 I think it infected about 500 million people, so one in three people in the world alive at that time and that it killed 50 million of them. Welcome to World Versus Virus, a podcast from the World Economic Forum that aims to make sense of the COVID-19 outbreak. This week, the lessons history should have taught us. We do have this extraordinary ability to forget pandemics and then to panic when the next one comes. COVID-19 may be unprecedented in many ways, but a hundred years ago another deadly disease stalked a world that had already been devastated by the Great Wall. But what do we really remember about the Spanish flu? Pandemics have always gone hand in hand with xenophobia. There's always this human instinct, unfortunately, to point the finger at the other person at the other country and say it came from there. Subscribe to World Versus Virus on Apple, Spotify or wherever you get your podcasts. I'm Robin Pomeroy. When we look back on the big moments of history, what do we usually see as the turning points? Most often it's the wars that brought down empires and redrew the world map. So how will history remember COVID-19? In her book, Pale Rider, the Spanish Flu of 1918 and How It Changed the World, author and science journalist Laura Spinney argues that the Spanish flu outbreak was at least as significant as the two world wars between which it was sandwiched in terms of its impact on global politics, family structures, medicine, religion, the arts, you name it. She spoke to David Knowles. Would you tell us a little bit about the Spanish flu and give us a brief overview of what exactly happened in 1918? So it was a pandemic of influenza that struck in the early months of 1918. We generally say it struck in three waves. So there was a first kind of mild wave in the northern hemisphere spring of 1918, which receded in the summer or late spring. Kind of all the dates depend on where you were in the world. And then there was a second wave which erupted in the latter part of August and receded towards the end of that year. And then there was a third wave, which was sort of intermediate in severity between the other two, which emerged in the early months of 1919. We think it infected about 500 million people, so one in three people in the world, alive at that time, and that it killed 50 million of them. Those are the current estimates we work with. And the death toll could have been even higher because there was a big problem with under-reporting at the time. They didn't have a reliable diagnostic test. Why was it so deadly? Good question. So it was no ordinary flu. So pandemic flu is much worse than seasonal flu. And there have been flu pandemics throughout history and prehistory. We think there have been 15 flu pandemics in the last 500 years. And basically every seasonal flu that we are familiar with and that we catch every winter started out as a pandemic flu, which was much more virulent because it was new in the human population. And then gradually over time, it evolved, it mutated in order to become more benign and to sort of live in a more harmonious relationship with humanity. That was particularly virulent though, the 1918 pandemic flu. And there are lots of theories for why that was. Some of them have to do, and they're not mutually exclusive. Some of them have to do with the inherent biology of that virus. And some of them have to do with the state of the world at the time because that pandemic obviously emerged at a time when the world was at war. And so there were extraordinary circumstances, extraordinary conditions in the world. So lots of people were on the move, not only troops, but also civilians, you know, refugees and displaced persons. There was a lot of hunger. And, you know, all of these factors may have fed into the virulence of the virus. There was definitely something very abnormal about 1918. If you think about the five flu pandemics we've had since the 1890s, none of them has killed more than about 4 million people maximum. Whereas that one killed, as I said, minimum 50 million people. So it really was in a ballpark of its own. So you've touched a little bit on the world of 1918. Could we go into that into a little bit more detail? So the population is about a quarter the size of what it is today. Infectious diseases were still the main killer, unlike the kind of chronic degenerative diseases which kill us today. It was a world that didn't know viruses very well. The first viruses had been identified at the end of the 19th century. So when the Spanish flu erupted, we had germ theories. So people understood that microbes caused infectious diseases, but almost every doctor in the world thought they were dealing with a bacterial disease. And that kind of shapes the whole story. It means they had no reliable diagnostic test. It means they had no really good treatments. And it's sort of the reason why it was called many different things. And therefore we have a problem counting the dead as well. It was a world that did not have commercial airplanes. So the fastest way you could get around was by ship or by train. Cars had been invented. Henry Ford had invented his Model T, but they were really only the preserve of the rich still. Telephones were quite rare as well, quite an elitist thing. I mean, it feels it feels like we can reach out and touch it in some ways. There's a lot of similarities, but also a lot of, you know, really fundamental differences. If you think about one thing that I think is surprising is that illiteracy was much higher than than it is now. Even in advanced countries, it wasn't such a kind of taboo or rare thing as we think of it today. And that had an impact too, because the main way that news was transmitted was by newspapers in populations with higher literacy. That meant news traveled much more slowly and often with an effect of distortion. Why is it called the Spanish flu? Well, it's a historical