Two pandemics: Ghosts of the 1918 outbreak

Recently I’ve been reading a book (published in 2004) by Betty O’Keefe and Ian McDonald titled, Dr Fred and the Spanish Lady. The work examines the experience of Dr. Fred Underhill, who was the senior public health officer in Vancouver during the 1918 pandemic. While there had been a host of influenza pandemics through history, the 1918 pandemic killed perhaps 100 million people globally.

What struck me while reading the work was the manifold similarities between our experience of COVID-19 and that of almost exactly a century before. During our current pandemic some countries, such as Australia, New Zealand and Taiwan, acted quickly to enact travel restrictions. But that was the exception rather than the norm. Similarly, in 1918 troop ships brought influenza to Canada, even though during the crossings the ships would have to repeatedly stop for the burial of sea for returning soldiers (O-Keefe and MacDonald, 30-31). In 1918, travel restrictions were not implemented because everyone in Canada wanted to bring the troops home. While understandable, this was also tragic. During COVID-19 there were no effective limits on returning citizens in the United States, likely because there just was not enough public support for this measure. Of course, there were limits on non-citizens’ travel. But since the SARS-Cov2 virus does not discriminate based on citizenship, those countries that did not limit their citizen’s movement, and quarantine them on arrival, have paid a heavy price. …

Laura Spinney’s Pale Rider: A book review

Historical photo of the 1918 Spanish influenza ward at Camp Funston, Kansas, showing the many patients ill with the flu- U.S. Army photographer

After the wonderful histories of Alfred Crosby and John Barry, readers might wonder if there is truly anything new left to write about the 1918 influenza pandemic, which killed between 50 and 100 million people world-wide, at a time when the world’s population was much smaller. Laura Spinney’s detailed, beautifully written and insightful work shows how much study can yet be done on this topic.

As Spinney describes in the opening to her book, in the 1990s much of the writing on this pandemic had been done on Europe and the United States. Of course there were exceptions. In Canada Eileen Pettigrew created a rich narrative of people’s experiences from survivors accounts, while Betty O’Keefe and Ian MacDonald told the story of how medical officer Fred Underhill fought the disease in Vancouver, Canada. There were similar accounts of popular experiences with the pandemic in other countries, such as Australia and New Zealand. But voices in Asia, Latin America and Africa were often not included. Since the 1990s there has been a plethora of work in many different nations, at the same that scientific advances have made it possible to have a much better understanding of the pandemic.

Spinney’s history takes full advantage of this study. She also has a gift for seizing upon the lives of individuals to tell a broader story, whether it was a young man in Rio de Janeiro, Brazil or a scientist in Republican China. She weaves together these narratives to create an overarching view that is truly global. After reading the work I find myself curious to learn more details on individuals, such as a woman affected by the pandemic in South Africa, who then created a religious (and perhaps millenarian) movement.

While such individual accounts are powerful, I particularly like chapter fifteen, in which she described how the same virus had dramatically distinct impacts in different places. Why would the same disease cause mortality rates in excess of 80 percent in some remote Alaskan and Labradoran villages, and far lower rates elsewhere? Of course, the flu was not unique in this respect. I wrote an entire book trying to understand the diversity of HIV epidemics in Latin America. What is perhaps most striking to me is that after a century of earnest study, many of these questions remain unanswered.

What is clear was that the pandemic utterly devastated some locations. In Western Samoa, twenty-two percent of the population died. In the Pacific, on the island of Vanuatu perhaps 20 languages died because of the heavy mortality that the virus brought. Given Brazil’s catastrophic response to the COVID-19 pandemic, and the disproportionate impact that the virus is having on Brazil’s Indigenous peoples, might something similar happen in the Amazon rain forest now? As Spinney states, there was a strange paradox to the virus. Cities often saw high mortality rates, but isolation caused terrible vulnerabilities in remote communities.

What was also striking to me was her discussion of the influenza’s aftermath. In part, this was reflected in such societal trends as a loss of faith in science. Will we be struck by a similar trend with COVID-19? But there was also a physical legacy of the virus, as many people suffered either psychological trauma over the loss of loved ones, or debilitating physical effects that lingered long after the virus was gone. Of these, perhaps the most famous was encephalitis lethargica. While it cannot be proven that the 1918 influenza pandemic caused this disorder -again so much remains unknown about this tragedy- the onset of the one was accompanied by the emergence of the other, as some people remained paralyzed -but apparently aware- for decades. Will COVID-19 have similar health effects that linger for more than a generation? The thought is chilling, given that one recent pre-publication from Korea just reported that up to 90 percent of COVID-19 survivors still report symptoms months later.

