Pandemic Comparison

The Spanish Flu Versus Covid-19

Lynne Cohen
September 26, 2020
We are living in an “unprecedented reality” according to the recent Speech from the Throne. Certainly the effects of Covid-19 have been serious and far-reaching. But unprecedented? Hardly. As difficult as our current situation may seem, it doesn’t hold a candle to the situation 100 years ago when a vastly more terrifying global epidemic struck a far less prepared world. With a second wave of Covid-19 on the horizon, Lynne Cohen takes a close look at the Spanish flu of 1918-20 and finds many stark and revealing differences – as well as some unsettling echoes that suggest while times may change, our fundamental fears do not.
Pandemic Comparison

The Spanish Flu Versus Covid-19

Lynne Cohen
September 26, 2020
We are living in an “unprecedented reality” according to the recent Speech from the Throne. Certainly the effects of Covid-19 have been serious and far-reaching. But unprecedented? Hardly. As difficult as our current situation may seem, it doesn’t hold a candle to the situation 100 years ago when a vastly more terrifying global epidemic struck a far less prepared world. With a second wave of Covid-19 on the horizon, Lynne Cohen takes a close look at the Spanish flu of 1918-20 and finds many stark and revealing differences – as well as some unsettling echoes that suggest while times may change, our fundamental fears do not.
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What a difference a century makes. The 1918-1920 influenza was the worst known pandemic ever to hit humanity, infecting some 500 million people – one-third of the world’s population at the time. Today, notwithstanding the panicked claims from politicians and public health officials that we are facing an “unprecedented” crisis, one could be forgiven for concluding that, medically speaking, we are experiencing the mildest scourge in history. True, we still lack numerous important details about Covid-19 – that little gift to humanity from the sprawling city of Wuhan, China. These include the denominator of the fatality-to-case fraction (without which the disease’s actual death rate remains unknown), how deadly the widely expected second wave will be, and many others.

That looks familiar: Alberta Government Telephones operators in High River don masks during the 1918-20 Spanish flu pandemic.

But while the government-induced effects on our economy, culture, social life and mental health have been widespread and profound, Covid-19 has proved an entirely manageable public health crisis. In not a few smaller and/or remote jurisdictions, its impact has been remarkably light if not virtually painless. The overall mortality rate of victims appears to have been vastly over-estimated and may be as low as 0.2 percent, although this remains contested. Uncontested is that most of the victims are elderly, already ill or residing in nursing homes. To most of us, Covid-19 really isn’t much more dangerous than the seasonal flu. If it weren’t for the remorseless government and media propaganda as well as the required masking and social distancing, in many places it would be all-but invisible to the general public.

Contrast this with the victims of the Spanish flu. It is so called not because it originated in Spain as widely believed, but because during the Great War of 1914-1918 Spain remained a neutral country and, unlike the combatant nations, maintained a relatively free press which publicized the truth about what was killing so ruthlessly. Epidemiological evidence suggests the “Spanish” flu likely began in Haskell County, Kansas. Within a few short years it wiped out between 50 million and 100 million people from every part of the Earth.

Of course, that Earth was less urban, less globalized, less technologically advanced, poorer, more lightly populated and more physically active (though far less widely travelled) than today. None of that stopped the disease from spreading like a proverbial wildfire. The world’s populations weren’t that isolated, and the war triggered the movement of tens of millions of soldiers, prisoners, merchant seamen and refugees across continents and oceans. It was truly a world war. Further intensifying the tragedy was that many millions of the victims were aged 20 to 30, entering the prime of their lives.

Marching to war, spreading disease: It’s believed American troops brought the Spanish flu from the U.S. Midwest to Europe during the First World War.

Today, by contrast, a far higher ratio of the vastly lower number of people who are succumbing to Covid-19 are elderly and/or infirm. In many cases, this population makes up the vast majority – some 80+ percent – of all fatalities. In Alberta, to take one example, the average age of all deaths from coronavirus is over 80 years old, and for hospitalization, over the age of 60. Of the 9,192 deaths attributed to Covid-19 Canada-wide (as of September 23), young people below the age of 19 account for just two of those fatalities; those under the age of 50, a mere 77. Nearly 90 percent of all deaths have involved adults over the age of 70. 

