that he intended doing so. His excuse for this was that he had only one wireless operator physically capable of doing duty, and he considered the hour and a half during which the lines were open for Pago Pago messages could be better used by this operator for much-needed rest. In his sworn evidence the operator in question declares that he did not complain to any one of overwork, as at that particular time he was working only six hours per day ; that he was astonished to get such an order ; that the closingdown of wireless communication with Pago Pago did not shorten his hours of work ; and, finally, that the average time taken per day for wireless messages between Apia and Pago Pago did not exceed twenty minutes, and not an hour and a half as stated by Colonel Logan in his sworn statement. We are of opinion that Colonel Logan was either not aware of the position at the wireless station, or closed it against Pago Pago in a moment of exasperation. In his evidence the officer in charge of the wireless station of Apia stated, " According to international custom it is quite irregular to close down on any station. There is an obligation to communicate with all stations." We took considerable evidence in connection with the closing of Papauta Samoan Girls' School during the epidemic ; and in fairness to the principal, Miss Moore, and her assistant, Miss Small, we are of the opinion that Colonel Logan acted hastily, and without a full appreciation of the facts. We need not go into this subject, since it is set out in the evidence attached to this report, except to say that when Colonel Logan paid his visit on Sunday morning, the 17th November last, Miss Moore was out of bed for the first time, after an attack of influenza. At that particular moment seventy out of the 104 girls were down with the disease, and thirty were convalescent and were walking about the paddock in front of the house. Colonel Logan evidently mistook these convalescents for fit persons who should have been assisting and not loafing, as he thought, at school. Colonel Logan's statement that Miss Moore and Miss Small did nothing to assist in Samoa's hour of trouble is not, in our opinion, correct. We think they did everything they were humanly capable of doing in looking after the wants of villagers near the school, nursing, feeding, and burying their own pupils and plantation boys. It is noteworthy that only one girl out of the 104 residing at the school escaped the epidemic. Turning to the Medical Department, we are of opinion that there was a certain amount of confusion and lack of administrative ability shown during the ep demic. To some extent this was excusable. A calamity had descended upon the island, bewildering in its suddenness and awful in its consequences. The Principal Medical Officer and the doctors under him individually did splendid work, and no praise is too high to mark their devotion and self-sacrifice ; one of them, Captain Atkinson, carried on his work with a temperature above normah Nevertheless, we think there was little co-ordination in the work. Civilians, for example, were not encouraged to assist as they should have been. One particular band of lady workers, exhausted by walking miles daily carrying food from house to house to the Natives, attempted to open an auxiliary hospital in the Market Hall. General Skerman, who, however, at first encouraged the idea, next day condemned it, and the Natives who had been gathered together were sent back to their homes, his explanation being that, as there was plenty of room at the General Hospital, the opening of an auxiliary hospital would cause overlapping. The ladies' object, however, was to get as many as possible brought together into one place, so that the work of nursing and feeding, which they themselves were attending to, might be concentrated and lightened. In many cases Natives refused to go to the General Hospital. During our inquiry we visited Savaii and took evidence in many Native villages Much dissatisfaction was expressed by witnesses at the conduct of Dr. James, the medical officer stationed at Tuasivi. According to these witnesses Dr. James never once visited any Native patent either in his own village or those within easy walking distance, but contented himself with staying at home and handing out medicines to any one who called. In his evidence Dr. James declared he understood that was all he was expected to do ; that he had received no instructions either written or verba 1 from the Principal Medical Officer when he took up his duties in Savaii, beyond being informed that every three months he was expected to make a journey round the

