PANDEMIC TO PANDEMIC: What the Spanish flu can Teach Us About Covid-19
Before Covid-19 arrived, you may have heard of the Spanish Flu pandemic of 1918-1920, but probably would not have paid it much mind. In the West, the focus of history books about this period is generally on the First World War. We have numerous sources describing the horrific events of this conflict, the horrors of the trenches, and most of all the waste of life: World War I killed an estimated 17 million people and that is by anyone’s count a horrendous waste of life.
In comparison however, the Spanish flu pandemic killed anywhere between 50 to 100 million people worldwide. 50 to 100 million. That’s likely more than World War I and World War II put together. It was the greatest tidal wave of death since the Black Death, possibly even the greatest in human history. It affected every corner of the globe. In every continent apart from Europe more people died of the flu than from war. However, somehow the importance of this global catastrophe has until recently been only a footnote, at least in Western history textbooks. Why is this? Perhaps because the events of World War I are anchored in a geographical place and have a linear narrative that can easily be assembled. In contrast, the Spanish flu engulfed the world almost simultaneously and decimated the global population in a very short space of time (most deaths occurred over only thirteen weeks at the end of 1918). It’s a much harder picture to delineate, as everything is happening at once, everywhere. A disease such as this is also a social phenomenon as much as a concrete narrative – it is shaped not only by events but also by the scientific ideas, beliefs and cultures it affects, and in turn shapes those things. It cannot be separated from its historical, geographical and cultural context. Therefore, in order to study an event of this magnitude, one must study all the aspects of it; a gigantic and complex undertaking.
It is only since the 1990s, with the ubiquity of international travel, and with increasing concern over the rapid spread of viruses such as SARS and H5N1, that interest in what we can learn from the Spanish flu has grown. And now there’s the Covid-19 pandemic. It has disrupted modern life as we know it, there’s nowhere to hide from it and we are struggling to control, let alone combat it. So what, if any, lessons from 1918 can we use for this modern pandemic? Moreover, what should we have learnt from the Spanish flu that we haven’t with Covid-19?
I went looking for a book about the Spanish flu in order to try and shed some this light on both these questions, and ended up with Pale Rider: The Spanish Flu of 1918 and How It Changed the World by Laura Spinney. Why did I choose this particular book? Because, even though it was published in 2017, before the Covid-19 pandemic, it pulls together many disparate groups of information from different parts of the world about how they were exposed to the disease, how different cultures dealt with it and ultimately how these societies were affected by the chaos that it brought. From the Yupik of Alaska to the Persian shrine city of Mashed, from the quarantine efforts in pre-Communist China to the post-flu orgies of Rio de Janeiro, the author has collated snapshots of humanity’s reaction to this most horrific of diseases with a storyteller’s flair, as well as a scientist’s eye for impartiality and acknowledgement of the many gaps in the narrative.
The world of the 21st century is very different from that of the beginning of the 20th century, never more so than in the global population and the rise of urban living over the last hundred years. We have much better medicine now than we had back then, as well as significantly better services in terms of hygiene, public health and living conditions. We also now have a much more well-nourished population, and many of the diseases that were rampant in the early 20th century are no longer an issue in the 21st. Having said all that, it is striking that we seem to have learn so little (or at least refuse to adopt our learnings) about some of the simplest things that we know will prevent the spread of a virus, be it influenza or coronavirus. For example, one study made of the Spanish flu in 2007[i] showed that public health measures such as banning mass public gatherings and imposing the wearing of masks cut the death toll in some American cities in 1918 by up to 50%. The timing was critical however: measures had to be introduced early and kept in place until after the danger had passed. Conversely, in places such as Zamora in Spain, where mass gatherings were encouraged (the bishop was particularly active and church attendance was almost obligatory), the death rate was twice that of any other Spanish city. In the face of this sort of evidence, why then has mask wearing been so slow to catch on in various parts of the world? And why has it been so hard for authorities to make the decision early on to close down places of worship, sports venues and other places where people gather together in numbers?
So, back to my original questions:
* What lessons from 1918 can we use for this new, modern pandemic?
* What should we have learned from the Spanish flu that we haven’t with Covid-19?
Regardless of our massive technological and medical advancements in the last hundred years, are we dealing with Covid-19 any better now than we did with Spanish flu in 1918? There are inevitable similarities around that pandemic and this, but the ones that really interest me are cultural rather than technological.
