The disease that dwarfed a war: Spanish Flu

Catastrophic events are sometimes useful for the lessons they teach us. Like when the local football team you play for got thrashed 15-0 and from that moment on you unanimously decided never to play Jim in goal again. These disasters are useful because they give you tangible examples of what to avoid at all costs in the future.

Likewise, when struggling to assess the risks posed by the viruses circulating today it is often useful to turn to history for relevant examples. As examples go, it’s fair to say that the Spanish flu outbreak of 1918 is difficult to trump.

This pandemic killed more people more quickly than any disease in recorded history. In just a couple of years the virus had spread across the war-torn world, killing an estimated 50 million people in its destructive path. Just to put this figure into perspective, the world population at this point was a mere 1.8 billion, meaning the virus wiped out close to 3% of humanity. Today the population sits around the 7.3 billion mark, so if a virus killed 3% of the population now that would equate to a whopping 219 million people, or nearly 70% of the entire population of the US.

Sp-flu-alberta-field
Although this looks like an edgy album cover it’s actually depicting Canadian farmers trying to protect themselves from the Spanish Flu

When considering the ghosts of pandemics past, the devastating bubonic plague that decimated the population in the 14th century is often cited as an example. However even this horrendous outbreak pales in comparison: more people died in a single year of the Spanish Flu than in four years of the Black Death.

So what made this particular flu outbreak particularly devastating?

In short, the pandemic kicked off because a large majority of the population had never been exposed to this particular strain of flu before and therefore had no immunity to it, then its spread was accelerated beyond belief by the appalling conditions of the war.

The war was also to blame for the name of the outbreak. With both sides desperate to avoid looking weak at this crucial military period, the devastating truth regarding the number of fatalities was kept firmly under wraps. Whereas the neutral Spanish had a far fewer restrictions on the press, so were the only ones who reported figures in all their shocking accuracy. This made it look like the pandemic had focused a disproportionate fury against the Spanish, hence the name.

One of the hallmarks of this outbreak was the age of the majority of victims. Flu traditionally kills the very young and the very old, preying on those with the weakest immune systems who make the easiest targets. However the 1918 outbreak was startlingly different, decimating 20-40 year olds. A recent study claims that this is because people in this age group lacked resistance to the H1N1 strain that caused the pandemic, as they had been exposed to a fundamentally different H3N8 virus, which provided them with no protection when the onslaught began in 1918. The following graph shows the clear ‘W curve’, with a worrying spike in the 20-40 age range: just the age that people were going to war.

W_curve
The additional spike in deaths that give us the W curve

This is like almost dying of dehydration in a drought one year, so ensuring you have ample supplies of water the following year only to find your house flooded. The water supplies are now completely useless because you are faced with a completely new threat.

Although examining the causes of the 1918 outbreak is a useful exercise, the real issue is how we use the harrowing example to prepare ourselves for the inevitable flu pandemics of the future. How do we get Jim to play in midfield rather than in goal, so to speak.

Thankfully pretty much every facet of life has advanced since the grim, war-ravaged world of 1918, with the dawn of the internet allowing news of pandemic threats to spread almost instantaneously, vaccines able to provide a potent defence against infection and general conditions of sanitation having improved beyond recognition.

But despite these vast contrasts, there are certain aspects of the response to the 1918 outbreak that we can learn from. One is the adoption of effective mass public health advertising. In 1918 James Niven, Manchester’s Medical Officer of Health, distributed 35,000 paper leaflets with clear and concise information on avoiding infection and isolating the unfortunate victims. As a result of Niven’s pioneering work, only 1,700 Mancunians died from the outbreak, compared to 10,000 Londoners. In 2009 the BBC released a poignant television drama following Niven’s work in the autumn of 1918, give it a watch if you have a spare hour and are not feeling too sad (SPOILER: it’s not exactly a laugh-a-minute).

Rather appropriately, this drama was released during the panic of the swine flu outbreak, while adverts like the one below were being broadcast. This shows that Niven’s simple methods of giving the public a no nonsense message have clearly stood the test of time.

There have been several serious flu outbreaks since the 1918 catastrophe, most notably the Asian Flu in the late 1950s and the Hong Kong Flu in the late 1960s, both of which killed over a million people.

Perhaps Niven’s influence on the 2009 swine flu prevention tactics was even more apt, because it was actually the same strain of influenza – H1N1 – that caused both the Spanish Flu and the 2009 swine flu outbreak. In this way the story comes full circle.

The Spanish Flu provides an unavoidable example of the devastation that can be caused by a pandemic influenza virus, one that should be used as a justification for the attention and money that should be used preventing a similar outbreak in the future.

Pandemic Potential = 10/10

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