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Spanish flu: the virus that changed the world
In spring 1918 a disease began to sweep around the planet – a lethal virus that infected a third of the world's population and left upwards of 50 million dead. Laura Spinney explores the devastating impact of the Spanish flu pandemic and how it compares to the Coronavirus crisis
The Spanish flu pandemic of 1918–20 infected a third of the global population and left at least 50 million people dead – a greater number, possibly, than the Second World War. Explore the dramatic effects of the outbreak here, including the ways in which the world struggled to come to terms with the disease – medically, socially and politically… How many people died from Spanish Flu? Why was it called 'Spanish Flu'? How did Spanish Flu spread? And who did it affect? Political aftermaths of Spanish Flu How does Spanish Flu compare to Coronavirus? Where did Spanish flu originate? One of the few certainties we have about the Spanish Flu 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. The Spanish felt, and to a very great degree were, stigmatised by this. There is also no way of being certain where Spanish Flu originated, although the trenches of the First World War, where poor sanitation and disease was rife, are an often-cited contender. The filthy, rat-infested conditions undoubtedly affected the soldiers’ immune systems, making them more vulnerable to illness. It is thought the first cases were in military forts in the United States before spreading at an alarming rate to Europe. But yet the pandemic was called ‘Spanish Flu’ – again, a result of the war. Why was Spanish Flu called Spanish flu? Wartime censorship exaggerated the affects of the virus in Spain. While Britain, France, Germany and the United States censored and restricted early reports, papers in Spain – as a neutral country – were free to convey all the horrid details of the pandemic. This made it look much worse there, so the unfortunate name spread with the disease around the world. Monday 4 March 1918: the day Spanish Flu strikes the world Written by Dominic Sandbrook When Private Albert Gitchell awoke on Monday 4 March 1918, he felt awful. A company cook at Fort Riley, Kansas, Gitchell was supposed to be serving breakfast to hundreds of young American recruits, who were waiting to be shipped off to the battlefields of France. But when the doctors had a look at him, they realised that, with a temperature of more than 103, Gitchell was in no state to work in the mess. A few hours later, another man, Corporal Lee Drake, appeared at the infirmary with similar symptoms. Then another, Sergeant Adolph Hurby. Still the men kept coming: there were 107 by lunchtime and more than 500 by the end of the week. By the end of the month, no fewer than 1,127 men at Fort Riley had come down with flu – and 46 of them had died. In the next few months, as American soldiers flooded into Europe, they brought the deadly influenza with them. With vast armies surging across an exhausted continent, the conditions were perfect for a pandemic. This was one of history’s deadliest disasters. Across the world, some 500 million people had been struck down by flu by the end of 1920, perhaps 100 million of them fatally. Many governments banned public gatherings or buried the victims in mass graves. Reporting restrictions in the combatant nations meant that the disease’s progress in neutral Spain drew disproportionate attention: hence its nickname, Spanish flu. Only one populated part of the world reported no cases at all: the island of Marajo, at the mouth of the Amazon. How many people died from Spanish flu? The Spanish flu was one of the deadliest disasters in history. It lasted for two years – between the first recorded case in March 1918 and the last in March 1920, an estimated 50 million people died, though some experts suggest that the total might actually have been twice that number. The ‘Spanish flu’ killed more than the First World War, possibly more even than the Second World War – indeed, perhaps more than both put together. The pandemic struck at a critical juncture in the evolution of understanding of infectious disease. Well into the 19th century, epidemics were considered acts of god – a notion that dated back to the Middle Ages. Bacteria were first observed in the 17th century, but initially weren’t connected with human illnesses. In the late 1850s the French biologist Louis Pasteur made the connection between micro-organisms and disease, and from a couple of decades later German microbiologist Robert Koch furthered modern concepts of infectious disease. ‘Germ theory’ was disseminated far and wide, slowly replacing more fatalistic ideas. The dark history of quarantine practices By the 20th century the application of germ theory, combined with improvements in hygiene and sanitation, had made significant inroads against the so-called ‘crowd’ diseases that afflicted human communities, especially those inhabiting the great cities that had mushroomed in the wake of the industrial revolution. Throughout the 19th century, so many urbanites had been lost to such diseases – cholera, typhus and tuberculosis, to name but three – that cities needed a steady influx of healthy peasants from the countryside to keep up their numbers. Now, at last, they had become self-sustaining. By 1918, then, faith in science was high, and some scientists had even adopted a certain swagger. Twelve years earlier, this had prompted the Irish playwright George Bernard Shaw to write The Doctor’s Dilemma, in which an eminent doctor, Sir Colenso Ridgeon – a character based on Sir Almroth Wright, who developed the typhoid vaccine – plays god with his patients’ destinies. Shaw was warning doctors against hubris, but it took an outbreak of another ‘crowd’ disease – influenza – to bring home to them just how little they knew. <img src="https://images.immediate.co.uk/production/volatile/sites/7/2017/02/GettyImages-515485220-sml-0e2a971.jpg" width="1063" height="1503" alt="Dr Robert Koch (seated), influential in developing ‘germ theory’," title="Dr Robert Koch (seated), influential in developing ‘germ theory’, and his student Richard Pfeiffer at work in the late 19th century. During the ‘Russian’ flu epidemic starting in 1889, Pfeiffer claimed to have identified the bacillus responsible – though flu is actually caused by a virus. (Getty Images)" /> When scientists thought about ‘germs’ in the early 20th century, they generally thought about bacteria. The virus was a novel concept; the first virus, discovered in 1892, infected tobacco plants and had been detected indirectly by its ability to transmit disease. Unlike many bacteria, it was too small to be seen through an optical microscope. Without having actually seen viruses, scientists debated their nature: were they organism or toxin, liquid or particle, dead or alive? They were veiled in mystery, and nobody suspected that they could be the cause of flu. What happened when Spanish Flu hit Britain? During the previous flu pandemic – the so-called ‘Russian’ flu, which began in 1889 – a student of Koch’s named Richard Pfeiffer claimed to have identified the bacterium that caused the flu. Pfeiffer’s bacillus, as it became known, does exist and does cause disease – but it does not cause flu. During the 1918 pandemic, pathologists who cultivated bacterial colonies from the lung tissue of flu victims found Pfeiffer’s bacillus in some, but not all, of their cultures, and this puzzled them. To add to doctors’ puzzlement, vaccines created against Pfeiffer’s bacillus seemed to benefit some