Compliance and Trust
One of the most fascinating debates during Covid-19 is that of getting people to comply. Today, we are seeing riots taking place protesting national lockdowns, social media is awash with anti-vaxxers and conspiracy theorists, and the wearing of masks in some places is a political statement rather than health measure. Some posit that countries with a strong adherence to personal freedoms do much worse in a public health crisis because individuals expect to make up their own minds about the level of containment that they adhere to, whereas more authoritarian regimes with a central, top-down authority do better at mandating what their citizens can and will do. The events of the Spanish flu suggest that this is not necessarily so however. In the USA, for example, in 1918 conscientious objectors to World War I were labelled as ‘slackers’ - but so were people who refused to comply with anti-contagion measures, a far cry from many Americans’ response to Covid-19 today. Conversely, in an authoritarian country such as Japan, still an aristocratic oligarchy in 1918, the authorities did not even consider closing public meeting places. Today Japan is a democratic country, yet despite its early exposure to Covid-19 its death rate stands at a relatively low 6,424 (at the time of writing), from a population of more than 126 million. This is arguably partly due to the public’s compliance with the authority’s safety requirements (as well as to other factors including removing shoes when indoors, a culture of bowing rather than shaking hands or kissing cheeks, and the tradition of wearing masks which, ironically, comes directly from Japan’s encounter with the Spanish flu in 1918).
One thing that does seem to correlate between the two pandemics is the sense of fatigue that such radical health safety measures engender. As today, in 1918 role models forgot to adhere to restrictions that they had set out, illogical choices were made in terms of what could stay open and what was shut down, and faulty theories or incorrect or contradictory information about vaccinations or the efficacy of public health regimes was propagated through the newspapers, the main means of communicating with the public at the time.
One difference between now and then was the generally paternalistic attitude of the authorities towards their populaces in 1918, hiding the full scale of the pandemic in the belief that the public couldn’t be trusted with it. Today we have the opposite problem; the flood of information, mixed in with speculation and conspiracy theories through the internet, muddies the waters almost as much the lack of information would have done a century ago. The Corriere della Sera newspaper in Italy provides an interesting example of what might have happened back in 1918 had the authorities disseminated the factual information that they had: the newspaper initially reported daily death tolls from flu, until the authorities stopped the practice, believing that it stirred up anxiety among the populace. However, the ensuing silence bred even more anxiety, since people could see for themselves the numbers of dead and dying in their midst. People drifted back to churches for deliverance and sought distraction with illicit gatherings, leaving their masks at home, and the public health infrastructure inevitably collapsed.
What can we learn from this? That early compliance works, that giving the public accurate information in a measured and logical manner is key, and that losing public trust has far reaching consequences. Other examples from the 1918 pandemic demonstrate that that maintaining a consistent (and simple) message is extremely important, and that understanding how different cultures will react differently is vital.
What are We Doing with Our Knowledge?
Thankfully, as medicine has evolved, so has our understanding of the Spanish flu as a useful record that we can use to track potential pandemics in the future. We don’t have the mass displacement of people that took place during the First World War, but instead we contend with widespread international travel of people and goods, where geographical isolation is no longer a barrier. Our increased medical knowledge has given us better disease surveillance and more effective medicines and vaccines than in 1918, but today’s global population is also older and, in some places, has become more vulnerable through lifestyles choices such as obesity.
Here’s a scary statistic: in 2013 a company[ii] specialising in catastrophe scenarios tried to estimate how many people would die if a flu as virulent as the 1918 pandemic struck the world today. The figure they arrived at was between 21 and 33 million deaths worldwide (figures from other estimates vary widely, from several million to upwards of 100 million dead). So far Covid-19 has claimed approx. 2.3 million lives globally. Imagine it 10x as virulent as it is currently. It’s a terrifying prospect and suggests that we need to be serious in our preparation for more pandemics.
Thankfully this threat is one that is taken seriously by medical bodies around the world. Various factors are taken into account, not only tracking viruses with the potential (such as Covid-19) to mutate enough to make the jump from animals to humans, but also including things like weather patterns, pollution levels and animal and bird migrations. A report in 2016 from an independent, international group of experts[iii] estimates there to be a 20% chance of four or more pandemics occurring over the next 100 years, at least one of them a flu virus. (The H5N1 strain of influenza A is currently the frontrunner, should it mutate to become transmissible between people. It has a mortality rate of 60% of those infected – 10% more than the Ebola virus.) The report also calls for global funding to build a framework that will create effective laboratory networks, stringent disease surveillance systems, a skilled and supported public health workforce, and effective engagement with communities to provide an informed and compliant public.