This is not to say the passing of the elderly or already-ill, including those in nursing homes, is not horrible or any less important. It is to be avoided whenever possible and grieved when it isn’t. The point is that logic suggests a healthy non-senior Canadian should be more concerned about dying in traffic, while boating or during a thunderstorm. Or worrying about what they eat. In late July and August, salmonella bacteria traced to red onions imported from the U.S. sickened nearly 400 Canadians between the ages of 3 and 100, sending 59 to hospital; the month-long outbreak generated just the barest of news media interest. Meanwhile, millions of our fellow citizens behave as if the threat of Covid-19 outweighs all other risks combined, and as if it is virtually the only important issue that even exists.

Can we compare the pandemics when the most at-risk populations are entirely different cohorts?
When comparing pandemics, one should start by looking at who is most at risk within the population.
Most at risk: While the Spanish flu primarily targeted healthy adults aged 20 to 30 , Covid-19 has proven deadliest among the elderly and infirm, particularly those in nursing homes.

Not long after Covid-19 arrived on our doorstep in January, some curious people began to wonder about how it might compare to the Spanish flu as experienced by their great-grandparents or grandparents 100 years ago. As I recall mine never talked about it. We wonderers had heard that the Spanish flu was bad, that millions died and that it affected the post-war Treaty of Versailles in some way. Beyond that, it remained a mere vague historical reference, just another bad event among many, yet far less vividly rendered than even my elementary school social studies unit on the Black Death that occurred over 550 years earlier.

For illumination, I recently turned to what many consider the definitive work on the Spanish flu: The Great Influenza: The Story of the Deadliest Pandemic in History, a New York Times bestseller. As author John M. Barry, a professor at the Tulane University School of Public Health and Tropical Medicine in New Orleans, explains in the revised 2018 edition, the Spanish flu hit high and low and not only mowed down millions but influenced global politics. U.S. President Woodrow Wilson, for example, was almost certainly stricken. In fact, Wilson was obviously ill during the Versailles Treaty negotiations. According to Barry, it might even have been among the causes of his strange reversal on what the peace agreement should look like. Though historians and amateurs alike continue to debate the treaty’s role in the rise of fascism in postwar Germany, virtually none would say it had no effect. Meaning that this disease, like many plagues before it, helped shape history itself.

The Spanish flu’s role in history: (l-r) Italian prime minister Vittorio Orlando, British prime minister David Lloyd George, French prime minister Georges Clemenceau and U.S. president Woodrow Wilson (likely suffering from the flu) negotiate the Treaty of Versailles in 1919.

Among the few things the typical Covid-inspired Spanish-flu sleuth might already know is that its symptoms were somehow ghastly. But what exactly were they? Why don’t we recall? Prominent writers of the era, including John Steinbeck and Ernest Hemingway, experienced the milieu first-hand and remembered the Spanish flu vividly. Yet, as Barry explains in The Great Influenza, they never wrote in great detail about it. “The disease has survived in memory more than in any literature,” Barry writes. “The writers of the 1920s had little to say about it.” Mary McCarthy, who lost both her parents to the disease, wrote about being a young orphan in Memories of a Catholic Girlhood but, Barry notes, “she said almost nothing of the epidemic.”

Barry vividly fills in the missing information and imagery – and it is shocking. The sufferers’ range of agonies seemed to know no bounds. At first the disease “presented with what seemed common symptoms, although with unusual intensity,” Barry explains. The manifestations were noticed in increasing numbers of patients by Loring Miner, a doctor in Haskell County, Kansas, likely the originating centre of the Spanish flu. “[V]iolent headache and body aches, high fever and non-productive cough,” Barry writes of Miner’s experience. “He had seen influenza often. He diagnosed the disease as influenza. But he had never seen influenza like this. This was violent, rapid in progress through the body, and sometimes lethal. This influenza killed.” 

A definitive history: John M. Barry’s The Great Influenza reveals the near-apocalyptic impact of the Spanish flu.

