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COVID-19 and Lessons from the Spanish Flu
In 1918, humanity faced a deadly global pandemic– the Spanish Flu. The CDC estimates that the disease killed at least 50 million people and infected a third of the world population.
Today, hand-washing and physical distancing are a part of daily life, as are grim tallies of the sick and the dead.
Even though science has made tremendous advances since then, our methods for slowing the spread of the novel Coronavirus are very similar to those used 100 years ago.
Within the social and political climate of 1918, we will examine how the people who lived a century before us responded to the crisis of a global pandemic. There were important and encouraging lessons to be learned then about prevention and readiness, as there are today from COVID-19.
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Featuring: Making Contact Staff:
Making Contact Staff:
Monica Lopez: This week on Making Contact
Flu is the Democratic Disease because nobody’s immune to it. Rich, poor, everyone can catch the flu, but actually it’s not quite accurate. Everyone can catch the flu. But the people who are the most vulnerable to it are the people who, for example, living in poor substandard accommodation or they’re overworked or they’re malnourished or they’ve got poor access to healthcare.
And those things, unfortunately, align with people who are the poorest in society. So socio economic status has a major impact. Even today in disease outbreaks, it undoubtedly will in this COVID-19 pandemic. And it certainly did in 1918.
I’m Monica Lopez and this is Making Contact. Just over a century ago, humanity faced a deadly global pandemic. The Spanish flu. The Centers for Disease Control estimates that the disease killed at least 50 million people and a third of the world’s population was infected.
By the time this show went to air, my hometown of Los Angeles was among 75 percent of the U.S. population living under some kind of stay at home order to limit the spread of Covid19.
Hand-washing and physical distancing are part of daily life now, as are grim tallies of the sick and the dead. And even though there have been tremendous advances in science, our methods for slowing the spread of this new Coronavirus are pretty much the same as people who were avoiding the Spanish flu one hundred years ago.
Today, we’ll look at what was going on socially and politically in 1918 and examine how the people who lived a century before us responded to the crisis of a global pandemic.
There were important and encouraging lessons to be learned then about prevention and readiness, as there are today from Covid-19.
In this program, we’ll hear excerpts from a conversation with Laura Spinney, science journalist and the author of Pale Rider The Spanish Flu of 1918 and How it Changed the World.
Spinney begins by explaining the trajectory of how the Spanish flu spread.
Flu pandemics do seem to have this characteristic pattern that they come in waves and that theres an initial Herald wave. It’s particularly cruel if you think about it, because we kind of lulled into a sense of false security by that first wave and then it goes away and then the real thing hits. So the idea now is that a very virulent pandemic strain kind of emerged in the early months of 1918 through a background of the usual seasonal flu.
And so it didn’t seem so bad. It was kind of pushing through a background of milder flu. And perhaps at that stage, this new strain had not yet acquired the ability to transmit easily between human beings. Then something happens around the late spring, early summer, and the virus mutates and it becomes highly transmissible amongst human beings.
And then that pure pandemic strain comes back with a vengeance in the late summer. That’s the idea. And there’s good evidence for it in the sense that scientists sequenced the genome of the virus that caused the pandemic strain from 1918. They sequenced it back in 2005. And they have samples from people who died of the spring wave and people who died of the autumn wave. And they can compare those sequences and they can see how they changed.
One of the problems with the Spanish flu, as with any flu pandemic, is it doesn’t really fit a nice linear narrative.
The number of waves and the timings of the waves depended on why you were in the world and they were staggered within in the southern hemisphere with respect to the north. So they came later in the south with respect to the north. That’s why we normally say that the pandemic lasted two to three years (its quite difficult to measure the end of the pandemic), but two to three years because those waves came later in the south. So if you’re talking about the northern hemisphere, then we generally speak about three waves. We start with a sort of mild one in the northern hemisphere spring of 1918. That wasn’t that different from seasonal flu and caused the usual sort of havoc, but nothing too dramatic, especially in a world that was at war–so it was kind of the least of their problems–And it went away later that spring, early that summer. And then you got the second wave, which is really the wave.
This was the major wave of death. It was so different from that first wave that people called it a different disease they considered it was not the same disease in the sort of tail end of August 1918.
