Could SARS Set off Another Great Pandemic?

We once assumed that infectious diseases such as influenza could be controlled. The availability of modern antibiotics persuaded many of us that any real threat from a flu microbe was as quaint as wind-up phonographs and rumble seats. In the 1960s the surgeon general's office declared that old-time infectious diseases had been conquered. Now humanity's microscopic enemies have appeared once more to challenge human hubris. Severe acute respiratory syndrome, SARS, has advanced out of southern China to menace Hong Kong, Toronto and, probably, the rest of the world. Again a disease explodes out of nowhere — a new flu that spreads easily, sickens people quickly and kills them sometimes. It also pays its call on a world that has no antidote.

Still, we live in modern times. Public health departments are well acquainted with microbial threats to public health. We have seen nearly a century of medical progress since the last great flu epidemic. That was in 1918. It was a different influenza in a different world. But two things about that epidemic 85 years ago seem similar to today's new threat to public health: the specter of a pandemic, and the complacent American response.

The so-called "Spanish" flu epidemic of 1918, like SARS, probably originated in China. From World War I troops it spread throughout the world. When it appeared in the spring of 1918, U. S. public health authorities were not unduly concerned. This flu, after all, seemed fairly benign. People would usually recover, as they do today, unless they were at the extremes of life — very young or very old. SARS, as some observers have noted, is also somewhat benign. People usually recover, as they do from more familiar strains of flu.

As the Spanish flu spread along the East Coast in the summer of 1918, city leaders responded mildly. In Philadelphia people were told they had nothing to fear. It was only the flu and by August it seemed to be subsiding. But the greatest menace then, as always, was mutation.

As science fiction buffs know, in the popular Star Trek series space heroes battle the galaxy's most fearsome foe: the Borg. That half-human civilization has the capability of learning from its enemies' resistance and changing, or mutating, to a more lethal force. In fall 1918, the Spanish flu became the Borg.

In fact, the microbe mutated to cause the deadliest pandemic in human history. Before it subsided in 1919, it had killed 20 million people around the world, more than the number who died in World War I battles. In the United States it killed 550,000.

Philadelphia became famous because it suffered more than any other U.S. city: 13,374 flu deaths. What was really shocking were the persons who contracted this deadly strain: young healthy adults aged 20 to 29. And its speed! A person would feel perfectly fine one day, have a little cough the next. Two days later the victim would be dead.

Then, as now, people hoped that advances in medical research could cope with this lethal mutation. After all, by the twentieth century doctors had made good progress against history's greatest killers: smallpox, typhoid, tetanus, malaria. Then, as now, people expected a cure would soon be found. Health researchers worked desperately to isolate the virus, and formulate a vaccine. In 1918 they failed. Their suggested treatment: wait and hope.

Health care researchers today may rely on a vast store of knowledge unknown to doctors then. But they haven't come up with an antidote to SARS. A vaccine may yet be formulated, but will it be formulated in time? In the fall of 1918, more than 21,000 Americans were dying each week. The virus that caused the Spanish flu was eventually isolated — in 1933, the pandemic long gone.

In 1918, doctors could only recommend what they recommend today — that we wear masks and avoid gatherings where the microbe can be easily spread. In some cities in 1918, anyone leaving the house had to wear a mask, either a cotton one (which proved to be useless) or a full-sized gas mask (which proved to be ridiculous).

Any kind of public assembly was banned. Movies were canceled. Schools were closed. Public health officers in the East who had underestimated the flu's speed warned their counterparts in the West to control the spread not by vaccine but by preparation: "Hunt up your wood-workers and cabinet-makers and set them to making coffins," one warned in the 1918 American Journal of Health. "Then take your street laborers and set them to digging graves. If you do this you will not have your dead accumulate faster than you can dispose of them."

Much has changed today. Yet as Dr. Alfred Sommer, dean of the Johns Hopkins Bloomberg School of Public Health, has warned, "The microbial world will always remain a significant health threat, given its capacity to continue to mutate new, dangerous strains infecting man."

Indeed, the Spanish Flu epidemic might serve to warn us of this truth. Oddly, however, most people nowadays have barely heard of it. Why should we have forgotten the modern equivalent of the medieval Black Death? Perhaps because it killed mostly the young: no famous general, no celebrity entertainer, powerful politician. Perhaps AIDS blew us out of the kind of complacency common to earlier generations. But the flu is not AIDS. What the 1918 pandemic reminds us is that the flu could kill even more efficiently. Let's hope complacency doesn't give SARS the chance to become another "great one."

Ross Collins is an associate professor in the Department of Communication, North Dakota State University, and a writer for the History News Service.