Books About the History of Flu Epidemics

I attended a book discussion meeting last night about John Barry's The Great Influenza: The Epic Story of the Deadliest Plague in History. During the discussion, the following books were also recommended.

Flu: The Story Of The Great Influenza Pandemic by Gina Kolata
America's Forgotten Pandemic: The Influenza of 1918 by Alfred W. Crosby
The Devil's Flu : The World's Deadliest Influenza Epidemic and the Scientific Hunt for the Virus That Caused It by Pete Davies
The Monster at Our Door: The Global Threat of Avian Flu by Mike Davis

I have previously recommended The Swine Flu Affair: Decision-making on a Slippery Disease by Richard E. Neustadt and Harvey V. Fineberg.

I guess the theme of this posting is that history is sometimes a guide for future action, and the history of the flu is heavily documented. I would note that there is a "fallacy of availability" in decision making. We should not plan for the future assuming that the most easily recalled event is the most probable event to be repeated in the future. The 1918 flu pandemic was the worst in recorded history, and is not likely to be repeated. While many experts agree that a flu pandemic will occur in the future, and indeed within a time frame more likely to be counted in years than in decades, that pandemic may be more like the lesser flu pandemics of the last three centuries.

Developed nations are likely to take effective steps to limit the effects of a pandemic on their citizens. Medical care has advanced enormously since 1918, and the lethality of flu is likely to be greatly reduced for those who can benefit from modern medicine. Unfortunately, most of the world's people are not so lucky, and if a pandemic rages in the poor countries of Asia, Africa, and Latin America, modern transportation systems will probably assure that it reaches the richer nations of the world as well.

Of course, preparation for a pandemic is appropriate. Even one chance in a hundred of a catastrophe killing tens of millions of people demands serious public health efforts. The question is how much preparation, and how urgently. As I have pointed out before, many prudent measures are essentially without cost -- their benefits even in the absence of a pandemic exceed their costs. Such measures would include improving epidemiological surveillance systems, development of improved vaccine production technology, improved vaccines for avian flu, creating stocks of vaccines (when they are available) and antiviral drugs, improving poultry raising techniques to help farmers avoid danger to their flocks, and seeking to assure that medical care facilities are adequate to meet emergency needs.

Perhaps some of the simplest approaches are among the most important. Thus I would stress public education about hand washing, the need to avoid contact with (and eating) sick animals, and the importance of reducing contacts of and with people with the flu.

It has been estimated that 17 million people die a year because they are too poor to live. They, there families and their countries can't come up with the resources for even simple, life-saving treatments. Some 9,000 people die each day of AIDS, while only a small fraction of AIDS patients receive antiviral medication. The world has to balance spending money on a possible flu pandemic against spending to save lives that otherwise would surely be lost to diarrhea, other respiratory infections, or malaria. Indeed, it costs so little to save a life from these diseases of poverty that investments in flu preparedness would have to be very cost-effective to be economically justified.

Recall that two of the three pandemics that actually did occur in the 20th century were an order of magnitude less lethal than the Spanish flu. Reducing a death toll to a half million people, as compared with the one million who might otherwise die sounds very important and useful, until one realizes that the US$7.1 billion flu initiative announced by the White House could save millions of lives if applied effectively to the diseases of poverty.

For example, the Copenhagen consensus last year reported:

Combating HIV/AIDS should be at the top of the world's priority list. That is the recommendation from the Copenhagen Consensus 2004 expert panel of world-leading economists. About 28 million cases could be prevented by 2010. The cost would be $27 billion, with benefits almost forty times as high.

Prorating, Bush's flu initiative, if used against AIDS in developing nations, could avert seven million cases (1/4th of the full initiative), and thus seven million deaths, most of people in the prime of life.

I suppose, however, that this prescription is pretty bloodless. Perhaps one should read not only the formal histories, but fiction that conveys the human dimension of the tragedy of the 1918 flu might help. Great writers have produced such fiction. Katherine Anne Porter's novela, Pale Horse, Pale Rider, describes her own experience with the 1918 flu. So too, Thomas Wolfe's Look Homeward Angel contains a chapter based on the death of Wolfe's brother from the flu in 1918.