My daughter was home and we were watching 2 years worth of Downton Abby over the last 3 or 4 days. If you have been under a rock, have no access to popular media, or are purposefully boycotting tales of economic injustice, this is a BBC/PBS series about an English manor house, the lords, the ladies, and their servants (Also, if you are like my friend Tonya Caylor and are busily trying to play catch-up today, don’t read this until the end of your marathon). Last night the “Spanish Flu” of 1918-1919 hit, following the Armistice. The flu conveniently killed off one of the more troublesome characters, setting the stage for the Big Wedding.
While my wife and daughter were watching the costumes and the proper behavior, I was watching the doctor’s response to the flu. The family had just sat down to dinner (so it was likely around 7) without the head butler (who was ill) and the Lady of the house excuses herself from the table.
“Shall I ring the doctor?” someone asks at 7 at night…I can see how telephones were not a doctor’s friend.
“No,” says someone with sense, “it is late.”
That lasts for one scene and as the Countess becomes sicker the doctor is summoned. It is likely 10 pm….I wonder, if it had been the fish monger who rang him would he have gotten out of bed?
The doctor very quickly makes the diagnosis of Spanish Influenza (this part hasn’t changed, when flu hits doctors see flu everywhere they turn) and prescribes milk and cinnamon (the Tamiflu of its day). The case fatality rate on the show (the number of people dead/the number of people infected) was about 33%.
My wife asks me with a look of concern, “That can’t happen today, can it?”
The answer is…someday it will. What likely happened in 1918 -1919 was an antigenic shift of influenza (see picture below)
What we know is that this happens predictably and occasionally with tragic results:
At least two of the major Influenza pandemics of the twentieth century, H2N2 in 1957 and H3N2 in 1968, resulted from reassortments between viruses from two different hosts, avian and human.
Why is this a problem? Under the best of circumstances, the influenza virus wants to keep the host alive. People, birds, pigs, monkeys all play an important part in the ongoing life of the virus. It cannot live on its own and wanders the world from sick person to sick person. A dead host is not helpful. The reason the 1918 strain was so lethal (20,000,000 known killed worldwide) was partly the human factor (we were moving folks from continent to continent to fight a war) and partly the virus (it in now known that this strain savagely attacks the lungs, leading to quick death in otherwise healthy people). It was not very successful as a virus…
Doctors spend a lot of time worrying about this. We worry for our patients (treatments are limited despite what drug companies tell you), for ourselves (health care workers will be among the first exposed), and for our future (when this happens the response is never pretty).
What should you do? As the Bible tells us, we know not the day nor the hour, but the CDC pays a lot of attention to potential pandemic flu (the belief is it’ll come from pigs and China). We can let our congressmen know that funding for this type of effort is covered in the “general welfare clause” of the constitution and should not be negotiable. When it comes, having warning will allow us plan for treatment (mostly supportive care) as well as to minimize deaths through isolation until it runs its course.
Regular flu season is now upon us, and it kills 50,000 Americans in an average year, mostly the young and the old. There are some things we can do to keep deaths from the regular flu down as well:
1) We can get vaccinated every year. That goes doubly true for health professionals. It isn’t too late this year, in case you’ve yet to get one.
2) The virus is spread through respiratory droplets. We can cover our coughs, wash our hands, and stay home if febrile.
3) While there is a treatment, it is not very effective (reduces febrile days by 1) and must be taken early. If you only have a mild case then rest, fluids, and ibuprofen may be all you need.
If you get the flu, I recommend Downton Abbey. It’ll last as long as the flu and make you feel better, too.
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January 7, 2013 at 1:22 am
Robert C. Bowman, M.D.
This was good advice – much better advice than CNN – who panics people into going into urgent cares and ERs. When they do so, they do get exposed to epidemics even if they did not have them and then spread them even more. Tamiflu is small change and getting less. Prevention is the key.
One of the big issues for rapid transmission, is entire families taken out – the lack of basic hydration and care multiplies the death rate. Nursing care was largely overseas at Spanish Flu time due to WWI.
A friend of mine found this out with norovirus that hit 12 of 16 people at her house in 2 days. All she did was laundry and try to stay healthy.
A rural doc in Kansas is the likely discoverer of Spanish flu, that hit the army bases and went overseas – got more virulent in the process – and hit US. Only Gunnison Colorado and Australia escaped it, until Australia let a troop ship in past isolation. Barriers work, if enforced. Also the flu continues to mutate and likely away from the combination required for high death rates – delaying transmission may be the only ally in some situations.
The point of isolation is to slow the spread of any epidemic – worst case scenario would demand shutting down air and ground transport for a time.
School districts paid by attendance know this as they sometime shut down school for a few days – and make more money as fewer kids are impacted overall.
Business as usual is what will result in spread of the next epidemic. Shutting down commerce and people interactions for a time could be most important.
Leaders will need to make tough choices to slow epidemics down so that overwhelmed health resources can catch up. And if you live in locations with top concentrations of people – you can expect worse spread, worse morbidity, worse mortality, and chaos until the epidemic has its way.
For example half of nurses indicated they might not show up for work in an epidemic. This was not fear of illness or lack of service orientation – it was a matter of who cares for my family and children when we are shut in and isolated and do not have relief coming. Thinking ahead to address many needs is very important – but crisis usually comes before much thought.
Spreading out people is a really good idea. We know that epidemics and disasters will occur and concentrations of people magnify the carnage. Spreading people out is important – away from coastal areas, away from hurricane prone areas, away from earthquake prone areas, away from each other, and away from highest cost/property value areas.
Also there is only one rapid redistribution of goods and materials that could address crisis needs – the Walmart distribution system. But getting to this understanding may be way beyond our capabilities.
But we fail to enact such policies – and those in charge of disasters actually support the concentrations of people in vulnerable areas (flood insurance, etc.).
Interestingly the WWI folks were some of the best at such logistics, and Wilson was not a war type person – but he and his cabinet were committed to wrecking such havoc on any enemy that they would not dare again. Sadly his hope for preventing the next war – during the peace signing – was destroyed by – you guessed – the Spanish Flu which severely limited his capacity and resolve.
January 7, 2013 at 1:48 am
Robert C. Bowman, M.D.
The Great Influenza by John Barry was a major source for my comments, along with FEMA documents and growing up in Texas City just after its major disaster ship explosions of 1947 (fertilizer to restore Europe and Asia – pushed to fast and too dangerous). Also a source has been family wiped out financially by scams and hurricanes with insurance companies and banks contributing individually or collectively for worse result for my family – and yours.