Flu - the lessons of history

Published on Wednesday 1 July 2009 19:02

IT BECAME known as "the forgotten flu pandemic", all too often regarded in hindsight as an adjunct to the carnage of the First World War, yet the great influenza pandemic of 1918-19 wiped out an estimated 50 million plus lives worldwide, including some 228,000 people in Britain alone.

The so-called Spanish influenza pandemic, sometimes thought to have killed as many people as the Black Death, was caused by a highly virulent version of the same H1N1 strain of virus causing the current swine flu outbreak, and was first reported in a US army encampment in Kansas, whence it spread to France with American troops entering the conflict there. It also apparently spread to Clydeside, as the earliest British cases were recorded in Glasgow in May 1918, before sweeping across the country.

As Britain records its third swine flu fatality and with some 6,500 cases recorded (1,000 of them, including two of the deaths, in Scotland), and as the World Health Organisation tallies almost 71,000 cases, and 311 deaths, across the globe, attention is turning once again to the 1918 outbreak – as well as to the subsequent and relatively less virulent 20th century pandemics of Asian flu in 1957 and the Hong Kong flu in 1968 – to see how the authorities coped and what lessons can be learned in dealing with what appears so far to be a milder strain.

"Spanish flu" – so called simply because British newspapers, reluctant to carry worrying news about outbreaks at home, concentrated on reporting the illness's impact in Spain – hit a Britain whose health and other resources were already weakened by four years of war and associated food shortages, while antivirals, antibiotics, genetic analysis and other 21st-century medical weaponry were yet to be developed. Doctors were shocked by the severity of the symptoms, which seemed to attack a disproportionate number of the young and healthy, as often perfectly strong people started collapsing at home in the street and at work, sometimes dying within the day.

Various, sometimes desperate, methods were adopted to try and contain the infection: streets were sprayed with disinfectant and some people wore anti-germ masks; cinemas and dance halls were closed; some factories lifted smoking bans under the delusion that tobacco fumes could kill the virus.

But as H1N1 continued to sweep remorselessly through Front Line and Home Front alike, eroding industry and stretching medical resources to breaking point, one of the greatest contrasts with today's outbreak is that while swine flu makes daily headlines, the scale of the 1918 outbreak was astonishingly underplayed by a press still observing voluntary wartime censorship. It is a phenomenon that author Mark Honigsbaum describes as "not merely a psychological curiosity but a gaping hole in the historical record", which is why, earlier this year he published Living With Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918 (Macmillan).

"The key difference was that there was no real media reporting in 1918, and most people in the UK didn't realise it was a pandemic," says Honigsbaum, a journalist and author specialising in the history of disease and currently based at the Wellcome Trust Centre for the History of Medicine at University College London. "They talked about 'the Spanish Lady', which made it sound like a joke, something rather effeminate that a real man wouldn't worry about."

So it became the forgotten pandemic, scarcely documented, although, as Honigsbaum points out, the Times was moved to comment in December 1918 that "Never since the Black Death has such a plague swept over the face of the world … never (perhaps] has a plague been so stoically accepted,"

While clearly those battling the 1918 pandemic did not have the benefit of today's antivirals and antibiotics, another major difference, Honigsbaum says, was that not only was the world embroiled in a devastating war but there was no World Health Organisation to issue alerts or monitor the spread of the virus, nor was there National Health Service or even a Ministry of Health. "Basically, the response to influenza in 1918 was handled by local Medical Officers of Health. Places like Edinburgh, Glasgow, Aberdeen … all would have had their own MOHs, who would report to the town hall and the local health committee, and although they took advice from an organisation called the Local Government Board, a precursor of the Ministry of Health, they were pretty much free to decide on their own measures."

As an example of the resulting differing approaches, Honigsbaum says that in some areas schools were closed, but in others, the authorities decided to leave the schools open – "because if children didn't go to school, they would just hang about in cinemas, which were thought to be corrupting to their morals".

Not only was the response to the pandemic unco-ordinated, but half of Britain's doctors and nurses were away at the front. In researching his book, Honigsbaum came across descriptions of doctors run off their feet, or carrying large bunches of keys so they could admit themselves into stricken households. "I found accounts, for instance, of a doctor visiting one day, but the family simply unable to get him to come back. A son might perhaps recall a doctor coming to see his father and recommending, typically, that he should take plenty of fluids, maybe some whisky or brandy or, if you had congestion in the chest, he would recommend poultices. But then they would recollect that by the time the doctor came back, the father or mother was dead.

"It seems unimaginable today, when the second we feel ill we call the NHS flu line or expect to be able to see our GP, but what's interesting now is that in really badly affected areas like the west Midlands, they're having so many 'worried well' coming to accident and emergency that they're trying to set up separate areas for them. So we could still get the same sort of problem now, if so many people start thinking they're ill and demand access to their GPs and or hospital services … there's a limit to what even the NHS can deal with."