And it acted fast. Some victims died within 24 hours of becoming ill; there was no need for testing to know you had it. Writes Barry: “Soon dozens of [Miner’s] patients – the strongest, the healthiest, the most robust people in the county – were being struck as suddenly as if they had been shot.” The pain was indescribable. “Victims’ lungs were being ripped apart as a result of, in effect, collateral damage from the attack of the immune system on the virus,” Barry writes. “The lungs became the battleground between the invaders and the immune system. Nothing was left standing on that battleground…What was killing young adults a few days after the first symptom was not the virus. The killer was the massive immune response itself.”

Philadelphia became among the hardest-hit U.S. cities. “Symptoms were terrifying,” writes Barry. “Blood poured from the noses, ears, eye sockets; some victims lay in agony; delirium took others away while living…Three deaths in a family were not uncommon.” It spread as fast as it acted. “In ten days – ten days! – the epidemic had exploded,” writes Barry, “from a few hundred civilian cases and one or two deaths a day to hundreds of thousands ill and hundreds of deaths a day.” Even harder than treating the sick and dying were dealing with the dead. “The most terrifying aspect of the epidemic was the piling up of bodies,” Barry writes. “Undertakers, themselves sick, were overwhelmed. They had no place to put bodies. Gravediggers were either sick or refused to bury influenza victims.”

The results were apocalyptic:

“The city morgue had room for thirty-six bodies. Two hundred were stacked there. The stench was terrible. No more bodies could fit. Bodies lay in homes where they died, as they died, often with bloody liquid seeping from the nostrils or mouths. Families covered the bodies in ice; even so the bodies began to putrefy and stink. Tenements had no porches; few had fire escapes. Families closed off rooms where a body lay, but a closed door could not close out the knowledge and the horror of what lay behind the door. In much of the city… people had no room that could be closed off. Corpses were wrapped in sheets, pushed into corners, left there sometimes for days, the horror of it sinking in deeper each hour, people too sick to cook for themselves, too sick to clean themselves, too sick to move the corpse off the bed, lying alive on the same bed as the corpse.”

Soon, Barry writes, “The streets of South Philadelphia literally stank of rot and excrement.” Would that the Spanish flu had been contained in a few unfortunate places. But, as we know, it raced around the world, wreaking havoc wherever it went. Barry often refers to the human effects as “violent” and even at times “cannibalistic.” The pandemic was so destructive, ordinary people, thinking the Black Death had returned, contemplated the end of humanity.

It's difficult to justify we are worse off today when comparing pandemics.
When comparing the pandemics, Philadelphia in 1918 was hit in ways unimaginable by those in 2020.
Philadelphia was particularly hard-hit by the Spanish flu: Street sweepers maintain public cleanliness (top left), workers dig a mass grave to bury victims (top right) and a sign at the Philadelphia Naval Aircraft Factory warns workers about the dangers of spitting (bottom).

Barry’s expertise has made him a sought-after adviser to the public and private sectors in the U.S. and abroad about preparing for another influenza pandemic. Thankfully, he wrote The Great Influenza before Covid-19 – or more properly, SARS-CoV-2 – crashed upon our shores. I thought it important to find sources whose views were uncoloured by and detached from potential influence by our current pandemic. This way, I thought, the perspective and conclusions would be as objective as possible. The 550-page The Great Influenza proved perfect in that regard. 

My instincts seem to have been sound, for Barry has largely adopted the establishmentarian mindset regarding Covid-19. He politely declined my interview request, citing time pressures. In his view, as he stated in an e-mail to me, while “1918 was much more lethal [than coronavirus], this is plenty lethal enough to justify extreme action. And the only way to restore the economy, to get people back in the stores and kids in schools, is to make it safe.” 

Barry in other words supports the harsh and strict measures – closing down the economy, social distancing, constant washing – to ostensibly flatten the curve, protect the health-care system and save lives. In an interview with New Yorker editor David Remnick, who calls the book “invaluable,” Barry muses: “I agree with Trump on one thing, the economy will come back, people will want everything when this is over.” On a personal level, Barry and his wife are self-isolating and only walking for brief exercise sessions, since “straying can kill.”

