TORONTO - Could it really happen again?
Influenza scientists repeat like a mantra that when it comes to flu pandemics, the question is not if, but when.
And yet 90 years after the worst one -- the Spanish flu of 1918-19 -- and 40 years after the most recent one, it's tempting to wonder why there hasn't been a pandemic since the Hong Kong flu of 1968.
With the current state of influenza knowledge, there is no satisfying answer to the question. Flu pandemics occur when they occur. There's no way to predict the timing of the next one or whether its impact on global health will be mild, moderate or severe.
"Forty years, 50 years, 30 years -- I think again the disease just sort of sets its own pattern for when it's going to cause another pandemic," says Dr. Keiji Fukuda, head of the World Health Organization's Global Influenza Program.
For Fukuda, one of the key lessons the world should take from the Spanish flu pandemic is that something that happened once can happen again.
"If anything, compared to 1918, the conditions that you need for these kinds of large epidemics of respiratory disease to harm a lot of people are worse now than they were back in 1918," he says, noting the world got an unpleasant reminder of that with SARS.
"You know, we have these enormous urban populations. We have more people than ever living in the world. And so in a lot of ways, for a pandemic virus the ground is just more fertile."
Jet travel means germs can cross vast distances in hours, not the weeks or months of eras past.
And a peculiar reality of modern urban life amplifies the vulnerability, says influenza expert Dr. Danuta Skowronski. In large cities, one's neighbours are as likely to be total strangers as they are to be friends.
"Today we're very interconnected globally on an international scale through air travel. . . . And yet we hardly know our neighbours, especially in urban areas," explains Skowronski, who is with the British Columbia Centre for Disease Control in Vancouver.
"And that may be an important lesson from the 1918 pandemic. Because when there is a pandemic soaring around the world, we may not have access to distant supplies. (But) we may need to rely on our closest communities far more than we are actually used to now."
Skowronski and some colleagues thought learning about how people coped through the Spanish flu would help public health authorities plan for a future event. About 18 months ago they started an effort to preserve first hand accounts of the time by interviewing people old enough to remember living through the outbreak.
More than 200 people responded to the BCCDC's appeal. The U.S. Centers for Disease Control undertook a similar effort, recently publishing "The Spanish Flu Storybook." ()
"We wanted to know How did people manage? What were their individual responses? Because pandemics -- even the 1918 pandemic -- are not only about death. In fact, the vast majority of people who were affected in 1918 survived."
Published accounts of the event documented cases where some infected people died from neglect, not the illness, because healthy people were too frightened to help them.
But the stories Skowronski's team heard were of resiliency and neighbourliness. Sick people being cared for by family members or by a nurse who lived nearby. Neighbours and relatives sending soup or tending a sick family's livestock.
While those recollections may sound like the response of a long-gone era, stories that emerge after the next pandemic will likely sound very similar, Skowronski said.
"Even in our modern era, we won't have access to vaccines (in the early days)," she says.
"Antivirals and antibiotics will be in short supply. So some of those same community efforts, public health efforts we will have to use as well in the initial stages of a pandemic. So they are very relevant, even today."