Honigsbaum acknowledges that the present H1N1 virus appears to be a milder strain than some predecessors: "Every pandemic is different and not all pandemic viruses cause high mortality, but what they do have in common is that they cause a lot of people to get ill. And the real worry is that come the autumn, which is the classic period for flu, you'll get huge numbers of people experiencing symptoms they haven't experienced before, and they read that it might be swine flu and they're panicked, and panic is what can break the system."

Some things haven't changed, however. "Basically, in 1918 the government decided that there was a war going on and anyway they didn't have enough doctors, and even if they did, there were no drugs or treatment. The message was 'carry on as normal'. If you were ill, you were to stay at home and isolate yourself, and if you go out in public, cover your mouth with a handkerchief if you cough or sneeze and dispose of it afterwards

"The same message, almost to the letter, now appears on the flu leaflets we've been getting through our doors – 'Catch it, bin it …' So some of the basic tools we have are no different. it's what they call social isolation: if you're ill, keep calm and don't spread the germs around."

Despite the development of far more sophisticated intensive care procedures, antibiotics and antivirals, a fundamental lesson from the 1918 pandemic, however, remains the importance of quality nursing care in limiting mortality, according to Dr Malcolm Nicolson, director of Glasgow University's Centre for the History of Medicine. "This is still a crucial issue," he says. "The question is what would happen in a serious pandemic when the health professionals were themselves falling ill in large numbers, as happened in 1918-19."

He agrees that this time around we are better prepared for a pandemic, although he questions to what extent this presumed readiness is actually protecting us.

"In a sense this is what they've been waiting for and is justifying our preparedness and all the contingency planning," he says. "But on the other hand containment (of the virus] is not working because of the mobility of the population and because diagnosis has proved problematic. The laboratories are swamped with swabs taken by GPs, more often than not from the 'worried well'. Also it is difficult to impose isolation on people who may have the disease but whose symptoms are mild.

"There is clearly a public education challenge here. Early in the outbreak, Tamiflu (the anti-viral drug] was being issued on a preventative basis and there are questions as to whether resistance will develop against it."

"But I don't think we really have an accurate estimate of (the current figures], and this isn't irrelevant historically. It was some years after the 1918 pandemic before the full pattern of its spread was understood; now the issues of diagnosis, of tracing, of controlling public anxiety have all been tested in this current outbreak and one hopes that important lessons are being learned that will stand us in better stead in the event of a more serious one in the future."

Flu outbreaks then and now, Nicolson adds, continue to raise major issues about where these pandemics are originating, such as, in the case of the current outbreak, the pig farming industry in Mexico – "sometimes with thousands of hogs on extensive farms, making them a melting pot for new viruses, which can pass between pigs and then on to human beings.

"Equally Asian flu comes from intensive poultry farming, which is traditional in South-East Asia and is becoming even more intensive due to population pressures and export markets. So we should be asking quite fundamental questions about how preventative measures could help."

And one other important advantage we have over our pandemic-stricken forebears in 1918 is the development of near-instantaneous global communications.

As a spokesman for the Scottish Government puts it: "Improved communications such as the internet and efficient phone systems mean that information is being shared far more quickly. And knowledge is power when it comes to dealing with these things."

PANDEMICS FROM 1580 TO THE PRESENT DAY

&#149 The first recorded true influenza pandemic may have been in 1580, when illness spread northwards from the Mediterranean to the Baltic, leaving some 9,000 dead in Rome alone.

&#149 In November 1562 what appears to have been flu swept through the court of Mary, Queen of Scots, one chronicler noting it as "a new disease that is common in this town, called here the Newe Acquayantance, which passed also throughe her whole Court, neither sparing lordes, ladies nor damoysells, not so much as either Frenche or English".

&#149 Also in the late 16th century, the English army in Ireland was badly stricken by flu, while accounts suggest that it struck Africa and Asia at the same time.

In the 17th century, three pandemics are thought to have occurred, including one during the year of the Glorious Revolution, 1688, when masses died, "as in a plague".

&#149 The 18th and 19th century saw further major outbreaks, with particularly severe pandemics recorded in 1836-37 – when 3,000 people died in Dublin alone – and in 1847-48.

&#149 In the 20th century, the most devastating occurrence was the uniquely virulent pandemic of 1918-19, with global estimates varying between 50 million and 100 million deaths.

&#149 Since then, Asian influenza in 1957-58 was an avian flu originating in China, with deaths worldwide estimated at between one and four million. And in 1968, Hong Kong flu caused some million deaths worldwide, particularly among the elderly.