Still, what most struck me is that we are now having the same debates now that we had over a century ago: “One 2007 study showed that public health measures such as banning mass gatherings and imposing the wearing of masks collectively cut the death toll in some American cities by up to 50 percent (the US was much better at imposing such measures than Europe).” While now it is the US struggling to persuade its citizenry to wear masks, there is a haunting quality to the debates from this time. Some challenges that faced public health authorities then echo during the COVID-19 pandemic now, although (as far as I know) the death threats and public vilification of public health leaders was uncommon in America a century ago. So perhaps things have gotten worse. Spinney’s last two chapters are remarkably prescient for a book that was published in 2018.

I’ve spend much of the last twenty years working on public policy and infectious disease, first with my book on HIV/AIDS, and more recently with Zika and avian influenza. Some factors are constant, such as the fact that conspiracy theories emerge with every pandemic. One of the most common human urges when faced with an outbreak is to find someone to blame. But what depresses me is that I don’t think the historical studies or public policy achievements make much difference in the long run. In 2018 I published an article on wet markets in Hong Kong, which recommended that the special administrative region consider closing them. Of course, COVID-19 did not emerge in Hong Kong, but likely from a wet market in eastern China. One of the reasons that I hate conspiracy theories is that the distract from the real actions that could make people safer. They also make pandemics and outbreaks seem mysterious and unpredictable.

In fact, people have been studying coronaviruses in China since SARS emerged in 2003 precisely because such an event might take place. This was entirely predictable. As I said in an earlier blog post, how much human suffering might have been avoided if China’s wild game markets -which particularly cater to an older and wealthier clientele- had been closed. Yet even the Chinese government -with all its power and influence- either would not or could not do this. And now social media accounts spread tales that this outbreak is caused by 5G, and people in Britain burn cell towers. Two million people have died globally and winter is drawing closer in the northern hemisphere. We all know what happened in November 1918. Now we must now hope that a different virus will have a dissimilar impact.

Yet behind the scenes scientists have laid the groundwork that will allow for vaccines to be more quickly developed, because much basic science work has been completed. For all the frustration with sciences’ failures and limitations, the hope that we have now doesn’t come from conspiracy narratives -which don’t lead to any constructive steps- but from the often ignored work by nearly anonymous scientists in global laboratories. This work lacks the drama of the conspiracy theories, but the time-consuming and methodical study has laid the groundwork for the greatest vaccine push in human history. Conspiracy theories are easy to create. Real public policy or scientific advances are far more difficult, time-consuming and (often) difficult to understand. Spinney’s work is built upon a detailed examination of both the historical and scientific literature that has been built up over the last century, particularly the last twenty years.

It has long gone out of fashion in academia to look for lessons or a moral in history. But if this line of thinking is taken too far, it might lead people to question the value of history entirely. If historical study cannot give us lessons for the present period, isn’t it little more than a hobby for the affluent few? Laura Spinney’s brilliant book shows how a careful understanding of history can provide us the context to better understand current challenges. Sadly, in this current moment, it’s probably difficult to interest people in reading a work about a past outbreak. Spinney’s magisterial, carefully researched and beautifully written book deserves a broad audience. Highly recommended.


Spinney, Laura. Pale Rider : The Spanish Flu of 1918 and How It Changed the World. First US Trade Paperback ed. New York: PublicAffairs, 2018.

See also the following works for more reading on this topic.

Barry, John M. The Great Influenza : The Epic Story of the Deadliest Plague in History. New York: Viking, 2004.

Crosby, Alfred W. America’s Forgotten Pandemic. West Nyack: Cambridge University Press, 2003.

Canadian popular histories:

O’Keefe, Betty, and Ian Macdonald. Dr. Fred and the Spanish lady: Fighting the killer flu. Heritage House Publishing Co, 2004. (Full disclosure: this press also published my history of an evil spirit in Algonquian belief. Please note that I have no control over the price of physical copies of this book on Amazon, which sometimes surges to hundreds of dollars for mysterious reasons. So if you click on this link for my book, please don’t send me unhappy emails to complain about the book’s price).

Pettigrew, Eileen The silent enemy: Canada and the deadly flu of 1918. Saskatoon: Western Producer Prairie Books, 1983.