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island, calling at the various villages en route. He took one such journey during his six months' residence at Tuasivi. General Skerman in his examination admitted he had given no written instructions to Dr. James, but had had a general conversation with him before he commenced his duties. He did not specifically inform him'that he was expected to visit the surrounding Native villages, but thought Dr. James would understand that he was expected to do so. On the other hand, Dr. James stated he was so busy handing out medicine during the epidemic that he had no time to pay visits, and that, in any case, he was better employed attending to visitors. Be this as it may, we consider he, and every other doctor acting under the Principal Medical Officer, should have his duties clearly defined in writing when he joins the Administration. We are of opinion that had Dr. James even visited the Native villages within, say, a three-mile radius, much suffering, and possibly many lives, might have been saved during the epidemic. Dissatisfaction was expressed at many of the meetings of chiefs which we attended at the various villages in Upolu and Savaii, in regard to the unequal distribution of food which took place during the epidemic. This matter was undertaken by the military, but owing to the shortness of labour and the enormous pressure of work we were astonished that as much had been done as was done. No words of ours can convey to you our appreciation of the magnificent work done by all ranks of the military, from Major Richardson down to the private soldier. We found that during the epidemic period Colonel Logan did splendid work in visiting the Native villages, seeing to the feeding of the Native population, and personally burying the dead. As American Samoa had entirely escaped the ravages of influenza we decided to visit Pago Pago. This we were enabled to do by the courtesy of Governor Terhune, who was good enough to send the steamer " Fortune " for our conveyance. We found that on the 3rd November, 1918 (Samoan time), the s.s. " Sonoma " called there en route from San Francisco to Sydney. On medical examination it was discovered that two passengers on board were suffering from pneumonia, the aftereffects of influenza ; and, although no official information had reached Pago Pago relative to the seriousness of that scourge in the United States, the Health Officer decided to quarantine the vessel alongside the wharf. When it was known there that pneumonic influenza had broken out in Upolu still greater precautionary measures were instituted. The report of our visit to Pago Pago is attached to the evidence, and it will, we are sure, be read by you with much interest. We desire here, to place on record our appreciation of the kindness we received from Governor Terhune, Mrs. Terhune, Lieut.-Commander A. A. Garcelon (Captain of the Yard), and all the other officers and men of the United States Navy during our visit to Pago Pago. We also desire to place on record the. courteous assistance that we received from Colonel Tate, the Acting-Administrator of Western Samoa, and from all the officers acting under him ; also from Mr. Richard Williams, the Deputy Administrator of Savaii. We desire in addition to thank the civilian residents of Apia for the kindness they extended towards us, and for the manner in which they assisted us to obtain evidence that they thought might help us in coming to a fair and just conclusion. We beg to report that the high Samoan chiefs met us always and at all places in the most friendly manner, and that they did everything in their power to make our visit agreeable to us, and of some little value to Your Excellency's Government. During the work of our inquiry we examined European witnesses in Auckland, Wellington, Suva, Apia, Savaii, and Pago Pago, as well as the duly elected Samoan representatives in Apia, Fagamalo, Safune, Safoto, Tuasivi, Safotulafai, Iva, and the districts surrounding these places. In conclusion, we beg to state that in reading this report it must be borne in mind that the Dominion, during the period under review, was absorbed and had her whole attention focussed on the influenza epidemic in New Zealand ; and, further, that it is easy to criticize, in the light of after-events, the conduct of individuals in a time of extreme distress. We have, &c, George Elliot, Chairman. Thos. Wilson. W. H. Sefton Moorhouse.

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AMERICAN SAMOA, Port of Pago Pago, Samoa, , 191 To Master i of all Vessels entering: this Port :- ■• Pursuant to the regulations governing the entry of vessels into this port, you are hereby notified and directed to answer all of the questions below for the information of the Health Officer of this port. Approved : H. L. Dollard, J. M. Povkr. Health Officer of the Port. Governor of American Samoa. Name of vessel: Name of captain or master : From what port ? When did you leave above port ? En route to what port ? At what ports have you called ? Has any one been sick aboard ship (passengers or crew) within the last three weeks ? If so, what were the symptoms ( On what date and where was your vessel last fumigated ? Was any of your cargo fumigated before being received on board ? Does any of the cargo for this port need fumigating % Number of ship's crew : Number of passengers on board : Number of passengers for this port: (Signed) [Form required by Fiji Health Authorities.] QUARANTINE. [No. 13. Schedule op Questions. Questions. Answers. What is the name of the vessel ? What is the name of the officer in command ? To what port does she belong ? Whence do you come ? When did you quit your port of lading ? To what place are you bound '( At what ports or places have you touched on your voyage since you left the port of lading, and on what dates did you quit each of those places ? What vessels have you had intercourse or communication with on your passage, and. on what dates, and whence did they come, and what was the nature of the communication I Did any infectious or contagious disease exist at the place from which such vessels came ? Did any infectious or contagious disease exist at or in the vicinity of the place whence you sailed, or on board any vessel with which you had personal intercourse or communication on your passage, or at any of the places at which you have touched ? Are there any persons on board your ship affected with any infectious or contagious disease, or has any person died or been ill of a disease of that nature during the voyage ? And, if any, what number ? And if any have died or been ill of such a disease, were their bedding and clothes destroyed ? What number of officers, mariners, and passengers have you on board ? Have you any, and what, bill of health '. [Date.] [Signature of Commander, Master, or Surgeon.]

Approximate Cost of Paper. —Preparation, not given ; printing (1,000 oopies), £12 10s.

Authority : Marcus F. Marks, Government Printer, Wellington.—l9l9.

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