Coronavirus: what might we learn from pandemics in the past?
As Covid-19 dominates the news, read our interview with Laura Spinney (author of Pale Rider, an account of the 1918 influenza pandemic known as Spanish flu) from the HistoryExtra podcast. In the interview, Spinney draws historical parallels with other pandemics in history and asks what we might learn from disease outbreaks in the past
Note: this is an unedited transcript of our recent podcast Coronavirus – a historical perspective
Matt Elton, editor of BBC World Histories Magazine: Obviously, Coronavirus is something that’s hitting a lot of headlines at the moment. Why does it strike such a chord, why are we so afraid of pandemics?
Laura Spinney: Well, I think it’s something very primitive in us really. I mean, we’ve had to deal with epidemics of infectious disease, plagues if you like, to use a more kind of ancient and Biblical term, since we settled down in kind of semi-permanent settlements, since we started farming, that is, about 10, 12,000 years ago. And, you know, these diseases that kind of adapted to big groups of densely-living people, we call them the crowd diseases, and they kind of evolved in parallel with us as we adopted those new, more sedentary lifestyles. So it’s been a kind of arms race for a very long time, they know us very well and unfortunately because they’re small and they reproduce much faster, they tend to be a step ahead. They can just mutate and adapt and, you know, they’re just wherever we don’t want them to be before we can do anything about it and we’re seeing that again now. In some ways, there are many aspects, I think, of a pandemic which don’t change over time. There are many that do but there are many that don’t and those are the ones that speak to our, obviously speak to our most ancient fears.
ME: And, of course, it’s natural for humans to look back at past examples of a similar thing to see if there’s any parallels or any lessons that could be drawn. Do you think there are particular pandemics from history that are most useful to look at in terms of parallels or is it just not a useful exercise generally?
LS: No, I do think it’s a useful exercise, I just don’t know why we immediately rush to pick the worst possible example. Given that the Spanish Flu, or the not Spanish Flu, we should really call it the 1918 Flu, was pretty much forgotten for most of the last century, even though it killed a staggering 50 to 100 million people, the fact that we’re now, everybody’s talking about it, that’s the only parallel we can draw is somewhat ironic. I mean, if you just think about flu pandemics because obviously we’ve had pandemics of other diseases, although flu does tend to be considered the disease that lends itself most easily to pandemics, we have had three flu pandemics since 1918 and none of them killed more than about four million people. The last one we had was sometimes considered rather anti-climactic, if that’s not a politically-incorrect thing to say, given that lots of people died nevertheless. But 600,000 people died in the 2009 H1N1 pandemic which is considerably less than in any other pandemic. So there are other kinds, other leagues of pandemics that we could be comparing it with and that we’re not.
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ME: So is there a more useful historical parallel to draw?
LS: Well, that’s the killer question, isn’t it? The thing is, there’s so much we don’t know about this bug yet. We don’t know, for example, exactly how lethal it is. And the other problem is that we don’t really know how lethal, for example, the Spanish Flu was, for different reasons. We don’t know how lethal this current one is because we don’t have very much data yet. So you might have seen a figure floating around of a case fatality rate of 3.4%, which refers to the proportion of people who catch the Covid-19 infection who go on to die of it. The number that’s often quoted for the Spanish Flu, for example, case fatality rate is 2.5% but it’s a very, very, very controversial figure because the numbers are so vague. I mean, we think that probably 50 million people died but there was no form of reliable test at the time so we can’t be sure about that and that just throws all the numbers out. So it’s really difficult to make the historical comparisons, even if you have accurate data now, which we don’t. So on both sides of the equation, if you like, it’s a moving target.
ME: The other side of this, of course, is although we may not be able to draw historical parallels with a specific pandemic, there is something perhaps to be gained from how people dealt with them or how they reacted to them at the time. Are there useful parallels in terms of that?
