Source of book: Borrowed from the library
First of all, this book was published in 2017. This is important for a number of reasons, as will become apparent. Covid had not yet happened. Yet, this book accurately predicted the main challenges of a pandemic, including the way that public health has become politically toxic for a significant portion of our society.
The prediction was possible, because all of the issues we faced with Covid were issues during the 1918 influenza pandemic, the subject of this book.
As Spinney notes at the beginning of the book, the two world wars have essentially sucked up all the oxygen in our consciousnesses regarding the first half of the 20th Century. Which is likely completely backwards. As horrible and awful and bloody and traumatic as the wars were, there was actually a greater source of human death, injury, and suffering than either war.
Although exact numbers are impossible to know for certain, the best estimates of the death toll from the 1918 epidemic certainly exceeded either of the world wars individually, and very likely exceeded the combined death tolls of both wars.
How many died? In the two year period between March 1918 and March 1920, somewhere between 50 and 100 million died of the disease. That’s somewhere between 2.5 and 5 percent of the world population. And, I might mention, significantly more in both numbers and percentages than Covid.
So why is this pandemic less familiar? As Spinney discusses, wars tend to get all the press during and soon after their dates. Pandemics take longer to be remembered, but they endure far longer.
As an example, how many can recount the events of the 100 Years War? (A few nerds can, of course, but not the average person.) In contrast, how many know about the Black Death, which occurred at the same time? And, these days, the 100 Years War is of less interest to historians than the Plague, which killed an appalling percentage of the population of Europe, and had a far more lasting effect on the trajectory of history than the war.
But that only became apparent in retrospect. Forget the Spanish Inquisition: nobody expected the end of Feudalism.
The book covers a lot of ground, starting with a quick history of influenza and humans. It has plagued our species ever since we began keeping livestock - it is a disease that jumps to humans from birds, mostly, often with pigs or horses as the intermediate step.
Thus, pandemics have swept through the human species regularly, and, as the result of larger populations and greater contact through global travel, have increased in size and impact.
The 1918 epidemic was the worst we have seen, but it also was the first that was documented well enough for there to be useful data. Which eventually led to incredible advances in microbiology and epidemiology.
It is no exaggeration to say that the reason Covid-19 was unable to kill the way that the 1918 flu did was because we used our knowledge from the prior epidemic to prevent transmission and create vaccines and treatments that saved countless millions of lives.
Although technology did not enable us to actually see viruses until later, the 1918 flu demonstrated that there was some pathogenic agent smaller than bacteria, that was able to infect humans and transmit disease between them. Even without knowing what viruses were, we were able to track how they spread, and determine how best to prevent transmission.
We also, eventually, were able to use vaccination technology to grow viruses and create new vaccines, which would eventually virtually eliminate deadly diseases like Polio and Measles from many countries. These vaccines would also greatly reduce the mortality and morbidity from influenza and, yes, Covid-19.
After giving the background, most of the book looks at the various facets of the pandemic around the world. It ends with a discussion of public health, and the measures necessary to keep future pandemics in check.
There is a lot of fascinating stuff here, and it seems particularly relevant in understanding the Covid pandemic as well as preparing for future pandemics.
It is also a bit chilling, because we are looking at a potential new pandemic jumping from birds to humans, at the same time that the Trump/Musk administration is gutting public health here in the United States. We could very well find ourselves in a position where we suffer greatly disproportionate deaths from the rest of the world because of our self-inflicted stupidity. Sigh.
I will also note with approval that Spinney ties in a lot of interesting cultural references - while the 1918 pandemic never became truly constant in the writing and art of the time the way Covid seems to have done, there actually are more references than I realized. I will try to highlight a few of them.
Let’s start with this one. Everyone knows Edvard Munch’s evocative painting, The Scream. It was created just after an earlier flu pandemic, when the artist was still feeling tired and ill from his own bout with the illness.
I want to note, once again, that this book was written and published before Covid. But check out this bit. Apparently, Covid was not the only virus to have caused sensory issues, and also long and lingering effects.
