Parallels Between Pandemics: Plague, “Spanish” flu and COVID-19
It is interesting to look at how pandemics behave and how we behave in pandemics.
“At the root of every pandemic is an encounter between a disease-causing microorganism and a human being”, emphasises Laura Spinney in her book, “Pale Rider: The Spanish Flu of 1918 and how it changed the world” , adding that pandemics are “shaped by numerous other events taking place at the same time - the weather, the price of bread, ideas about germs, white men and jinns.” A pandemic is as much a social phenomenon as it is a biological one. It cannot be separated from its historical, geographic, economic and socio-cultural context. History offers a mirror that helps discern patterns in biological behaviour, societal priorities and responses to these outbreaks.
Pandemics and epidemics became part of the human condition after the domestication of animals, agriculture and urbanisation. Humans living in close proximity to animals allowed disease causing organisms to proliferate, evolve and jump from one species to another. Among pandemics caused by such cross species jump of a virus or bacteria the two biggest killer pandemics were plague and the “Spanish” flu (a misnomer as it did not originate in Spain). It is interesting to look at how pandemics behave and how we behave in pandemics , especially when looking at the two biggest killer pandemics and the latest one COVID-19.
Pandemics and Ports of Entry
Plague, unlike the other two, is caused by a bacteria (Yersinia pestis) transmitted from rats to humans by the rat flea. The classic bubonic plague is a severe disease, characteristically producing enlarged lymph nodes (“buboes”) and leading to extreme suffering, prostration and death. In the absence of antibiotics 50-80% of those who contracted this infection died from it. Compare that to a case fatality rate of 3-8% for the Spanish flu and an estimated 1% for COVID-19.
There were multiple waves of plague pandemic from the 6th century, to the Black Death between the 14th and 17th century and the modern plague pandemic, between the 1870’s and the early years of the 20th century. The Black Death and the modern plague pandemic probably are most relevant to the Indian context. Along with bubonic plague was a variant, the pneumonic plague, transmitted through respiratory secretions between humans, that had predominantly respiratory symptoms like severe pneumonia and acute respiratory distress syndrome (ARDS) similar to the Spanish flu and COVID-19, though unlike the plague, Spanish Flu and COVID-19 are caused by viruses- the Influenza virus and the Novel-Coronavirus respectively.
Over centuries all pandemics have spread through paths for human trade, commerce and travel, with ports becoming primary points of entry.
The Black Death that killed 75-200 million people across Europe, Asia Minor and North Africa entered via ships carrying grain spices and textiles but also rats laden with flea carrying the plague bacteria. Later there was probably overland transmission too from the Silk route. In the 1870s too, the seaports of Bombay (Mumbai) and Calcutta (Kolkata) were the entry points for plague. These two cities, particularly Mumbai, suffered huge casualties, before the pandemic crept into the hinterland. The Spanish flu also entered India through Bombay in 1918, inadvertently carried by Indian soldiers returning from European battlefields in World War I. The COVID-19 pandemic too has entered India through ports - now airports.
Pandemics, Gender & Nutrition
Across the world millions died during the Spanish flu, particularly, a large percentage of young. This mortality among the young and predominantly men was attributed to a “cytokine storm”, which is an overreaction of our immune system to an infection. However, there was an interesting observation in both, the Spanish flu pandemic and the influenza epidemics. Significantly lower number of women died of these infections. This appears to be replicated in the current COVID-19 outbreak. Women’s mortality is anywhere between a third to a quarter of that of men.
However, in India, during Spanish flu many more women died than men. This has been attributed to the poorer nutritional status of women in India at the time and thus an inability to mount an adequate immune challenge. A balanced immune response, is of essence in any infection. Both an overreaction (“cytokine storm”) or an inadequate immune response can be dangerous. In India, women tended to eat only after the men and children had eaten and thus possibly got even less nutrition, and thus, couldn’t mount an adequate immune response. India’s deeply patriarchal society and its inherent gender biases may have inverted the usual mortality trends of the Spanish flu.
Malnourishment which compromises the body’s ability to mount adequate immune response is a well-known cause of higher mortality during pandemics. The Black Death in Europe was preceded a few years earlier by the Great Famine. The 1870s plague pandemic and the Spanish flu were preceded by famines in India. Of the many reasons for the poor and the marginalised suffering significantly worse outcomes in most pandemics, the most compelling one is poor nutrition. Hence, though pandemics cause deaths across social classes, the poor are hit the worst. In COVID-19 too, the cause of severe illness/death in the elderly is due to an inability to mount an adequate immune challenge and secondary bacterial infections on top of the viral. Would malnourished poor with compromised immunity stand a chance when the virus moves from the jet setting air travellers and relatively well-off sections to the lower socioeconomic strata?
