H1N1 and the 1918 pandemic: Whatís different and what isnít
The current H1N1 flu pandemic has at least four similarities to the flu that devastated the Western world in 1918–20.
- Both involve swine influenzas
- Both, as we far as we know, started in North America. It’s now generally accepted that the 1918–20 flu started in Kansas, perhaps at Fort Riley, perhaps in Haskell County, where it seems to have existed in January 1918. The current H1N1 apparently started in Mexico
- Both then spread to many other countries. The 1918–20 influenza was named “Spanish flu” because the United States and its allies did not want it known how badly their troops were infected. When the flu broke out in Spain, the government there had no such qualms; it was not a belligerent during the First World War
- Both, at least so far, are more threatening to younger persons and not so threatening to the elderly
Of course, the lessons to be learned from the 1918–20 pandemic, and the factors that will likely create significant differences this time, deserve a closer look.
What happened the last time
As this is being written, H1N1 has caused a lot of sickness but relatively few deaths. That is in sharp contrast to 1918–20, when the flu caused at least 50 million deaths worldwide, far more than the 10 million estimated to have died during the First World War.
It’s possible, of course, that the current flu will remain relatively mild, and that the death toll will stay low. But it’s worth looking at what happened in 1918–20 to get a sense of what might happen if the current strain mutates into a deadlier one.
The first thing to note is that the death rate does not need to be all that high for flu to kill a lot of people, because during a pandemic so many people get infected. It’s estimated that 1 billion people got the flu in 1918–20 and that the overall death rate was around 5 percent.
To put it another way, 95 percent of those who got sick recovered, but because so many got sick, that 5 percent death rate killed millions, including at least 500,000 Americans.
The second thing to note is that the deaths were not spread evenly among the population. Soldiers were more likely to die than civilians. Young people, ages 20 to 40, were far more likely to die than individuals older than 60. Native Americans were far more vulnerable than others; entire villages were wiped out in Alaska.
Though the death rates are low, similar patterns seem to be emerging this time. And a look at the 1918-20 flu suggests other things we might expect.
The flu might infect young, otherwise healthy people, so police, fire and ambulance agencies could well find themselves short-staffed. In 1918–20 the San Francisco Fire Department was decimated by the flu.
The flu could affect all those who live in an institution, such as a home for the aged or a prison. There will be a severe impact on healthcare institutions such as hospitals, which will be overloaded with patients and short of staff. There will be a desperate call for skilled persons not in the work force to assist and for others to volunteer.
The flu might cause special problems in colleges and universities when students arrive for the fall term. It would likely spread quickly among those grouped closely together, such as sports teams and students in dormitories.
It’s more than possible that every member of a family will become sick at the same time. It’s also likely that those who live alone will become too sick to care for themselves. Both of these situations will create problems for social service agencies.
It’s also likely that the devastating impact, if it happens, won’t last very long. When a disease affects so many people, there are very soon none left to be infected.
That also means, however, that those who die will do so in a short period. Some estimate that the funeral system will have to cope with up to six times as many bodies as usual in a given period. In 1918–20, there were problems collecting bodies and disposing of them, and almost every community had a shortage of grave diggers.
Given all these things, someone will have to decide what precautions are needed. Should schools and businesses be shut down? Should all forms of public assembly, including movies and sports events, be shut down? Should church services, including funerals, be banned? All these things were done in 1918–20.
What might be on our side
Of course, there will also be differences from 1918–20, some of which could work to our advantage.
For one thing, we now know a lot more about influenza than we did 90 years ago. We know what causes it, and we know how to develop a vaccine. The only problem is that developing a vaccine takes time, and it might not be available in sufficient quantities before the flu becomes deadly.
That may lead to some tough decisions. Who deserves priority? It’s easy to suggest that healthcare workers should come first, but what about soldiers who are already putting their lives at risk? What about their families?
Usually special arrangements are made each fall to provide flu shots for the elderly. But given the current pattern of infection, should the elderly be omitted if there is a shortage?
For another, our healthcare facilities are better able to cope than the facilities of 1918–20 and, on the whole, the population is healthier, as shown by increases in life expectancy. Our ability to identify the disease and track it has also vastly improved, and countries now have pandemic plans that can be activated quickly.
Third, we know that those who die are not a threat to others. Only the living spread the disease.
Fourth, we now seem more willing to talk about and report the disease and its spread. There is evidence that health officials and the media downplayed the severity of the 1918–20 flu.
What will be working against us
Other comparisons between H1N1 and the 1918–20 pandemic include factors that will quite possibly make the current pandemic more severe.
First, in contrast to a disaster, which usually impacts one location, one community or one area, the flu will hit many places at once, so each community will have to depend on its own resources. Mutual aid is unlikely to be useful, since everyone will have the same problems at the same time. Similarly, national response teams are not likely to be of much use.
Next, although it’s unlikely that much can be done to stop the spread of the flu, some people will of course try to stop the infection reaching their institution, their town or their country.
In Canada, in 1918, the University of Saskatchewan quarantined itself. Some small communities did the same, as did countries such as New Zealand and Australia. The university was successful and escaped the flu, but the others were not. Because of tight controls, there was a delay before the flu hit Australia and New Zealand, but it struck just the same.
There was also a delay in some Northern communities that were isolated until the ice broke in the spring and boats began bringing in supplies and, as it happens, the flu.
Third, we can expect the flu to spread much more quickly than it did in 1918 or than other pandemics in earlier times did.
In the 17th century, the bubonic plague was spread by travellers moving slowly from country to country and by ship. In 1918–20, the flu was also spread by travellers, some of them moving by rail, others still by ship. The flu reached Europe, for example, with American soldiers heading overseas.
It reached Canada through American soldiers headed across the Atlantic from the Nova Scotia port of Sidney and through Roman Catholics attending a eucharistic congress in St. Jean, Quebec. It then spread across the country as Canadian soldiers travelled by train to Vancouver, where they were to become part of a British-American-Canadian contingent sent to Russia to fight the Red Army. All this took time.
In 2003, in contrast, SARS hit Toronto within days after an outbreak in Asia, when one woman returned from Hong Kong by air. That led to at least 257 people being infected and 33 deaths, a death rate of 9 percent. Among those infected were a group of nurses who shared a washroom and usually ate together.
Finally, we can expect that the current outbreak, if it follows past patterns, will strike more than once. The 1918–20 pandemic is recognized as taking place in three waves, starting in the northern spring and summer, May–July, of 1918. This relatively mild wave attracted minimal attention.
The searing wave, the second, burnt its way around the globe in the northern autumn and was followed by another, less-severe wave in 1919.
There were two back-to-back waves of SARS in May 2003 in Toronto.
Fortunately, given all the attention, we can expect that, whatever happens, the situation will be reviewed. Were monitoring systems appropriate? Were plans adequate? Were the right decisions made?
Pandemics appear to strike on average four times every century. No matter what happens this time, some form of flu will strike again.