patients. In fact, these vaccines were effective against secondary bacterial infections that caused pneumonia – the ultimate cause of death in many cases – but scientists didn’t know that at the time. They would realise their mistake too late. Why was it called 'Spanish flu'? The Russian flu had acquired its name because it was thought to have originated in Bukhara in Uzbekistan (at that time, part of the Russian empire). The pandemic that broke out nearly 30 years later will always be known as the ‘Spanish flu’, though it didn’t start in Spain. It washed over the world in three waves which, in the northern hemisphere, corresponded to a mild wave in the spring of 1918, a lethal wave the following autumn, and a reprisal in the early months of 1919 that was intermediate in virulence between the other two. The first cases were officially recorded in March 1918 at Camp Funston, a military base in Kansas. Within six weeks the disease had reached the trenches of the western front in France, but it wasn’t until May that the flu broke out in Spain. Unlike the United States and France, Spain was neutral in the war, so it didn’t censor its press. The first Spanish cases were therefore reported in the newspapers, and because King Alfonso XIII, the prime minister and several members of the cabinet were among those early cases, the country’s plight was highly visible. People all over the world believed that the disease had rippled out from Madrid – a misconception encouraged by propagandists in those belligerent nations that knew they’d contracted it before Spain. In the interests of keeping morale high in their own populations, they were happy to shift the blame. The name stuck. Could flu really kill thousands again? Understandably, Spaniards smarted at this calumny: they knew they were not responsible, and strongly suspected the French of having sent the flu across the border, but they couldn’t be sure. They cast around for a different label, and found inspiration in an operetta performed at the capital’s Zarzuela Theatre – a hugely popular reworking of the myth of Don Juan, featuring a catchy tune called ‘The Soldier of Naples’. The catchy disease became known in Spain as the ‘Naples Soldier’. But though the Spanish flu didn’t start in Spain, that country did suffer quite badly with it. In the early 20th century, flu was viewed as a democratic disease – nobody was immune from it – but, even in the thick of the pandemic, it was noted that the disease struck unevenly. It ‘preferred’ certain age groups: the very young and the elderly, but also a middle cohort aged 20 to 40. It preferred men to women, with the exception of pregnant women, who were at particularly high risk. These age and gender-related patterns were repeated all over the world, but the virulence with which the flu struck also varied from place to place. Inhabitants of certain parts of Asia were a staggering 30 times more likely to die from the flu than those in parts of Europe. In general, Asia and Africa suffered the highest death rates, with the lowest seen in Europe, North America and Australia. But there was great variation within continents, too. African countries south of the Sahara experienced death rates two or even three times higher than those north of the desert, while Spain recorded one of the highest death rates in Europe – twice that in Britain, three times that in Denmark. The unevenness didn’t stop there. In general, cities suffered worse than rural areas, but some cities suffered worse than others, and there was also variation within cities. Newly arrived immigrants tended to die more frequently than older, better-established groups, for example. In the countryside, meanwhile, one village might be decimated while another, apparently similar in every way, got away with a light dose. Why Spanish flu isn't a 'flu' at all... On 28 September 1918, a Spanish newspaper gave its readers a short lesson on influenza. “The agent responsible for this infection,” it explained, “is the Pfeiffer’s bacillus, which is extremely tiny and visible only by means of a microscope.” The explanation was timely, because the world was in the grip of the most vicious flu pandemic on record – but it was also wrong: flu is caused by a virus. Unfortunately, it wasn’t just one Spanish newspaper that had misidentified the causative agent of the disease. The idea that flu was caused by a bacillus, or bacterium, was accepted by the most eminent scientists of the day, who would find themselves almost entirely helpless in the face of the scourge. How did Spanish flu spread? And who did it affect? The flu seemed to strike with an element of randomness, and cruelly so. Because adults in the prime of life died in droves, unlucky communities imploded. Children were orphaned, elderly parents left to fend for themselves. People were at a loss to explain this apparent lottery, and it left them deeply disturbed. Attempting to describe the feeling it inspired in him, a French doctor in the city of Lyons wrote that it was quite unlike the “gut pangs” he had experienced while serving at the front. This was “a more diffuse anxiety, the sensation of some indefinable horror which had taken hold of the inhabitants of that town”. It was only later, when epidemiologists zeroed in on the numbers, that patterns began to emerge, and the first elements of an explanation were put forward. Some of the variability could be explained by inequalities of wealth and caste – and, to the extent that it reflected these factors, skin colour. Bad diet, crowded living conditions and limited access to healthcare weakened the constitution, rendering the poor, immigrants and ethnic minorities more susceptible to infection. As French historian Patrick Zylberman put it: “The virus might well have behaved ‘democratically’, but the society it attacked was hardly egalitarian.” Portraits of a plague: the 19th-century pandemic that killed 12 million people Any other underlying disease made a person more susceptible to the Spanish flu, whereas prior exposure to the flu itself modulated the severity of a case. Remote communities without much historical experience of the disease suffered badly, as did cities that were bypassed by the first wave of the pandemic, because they were not immunologically ‘primed’ to the second. For example, Rio de Janeiro – capital of Brazil at the time – received only one wave of flu, in October 1918, and experienced a death rate two or three times higher than that recorded in American cities to the north that had received both the spring and autumn waves. And Bristol Bay in Alaska was spared until early 1919, but when the virus finally gained a foothold it reduced the bay’s Eskimo population by 40%. Public health campaigns made a difference, despite the fact that medics did not understand the cause of the disease. Since time immemorial, whenever contagion is a threat humans have practised ‘social distancing’ – understanding instinctively that steering clear of infected individuals increases the chance of staying healthy. In 1918, social distancing took the form of quarantine zones, isolation wards and prohibitions on mass gatherings; where they were properly enforced, these measures slowed the spread. Australia kept out the autumn wave entirely by implementing an effective quarantine at its ports. Exceptions proved the rule. In 1918 Persia was a failed state after years of being used as a pawn in the ‘Great Game’ – the struggle between the British and the Russians for control of the vast area between the Arabian and Caspian Seas. Its government was weak and nearly bankrupt, and it lacked a coherent