Flu patients at an emergency hospital near Fort Riley, in Kansas. Photo via AP Images.

Flu season is approaching, and once again, drug stores across America will begin putting up signs advertising flu shots. Should you bother? Read Laura Spinney’s Pale Rider: The Spanish Flu of 1918 and How it Changed the World, then get back to me.

The Spanish flu pandemic of 1918 gets relatively short shrift in the history books, especially compared to World War I, which helped create the crisis. But the death toll was absolutely enormous, and the virus made its way far beyond the countries actively involved in the conflict. There were vast variations in impact and experience of the pandemic, but this was truly a global event. In Pale Rider, Spinney brings together the long mutual history of humanity and influenza, the science of the virus, medicine’s attempts to understand it, and stories of how different communities around the world handled the outbreak.

I talked to Spinney about why the pandemic is less well remembered than World War I—despite the fact it killed more people—the ramifications for the medical profession and also why yes, you should go get your flu shot. Our conversation has been edited for length and clarity.

What was the scale of the epidemic of 1918? From your book I got the impression that historians have really dramatically upped the estimates even over the last decade or so.

You’re absolutely right that the estimates have increased over the years. And the reason for that is because there was no real diagnostic test in 1918, so there’s no real hard data. But the latest estimates suggest that somewhere between 50 million and 100 million people died. You can see in that vast range how difficult it is to pin down hard numbers. But to put that in a little bit of context, there’ve been quite a number of flu pandemics in the history of humanity. The previous one, the so-called Russian flu, which took place in the 1890s, killed around a million people. That wasn’t that long before, the global population hadn’t increased that much. And of the three flu pandemics that we’ve had since 1918, the worst killed on the order of 4 million people globally.

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Was it all the transport movements associated with World War I that did that? Was it an especially virulent strain? What made it orders of magnitude larger than, say, the Russian pandemic?

The current thinking is that it was a combination of the two. The reason that we do have pandemics periodically, in wartime and in peacetime, is because a new strain spills over from another animal host species into the human species. And it’s always virulent to begin with, because it’s not well adapted to us yet. Gradually, over time, it moves into more of an equilibrium with humans so it’s less virulent. But at the beginning, they’re always fairly bad.

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But the reason the Spanish flu was so bad was probably because of the state the world was in when it emerged. In 1918, as you know, that was the last year of the First World War. Large amounts of people in the world were hungry, stressed, displaced, injured. There were large troop movements going on, which was an ideal vehicle for an emerging virus to travel around the world. So it wasn’t an ordinary world. Not that the world is ever the same at two different times, but a world war is a pretty exceptional circumstance.

In terms of sheer numbers it’s bigger than World War I, right?

Much bigger. The estimates vary again. A figure you’ll see for the number of dead in the First World War often is 17 million. So I’ll let you make the comparison—it’s much, much bigger. In fact, if you think that the Second World War killed on the order of 50 to 60 million, it probably killed more than that as well, and may even have killed more than the two world wars combined.

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The way you learn about the pandemic is that it’s presented often as an afterthought. Certainly in comparison to World War I. It’s not forgotten, because obviously it comes up every time somebody is trying to remind you to get your flu shot. But in comparison to the scale of the impact—it’s possibly a larger death toll than the two world wars combined, and yet they’re defining events of the twentieth century and the flu is like oh, remember to get your shot. Why is it?

You’ve asked the most interesting question. To me, it’s absolutely fascinating why we remember certain historical events more than others. Why does an event like the Spanish flu, which claimed so many more lives than the First World War, get such little space in our history books? And I don’t know why. I don’t think anyone knows why. Collective memory, historical memory is a fascinating subject and it’s one that social scientists have studied for a long time. Neuroscientists are just getting into it. But I don’t think we can say for the time being why it is we remember some things more than others. There are lots of theories. For example, we like a good story. We like a narrative with a beginning, a middle, and an end, and wars fit that schema quite easily, don’t they? You’ve got declarations, you’ve got truces, it helps if you’ve got a few heroes along the way, and also you can understand who the enemy is. It’s somebody who looks a bit like you.

In a pandemic, there’s no real beginning and end. There are no heroes. And the enemy is something invisible that you don’t really understand. You certainly didn’t understand it in 1918, when “virus” was a brand-new concept. The first viruses were discovered at the end of the nineteenth century. Most doctors in the world thought that the disease they were dealing with in 1918 was bacterial. It really was a mystery, and they just didn’t have the vocabulary to tell that story. I think that is one major reason why we forgot.

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But you know, memory is a dynamic process, and I think memory of Spanish flu is something that’s growing. It’s coming more and more into our consciousness. Hopefully books like mine are helping with that process, because there are reasons why we should remember certain historical events, and one reason why we should remember the Spanish flu is because we’re likely to have another flu pandemic, and if we remember how bad that one was, we might take some steps to prepare ourselves better for the next one.

You also noted was that it tends to be men who go to war whereas typically it’s women who tend to nurse a sick person.