LS: Yes, there are. So we would obviously love to have a vaccine against Covid-19 now but we don’t and we may have to wait a year to 18 months for that. They had no vaccine at all in 1918. Or rather, they did make vaccines but they were useless, pretty much, because they were essentially vaccines against bacteria in the respiratory tract whereas, as we know, flu is a viral disease.
So in terms of that, we are much advanced compared to 1918. But we don’t have that vaccine yet. We so have anti-viral drugs for treating the sick and we do have antibiotics which will be useful for treating the bacterial complications that may cause pneumonia in some cases, as they did also in 1918, interestingly. But the only thing that actually stops people falling sick is the vaccine and we won’t have that for a while. So what do we have? We have strategies of containment, strategies that are collectively known as social distancing. And those are surprisingly unchanged since 1918, or even since much, much before that. I mean, they’re basically things like quarantine, isolation, wearing masks, although masks have always been debateable. It depends on the pathogen but once again, it’s looking like they may not be as effective as we hoped they would be. And hand washing is another thing. Basically, any kind of barrier technique that keeps the sick and the healthy apart and therefore reduces disease transmission. Because it’s looking pretty much now, at this stage, with the WHO having declared the pandemic, that it was a pandemic yesterday, as if containment is not going to work very well, if at all. And so what the governments are moving to now is more a sort of delay tactic, which will push off the peak of the epidemic, hopefully, until later in the year, towards the summer.
And what everyone’s pinning their hopes on is that this bug will be a sort of seasonal bug, a bit like flu, and will kind of recede when the warm weather comes. At the very least, they want to push off that peak while the health systems are already coping with many other winter respiratory conditions and so try and lessen the burden on them. But basically, whether you delay or whether you contain, as long as you’re before the sort of mitigate stage, which is where Italy and South Korea and Iran are, you know, they’ve got widespread community transmission and they’re just trying to treat everybody and, you know, reduce morbidity and mortality as much as they can. We’re the step before. But essentially the techniques for delaying that peak of the pandemic are pretty much the same as containment and they all involve social distancing. So that’s where we are, and that’s a long-winded way of saying that historical parallels are useful there because the techniques for containment were the same in, for example, 1918 or 1957 when we had another flu pandemic, or 1968 or 2009 and today, they’re all the same.
ME: To what extent does today’s transmission of the panic or of the media coverage of this epidemic compare to that of 1918, say?
LS: Well, I think it is different. I mean, fake news is not a new phenomenon, fake news is as old the hills. But, you know, with the advent of the internet, the speed and the volume of both information and fake information that we can transmit have just, you know, been amplified to an extraordinary level. So we’re dealing with the disadvantages and the advantages of that. In 1918, you know, most people read the newspapers, that’s how they got their news, so it was a slower medium.
And then, on top of that, there was a war on, at least for the first part of the pandemic and so you had things like wartime censorship interfering with things. And many countries, at least at the beginning of the pandemic tried to suppress the information that they had this illness spreading in their populations because they didn’t want to supposedly lower morale of their populations while everybody was concentrated on the war effort. And of course, that slowed down, you know, even if they had had techniques for dealing with this disease, it would have slowed down any response beyond any hopeful stage. Because one of the key things you need to do with an epidemic is to stop it or to contain it as early as you can. Because you get this kind of exponential growth in cases at the beginning because everybody is susceptible to this bug.
ME: I’m really interested in the other social forces that might have changed since earlier pandemics. Organised religion, for instance, seemed to have played a big role in the past but doesn’t so much today, is that right?
LS: Yeah, I think so. And I think that also has a positive negative aspect to it. So for example, to start with the positive, in 1918, doctors were pretty useless in the sense that they had nothing in their medicine cabinets really to offer, apart from aspirin. In fact, the people on the sort of conventional medicine side who were the most useful were nurses. They’re the only ones who can make any difference between life and death by keeping patients warm and hydrated and so on. But because doctors really had nothing to offer and because they were nevertheless, in many cases, very brave and, you know, in the front line and falling sick in droves themselves and often dying, others had to step into the breach and perform that kind of, if not doctor, then nursing role. And very often you saw it was priests and nurses and, you know, other people from the main faiths, or even the lesser faiths. So on the positive side there was that.
