1918 Influenza Pandemic: Lessons for Homeland Security

BY PATRICK S. MAHONEY

A casual review of literature and training materials on homeland security reveals a curious historical trend: The discipline’s timeline seems to go blank before 1993. That was the year an al Qaeda-related group of conspirators detonated a truck bomb in the subterranean parking garage under the World Trade Center. The bombing, by the planners’ reckoning, was unsuccessful but proved to be a watershed in American security and emergency response circles. Serious mass terrorism had finally landed on American soil. Lessons from that bombing and the Oklahoma City blast two years later provided the foundations of the American homeland security paradigm, in which we all partake.

The sarin attacks on the Tokyo subway system, the 9/11 (2001) attacks on the World Trade Center and the Pentagon, the anthrax mailings of 2001, and the uneasiness over bird flu have all been added to the regular rotation of topics in the homeland security field.

Each of these incidents and trends can teach us much about how we should plan to respond to conventional, biological, chemical, and unprecedented threats. Still, 15 years isn’t much history on which to found an entire professional discipline. The fire service and homeland security planners in general should look back before 1993 to find relevant events that provided lessons that can be useful today. The whole Civil Defense establishment of the Cold War, for example, bears some striking and seldom-discussed similarities to the contemporary homeland security regime.

It is easy to dismiss out of hand pre-9/11 lessons. After all, 9/11 did change everything in some ways. In other ways, society is little different from the way it was September 10, 2001, or February 26, 1993. People still interact more or less the same way, and the response bureaucracy still functions more or less adequately. Then, as now, the fire service was on the front lines. Likewise, the most calamitous public safety and health event in world history has many valuable lessons.

THE 1918-1919 INFLUENZA PANDEMIC

In the winter of 1918 and the spring of 1919, a pandemic swept the world, killing more people in 24 weeks than AIDS has killed in 24 years.1 In the United States, entire cities shut down: Philadelphia was so overwhelmed with corpses that they couldn’t be buried fast enough, and in Boston various hospitals reached their breaking points as doctors and nurses themselves fell ill and the whole city transitioned to one giant mass-casualty incident. Very little was written in the press at that time because of ongoing censorship related to World War I, but the so-called Spanish Influenza absolutely crippled the domestic life of this country. The public health and scientific medicine disciplines were fairly well developed in that eminently modern world. Lessons from the management of the pandemic are indispensable for today’s planners but are absolutely invisible in the fire service. Given the current threats posed by biological weapons, we should seek all the knowledge we can about how to handle an infectious disease epidemic. The 1918-1919 pandemic offers some extremely pertinent lessons.

THE THREAT

The World Health Organization (WHO) and the Centers for Disease Control and Prevention maintain close watch on influenza outbreaks around the world, and it is commonly acknowledged that another pandemic is inevitable. Of particular concern is the much-ballyhooed “bird flu,” properly known as Avian Influenza, a term commonly referring to the influenza type H5N1. Strains circulating in Asia are considered to be highly pathogenic Avian Influenza and have more than a 60-percent case mortality rate for humans. Fortunately for the world, the H5N1 virus has not become transmissible from person to person but remains endemic among birds.

However, influenza is a wily and dynamic virus capable of mutating extremely rapidly. The few human cases of H5N1 (mostly acquired through close contact with infected poultry) paint a disturbing picture. Of 381 infections between 2003 and April 2008, more than 62 percent of those infected died. In 2003, the first four human cases of H5N1 arose; the number of cases grew to 46, 98, and 115 cases, respectively, in the next three years. The year 2007 was a relatively mild year for bird flu, with 85 infections, according to the WHO. Should the virus mutate and become contagious from person to person, an incredible pandemic could sweep a world exponentially more globalized than that of 1918. A human-transmissible strain of the flu could wreak havoc on the world’s healthcare systems, economy, and social and government services. The 1918-1919 pandemic killed upward of 100 million people around the world.2 The death toll was undoubtedly exacerbated by World War I and the lack of suitable antibiotics.

LESSONS FOR THE 21st CENTURY

Following are some of the lessons that can be learned from the 1918-1919 pandemic.

1 Do not assume a pandemic will hit the elderly, the very young, and the infirm the hardest. The U-shaped graph that shows influenza infection rates higher at the extremes of ages was not present in the Spanish Influenza pandemic. For a variety of reasons, the graph was shaped more like a “W,” with a peak in the prime of life.3 People in their 20s and 30s bore the brunt of the disease, and services dominated by the vigorous and the young—healthcare, the military, the police, sanitation services, the Red Cross—were consequently hard hit.