sanitary infrastructure, so when the flu erupted in the north-eastern holy city of Mashhad in August 1918, no social distancing measures were imposed. Within a fortnight every home and place of business in Mashhad was infected, and two-thirds of the city’s population fell sick that autumn. With no restrictions on movement, the flu spread outwards with pilgrims, soldiers and merchants to the four corners of the country. By the time Persia was again free of flu, it had lost between 8% and 22% of its population (that uncertainty reflecting the fact that, in a country in crisis, gathering statistics was hardly a priority). By way of comparison, even 8% equates to 20 times the flu-related mortality rate in Ireland. <img src="https://images.immediate.co.uk/production/volatile/sites/7/2017/02/GettyImages-514877124-sml-17b6bb7.jpg" width="2008" height="1808" alt="Schoolgirls in Tokyo don protective face masks to guard against flu transmission during the outbreak. The use of such masks by the Japanese public boomed during the 1918–20 epidemic and subsequent disease outbreaks, and remains common in Japan today. (Getty images)" title="Schoolgirls in Tokyo don protective face masks to guard against flu transmission during the outbreak. The use of such masks by the Japanese public boomed during the 1918–20 epidemic and subsequent disease outbreaks, and remains common in Japan today. (Getty images)" /> Where disparities in rates of illness and death were perceived, people’s explanations reflected contemporary understanding – or, rather, misunderstanding – of infectious disease. When Charles Darwin laid out his theory of evolution by natural selection in On the Origin of Species (1859), he had not intended his ideas to be applied to human societies, but others of his time did just that, creating the ‘science’ of eugenics. Eugenicists believed that humanity comprised different ‘races’ that competed for survival, and by 1918 their thinking was mainstream in industrialised societies. Some eugenicists noted that poorer sectors of society were suffering disproportionately from the flu, which they attributed to a constitutional inferiority. They had also incorporated germ theory into their world view: if the poor and the working classes were more prone to infection, reasoned the eugenicists, they only had themselves to blame, because Pasteur had taught that infection was preventable. The Black Death: the historians’ view The terrible consequences of this line of thinking are illustrated nowhere better than in India. That land’s British colonisers had long taken the view that India was inherently unhygienic, and so had invested little in indigenous healthcare. As many as 18 million Indians died in the pandemic – the greatest loss in absolute numbers of any country in the world. But there would be a backlash. The underpowered British response to the spread of flu fuelled resentment within the independence movement. Tensions came to a head with the passing into law in early 1919 of the Rowlatt Act, which extended martial law in the country. This triggered peaceful protests, and on 13 April British troops fired into an unarmed crowd in Amritsar, killing hundreds of Indian people – a massacre that galvanised the independence movement. The political aftermath of Spanish Flu The Spanish flu prompted uprisings elsewhere. The autumn of 1918 saw a wave of workers’ strikes and anti-imperialist protests across the world. Disgruntlement had been smouldering since before the Russian revolutions of 1917, but the flu fanned the flames by exacerbating what was already a dire supply situation, and by highlighting inequality. Even well-ordered Switzerland narrowly avoided a civil war in November 1918 after leftwing groups blamed the high number of flu deaths in the army on the government and military command. <img src="https://images.immediate.co.uk/production/volatile/sites/7/2018/09/GettyImages-597915863-85df63b-scaled.jpg" width="2560" height="2027" alt="Influenza pandemic of 1918" title="A temporary hospital erected in Oakland Municipal Auditorium in Oakland, California with volunteer nurses from the American Red Cross tending the sick during the influenza pandemic of 1918. (Photo by Underwood Archives/Getty Images)" /> There were still parts of the world where people had never heard of either Darwin or germ theory, and where the population turned to more tried-and-tested explanations. In the rural interior of China, for example, many people still believed that illness was sent by demons and dragons; they paraded figures of dragon kings through the streets in the hope of appeasing the irate spirits. A missionary doctor described going from house to house in Shanxi province in early 1919, and finding scissors placed in doorways – apparently to ward off demons “or perchance to cut them in two”. Even in the modernised west, people vacillated. Death often seemed to strike without rhyme or reason. Many still remembered a more mystical, pre-Darwinian era, and four years of war had worn down psychological defences. Seeing how ill-equipped their men of science were to help them, many people came to believe that the pandemic was an act of god – divine retribution for their sins. In Zamora – the same Spanish city whose newspaper stated with such confidence that the agent of disease was Pfeiffer’s bacillus – the bishop defied the health authorities’ ban on mass gatherings and ordered people into the churches to placate “God’s legitimate anger”. This city subsequently recorded one of the highest death tolls from flu in Spain – a fact of which its inhabitants were aware, though they don’t seem to have held it against their bishop. Instead they awarded him a medal in recognition of his heroic efforts to end their suffering. This exemplifies how responses to the flu reflected gulfs in understanding. The 1918 pandemic struck a world that was entirely unprepared for it, dealing a body blow to scientific hubris, and destabilising social and political orders for decades to come. Laura Spinney is a journalist and the author of Pale Rider: The Spanish Flu of 1918 and How it Changed the World, (Jonathan Cape, June 2017). This article first appeared in issue 4 of BBC World Histories How does Spanish flu compare to Coronavirus? In an episode of the HistoryExtra podcast recorded in spring 2020, Laura Spinney expanded on how the Spanish Flu pandemic statistics stack up against the early data recorded about Covid-19. “You might have seen a figure floating around of a case fatality rate of 3.4 per cent, which refers to the proportion of people who catch the Covid-19 infection who go on to die of it," she explained. "The number that’s often quoted for the Spanish Flu fatality rate is 2.5 per cent – but it’s a very controversial figure because the numbers are so vague. "We think that (probably) 50 million people died of Spanish Flu, 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. On both sides of the equation, if you like, it’s a moving target." Read a transcript of the podcast here Discover more about pandemics through history Coronavirus: what might we learn from pandemics in the past? Epidemiology: the history of disease and epidemics (via BBC Science Focus) Everything you need to know about the Black Death Black Death quarantine: how did we try to contain the most deadly disease in history?
"Far too little, too late": what happened when Spanish Flu hit Britain?
A century ago, a devastating pandemic killed countless millions worldwide. But how did Britain cope when Spanish Flu reached its shores in 1918? Robert Hume says it was a tragic case of far too little, too late...
