December 23, 2006
Influenza Like 1918 Strain Would Kill 62 Million

Tens of millions would die but your risk would be lowest in the most developed countries.

Boston, MA - In recent years, health professionals and the general public alike have been acutely aware of the potential ravages that could result from a flu pandemic. Although many people might still recall the pandemics of 1968 and 1957, it is the infamous 1918-1920 pandemic--and the possibility of a recurrence on that scale--that causes the most trepidation.   

Strangely, researchers still don't know exactly how many people died from this particular strain of the flu virus in that pandemic, and they know even less about how mortality rates varied in different parts of the world. In fact, most historic information is based on eyewitness accounts and not on statistical analysis. Now, a team of researchers from Harvard School of Public Health (HSPH) and the University of Queensland in Australia have re-analyzed data from 27 countries around the world to estimate both the global mortality patterns of the 1918 pandemic and, based on 2004 population data, how a similar pandemic would affect the world today.   

These findings, to be published in the December 23, 2006 issue of The Lancet, show that mortality rates for the 1918-1920 pandemic were disproportionately high in communities where per capita income was lowest. If the same pandemic were to occur today, approximately 96 percent of deaths would occur in developing countries.

In event of a pandemic if you can manage it your best option is total physical isolation. If you can telecommute to work and rarely go shopping or anywhere else with people your odds of getting the flu will be extremely low.

The difference in risk from the lowest to highest death toll regions varied by a multiple of 39 in the 1918 outbreak.

For many decades, published epidemiological literature assumed that mortality rates from the 1918-20 pandemic were distributed fairly equally. A simple population count from that period would lead to the conclusion that about 20 percent of all fatalities occurred in the developed world. "But when you look at the data," said Murray, "that number shrinks to about three or four percent."

The disparities between the developed and developing worlds during this period are striking. For example, in Denmark 0.2 percent of the population succumbed to the flu. In the United States, that figure is 0.3 percent (based on data from 24 states). In the Philippines, the mortality rate was 2.8 percent, in the Bombay region of India, 6.2 percent, and in central India, 7.8 percent, which was the highest rate of the countries and regions analyzed. According to this data then, from Denmark to central India, death rates from the 1918-1920 flu pandemic varied more than 39-fold.

What caused the disparity in death rates? One possibility: nutrition. Poorer people died at higher rates because their immune systems were weakened by malnutrition. Also, in more developed countries perhaps people could better afford to go about their daily activities without coming into close contact with others. Anyone who can afford total isolation can avoid catching a pandemic flu virus.

62 million would die if an influenza virus of similar lethality spread in a pandemic today. Will H5N1 avian flu virus adapt to human spread and cause this scenario to come true? Or will H5N1 even exceed the 1918 strain in lethality? Your guess is as good as mine.

The researchers then took the relationship observed in 1918 between per capita income and mortality and extrapolated it to 2004 population data. After adjusting for global income and population changes, as well as changes in age structures within different populations, the research team estimated that if a similarly virulent strain of flu virus were to strike today, about 62 million people worldwide would die.

The economic disruption would be enormous as people became too sick to work, needed care, and became too afraid to go to work. We need to think ahead about measures that can simultaneously decrease the risk of infection and reduce economic disruption. In event of a pandemic I have argued for a response I call "workplace cocooning" which would be live-in workplace quarantines where people live and work in the same place and never leave their workplace for months until vaccines make human contact safe again. Some would live and work at home and telecommute. Others would get together in workgroups and live and work either in a regular workplace or in a big farm house. Larger groups could live and work together in an otherwise empty hotel (travel would collapse) converted to serve as both offices and living space.

Sailors on ships could stay on ships for the duration and never get off the ships in ports while their ships are unloaded and loaded. Truck drivers could stay in their cabs while the trailers get loaded and unloaded at warehouses by workers who would live in the warehouses and never leave during the pandemic.

The idea is to divide up people into workgroups and avoid contact between workgroups while allowing contact to do necessary collaborative work within workgroups. This model would not work well for every occupation or individual. But enough people live by themselves or in small families that consolidation of groups into combined group homes and workplaces would allow a large fraction of the population to continue working with little risk of infection.