Such an odd distribution of cases across the age spectrum could leave the fire service decimated. The United States Fire Administration estimates that 49.8 percent of the nation’s firefighters fall in the 20-to-39 age bracket, which was so hard hit in 1918-1919.4 Any epidemic or pandemic unduly affecting this age bracket may paralyze the fire and EMS services, which will be heavily stressed by an increase in calls for service. Beyond actual incidences of infection, there is the problem of public safety personnel skipping work to take care of family or simply out of fear. Some studies show that up to 40 percent of healthcare workers can be expected to engage in “intentional absenteeism” in a flu pandemic.5

2 Public health and welfare officials in 1918-1919 found that the extreme and incapacitating sickness afflicting those of child-rearing age left many children and sick people of all ages with no caretakers. Stories abound of Red Cross and other aid workers finding whole families lying starving in their beds with bodies strewn about. In contrast to the World War I era, where what we today call Non-Governmental Organizations (NGOs) provided most relief, our society today relies on government aid in relief of disasters. The modern all-hazards fire service will be the first in line to respond to torrents of difficulty breathing and person-down calls. Departments strained by personnel shortages of their own will have to find ways to cope with soaring run totals, some calls more real than others.

Anecdotal experience with the anthrax scare of 2001 suggests that any infectious outbreak receiving significant media coverage will be closely followed by a wave of mass hysteria and related false calls for service. Most of us can recall the absurd white powder calls of the fall of 2001; a significant epidemic of infectious disease will bring the hypochondriacs out in droves. Fire service leaders need to analyze their staffing needs now and make contingency plans for skeletal staffing and significant numbers of service calls, some including patients with no one to care for them. Consultation with local medical control over possible rationing of care should be conducted before a pandemic strikes, and the decisions should be implemented in advance.

3 The 24-hour news cycle devours information. When no new information is available, the talking heads repeat the old information ad infinitum and consult “experts” who reiterate the need to be scared. Information management is crucial in this climate, as the hysteria over anthrax demonstrated. Public information officers must be cautious with their terminology, walking the fine line between dishonesty and alarmism, choosing words carefully but not lying to the public.

In 1918-1919, the wartime press faced severe legal and back-channel pressure from the government to print only good news. Newspapers printed, day after day, stories claiming that the tide had turned and the pandemic was in decline, even as it was spiraling out of control. It did not take long for the public to lose all faith in the information distributed by local health authorities and the media. Public health and emergency officials must maintain trust with the public if cooperation in public hygiene measures is to be expected. Once lost, trust cannot be regained, and appeals for public cooperation will fall on deaf ears.

Dishonesty and public relations placebos differ only by shades, but the latter can certainly be useful. In 1918-1919, San Francisco braced itself for the pandemic by distributing gauze masks to the population. The medical community knew the masks were all but useless in the prevention of infection, but they made the public feel better and produced a sense of calm. (3, 110) The government has a long history of specious claims that calm the public in the face of insuperable hazards, from duck-and-cover in the early years of the Cold War to duct-taping windows in the wake of 9/11. Those of us in the response community may regard these recommendations as absurd, feel-good campaigns, but that does not change the fact that they serve a legitimate purpose. People need to feel that they have some semblance of control; giving them that sense of control is a worthy objective. Balancing this need with the need to maintain the public trust is the supreme challenge of our spokespeople.

Public relations representatives may also face challenges posed by the spread of irrational fear. E-mail whispering campaigns and apocryphal Web sites routinely spread misinformation taken as fact by large segments of the public (the 9/11 “Truth” community is a case in point). In 1918-1919, there were plenty of wild rumors floating around, some more pernicious than others. Least helpful was the manifestation of wartime fear of the Germans that had many convinced that Bayer aspirin was responsible for the spread of the influenza. As basic and as helpful to the sick as aspirin was, baseless fear kept many from using the drug. Officials must be prepared to challenge and discredit unhelpful and unwarranted fears.