How was Britain affected by the Spanish flu pandemic of 1918? Robert Hume considers the key questions: How did Spanish flu arrive in Britain? How did people protect themselves against Spanish flu? How did Britain officially respond to Spanish Flu? How did the British media respond to Spanish Flu? How many people died from Spanish flu in Britain? Spanish flu in Britain: an introduction “Soon after the war ended, there was a strange kind of flu,” recorded John Pears Jackson, who farmed near Keswick, and died in 2005, aged 98. “Many thousands of people, in England alone, died, including a lot of men and women in Cumberland, some of whom I knew. With none of the drugs and antibiotics we have today, doctors were powerless, and strong men and women were dead in the course of a few days… People drank whisky… and dosed themselves with all kinds of medicines. One farmer I knew swore he cured himself with paraffin oil.” Margaret Pitt, then a pupil at Milton Mount College in Gravesend, recalled being offered something milder to drink: “The school was warned [of] the coming epidemic, so they tried to get us all home early before the Easter holidays. Telegrams were sent to our parents… Our trunks were packed and sent off. Then we all came down to the main hall ready for our journey, in coats, hats and gloves, and our hand luggage. The nurse and her assistant were there with thermometers to see if we were developing the virus. I think about half of us were sent back to bed, some were very upset as they were anxious to go home. I was one of those who had to go to bed. We were given plenty of drink… milk.” Why was Spanish Flu called Spanish flu? The British Medical Journal referred to the sickness – characterised by shivering, headache, sore throat and fever – as ‘Spanish flu’ because it was first recorded in Spain. Offended by the slander, Spaniards named the illness the ‘Naples soldier’. The German army called it ‘Blitzkatarrh’, and British troops referred to it as ‘Flanders grippe’ or the ‘Spanish lady’. One recent study suggests it originated in China, and was transported by labourers heading for the western front. Other investigations concluded that its epicentre was a military camp – either in Kansas, or Étaples, northern France. Some claimed that mustard gas and battlefield fumes were responsible; others that it was a German biological weapon. It’s estimated that somewhere between 25 and 100 million people died worldwide in what is, in absolute terms, the worst pandemic ever recorded. Only St Helena in the South Atlantic and a handful of South Pacific islands did not report an outbreak. Whereas, today, flu is especially dangerous for the very young and the elderly, in 1918 it mainly affected young adults. Those aged 75 and above had the lowest death rate of all. How did Spanish flu arrive in Britain? Troops travelling home by boat and train at the end of the war took the flu into the cities, from where it spread to the countryside. The disease swept across Britain in three waves: mild in spring 1918; devastating in autumn 1918; and moderate in early 1919. The port of Glasgow was the first place to record the flu, in May 1918, an unusual time of year for the sickness to appear. Young women, especially those working in factories, were worst affected. It reached London in June. By late August it seemed a spent force; but in October it returned with a vengeance, and reached every corner of the land. The speed at which influenza struck defied efforts to deal with it. In July, a woman in Leicester stopped a doctor in the street, and while they were talking she collapsed and died. The brother of William Hall from Rosley, Cumbria, recorded in his diary: “We did not know he ailed anything until the morning of the day he died.” The infection spread at an alarming rate. On 14 February 1919, poet Robert Graves returned from Limerick to his home in Hove, accompanied by “the Spanish Lady”. Within a couple of days, almost his entire household had contracted the flu. Throughout Britain, a shortage of undertakers and grave diggers led to bodies lying unburied for days, and many funerals taking place at night. How did people in Britain protect themselves against Spanish Flu? Local authorities and the press did offer some useful advice. The Bexhill-on-Sea Observer advised readers to avoid crowds by catching a later train home, sitting outside the bus, and wearing an extra coat. In Brighton, publicans were urged to thoroughly wash the outside lips of drinking glasses in running water, while a pamphlet recommended people to “give up shaking hands for the present, and give up kissing for all time”. A number of constructive measures were taken. In Rotherham, posters were displayed in prominent parts of the town, and health visitors and school nurses distributed leaflets from door to door, encouraging people to keep dirty handkerchiefs out of the reach of children. The Borough of Hackney recommended that victims stay isolated, go to bed the moment symptoms appeared, and gargle with potash and salt. In Keswick, Cumbria, the Medical Officer arranged for a free supply of “disinfectant mixture”. Every morning, formalin was sprinkled on the floor of Brighton’s public library and post office, and tramcars were fumigated in Doncaster. 10 facts about the Black Death The focus – if there was one – lay in minimising the risk of infection through contact. Hundreds of elementary schools were closed during the height of the epidemic. Cheltenham Boys’ School took the reverse step of locking staff and pupils inside the building. Election candidates in Sunderland abandoned house-to-house canvassing, and turned down requests to take voters to the polls. Recognising the value of fresh air to stem the spread of influenza, cinemas were required to be ventilated in London for 30 minutes every three hours. Those in Wolverhampton were ordered to ban children, and remove all carpets. For three consecutive nights, a Walsall cinema showed a 15-minute public information film that featured Dr Wise and a foolish patient. However, some of the advice was useless. One government official simply encouraged people to “clean [their] teeth regularly”, while the News of the World suggested readers “eat plenty of porridge”. Dr Robertson Dobie of Perthshire noted that hardly any of his flu patients worked at the local jam factory – where they lived in a sugary atmosphere all day – and prescribed jam and sweets. “In two months,” he predicted, influenza “will be a thing of the past.” Often, recommendations proved difficult to put into practice. “Terribly overcrowded and insanitary conditions rendered any attempt to cope with the disease futile,” recognised a health report in Rotherham. Where up to seven people occupied one small bedroom, isolation, ventilation and cleanliness were impossible. Although the town had an isolation hospital, space was available only for the severest cases. It was hard to “keep warm” and “eat good food”. “We might as well ask for the moon… the luxury of sitting in front of a roaring fire with all the windows open is not for rationed people”, rebuked the Bexhill-on-Sea Observer on 16 November 1918. Could flu really kill thousands again? Too few copies of the public information film were available. Local authorities had to apply in writing to borrow it, and prove that flu was already rampant in their area. The lack of internal plumbing made it hard for Brighton publicans to rinse glasses thoroughly, while dozens of people continued to squeeze into the town’s trams because there were no resources to build any more. When action was taken, the reasoning behind it was sometimes questionable. Physiologist Sir Leonard Hill recommended the deep breathing of cool air and sleeping in the open. Several isolation hospitals apparently placed patients in “soaking wet beds and sprinkled them regularly with cold water to keep them completely sodden”, hoping it would stimulate their immune systems. Meanwhile, at the George Hotel, Nottingham, Sister Veitch offered flu victims electric shock treatment. Many key ways in which the disease was spread were not addressed. Schools in London only closed if staff absenteeism made it impossible to keep them open. Secondary schools remained open throughout, as did churches, on the grounds that during a crisis people should turn to religion, not be excluded from it. It was a case of business as usual in Britain’s factories, too. Those in the Black Country relaxed their no-smoking rules, believing that cigarette smoke would prevent infection. Public parades and pageants were also allowed to go ahead. Armistice celebrations on 11 November meant tens of thousands taking to the streets. The authorities’ reluctance to act, and confusion among doctors – who called influenza “the obscure disease” – left the door wide open for quack remedies such as Thompson’s Influenza Specific, which claimed to “act like magic”; and Dr Williams’ Pink Pills for Pale People. Eating raw onions – as did the