But Barry also knows: pandemics are politics. That a historian of his stature would seek to rationalize 2020’s sweeping shutdowns makes me glad I sought out a book written untainted by today’s events. Too many things being done today remain arguable or unanswerable. In The Lockdown Contrarians Were Right, C2C’s Gwyn Morgan reached nearly the opposite conclusions to Barry: that the government measures collectively have been far worse than the ravages of the coronavirus itself, resulting in untold agony caused by lost jobs and severed human connections. 

The Hong Kong flu of 1968-69 killed more people worldwide than Covid-19 has to date, although it is little remembered today.

Meanwhile, its overall death toll so far has been only somewhat higher than a nasty influenza year, which the WHO itself estimates kills up to 650,000 people every year. And that’s to say nothing of the Hong Kong flu of 1968-1969. It felled at least 1 million people worldwide, more people than Covid-19 so far (though at 100,000 and 4,000, respectively, it killed fewer in the U.S. and Canada than Covid-19). Far more children died of the Hong Kong flu than of Covid-19. Yet it triggered virtually no abnormal government measures nor excessive news media coverage, much less public panic. In any case, the definitive assessments of the public policy responses to Covid-19 won’t be written for years or even decades and, like The Great Influenza, will be works of history.

Barry commences his book not with the epidemic, a mild disappointment for readers hungry for quick facts illuminating the pandemics’ differences, but with an engrossing lesson on the development of medical science, or rather, on the many centuries of non-scientific medicine. From Periclean and Hippocratic Greece in the 5th century BC to the last few decades of the 19th century, the core of medical practice changed little. Employing an equilibrium model of the healthy body, it relied mostly on logic, observation and bleeding – lots and lots of bleeding. 

Once medicine moved, after two-and-a-half millennia, into the laboratory, it was a mere 50 or 60 years before the worst-known pandemic in history exploded. Europe initially held the lead over the U.S. in all areas of medical practice, education and research. But just a few decades after the American Civil War, America overtook France, Switzerland and Germany, gaining an impressive international lead it has held ever since.

When comparing pandemics, should we only look to the situation of 1918?
We can compare the deadliness of various pandemics, but we can also compare the quality of our medical response.
For several thousand years, medical practices were largely unscientific, and often deadly for the patient.

Barry focuses heavily – excessively, in my view – on the personalities and lives of the era’s leading scientists, among them Oswald Avery, William Henry Welch, Simon Flexner, Richard Shope, Paul Lewis and William Osler. Many others also heroically spent most waking hours in laboratories researching a vaccine. The concept was well-understood, with the world’s first vaccine (against smallpox) having been introduced more than 120 years prior. 

Unfortunately, they never found one for influenza; nor a cure. The first major medical discovery after the Spanish flu finally dissipated was penicillin, the miracle antibiotic grown and discovered by mistake in a petri dish by Scottish bacteriologist Alexander Fleming almost a decade later. Something like this would, of course, have been a godsend during the Spanish flu’s worst days; after the virus entered and ravaged the body it was bacterial pneumonia that usually killed.

Too late to make a difference: Scottish scientist Alexander Fleming discovered penicillin in 1928, nearly a decade after the Spanish flu epidemic had subsided.

The starkest differences between then and now include the age range of typical victims, the severity of symptoms and the mortality rates. In some smaller, ill-equipped communities, including in Northern Canada, the Spanish flu felled as many as 50 percent of all residents. Covid-19, as we’ve seen, has largely bypassed many remote communities. On average, the Spanish flu apparently killed about 10 percent of those infected. 

Among our ruling establishment’s greatest fears when Covid-19 hit was that health care systems would be overwhelmed. Except in northern Italy and, perhaps, a few U.S. cities, this nightmare never came close to reality. With the Spanish flu, it did. Many hospitals, Barry writes, especially military facilities, became completely overrun. In one camp, 6,000 patients were crowded into a clinic meant for 1,250. In another, war preparations completely stopped in order to fight the disease. “The hospital staff could not keep pace,” Barry writes. “Endless rows of men coughing, lying in bloodstained linen, surrounded by flies – orders were issued that ‘formalin was to be added to each sputum cup to keep the flies away’ – and the grotesque smells of vomit, urine and feces made the relatives in some ways more desperate than the patients.” Bribes were offered for extra care of loved ones.

