November 6, 2018

In France, where I live, there are more than 170,000 monuments to the First World War. To my knowledge, there is only one to the 1918 influenza pandemic. A simple stone cross, it stands at Lajoux in the Jura Mountains, close to the border with Switzerland.

This relative neglect of the 1918 pandemic is almost understandable in France, which lost approximately six times as many citizens to the war as it did to the flu. But that neglect is repeated in almost every country in the world, and globally it is much harder to explain. The pandemic is estimated to have killed between 50 and 100 million people worldwide, compared to around 18 million for the war. Why, then, do we commemorate the war but not the flu? Is a death from disease less important than a death by combat, and if so, shouldn’t that trouble us?

I think it should, and not for purely moral or philosophical reasons. The threat of pandemic is no historical artefact; in fact, another flu pandemic is almost inevitable. The World Bank estimates that if a strain of the influenza virus as dangerous as the one that triggered the 1918 pandemic were to emerge in future, it could kill 33 million people in the first six months of the ensuing pandemic, and trigger a major recession. Yet governments are not making the relatively small investments that would render healthcare systems resilient to such a disaster, and vaccine hesitancy is on the rise in many parts of the world.

In the event of a pandemic, a vaccine against the novel strain of the virus would be our best chance of slowing its spread and of preventing those healthcare systems from being overwhelmed, so that they can continue to effectively process the sick. But uptake rates for the seasonal flu vaccine – the best proxy for how willingly people would vaccinate themselves against a novel strain – are falling off in the long term as young adults lose confidence in the vaccine’s safety and importance. With an absence of memorials to past pandemics in general, and to the 1918 episode – possibly the worst in human history – in particular, it seems that we have forgotten their horror.

One reason for this collective lapse in memory may be that, until very recently, we did not understand the true scale of the pandemic. The first estimate of the death toll of the 1918 pandemic was published in the 1920s, and put it at around 22 million – placing it in the same ballpark as the First World War for loss of life. In 1991, that figure was revised upward to 30 million, and seven years later to 50-100 million, indicating that it was between three and six times as deadly as the war.

These revisions attest to the difficulty of diagnosing flu at a time when viruses were a relatively new concept. Most doctors thought they were dealing with a bacterial disease, and so in the historical records, many cases of what modern observers might reasonably suspect to have been flu, go by labels as diverse as cholera, typhus and pneumonic plague. By contrast, war dead were relatively easy to count – they wore uniforms, displayed exit wounds, and fell down in a circumscribed arena.

Memory is an active process, and unless we keep recounting them, events fade from it. After a war, at least one side generally has an incentive to mull over what happened; not so after a pandemic, where nobody wins. The communities traumatised by the 1918 flu wanted to forget it as quickly as possible, as did the scientists and doctors who had failed them.

Things change, though. New generations are born, and, unshackled from the trauma, seek to reconstruct the past. A hundred years after the 1918 pandemic, historians and scientists have a better idea of its scale, structure and impact. Though many questions remain unanswered, they understand the nature of flu pandemics sufficiently to know that there will be another, and though it might not be as bad, it could also be worse.

But expert knowledge is only half the battle. Ordinary people need to understand it too, so that they comply with the public health measures that will be proposed in the event. A pandemic is a potential tragedy of the commons, a game theory problem, because interventions such as vaccination work best when everyone complies.

On top of that, an important lesson from 1918 and subsequent pandemics was that forcing people to comply, through threat of punishment, is often counter-productive. In places where public meetings were banned, for example, often gatherings simply moved ‘underground’. Public health campaigns are most effective when people comply of their own free will, but that presupposes that they understand the danger, and trust the authorities to act in their best interests.

Such trust does not come cheap, and depends on memories of what went before. When it comes to understanding the danger, it helps if, while navigating through the world in their daily routine, people encounter reminders of similar disasters in the past. Durable physical monuments to the 1918 flu are lacking, as are more ephemeral ones. Notoriously, and with very few exceptions, artists who lived through it ignored it in their work. But I think the situation is changing.

Now that the pandemic’s contours are becoming more precisely delineated, now that the vocabulary exists to describe it, novels are being written about it, dance pieces are commemorating it, and TV dramas such as Downton Abbey are folding it into their storylines.

The ephemeral monuments, at least, are proliferating, and the 1918 flu is entering popular culture. Soon it will become unavoidable – just as the Black Death of the 14th century, another pandemic that overlapped with a war, the Hundred Years’ War, did. Then, perhaps, people will remember the horror. And then they will take it seriously, and prepare themselves for the next one.

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