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swine_cartoonMy 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.