The most commonly accepted estimate suggests that 50 to 100 million people died in the world of the Spanish flu. And the vast majority of those deaths took place in the 13 weeks between the middle of September and the middle of December 1918. So this vicious second wave then retreats towards the tail end of the year. And then there’s a sort of a recrudescence in the early months of 1919, which we kind of refer to as the third wave. And that was intermediate in severity between the other two. There is a school of thought that that wasn’t really a separate wave. It was kind of the tail end of the second wave with interruptions due to end of year holidays, Christmas and Hanukkah and so on, which meant that people’s patterns of movement and collecting together changed. And so that changed the pattern of the of the wave and how it rolled out.
The consequences of losing at least 50 million lives to the Spanish flu over a few short years were catastrophic. Equally devastating was that adults in the prime of their lives were very susceptible to the disease.
So just a preliminary note about Covid-19. Up to now people have been saying that is the elderly and the people with other conditions who are particularly vulnerable. But I think that’s not all who’s vulnerable.
The people in the intensive care units also, in some cases, much younger. However, Spanish flu very clearly differed from seasonal flus in that age profile respect. Most flus are worst in the very young and the very old. So they have a kind of U-shaped mortality curve. And that one had famously W-shaped mortality curve, which means that there was a middle age group of adults aged between 20 and 40 who were also particularly vulnerable. And in fact, the right hand stroke of that W was lower than it is usually in a flu season, meaning that elderly people seem to have been slightly more protected in the pandemic than they were in the usual flu season.
But there was a group of adults in the prime of life who were particularly vulnerable. And that’s one of the reasons why this pandemic was so devastating to human communities, because it wiped out the productive members of those communities, the breadwinners, the pillars, the fathers, mothers. And at a time when there was really no safety net to speak of, even in wealthy countries, to catch those who were left behind– the elderly parents and the young children, mainly
As with many public health concerns, there were other determining factors that raised or lowered a person’s chances of dying from the Spanish flu. It wasn’t limited to age
The flu is called the Democratic Disease because nobody’s immune to it. Rich, poor, everyone can catch the flu, but actually it’s not quite accurate. Everyone can catch the flu, but the people who are the most vulnerable to it are the people who are, for example, living in poor, substandard accommodation, where they are densely packed. And maybe the living arrangements are not well ventilated or they’re overworked or they’re malnourished or they’ve got poor access to health care or they have underlying conditions.
And those things, unfortunately, align with people who are the poorest in society, generally, the people at the bottom of the social ladder. So socio economic status has a major impact. Even today in disease outbreaks, it undoubtedly will in this Covid-19 pandemic and it certainly did in 1918.
So if I was to give you the example of India, which was a British colony at the time, 18 million Indians died. we estimate in the Spanish flu, which is the equivalent of the entire death toll of the First World War.
And it highlighted when the pandemic struck India, it highlighted really how pathetic the health care provisions were of the colonial authorities for the indigenous population. I mean, they weren’t brilliant for the white colonialists either–and a lot of doctors were away at the front.But there was practically nothing for Indians. And that became blatantly clear.
And in fact, interestingly, the people who sort of stepped into the breach –because there were no doctors, nurses to look after the people who were suffering in such large numbers, especially in outlying areas– were the people who had already organized themselves to some extent in the fight for independence. So India has a very cast- ridden society, but these were people who had managed to reach out of their own classes and costs to each other in order to fight in the name of independence. And because they’d managed to do that, they also managed to coordinate themselves to help in the public health effort. Now, perhaps what they did didn’t make that much difference because they were no better off than doctors at the time in terms of treating this disease.
But it had a major social impact, what they did and long term consequences, interestingly, for the fight for independence.
Monica Lopez: You’re listening toCovid-19 and Lessons from the Spanish flu on making contact. And Laura Spinney, science journalist and author of Pale Rider The Spanish Flu of 1918 and How It Changed the World.
Very special. Thanks to KPFA Radio and Sasha Lilley of AGAINST THE GRAIN for allowing us to edit and broadcast this interview. To hear the entire interview, their site is here.