In an infectious outbreak, dense populations and the poor, who often forgo prophylactic medical care, will be especially hard hit. In a great many of the communities in this country, the poorest and mostly densely packed neighborhoods have significant numbers of immigrants, many of whom distrust the government. In the 1918-1919 pandemic, many immigrants died for fear of local authorities who were only trying to help them. (3, 68)

Regardless of immigration status and the complexities of today’s political climate surrounding immigrant populations, fire and EMS providers need to cultivate and strengthen relationships with these communities. Many fire departments have refused to cooperate with law enforcement actions for the sole reason that the community’s trust in the fire department is priceless; similarly, immigrants should trust the fire department whether they are here illegally or not. As is the case with honesty in general, public trust is essential to public cooperation. Immigrants must believe they can turn to the fire service for help and trust the fire, EMS, and public health authorities who recommend safe behaviors and preventive measures.

4 Do not lull in the eye of the storm. Pandemics can wash over a population in waves, with gaps as long as several months in between. There were three waves in the World War I pandemic, and the trough between them offered valuable recuperation and preparation time, although too few communities availed themselves of this luxury.

Should we be faced with an influenza or other infectious pandemic, we must act quickly as soon as time and logistics allow us to restock and recoup our strength. Medical supplies, personal protective equipment, prophylaxis, and emergency supplies are essential for the fire service to maintain a working presence in the face of a pandemic. We need to stock our stations with food and the bare essentials. A pandemic can reach the point at which local governments collapse; the fire service simply cannot allow itself to collapse. To whom would a community turn for fire, rescue, and emergency medical services?

A corollary to this concern is the collapse of the Just In Time (JIT) inventory system. Many businesses today forgo significant inventory stocks, seeing materials sitting idly on shelves as money tied up and not moving. JIT is a concept whereby supplies are delivered only when needed, leaving producers subject to demand shocks. Any stutter in the supply chain can reverberate down the line.6 The real-world consequences for the public and the fire service come from the shortages of consumer goods. Supply chains are vulnerable to high levels of lost time because of sickness, something endemic to a pandemic. Just as with hurricane and blizzard preparedness, local fire and EMS departments should take precautions to ensure that operations can continue after grocery store and pharmacy shelves are empty and more specialized suppliers have nothing to offer. A buffer stock of food and other items essential to operations should be kept on hand; such preparations would prove useful if any natural or intentional disaster were to occur and would have benefits well beyond any possible pandemic.

• • •

The threat posed by a pandemic is real, and the likelihood of a pandemic in the near future is high. The fire service must take steps now to prepare, lest the country fall into the same misfortune of 1918-1919. Pandemic preparedness should not be undertaken in a vacuum but must take its cues from established procedures and norms. We should not reinvent the wheel. We should not forget the lessons of the past and should always bear in mind that many of the things we call “homeland security” threats today have been around in one form or another for a long time. Preparing for an influenza pandemic has the beneficial side effect of preparing for a biological warfare or terrorist event. An infectious pandemic by any other pathogen poses many of the same challenges and can be addressed in much the same way. Fire and EMS planners would truly be remiss to neglect preparations for an event that is so likely and so dangerous.

References

1. World Health Organization, http://www.who.int/csr/disease/
avian_influenza/country/cases_table_2008_01_03/en/index.html/.

2. Barry, JM. The Great Influenza. (New York: Penguin), 2004.

3. Crosby, AW. America’s Forgotten Pandemic. (New York: Cambridge University Press), 2003, 24.

4. U.S. Fire Administration, http://www.usfa.dhs.gov/statistics/firefighters/index.shtm/.

5. “Hospital staffing and surge capacity during a disaster event,” Association of Public Hospitals and Health Systems. May 2007. Retrieved February 11, 2008, from http://www.calhealth.org/public/press/Article%5C112%5C6.28.07%20May2007_Research_Brief%20(2), 3.

6. Savaglio, Fred and Bob Freitag, “Just-in-time inventory: Effects on earthquake recovery.” Cascadia Region Earthquake Workgroup. 2005. Accessed March 6, 2008 from http://www.crew.org/papers/JITfinal032405.pdf/.

PATRICK S. MAHONEY has been in the fire service since 1998 and is an engineer/operator and hazmat team member with the Baytown (TX) Fire Department. He has been a volunteer captain and training officer. He has a bachelor’s degree in political science from the University of Houston and is pursuing a master’s degree in homeland security from Texas A&M University. He has certifications from the Texas Commission on Fire Protection for intermediate firefighter, driver/operator-pumper, and hazardous materials technician.

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