Pale Rider: The Spanish Flu of 1918 and How It Changed the World (Laura Spinney)

Since I am an apocalypse monger, but a practical one, I do not worry about alien invasions or the reversal of Earth’s magnetic field, but I do worry about pandemics.  This book, Laura Spinney’s Pale Rider, is a recent offering in the pandemic literature that has become popular in the past twenty years.  It focuses on the only known pathogen likely to create a future pandemic, the influenza virus, through its greatest past outbreak, the Spanish Flu of 1918.  I read books like these partially for history knowledge and partially to understand what to do in a similar future situation, and Pale Rider is useful for both.

The title, though Spinney does not acknowledge it, comes from the Apostle John’s vision of the Fourth Horseman in Revelation 6:8.  “And I looked, and behold a pale horse: and his name that sat on him was Death, and Hell followed with him.”  (True, the horse, not the rider, is the pale one.  Spinney probably stole the elision from the 1985 Clint Eastwood movie of the same name.  I guess Pale Horse doesn’t have the same eerie resonance.)  The title is just an eyecatcher, not a signal of coming deep thoughts about humanity.  In practice, Spinney plays it straight, alternating between the history of the pandemic, so far as it is known, and scientific discussion, both about the pandemic itself and about the current and future state of the influenza virus.

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World War I plays a large part in the history.  The war meant that large numbers of people, mostly men, were packed together in close proximity, and it also created a lot of movement that would not otherwise have happened, such as Chinese workers being shipped through the United States on their way to Europe.  Still, while modern scholarship has figured out a lot, much of the history of the pandemic is guesswork, which Spinney freely admits.  We don’t even know where the pandemic started—Spinney notes that the major candidates are China, France, and Kansas, which is a pretty broad spread.  As a result, much of the book is anecdotes, rather than summaries of actual statistics of the time—but well-chosen anecdotes, from all around the globe, that give the reader a good flavor for the time and the events.

Though it seems close in time, 1918 is a foreign country to us.  As Spinney says, “People regarded death very differently.  It was a regular visitor; they were less afraid.”  That’s not to downplay the emotional impact of the flu and the deaths it caused on the people of 1918, but they bucked up and got on with life more than I think we would.  Parents regularly outlived their children.  Many adults died early (my great-grandfather, a Budapest journalist, died in 1908 of tuberculosis, a young man), though it’s a myth that older people were rare in any past human society.  It’s not for nothing that Psalm 90 says “The days of our years are threescore years and ten.”  More generally, most people died of infectious diseases, “not the chronic, degenerative diseases that kill most of us today.”  Leaving aside lifespan, I suspect the former is preferable—people live in fear of cancer, Alzheimer’s, ALS, and so forth, afraid of the long, slow, painful, decline.  If you have to go, better to check out with a high fever and a few days of annoyance!

The name “Spanish Flu,” as with the names of many diseases, is a misnomer, since it didn’t start in Spain at all.  All disease naming, even today, carries a propaganda element.  Perfectly reasonably, nobody wants to be tagged with responsibility or even be associated with the origin of a disease.  For example, Spinney notes that some Chinese were unhappy a decade ago with the name SARS, an acronym for “severe acute respiratory syndrome,” because Hong Kong, one of the regions affected, has the acronym SAR, for “special administrative region,” in its official name.  And AIDS was originally more accurately called GRID, for “gay related immune deficiency,” until the propagandists of both Left and Right decided to pretend it was a threat to America as a whole, a pretense that continues even today, though only halfheartedly.  Nowadays, the preferred mechanism is to name diseases mechanically, based on effects and other relevant qualifiers, which is probably a better, if less colorful, solution.  Making it worse for the Spanish, it’s not even clear whether some outbreaks of the time were the Spanish Flu at all.  Spinney mentions confusion with several other diseases, including typhus, noting that disease, spread by fleas, “has long been regarded as the disease of social collapse.”  It’s therefore indicative that, according to CNN a few weeks ago, typhus has reached “epidemic levels” in Los Angeles and Pasadena, as the derelict homeless population is allowed to expand in those areas, though kept well away from the gleaming castles of the Lords of Tech.  If we’re lucky, though, such collapse will hasten California’s breakdown and the resulting implementation of my plan to enable the underclass to flourish.

