(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)
Charles Rosenberg’s 1992 essay “What Is An Epidemic” characterises an epidemic into four Acts, and utilises Albert Camus’s 1948 novel “The Plague” to describe these Acts of “Progressive Revelation”, “Managing Randomness”, “Negotiating Public Response”, and “Subsidence and Retrospection” (Rosenberg, 1992). Whilst this “Four Acts” model cannot fit all mass disease events, it is a useful lens which will be used here to explore the cultural impacts of population-scale diseases. This essay focuses on one historic epidemic: Spanish Flu during 1918-1919, drawing on parallels with other historic pandemics such as HIV/AIDS in the 1980s, and Ebola in West Africa during 2014, and critically addresses how those lessons were later applied to the Covid-19 pandemic of 2020.
Culture is the manifestation of the history, knowledge, values, and beliefs of people, and plays a significant role in the spread of disease by influencing how often and the manner in which people interact, and the scale of interactions, alongside rituals, ceremonies and traditions. These include everything from purchasing groceries to attending large concerts. Culture is fundamental to epidemiology: it is a contributing factor in how rapidly a disease spreads, to whom, and to how people who are diagnosed are treated, or if they are treated at all (Bristow, 2010).
Spanish Flu constitutes a prime example of a post-germ theory, pre-influenza vaccine, epidemic in developed urban centres. Pharmaceuticals to effectively treat influenza were not widely available, and as such non-pharmaceutical interventions, including behavioural changes, were the primary response. The US rather than European context of Spanish Flu is more pertinent to cultural change, as World War I and its impacts obscures much of the impact of the disease and its effect on culture in Europe. The virus did not originate in Spain, and was termed Spanish Flu because Spain did not censor its press during the war, unlike many other countries, so those first Spanish cases, including the King of Spain, made for a highly visible disease that became known as Spanish Flu (Whiting, 2020). The epidemic lasted for two years from the first recorded case in March 1918 to the last in March 1920, killing an estimated 50million people, though the true death toll may be up to twice that number (Johnson and Mueller, 2002). The Covid-19 death toll at time of writing is 4.1million people (Dong et al, 2021).
Act I, Progressive Revelation.
“Progressive Revelation” is the slow acceptance and acknowledgement of the problem, a slowness which may be explained by the suggestion that acknowledging it can threaten existing economic and institutional interests and power structures (Sajtos et al, 2021). At the time of the Spanish Flu epidemic, people and information travelled more slowly than they do today. There were no commercial aeroplanes, and cars and telephones were the preserve of the rich: although the 1918 influenza virus spread slower than Covid-19 (Terry, 2020), the spread of information about the dangers, precautions and treatments was equally slow.
The history of medicine is incomplete without the stories of the patients, their experiences, beliefs and behaviours (Porter, 1985), and it is this narrative backdrop that provides us with the greatest understanding of the epidemic itself. In post-germ theory USA at the time, life expectancy was on the rise and it was perceived by some at least that infectious diseases may be a thing of the past (Karlen, 1996). Influenza, however, was a familiar visitor, bringing sickness every year, which made the public complacent, a fact which even prior to 1918 caused concern for public health officials who recognised the need for public vigilance (Anderson, 1894). Public complacency was similarly a worry early in the Covid-19 pandemic as the previous SARS-CoV epidemic of 2002, and the H1N1 epidemic of 2009 were remembered as diseases that were significantly less transmissible or deadly than initially feared (Rogers, 2020). Health authorities in 2020, conscious that public complacency could hamper measures to control the pandemic if they were not adhered to, ensured that messaging was as clear and commanding as possible, whilst trying to avoid hysteria or spectacle (Krpan and Dolan, 2021).
Early behaviour change is an essential strategy in the management of an epidemic. For example, the rapid spread of the 2014 Ebola epidemic in West Africa was partly related to cultural practices of washing the dead to help them transition to the afterlife (Manguvo and Mafuvadze, 2015). Even once it was recognised that Ebola spreads through physical contact with an infected person’s bodily fluids, the value placed on these rituals, as with many cultural practices, meant that behaviour change was difficult to engender. Some families were so motivated to continue their funeral rites that they bribed corpse collectors to provide false cause of death reports (Dixon, 2014). Like Ebola, Spanish Flu also delayed or prevented funerals, and meant many were buried in mass graves, all of which deprived families of their traditional mourning process. This experience, along with a fear of infecting loved ones with an invisible disease, is believed to have inspired many of the zombie-like figures in the works of H. P. Lovecraft and the 1919 silent film “J’accuse” by Abel Gance, through a desire to visualise an invisible monster (Outka, 2019). Learning this lesson, visually engaging the public as early as possible particularly in order to convey the human impact of the disease, has proven powerful in encouraging behaviour change during the Covid-19 pandemic (Wilson and Frey, 2020).