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Coming up, science journalist Laura Spinney describes how this massive public health crisis of the Spanish flu forced countries to grapple with systemic inequality and social unrest, and eventually led to universal healthcare.
So I mentioned earlier the socio economic effect and people werent blind to it. They were seeing that, you know, the poorer and the working classes were the ones who were taking the brunt of it.
Just to give you a nice little vivid detail, I think is the fact that in Paris, where I live, one in four women who died of the Spanish flu was a maid.
And for a long time, just also to speak to that socioeconomic point, epidemiologists were puzzled by that observation that one of the highest death rates in the capital, the French capital, Paris, was in some of the wealthiest districts until they realized that the people dying, they weren’t the owners of the of those addresses. They were the maids and the servants who were living in the chilly le grenier upon the tops of the houses. So that socio economic effect was very visible. And I mean, the turbulence was that already the class tensions were there. There’s no doubt about that.
You know, this was the time of the Russian revolutions just earlier, a few years earlier. And the Russian civil war. And it was most definitely in the air. Even the United States was a red scare around 1921. But you have, I think, the Spanish flu feeding into that and exacerbating it in many parts of the world, even in Switzerland, well organized Switzerland, because in the Swiss military, it was noticed that it was the men in the ranks who were feeling sick in droves and not the offices. And, you know, it just kind of fed a general disgruntlement. And Switzerland came very close to revolution in the autumn of 1918 that managed to avoid it.
Laura Spinney explains that in the early nineteen hundreds, people expressed their long held beliefs about race and class much more openly. And that contributed to how the pandemic affected different populations.
I t’s not very widely recognized, perhaps, that the whole idea of eugenics, which was so discredited after the Nazis took it up in the 1930s, was actually quite a mainstream idea in the time of the First World War and the Spanish Flu. So in a lot of countries, there was an idea that if the lower classes caught these infectious diseases and died in large numbers, it was something to do with them, with their sort of lack of fiber and their lack of they would just, quote, poorer quality human beings who hadn’t the drive to succeed in life and to have a better quality of life in general.
One of the reasons the British were so slack in India and they weren’t I mean, they weren’t the only ones was that they felt it was something that the native Indians were to some extent responsible for their own misery. And there was nothing you could do about it.
And public health meant containing those diseases in the underclasses, not letting them spread to the elites. That was that was very much the mainstream mentality then. And I think what the pandemic showed in 1918 in no uncertain terms, was that you could not blame an individual for catching a disease or treat them, him or her in isolation. It was a social problem and had to be treated at the level of the society, at the level of the population. And so although the idea of kind of socialized medicine, universal health care that’s available to everybody had been floated from the late 19th century, particularly in Germany, Germany was a pioneer in this, nothing had really come of it so far.
And that’s not surprising, given that it takes time and a great deal of effort to put such a system in place. I mean, first we have to work out how are you going to pay for it? The Germans had a sort of national insurance scheme from the late 19th century, which pretty much lives on today in the in the method that it uses to pay for health care.
And so you have to do that first and then you have to reorganize the way you you do you distribute health care, because in the 19th century, doctors were generally either self-employed or employed by charities or religious institutions. They were not organized in a sort of a national nationwide system with community district provincial levels as they are very much more today. So it’s a massive task to put in this system.
And what I argue in my book is simply that the pandemic gave it (universal healthcare) a huge stimulus because it was it it was realized that you had to tackle this as soon as it happened and you had to tackle it across the board.
So I think every nation, a big nation, knew whether it was capable of doing such a thing, realized that. And you see starting in the 1920s, the kind of consolidation and reorganization of health care systems everywhere, but different countries took different approaches to particularly the way they paid for it.
So in in the in Europe, many nations following the Russian model, sort of went the way of national insurance schemes and you pay for it indirectly through your taxes. But the care is free at the point of delivery.
Whereas in the states a different model was pursued has to be said partly because of fear of communism and too much state intervention where it would be paid for instead by employer based insurance schemes. And those kind of proliferated through the 1930s. But in a way at the time, even though they were paying for it by different methods, the underlying concept was the same, which was to expand access to healthcare and make it far more organized in a nationwide sense and accessible to all, or to as many as possible.
Spinney explains that the Spanish flu pandemic of 1918 receded gradually over time with further outbreaks of milder disease.