accident and an unjust one because one of the few things we know for sure about that pandemic is that it didn't start in Spain. We don't know where it did start, but we know that there were cases in at least, for example, the US, Britain, France and probably some other European countries before it was in Spain. The thing was that Spain was neutral in the war, so it didn't unlike those other countries censor its press. And when the first cases broke out there in the spring of 1918, the newspapers in Spain reported on them, whereas in these other countries it was kept out of the news. And those first Spanish cases included Alfonso the 13th, the King of Spain. So he made it very visible. He went on to recover by the way. So that name just kind of stuck, unfortunately, with the encouragement of the other warring nations who were quite happy to point the blame at somebody else. There is a parallel with today because pandemics have always gone hand in hand with xenophobia. There's always this human instinct, unfortunately, to point the finger at the other person at the other country and say it came from there. What aspects of society do you see really changing because of the flu? So it's a big, big question. I mean, I think when you think about the consequences you have to divide them up into short-term, middle-term and long-term. I mean, so for example, to give you a short-term one, a lot of people who were very ill with, for example, TB, which was a massive killer at that time, were purged from the population. They were probably the first to die of the Spanish flu because they were already, you know, weakened. And so the effect of that was to produce a kind of jump in life expectancy because the people who were ill died and the people who were left behind were healthier. There was also a baby boom in the 1920s and that has always been put down to the war and the men returning from the front in a sort of new wave of conceptions. But there is an argument that the flu could have contributed, we can't say to what extent, it's quite difficult to disentangle the two, but that it contributed because it once again purged the least healthy from the population, leaving behind a smaller but healthier population that was able to reproduce at higher numbers. And one of the clues to that is Norway, in fact, because Norway had a baby boom even though it was neutral in the war. So there's obviously an effect there, it's just difficult to say how much each thing contributed. And of course, I'm talking at the population level, I'm talking purely about kind of population mechanisms at the moment, you know, a lot of people died, there was a lot of human misery and you have to take that into account when you're thinking of all these population level changes. Amongst those who were very vulnerable to the Spanish flu were the 20 to 40 year olds. So normally flu is most dangerous to young children and to the very old. But in 1918, bizarrely, it was this middle age group. And because it was a time when there wasn't much of a social welfare net, even in wealthy countries, that meant lots of the dependence in families were left without a visible means of support because the breadwinners were taken out. Tragically, they were often the men who'd returned from the war and then died of the flu. It was a horrible double whammy. They left behind elderly people and sometimes small children at a time also when adoption wasn't organised. This is one of the great tragedies of 1918 is that those people, those dependents just kind of vanish into the cracks in history. We don't really know what happened to them. We get the occasional glimpse. We know, for example, from a study in Sweden that a lot of old people moved into workhouses and a lot of the orphaned children became vagrants, depending on where they were in the world, or went into service, or unfortunately went into a life of crime and abuse and exploitation. There are these tragic stories that to me are waiting to be told about 1918. Given the numbers, think of that multiplied to the scale we're talking about. We may never be able to tell them. We have glimpse, we have anecdotal reports, but we don't really have a lot of good data on those people. I explained about the 20 to 40 year old age group being vulnerable and within that age group, it looks as if men were more vulnerable than women overall, globally, though there were regional variations. Pregnant women were particularly vulnerable and they died or survived and had miscarriages at frighteningly high numbers. One of the theories is that the massive inflammatory reaction that the virus provoked in the lungs, it drew all the body's resources to fight this infection and took those resources away from the womb and the growing fetus, and that that's what provoked the miscarriages. But the point is that not all those babies died, some of them lived to be born, and we have to assume that those babies survived those enormous physiological stresses while they were in the womb. And in fact, that generation, we know, they were minutely smaller than cohorts either side. They were smaller physically, which is a kind of reflection, I think, of the stresses on their physical organs while in the womb. So that generation were physically and cognitively slightly reduced. They also, as they grew up, were more likely to suffer from heart attacks, to go to prison. All sorts of bad things were associated with that bad early start in life. And there was a really unfortunate generation because they're also the ones who came of age just in time to go and fight in the Second World War. For me, that is the lost generation of the early 20th century because there must have been millions of them. Something you've written a little bit about was the crisis in science during the pandemic and after, linked to that, the rise of alternative medicine. Would you like to talk through that a little bit? So