Certainly in those days, yeah. And I think that’s another really important point. When i was writing my book, the number of people who said to me, “Oh, I know there was this guy in my family, great uncle, who died of the flu”—a lot of people have Spanish flu memories but they’re individual family memories. Maybe a little bit dusty, a little bit vague. What we haven’t done as a society is to connect up the dots and have a collective memory of something on the scale that it was. That’s what’s missing. And I don’t know what it takes to create that collective memory out of millions and millions of individual memories, but for some reason, we haven’t done it. We’ve discussed some of the reasons that may have contributed to that.

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The female thing is really interesting as well, because at least in the past it was men who wrote the history books, right? It was men who were the doctors. So the male point of view is more audible, more visible, in the times we’re talking about, anywhere. There may have been in the female consciousness some greater sense of the scale of the thing they were facing. They were the ones who were nursing the sick, laying out the dead, and taking in the orphans. And presumably they were talking to each other. Of course they were also falling sick. But one of the statistics that we know of is that more men overall died than women. There may be a female story that’s still waiting to be told.

In the book, you suggest one of the few things one could actually do to help somebody through the flu in 1918 was to keep them hydrated. Did people have a good sense of what they could do that would work?

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To some extent. Humans have been dealing with infectious diseases since the beginning of time. Since the beginning of humanity, anyway. One thing that we tend to do right is that we understand that when an infectious disease comes along, we need to keep away from an infected person. That’s something we do right. Public health experts talk about social distancing, and even non-human primates, chimps and gorillas, do that. So there’s a very old, very deep understanding that you have to keep away from an infected individual.

Subsequent inventions like antibiotics—which don’t work on a virus, but lots of people who caught the Spanish flu actually died of secondary bacterial complications that caused pneumonia, so they would have been helpful. But in 1918 there were none of those. There were no antiviral drugs and there was no flu vaccine. Those were brilliant inventions that have transformed the way that we deal with infectious diseases, and they just didn’t have them in 1918.

They did what they could, but they really had very little to go to battle with against this disease. They had aspirin for calming the fever, the inflammation. They had not much else, really, apart from the public health side—quarantine, banning mass gatherings. Some of those measures could be effective if they were implemented properly. But on the actual treatment side, once somebody was ill, apart from careful nursing and keeping them hydrated, apart from aspirin, there was very little they could do. They did try some crazy folk remedies, though. They tried everything. They were desperate and very, very scared.

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You note in the book that this is a transitional period in the history of medicine, where it’s being professionalized and what we think of as modern medicine is splitting off from things like homeopathy. It’s defining itself against these other alternative options. What were the short and long term implications for how people viewed scientific approaches to medicine and professionalized medicine in the wake of the flu?  

Doctors and scientists collectively realized that they had failed, and they had failed on a very large scale. So they went back to the drawing board, starting in the 1920s. Starting even in the thick of the epidemic, there were people doing experiments on themselves, brave doctors who wondered is it really a bacterium causing this disease or is it something else, could it be one of these newfangled things they call a virus. And virology grew as a field; immunology, public health evolved very rapidly in the subsequent decades; the first flu vaccine came online in the 1930s. So there was rapid progress afterwards.

On the other hand, in the immediate aftermath of that pandemic, people looked at conventional medicine, as we call it, and they were very skeptical. What did these people do for us in this complete catastrophe? They didn’t do very much at all. Here’s my family devastated, my community, there’s no much left of it. So there was a kind of global turning against conventional medicine, at least in those parts of the world where it had already established itself as kind of the mainstream. And in those parts of the world, what you see is an embracing of alternative systems of medicine. Homeopathy, naturopathy, osteopathy, chiropractic, all of those things took off in the 1920s. And for one very concrete reason, which is they claimed to have cured more people than conventional medicine. Now, to be perfectly honest, they probably didn’t. But those were the claims and people were listened to them. They were receptive at that time.

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How does the institution of public health fare in this? To what extent where there institutions of public health and how did they fare against the pandemic?

This is something we can’t generalize about because there’s massive variation across the globe. There are countries where there was absolutely no public health infrastructure and there were parts of the world, for example, the States, New York was a paragon of virtue in this way. They were well set up in terms of public health for the time.

But a lot of brave and hardworking people tried to put a lot of measures in place to protect the community. More or less wrong-headed, in retrospect, but it’s very well to criticize in hindsight. They were doing their best. The interesting thing about public health is when you’re talking about the 20th century and cities that number in the millions and you want to impose a public health campaign, the powers that be in that city have to give you a mandate to do it. And they have to give you the resources to do it. And if they don’t, or if there’s resistance from different parts of the power structure in that city, then you’re not going to be able to put into place the measures that make a difference.

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When they were given the resources, how effective could they be against the pandemic?

They could be really effective. There’s one study I cite in my book, I think it dates from 2007, that showed that collectively public health measures such as banning mass gatherings, imposing the wearing of protective masks, cut the death toll in some US cities by up to 50 percent. That’s enormous.

