Spanish Flu, and what it teaches us about social distancing

First of all, hi there to all my readers! I’m sorry I haven’t written anything in a while. Things have been intense with the day job – any teachers reading this will know that working from home and delivering remote learning is actually a lot more labour intensive than face-to-face teaching. Like so many other people, I’ve also been finding social distancing tough. I’ve been asked how I cope with it, and the simple answer is, because I know that I have to. In this article I will be looking at the 1918-19 Spanish Influenza pandemic, and explaining the lessons we can learn from it about social distancing.

It’s inevitable that parallels will be drawn between the situation now, and the Spanish Flu pandemic. This time 100 years ago, the world was reeling from a devastating global pandemic that had killed more people than the preceding four years of war.

It has been suggested that Chinese labourers brought the disease to Europe

The origins of Spanish flu have been hotly debated. There is speculation that the virus originated in China, and was brought to Europe by Chinese labourers working for the British and French armies – a theory that has been seized upon by conspiracy theorists looking for evidence of sinister Chinese involvement in the current pandemic.

Those studying Spanish flu, particularly epidemiologists, have a wealth of data to work with. It was the first global pandemic to occur in an age where there was good record keeping in both military and civillian hospitals.

The initial outbreak was probably Fort Riley in Kansas

Detailed studies of records kept by the US Army have actually narrowed down the origin of the disease to the state of Kansas, and the US Army training camp at Fort Riley. The evidence strongly supports the theory that the disease jumped directly from birds into humans, with ‘patient zero’ being a farm worker from a poultry farm who caught the disease just before enlisting in the US Army.

Wartime conditions were almost ideal for spreading the virus. After the first cases were reported, the illness spread rapidly through Fort Riley; movement of troops ensured that it spread rapidly to other camps and into the civilian population. Troops with the illness were sent overseas to fight, meaning that the disease very quickly spread to England and to continental Europe. It is ironic that the entry of the USA into the war, which was instrumental in bringing it to an end, also ensured that the Spanish flu outbreak became a pandemic.

Nurses in a military hospital treating a patient with Spanish Flu

I won’t dwell here on the disease itself and its effects. If you want to know more, I thoroughly recommend Lyn McDonald’s book ‘The Roses of No Man’s Land’ which contains harrowing first-hand accounts from doctors, nurses and others, of the effects of the illness in crowded military hospitals, camps and troopships.

Spanish flu spread rapidly on troopships such as the RMS Olympic (sister ship to the Titanic)

What I find interesting, and highly relevant, about the Spanish flu pandemic, are the lessons we can learn about social distancing. Wartime conditions meant that social distancing simply wasn’t possible – in fact, the opposite was the case with people crammed together in hospitals, training camps, troopships and, of course, the trenches themselves.

King Alfonso XIII of Spain became seriously ill but survived

Another, more pernicious factor that contributed to the spread of the disease was lack of public information. Basically, the public were not told about the illness for fear that it would damage morale in the critical final months of the First World War. People who could have practiced social distancing didn’t, for the simple reason that they did not realise there was any need to. The pandemic got its name because in neutral Spain, there were no restrictions on the press; they were even free to report when King Alfonso XIII became seriously ill. This led to a misconception that Spain was particularly hard hit.

Not only was social distancing not practised, the British government actually discouraged authorities from putting measures in place to limit the spread of the infection. Medical officers in large cities were discouraged from closing schools, churches, cinemas, theatres, dance-halls etc.; again, out of fears that this would damage morale.

Dr James Niven, medical officer for Manchester during the pandemic

One man who went against this was Dr James Niven, medical officer for Manchester. Against direct advice from the government, he closed schools and entertainment venues, and distributed posters and leaflets giving information about the illness and advice on how to protect against infection (mainly, ‘wash your hands’ – sound familiar?). Niven insisted on quarantine for those who were sick, gave regular interviews to the Manchester Guardian to keep the public informed, and took measures to deal with delays in funerals.

As a result, the rate of infection in Manchester was lower than in other large cities with similar population densities. The death rate among those infected was also lower, because medical services were now overwhelmed as they were elsewhere. High tech devices such as ventilators were not available in those days, but high quality medical care, particularly intensive nursing, could make all the difference between surviving or dying from the illness.

One of Niven’s posters informing the people of Manchester about the Spanish Flu

I’ve no doubt that during the Spanish flu pandemic, there were those living in Manchester who resented the restrictions. Why were their cinemas closed when those in other cities remained open? No doubt, too, there were those who regarded Niven’s information campaign as exaggerated or scare-mongering. I also am in no doubt that if I went back in time to 1918 and had to live in a large city in the UK, I would choose Manchester with its social distancing.

In my next post I will be discussing the differences between oxygen therapy, continuous positive air pressure (CPAP) and ventilation; and the role they all have to play in helping people survive COVID-19. Stay well and safe, everyone.

