Has anything like long Covid happened before?

Well, yes or I wouldn’t ask the question. Let’s start with the Russian flu, which ran from 1889 to 1892, and its after effects.

 

The Russian flu

Geographical names for pandemics have gone out of fashion, since they’re generally wrong and lead people to blame entire countries for things they suffered from themselves, but the Russian flu was at least first spotted in Russia and to date no one seems to have gotten around to renaming it. So, Russian flu it is. 

Извините, Россия.

That doesn’t make the name correct, though. The Russian flu might not have been a flu at all but a coronavirus. And just to confuse the issue a bit more, the flu was also called the grippe at the time. That becomes relevant in a few paragraphs.

Whatever we call it, the Russian flu seems to have been highly infectious. Half the population of St. Petersburg got it, and it (that’s the disease, not half the population of St. Petersburg) moved across Europe, arriving eventually in Britain. Not because it had been watching Downton Abby and wanted to tour the great houses. Diseases don’t have destinations or intentions or TV sets, and Britain wasn’t its final destination anyway, just a stopover. I give Britain special mention because it’s what I allegedly write about here, although the pandemic’s led me off in other, less predictable directions. 

The Russian flu is now considered the first modern pandemic (no, we’re not going to stop and define that), spreading worldwide along the paths so helpfully laid out by train lines, roads, navigable rivers, and steamships, and demonstrating that it was spread by human contact and by the wonderful ways that humans could now travel.

The Black Death was green with envy. 

Irrelevant photo: roses

In a nifty preview of what would happen with Covid, public health officials in the US watched the virus cross Europe and played it down. It was a particularly mild strain of flu, they said. And when it inevitably disembarked, without passport or visa, on American soil, they swore the first cases were either common colds or just a seasonal flu. 

Nothing to worry about, folks. It’s all under control.

The New York Evening World wrote, “It is not deadly, not even necessarily dangerous. . . . But it will afford a grand opportunity for the dealers to work off their surplus of bandanas.” 

Yeah, I’m having flashbacks to the beginning of the Covid pandemic myself.

This wasn’t a mild disease. Worldwide, an estimated 1 million people died. A survivor said, “I felt as if I had been beaten with clubs for about an hour and then plunged into a bath of ice. My teeth chattered like castanets, and I consider myself lucky now to have gotten off with a whole tongue.”

It also had serious after effects and some uncounted but substantial number of people had them. More than three months after having been ill, the English women’s rights campaigner Josephine Butler wrote, “I am so weak that if I read or write for half an hour I become so tired and faint that I have to lie down.” 

If exhaustion wasn’t bad enough, some people had the added insult of insomnia. 

A Victorian doctor, Morell Mackenzie, said the flu seemed to, “run up and down the nervous keyboard stirring up disorder and pain in different parts of the body with what almost seems malicious caprice.” 

That sounds like he’s describing the flu itself, not the after effects, but the Lancet, which is a medical journal and can be assumed to know what it’s talking about, put that quote and the next one inside a discussion of the after effects. 

Another doctor, Julius Althaus, wrote, “There are few disorders or diseases of the nervous system which are not liable to occur as consequences of grip”.

The collection of symptoms went by an assortment of names: neuralgia, neurasthenia, neuritis, nerve exhaustion, grippe catalepsy, post-grippal numbness, psychoses, prostration, inertia, anxiety, and paranoia. The range on offer backs up my theory that when you can’t cure a disease it helps to change its name from time to time. 

We’d be on shaky ground if we tried to sort the after effects of the Russian flu from–well, everything else that might’ve been available, including psychosomatic problems, tight corsets, and zombies, but observers in the mid-1890s blamed it for everything from a high suicide rate to general malaise. According to the Lancet article, the image of England at the time was “of a nation of convalescents, too debilitated to work or return to daily routines.” 

I would have assumed that the description applied only to the upper class, who could afford not to return to work or daily routines, but what happened in Tanzania (called Tanganyika at the time) shows that I’d be underestimating what post-viral syndromes can do to a person.

 

The 1918 flu

Let’s back up briefly. 