Share |      Randall Parker, 2006 December 23 09:22 PM  Pandemic Death Toll

Phil said at December 24, 2006 2:19 AM:

So, it would just be a minor blip, taking out under 1% of the global human population, and those 62 million souls would be replaced in less than a year.

The 1918 pandemic killed around 2.5% of the then world population.

We could really do with a pandemic 100 times more effective to reduce human numbers to a sustainable level.

hibbs02 said at December 24, 2006 3:57 AM:

Hell, since we're wishing for lots of people to die for our personal convenience why not set it up so that everyone but me and 20,000 supermodel hot women in various skill sets to maintain civilization (including a sperm bank) were killed. That would be nice, though tiring and dehydrating, for me at least.

On a more serious note, part of the reason the 1918 Flu was able to kill so many people was because of ignorance and lack of tools that we have today. But, now that we have much better reporting, medical knowledge, drugs, communications, etc I don't know how much credence to give these kinds of stories especially considering the source. Part of the question is where it starts. I have a much higher confidence that it would be quarantined, treated and stopped in the US as opposed to say parts of India, Africa or South America. Even China now has experience with aspects of this type of situation, lots of well trained techs and absolute government control so the chances of spreading out are greatly reduced.

That being said you can spend $200 or less and greatly increase your survivability (not to mention comfort) in any of the various doomsday scenarios the media likes to spin. That's just good common sense. Personally I'm betting on smuggled nukes before any of these disease stories.

Bob said at December 24, 2006 9:13 AM:

... to reduce human numbers to a sustainable level.

Remember, Phil, "Think global, act local." I'm sure we agree on what you should do on a strictly personal level to contribute to this vision...

Phil said at December 24, 2006 9:48 AM:

Remember, Phil, "Think global, act local." I'm sure we agree on what you should do on a strictly personal level to contribute to this vision...

I'll kiss all the birds under the mistletoe this xmas in the hope of catching H5N1 :-p

hibbs02 suggests that now we have better communications etc such pandemics would spread more slowly; on the other hand we now have "instant" air travel which can spread apparently healthy people who are incubating the disease around the globe in a matter of hours.

The varying mortality rates in the 1918 pandemic might also be in part related to population densities. And historically population density might well have been related to poverty. If you live in a crowded. busy city, your germs are more likely to successfully spread.

Jane Shevtsov said at December 24, 2006 10:21 AM:

And what about age structure? Young folks were more likely to die of the 1918 flu, and wouldn't there have been proportionately more of them in poorer communities?

Randall Parker said at December 24, 2006 11:13 AM:


You are absolutely correct. If the next pandemic strikes down more people in their 20s and 30s then that'll hit much harder on younger populations.

The H5N1 flu appears similar to the 1918 strain in that it causes an excess inflammation response. I suspect that means it will kill younger people more because older folks have aged immune systems whose very agedness may reduce the ability of their bodies to over-react.


You are right about the airplanes. We won't have to wait for ships to carry infected people between continents. That'll happen extremely quickly. Also, people in cars fleeing urban areas will carry the virus with them to wherever they go. Hard to tell how all that will balance out.

I think the internet does work in our favor. You all know (because I told you) that as soon as a pandemic begins you should immediately figure out how to arrange a workplace cocoon that'll keep you working produdctively while isolated from the larger society. Work from home by yourself if you can. But otherwise try to convince employers to organize isolated live-in workplaces.

Robert Schwartz said at December 24, 2006 10:28 PM:

I think that the comparison with 1918 is at best difficult and probably not all that enlightening. 1918 was a year of the great war. Europe was devastated. General levels of health and nutrition were much lower in most of the world than they are now. I am far less concerned by a pandemic disease than I am by human malice.

Phil said at December 25, 2006 2:16 AM:

Well, Robert, looking at general obesity and malnutrition levels (and I mean that in a broad sense) in the West these days that's a moot point.

For those who are interested in oral history, here's an interesting webpage about how the 1918 pandemic affected my homeland, New Zealand.

"The virus had an especially deadly impact on Maori, whose death rate, 4.2 percent, was about seven times that of Pakeha. Many people blamed substandard housing 'Maori rural dwellings often had earthen floors and were damp and overcrowded' but the small size and isolation of Maori settlements also compounded the misery. The flu spread so fast that remote communities had little or no warning of its arrival. In the absence of outside help, there were often not enough locals left standing to care for the sick."

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