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On the negative side, because I think organised religion was much more powerful, they could have a nefarious effect on the messaging occasionally. I mean, you would always hope that the powerful leaders and the powerful influencers will, you know, coincide with the message that reinforces the public health message. But that didn’t always happen. So I can give you the example of Zamora, which is a town in north-western Spain, which was and in fact still is, very pious Catholic city. And there was a very charismatic, very influential bishop there at the time who basically just defied the provincial authorities. And at the height of the pandemic, in the autumn of 1918, ordered his flock into the churches to pray for forgiveness for their sins, which he insisted was the cause of this terrible punishment, divine punishment. And so everybody crowded into the churches and made their prayers to St Roch, who is the patron saint of pestilence and plagues. And that meant lining up to kiss his relics, everybody kissing the same relic. And Zamora went on to record one of the highest death rates from that flu in the whole of Spain, if not in the whole of Europe. So, you know, very kind of clear effect there. And I think today, you know, you do see the effect of religion but it’s very kind of marginal. So there are reports of people in the Iranian shrine city of Qom licking the shrine defiantly. And we hear that some of the early clusters in South Korea came from churches. But, generally speaking, there has been much less of an effect of organised religion, I think.
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ME: Is that the mechanism by which people in the past would have found out about pandemics or would they have learnt about it from another source?
LS: I mean, I think that if your community leader was also your religious leader, that was quite often the way you found out about it, was probably also the source you looked to for guidance and how to live through this terrible thing and how to mitigate it, if possible. Of course, there were much higher levels of illiteracy in the world at that time, even in the supposedly advanced countries. And so that was much more of a feature, literate people obviously read newspapers but that wasn’t necessarily the most common means of information moving around, no.
ME: Another way in which the world is different today is that it’s much more globalised and much more interconnected. Do you think that makes it much harder or even impossible to contain or stop such pandemics as this?
LS: Well, it looks like it, doesn’t it? I mean, as soon as the WHO declared, because the WHO declared a pandemic yesterday but it had already declared a global health emergency on the 30th of January. And, you know, that was the step that unlocked its maximum resources and powers for dealing with this disaster. The word pandemic, it depends who you ask, did it matter that declaration yesterday? I think the WHO made it because it was worried that people were being too complacent and not acting in time, and previously they were trying to avoid panic, which is also counterproductive. But they declared a global health emergency on 30 January and, at the same time as they did that, they basically put out the advice not to close borders because we know it doesn’t work, we’ve learnt it over and over again through previous pandemics.
And many countries promptly did exactly that. And now what they’re finding is that the virus is inside their countries and they are less than prepared for it. So not only did it not help, I think, it also meant that they were more on the back foot when it came to actually beginning testing and detecting and all the rest of it that goes into good containment which, you know, maybe it’s too late for that anyway. So are we globalised, of course we are. There was no commercial, there were no commercial air flights in 1918 and so the fastest people got around was by steam ship or train. And now, you know, a person and the germ they’re carrying, can travel round the world in days, if not hours. And, you know, we’ve seen the lightning speed with which this germ has got around the world. And so I think, I don't know, you know, perhaps we could have slowed it down but we also know that screening at entry and exit points is less than completely effective. Not only because there’s a question over whether people may be infected and asymptomatic but mainly because there’s an incubation period, which is on average three to five days, can be up to 14. So that means people can be infected but they’re not yet showing the symptoms and if they’re travelling across a border in those three to five days, then fever screening, temperature screening won’t pick them up.
ME: You mentioned national borders there, and alluded earlier to the idea that Spanish Flu got that name, and perhaps we shouldn’t call it that. What does that name tell us about this part of the story?
