Covid-19 and the 1918 ‘Spanish ‘flu’: differences give us a measure of hope

Michael Bresalier | 02 April 2020

From the moment it became evident that the new coronavirus would become pandemic, there have been an outpouring of comparisons with the 1918 influenza. We have learned of its devastating death toll (50 million worldwide, equal in proportion to 200 million today), of effective and ineffective efforts to limits its spread, of its crippling impact on healthcare systems, of its costs to nations, communities, families and individuals, and of the failure of governments to take the threat seriously and to prepare their populations. 

A recent article by David Morens, Peter Daszak and Jeffery Taubenberger in the New England Journal of Medicine highlights the 'alarming similarities’ between Covid-19 and the 1918 influenza pandemic, not least in terms of how both respiratory infections initially spread under-the-radar and then suddenly ‘exploded… almost everywhere at once’. Few are better placed to draw such comparisons: Morens and Taubenberger have been studying the virology of the 1918 pandemic for decades. Their work, including sequencing the 1918 virus and reconstructing its epidemiology, has been key to establishing the pandemic as the essential historical reference when other epidemics and disease emergencies strike. 

As a historian of influenza, I see much value in looking to 1918 for lessons. But I am also wary about what we want it to teach us and how it is used. In the rush to find parallels, important differences between the two pandemics get quickly obscured. We lose sight of how much has changed between then and now. 

It is worth taking stock of a few critical differences between the 1918 influenza and Covid-19 and what these can teach us. 

A war pandemic

It is essential to remember that the 1918 pandemic emerged in the midst of the First World War. As many historical epidemiologists have pointed out, war conditions – especially intercontinental troop movements throughout 1918 – not only facilitated the rapid spread of influenza virus, but in all likelihood helped escalate its virulence. 

But the war was also important in shaping responses. Wartime censorship restricted reporting on the early spread of the pandemic and lead to it being incorrectly labelled ‘Spanish ‘flu’. The war meant that there was little sharing of medical and scientific information between countries, even amongst allies. Medicine was mobilised for war. Medical and military officials prioritised the health of their own militaries and nations. Indeed, for military planners on either side of the conflict, strategic advantage could be had in not sharing information about the disease.

In almost every country, war priorities had to be balanced against public health and medical priorities. While these were not always at odds, for combatant nations, winning the war was more important than winning the battle against influenza. As the toll of the pandemic sky-rocketed before the end of the war in autumn 1918, the response by Britain’s medical and military authorities was typical: the chief medical officer of health and the War Office counseled the nation to ‘carry-on’. With a few notable exceptions, authorities around the world adopted versions of this approach, with dire consequences. 

Medical systems and know-how

What did medical and public health authorities have in their toolkits to counter the pandemic? By 1918, influenza was widely understood to be a highly infectious disease, spread by person-to-person contact and through the air over short-distances. This knowledge was the basis for the adoption of a variety of social distancing and isolation measures – what we now call Non-Pharmaceutical Interventions (NPIs). As numerous studies have shown, where these measures were adopted early on and systematically, the incidence and case-fatality rate of the disease was lowered. But NPIs were, at best, adopted in a piecemeal manner, city-by-city or in larger cities like London, borough-by-borough. Only a handful of countries, notably Australia, implemented country-wide quarantine, which slowed the introduction of the disease. No country adopted wholesale social distancing or isolation measures for their populations.

There are a number of reasons why NPIs were not systematically introduced. War demands were important. Lack of political will was another factor. Influenza was widely viewed as little more than a burdensome but generally mild malady. But also critical was what medical experts at the time did not know. Uncertainty reigned throughout 1918 about whether the disease was indeed influenza. Who it most affected, the severity and nature of the symptoms it produced, and how it killed – all of these did not conform to expected patterns. Most notably, there was widespread uncertainty about the specific cause of influenza. A loose medical consensus before 1918 held that the agent was a bacillus, first identified in the early 1890s. Systematic testing was virtually impossible because the bacillus was difficult to grow in cultures. Initially, it couldn’t be isolated with any regularity among the sick, raising doubts about its role or if the pandemic was in fact influenza. When it started to be found more frequently, researchers at medical, public health, military and commercial laboratories rushed to manufacture vaccines, most of which were made from a mixture of bacteria. While they may have had some effect on secondary infections, none of them prevented the disease. 