The 1918 flu epidemic used to be called the Spanish flu and sometimes still is. It didn’t originate in Spain, it’s just that Spain put up the first Instagram post. But it was at least genuinely influenza.

How serious was it? Worldwide, at least 50 million people died. About half a billion people—that was a third of the world’s population–were infected. So no, this is not the pandemic you’d want to challenge to a wrestling match. 

Like the Russian flu, its after effects were fierce. They included apathy, depression, tremors, restlessness, and sleeplessness. 

A New Zealand book collecting people’s experiences includes references to “loss of muscular energy” and “nervous complications.” Along similar lines, a South African collection includes this: “We were leaden-footed for weeks, to the point where each step meant a determined effort. . . . It also was very difficult to remember any simple thing, even for five minutes.”

But they got off lightly compared to people in Tanzania, where the flu was followed by a wave of exhaustion so severe that in some parts of the country people couldn’t plant when the rains came and in others couldn’t harvest when the crops were ripe. The result was a two-year famine, called the famine of corms, named after a part of the banana plant that people ate in desperation. 

One strand of post-epidemic symptoms was called encephalitis lethargica–EL for short–or sleepy sickness. It left people not fully asleep but not what you’d call awake either. They were aware of their surroundings but not functioning in anything like a normal way. 

Worldwide, an estimated 500,000 people had EL. A third died, a third recovered, and in the final third the symptoms went on.

Unborn children were also affected. A 2009 study looked at people who, based on when they were born, could have been exposed to in the womb to the 1918 flu. Compared to people born either slightly before or slightly after them, they were 25% more likely to have heart disease after the age of 60. They were more likely to have diabetes. They were, on average, shorter. They had less education and their “economic productivity” was lower. I think that means they made less money. I can’t think how else anyone would measure it. 

 

What does that mean for the Covid pandemic?

No one knows yet how many people have long Covid, which is of several names for Covid’s after effects. No one knows how many people will recover and how many will carry at least some of the effects with them through life. 

No one has a clue what the effects will be on children born during or just after the pandemic, or if there’ll be any, and I’d be surprised if many people are worrying about that yet. They’re kind of busy with more immediate problems.

No one’s even agreed on a definition of long Covid.

It is known that people who have mild or even asymptomatic cases can get long Covid, and that children can. 

It is, as one researcher put it, “One of the reasons I worry so much for people with long-Covid is the . . . uncharted aspect of it. . . . It’s one of the reasons why I do worry when I see people being laissez faire, saying ‘Well, if we’ve got [to] the stage where people aren’t dying, and aren’t filling up the intensive care units, do we need to care?’ And the answer is, I think, until we’ve got more data, we don’t know how much we need to care.

 

A recent study identified 203 symptoms in 10 organ systems. After seven months, many people in the study still hadn’t gotten back to their earlier levels of functioning. When the study was conducted, 45% had to work a reduced schedule and 22% weren’t able to work at all. 

And in a peripherally related seam of worries, a study has called attention to the estimated 1.5 million children around the world who’ve lost a parent or a grandparent who was either raising them or lived with them. It’s an overlooked side effect of the pandemic.

We don’t need zombies, folks. This is scary enough.

A short history of the 1918 flu pandemic

Now that we know at first hand what a pandemic is, this might be a sensible time to learn more about the 1918 flu–that thing most of us know as the Spanish flu. 

Spain’s connection was minimal. The disease first got public recognition there and that’s about it. World War I was still being fought, and newspapers were still censored in Germany, Britain, France, and the US–and possibly in assorted other countries that don’t get a mention. They weren’t allowed to mention the flu. You couldn’t publish anything that might lower morale.

Epidemics, you might have noticed, do lower morale.

Spain, though, sat on the sidelines in World War I. It didn’t censor its papers–at least not for any mention of morale-lowering diseases, although I wouldn’t rule out the possibility of censorship on other issues. So Spain broke the story and its reward was that the world blamed it for the disease it had mentioned. 

Irrelevant photo: a peony

Recent epidemiological research hints that the virus might have been circulating for two years before reaching pandemic levels, and US troops could have been–well, I don’t know if calling them the source of the epidemic would be correct, but the first known cases were in Fort Riley, Kansas, and they didn’t stop the US from shipping soldiers to fight in Europe. So you could make an argument that the US was the source. 