inhabitants of Saffron Hill – was also believed to keep “the dreaded scourge at bay”. Baffled doctors in Manchester prescribed an age-old tonic: whisky. View oEmbed on the source website How did Britain officially respond to Spanish Flu? Although recognised as contagious, the disease was not mentioned in parliament until late October 1918, and was not made ‘notifiable’ to the authorities until the third wave struck in early 1919. Even if it had been, there was no strategy for tackling it. Britain had no National Health Service until 1948, and there was only a patchwork of institutions to deal with health issues. The central board of health merely had power to give ‘advice’ to local authorities, and the Local Government Board kept a low profile, issuing the occasional memorandum. Therefore, the British response was a decentralised and uncoordinated one. Every town had to rely on its own resources and existing facilities to cope with the outbreak. The result was the proverbial “much talk, but very little do”. Other factors compounded the country’s difficulties. The epidemic could not have struck at a worse moment. The First World War had diverted a vast number of medical staff: some 52 per cent of doctors were at the front. Those not in military service – doctors over 50 years old and often lacking up-to-date training – were run off their feet. At Kingston-upon-Thames, one doctor reported: “From early morning till late at night I have done nothing but rush from one flu patient to another.” Having been called to 35 flu victims in one street, a Nottingham doctor simply told flu sufferers to pass his prescription on. At Bookham, Surrey, the only doctor was himself a victim. The medical profession didn’t fully comprehend the severity of the disease. In the summer of 1918, the Royal College of Physicians announced that Spanish flu was no more threatening than the still well remembered ‘Russian flu’ of 1889–94. The British Medical Journal accepted that overcrowding on transport and in the workplace was necessary to help the war effort, and implied that the inconvenience of flu should be quietly borne. Individual doctors tried to play down the severity of the disease to avoid spreading anxiety. In Egremont, Cumbria, where the death rate was appalling, the medical officer asked the rector to stop ringing the church bells every time there was a funeral because he wanted to “keep people cheerful”. How did the British media portray Spanish Flu? The press did likewise. The Times suggested that the illness was probably a result of “the general weakness of nerve-power known as war-weariness”, and the Derby and Chesterfield Reporter, 12 July 1918, declared that it was “not really a matter for alarm”. The Manchester Guardian scorned protective measures: “Women are not going to wear ugly masks.” What’s more, masks would steam up people’s glasses, and be of “doubtful usefulness at mealtimes”. The Sussex Daily News joked that influenza was no more than “an ingenious attempt” to sabotage the forthcoming general election, while Hanningtons department store in Brighton declared that the best way of treating influenza was spending money at their sale. Other countries, no less affected by the war, made more rigorous efforts than Britain to deal with the flu. In the United States, schools, churches and cinemas were closed, and public gatherings were banned. Health departments distributed masks, shops were not allowed to hold sales, and funerals were restricted to 15 minutes. It was forbidden to travel by train unless you carried signed certificates that you were clear, and overcrowding was reduced by introducing flexitime at work. Parts of Arizona outlawed handshaking, and in San Francisco drinking fountains were sterilised with blowtorches every hour. Meanwhile, Canada built an emergency hospital for flu victims in Vancouver. In France, schools, theatres and churches were closed down, extra staff were recruited to clear rubbish tips, and spitting in the street became a criminal offence. Train passengers in Spain were “generously sprayed with foul-smelling disinfectant”. Australia succeeded for a while in imposing a national quarantine. Passengers had to stay in isolation before being allowed to enter the country. Read more about the history of medicine How did people in the past treat illness, injury and disease? What medicines did they use? Beating the Black Death: did medieval medicine help people to survive? Ask the medieval doctor: 6 ailments and their treatments When was the first caesarean? How many people died from the Spanish Flu in Britain? By the summer of 1919, when the flu pandemic subsided, 228,000 people had died in Britain. Letters to newspapers condemned the government’s slowness to demobilise doctors at the front, the authorities' “timidity” to act, and “armchair complacency”. A correspondent in the Hackney Gazette of 8 November 1918 had complained: “Schemes for checking these terrible visitations need to be thought out and prepared beforehand,” while another observer had remarked in the Perthshire Advertiser, 26 October 1918: “We possess much more stringent laws in regard to the health of animals than to that of human beings.” The crisis hastened the Local Government Board’s replacement by a new Ministry of Health. Meanwhile, scientists attempted to identify what had brought Spanish flu. Existing wisdom that the disease was caused by a bacterium was wrong. Only in 1933, with the invention of the electron microscope, did a team at the National Institute for Medical Research in London demonstrate that an extremely infectious virus (H1N1 A) caused influenza, and that droplets shed by coughing and sneezing transmitted it from person to person. Fifteen years earlier, the priorities of war, determination to play down the seriousness of the illness, and limited medical knowledge resulted in a state of inertia, and allowed Punch to quip that those citizens who “insisted on having influenza”, did so “at their own risk”. Dr Robert Hume is a writer and former head of history at Clarendon House Grammar School, Ramsgate, Kent This article was first published in the January 2018 edition of BBC History Magazine
Why was there a backlash against face masks during the Spanish Flu pandemic of 1918?
At the height of the Spanish Flu pandemic of 1918–9, many Americans refused to wear face masks designed to reduce the spread of the illness. But why? Professor E Thomas Ewing explains…
The Spanish Flu was a lethal virus in 1918–9 that is estimated to have infected a third of the world's population and left upwards of 50 million dead. Like today, as governments around the world try to contain the spread of COVID-19, American citizens were asked to wear face masks in order to reduce the spread of the illness. But, as Professor E Thomas Ewing explains, many Americans refused to cover their faces. Here he explains the reasons why, and asks what lessons can be learned… In early December 1918, two women were fined for violating the mask ordinance in Ogden, Utah. Rhoda Williams, a department store clerk, pleaded guilty “to the non-wearing of a mask while attending on customers”. Williams had asthma, so wearing a mask was “a miserable experience”, according to her physician. The judge expressed “human consideration” for her plight but fined her $10. Mrs Reynolds, a bakery employee, also pleaded guilty, but objected that these “rules are framed to hit those who have to work for their living the hardest”. Determining that Reynolds had “not willfully, but carelessly” forgotten the mask order, the judge fined her $5. Why was the 1918-19 pandemic that killed 50 million people known as ‘Spanish Flu’? These two cases from 1918 should resonate with citizens all over the world in the summer of 2020, some of whom are struggling to comply with mask orders, recommendations, and regulations in response to COVID-19. Ogden’s “Influenza Regulations”, implemented on 26 November 1918 during the Spanish Flu pandemic, anticipated similar requirements: “All persons attending upon patients suffering from influenza and barbers, dentists, clerks, elevator operators, and others of similar occupations, and persons coming in close contact with the public, shall wear masks.” The Ogden Standard, like newspapers across the United States, published guidance on making masks early in the pandemic: “Take a piece of gauze, eighteen by twenty-four inches, fold it four times evenly, attach four taps to the corners and you are provided with the best preventive against Spanish influenza yet devised.” Spanish flu: the virus that changed the world In 1918, as in 2020, Americans responded to mask regulations with behaviours ranging from eager compliance, to indifferent neglect, to open defiance. The cases of Williams and Reynolds are especially suggestive of a backlash against these regulations: masks were uncomfortable, difficult for those with certain health conditions, and could be easily forgotten. Why were individuals punished for