During the early phases of the 1918 pandemic, many governments attempted to impose “maritime quarantine” in order to prevent the spread of the disease from elsewhere, but it was often imposed too late or was breached by people not yet symptomatic (Crosby, 1976). Australia was the notable exception, successfully delaying the second wave of the pandemic (Crosby, 2003), and indirectly protecting many Pacific islands from the worst of the disease (Shanks et al, 2018). This cultural lesson was only learned by a handful of governments responding to Covid-19. Some governments such as New Zealand, which suffered 5 deaths per million people, implemented full border controls very early on, in contrast to the UK, which kept borders open and suffered 1,900 deaths per million (Our World In Data, 2021). Most Western governments attempted to implement a modern-day equivalent of maritime quarantine using border testing and quarantine. However, the 2009 H1N1 epidemic experience showed that only 6.67% of cases were accurately detected through border testing (Gunaratnam et al, 2014), and education programmes to encourage people to only make essential travel, and get tested prior to travelling, were proven to be more effective (Grépin et al, 2021).
Act II, Managing Randomness.
In Rosenberg’s second Act, “Managing Randomness”, a recurring epidemic theme is the scapegoating of groups already seen as undesirable or undeserving. Rosenberg suggests this is an effort to create order and meaning out of chaos, and has been recorded in many epidemics, including impoverished Jews who were blamed for the cholera pandemic of 1892 (Markel, 1999), Chinese immigrants for the bubonic plague outbreak in San Franscico in 1900 (Kraut, 1994), and the stigmatisation of gay men and Haitians in the HIV/AIDS epidemic in the 1980’s (Grmek, 1990). Even amongst some medical professionals in 1982, HIV became known as “GRID”: Gay-Related Immune Deficiency (Epstein, 1996). In general, immigrants were not blamed for Spanish Flu, possibly because it struck individuals of all groups and classes (Kraut, 2010). In 2020 however, President Trump’s “Chinese virus” statements led to a rise in Asian hate crime (Kurtzman, 2021), and naming Covid-19 variants as originating from a particular country, align with this leitmotiv of pandemics (Markel, 2007). Scapegoating and stigmatising certain groups makes it more difficult for those people to get treatment, and distracts from the true causes of the disease. This is clearly a lesson yet to be learned.
Just as “big pharma” conspiracy theories grew during the Covid-19 pandemic, during 1919, rumours emerged that Spanish Flu was linked to the German pharmaceutical firm Bayer intentionally spreading disease, and was compounded by the start of the epidemic coinciding with the end of WW1 (Cohut and Guildford, 2020). Physicians of the time were unaware of the side effects of high doses of aspirin, which can result in hyperventilation and pulmonary oedema – symptoms often seen in early deaths from Spanish Flu. Many victims were treated with high dose aspirin, and as a result, a significant proportion of Spanish Flu deaths may in fact be attributable to aspirin toxicity (Starko, 2009), a correlation which emboldened the conspiracy theorists. In the face of uncertainty, governments and healthcare organisations during Covid-19 attempted to provide as much clear and accessible information as early as possible, to enable people to spot conspiracy theories before they fell for them (Douglas, 2021).
The economic impact of the 1918 epidemic was greater for developing countries than developed countries (Murray et al, 2006). Learning from this lesson, the Indian government prioritised healthcare, supply chains and employment opportunities during the Covid-19 crisis in order to avoid deeper economic harm (Sharma et al, 2021). However, not all economic lessons have been so clearly learned. The impact of Spanish Flu exacerbated the increasingly protectionist approaches of governments after World War I, restricting the free movement of people and goods (Boberg-Fazlic, et al, 2021). Similar nationalistic and protectionist approaches are already being seen as a result of Covid-19, highlighting “the downsides of extensive international integration while fanning fears of foreigners and providing legitimacy for national restrictions on global trade and flows of people” (Legrain, 2020).
Economically and sociologically, Spanish Flu provided a stimulus to socialised healthcare through a realisation that treating disease at an individual level was insufficient for managing pandemics that affected entire populations. Prior to 1918, there persisted a eugenics-based belief that disease was a particular problem of the lower classes due to their inherent inferiority (Lombardo and Dorr, 2006). After the 1918 pandemic, it was clear that treating individuals in isolation or blaming people for becoming infected was an ineffective strategy, and subsequently many governments embraced socialised medicine; Russia first, via a state-run health insurance programme, followed by other European countries. The USA followed suit in their own way by consolidating healthcare into employer-based insurance schemes (Spinney, 2017).
