The Great Influenza - a summary

THE GREAT INFLUENZA

by John M. Barry, 2004

A SUMMARY

(The beginning of the book can be a bit of a slog as the author introduces the main characters and sets up the scene as to medical advances at that time. Rather than the reader giving up entirely, I would recommend skipping to Part IV or V and continue.)



The 1918 influenza killed a documented 20 million people worldwide but due to underreporting it is believed the actual number was more like 50-100 million.



Most vulnerable turned out to be those in the 21-30 age group.



In the US it is believed to have arrived first in Haskell, Kansas. From there it spread to a nearby army camp and to other camps from there and then to cities and towns throughout the US.



It arrived in a first mild wave in the spring followed by a second wave much more aggressively about mid-September. Another lesser wave hit around the end of the year.



From the afterward

Hospitals, like every other industry, have gotten more efficient by cutting costs, which means virtually no excess capacity – on a per capita basis the United States has far fewer hospital beds than a few decades ago.



The 2009 H1N1 swine flu pandemic…killed ‘only’ an estimated 150,000 to 547,000 worldwide with probably 12,000 US deaths. The average age was only forty.



By comparison, the ordinary seasonal influenza kills between 3,000 and 56,000 a year depending mainly on the virulence of the virus and to a lesser extent on the efficacy of that year’s vaccine.



So where are we now? What are the lessons?

1.   All pandemics (1889, 1918, 1957, 1968, 2009) come in waves.

2.   Every wave has been a little different. CDC mantra: “When you’ve seen one influenza season, you’ve seen one influenza season.”

Consider for a moment that prior to the emergence of H5N1, the U.S. government was spending more money on the West Nile virus than on influenza. While influenza was killing as many as 56,000 Americans a year, West Nile in its deadliest year killed 284.



How prepared are we for a new pandemic?

The World Health Organization and governments have developed a good surveillance system. The problem is that it is incomplete – too many countries still do not participate – and dependent on governments to cooperate.

Much of the U.S. vaccine supply is manufactured outside the country; in a lethal pandemic, there is a question whether another government would allow its export before its own population was protected.



What else can be done?

In the past several years numerous governments have looked at NPIs (non-pharmaceutical interventions) – i.e., ways to mitigate a pandemic’s impact using public health measures.

The only way to avoid it is to completely isolate oneself from society for the six to ten weeks it takes an outbreak to burn through a community, including not accepting deliveries, not going out, and so forth. That is infeasible.



Modelers have concluded that “layering” several interventions – most of them different kinds of “social distancing’ – would at least stretch out the length of an influenza outbreak in a local community, easing the strain on the health care system.



One tool of no use is widespread quarantine.  He goes on to say “…if the overwhelming majority of army bases in wartime could not enforce a quarantine rigidly enough to benefit, a civilian community in peacetime certainly could not.”



Closing borders would be of no benefit either. It would be impossible to shut down trade, prevent citizens from returning to the country, etc. That would shut down the entire economy and enormously magnify supply chain problems by ending imports – including all health-related imports like drugs, syringes, gowns, everything. Even at that, models show that a 90% effective border closing would delay the disease by only a few days, at most a week, and a 99% effective shutting of borders would delay in at most a month.



That doesn’t leave much for an individual to do other than mundane tasks such as washing one’s hands. Doing it in a disciplined way every time, every day, for weeks, is difficult. But discipline matters.



Surgical masks are next to useless except in very limited circumstances, chiefly in the home. Putting a mask on someone sick is most effective because it will contain droplets otherwise expelled into the room. N95 masks would be more appropriate in that situation and they do protect, but they need to be properly fitted and properly worn. This is harder than it sounds.



Other recommendations are generally simple and obvious: for example, keeping sick children home from school – which is standard behavior – and having sick adults stay home from work – which is not standard behavior. Another is exercising “cough etiquette” – coughing and sneezing into one’s elbow and not one’s hand, since that hand will eventually reach for a doorknob. Telecommuting is another obvious action.

In a truly lethal pandemic, state and local authorities could take much more aggressive steps, such as closing theaters, bars, and even banning sports events.



Possibly the most controversial NPI is closing schools. The argument for school closing: because adults have much more cross-protection from exposure than children do, children usually suffer higher attack rates. But closing schools places an economic burden on working parents because it has to be sustained for weeks.



Finally, if any NPIs are to have any effect, the public has to comply with the recommendations and sustain that compliance.



The biggest problem lies in the relationship between governments and the truth. Part of that relationship requires political leaders to understand the truth – and to be able to handle the truth. If there’s a lesson from the 2009 pandemic, it’s that too many governments were incapable of doing so. Every Western government and many non-Western ones had prepared plans for a pandemic, as did the World Health Organization. They were reasonable plans that included good recommendations. Many of the plans attempted to limit the role of personality by laying out explicit steps to take – or not to take – based on certain triggers. But planning does not equal preparation, and too many political leaders ignored the plans.



Emotion is not the absence of reason; emotion corrupts reason.



Either way, whether a politician saw an advantage and knowingly did something at best unproductive or whether he or she acted out of incompetence or fear, the human factor, the political leadership factor, is the weakness in any plan, in every plan.



As horrific as the disease itself was, public officials and the media helped create that terror – not by exaggerating the disease but by minimizing it, by trying to reassure. A specialty among public relations consultants has evolved in recent decades called “risk communication”. I don’t much care for the term. For if there is a single dominant lesson from 1918, it’s that the governments need to tell the truth in a crisis. Risk communication implies managing the truth. You don’t manage the truth. You tell the truth.



So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that.



Those in authority must retain the public’s trust. The way to do that is to distort nothing, to try to manipulate no one. Lincoln said that first, and best. A leader must make whatever horror exists concrete. Only then will people be able to break it apart.