COVID-19 and the ‘Spanish' flu

As we enter the fourth month of the UK leg of the Corona World Marathon, it is worth reminding ourselves of the battle rhythm of its closest relative and ancestor, the so-called Spanish flu of 1918–1920.

The most likely origin of that pandemic was in the rural areas of Texas, at a time when the Lone Star State was known more for poverty than for oil. In his epic account of ‘The Great Influenza’, John Barry recounts how a handful of cases of a most virulent strain of influenza virus were first brought to the attention of Loring Miner, an unusual rural doctor with a taste for the classics.¹ A man rather in the tradition of our own Will Pickles of Wensleydale, Miner was a medical scientist before such a breed had barely taken root in the United States. In January and early February of 1918, he saw a succession of patients who were brought down with violent headaches and body aches, a high fever and a non-productive cough, killing many of them. Dr Milner, who was unusual in having created his own small laboratory in his practice, explored the blood, urine and sputum of his patients in a desperate effort to identify the cause of the illness, searched the literature, discussed with colleagues and reported his experience to the U.S. Public Health Service which, according to Barry, offered him neither assistance nor advice. And then the disease seemingly disappeared.

The influenza soon reappeared in a large military camp 300 miles away where thousands of young recruits were being mobilised to join the allied forces in Europe for the final phases of World War I. In a bitterly cold winter and in overcrowded under-heated conditions, where they huddled together for warmth, these and hundreds of thousands of brother squaddies in many similar camps across the country had been cooped up waiting for their mobilisation.

At the beginning of March, the same clinical picture that Dr Milner had seen in Haskell began to emerge in this, and later other camps, and ravaged through the troops. Before long it seems to have travelled with them into the battlefields of France and Belgium and soon impacted on the German troops, if anything with greater ferocity and possibly contributing to their failure to secure victory. The virus subsequently returned to the United States as it did to all corners of the world becoming known as the ‘Spanish Flu’ only because censorship in the field of war had failed to report its true origins. By the time of the last victim in December 1920, the pandemic had accounted for between 50 and 100 million lives worldwide.

This ‘Spanish flu’ has been much referred to over the last three months, as our efforts to get to grip with COVID-19 have seemed at each point to be too slow and insufficiently determined. Out-of-date planning documents for determining the response to a UK epidemic has been criticised for their over-dependence on influenza as a model for future emergencies. The failure of government to release publicly and act on the damning recommendations from the 2016 Cygnus flu pandemic exercise has added fuel to the fire; and as the tally of deaths looks set to exceed that of our European neighbours, calls have begun for an official enquiry into what is beginning to seem like a major failure of the public health system in England that was only recently radically refashioned in 2013.

Although the COVID-19 virus responsible for the current pandemic is in fact a corona rather than an influenza virus, a re-reading of Barry's book offers a profound deja vu. Not only did the 1918–1919 pandemic creep up silently on an unprepared world, but many of the same elements were to be found as regards not only the clinical course but also the societal and political response.

Hesitancy and resistance in the face of a growing emergency, a weak public health system and a political leader distracted by his sense of mission to engage in all-out war with Germany, distracted attention from the enemy virus within the USA that was biding its time, ready to wreak havoc on an unknowing world. Will we ever know whether our own leader's hostility to the European Union and obsession to deliver Brexit lay behind our failure to join in the European Union wide purchase of essential testing and Personal Protection Kit?

This single-minded focus on the war effort lay behind the disastrous decision to go ahead with a carnival involving 100,000 people crammed onto the streets of Philadelphia to promote the sale of War Bonds when the virus had already entered the room. Within days, thousands of Philadelphians were sick and dying; a grim echo of our thousands of February half-term break returnees from virus laden ski slopes of Austria and Northern Italy and the failure to prevent either the Cheltenham race festival with its 250,000 race goers or the European football match between Madrid and Liverpool at Anfield in the second week of March when the virus was rampant in Spain and gaining pace here at home. In that same week, the number of deaths in the UK began to climb steeply from barely 100, doubling every two days to top 1000 by the Saturday 14th.

Nor should the sorry saga of the cruise ship Diamond Princess and a succession of other large floating Petri dishes of contagion come as any surprise. When the 1918 pandemic returned to the USA with a vengeance in late summer, a succession of merchant and troop ships plying between the eastern seaboard ports and military bases acted as profoundly efficient intermediate hosts to the virus, enabling it to leap rapidly between different parts of the country.

In public health, as in life generally, the cliché that if you don't learn the lessons of history you are destined to repeat the same mistakes rings especially true today. When the inevitable enquiry meets and pores forensically, one hopes, over the COVID tragedy of 2020, it is likely to conclude, among many other things, that the government's panel of advisers was drawn too narrowly. For, while medicine, virology and modelling may be essential in major events of this kind, they are by no means sufficient and that among those others to be included next time is a top-notch public health historian.

Declarations

Competing Interests

None declared.

Funding

None declared.

Ethics approval

Not required.

Guarantor

JA.

Contributorship

Sole authorship.

Acknowledgements

None.

Provenance

Not commissioned; editorial review.