The impact of Covid-19 on the global economy and population has made proved that such a framework is indeed worth focussing on. It has forced laboratories and medical facilities to work together as never before. It has energised WHO and others to actively seek out potential virus hotspots and get better at tracing how current known viruses mutate and spread. Most importantly, it has shown us how important public health services are and how vital it is to engage effectively and in a non-political manner with the public.
The last point can be best demonstrated by contrasting the impact of Covid-19 on two countries with opposing strategies: Vietnam and the UK. Vietnam, possibly learning lessons from the SARS outbreak in 2003, treated the arrival of Covid-19 as a non-political public health crisis, with penalties for those trying to benefit commercially. It acted early and aggressively in locking down its borders. It adopted a blanket contact tracing system and hospitalised every infection. It embraced freedom of information on Covid-related matters, and allowed state media to report freely on the pandemic. On the other hand, the UK has only just now locked down its borders, has suggested (rather than enforced) self-isolation for potential carriers, has a badly functioning (and non-compulsory) test and trace system, and vacillates with different policies of containment for different areas at different times, confusing its populace and losing public trust. How do these differences in approach stack up in reality? Here are the numbers to date:
* Vietnam (pop. 95 million) = 35 deaths
* UK (pop. 65 million) = 113,000 deaths
Knowing what to do in a pandemic, and doing it properly, does indeed make a massive difference.
Can the Aftermath of the Spanish Flu Show Us What a Post-Covid World Will Look Like?
We are now almost a year in to the Covid-19 pandemic and many of us now put our faith in the vaccination programmes that are rolling out around the world. Assuming these work and we are finally able to get a handle on the virus and its variants, how will we act once Covid-19 is no longer the ruling factor in our collective lives? Many propose that, like the aftermath of the 1918 Spanish flu, we will again head for an era of the Roaring Twenties, where social norms changed irrevocably and parts of the world went through a period of libertarianism that changed our societies forever. I would argue that this is not necessarily a given. Although there is certainly bound to be a massive upswing in social events when people are finally able to meet up again, there is no guarantee that the 2020s will provide the same intellectual openness and trampling of boundaries that occurred in the 1920s.
Why do I think that? Firstly, the start of the 20th century was the beginning of a period of extraordinary cultural and social upheaval: populations were growing hugely, especially in urban areas, and people were travelling around the world as never before, experiencing new cultures and new ideas first-hand. This globalisation went hand in hand with the rise of the industrial age and the pre-eminence of the scientific model. The questions arising from the inception, spread and treatment of Spanish flu in 1918 had shown that that study of medicine required open-mindedness, experimental rigour and a healthy dose of humility. These concepts mirrored the scientific rigour required across many other fields that we consider bedrocks of our modern societies today; from psychology to physics, meteorology to mathematics.
Secondly, unlike a hundred years ago, in 2021 we are not adventurers beginning a journey of discovery about the world beyond our birthplace, nor are we enraptured with the possibilities of new scientific avenues of discovery and exploration. Nor (thankfully) are we celebrating surviving such catastrophes as the Spanish flu or the First World War. We have connected ourselves through technology and infrastructure to the rest of the world in an unprecedented way and are constantly bombarded with new ideas and new ideologies. We have developed our sciences to the point where our medical professionals can create vaccines within months and roll it out to a global population at a hitherto unheard-of speed.
Instead, today’s problems have as much to do with the existential as the concrete. Tackling climate change, for example, or global poverty or racial discrimination is as much a matter of collective will and changing societal norms as it is of science or industry. My hope is that the most positive change to come out of our experience of Covid-19 is not that of amazing parties (though I’m certainly looking forward to those as well!), but the conscious realisation that humans can indeed choose to make radical changes, and to accomplish truly extraordinary things in a very short space of time, if we really want to. These changes are something that we need to understand and be prepared to do again – and quickly - if we are to survive the next threat to our existence, be it the next pandemic or the results of climate change.
[i] M.C.J. Bootsma and N.M. Ferguson, ‘The effect of public health measures on the 1918 influenza pandemic in US cities’, Proceedings of the National Academy of Sciences, 1 May 2007
[ii] AIR Worldwide
[iii] The Commission on Creating Global Health Risk Framework for the Future, an independent, international group of experts convened by the US National Academy of Medicine in 2016. A. Gulland, ‘World invests too little and is underprepared for disease outbreaks, report warns’, British Medical Journal 2016