“The first wave hits the poor, the second wave hits the rich”: Lessons from the 1918 pandemic

The poor came down with influenza first and were overall most affected, while the rich with less exposure in the first wave tended to have higher morbidity in the second wave. This finding is concurrent with prior studies documenting that the poor had the highest 1918 pandemic mortality. Although this study could not tease out the mechanisms for the SES crossover in morbidity, results suggest that preparedness plans should consider how (non‐)pharmaceutical interventions can hinder socioeconomic morbidity disparities in future pandemics. Surprisingly however, social inequalities in pandemic outcomes do not form part of the discussion in international preparedness plans for pandemic influenza. This is not conducive to achieving the international goals of eradicating poverty, reducing social inequalities and ensuring good health for all by 2030.

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My knowledge about the 1918-1919 influenza pandemic is woeful. I was prompted to learn more by this diagram from the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19), which describes COVID-19 as similarly transmissible to the H1N1 influenza in 1918-1919. I’ve been reading a few articles, keeping an eye out for potential lessons for our looming COVID-19 pandemic.

I’m just beginning to read into the literature. There are some pretty clear lessons—though no thunderclap revelations. These include:

• Handwashing was effective then and will remain amongst our most effective practices now .
• There will likely be two or more waves of COVID-19 .
• In the absence of specific treatments, we’ll have to rely on community mitigation measures to contain the virus, as was the case in 1918 .
• There is likely to be a social gradient in transmission, i.e. the poor are more likely to get COVID-19, at least at first . This is a concern that some have already flagged in the U.S.
• If there is a social gradient in the disease, there needs to be a social gradient in our response. The most affected locations and communities should be the focus of the health system’s initial response (we can’t just assume this will be the case). If antiviral therapies are found to be effective, or if a vaccine is eventually developed, consideration should be given to deploying them to poorer areas first .
• Air pollution may increase the impact of the pandemic (important given the recent bushfires and poor air quality in Australia).
• We’re much better placed to respond now than health systems were in 1918. Things like intensive care units and protective equipment simply didn’t exist then .
• The economic impacts of the pandemic will likely have health consequences that dwarf those of the virus itself.

The social impacts of the 1918 pandemic were far-reaching, but also still seem to be poorly understood. “What if” questions abound but are unanswerable. For example, the Indian independence movement was strengthened by the British mishandling of its influenza response in India. Would independence have happened in the same way without the pandemic?

It’s similarly difficult for us to imagine what COVID-19’s far-reaching future social consequences will be.

I’ll keep reading. Your suggestions about good sources are welcome.

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