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Lessons From a Public Health Catastrophe

A hundred years ago, the Spanish flu killed tens of millions. As governments prepare for the next pandemic, there's much to learn from the responses to that outbreak.

An influenza ward at the U.S. Army Camp Hospital in Aix-les-Bains France during the Spanish Flu epidemic of 1918-19.
Whenever I forget exactly when the Spanish flu pandemic began sweeping the world, I check my historical mortality tables. The U.S. cohort table for 1900 shows that people born in that year saw a heightened mortality in their 18th year. Mortality more than doubled in a single year, for both males and females.

Those tables are just part of the documentation of a larger story: The influenza pandemic that began in January 1918 was the worst natural disaster in modern history. While death-toll estimates vary greatly, it is believed to have killed somewhere between 50 million and 100 million people around the world. In terms of lives lost, it may have been exceeded only by the bubonic plague of the 1300s -- the Black Death.

Just as governments prepare for relatively frequent disasters such as hurricanes and ice storms, as well as infrequent emergencies such as major earthquakes and terrorist attacks, the experience of the Spanish flu pandemic shows that governments should plan as well for such infectious disasters. There are two aspects of the Spanish flu pandemic that governments should particularly remember and consider in this centenary year: communications and operations.

With respect to communications, consider how the Spanish flu got its name: Spain was one of the few major countries that did not suppress reporting on the pandemic. Spain was a neutral power during World War I, so it didn't have the motive for quashing news of something even deadlier than war rushing through its population. Even the United States, the likely origin of the pandemic, kept the information restricted. As a result, some localities suffered more than they might have due to delayed response because they did not realize what was going on.

The problem extended beyond the quashing of information. Too often, governments projected certainty when there was uncertainty. This produced distrust among the public, leading to people not adhering to knowledgeable official advice in preventing the pandemic's spread.

As for operations, let us contrast two cities and their responses: Boston and New York City. Both being major ports, they saw ships with ill military men returning from World War I starting in August 1918. The need was to prevent the disease from spreading to the civilian population. Boston's health commissioner thought the rapidity of the infection meant that the epidemic would burn itself out quickly. That was not the case. By the end of the pandemic, Boston had an excess mortality of 710 deaths per 100,000 people.

Contrast this to New York's approach. When notified of sick people arriving in its harbor, ships were quarantined immediately and patients were isolated from the general public. New York City had been well prepared due to its general policy for dealing with epidemics and having in place a system to impose quarantines, curfews and crowd control to limit the spread. Even with ideal policies, this extremely virulent disease did spread. However, due to the efforts of the city government, mortality was reduced. The excess death rate for New York City was 452 per 100,000 people, the lowest for any city on the East Coast.

A final aspect to consider in preparing to respond to a pandemic is the age group that was hardest-hit by the Spanish flu: young adults, particularly those between the ages of 25 and 34. Excess mortality due to the pandemic was much higher for this age group than any other, over 900 deaths per 100,000 people.

That's not an anomaly: People in prime ages may be felled in larger numbers in a pandemic than the very young and the very old, who are the usual sufferers in seasonal flu epidemics. So governments may find the population they generally rely on to provide critical services in a pandemic - such as EMTs, public-health workers and hospital staff -- to be the ones most severely affected. Pandemic preparation plans should include the possibility that many core workers may be incapacitated.

In too many cases, governments already struggle to provide an adequate response to a typical seasonal flu outbreak, in which deaths are typically measured in the tens of thousands. This past flu season was fairly bad, with the Centers for Disease Control and Prevention reporting a peak incidence (percentage of outpatient visits for influenza-like illness) approaching levels seen from the 2009 swine flu pandemic, though mortality levels were much lower.

As severe as the 2017-18 flu season was for the United States, though, the Spanish flu pandemic was a disaster of a different order, taking the lives of an estimated 670,000 Americans at a time when the nation's population was less than a third of today's. It may seem hopeless to try to prepare for a public-health catastrophe of that magnitude. But being ready to keep the public informed and to move quickly to contain any outbreak that does occur -- to learn from what happened a hundred years ago -- is the right place to start.

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