We now know that medical experts were fighting against the wrong agent: only in 1933 was a virus established as the cause of influenza. It was not that experts were ignorant or naive. They were acting on the best available scientific knowledge. It is just that ‘virology’ as we know it was not part of the standard medical toolkit in 1918 and it would not be until well into 1930s.

If the pandemic highlighted key limitations in the existing science of influenza, it also highlighted key limitations in existing health care systems. A standard image of the pandemic is one of medical and health systems being pushed to the point of collapse, with rows upon rows of men in makeshift cots. These have served as an analogue to the harrowing scenes from the Covid-19 outbreak in northern Italy, and a warning to others. But, without diminishing the human toll, we need to be cautious in making comparisons. Even the most highly developed health systems in 1918 – in Britain, Germany or the USA – bear little resemblance to present-day systems. National health services simply did not exist. The industrially advanced nations offered, at best, an uneven mixture of public and private hospital provision and access. Before the pandemic struck, these systems were already under immense pressure, with thousands of nurses, doctors, surgeons and other specialists having been commissioned to fight in the war. At least half of Britain’s nurses and doctors had been enlisted by 1918. Even if staffing was not an issue, hospitals could offer little more than nursing or palliative care to the sick: there were no respirators to assist with breathing; no antibiotics for complications resulting from bacterial pneumonia or similar respiratory diseases; and no antiviral drugs to be taken off the shelf and tested. 

Global health

It is on the international stage where we find the most striking differences between 1918 and 2020. The global health system that has been so crucial to the response to Covid-19 simply did not exist in 1918. While efforts had been made before the pandemic to coordinate international regulations and create formal bodies to monitor infectious diseases, these came to a halt during the war and would only be resumed in the aftermath of the pandemic. Nothing like the World Health Organization existed to advise on and align approaches, to facilitate the sharing of vital scientific information and resources, to encourage international cooperation or to highlight the potential impact of the pandemic, especially on the most vulnerable people in the world. There was no global response to the first-ever global pandemic.

In the absence of a global health system, countries were left to piece together their own approaches, sharing information of what others were doing and how best to prepare. Knowledge about what did or did not work came through informal, professional or diplomatic channels or, in the case of Britain, through the formal networks of the empire. The brute fact that the overwhelming burden of the pandemic fell on the shoulders of the peoples of India and China suggest that this system was wholly ineffective.

Covid-19 and history

Looking back to 1918 reminds us of how the conditions and capacity to respond to a pandemic have changed. It is not that there are no parallels or continuities between the two pandemics. There are many. Aeroplanes have replaced steamships in circulating people with viruses around the globe; some leaders have played down the threat or counseled business-as-usual; governments are trying to balance protecting their people with protecting their economies; many nations have decided on their own courses of action, despite WHO calls for international cooperation and alignment of responses. 

Pandemics can exacerbate social, economic and geopolitical divisions. But they also have the power to unify. Historian Samuel Cohn recently observed the striking ways in which pandemics bring societies together and inspire ‘individuals and communities to remarkable feats of compassion and abnegation.’ We are seeing similar remarkable acts of altruism with Covid-19. Medical and scientific communities across the world have come together. From the very beginning they have shared almost everything they have learned about the virus and how to control it. 

The past can provide important lessons, but every pandemic is also a step into the unknown. We need to bear in mind crucial differences in the context in which influenza and Covid-19 emerged, in the state of medical and scientific know-how, in health care infrastructures, and in the world’s ability to respond. We are in better position than ever before to tackle this pandemic. We have the science, medical technology, and systems to mitigate its impact. But they will not be effective without political will, cooperation, and the sharing of vital medical and scientific resources.

Putting Covid-19 in historical perspective reminds us that each pandemic brings with it unique problems that require unique solutions. It can teach us how we got to where we are now. And provide us with a measure of hope.

References

Cohn Jr., Samuel K.  Epidemics: Hate and Compassion from the Plague of Athens to AIDS (Oxford: Oxford University Press, 2018).

Morens, D.M., Daszak, P. and Taubenberger, J.K.  “Escaping Pandora’s Box — Another Novel Coronavirus.” New England Journal of Medicine online.  

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• Bresalier, Michael
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About the author

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Michael Bresalier is a historian of medicine and international health at Swansea University, UK. He is the editor of 100 Years of Influenza: Afterlives of the 1918-19 Pandemic (Routledge, forthcoming) and is currently completing a manuscript on the history of British influenza virus research, The Viral Pandemic: Science, medicine and the making of modern influenza.