Anyway, various interesting facts pop up throughout Pale Rider.  For example, recently the estimated death toll for the 1918 pandemic has been substantially revised upwards.  It might have been as many as 80 million people.  I think it’s generally known nowadays that the Spanish Flu tended to kill healthy young adults to a greater degree than most flu viruses, or, for that matter, most illnesses.  This has long been attributed to a “cytokine storm,” where a robust immune system over-responds, in this case drowning the victim from within.  But the Spanish Flu did not kill teenagers at any higher rate than normal, and their immune systems are just as robust as an adult’s.  Spinney acknowledges this, and the mystery, then drops it; I would have liked to know the current state of thinking on that disparity.  Moreover, while it’s true that relative to normal flu, healthy adults died more, it’s also true that the Spanish Flu killed the very young and very old just like a normal flu, creating a “W-shaped mortality curve.”  And it killed pregnant women most of all, in perhaps the saddest effect of the epidemic.  Still, it wasn’t like pandemics in the movies, or the Black Death, where bodies stacked up in the streets.  The death rate for those infected was 2.5% (with substantial geographic variation); most people who got the Spanish Flu experienced nothing different from a normal flu.

Deep down, most of us think that while today a new pandemic might kill quite a few people, we would soon enough, by throwing money and scientists at it, find a cure and get back to normalcy.  That confidence is misplaced, I think—one has only to see the enormous resources thrown at AIDS over the past thirty years, where a cure appears no closer, to realize that it’s not that simple.  There’s no guarantee of an effective treatment in any quick timeframe, much less a cure.  Another misapprehension, I think, is that today’s bloated government would be helpful.  At best, government is a mixed blessing in such situations.  True, sometimes the government, especially local government, is effective at organizing a response.  Spinney talks about the city’s efforts in New York to contain and treat the flu, which were reasonably successful.  But Spinney also relates how the crew of a Coast Guard vessel was sent to remote Alaskan villages, where the local Eskimo people died at high rates.  Instead of helping, the government workers mostly held dances on board and stole valuable church goods (the locals were Russian Orthodox, from the earlier Russian presence in Alaska).

Along these same lines, our thought about a pandemic today tends to be distorted by narratives of past pandemics that took place in vastly different situations.  Thus, in 1918, treatment options were extremely limited, but follow-on effects, especially food shortages due to supply chain failure, were rare.  As to treatment, in 1918 there were no antiviral drugs and there were no ventilators or other sophisticated equipment that might help those with lung failure.  Those who ended up in the hospital were little better off than those at home.  Today, in any similar pandemic, or one worse, demand for any available effective drugs and for sophisticated medical care, as well as simple hospital beds, would far outstrip supply, resulting in the need to triage such medical offerings.  As to food, even cities in 1918 had a lot more food available; they did not have food trucked in just-in-time from across the country, like we do today.  That means store shelves would be bare within a few days, and for most of us our food would run out, if the trucks stopped running, something the victims of the Spanish Flu generally did not have to face.

What would result today, from these changes in treatment and food supply, is that inequality would immediately rear its head in any really bad pandemic.  That happened in some places during the Spanish Flu.  For example, Spinney quotes the Brazilian writer Pedro Navo, who lived through the pandemic as a boy in Rio de Janeiro.  “There was talk of . . . chicken-stuffed jackfruits put aside for the privileged—the upper classes and those in government—being transported under guard before the eyes of a drooling population.”  But generally, the poor suffered more because they caught the flu at higher rates due to inferior housing conditions (children were kept in school to keep them out of their homes), not from getting worse treatment or no food.  Today, we would struggle with equitable allocations of both treatment (palliative or curative) and food.

