Living with Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918

February 12, 2009

The rise in flu cases registered in the UK just before Christmas saw infection rates reach an eight-year peak, duly dubbed a "crisis" by some newspapers.

This wave of illness affected 60, 70 or perhaps 80 people in every 100,000 via a virus that causes serious problems to few. The most vulnerable are routinely offered protection by vaccination. Failing that, antiviral drugs and antibiotics to control secondary infections can help.

If that was a crisis, what would we call a repeat of the greatest flu outbreak in history? In 1918-19, between a quarter and a third of the British population was stricken with a vicious flu strain.

More than 200,000 people died, mainly from the pneumonia that took hold after the virus disrupted their immune systems. Their "forgotten" story was a small part of a global pandemic now thought to have killed 50 million, but is the main focus of Mark Honigsbaum's book.

Forgotten? Surely the 1918 pandemic is trotted out whenever flu is mentioned nowadays? It gives emergency planners nightmares. Any appearance of avian flu strains that might recombine genes with viruses that spread easily between people is met with mass culls and the stockpiling of antiviral drugs.

Honigsbaum's case is that in spite of this, and despite the extensive medical and historical literature about the pandemic, it is surprisingly hard to discover what it was like at the time. We have better accounts of the Black Death than the 1918 pandemic. The reason seems to be a widespread stoicism, part officially invoked, part genuine.

The horrors of the Great War were on a different scale to the disease and lasted longer. The cultural work needed to deal with the war largely blotted out recollections of the epidemic.

There are hardly any living witnesses, but Honigsbaum does a good job of reconstructing the UK's experience of the killer flu. He is helped by largely unused letters collected in the 1970s by Richard Collier when he wrote his global history of the disease.

These, together with diaries, newspapers, official reports and medical memoirs, add up to a rich account of a country coping with a disease against which there was no defence, which mostly meant burying the dead and carrying on.

Would we do any better now? Medically, yes. We know about viruses and their genes. We understand how they are transmitted and how the immune system responds. Disease surveillance is far superior too.

Socially, the questions are more troubling. Honigsbaum suggests that we have become more interdependent and less resilient.

How would food supplies and power distribution hold up if a quarter of the population stayed off work for a few weeks? Add intensive-care units overwhelmed by those suffocating because their lungs were filling with pus, plus 24-hour rolling news keeping us informed about the worst, and stoicism might be in short supply.

His conclusion is not quite so alarming, though. Although the precise origins of the 1918 flu strain remain obscure, the bird flu strains around now are bad at infecting people. The mutation needed to make them more infectious might also make them less virulent.

It is sensible to assume there will be another global pandemic, but little reason to think it will resemble the horrors of 1918.

Living with Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918

By Mark Honigsbaum. Palgrave Macmillan, 256pp, £16.99 ISBN 9780230217744. Published 30 October 2008

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