Shawn Smallman

Wet Markets and Avian Influenza

Map of Hong Kong by Shawn Smallman, Apple pencil in Procreate

This week I had an article published: “Wet Markets and Avian Influenza: Public Policy Decisions in Hong Kong.” Because the Journal of International and Global Studies is open source, you can read the article by clicking on the link above if you are interested. You can also read the abstract here:

After the emergence of H5N1 avian influenza in 1997 Hong Kong implemented a sophisticated system to regulate live poultry markets. While this system is well designed and thorough, it also has limitations. The rise of H7N9 avian influenza (which is typically acquired through contact with poultry, including in live markets) makes this an appropriate time to revisit the ethical and practical issues related to this trade. Based on data from field observations of live markets in Hong Kong, and interviews with experts in the field, this paper recommends that the government of Hong Kong create a committee to examine the pros and cons of ending live poultry markets in this Special Administrative Region.

Shawn Smallman, 2018

The 1918 Flu Pandemic

“Virus” by ddpavumba at

The 1918 influenza pandemic was the disease outbreak that took the greatest toll in the twentieth century. Globally, perhaps between fifty and a hundred million people died. There are a wealth of wonderful books on the topic. I particularly recommend both Alfred Crosby, America’s Forgotten Pandemic and John Barry, The Great Influenza. Eileen Pettigrew’s Silent Enemy is an excellent popular account of Canada’s experience of the pandemic.

Years ago I was visiting a graveyard in Portland, Oregon. There were three graves next to each other, a man, a woman, and a child, who had all died within a few days of each other in November, 1918, almost certainly from the flu. It’s hard to imagine now what that lived experience must have been like. So many families have stories of ancestors who fought in World War One and survived, only to die on their way home.

My own grandfather was traveling in the Peace River country of northern Alberta at the time. He had decided that he was bored on the farm in southern Ontario. He and a friend had set out on an adventure to travel to the Yukon. Then his friend came down with the flu that fall in 1918. Although they never did make it to the Yukon, my grandfather helped to get his friend Frank home, where -as far as I know- he had a long and happy life. Of course, this was only one insignificant moment in the global disaster that impacted families from India to Australia, and took tens of millions of lives.

There is a fascinating new podcast series on this outbreak, which is well-researched and thoughtfully presented: Going Viral: the Mother of All Pandemics. The presenters have deep historical knowledge, and have invested an immense amount of time in preparing this engaging work. I enjoyed their trip to the former battlefields of France to try to track down the pandemic’s origin with Dr. John Oxford. One would think that there wasn’t much new left to say on this topic. Yet in their search for the true origins of the pandemic they look at provocative thinking and current debates, such as Mark Osborne Humphries’ idea that perhaps the pandemic actually began in China. They are also engaging speakers; one can imagine listening to them as a student, and being captured by their lecture style. You can find the podcast on iTunes and similar venues. Given the proliferation of H7N9, the diversification of influenza clades, and the fact that we still don’t have a universal influenza vaccine, this history remains sadly relevant. Highly Recommended. If you are interested to learn about more recent debates, you can also read my own work on influenza and pre-pandemic vaccines as well as conspiracy theories. Both of these articles are publicly available for free. You can also find more freely available articles on influenza here.

Shawn Smallman, 2018.


Influenza Humans Commons

Colorized transmission electron micrograph of Avian influenza A H5N1 viruses. By Photo Credit: Cynthia Goldsmith Content Providers: CDC/ Courtesy of Cynthia Goldsmith; Jacqueline Katz; Sherif R. Zaki [Public domain], via Wikimedia Commons
The Influenza Humans Commons is a collection of open-access articles on influenza, which is a great resource both for research and for course materials. You can find my own article, “Whom Do You Trust? Doubt And Conspiracy Theories In The 2009 Influenza Pandemic,” at this site, where it was recently among the top ten downloads. This is the paper’s abstract:

The 2009 pandemic of H1N1 influenza led people around the globe to create narratives about the epidemic defined by the question of trust; these narratives ranged from true conspiracy theories to simply accounts in which mistrust and betrayal formed a motif. In particular, most of these narratives reflected a fear of capitalism and globalization, although in specific regions, other issues—such as religion—played a more central role. These stories were not unique to the H1N1 pandemic but rather have appeared with every contemporary outbreak of infectious disease. This paper will examine conspiracy theories and moral panics related to the H1N1 pandemic in different world regions to explore how the disease became associated with economic and social systems in these accounts.

