In 1918, the Spanish flu killed more than 50 million people around the world. The lessons of that outbreak could save countless lives in the fight against the coronavirus
By Jonathan D. Quick
The Wall Street Journal
March 6, 2020
The “Spanish” flu of 1918 was one of the deadliest pandemics in human history. Seeming to come from nowhere in the waning days of World War I, it spread through a war-ravaged world like wildfire. In a matter of months, a third of the world’s population was infected, 50 to 100 million people died, and the global economy shrank by 5%.
The world of 1918 was very different from today’s, where the new coronavirus is emerging as another potential pandemic. A century ago, antibiotics, modern hospitals, intensive care units and instant communication did not exist; most people lived in rural communities; intercontinental travel took weeks rather than hours. Now the world’s population is four times larger, with more than half living in urban areas. National economies are heavily intertwined because of globalization. Health services are highly sophisticated in wealthy countries, though their quality varies greatly in the rest of the world.
From a public health perspective, however, there are important similarities between the 1918 flu and the 2019 coronavirus. Both were previously unknown viral strains for which there was no existing vaccine or proven medical treatment. Both spread through respiratory droplets and killed primarily by means of pneumonia and other complications. Both caused severe economic disruptions. With the growing risk of a full-blown pandemic, applying the lessons of the 1918 flu could save countless lives in 2020.
Provide effective leadership. In 1918, Philadelphia was one of the hardest-hit American cities, partly because it was, as the muckraker Lincoln Steffens put it, “the worst-governed city in America.” In his book “The Great Influenza,” the historian John M. Barry describes the efforts of Dr. Wilmer Krusen, director of Philadelphia’s Public Health and Charities department, a well-intentioned man who lacked public health experience and was prone to inaction. On Sep. 28, 1918, he allowed the city to proceed with a Liberty Loan parade to sell millions of dollars in war bonds, despite warnings that the event would spread illness. The parade drew 200,000 people; within 72 hours, every bed in the city’s 31 hospitals was filled.
By contrast, Mr. Barry shows, St. Louis had the most success of any large American city in fighting the pandemic. Dr. Max Starkloff, the city’s health commissioner, said that his goal was to “keep the epidemic out of the city, if possible, and if that fails, to use every means to keep it down to the lowest possible number of cases.” He created an advisory body that included representatives of the city’s chamber of commerce, schools, medical society, university, Red Cross and local public health services. He pursued what he called “intelligent citizen cooperation” through active outreach to the community. And he engaged health department staff, policy makers and teachers to implement individual quarantines and bans on public gatherings. Thanks to Starkloff’s rapid, inclusive and systematic efforts, St. Louis’s mortality rate from the flu was half of Philadelphia’s.
Leadership mattered even more at the national level. President Woodrow Wilson was so focused on winning World War I that he would not listen to repeated warnings about the pandemic from the chiefs of the Army and Navy, or even from his own personal physician. The U.S. ended up losing 675,000 lives to influenza, compared with 53,000 killed in combat in World War I.
The past century has reinforced the importance of thoughtful, principled, decisive leadership in combating epidemics. Smallpox was officially eradicated in 1980, in what might be the greatest achievement in the history of public health. Dr. D.A. Henderson of the U.S. Centers for Disease Control and Prevention was the tenacious advocate who convinced the World Health Organization to take up the challenge of eliminating smallpox everywhere in the world; he then led the campaign to victory.
In 2003, President George W. Bush launched his Emergency Plan for AIDS Relief, which was crucial in helping the people of Africa to confront the AIDS epidemic. He announced the program with words of grace and compassion, without blame or judgment: “I propose … a work of mercy beyond all current international efforts to help the people of Africa…. This nation can lead the world in sparing innocent people from a plague of nature.”
Rely on classic public health measures. In 1918, the lack of national leadership meant that every city and state pursued its own approach to dealing with the epidemic. This created a series of natural experiments that allowed later researchers to assess the effectiveness of different approaches. They found that cities which implemented isolation policies (such as quarantining houses where influenza was present) and “social distancing” measures (such as closing down schools, theaters and churches) saw death rates 50% lower than those that did not. The cities that fared best were the ones that started isolating patients early and continued until the epidemic was unquestionably under control.
In the century since the 1918 outbreak, studies of seasonal flu infections and occasional pandemics have underscored the benefits of hygiene instruction and regular handwashing, which can reduce influenza cases by more than 40%. During the 2009 “swine flu,” school closures in Texas reduced acute respiratory illness by 45% to 72%. Such classic public health measures are sometimes as effective as the seasonal flu vaccine, which reduced infections by less than 40% in four of the last 12 U.S. flu seasons.
