A review of Barry’s “The Great Influenza”

By Mary Odum

BarryCoverThis week I finally read John M. Barry’s 2004 book, The Great Influenza: The story of the deadliest pandemic in history. Barry explains the lessons that we should have learned from the Great “Spanish” influenza pandemic of 1918. The book is well written, albeit with a lengthy introduction of the medical researchers and their personalities. If you don’t enjoy the history of Medicine or details of early virology research, you can skip that part. In his afterword, Barry states that a future pandemic is certain to occur, and we are in no way ready for it. Since my PhD is in Nursing-Health Policy, this is a topic that interests and worries me greatly, so I will expand on my earlier post as this threat has continued to expand and evolve. This post serves as book review and comparison of similarities and differences between the Great Influenza pandemic and the current looming threat of another pandemic, Ebola (EBOV).

Time to start plotting this on a log scale? (WHO, Nature)
And according to WHO, these numbers are probably “vastly underestimated.” Time to start plotting this on a log scale? (source WHO, from  Nature, 26Aug14)
Similarities between the two viral pandemics
  • Both are RNA viruses, transferred from animal populations to human, with high mortality and antigen drift/shift (more rapid with flu) and various strains which may mutate
  • There was/is an early focus on cure instead of care. There is no effective cure, thus supportive care becomes the only treatment
  • Both viruses have relatively high mortality rates, and both emerged into a virgin or antigen-naïve population, which can lead to exponential growth and pandemic status fairly quickly if quarantine is not effective. In the Great Flu, the disease may have emerged from domestic animals in the US midwest, while Ebola is emerging from West Africa
  • There is a shortage of beds, doctors, and especially of nurses, with high death rates among health care providers, so that general healthcare provision stops
  • Globally we have a limited number of production facilities for cures and vaccines
  • Inadequate personal protective equipment (PPE) in both situations. In 1918 communities made ineffective, homemade, gauze masks, and West African countries are in dire need of adequate PPE supplies to care for patients
  • The disease emerges in areas with weak public health systems for surveillance and quarantine
  • Governmental and community propaganda downplays the situation as groups try to avoid panic or economic loss
  • There is slow or inadequate quarantine and intervention by countries
  • Government propaganda does not match visible reality, causing panic and lack of commitment to public health efforts, aid, and quarantine efforts
Differences between the Great Flu and Ebola situations:
  • We know much more about viruses today, our surveillance is better, and our science is better, but we still have no cures for many viruses
  • Ebola has a longer incubation time of 2 to 21 days, but Ebola is not infectious until symptoms appear. The Great Flu incubated for 2 days and was infectious before symptoms occurred
  • Flu deaths commonly resulted from Adult Respiratory Distress Syndrome (pulmonary suffocation of sorts) or secondary bacterial pneumonia, while Ebola deaths result from massive hemorrhage, shock, and multiple organ dysfunction syndrome
  • We now have antibiotics and advanced medicine for secondary infection and supportive care (fluids, oxygenation, and various types of coagulants), even though it would be inaccessible to most in a crisis
  • Transmission in Ebola is not yet airborne, although the copious hemorrhagic body fluids create a situation where droplet spread (non-contact) is aggravated with close proximity or from fomites
  • Global air travel, fluid national borders, international trade, and mobile social behavior creates a vector for rapid global dissemination. The Great Flu occurred similarly, but in the presence of a global war with concentrations of mobile military men spreading the disease
  • Global population has expanded from 1.8 billion in 1918 at the time of the Great Influenza, to 7 billion today, with large urban populations,  great inequality in living conditions, more pollution, less natural resilience, and a larger immunosuppressed population thanks to modern medicine (chemo, medical and background radiation, the elderly, and transplant and other medically immunosuppressed patients). The Great Flu killed between 50 and 100 million people, most of which occurred in 24 weeks. We simply have too many people, too much inequality, and too complex of a system for effective quarantine or treatment of any pandemic from here on out.
  • There are similar population densities today in domestic animals in concentrated food lot situations, increasing potential for animal to human transmission of viruses

But perhaps the biggest difference between the 1918 pandemic and today is our modern culture. Our modern first world economies are less resilient and people are less autonomous and more reliant on a global logistics system, so even a mild pandemic that resulted in slowing of trade would result in panic and high death rates from cessation of commerce, healthcare, and other dependencies. We expect that basic needs and security/safety needs will be taken care of by the society at large, with no need to show food security, face dangers, or protect our own health. We expect that our high-tech, wealthy societies will always keep us safe.