LS: So it’s called the Spanish Flu because when it first manifested itself in the Northern Hemisphere spring of 1918, the world was still at war and the belligerent nations, which already had flu within their boundaries and they included the US, Britain and France, kept that information out of their newspapers, they were censoring them. Again, as I mentioned earlier, the stated goal, or the later stated goal being to protect the morale of their populations. And so even their populations weren’t necessarily aware that there was flu in their midst. Spain, on the other hand, was neutral in the war and so didn’t censor its press and so when they had the first cases there, in the spring of 1918, they reported them. And so it seemed to the whole world, including the Spanish, including people in the other countries that were already infected, that this disease was rolling out from Madrid. And the King of Spain, Alfonso XIII, was among those early cases, he went onto recover, but his case sort of lent it a great deal of visibility.
Of course, it’s unhelpful. One of the few certainties we have about that pandemic is that it didn’t start in Spain, we actually don’t know where it did start but we know it didn’t start in Spain. And the Spanish felt, and to a very great degree were, stigmatised by it. In 2015, the WHO put out guidelines for how to name a disease and I think the motivation for that was mainly to avoid this kind of stigmatisation, this kind of kneejerk naming of a disease after the place it appears to first manifest itself, or the sector of the population or the animal it first appears in. because remember, 2009, H1N1 flu was initially called swine flu. You could think about AIDS which was initially called gay-related immune deficiency and stigmatised the homosexual community, unhelpfully for everybody, including heterosexuals, who nobody thought about how it might be being transmitted in that community. Meanwhile homosexuals were getting stigmatised for being the ones who transmitted it, so it was unhelpful to everybody. The swine flu name was unhelpful in many ways, for example, the Egyptian government ordered the slaughter of the country’s swine herd, which was mainly the property of the minority of Coptic Christians in that country, so their local economy was wiped out in one stroke. And in fact, by the time it was in humans, it was a disease that was being transmitted from human to human so it made no difference either. And in fact, to go back a little bit further in history, that swine flu was given to pigs by humans in 1918. So it came back from pigs to humans in 2009, you know, ironic historical reprisal. So naming doesn’t help. And this time, I think, it’s really interesting and one of the small things we can applaud ourselves for is that we have not given this outbreak a stigmatising name. It’s not the Chinese Flu, it’s not the Pangolin Flu, it’s Covid-19, which may sound mundane but it’ll do the job.
ME: Do you think the responses to this particular pandemic in various parts of the world tell us about historical situations in those countries or historical pandemics in those countries?
LS: So one of the things that public health experts are absolutely clear about is that the best way to impose a public health, a set of public health measures is not to impose them in the authoritarian way that the Chinese did. But if you can possibly manage it, to have people complying with you voluntarily, because you’re much more likely to be able to contain that disease that way. People don’t like to be told what to do. But if you want people to comply with you voluntarily two things are needed. The first is they have to be properly informed about the threat they face, so that they understand why you’re asking them to do these things and to restrict their normal lives in certain ways. And the second thing is they have to trust the authorities, they have to trust that those authorities are acting in their collective interest. And the thing is, that if that trust isn’t there when the pandemic breaks out, then it’s too late to build it.
So I think you could look, for example, at the case of South Africa in 1918, where as in many other countries, when the epidemic arrived, doctors and scientists scrambled to produce a vaccine. Again, as I mentioned earlier, the candidates, the vaccines they developed were fairly, uniformly, useless because they were against bacteria and not the virus. But they launched a national, a nation-wide vaccination campaign and white South Africans dutifully lined up to get the vaccine and black South Africans basically boycotted it. Because white, the predominantly white doctors had never shown much interest in their health before and they couldn’t understand why they were doing so now. And there were rumours that circulated in the black population that the doctors were trying to kill them with their long needles. So, you know, that’s a very clear and graphic illustration, I think, of how if the trust is not there, if you don’t believe that the authorities and the doctors coming towards you in their white coats are acting in your interest, then you will not do what they want you to do, certainly not voluntarily.