Economics and Politics of COVID-19
In this context, we need to look at the consequences of the severe nationwide lockdown and economic downturn which has followed it. This could push 400 million more Indians into severe poverty, according to the ILO. As history tells us, an underfed people are sitting ducks for worse outcomes during pandemics. Is the treatment for COVID becoming worse than the disease?
Yet another reason why poor suffer more in pandemics is overcrowding. Tight urban spaces with over half a dozen people sharing one room cannot be conducive to physical distancing. People living in multi-bedroom houses may blame those not adhering to physical distancing but doing that ignores the lived realities of the vast multitude of people in India and across the world. When people in these spaces come out for a breather, the police beat them back into those crowded spaces. Similarly, during the Black Death, poor people suspected to have contracted the plague were forced inside their tight living or working spaces with others, the doors locked and marked. Very few escaped those chambers of death. Aren’t we doing the same to our people, albeit to a less severe degree in the 21st century?
Though separated by centuries, people’s response to these measures seem to remain similar.
During the Black Death in Europe and modern plague and Spanish flu in India, draconian laws and enforcement led people to flee urban spaces to their rural homes. We are seeing the same with this epidemic.
Millions are fleeing to their villages when forced to stay in crowded urban spaces, without the permission to step out, without adequate food and social security. Many of them, tragically, are not allowed back inside their villages out of fear, when they reach there, like in previous pandemics.
Bigotry and Pandemics
Stigmatisation, social ostracising and public shaming of those with or suspected of the disease has also been a common thread during all pandemics. This ends up being counter-productive, as those infected try to hide the fact and tend not to access healthcare facilities, leading to worse outcomes for the individual and further spread of the disease in society.
A related phenomenon is scapegoating.
When war-like rhetoric is used by governments to contain the pandemic, in the setting of irrational fear of an invisible and possibly incurable “enemy”, it leads to vigilantism and urge to find a “visible enemy”.
Jews during Black Death and German and Italian immigrants in the US during Spanish flu faced bigotry and scapegoating. Chinese, and Southeast Asians in the US faced this during the current pandemic. In India, it is being directed at a minority community and people from the north-east. To effectively contain and mitigate this epidemic, one should use rational thinking, accurate science, have compassion and earn people’s trust and not use militaristic posturing. In this regard, do we follow Kerala’s path, where perception of the state machinery being unbiased, led to all social and religious groups acceding to testing and quarantine if necessary, without any attacks on healthcare workers? Or, do we take the path of states where the biased character of the state machinery has evoked mistrust and violent reactions against healthcare workers?
How we deal with this bigotry against certain sections of our own people, will not only be a test of our character, but could determine our ability to stem the tide of the pandemic.
During the 1870s plague pandemic in India, the British colonial government brought in the draconian Epidemic Act in 1897 (which is the one we are still using), without taking the people into confidence. This involved mass sanitation, measures to stop social and religious gatherings, social distancing, invasion of private property to search for plague suspects etc. These measures may seem well-intentioned, but they reveal a sheer contempt for people and a naked paternalism, blissfully blind to the plight of people. As historian and author David Arnold (Colonising the Body: State Medicine and Epidemic Disease in Nineteenth-Century India) says, "Never before had the state in India intervened so directly and forcefully in the lives of the Indian people. This produced a massive backlash from Indians of all classes, who deeply resented the physical inspections and the invasion of their homes, including riots and attacks on Europeans and health workers."
When it came to the Spanish Flu, the British did little, except advice social distancing. They did nothing to improve the health infrastructure. They left people to their own means. Even the Mahatma and many of his colleagues were infected. He managed to recover, but millions didn’t. While the British government stood by, multiple voluntary and charitable groups set up dispensaries and hospitals, provided food and medicines, removed dead bodies and cremated/buried them. These organisations became the building blocks of the anti-colonial movement. Both David Arnold and Laura Spinney, believe that, these two epidemics strengthened the Indian freedom movement.
Past pandemics have lessons for us embedded in their stories. It is up to us to listen carefully, analyse past mistakes and adopt measures that could work to our advantage, without causing severe distress to large sections of society. The important question is, will we learn from the past or repeat the mistakes?
(Dr Sumit Ray is a Critical Care Specialist working in Delhi NCR and Dr Sandeep Kumar is Associate Professor, Department of Neurology at Harvard Medical School)
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