People reported dizziness, insomnia, loss of hearing or smell, blurred vision…Many patients remarked, on regaining consciousness, how washed out and dull the world appeared to them - as if those cyanosed faces had drained all the colour from it.
Any of that sound familiar? While I myself haven’t had Covid (shocking, I know, even though I have been vaccinated according to recommendations), this matches what others have said - and the way the colorlessness lingers for months afterward. I remember similar things from some particularly terrible bouts of flu from my childhood.
Bound up with the pandemic itself was the public health response. Spinney takes a look at Brazil, and the problems that face any government trying to treat or prevent pandemics. In that case, a dictator in the 1900s ordered mandatory smallpox vaccinations. Since he was unpopular, vaccines became unpopular, as did social distancing, masks, and other public health measures. This lead to catastrophe during the 1918 pandemic.
On 12 October, the day that the flu spread through the elegant guests at the Club dos Diaros, the satirical magazine Careta (Grimace) expressed a fear that the authorities would exaggerate the danger posed by this mere limpa-velhos - killer of old people - to justify imposing a ‘scientific dictatorship’ and violating people’s civil rights.
Does that sound familiar? In reality, the 1918 flu turned out to be a killer of young people - those in the 20s and 30s - not just the old. Covid likewise struck down a shocking number of otherwise young and healthy people.
One of those was another artist, Egon Schiele, whose work is some of my favorite of the era. (I have a bookmark with one of his portraits on it.) In one of his very last paintings, The Family, he portrays himself, a pregnant woman (probably modeled after a former lover, not his actual pregnant wife at the time), and a small child. The book includes this picture.
Soon after, his wife contracted the flu, and died along with the unborn child. Schiele would follow a few days later. He was age 28. So much for a “killer of old people.”
Other governments took a different approach, which likewise led to problems.
The 1918 pandemic is often referred to as the “Spanish Flu.” What it was was certainly NOT Spanish. As the book explores, there are several plausible sources for the disease - we will never know for sure - but none of them were Spain.
The possible origins include China, two different places in the United States, and one in northern France. The reason Spain became associated with the pandemic is that it was one of the first - and only - European countries to track and accurately report the disease. Because Spain was neutral in the war, it had no reason to hide casualties in the name of morale. Both the Axis and Allied powers suppressed the devastation of the flu as it burned through the trenches of the Western Front.
Whether trying to preserve morale, or actively trying to stop the spread, governments faced an uphill battle. Then, as now, a high percentage of the population rejected germ theory as the true explanation for contagious disease, instead seeing pandemics as a judgment from God. Or worse, as the result of “those dirty people.”
As the book notes, Apartheid in South Africa got its start in the pandemic, with segregation of neighborhoods justified on the grounds that it was those filthy black people who spread the flu. (Incorrect, but in truth the impoverished always die at higher rates than the rich - being half starved or suffering from mining diseases exacerbated the flu.)
Other methods are far more effective. One of which is the quarantine. Which comes from “40 days” - the time that infected ships were kept at anchor before being allowed to disembark at Venice.
Speaking of quarantines, one of the reasons that Covid got a foothold in the United States was that Trump - who clearly believes in the “those dirty people” theory of disease - kept Chinese travelers out, while letting in Americans returning from China and elsewhere without testing or isolating. A friend of mine, infected with Covid - he had a positive test in Asia - was told to just come on back in. He did the right thing and self-isolated until he was well, but countless others spread the disease.
The book goes into marvelous detail about the way disease spreads, and the need to isolate “superspreaders” - those who for various reasons tend to infect dozens. (People who shed lots of viruses, and those who are particularly social tend to do this. Knowing how many are infected and how many remain vulnerable is also important.
Here is an interesting bit:
Two years [before 1918], in his ‘theory of happenings,’ the British malaria expert and Nobel laureate Ronald Ross had come up with a set of differential equations that could help determine, at any given time, the proportion of a population that was infected, the proportion that was susceptible, and the rate of conversion between the two (with some diseases, infected individuals could return to the susceptible group on recovery). A happening, according to Ross’s definition, was anything that spread through a population, be it a germ, a rumour, or a fashion.
