WITH hopes high that the northern hemisphere flu season is , it seems a good time to point out that, unlike annual outbreaks that fade as spring arrives, flu pandemics don’t respect seasons. A hundred years ago, the worst such pandemic on record was just starting – the first case was recorded on 4 March 1918 – and north of the equator it wouldn’t peak until the autumn.
In this centenary year of Spanish flu, a lot of ink has been spilled on the inevitability of another flu pandemic. One aspect that gets little attention, yet holds vital lessons, is that mortality in 1918 was massively skewed by social and economic inequality.
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In poorer parts of Asia, you were 30 times more likely to die than in richer parts of North America or Europe. Even within wealthy cities, telling patterns emerged. In New York, death rates were highest among immigrants. In Paris, the fact that the flu was most lethal in the wealthiest districts was puzzling, until it became clear who was dying – not property owners, but servants in cramped and draughty quarters.
Although inequality wasn’t the only thing shaping death rates, it accounted for a significant part of the variability. The same was true in the 2009 flu pandemic. In England, the mortality rate in the poorest fifth of people was triple that among the most affluent.
Pandemic preparedness committees have yet to take such lessons into account. They still define vaccine priority groups using medical criteria such as pregnancy or age, not social ones.
The WHO, European Union and countries including the US know of the link between socio-economic status and health, and many nations have vowed to reduce it. There is an odd gap between this thinking and that of pandemic committees. They might argue that they can’t address all of society’s ills, but to ignore social disparities is to undermine a lot of what they do.
If a new pandemic flu hit Europe, it isn’t hard to imagine where it would find the easiest pickings: the refugee camps of Italy, France and the Balkans. Being in such cramped and unsanitary places makes people sitting ducks. Flu would spread from there, and although the poor might die in larger numbers, the rich would not be spared.
What would taking social inequality into account mean for pandemic committees? Inviting social scientists, perhaps even a historian or two, to join them, and identifying social indicators that correlate best with pandemic vulnerability. Alongside biomedical indicators, these would guide vaccination priority and other public health measures.
More generally, it would mean recognising that a pandemic isn’t a purely biological phenomenon – it is also a social one.
This article appeared in print under the headline “Spanish lessons please”