Unlike 100 years ago, isolated communities today have largely escaped the grasp of the global pandemic. (Pictured, a roadblock in Lac La Croix, northwestern Ontario.)

Politics is another major area of difference. In spring 2020 legislatures all but shut down across the country and we were graced with months of daily prime ministerial press conferences from Rideau Cottage and often-worrisome government by fiat. Recall the brief attempt by the Liberals to grant themselves unlimited spending power with no parliamentary oversight. Several premiers did the same. Some liberal-leaning newscasters urged the PM to invoke the Emergencies Act, akin to martial law, which would have overridden many of the independent public health initiatives being tried by the provinces. Thankfully, he didn’t oblige. Nevertheless Canadians had to deal with an unprecedented shut-down of economic, educational, travel and house-of-worship activities, the consequences of which have not been fully tallied. In 1918, there was no need for restrictive legislation as the Canadian War Measures Act was in force to guide the country through a world war.

The long-neutral United States, by contrast, had only entered the war in April 1917. Wilson then launched a crusade for “total war”. As Barry explains: “America had never been and would never be so informed by the will of its chief executive, not during the Civil War with the suspension of habeas corpus, not during the Korea and the McCarthy period, not even during World War II. [Wilson] would turn the nation into a weapon, an explosive device. As an unintended consequence, the nation became a tinderbox for epidemic disease as well.” 

American press and health officials who had tasted wartime censorship now also conspired to withhold the ugly truth about the pandemic for fear it would undermine morale and the war effort. The conspirators issued a stream of lies contradicting what citizens were experiencing and seeing with their own eyes. “The so-called Spanish influenza is nothing more than old-fashioned grippe,” the Associated Press quoted one official as saying (using the German word for flu). In soon-to-be-apocalyptic Philadelphia the Evening Bulletin, according to Barry, “Assured its readers that influenza posed no danger, was as old as history, and was usually accompanied by great miasma, foul air, and plagues of insects, none of which were occurring in Philadelphia.”

A surge that never came: With a few exceptions, such as the northern region of Italy, most health care systems around the world were not overwhelmed by Covid-19 patients. (Pictured, Papa Giovanni XXII hospital in Bergamo, Italy.)

Not known as someone ever at a loss for words, President Wilson himself never even spoke publicly on the Spanish flu. Indeed, thousands of newspapers and health authorities played down the pandemic for more than a year, urging people to keep their bowels loose and not to be afraid. The real world was completely different. “Outside Little Rock lay Camp Pike, where eight thousand cases were admitted to the hospital in four days,” writes Barry about just one of innumerable examples.

Today, by contrast, public health officials and political leaders are constantly before the cameras and we fervently hope they and the news media are telling us what is really happening. But are they? Is it not a kind of falsehood to breathlessly report the number of coronavirus cases as if these are somehow linked to deaths or severe illness in a country where most cases are minor or symptom-free? It is disingenuous to continuously broadcast about the “mounting death toll” (a redundancy that has no logical purpose other than to stoke fear), to talk about “spikes” and “hot spots” when, in fact, hardly anyone is even being hospitalized. And it is unfair to imply that all of us are at great risk all the time, unless self-isolated or masked, when it is clear the risks vary wildly by age category and the overall state of a person’s health.

It's night and day when comparing the government response to the pandemics. While government officials played down the impact of Spanish flu, today there’s no shortage of announcements, data, analysis and critiques.
News coverage is always in ample supply: While government officials played down the impact of Spanish flu, today there’s no shortage of announcements, data, analysis and critiques.

It is a great loss to the reader that Barry did not devote the closing section of The Great Influenza to its political and cultural repercussions. Instead he chose to trace the careers and lives of his favourite scientists to their deaths.

Although it is much too early to analyze the societal after-effects of Covid-19, it is already obvious that some of the Spanish flu’s consequences were very different. The earlier pandemic left millions bereft: children without parents, parents without children, communities halved and large cities decimated. When it finally dissipated, there must have been a collective sigh of relief felt around the world. “Academics agree that the end of the pandemic occurred in 1920, when society ended up developing a collective immunity to the Spanish flu, although the virus never completely disappeared,” states euronews report from June. Without today’s social programs (at least in developed countries), many orphaned children were forced to work or scrounge to survive. 