Media and the elephant in the room

The mainstream media such as newspapers of record are carefully avoiding the real issues with this outbreak, focusing instead on hopeful research on treatments, inaccurate data, or unimportant details that miss the elephants in the room. Increasingly in modern society, our inability to see the big picture leads to a comforting but dangerous focus on nonessential details. Here are some narrowly focused reports from the mainstream media:

  • Focus in the media on cures and not effective public health measures . . . or avoidance of the topic of EBOV completely
  • Bush meat will bring Ebola to US (from the Washington Post and Newsweek–in other words, if you avoid bushmeat, you will be safe)
  • Governments’ and World Health Organization’s (WHO) assurances of low risk of transmission via air travel. This assurance contrasts with high-tech treatment of high visibility patients brought back to first world countries using Tyvek full-body suits, closed ventilation systems, and bubble pods.  How do the CDC recommendations for air transport of Ebola victims match up with WHO advice to keep flying? This evidence-based discussion below of the difference between airborne and droplet transmission of viruses is illuminating. Droplet aerosols are spread without direct contact up to 3 feet away, and Ebola is a very messy disease to care for. The issue is not as clearcut as the WHO would like us to believe. CDC recommendations for protection appear to be conflicting, in transition, and environment dependent.

    http://virologydownunder.blogspot.com/2014/08/ebola-virus-may-be-spread-by-droplets.html?spref=tw
    http://virologydownunder.blogspot.com/2014/08/ebola-virus-may-be-spread-by-droplets.html?spref=tw
  • The idea that gloves, gowns, and masks are adequate protection contrasts with data showing that a high proportion of healthcare workers are catching Ebola
  • Mainstream media trumpet isolated recoveries of American patients while ignoring WHO’s warning of a massive underreporting of illness and mortality in West Africa and shadow zones

In Barry’s afterword, he makes the pitch for more surveillance and vaccine ability to prepare for future pandemics. The author focuses on the hope of technology to effect prevention and cure. I have no such faith in the idea that technology can rescue our overpopulated world. Pandemic and loss are expectations that are based on physics. All we can do is begin to develop a smaller, simpler, local society based on less energy and less expectations, and learn how to look out for ourselves within local communities of support.

In my earlier post I recommended some simple personal advice for preparation for pandemics (and don’t forget the bleach). In this situation, personal protection is primary. Pandemics will happen, and many will die. Is a pandemic a more humane and environmentally sound way of inevitable population reduction than war? Or will we have to suffer through some toxic combination of all four horsemen?

If we could influence health policy, recommendations at the larger scale might include:

  • A shift in focus for western medicine where waning resources that are now spent on secondary and tertiary care are transferred to public health and better basic universal healthcare (the base of the pyramid below)
  • This shift in healthcare focus could be coupled with a global initiative to battle inequality in preparation for descent
  • More support/aid for global access to birth control
  • Develop a primary societal goal of protecting whatever environment is left so we have something to fall back on in descent
TR Frieden April 2010, 100 (4) AJPH Genetics is at the top of the pyramid, while environmental medicine is at the bottom.
TR Frieden April 2010, 100 (4) AJPH Genetics is at the top of the pyramid, while environmental medicine is at the bottom.
  • http://www.who.int/csr/disease/ebola/5-september-2014-en.pdf?ua=1

    The further this epidemic grows, and it is growing exponentially, the harder it will be to stop. With global air travel, this disease will be transmissible in ways that previous pandemics have not been. Transmissibility may be higher than previously thought, with some attempts to calculate R0 (R-Nought) at a number similar to the 1918 Pandemic. R-Nought will be different in different cultures and health care systems.