Social distancing: Why it’s important, and why we find it so difficult

Social distancing has been in the news a lot in the last few days here in the UK, mainly because we Brits seem to be very bad at it! Friends in countries that are locked-down, like France and Spain, are telling me how shocked and horrified they are by scenes this weekend of crowds flocking to parks, beaches and beauty spots. The UK government is threatening lock-down unless we start to take things seriously. In this post, I will discuss why social distancing is important, and some possible reasons why we are finding it so difficult.

Exponential growth curve for hypothetical ‘Virus X’.

Why do we need social isolation? Let’s think about how disease spreads. A person gets infected with a disease, we’ll call it Virus X. That first person to be infected is called Patient Zero. On the first day, Patient Zero infects two other people. On the second day, they each infect two more, and so on. After a week, we have 256 patients.

If each patient infects 5 people a day, then after one week there will be 78125 people with the disease. If each infected person passes the virus on to 10 people, then after a week there will be 1 million with the disease. You get the picture. This process is called exponential growth and is shown on the right. If the shape of that curve is familiar, it’s because you have probably seen it on graphs showing the number of cases of COVID-19 in the UK, like the one below.

Cases of COVID-19 in the UK. In blue, you can see a classic exponential growth curve.
Comparing the spread of ‘Virus X’ with and without social distancing.

How does social distancing help? Basically, unless an infected person is in close contact with someone else, they can’t spread the virus. Exponential growth will still occur, because there will always be some in the population who cannot practice social distancing, i.e. key workers. But the rate of exponential growth will be much slower. This is known as ‘flattening the curve’ and is shown on the left.

An additional consideration is that although discoveries about COVID-19 are being made at an unprecedented rate, there is still a lot that we don’t understand. When you get an infection, it will be several days before you start to show symptoms; this is called the incubation period and varies between different pathogens. When the level of the pathogen in your body drops below a certain level, your symptoms will go away; but you are not yet fully clear of the infection.

A few people have asked me why this pandemic is so different from the 2009 Swine Flu pandemic. With Swine Flu, we were dealing with a new strain of a very well understood virus. In particular, it is known that influenza viruses can only be passed on to other people by patients who are symptomatic. During the incubation and recovery periods, patients cannot pass the virus on except under exceptional circumstances. This meant that only those who were actually ill needed to be isolated. In addition, it is known that patients who recover from influenza viruses will then be immune to the disease.

With COVID-19, the incubation period is up to 14 days, and we still don’t know at what point patients become infections. We also don’t know how long it takes for recovered patients to cease to be infectious, and whether people who have recovered have immunity. We need to know whether immunity develops; how strong it is; and how long it lasts.

Look at the two diagrams below, showing the spread of the hypothetical Virus X through a population. On the left is the situation on Day 1, on the right is the situation after one week. The top diagram shows a population that is not practising social distancing, the bottom diagram shows a population that is. Speaks for itself, doesn’t it?

So, why is social distancing so difficult? Especially for us Brits, who historically have a reputation for doing as we are told. One reason is that we are having to break habits that have become ingrained over many years. Take this scenario: you are in a queue at the supermarket. The person in front of you moves forward, what do you do? You move forward too, to close the gap. This is not neccessarily deliberate, it’s a habit, and changing habits requires conscious thought. The good news is that it doesn’t take long for new habits to develop. I went shopping today (because I needed to, I hasten to add), and everyone was keeping their distance in the queue without needing to be reminded.

Another reason is people are used to freedom of movement. It’s a sunny spring weekend, the kids have been stuck in the car, let’s go to the beach because social distancing means no one else will be there. Unfortunately, hundreds of other people have had the same idea, and when you get there, it’s heaving. Do you have the strength of mind to turn the car round and tell the kids we aren’t going to the beach after all?

Recent panic buying is not helping either. Those of us who have continued to shop sensibly and responsibly have found that due to panic buying, we have had to visit multiple shops to get the basics. I’m trying to practise sensible social distancing due to my asthma, but it’s difficult when you have to visit 3 different shops to find toothpaste! Thankfully things seem to be settling down a bit. This morning I went to a local supermarket and was able to pretty much get my normal weekly shop, much to my relief!

Possibly the biggest barrier to social distancing, though, is the fact that we are primates, and by and large, primates are social animals. Our brains are not wired for isolation and I know I am not alone in worrying about how this will affect my mental health. However, there is a lot we can do to combat this.

The good news is that we live in an age where technology has made it easier than ever to keep in contact with friends and loved ones. So take advantage of Facebook, Zoom, WhatsApp, Skype and everything else that’s out there. Reconnect with people you’ve lost touch with. Share memories of good times! And keep remembering, social distancing isn’t forever; and the better we are at it, the less time it’s likely to last.

In the next couple of days I will be posting some ideas about simple experiments you can do at home to engage children with science while they aren’t at school, so watch this space! As always, if you have specific questions or concerns you’d like me to address, let me know. Stay safe and well, everyone.