not wearing masks, and what do these motivations reveal about the challenge of enforcing similar rules in 2020? The arrest of individuals for defying the mask ordinance in San Francisco received the most attention, both in 1918 and subsequently, because they highlighted the confrontation between policy mandates and individual actions. More than 1,000 “mask slackers” were sent to jail during the first two weeks of the ordinance. On 21 November the mask order came to an end, after just four weeks of enforcement. As the number of new cases of Spanish Flu surged in the new year, the mask ordinance was implemented again, effective 17 January 1919. Two weeks later, on 1 February, the mask order was rescinded again, as the influenza situation improved enough to allow normal public behaviours to resume. Photographs taken in San Francisco illustrate how public behaviour was modified by mask requirements. In one photograph, a masked policeman has custody of two men, one wearing a mask correctly and the other with a mask around his neck. In a second photograph, a policeman wearing a mask speaks directly to a woman with no mask. The caption, “Get one like this right away,” suggests the officer is warning the woman to put on a mask. A third photograph shows a policeman escorting a masked man past a seated masked man holding out a mask. The escorted man holds a cigarette, so it’s possible he pulled off his mask to smoke. Our research at Virginia Tech has uncovered similar defiance to mask ordinances elsewhere in the United States. In Sacramento, California, Frank Bobich told police he would rather “be killed or hanged” than cover his face, even though he had a mask in his pocket. In Fort Wayne, Indiana, C McKown was arrested when he defied a request from a police officer to put on a mask while riding a streetcar. In Bakersfield, California, with a population under 20,000, John Lynch was arrested “for deliberately declining to wear a mask in a local picture theater” after he was advised to put on the mask. Lynch “was so vehement that the city or anybody could not make him put on a mask that the policeman took him in tow to the city dispensary of justice”. It is important to ask, however, how representative these defiant actions were among the population as a whole, and even among those arrested for mask violations. In other examples reported in newspapers, defiance of the mask ordinance was justified by claims that masks themselves were unsafe or not healthy. In Tucson, Arizona, mechanic C Sutton admitted to not wearing a mask but claimed “it was not safe to do so, as it would have interfered with his vision and rendered himself liable to injury from the machine.” In Santa Barbara, California, Dr J Clifford responded to his arrest with a pledge to “fight this case” because “I, as a physician, do not believe that the mask as prescribed by the board of health is of any use whatsoever in preventing the spread of an epidemic.” In Pueblo, Colorado, steel worker James McLaughlan defied an officer’s repeated requests to don the mask, “stating that he recently came from Chicago where the wearing of masks was considered injurious to the health”. A matter of convenience? Our research also suggests that many violations of mask ordinances resulted, as in the cases from Ogden cited above, from indifference, ignorance, or convenience. In Stockton, California,, lists of arrests published in the local newspaper suggest that individuals either did not know about the ordinance or had neglected to put on their masks. In Lima, Ohio, most of the 70 people arrested on one Saturday night had a mask, “either in his hand, or his pocket, or had slipped down over his chin.” In San Francisco, most of the 110 arrested on the first day had masks around their necks, which suggests their refusal was more about convenience than principled opposition to the rules. Although the sources do not provide detailed information about the social status of those arrested, the available evidence suggests that those arrested in public, including on streetcars, outside restaurants, or on the street, probably represented a range of occupations. By contrast, those charged with violating mask requirements for specific occupations were more likely to come from lower-middle social strata that included mechanics, conductors, or clerks. In this context, the arrest of a physician such as Dr Clifford for a health regulation violation suggests an unusually deliberate infraction by a member of middle-to-upper-class American society. The differential impact of ordinances and enforcement were fully expressed in the number of Ogden citizens fined for violating the mask ordinance while doing their jobs. Just one day after the regulations went into effect on 28 November 1918, Mrs W Rayama was fined $5 while working in the family barbershop. S Hill, aged 21, was arrested for “waiting on customers without wearing a mask”, and I Ikemott, a restaurant owner, was “charged with not wearing a mask while he waited on patrons”. The fact that two of those arrested, Rayama and Ikemott, were identified as “Japanese” suggests that these laws reinforced structured forms of racism that concentrated certain ethnicities in specific service occupations where masks were required. <img src="https://images.immediate.co.uk/production/volatile/sites/7/2020/07/GettyImages-50599275-ab74475-scaled-e1595579437163.jpg" width="1024" height="740" alt="Seattle policemen wearing protective gauze face masks" title="Seattle policemen wearing protective gauze face masks during the Spanish Flu epidemic of 1918. (Photo by Time Life Pictures/National Archives/The LIFE Picture Collection via Getty Images)" /> On 6 December 1918, “a non-mask parade, made up of clerks and waitresses who had been caught in the act of not wearing their masks while waiting on customers” appeared in court. The suggestion that these defendants “regarded their appearance in no very serious fashion” indicates that the ordinance failed to change behaviour. It also suggests that the non-wearing of masks was not regarded as a political act. In addition, the eight names listed in the newspaper (“Miss Goodnuff, Miss Bartlett, Miss Read, Mrs Herring, Miss Brown, Miss Jackson, Mr Morris, and Frank Lowdner”) did not appear to come from the minority ethnic populations, suggesting that being young and white might have contributed to a perception that these laws were not to be taken seriously. In Ogden, the decision to revoke the mask ordinance occurred relatively quickly, on 9 December, just a few days after the arrests described above. City health officials admitted they “had received many complaints that the mask ordinance was working unequally, and poor people were being fined for negligence while others of bigger pockets were not being caught.” A delegation of railway workers stated that “the wearing of the mask was for them an impossibility, as they were unable to keep them clean or get them sterilized and changed.” After further discussion, the motion “banishing the mask regulation” was passed and went into effect immediately, bringing the two-week experiment in social regulation to an end. Lessons for today The resolution of the mask situation in Ogden suggests important lessons for today. During the COVID-19 pandemic, public confrontations with those enforcing mask rules; shaming of those defying guidelines; and public displays of unmasked resistance have attracted extensive media coverage. In today’s difficult public climate, we can perhaps learn a lesson from Ogden’s decision to end the ordinance by listening to multiple points of view, acknowledging differential enforcement on marginal populations, and modifying policies as conditions change. Podcast: A history of pandemics: from Spanish Flu to COVID-19 Most importantly, however, the mask backlash of 1918 teaches us the importance of situating individual short-term behaviour in the context of social needs. In 2020, Americans can anticipate wearing masks for many months, if not years. Even in the early stages of the mask orders in Ogden, the newspaper described willing participation and demonstrated reluctance; both patterns of widespread social behaviour appeared to cut across social class. Both of these widespread public behaviours in one city with moderate mask policies provide a cautionary warning for dealing with COVID-19 in 2020. The historical record forces us to ask which trajectory will be more sustainable: a commitment to changing individual behaviour to bring lasting improvement in public well-being, or a growing backlash against onerous health regulations that could allow the virus to infect many thousands more victims? E Thomas Ewing is a professor in the Department of History at Virginia Tech and the associate dean for graduate studies and research at the College of Liberal Arts and Human Sciences. He teaches courses in Russian, European, and world history. This article was co-written with assistants Jessica Brabble and Ariel Ludwig.