And here we get into how this applies to addressing a pandemic. Remember, this was written before Covid!
Ross’s work, along with that of others, illustrated in hard numbers something that people had long understood instinctively - that a happening will begin to recede when the density of susceptible individuals falls below a certain threshold. An epidemic will run its course and vanish on its own, without intervention, but measures that reduce that density - collectively called ‘social distancing,’ - can both bring it to an end sooner, and reduce the number of casualties.
This is what I never could get right wingers to understand. Slowing the spread of a pandemic through distancing actually makes the pandemic shorter, not longer. And a lot less deadly.
You can think of the area under the epidemic curve as reflecting the total amount of misery that it incurs. Now, picture the difference in size of that area when the curve is high and broad - that is, without intervention - and when it is low and narrow, with intervention. That is potentially the difference between an overwhelmed public health infrastructure, where patients can’t get treated, doctors and nurses are pushed beyond exhaustion and dead bodies accumulate in morgues, and a functioning system that, though stretched to its limit, is still managing the flux of the sick.
Covid was right on that ragged edge. My wife was on the frontlines, and worked absurd hours under difficult conditions, and still has trauma from that. A look around the world shows that the US probably had around a million extra deaths (and far more hospitalizations) because of its poor response to the pandemic. We weren’t the worst, but we weren’t great.
And, with Trump and RFK Jr. continuing to undermine trust in public health, vaccines, and quarantine measures, the next pandemic will almost certainly end up in the catastrophe described above. As if we were in the fucking Middle Ages again.
Again, re-read that paragraph. This was written before Covid, and it was totally prophetic.
Another thing that was familiar? The 1918 flu likely killed in a similar way as Covid, through a “cytokene storm” - the immune reaction that overwhelms the patient’s body.
“Long Flu” - like “Long Covid” - was also a reality. The book looks at some studies which show significantly elevated rates of depression and chronic fatigue.
The flu virus may act on the brain, causing depression, but depression is also a common response to bereavement and social upheaval. How to disentangle the two?
Because of the limits of diagnosis at the time, it isn’t possible to completely link this to the flu, but there is significant spike afterward. We will have a similar problem in our own time. How do we separate the lingering effects of Covid from the effects of Trump and MAGA and their destruction of the world order, the Federal government, and the rule of law? That will be an interesting thing for future generations to determine…
Yet another issue that resonates with our times is the problem of scientific authority. Back then, to be clear, the flu and viruses generally were poorly understood at best. Although things were moving in a positive direction.
One mistake made was that at one point, a bacterium was thought to cause flu - and it was given the name Haemophilus influenzae. The mistake was understandable, because the flu often leads to secondary bacterial pneumonia - and Haemophilus is one cause of that.
As the result of this mistake, a vaccine was developed for the bacteria. This was a good thing, because it prevented some disease. In fact, my kids and I have received that vaccination, because it is still in use.
That said, a lot of what mainstream medicine thought it knew at that time turned out to be incorrect. And much mainstream treatment of the 19th Century turned out to be not merely wrong but harmful.
By 1918, the medical establishment was barely becoming able to do better than alternative treatments. It still lacked the credibility to convince many people, unfortunately.
One rather humorous incident arising out of this involved another artist, Gustav Klimt. He was commissioned in 1901 to decorate a university ceiling: the theme was to be the triumph of light over darkness. Klimt’s painting, instead, had Death apparently triumphing not only over life, but over medicine.
This isn’t entirely wrong - death comes for us all - but it created a big stir. The university refused to use the painting, so Klimt demanded it back so he could sell it elsewhere. The university claimed it was state property, and sent agents to seize it. Klimt drove them off with a shotgun…and kept the painting.
At this point, I will mention that Spinney is British, not American, so her perspective on health care systems is from outside the American Exceptionalism bubble. A case in point is the chapter entitled “Healthcare for All.”