But the trouble was they had to be introduced early and they had to be kept in place until after the danger had passed. If you lifted them too early, the virus just gets exposed to a huge population of immunologically naive hosts, and you quickly ramp up to another peak of death. There were three waves of the pandemic in the northern hemisphere. Ideally you’d keep it in place until the end. Otherwise people are going to die. They didn’t know there were going to be three waves, obviously, so a lot of people and in a lot of places the measures were lifted after the second wave and they were caught unawares by the third. That was one problem.

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Secondly, people suffer from public health measure fatigue. After a while they just don’t want to put their masks on anymore. Or they want to go back to their churches and their schools and resume their normal life. Unless you have that mandate, unless you have the ability to impose and police measures, and unless you have the goodwill of the people and the understanding of the people and they’re informed and educated and engaged, then to keep those measures in place for long enough is a real problem. Probably would be today, as well.

The time you most often hear about the pandemic of 1918 is when it’s time to talk about the possibility of another pandemic. Should it give us the shivers? Should we be scared? To what extent would that ever be possible again?

I think that we should be scared. There will definitely be another flu pandemic, okay? We don’t know how bad it’ll be. The more prepared we are, the better. If we can avoid wars as well, that would help. I don’t mean to sound flippant—I’m serious. But I think that we do need to be scared.

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I don’t think it’s that helpful, personally, to throw out really huge, scary numbers. We find it hard to compute very large numbers. It’s hard to feel sympathy for 100 million dead. It’s much easier to feel sympathy for your neighbor next door who’s dead. We need, as human beings, to be able to personalize death. But a flu pandemic could potentially be huge. We have a lot more in our tool cupboard, if you like, than they did in 1918, but the world is also much better connected. We travel faster, the viruses we carry travel faster. It could potentially explode much more rapidly than it did in 1918, and that was rapid. But then, on the other hand, we have better surveillance these days. We in theory can see things coming more easily.

We can’t really say how bad it would be, but a flu pandemic is always pretty bad.

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I will say that this book and definitely reminded me to book my flu shot and my kid’s flu shot, I asked my husband about his flu shot, I’m going to annoy everyone at work about their flu shot…

I think you should! And the other thing to say is the flu vaccines are getting better every year. The science is progressing. I’m actually at a flu conference in Riga here, and they’re going to be discussing new ways of speeding up the process of manufacturing the vaccine so we have enough ready in time if there was a pandemic, of matching it better to the strain that might emerge. There’s massive activity in this area, so every year the flu vaccine you get is better than it was last year. There’s an idea out there that it’s not very good, that it doesn’t give you much protection, and I think that that needs to be banished.

When people talk about the flu shot at the watercooler or whatever, I do think the popular perception is, “Is there a point?” If you work in a hospital or you’re older you have to get it, but I think a lot of young adults wonder, why do I need to get this, does it matter?  

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Well, do you remember the section of my book where I talk about that human genes can contribute to your response to the flu? I think the figure is something like one in 10,000 people don’t make interferon, which is the vital first-line defense against viruses, and those are the people who are most likely to die quite quickly and horribly in a pandemic. Now, unless somebody’s had their genome sequenced, we don’t know whose those people are. They don’t know who they are. So that vaccine could really save your life.

And the other way to think about it is that you should be thinking of it really as your civic duty. I was talking to a woman the other day, her son, I think he’s around 8, he had a childhood cancer. He had chemotherapy, so his immune system is compromised. All the children in his class who don’t have the vaccine for whatever reason are putting his life at risk, because he can’t have the vaccine himself. And he’s going to be very vulnerable even in a seasonal outbreak, let alone a pandemic.

So we have to think of it as a collective thing. We have to think of it as not only for our own good, but as a social duty.

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Really, what does it cost? In Europe, it costs a few euros. It’s very unusual that you have side effects. And where I live, you can go into the chemist and they’ll do it there for you. It takes a few minutes.

Just for people who are reading this and wondering—I know the vaccine protects against a specific strain. Does it provide any additional protection? If I get the flu shot and the strain that’s going around my office is not the strain they bet on for the vaccine, does that flu vaccine still provide me some protection in general?

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It does. There’s always some overlap. As you have understood from the book, the flu virus is very labile. It evolves all the time. So the further it’s evolved away the strain you’re getting or strains, rather, now, because vaccines contains more than one, the less protected you are. But there’s always overlap. If you think that every flu pandemic since 1918 has shared genes with the virus that caused the 1918 pandemic, by being exposed to the proteins that are the products of those genes, you are getting some protection. You may not have all the proteins that are in that flu virus but you’ve got some of them, and that’s better than nothing.

It is possible that an entirely new strain emerges. And that’s the danger—that nothing we have gives us any protection. And then we’re back at the drawing board. All of us are completely naive to that strain. That’s the worst case scenario.

But in the meantime, get your flu shot.

In the meantime get your flu shot.

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This article originally stated that the Russian flu took place in the 1880s; it was in fact the 1890s. We regret the error.