ME: The Spanish Flu destabilised social and political orders for decades, do you think that that is possible in this case?
LS: Well, yeah, it’s certainly possible. You can already see the economic damage it’s doing and people have a tendency to look at their governments after some terrible disaster and to hold them responsible for what happened. So, you know political consequences are also possible. And then when you’ve got the two things together in concert, if the economy suffers then the politicians are likely to be blamed for that as well. Of course, the politicians are doing their best to shift the blame.
I mean, you saw Mr Trump’s announcement yesterday that he was restricting travel to the United States from Europe with the heavy suggestion that Europe had somehow mismanaged the disaster in the same way, or just as badly as the Chinese had, to, you know, reproduce his narrative. Whereas the plain fact of the matter is that the disease is already in the United States, there have been reports that they haven’t been testing for it properly. So the problem is very much theirs as much as it is Europe’s. But Mr Trump has decided to play a political game with it and I’m sure that’s not unconnected to the fact that there is a presidential election coming up this year.
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ME: Finally, what lessons do you wish that we would learn from the past, but don’t, and why do you think we don’t learn from them?
LS: Well, I think the lessons we should learn in a very general sense are to try and, because we go through this cycle of panic and complacency. So we panic when it happens, when we should think calmly and rationally and just do, you know, what the experts tell us to do. And then when it’s passed, we immediately forget about it and become complacent again and don’t do any of the long-term things that the experts ask us to do.
So for example, when the WHO declared its global health emergency on 30 January, it even took that opportunity to repeat a message that it’s been saying for a long time, which is we need to invest in the long-term in better health infrastructure in the poorer parts of the world, because when a pandemic strikes, we are only as safe as our least-safe place. So, you know, we should be doing things like that, when the pandemic passes, which of course it will, eventually. Will we remember to do that? I very much hope so.
I think this pandemic is throwing up other things which are really interesting which we should take on board and discuss when it’s passed, how to fix to so they’re not weaknesses again. I can mention two. I mean, I think the first is how we get our news out. The fake news problem. A lot of young people have said to me the problem is that good information is behind paywalls where as fake news is free. The assumption there is that they shouldn’t have to pay for the information and I think older generations were used to paying for their news but that’s not the expectation with the internet anymore. So we desperately need a new business model, we’ve been talking about that for a while in news circles but I think this pandemic has really thrown it into relief how important it is that we have ways to get quality information out there and that people know which is which.
So that’s one thing. And my list is not exhaustive, by the way. Another thing that I think is really interesting is that it’s showing up the weaknesses in our various health systems, national health systems. So the problem in the United States has been that lots of people have been excluded from testing and from care, and not just for this pandemic but this pandemic is really highlighting that. A lot of people were not getting access to Covid-19 testing when they needed it. And of course, you can’t control an outbreak of disease if you don't know who’s got it and who they’ve been in contact with. On our side, in Europe, where we have more socialised medical healthcare systems, which by the way, were the kind of fruit of the 1918 pandemic, when they realised how important this was. Our systems tend to be paid for indirectly by taxes or insurance, national insurance schemes and we get our healthcare free at the point of delivery. So that means that, in theory, anyone can get tested for Covid-19, assuming the tests are available. There have been some reports that they haven’t been but that’s another problem. But the problem is that our health systems are completely overloaded. They are arguably no longer fit for purpose. They were built for much smaller and much younger populations and they’re struggling to support older and bigger populations and not doing very well. So we may have to have a rethink on our side about how we fund our health systems and how we adapt them, going forward, for a different kind of population. So those are just two things that I think that we could be thinking about in the long term, once this pandemic passes.
Matt Elton is the editor of BBC World Histories Magazine
Laura Spinney is a British science journalist, novelist, and non-fiction writer
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