The very rich would certainly get treatment and food.  Steve Jobs famously jumped the line to get a liver transplant by having a private jet ready to take him at an instant’s notice to get a new liver.  (He needed one because he initially refused to have surgery to cure his pancreatic cancer, one of a small percentage of such cancers curable by early surgery, preferring to try herbs and meditation first.  He chose poorly, and he doubly ripped off someone poorer than him.)  The very rich could also hire private doctors, nurses and machines.  And, of course, with enough money you can always get food.  Everybody else would have to fight for a space in the ICU or for limited doses of whatever drugs might be effective, and wonder where their next meal was coming from.

It wouldn’t be anarchy—people won’t abide anarchy, and individuals are often less selfish in practice during disasters.  But some mechanism of allocation of both treatment and food would arise.  I suspect treatment would be allocated along two axes.  The first would be through personal or class connections, just as under any non-free market system.  When my aunt, not an English citizen but the widow of an Englishman, though she had not lived in England in decades, was diagnosed with cancer, she returned to England from Asia, was illegally entered into the NHS, then moved to the front of the line with the best oncologists—all because she knew the right people in the professional-managerial class.  Communism had similar mechanisms of allocation:  the nomenklatura got the good stuff, and the top echelon of the nomenklatura got medical treatment in the West (like Fidel Castro), since their medical systems were so terrible.  (Spinney credulously takes at face value Lenin’s pronouncements that he was going to offer great medical care to all Russians; she probably believes that the Soviet Constitution meant what it said too.)  Allocation through connections is not a great system, and would in practice benefit the professional-managerial elite that has already dragged down America, but it’s the kind of thing that characterizes every human society, as Francis Fukuyama has noted.

The second axis, the group that would really jump the line on treatment allocation, is far more pernicious.  That’s government workers.  The process would start with Congress, which would pass laws ensuring they and their families were prioritized—for the good of the country, you know.  Naturally, Congressional staffers and their families would also have to be included.  And, of course, executive and judicial branch workers.  Then, logically, administrative agencies—how could the country survive if EPA and EEOC drones died, or had to see their families die, or even had their work hampered by having to worry about their health?  So most, if not all, federal government employees would be deemed essential and jump in line before the general population.  (A few government workers might not want to so benefit at the expense of the more deserving, but they would be kept silent, directly or by peer pressure, since to question this process might result in its crumbling.)  Sometimes the country just has to make hard choices; if prioritizing bureaucrats in Imperial City means the average Joe in Iowa City has to die, that’s unfortunate, but what else can we do?

The same process would probably flow downwards to the state and local level, though for treatment allocation, that would not result in much additional allocation to such government workers, since the federal government would hog all available resources.  On the local level, food would be the real problem, and I expect many local governments, if food was short and not obviously coming anytime soon, would attempt to steal food from any place they could find it—stores, farmers, and individuals—to “ensure equitable distribution,” and then give it to their friends.  Another reason to make sure you have enough guns.

Maybe this is all too cynical.  It’s possible that government workers (other than Congress, which is irredeemable) would not take advantage of their power.  Spinney notes that, somewhat surprisingly, in the Spanish Flu most people did not just “shelter in place,” which would have maximized their chances.  Instead, they tended to try hard to help each other.  As I say, you see this same pattern in most disasters—average people tend to view others as more, rather than less, deserving of help, even at personal risk.  Selfishness decreases, when you think it would increase.  Spinney calls this “collective resilience,” and I have no doubt it’s the reality, even in today’s more atomized society where intermediary institutions that were the primary administrative mechanisms of such have disappeared.  I just don’t think that in practice it applies to the federal government, whose workers are taught to feel themselves superior and who show themselves incompetent in most disasters—see, e.g., Hurricane Katrina (though there the local government was even worse).  But, in fairness, maybe I’m wrong and in practice the government would be a help, rather than a selfish hindrance, in a fresh pandemic.  Let’s hope we don’t find out.

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