Act III, Negotiating Public Response.
Public response must be negotiated in order to build collective, sustained, and consistent action against epidemics. Rosenberg’s third Act, “Negotiating Public Response”, describes how prophylactic measures were strictly enforced in slums and poor areas of the city, but less so in affluent areas, despite affluent areas generating many cases (Rosenberg, 1992). Although public adoption of facemasks was relatively high in the US during the Spanish Flu epidemic, due to a consensus that influenza was airborne (Crosby, 1976), the surgical masks adopted by the public at the time were made of gauze, which was insufficient to prevent the spread of virus particles (Nakayama, 2020). Cities where masks were compulsory suffered as much as cities where masks were optional (MacDougall, 2007) and there was significant opposition on some fronts to the wearing of masks (The Seattle Star, 1918). During the Covid-19 pandemic, effective mask materials such as N95 have been widely available and largely adopted in countries where wearing masks in public was previously rare, but has been accompanied by vocal opposition from some (Barceló & Sheen, 2020). The same tension between individual liberty and collective responsibility arose in the HIV/AIDS epidemic in the 1980s, where there was initially strong resistance to the percieved oppression of gay people and their rights, including wearing of condoms. This is understandable response, given the wider context of gay freedom that had been so hard-won (Berridge, 1996; Shilts, 1987), and illustrates a key cultural barrier to proactive public engagement.
Schools have an ability to engage with and influence the public response. In 1918, American schooling was in the process of transformation; by 1920, almost 65% of the eligible population had attended school, with attendance rates consistently over 90%, a significant increase in uptake (Ross, 1924). Children in public schools were subject to regular health inspections and believed to be better protected from the threat of infectious disease than those out of school (Doty, 1911). Many schools had full-time nurses, smallpox vaccination programs, and contingency plans for serious disease outbreaks (Stern et al, 2010). Most schools in the USA closed during Spanish Flu, but some schools such as those in New York, Chicago and New Haven, opted for a successful strategy of remaining open during the epidemic under a rationale which recognised the role that schools could play in monitoring the spread of disease, communicating health and hygiene information to parents, and providing more hygienic school environments than many children had at home (Robertson, 1919). The lessons from this success were perhaps overlooked during the Covid-19 pandemic, when many schools in the USA were closed in efforts to hinder the spread of the virus, which has resulted in an increased attainment gap between higher- and lower-income families, exacerbated food insecurity, and increased the risk of childhood abuse or trauma (Van Lancker and Parolin, 2020, UNICEF, 2021).
Act IV, subsidence and retrospection
“The most vexing phase of an epidemic” (Markel, 2007, p. 47): the eventual decline in cases and the opportunity to reflect, learn and adapt. After 1919, enthusiasm for the scientific method in the USA waned, in part due to the significant blow to the prevailing consensus at the time that all diseases were caused by bacteria (Tognotti, 2003); if science was wrong about this, what else was science wrong about? Conversely, Chinese culture, which has typically embraced Traditional Medicine and suffered less from the impact of Spanish Flu (Cheng and Leung, 2007), learned valuable lessons and became more scientific after 1919, including improved public health surveillance and better data collection (Whiting, 2020).
Economically, Spanish Flu had a devastating impact and reduced the average GDP by 6% (Maas, 2020). The largest adverse macroeconomic events of modern times were World War II, the Great Depression of the 1930s, and WW1, followed by Spanish Flu (Barro and Ursúa, 2008). Such a devastating economic impact would surely leave significant scars on society, yet the cultural memory of Spanish Flu feels faint (Onion, 2020) and American culture in particular failed in some respects to acknowledge the impact of the epidemic (Bristow, 2010). It can be difficult for people to contextualise disease, particularly population-scale diseases (Outka, 2019). After a war, it may be possible to reconcile death with a sacrifice that was necessary for the war to end, and people who died in wars may be memorialised as heroic, but rarely are those who died in epidemics memorialised: instead, they are seen as only tragic (Bristow, 2010). Learning lessons from pandemics is much more difficult because the acute visual reminder of the scale of the deaths is not present, unlike deaths caused by conflict, which may leave scars on the land as well as the memory. As a result of this faint epidemic memory, many of the lessons that could have been learned from such a devastating pandemic have been lost, or painfully learned again during the Covid-19 pandemic.
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