Why was the 1918-19 pandemic that killed 50 million people known as 'Spanish Flu'?
The Spanish Flu pandemic killed an estimated 50 million people over three killer waves that spread throughout 1918-19, and infected a third of the world's population. But the deadly virus did not originate in Spain, so why is it called Spanish Flu? Plus, how should we talk about the new virus circulating the globe known as Covid-19?
Why is Spanish Flu called Spanish Flu? The H1N1 influenza virus is one of the deadliest disasters in history. It killed more people than the First World War – and in less time. But there are many misconceptions about the pandemic. Firstly, 50 million is a conservative estimate for the number of dead – the figure could be many times that number. There is also no way of being certain where Spanish Flu originated, although the trenches of World War I, where poor sanitation and disease was rife, are an often-cited contender. The filthy, rat-infested conditions undoubtedly affected the soldiers’ immune systems, making them more vulnerable to illness. Spanish flu: how the deadly virus changed the world Epidemiology: the history of disease and epidemics (via BBC Science Focus) "Far too little, too late": what happened when Spanish Flu hit Britain a century ago? It is thought the first cases were in military forts in the United States before spreading at an alarming rate to Europe. But yet the pandemic was called ‘Spanish Flu’ – again, a result of the war. Spain was not hit especially badly compared to other countries but wartime censorship exaggerated the affects of the virus there. While Britain, France, Germany and the United States censored and restricted early reports, papers in Spain – as a neutral country – were free to convey all the horrid details of the pandemic. This made it look much worse there, so the unfortunate name spread with the disease around the world. This answer was taken from BBC History Revealed magazine How should we name new diseases? We recently interviewed Laura Spinney about pandemics for the HistoryExtra podcast. Here's what she had to say about the origins of the Spanish Flu name – and why we should be careful about how we talk about the new coronavirus known as Covid-19... Laura Spinney: "One of the few certainties we have about the Spanish Flu 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. The Spanish felt, and to a very great degree were, stigmatised by this. In 2015, the World Health Organisation (WHO) put out guidelines for how to name a disease. 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, in 2009, H1N1 flu was initially called "swine flu". 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. 10 facts about the Black Death Black Death quarantine: how did we try to contain the most deadly disease in history? You can also think about AIDS, which was initially called gay-related immune deficiency and stigmatised the homosexual community – this was unhelpful for everybody, including heterosexuals. Nobody thought about how it might be being transmitted in that community. Meanwhile, homosexuals were getting stigmatised for being the ones who transmitted HIV, so it was unhelpful to everybody. So naming doesn’t help. And this time [with Covid-19] , I think, it’s really interesting. 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." Read the full interview with Laura Spinney here, or listen to the podcast. Read more about the history of pandemics here Tips on how to keep yourself healthy, happy and safe during the coronavirus pandemic, from across our community: How to work from home successfully during lockdown [via Science Focus] Enjoying nature despite COVID-19 [via Discover Wildlife] Fun craft ideas for kids to make at home [via Gathered] Bingeworthy space and astronomy podcasts for those in self-isolation [via Sky at Night Magazine] Astronomy in isolation: stargazing activities for those stuck at home [via Sky at Night Magazine] How to cope with anxiety and take care of your mental health during the coronavirus pandemic [via Calm Moment] 17 ways to practise self care when working from home [via Calm Moment] Coronavirus wellness resources to help you stay positive [via Calm Moment] 15 super fun DIY science experiments for kids to try at home [via Science Focus]
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. Why was the 1918-19 pandemic known as Spanish Flu? Portraits of a plague: the 19th-century pandemic that killed 12 million people 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. "Far too little, too late": what happened when Spanish Flu hit Britain a century ago? Could flu really kill thousands again? 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. 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. Spanish Flu: the virus that changed the world 10 facts about the Black Death 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. Listen | Catharine Arnold explores the story of the Spanish Flu outbreak that caused devastation across the globe a century ago 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. Listen to the full podcast interview with Laura Spinney here Matt Elton is the editor of BBC World Histories Magazine Laura Spinney is a British science journalist, novelist, and non-fiction writer
As COVID-19 dominates the news, Laura Spinney asks what we might learn from pandemics in the past
As COVID-19 dominates the news, Laura Spinney draws historical parallels with other pandemics in history and asks what we might learn from disease outbreaks in the past Read our transcript of the podcast interview here Why was the 1918-19 pandemic known as Spanish Flu?
Books interview with Paul Morland: “Even the Spanish flu pandemic wasn’t enough to stop population growth”
Paul Morland talks to Ellie Cawthorne about his new book on how demographic change has shaped global history, and is set to shape our future too
This article was first published in the January 2019 edition of BBC History Magazine Q: What exactly is ‘demography’, and why do you think it is an enlightening way to look at history? A: In some ways demography is quite simple, and that’s part of its appeal. It’s essentially about three things: the people entering the world, the people leaving it and the people moving across it – births, deaths and migration. So why does it have such an impact? Because the number of people in any given area, and the age and ethnic composition of that population, affect an area’s politics, economics, society and culture. In fact, it’s very hard to think of aspects of life that are not impacted by demography in one way or another. Q: Your book looks at population trends over the last 200 years. What have been the biggest changes in that time? A: Throughout human history there’s always been population growth and decline, but before the 19th century things were rather random. Around 1800, however, a pattern started emerging, which sees death rates falling while fertility rates stay high, meaning that a population grows until eventually the birth rate falls and the population stabilises. Why did this happen? Modernity. When you start to get basic public health measures and education on how to implement them, death rates fall very quickly. This pattern began in Britain, and then spread across Europe and the world. Want to read more articles from our December 2018 issue? Find the full issue here, including: Roman Britain’s final frontier Queen Anne's feuding favourites <img src="https://images.immediate.co.uk/production/volatile/sites/7/2019/01/1161912-a4e89bc.jpg" width="2451" height="1803" alt="Queen Anne, based on a work by Sir Godfrey Kneller, c1702–10. Anne's reign saw women take centre stage in fierce political debates. (Photo by Bridgeman/National Trust Photographic Library)" title="Queen Anne, based on a work by Sir Godfrey Kneller, c1702–10. Anne's reign saw women take centre stage in fierce political debates. (Photo by Bridgeman/National Trust Photographic Library)" /> Q: How did this pattern affect the balance of global power? A: It’s very important that the first population explosion happened in Britain. Britain had a number of environmental, cultural and institutional advantages that meant it was the first significantly-sized country to go through modernisation. In the 19th century, Britons became better educated, better housed, better fed and were more likely to get basic medical care. This meant they experienced an early fall in death rates, so the population ballooned. Without its first-mover advantage, Britain could never have become ‘the workshop of the world’ – the industrial revolution couldn’t have kept its momentum up without a large and growing population. This early population boom also essentially led to the British empire, with a huge movement of people from the British Isles to far flung parts of the globe. The world