    Throwing money at the problem will not fix it, and except for military resources, we do not have the excess health care personnel to devote to the problem–WHO estimates that in these African countries, 80 EBOV patients require 250 healthcare personnel to care for them. In western medical settings, that number would be much higher. We do not have the extra resources for a pandemic in our own countries, much less to send help to other countries. If you want to contribute, contribute to MSF, as healthcare personnel in Africa lack basic protection, with nurses in impacted countries buying their own gloves off the street, or even going without.

    Ebola will spread, and it will come to the United States. I cannot believe that TSA bureaucracy is still going through the motions of groping passengers, while no one checks the temperatures of passengers from flights inbound from Africa. Ebola will be a global gamechanger, IMO, economically, culturally, and in every other way.

    http://io9.com/this-is-how-the-ebola-epidemic-might-spread-if-its-not-1630615528

  • EBOV epidemic plotted on a log scale.

  • diesel

    Hi Mary, always enjoy your analysis and share similar views regrading the energy basis of civilisation. Came across the following article which I found interesting. http://aeon.co/magazine/health/the-next-pandemic-will-not-erupt-from-the-rainforest/ I find it hard to reconcile the argument being made in this article against your views. Ebola seems to have mutated to be much more deadly given the exponential rise in cases and the amount of medical staff infected.

    • Hi, Diesel, thanks for the opportunity of something to chew on. I see this morning that the US is sending military to help. Perhaps because the US over-reacted to the H1N1 (Swine) Flu in 1976 and 2009, and H5N1( many times since 2003), our leaders are under-reacting to this one. We lack the imagination and the worldview to respond appropriately to deadly, near term threats–instead displacing our fears to safe distant threats such as climate change and terrorism. Those flus did not excite me–Ebola does. The 1918 flu killed between 10 and 20% of its victims, and was deemed the worst pandemic ever. Now we have a messy, mobile, deadly virus that kills half its victims, that has emerged into 5 poor countries and counting, during a time of weakened public and primary health, gross overpopulation and overcrowding in urban populations and many war zones, and global overnight transportation for many.

      Your author talks about the the missing step of diseases that adapt to humanity over time–what makes a pandemic go is the antigen-naive population that we see in Ebola, especially as it emerges from the African continent. The disease has already mutated, apparently, to reduce lethality from 90% to somewhere closer to 50%, which makes it more transmissible. Pair that with an incubation period of several weeks and a very messy mode of spread, via any kind of body fluid, including sweat, urine, and feces, and it becomes the almost perfect killer. Throw the almost perfect killer into a perfect mutating ground, like the increased background radiation that now exists in the US and other places with nukes, combined with a medically suppressed population, and we will see what happens.

      The author Orent at your link says it; “Looking at epidemics and pandemics through this evolutionary lens makes it clear that the most important condition necessary for the evolution of virulent, transmissible disease is the existence of a human disease factory. Without social conditions that allow the evolution of virulent, transmissible disease, deadly outbreaks are unlikely to emerge. . . . . If the Great Plague of Athens tells us anything, it is to avoid social conditions that allow pathogens to evolve great virulence and transmissibility. Preventing disease factories – trench-like warfare conditions, crowded hospitals, enormous refugee camps – is our best protection. While alarmists among us wait for the plague to pounce out of the jungle, it is far more likely to come from inside us, our disease factories and our social world.” Ebola is both of these threats–an emergent, old deadly disease from the jungle that has finally emerged into a very vulnerable disease factory of 7 billion people–our urban populations are a human disease factory waiting to happen. Virus vectors are concentrated animal feeding lots of pigs, chickens, and other domesticated animals, via a mixing zone of disturbed natural habitats of wild reservoir animals. Our monocultures (including us), and our disturbed natural environment will be our downfall. We have met the enemy and he is us.