So every strain of seasonal flu that is now circulating in the world started as a pandemic strain. It started as a new strain in human beings. That was very virulent because I hadn’t yet encountered us as a host. And then because it’s in the flus, so to speak, evolutionary interest to moderate its virulence over time because it wants to keep us alive –us its host- in order to spread it far and wide. It gradually evolves over time to become more mild or less virulent. And so we kind of live with it in a more of a harmonious equilibrium with these occasional outbreaks of seasonal flu. So that’s what you see.
That’s why a pandemic never really ends. It just recedes gradually as the virus mutates, evolves and becomes less virulent. And that’s why the shape of a pandemic or an epidemic is. Is that kind of bell curve. So you see the pandemic coming on gradually. It doesn’t have a kind of concrete start either. It comes on as it emerges in the world and becomes transmissible between human beings. It peaks.
Well, it kind of increases exponentially to start with, because as it emerges, it encounters this completely immunologically naive population, which is us, and it’s surrounded by susceptible hosts. So it grows very quickly to begin with. And then either as people die or as they gain immunity because they recover, the pool of susceptible hosts shrinks.
And so you see the pandemic peaking, leveling off, receding. And then at the same time, you’ve got the the virus begins to mutate and become more benign. And so it’s still there circulating for a long time after, but it’s getting gradually milder.
So the flu recedes around 1920, 21, depending on where you are in the world.
But then there’s a kind of wave of, I suppose we might call it post-fire fatigue. You know, it had been a very vicious flu. And the people who recovered from it went through, very often, at least according to anecdotal and medical reports, a kind of phase of fatigue and lassitude and an even depression.
And in some parts of the world, there are even there’s even evidence that that affected the economy that, you know, so many people were kind of knocked out for a time that the economy actually suffered.
Monica Lopez: when the flu finally receded, it left behind a devastating loss of life and livelihood. Assessing that loss proved to be very difficult.
The figure that is generally given for Spanish flu case fatality rate, i.e. the proportion of people who feel sick with it, who go on to die is around 2 percent, 2.5 percent. But that’s incredibly hazy because there was no reliable diagnostic tests at the time.
So we really don’t know the exact numbers of who got sick. It’s always easier to calculate the number of dead because it’s hard to ignore them. But who is sick? Who is staying at home and not declaring their sickness? Perhaps because it’s mild or who is not suffering from flu, but some other respiratory infection is much harder to get at. And retrospectively, obviously, it makes it even harder.
So that and of the comparison in 1918 is a moving target and it’s often pointed out to me, why do you say that the CFR case fatality rate from 1918. Why do you repeat this figure of 2.5 percent? When we now work with 50 million at least dead and of an estimated 500 million cases in the world, which would give you a CFR of 10 percent. And if it’s hundred million dead, that’s 20 percent. I mean, I think both those numbers are possible, but the higher up you go towards global estimates rather than kind of city or country estimates, the vaguer you get and the harder it is to rely on those figures because they were for for one reason alone and there are many others, which is that they were counted differently in different countries. So obviously it’s useful to pool those numbers in order to get a sense of the global impact of that pandemic. But when you want to calculate things like lethality, it’s very difficult to use those figures.
So that’s why it’s hard to say whether it was 2.5 percent, 10 percent, 20 percent, but 2.5 percent. There’s there’s good reasons for working with that figure. Again, you know, with all the caveats that is uncertain because it’s drawn from places where the data was relatively well collected. So let’s say it’s 2.5 percent.
Now, moving on to Covid-19: On the original Chinese data, I think it was last week (ED Note: week of March 11th) the W.H.O. announced a provisional CFR of 3.4 percent. Now, obviously, that is alarmingly high if it’s true, but we can’t rely on that either because many more cases, again, may have gone unreported.
There may have been, for example, a situation where the hospitals in Wuhan were just overrun and could only take the most severe cases. So they weren’t seeing the less bad ones. It’s not to be taken as a final figure by any means. And the number of experts that I’ve spoken to, epidemiologists, experts in infectious diseases and so on, they say that they believe it will settle somewhere around 1 to 2 percent, which is still very high. The aught point one, the CFR that is given is typical of flu pandemics is around nought point one percent. So one to two percent is high. And it means that this is serious stuff. We need to take it seriously. At the same time, people have to understand, well, what hides behind these numbers.