we know today, full of English-speaking countries, is the product of that rollercoaster of Anglo demography – population explosion and mass emigration, which then spread across Europe. Today, of course, the migration is the other way around. At several points in the 21st century, we’ve seen hundreds of thousands of people a year move to the UK. Similarly, if you told somebody in France in 1900 that by 2018 we would have huge Algerian populations in Paris and Marseille, and no French populations in Algiers, they would have been absolutely astonished. Q: Tell us about the connection between population and war. A: On a very basic level, the number of fighters you can throw onto the battlefield is hugely significant. If you look at the battles on the First World War’s western front, it was a grinding competition of pouring ever more men into the trenches. When the quality of the soldiers’ training and armaments was broadly similar, numbers mattered enormously. That gave the Allies an edge, and when America entered the war it was the final straw. You could say that the First World War was determined in the cradles of the 1880s and 1890s. But it’s more complex than a pure numbers game. The age of a population is another factor: young populations can result in a lot of conflict, violence and fanaticism. It’s certainly true that if Syria (which has a median age of 20) had a population the age of Switzerland (where it’s well over 40), things would have turned out differently there. When you get to a certain age, you have interests: you’re more likely to be married with children and have more of an economic stake in society. Something you almost exclusively find is that when a population gets old, it has less crime, violence and civil strife. There is also some evidence to support the argument that as family sizes decrease, parents value their children more intensely. Families with one son are less willing to send him off to fight than a family with four sons. However, my sister has four sons, and I imagine she would disagree with that! A young population is more likely to result in conflict, violence and fanaticism Q: You suggest that populations can be remarkably resilient… A: I don’t mean this to sound heartless or cruel, as I do recognise that every life is valuable. But yes, these big cataclysmic events don’t actually have as much impact as you might think. For example, the First World War and the 1918 Spanish flu pandemic: these did slow population growth in Europe, but even the millions of deaths they caused weren’t enough to stop that growth entirely. A current example would be Syria. Syria’s population is about 20 million, and the country has lost around half a million in war casualties (not including people who have emigrated). Just in raw numbers, those losses could be recuperated in a very small space of time. Syria could see its population growing at 2 or even 3 per cent a year. Q: What is the most important factor in population change? A: For me, it has to be birth rates. Where contraception and education are available, and women have a choice, it’s a given that they have smaller families. Outside sub-Saharan Africa, there’s barely a country in the world where women have more than four children now. The fall in fertility rates across the globe in recent times is staggering. What I call the ‘infertile crescent’ now stretches from Spain to Singapore. One statistic that floors me is that between 1970 and 1980, China’s birth rate fell from 6 to 3 in a decade, and that was before the one-child policy was introduced. You simply can’t get much faster falls in fertility than that. Decisions like how many children to have feel very personal, but the individual choices you make are shaped by big social forces. And what’s fascinating is how different cultural, social and economic settings lead people to make different choices on aggregate. Q: You talk about ‘demographic engineering’ – what does that involve? A: Demographic engineering is when groups in conflict use demography in order to strengthen their hand against the other side. I talk about two types: hard and soft. Hard demographic engineering is when you change a population through demographic factors themselves – attempting to manipulate birth rates, death rates or migration. In its most extreme form it could even include genocide. One example of hard demographic engineering would be Northern Ireland’s Protestant establishment encouraging Catholics to emigrate in the 1960s and 1970s. This was a rather deliberate strategy to counter high Catholic birth rates and strengthen Protestant numbers. Another example would be the elevated birth rates of both Israelis and Palestinians when compared to similar groups – what could be termed ‘competitive breeding’, driven by a group’s desire to reinforce their numbers in a time of conflict. Soft demographic engineering is when you try and change a population through non-demographic means, such as redrawing boundaries or manipulating cultural or national identities. To take another example from Northern Ireland: when the state was founded, there was a decision to include six rather than nine counties, as those six counties constituted a much more sustainable Protestant-majority population. It was about defining the state in a way that favoured one group over another. Q: What does the future hold? A: I use the analogy of three colours: more grey, less white and more green. Firstly: more grey. Almost every society on the planet is ageing. In many ways, an older global population is a positive thing – it’s definitely more peaceful. But it also raises lots of economic problems, such as a falling working-age population and rising health care costs. Secondly: less white. The huge expansion in white populations we previously took for granted is now retreating, and historically majority-white countries are becoming much more diverse. Mass migration into Europe and America has changed the face of those continents, and identities will surely continue to shift in these nations over time. Towards the middle of the current century, the percentage of the US population that belongs to minority groups is expected to be more than 50 per cent, and that will surely have an impact. If you look at the ethnic makeup of Trump voters and his slim electoral victory, it’s clear he would not have been elected if America was less white. At the same time, Africa is about to have a huge population explosion – by 2100, there are very likely to be six or seven times as many Africans as Europeans. We’re in the middle of a massive shift in the global balance. The world is set to become much more African, and it will be very interesting to see how that will affect things. My last and perhaps most controversial prediction is: more green. The best UN data suggests that by the end of the century, population growth will be slowing towards zero. As the amount of additional agricultural output we need slows, coupled with rising agricultural productivity, there’s an opportunity for nature to take back some space. In countries with declining populations, such as Japan or Bulgaria, you can already find abandoned villages where wolves and bears are returning. So once we reach population stability, we could have a greener world as well. Q: Should we feel hopeful then? A: Having said all of this, you never know where things are going – there are always kinks in what we think the pattern is going to be. In 1798, Thomas Malthus described a world in which expanding populations would outstrip food supplies, and everyone would be living on the brink of starvation. But almost exactly as he was writing, the system he so beautifully described was collapsing and we started to see this amazing demographic transition emerge. Likewise, the postwar baby boom caught everyone by surprise. And now we’re living in uncharted waters. Take the rise in acceptance of LGBT+ rights for example – it will be interesting to see what that will mean in terms of demography. But who knows – we might get a population explosion we didn’t see coming. Or we might all be wiped out by a meteor or plague. Demography likes to play some funny tricks when you least expect it. Dr Paul Morland is an associate research fellow at Birkbeck College, University of London, specialising in demography. He is the author of Demographic Engineering: Population Strategies in Ethnic Conflict (Routledge, 2014). His new book, The Human Tide, is his first title intended for a non-academic audience.
Catharine Arnold explores the story of the influenza outbreak that caused devastation across the globe a century ago
Catharine Arnold joins us to discuss her new book Pandemic 1918: The Story of the Deadliest Influenza in History, which explores the story of the influenza outbreak that caused devastation across the globe a century ago.