Alternative theories, on the other hand, point to China, Britain, and France. 

 

Numbers

Although a lot of us learned to call the 1918 flu an epidemic, it was a full-blown international pandemic. (Hands up: How many of us even knew the word before last year?) The only part of the world that didn’t report an outbreak was Marajo, which I never heard of until I started researching this post. It’s an island in Brazil’s Amazon Delta. 

The pandemic ran from 1918 to 1919 and killed over 50 million people worldwide. Or possibly 100 million. No one was keeping count, so we’ll have to settle for guesswork. And to confuse the picture further, even if folks had been counting, the symptoms were easy to confuse with other diseases. 

An estimated 500 million people were infected–a third of the world’s population.

In Britain, 228,000 people died of the flu; 1918 was the first year on record in which deaths outnumbered births. And Britain got off more lightly than many countries.

By way of comparison, worldwide Covid deaths are currently just under 4 million, although that’s generally agreed to be an underestimate. Britain’s had 128,000 Covid deaths.. 

The flu pandemic killed between 10% and 20% of the people who became infected, and more people died of it in a single year than died of the Black Death between 1347 and 1351. I believe that’s in Britain. Or in England. Or somewhere. Who cares? It’s a sobering comparison.

It hit young adults particularly hard–people between 20 and 40, who you’d expect to have the most resistance–but it also hit children under 5 and people over 65. Most of us, though, will have heard about  the 20-to-40 age group because it’s unusual for a disease to zero in on them.

 

Spreading the flu

The flu spread both through the air on droplets–those things that people breathe, sneeze, coughe, or talk into the air. It also spread on surfaces. You’d touch a surface that had germs on it, give them a ride to your face, and have yourself a nice little bout of the flu. 

Soldiers returning home from northern France get a special mention in any discussion of how the virus spread. In France, they’d been coming down with la grippe, which consisted of sore throats, headaches, loss of appetite, and the cramped trenches it circulated merrily. But they tended to recover quickly. Doctors called it a three-day fever. 

From that, though, the disease evolved into something deadly. We’ll come back to that. In the meantime, let’s go back to those British soldiers returning home on cramped troop transports and trains. Following their path, the flu spread from railroad stations to city centers, from city centers to suburbs, and from suburbs to the countryside. 

 

The pandemic’s waves

The first wave of the pandemic hit in the spring of 1918 and was relatively mild. The second came in the winter and was the most deadly. In the past, when I’ve read that the second wave was worse than the first, I assumed that meant only that more people got sick. No such luck. The disease itself had changed. In the second wave, you could be fine at breakfast and dead by nighttime. 

Let’s go to Historic UK for the gory details: “Within hours of feeling the first symptoms of fatigue, fever and headache, some victims would rapidly develop pneumonia and start turning blue, signalling a shortage of oxygen. They would then struggle for air until they suffocated to death.”  

The third wave hit in the early spring of 1919, and was somewhere between the first and third in its virulence. Smaller, localized outbreaks went on into the mid ‘20s. But in August 1918, an observer could reasonably have thought that the disease had ended, and since the government still had a war to fight it kept its attention on that. 

For the most part, pubs stayed open. The Football League and FA Cup had been canceled because of the war, but men’s regional tennis competitions went ahead and so did women’s football, which in the absence of men’s games attracted big crowds.  

Hospitals were overwhelmed, and it didn’t help that medical personnel had been vacuumed up by the war. Medical students were brought in to help fill the gaps. Doctors and nurses worked themselves to the point of exhaustion. 

Graveyards were also overwhelmed. Think of them as the kind of high-end restaurants where you need advance bookings. The draft meant the country had a shortage of grave diggers, of funeral workers, of coffin builders. Horses had been drafted as well, so even getting the dead picked up was a problem. In Sunderland at one point, 200 bodies were left unburied for over a week. 

When the war ended (November 11, 1918, in case anyone asks, at 11 a.m.), crowds turned out to celebrate, helping to spread the disease. There just might be a lesson hidden in there for us.