We’re in a really interesting period now because we’re in this period where we have no vaccine. And so our best hopes of what are collectively known as social distancing measures that things like quarantine, isolation, masks, hand-washing, you know, self isolation, all these things which essentially work by keeping the sick and the healthy apart and so slowing the spread of the disease. And those do not change really very much over time. They are the same techniques that were being used in 1918. So I think that when you talk about social distancing, then, you know, the historical parallels do become valid.
And I think another lesson we’ve met we’ve learnt from 1918 on is that imposing health measures doesn’t work, at least not in our relatively free societies. And not, you know, I mean, it worked in China. They pulled it off. But I have to say, from what I’ve been reading, it was a fairly close run thing. I mean, imagine if you had 60 million people under lockdown and you had a rebellion, that would be quite hard to contain.
There were riots in the Sars outbreak in China 18 years ago when the government was very, very less transparent with information than it was this time. And even this time, the people broadly complied. There was a lot of frustration expressed on social media in China, especially after the death of the so-called whistleblower doctor. There was huge outrage expressed. So I think it was a gamble even on the part of the Chinese government.
Our governments and governments in general and the W.H.O. know that it’s far better if people comply voluntarily with public health measures. And but for that to happen, they need to be well-informed. They need to understand the level of threat they’re facing. And they have to trust the authorities to be telling them to do the right thing. They have to trust them to be acting in their collective interest.
Epidemiologists had been on the lookout for coronavirus outbreaks in October of 2019. Public health workers and government leaders even took part in a fictional coronavirus pandemic simulation hosted by Johns Hopkins Center for Health Security.
And as Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has repeatedly stated, a disease like COVID- 19, is the thing that’s kept him up at night. In late March, Fauci said that a second wave of covered 19 could emerge in the fall of 2020, but that the U.S. would be much better prepared to face it.
I think that disease outbreaks, even zoonotic outbreaks, the spillover of pathogens, new pathogens from animals to us, is probably something that we can’t stop altogether.
What we can do is stop those events turning into global health crises of the kinds we’re confronting right now.
And in order to do that, we need to have better surveillance at that animal human interface.
We need to invest in more robust health infrastructure all over the world, because as we’re seeing yet again, we’re only as safe is at least safe place. So we need to invest in health infrastructure in the poorest countries as well as the richest. We are doing better We do learn from each, you know, each catastrophe, I think. Each disaster.
There was a new ranking that was released last October by Johns Hopkins, I think, and various other organizations whose names I’ve forgotten ,called the Global Health Security Index. And that’s very interesting because it ranks countries on their pandemic preparedness along various different dimensions.
And so now we can see where each country’s weakness is when it comes to preparing for pandemics. No country is perfect. But, for example China –which is very strong on many things– detecting and responding to new pandemic threats, for example– it is not strong on prevention and particularly in the food security area.
So clearly now China needs to invest more in that. Ummm It perhaps didn’t act fast enough after the SARs outbreak to regulate the so-called wet markets–the live markets in animals– from where this new pathogen seems to have sprung. But these are things that take time to do so after, SARs the Chinese government –unLive markets, it didn’t work. They just went underground and became black markets. And it’s a very big part of Chinese culture. And in some parts of China, up to 60 people rely on those markets for up to 60 percent of their food.
So it’s not something that can be banished in one fell swoop. It’s something that needs to be regulated in an evidence-based way and subjected to much more rigorous surveillance. And if that’s one lesson we take away from this pandemic, then then that would be very good.
You’ve been listening to Laura Spinney, science journalist and author of Pale Rider The Spanish Flu of 1918 and How It Changed the World. Spinneys comments originally came from an interview with radio producer Sasha Lilley at Against The Grain at KPFA fm Making Contact Team is executive director Lisa Rudman, producers Anita Johnson, Salima Hamirani and Monica Lopez; associate producer Aysha Choudhary, audience engagement manager Katherine Styer. And I’m this week’s host, Monica Lopez. Thanks for listening to Making contact.