Give accurate information and build community trust. In every pandemic, people fall prey to stigmatization, distrust and rumor-mongering. The “Spanish” flu, as the 1918 pandemic is still widely known, did not originate in Spain. Rather, because the country was neutral in World War I, its uncensored press was the first to report on the disease. As a result, many around the world blamed the Spanish for the epidemic, and the nickname persists to this day.
As the flu spread in 1918, many communities found scapegoats. Chileans blamed the poor, Senegalese blamed Brazilians, Brazilians blamed the Germans, Iranians blamed the British, and so on. In the U.S., the country’s millions of new immigrants had often been stigmatized as disease carriers during previous epidemics, but the 1918 flu struck every social class and every part of the country, so no single ethnic group was blamed for it.
Some populations, though, were more vulnerable to the disease than others. A study of data from 438 U.S. cities, published last year in the journal Economics and Human Biology, found a wide variation in pandemic-related mortality rates in 1918, ranging from 211 deaths per 100,000 people in Grand Rapids, Mich., to 807 in Pittsburgh. Half of this difference was attributable to three factors—poverty, prior health status and urban air pollution. The same will likely be true with the coronavirus, which means that ensuring prevention and care for the most vulnerable is vital for saving lives.
Remarkably, despite the ubiquitous daily horror of the 1918 flu, there were few instances of flu-related attacks or riots. On the contrary, in her book “Pale Rider,” the science journalist Laura Spinney finds many examples of good Samaritans. In Alaska, 70-year-old Dr. Valentine McGillycuddy came out of retirement to fight the flu; in Tokyo, doctors went out at night to give free vaccinations to the poor; in Germany, the Catholic Church helped to train young women as nurses.
During pandemics, the reflex to help one another is more common than we might think. At the deadliest moments in 1918, when city governments in the U.S. were overwhelmed, volunteer groups—from Phoenix’s citizens’ committees to Philadelphia’s bluebloods—stepped in to distribute resources to those in need. When communities did lose trust in their leaders, it was often because, in Mr. Barry’s words, they had lied about the severity of the pandemic “for the war effort, for the propaganda machine that Wilson had created.”
What the public needed was accurate answers to the questions raised by the appearance of an unfamiliar, deadly disease. Where did it come from? How could I get infected? Can I pass it on to others? How can I protect myself and my loved ones?
The historian Nancy Tomes has shown that in 1918, since radio broadcasts and newsreels were focused on war news, people turned to the print media for information on the flu. From trade magazines like Variety to scientific journals such as Survey, journalists asked difficult questions about how the epidemic was being handled and presented the best available answers to their readers. In the face of highly variable responses from public officials, the media served as an essential ally of the public health community in fighting the pandemic.
As we now face the specter of a coronavirus pandemic, it is reasonable to ask: Are we more or less vulnerable today than we were a century ago? In some ways we are clearly better off. We have modern vaccines and medical care, dramatically improved communication tools and healthier, better nourished populations. Modern governments plan in advance for how to respond swiftly to outbreaks, and there are mechanisms in place for international cooperation.
Yet according to the 2019 Global Health Security Index, less than one in five countries is fully prepared for a global pandemic. More than a billion people don’t have access to essential prevention services, vaccines and medicines, and most of the world lacks intensive care services capable of handling severe cases of the coronavirus.
And we are vulnerable in other distinctively modern ways. Growing resistance to many antibiotics makes it hard to treat pneumonia and other bacterial complications. Large numbers of people suffer from heart disease, diabetes, cancer and other diseases that weaken the immune system. Rapid international travel has spread the virus at lightning speed. And as we are already seeing with the new coronavirus, globalized supply chains, dependent on just-in-time delivery of medicines, food and other essentials, are vulnerable to disruption in a global pandemic.
This face-off between the factors that reduce our vulnerability and those that increase it leaves humanity at considerable risk. Thousands, possibly millions, of lives depend on our ability to apply the lessons of 1918 and other pandemics. Only by taking full advantage of scientific and public health advances, investing in strong health systems and developing new technologies to prevent and respond to disease will we be able to meet the challenge of the new coronavirus—and the other outbreaks that will inevitably follow.
Dr. Quick, an adjunct professor at the Duke Global Health Institute, is the former president of Management Sciences for Health, a global public health organization, and served as Director of Essential Drugs and Medicines Policies at the World Health Organization.
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