I think it's really interesting because in those countries that had sort of embraced the scientific approach, mainly Western countries, you see kind of turning away from science after the pandemic because people were disillusioned with it, hadn't helped that the doctors had been caught on the back foot, so to speak. And so there is this kind of like turning away from the conventional medicine and towards the unconventionals, or the irregular as they were known at the time, the term alternative medicine didn't exist. But what you see from the 1920s, for example, in America, is alternative medicine, homeopathy, naturopathy, chiropractic taking off in a big way and spreading around the world. And, you know, often people would go to the conventional doctor and to the alternative doctor, or the irregular as it was called. And those alternative medicines kind of took on a new respect because they'd been rather looked down upon before. And they became known as alternative medicines, so, you know, a more respectable title. But at the same time, in countries that had not really embraced the scientific method, you see the opposite effect. So you see, you know, China becomes a little bit more scientific after the pandemic. There's a kind of move to, for example, better disease surveillance, a better public health, more organized public health, a centralized a collection of health care data, because they had not been very scientific before. And now they saw that maybe their salvation in order to prevent future pandemics was to turn towards science. One of the effects that we haven't mentioned yet is, and that I talk about in my book is that I think you can see that it gave a big boost to the concept of socialized medicine. So, you know, this has been discussed before, undoubtedly, it was a concept. But to put in place a socialized medical health care system, a socialized health care system, is not an easy thing. You have to find a way to pay for it. You have to reorganize all your doctors in the way that you deliver health care. And so no country had really got around to it yet. And I think that the pandemic is what gave the stimulus to do that because there was a realization that a pandemic was a global health crisis that you had to treat at the population level. You couldn't treat individuals and you couldn't blame. And there was no point in blaming individuals for catching an illness or treating them in isolation. You see from the 1920s countries, Russia was the first, but then followed by Western European nations putting in place these socialized health care systems. Along with that comes epidemiology. The search for causes and patterns and causes and effects and patterns in health care and in illness that is the kind of cornerstone of public health. If you can't see what's going on in a population in terms of health and ill health, then you don't know what measures to put in place. So the two go together. And so as a result of that, what happens is that the baseline health of population starts to become much more transparent, much more visible. And that includes in the colonized countries. Now Indians, for example, could see that they were much less healthy than their colonial masters in the country. It didn't take a huge leap of imagination to connect that to the fact that health care provision was much better for the white population. And so you get a kind of grassroots movement wanting a socialized health care, looking at Russia and wanting that system for themselves and a kind of general disgruntlement with the colonial system. So far we've talked about the largely positive impacts of the pandemic, turbo boosts to socialized medicine, et cetera. But you mentioned in your book that it put pay to a vigorous anti-smoking campaign. There had been a big push to stop people smoking beforehand. But during the pandemic, smoking was supposed to sort of protect you from the virus. It was kind of seen as a prophylactic. And all sorts of things were because the doctors had nothing official to offer. And so a lot of people took up smoking and it kind of became cool afterwards. It was a thing that cool people did. And by a weird mutation in the public mind, it became the thing that you should do and it became popular, especially in women as well. Does that go back in history? Is that the idea, I forget the word, but the idea that bad air can cause... Yes, you're right. It has deep roots in the kind of medieval idea of miasmas and noxious airs, causing infectious disease. And in fact, that idea, even though we're now talking in the realm of germ theory, germ theory had been around for half a century at least, you see that idea kind of reviving, I think partly because it was a time of war and people were psychologically exhausted after the four years of the war. And it was easier for them to kind of pick up on old tropes and seeking for explanations as they picked up on whatever was available. And there was a popular theory at that time that the kind of noxious gases rising from the battlefields of Flanders and floating all over the world were causing this pandemic. So yeah, that was very much linked, I think, to the idea of warding off the bad air with cigarettes and herbal fires and all sorts of other things. You write that... This line has sort of obsessed me. I can't get out of my head that the flu may have been democratic, but the society it struck was not, which obviously leads to disparity in terms of who's affected and who dies. That seems... When I read that, I thought, wow, that seems to ring true to what's happening today. So it's democratic, okay? The flu doesn't know, you know, the individual, it'll infect anyone. But... And so you see kind of Lloyd George, the king of Spain, all these celebrities came down with the flu in 1918 and, you know, Boris Johnson has had it today. Nobody is, in theory, spared. But if you look at the population level, there's