Pale Rider by Laura Spinney

I read this book about the 1918 influenza pandemic in late 2020 against the backdrop of the COVID-19 pandemic. This book predates COVID-19 by a few years and there are no explicit comparisons with the situation in 2020, but anyone who has lived through 2020 will find plenty of things to relate to. 1918 makes 2020’s pandemic response look like an extremely competent well-oiled machine in comparison.

The state of public health in 1918: The 1918 influenza happened at an awkward inflection point between pre-modern and modern medical thinking. Among scientists, the germ theory of disease was well-established and disease was increasingly viewed as an explainable phenomenon. Bacteria were known and had been correctly identified as the cause of some diseases, but viruses (which are much smaller) had not yet been observed in microscopes. Various viral diseases, influenza among them, were wrongly attributed to specific strains of harmless bacteria. Belief in germ theory was largely limited to highly educated people, a small minority even in the most advanced societies. Most of the masses continued to believe pre-modern explanations of disease involving fluid imbalances, bad air, evil spirits, or divine punishment. Most of the world’s people, including even most city-dwellers in rich countries, lived in shanty, crowded, damp, dirty, and poorly-ventilated residences unconnected to water or sewage. Infectious diseases like influenza, plague, tuberculosis, measles, typhus, dysentery, and cholera were frequent even in the best of times. The average person’s baseline health was poor due to frequent disease and poor nutrition. Eugenic and social Darwinist thinking was widespread among the upper classes, with disease prevalence among poor populations often blamed on their intrinsic inferiority rather than on their living conditions. Medicine was fragmented and decentralized, with minimal national health policies and with most doctors either self-employed or funded by local non-profits. Conventional and alternative medicine were starting to diverge, but their approaches to treating infectious diseases remained similar: experimental pharmaceutical concoctions, rarely tested, rarely understood, placebos at best and harmful at worst. Hospitals had a reputation as places where people went to die rather than went to heal.

The disease: Like all novel pandemic strains of influenza, 1918’s H1N1 strain likely arose when two different influenza viruses infected the same cell and accidentally traded genetic information, creating a new blended virus very different from its predecessors. Like with seasonal flu, the pandemic flu’s incubation period was 1-4 days. Transmissibility of the virus peaked with the onset of symptoms but was possible even before symptoms appeared. While most cases were similar to seasonal influenza, about 10% of patients experienced very severe disease, likely precipitated by cytokine storms from their immune systems. The onset of symptoms was sudden and escalated extremely quickly, with some patients dying on the first day or two of symptoms. Whereas seasonal influenza is most severe for children and the elderly, the pandemic strain also disproportionately killed people aged between 20 and 40. The severe variant of the disease seemingly struck people at random, but risk factors included being male, being pregnant, or having chronic pre-existing conditions like tuberculosis. The most commonly-used case fatality rate statistic is 2.5%, over 20 times higher than seasonal flu. The most common cause of death was respiratory distress caused by bacterial pneumonia. It was common for the corpses of victims to have swollen chests due to fluid buildup and blackened skin due to bacterial infections. A minority of survivors struggled with post-viral fatigue syndrome long after recovering from the acute infection.

How the pandemic unfolded: The ultimate origin of the pandemic strain is shrouded in mystery, though it is widely recognized to have spread through Allied armies in the US and Europe in spring 1918. The crowded conditions of the trenches and of troop accommodations allowed the virus to spread with great ease. The world was more interconnected than ever before, with World War I having increased global shipping and transportation. During and after the war, steamboats and railroads would together transport the new virus to all the world’s continents, from which it was able to spread to cities and rural areas alike. Once it reached cities, the influenza often spread explosively; sometimes as much as half of a city’s population was sick at the same time. Hospitals would overflow and corpses would pile up faster than they could be disposed of. Just as local outbreaks escalated rapidly, they also tended to decline rapidly, lasting too short for populations to develop a siege mentality. Like all influenza viruses, the pandemic strain was highly unstable and prone to mutations. The virus would continually change over time and new variants of the virus would get re-introduced to previously-affected regions by the world’s transportation network. The pandemic had four distinct waves between 1918 and 1920, with the late-1918 second wave being the most severe; however, many places experienced only a subset of the four waves. The total worldwide death toll has been estimated anywhere between 20 million and 100 million, with recent estimates typically being higher than older ones. As a general rule, cities were hit harder than rural areas and poor countries were hit harder than rich countries. Historically isolated populations with low immunity (Pacific islanders, Alaska natives etc) were hit hardest of all, with many small cultures getting permanently crippled.

Public and private responses: Due to wartime censorship and the slow transfer of information across distances, people were largely ignorant of the pandemic’s true extent and severity at the time it was happening. International cooperation was low and national governments were weak, resulting in an inconsistent hodgepodge of responses at the local level. While the responsible pathogen wasn’t known, influenza was correctly recognized as being contagious and airborne, spreading via mucus between people in close proximity. Seaport cities commonly ordered the crews of docking ships to temporarily quarantine on arrival, though the virus would usually end up escaping anyway. In western cities, common advice disseminated in newspapers included avoiding crowds, using a handkerchief, and staying away from symptomatic people. Some medical advice (eg keeping windows open for ventilation, leaving sick household members in isolation) ran counter to most people’s instincts about disease and therefore had a low rate of compliance. Some communities banned mass gatherings and ordered schools and some businesses to temporarily close. Religious groups around the world performed various ancient rituals to ward off disease, usually making the outbreaks worse by creating crowds, then claiming credit afterwards once the outbreaks fizzled out on their own. Governments worried that medical workers would flee their posts or that opportunistic crime would skyrocket, but both of these turned out to be very rare. No lab testing was ever done anywhere during the pandemic and diagnosis was made purely on the basis of symptoms. Front-line nurses attempted many experimental measures on patients with severe influenza but found little that was helpful besides keeping patients hydrated. A vaccine for the alleged influenza bacterium was developed and distributed at a small scale; while the vaccine didn’t prevent influenza, it showed some efficacy in preventing secondary bacterial pneumonia.

Legacy: Compounding World War I, the pandemic left behind significant numbers of cripples, widows, and orphans; those who didn’t have extended relatives to take care of them often ended up falling through society’s cracks. The cohort of children born in 1919 suffered from poorer health and lower socioeconomic attainment than the cohorts before and after. With western medicine and germ theory having failed miserably at one of their first big tests, there was a surge of interest in alternative medicine, though western medicine would go on to make advancements and regain its stature. Governments increased their role in healthcare by centralizing data collection, drafting standard policies, funding research, and improving sanitation infrastructure. The pandemic was overshadowed by World War I in much of the western world despite having a higher death toll. This historical amnesia can likely be explained by most local outbreaks being brief, disease outbreaks being a frequent occurrence, and the population’s ignorance about the pandemic’s global extent. It took several decades for interest in the pandemic to grow and for the pandemic to be recognized as a significant historical event in its own right.