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.

  • 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.