It will remain forever unknowable exactly what causal role the Spanish flu played in the monumental events that followed. But while early 20th-century people were noticeably hardier than people today, they were still susceptible to urban violence. The Spanish flu coincided with or preceded race riots in many American cities, including Chicago; Washington, D.C.; Tulsa, Oklahoma; and East St. Louis, Illinois. The “Roaring Twenties” became an age of incredible material and social progress, including for women’s suffrage, but were also the decade of lynchings, Prohibition and the rise of international fascism and communism. People probably had very little time to bemoan the wreckage left by the influenza.

Comparing pandemics involves more than just looking at the deadliness of the virus.
Comparing pandemics involves looking at the capacity and quality of a government's healthcare response.
From death to unrest: In the wake of the Spanish flu, the U.S. National Guard was called out to quell race riots in Chicago in 1919 (above) while in London, England in 1920, women rallied for the right to vote (below).

What is the same between the pandemics? Quite a bit, surprisingly. For one, the disease itself, influenza; both strains can be transmitted through the air and via surfaces like door handles. Both pandemics were caused by variations of the same virus, only mutated. Though Covid is considered a “novel” virus, which for one thing means no one is believed to have natural immunity, nevertheless both varieties are influenza. Barry explains, in excruciating medical detail, the science behind the broccoli-like organism that changes almost constantly – but also behaves somewhat predictably. 

Suicides today are also up, as they were in 1918. They included that of Colonel Charles Hagadorn, an American officer who ignored health officials and, only days later, had scores of horribly sick and dying young soldiers. He was overcome with remorse and shame. A predicted second, autumn wave of Covid-19 will reflect exactly what happened in 1918 − when the virus, in slightly mutated form, killed millions more without remorse.

Another similarity: we live in a world of terrified citizens, although those of 1918 had far more reason to feel extreme fear. The Spanish flu killed an estimated 30,000-50,000 Canadians at a time when the young nation numbered only 7.2 million people – or about 0.5 percent of the population. To be proportionately as bad, Covid-19 would have to kill about 175,000 of us – nearly 20 times more than have died so far.

We read and hear every day how parents are terrified to send their kids back to school and teachers feel unsafe to return. Yet as one report noted in July, not a single case has been found worldwide of a child giving a serious case of coronavirus to a teacher. In another study, France’s Institut Pasteur – named for internationally renowned microbiologist and founder Louis Pasteur – reported: Overall, the results of this study are comparable to those of studies carried out in other countries, which suggest that children aged between 6 and 11 are generally infected in a family environment rather than at school. The main new finding is that the infected children did not spread the virus to other children or to teachers or other school staff.”

The return to school has proven traumatic for parents and students during Covid, despite recent evidence young children are unlikely to transmit the virus to other children or staff.

Then and now, cancellations and closings were ubiquitous, including of schools and large sports events everywhere. In 1918 Kelowna, B.C., shut all “public and private churches, theatres, moving picture halls, pool rooms and other places of amusement and Lodge meetings.” People hunkered down at home. Sound familiar?

And for neither is there a cure. “No medicine, and none of the vaccines developed then could prevent influenza,” Barry writes. “The masks worn by millions were useless as designed and could not prevent influenza. Only preventing exposure to the virus could.” In other words, the same, simple measures worked then, and continue to work now: social distancing, quarantine where warranted, and proper medical-grade equipment. Writing in 2018, before anyone had ever heard of Covid-19, Barry adds: “Nothing today can cure influenza, although vaccines can provide significant – but nowhere near complete – protection, and several anti-viral drugs can mitigate its severity.” 

Of course, overall medical care for the masses has vastly improved since 1920. Thankfully, very few hospitals were overwhelmed by Covid-19, prompt hospitalization where needed has saved thousands, and many frontline physicians continue to use and report promising results from various treatments. Twenty-first century society clearly has the tools it needs to manage the current pandemic. But do we have the fortitude and willpower? Many people, it seems, are counting on a miracle vaccine and an all-knowing government to simply “make it go away”.

Lynne Cohen is a journalist and non-practising lawyer from Ottawa. She has four books published, including the biography Let Right Be Done: The Life and Times of Bill Simpson.

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