 

The expert advice

Sir Arthur Newsholme, the chief medical officer of the Local Government Board, wrote a memorandum in July 1918 advising people to stay home if they were sick and to avoid large gatherings. It wasn’t bad advice, and he promptly buried it. Britain had that war to fight.

Looking back on it in 1919, he said it could have saved many lives, but “there are national circumstances in which the major duty is to ‘carry on’, even when risk to health and life is involved.”

Keep smiling. Keep morale up. If you have to die, do it off stage.

The cabinet never discussed the epidemic. No lockdown was imposed, and I’m not sure the concept was available to be discussed. In 1917, it talked about forming a ministry of health to prevent disease and coordinate health care, but it did nothing about it until 1919, leaving localities to respond to the pandemic as well or badly as they could. 

In places, theaters, dance halls, movie theaters, and churches were closed for varying lengths of time, and in some places streets were sprayed with disinfectant. Some people wore masks. Some didn’t. Whatever happened, happened locally.

Public health messages ranged from the vaguely useful to the batty. Some factories relaxed no-smoking rules because cigarettes were known to prevent infection–or at least some people knew about it and probably thought the ones who didn’t were idiots or deliberately suppressing information.

But that’s just a guess.

In a Commons debate, M.P. Claude Lowther asked, “Is it a fact that a sure preventative against influenza is cocoa taken three times a day?”

The News of the World told people to “wash inside nose with soap and water each night and morning; force yourself to sneeze night and morning, then breathe deeply. Do not wear a muffler; take sharp walks regularly and walk home from work; eat plenty of porridge.”

Cleaning your teeth was also recommended. It might not keep you alive, but at least you’d die with clean teeth. Brandy and whisky were popular preventatives. So was ventilation, which would have actually helped, along with warm clothes. Worrying about your health, on the other hand, would make you more vulnerable. Besides, it could interfere with the war effort.

Predictably, in the absence of solid information, individuals were often blamed–for catching the disease; for spreading it; for taking risks that no sensible person would take, like passing up that third cup of cocoa.

People rushed to chemists to buy quinine, which was useful against malaria but roughly as helpful against the flu as turkey feathers. 

We can–and we might as well–laugh, but remember that there weren’t any antibiotics yet, which could have been useful against flu’s secondary infections. And there were no antivirals. The first vaccine for the flu wasn’t licensed until 1940. 

Many doctors prescribed what they had available: aspirin. Its patent had expired in 1917, so new companies moved in to produce it–I’d assume cheaply. Patients were told to take up to 30 grams a day, which is now considered a toxic dose. If you take anything above four grams these days, red lights start flashing and sirens go off. 

The symptoms of aspirin poisoning include hyperventilation and pulmonary edema, which is a buildup of fluid in the lungs. Some flu deaths may have been either caused or speeded up by aspirin poisoning.

To be fair, some of the recommended public health measures were useful, including ventilation, disinfection, limiting or banning large gatherings, quarantine, and isolation of patients, but they were applied unevenly. 

 

The pandemic’s legacy

Industrialized countries went into the pandemic with atomized health systems. Doctors worked for themselves or for charities or religious institutions. Public health policies–and this isn’t particularly about Britain–were colored by eugenics, a theory that, to simplify wildly and irresponsibly, managed to show that the people at the top of society were there because they were better genetic specimens and the people at the bottom were degenerate and a mess. So public health policy–or so the Smithsonian tells me–tended to be about protecting the elites from the diseases of the poor. 

When the pandemic died down and they had some space to think, the lesson many countries took from it was that healthcare had to be available to all, and free, although the moves in that direction weren’t universal or, at first, complete. Public health embraced the idea of not just treating disease but preventing it. Epidemiology–the study of diseases’ patterns, causes, and effects–came into its own, and epidemiology demands data, which governments, or some of them anyway, began to gather. One of the problems that article after article mentions about the flu pandemic is that it wasn’t a reportable disease, so doctors weren’t required to report cases to the government and wouldn’t have had a bureau to report them to if they’d been inclined that way. That meant no one knew the size or shape of the crisis.

In 1919, the forerunner of the World Health Organization was founded–an international bureau to fight pandemics.