If health authorities had learnt anything from the pandemic, it was that it was no longer reasonable to blame an individual for catching an infectious disease, nor to treat him or her in isolation. The 1920s saw many governments embracing the concept of socialized medicine - healthcare for all, free at the point of delivery.
Man, that would be so fucking nice to have, wouldn’t it? But we can’t have nice things here because a majority of white people in this country are racist as fuck, and would rather die than see black people have equal access to healthcare. But the rest of the First World did it.
Likewise, the 1918 epidemic led to the roots of the World Health Organization, first under the League of Nations, and eventually under the United Nations.
And, of course, Trump/Musk withdrew us from WHO, because sharing health information with the rest of the world for the good of all and to save millions of lives is too fucking “woke” for them. Best to just set ourselves up to get crushed by the next pandemic that we will not see coming and fail utterly to prepare for. God, people are so stupid.
The chapter on the artistic fallout of the pandemic was particularly interesting to me. I have, naturally, read a number of the works of the era that touch on the flu. You can read my thoughts on Pale Horse, Pale Rider by Katherine Anne Porter - the source of the title of the book (which ultimately comes from The Book of Revelation - the four riders of the apocalypse.)
Other authors touched on the subject. D. H. Lawrence suffered from long term effects of the disease. Luigi Pirandello, Samuel Beckett, and Franz Kafka all lived through it, and scattered references throughout their works.
The devastating effects of the flu in China led reformers like Lu Xun to push for Western medicine rather than the ineffective traditional remedies.
I want to finish, as the book does, with a couple of thoughts on how we need to act to address the next pandemic. Because there WILL be one, probably sooner rather than later. While no pandemic is predictable in all its details, there are things that can and should be put in place to address it.
In fact, these things were what prevented Covid from becoming the same level of catastrophe as the 1918 flu.
Despite all the uncertainty, there are things we can do to prepare. The 2016 GHRF report called for governments and private and philanthropic bodies to stump up around $4 billion a year for pandemic preparedness, and it recommended that the money be invested in four main areas: a skilled and motivated public health workforce; robust disease surveillance systems; effective laboratory networks, and engagement with communities.
Note that all four are on the DOGE chopping block, and have long been targeted not merely by Trump, but by the Republican Part - for decades.
I believe, based on growing up largely around Republicans - white Evangelicals in particular - that this is based in large part on a tribalist belief that God will spare the “good people,” so there is no need to invest tax dollars in preventing disease. In fact, maybe we should just let the world burn - we’ll be fine, right?
Of course, this is horseshit on a stick. In reality, churches that refused to close their doors lost many members to Covid - I am familiar with local instances and there are many across the nation. The death rates among Republicans were, adjusted for poverty rates, higher than for Democrats. This was directly due to refusals to use masks, distance, and get vaccinated.
Nobody is exempt from a pandemic, because germs don’t check your theological beliefs before infecting you. Our strength lies not in a social darwinistic belief that “good people survive” but in preparing and caring for everyone.
During the 1918 flu pandemic, and in Covid as well, survival rates tracked the willingness to sacrifice individually for the good of all. This requires trust, something that has been systematically undermined by the American Right Wing my entire lifetime.
Trust broke down between the two parties - or rather, was never built up. But trust is not something that can be built up quickly. If it is not in place when a pandemic declares itself, then however good the information being circulated, it probably won’t be heeded.
This is why I am concerned that the next pandemic will be particularly catastrophic here in the United States. Rather than working to build trust, half our nation is actively tearing it down, in the mistaken belief that they will be exempt from the pain. They imagine themselves like the young people in The Decameron, riding out the death from the comfort of their luxurious vacation homes, while the world burns around them.
In reality, what will happen is that they will find themselves instead in an Edgar Alan Poe story, “The Masque of the Red Death.” The plague will be among them before they realize it.
I very much recommend reading this book. Understanding the past is one key to changing the future for the better. Covid was not the first pandemic. Neither was the 1918 flu. And neither will be the last.
What we can do is prepare for the next one. And part of that is being prepared to use and share the knowledge of how pandemics spread and how that spread can be stopped. This book is a good start in that understanding.
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