a very clear disparity and basically, the poorest, the most vulnerable, the ones with the least good access to healthcare, the ones who work the longest hours, who live in the most crowded accommodation and so on. So in 1918, it was perceived this disparity, but because it was a time of eugenics type thinking, the idea was that those people who were more prone to the flu were constitutionally somehow inferior, that it was somehow their fault. Of course, eugenics was completely discredited after the Second World War and so now we understand we're more enlightened, we have more information, we understand that the reason those poorer groups in society are more vulnerable is because of the environment they inhabit and the fact that they don't have as good healthcare. But that effect is strong in every pandemic. If you look, there was a study conducted on the 2009 flu pandemic in England, which showed that the death rate was three times higher in the poorest fifth of the population and in the richest fifth. At the beginning of your book, you talk about this weird memory gap, that the Spanish flu is this huge thing that happened, but actually when you ask people what they think are the biggest things that happened in the 20th century, it's not usually brought up. Do you think this pandemic could go the same way? Will it be remembered at all? I don't know. I think this is really interesting. I mean, so two years ago I published my book and the reason I wrote that book was because it seemed to me that there was this huge hole in our collective memory about the worst disaster of the 20th century and I could hardly believe it. And now two years on from that, all I here talked about, I mean, obviously I am in a biased position. But people can't stop asking me about the 1918 pandemic. If we look back over the 20th century, we don't mention it as one of the big events. Nobody does really. Perhaps even today in these days of COVID, there's an effect of the new pandemic reviving the memory of the old. But having said that, it definitely is not remembered in the same way as, say, the two world wars, which are kind of seared onto our frontal lobes. You know, there is some different way that we remember pandemics. And one of the ways I tried to explain it in my book was that to me, that pandemic is remembered individually as millions of sort of discrete tragedies, not in a history book sense of something that happened collectively to humanity. Okay, will we remember this one? The precedents are not good. I mean, there were two other flu pandemics in the 20th century, the 1957 Asian flu and the 1968 Hong Kong flu. And depending on who you ask, the first one killed about two million people, and the second one about four million people. So we are nowhere near those yet. And yet we don't think of those or compare this pandemic to those. We immediately leap for the enormous one in 1918. We do have this extraordinary ability to forget pandemics and then to panic when the next one comes. Laura Spinney's book is called Pale Rider, the Spanish flu of 1918 and how it changed the world. She was speaking to David Knowles. I'm joined by Linda Lucina in New York. Linda, how are you? I'm good. Robin, how are you? Not bad. Thanks. Linda picks for us three stories every week from our coverage on weform.org. You usually pick a theme, Linda. Have you picked us a theme this week? My theme is stories that I just think need to get more visibility. Okay. Give us one of them. My first pick asks us to imagine what the pandemic would have looked like had it happened 20 years ago. So that's before high speed internet, before cloud-based networks, before Netflix and Zoom. Basically, work and school would have screeched to a halt, and even grocery shopping would have been much, much harder. And the economic impact would have been sort of unimaginable. And so it's just an important reminder of the systems that we've built in such a short time to make us more resilient. That story is called what would the COVID-19 pandemic look like if it happened 20 years ago by Timothy, Divini, the chair and professor of international business at the University of Manchester? What's your second story? My second story is from an author whose brother has an intellectual disability. So the pandemic has prevented her brother from moving into an independent home, but it's also cut off people with disabilities from activities that could ease their isolation and also from help that could ease the burdens on their families. And these populations really feel the crisis most acutely, and their needs really get overlooked. The story is called I hope he doesn't feel too lonely COVID-19 hits people with intellectual disabilities hard. It's by Kara Eusebio, who's part of the global shaper community in the World Economic Forum. What's your third story? My third piece is about all the models that we are eagerly looking at to understand when the lockdown should lift. A piece by scientists from Harvard and MIT explained that no model fits every situation. And to understand those models, it's important to understand why the models were created, what assumptions they make, where the model's data comes from, and from what context. So the models are all important for forecasting what might happen and basing policy on them. If you want to read more on that, it's called The Four Key Questions Policymakers Should Ask COVID-19 Modellers. It's live now on the website reform.org. Linda, thanks very much for your pig. Thanks so much, Robin. Thanks for listening to World Versus Virus. You can find all our coverage of COVID-19 at reform.org and follow us on Facebook, Instagram, LinkedIn, TikTok, YouTube, and on Twitter using the handle at weef. Please subscribe to receive the podcast every week. Just search for World Versus Virus on Apple, Spotify, or wherever you get your podcast. Thanks again for listening and see you next week.