Shawn Smallman, 2018

Flu, Protest and Iran

While many factors are driving the current protests in Iran, Michael Coston has pointed out that a significant outbreak of avian influenza in that country has driven up the cost of poultry and eggs, which has likely contributed to peoples’ food insecurity. His blog post is an interesting attempt to tie influenza to economic factors, which in turn may be connected to politics.

Shawn Smallman, 2018

Conspiracy theories and the 2009 influenza pandemic

The Journal of International and Global Studies is an open access journal, which has just published my article: Whom do you trust: Doubt and Conspiracy theories in the 2009 Influenza Pandemic. The article examines how people in widely separated world regions responded to the pandemic with motifs based around trust and betrayal. While the article focuses on influenza, it also discusses other diseases such as polio and Ebola. Currently the Ebola in West Africa has been waning, and Liberia has finally been declared to be free of the disease. Even now, however, public health workers have to struggle against a powerful narrative of denial, which depicts Ebola as a tool created by the West to sell expensive medications. As I discuss in the article, such narratives have deep roots.

Shawn Smallman

Randall Munroe, XKCD Creative Commons Attribution and non-commercial use 2.5 license

Bird Flu in the United States

As Americans and Canadians follow the threats posed by emerging infectious diseases they are accustomed to hearing news from distant countries such as Saudi Arabia or Liberia. While the threat posed by highly pathogenic avian influenza (HPAI) may move its focus from Indonesia to Egypt, events seem far from our borders. Yet the U.S. is now in the midst of a grave outbreak of HPAI, which is devastating flocks in the Midwest. While this is primarily an avian disease, there is always the risk that it may jump to humans. Even if it remains confined to poultry, the long-term economic effects are serious. The virus is unlikely to disappear or be eradicated at any time in the near future. As always, Maryn McKenna is one of the best observers of issues related to infectious disease. I highly recommend her recent article on this topic here. It’s important to note that there is no evidence that the virus is transmitting from birds to humans at the current time, and that the CDC is preparing a vaccine, just in case. As others have noted, the larger issue is the sheer number of HPAI strains circulating globally, which is very different from even a decade ago.

Update: one of the students in my “Introduction to International Studies” class recommended this article in Time. You can also see my most recent article on conspiracy theories and the 2009 influenza pandemic for free.

Shawn Smallman, Portland State University

Influenza and Respect

The French website Sentiweb tracks disease prevalence in the country. This winter the map of influenza-like illness in France has been a sea of red, which documents a particularly bad year. The situation in Germany is no better. Influenza viruses mutate over time, which means that every year vaccine makers must guess which strain of the virus is most likely to cause illness in the coming season. Sadly, this year’s vaccine was poorly matched with the strain of H3N2 that has caused the most illness. According to a study in the U.S. it was only 23% effective, while one study in Canada found that people were actually more likely to become ill if they had been vaccinated. You can’t have a much worse vaccine that that. This situation has meant that more people in the United States went to the hospital with an influenza-like illness than in most years, particularly amongst the elderly. At least in the United States the influenza season is now waning. In my home state of Oregon, influenza cases peaked last month. This sadly does not seem to be the case in France as this map suggests. As in the United States, the majority of cases in France have been the H3N2 strain.

People tend not to treat influenza with sufficient respect. Years ago I had a phone call from someone who wanted to drive to Portland to meet me in my role as the Director of International Studies. The morning of the meeting I woke up and knew right away that I had the flu.  It felt as though somebody had turned up the gravity in my room. I had a high fever and could barely stand. But not wanting to disappoint them, I dragged myself to the office. They didn’t show up, and after an hour I went home. I consoled myself that it was for the best, because they last thing that they needed was to catch my flu. …

Biopiracy and Vaccines

"Bromo Mountain In East Java, Indonesia" by suwatpo at
“Bromo Mountain In East Java, Indonesia” by suwatpo at

Mariah Tso, an undergraduate student, just posted a great summary of my article, “Biopiracy and Vaccines: Indonesia and the WHO Pandemic Influenza Plan” on the blog “Climate Vulture.” This blog is also a great resource for information on climate change. You can view the original article here. I also have a second article on influenza, which examines conspiracy theories and the 2009 pandemic, which is publicly available.

Shawn Smallman, Portland State University

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