Perspectives

The art of medicine

Revisiting the 1957 and 1968 influenza pandemics
Published Online The virus emerged in China in the winter of 1957 and spread Oct 17, 1957, there were few hysterical tabloid newspaper
May 25, 2020 rapidly worldwide via ships, aeroplanes, and trains. In April, headlines and no calls for social distancing. Instead, the
https://doi.org/10.1016/
S0140-6736(20)31201-0 it sparked a major epidemic in Hong Kong, where about news cycle was dominated by the Soviet Union’s launch
250 000 people were infected, and by June India had seen of Sputnik and the aftermath of the fire at the Windscale
over a million cases. Shortly afterwards, it made landfall in nuclear reactor in the UK.
the UK, and by September outbreaks were being reported By the time this influenza pandemic—known colloquially
in England, Wales, and Scotland. General practitioners were at the time as “Asian flu”—had concluded the following
“amazed at the extraordinary infectivity of the disease” April, an estimated 20 000 people in the UK and
and the suddenness with which it attacked younger age 80 000 citizens in the USA were dead. Worldwide, the
groups. Yet, while some members of the College of General pandemic, sparked by a new H2N2 influenza subtype,
Practitioners called for the UK Government to issue a would result in more than 1 million deaths.
warning about the dangers presented by the virus and The subsequent 1968 influenza pandemic—or
coordinate a national response, the ministry of health “Hong Kong flu” or “Mao flu” as some western tabloids
demurred. Instead, the virus was permitted to run its course. dubbed it—would have an even more dramatic impact,
The 1957 outbreak was not caused by a coronavirus—the killing more than 30 000 individuals in the UK and
first human coronavirus would not be discovered until 1965— 100 000 people in the USA, with half the deaths among
but by an influenza virus. However, in 1957, no one could be individuals younger than 65 years—the reverse of COVID-19
sure that the virus that had been isolated in Hong Kong was a deaths in the current pandemic. Yet, while at the height
new pandemic strain or simply a descendant of the previous of the outbreak in December, 1968, The New York Times
1918–19 pandemic influenza virus. described the pandemic as “one of the worst in the nation’s
The result was that as the UK’s weekly death count history”, there were few school closures and businesses, for
mounted, peaking at about 600 in the week ending the most, continued to operate as normal.
The relative unconcern about two of the largest influenza
pandemics of the 20th century—the Encyclopaedia Britannica
estimates that the 1968 pandemic, due to an H3N2 influenza
virus, was responsible for between 1 million to 4 million
deaths globally—presents a marked contrast and, to some
critics, a rebuke to today’s response to COVID-19 and the
heightened responses to outbreaks of other novel pathogens,
such as avian and swine influenza. “When hysteria is rife, we
might try some history”, opined Simon Jenkins in an article
in The Guardian titled “Why I’m taking the coronavirus hype
with a pinch of salt”. “The [1968] pandemic raged over
three years, yet is largely forgotten today”, commented
The Wall Street Journal, “a testament to how societies are now
approaching a similar crisis in a much different way”.
The ultimate testament to the supposed stoicism of
earlier generations, according to this line of thought, is the
1918–19 influenza pandemic, in which at least 50 million
people worldwide perished, but which resulted in few
public monuments and was largely “forgotten” by the
collectivity of society.
But were people really more stoical in 1918, 1957, and
1968? Or were there other factors that might account
for the dampened social and emotional responses to
Bridgeman Images

these pandemics? And what should historians make of

functionalist and, arguably, selective readings of history
that seek to draw moral lessons from the past?
British navy sailors in bed because of influenza in a warehouse near Ipswich, To answer these questions it is necessary to understand the
UK, which was transformed into an infirmary for 850 sailors, Sept 19, 1957 origins of the modern preoccupation with pandemics. Before

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 Perspectives

the mid-19th century, few medical commentators used the in 1890 that “dread” of the Russian influenza had been
term pandemic. That only began to change in the 1890s “started by telegraph”.
with the arrival of bubonic plague from southern China— Some critics of the UK Government’s response to
what became known as the Third Plague Pandemic—and the COVID-19 have levelled similar charges at today’s tabloid
Russian influenza pandemic that broke out in St Petersburg press and at disease modellers whose initial forecast
in 1889 and which was seen to spread rapidly to Berlin, that, in the absence of suppressive measures, severe
London, and New York through ship and rail connections. acute respiratory syndrome coronavirus 2 could result
However, perhaps the crucial factor was the way in the deaths of 500 000 people in the UK has been
that Victorian epidemiology and the science of vital widely credited with persuading the UK Government to
statistics made the pandemic form of influenza “visible” reverse course and institute a strict lockdown. But is it
to physicians in the UK who had long been sceptical of really necessary, they ask, to risk plunging the UK into
influenza, then viewed by some as a suspect Italian term an economic depression through lockdown measures
for the common cold. designed to prevent a wave of mortality given that deaths
Statistics had long been used in the insurance and attributed to COVID-19 are broadly in line with those seen
annuity businesses, but it was only in the 1840s that in previous pandemic years? There was no panic in 1957
William Farr, the chief statistician to the General Register and 1968, runs this argument, so why the panic today?
Office in the UK, began to use statistics in a systematic It is questionable whether deaths attributed to COVID-19
way to measure variations in the health of populations are comparable to those recorded during previous
and the occurrence of epidemics. One of the most influenza pandemics, given that between March and early
powerful tools in Farr’s kit was the “excess death rate”, May, 2020, alone the UK Office for National Statistics
calculated by subtracting the number of deaths observed recorded 55 000 excess deaths compared with the same
during an epidemic from the average during non- period last year. Furthermore, it will not be possible to
epidemic seasons. obtain an accurate accounting of the total excess deaths
In 1847–48, Farr had observed that influenza increased due to COVID-19 in 2020 before 2021 at the earliest and by
respiratory deaths in London by about 5000 compared then, assuming a vaccine is not deployed in the meantime,
with non-epidemic years. However, because of the difficulty
of distinguishing influenza from other respiratory diseases,
physicians had attributed just 1157 deaths to influenza and
the remainder to asthma, bronchitis, and pneumonia.
To persuade doctors of their error, and convince them
that influenza ought to be taken as seriously as cholera and
other notifiable diseases, Farr tabulated excess respiratory
deaths and made them a regular feature of the annual
mortality tables. In this way, he thought, statistics would
spur sanitary reform and “banish panic”.
What Farr could not have foreseen is that by making the
risks presented by influenza and other forms of respiratory
disease more visible to the medical profession, his statistical
innovations would have the opposite effect. This was partly
because it now became possible to measure the intervals
between the peaks in excess deaths from respiratory
diseases and show that influenza pandemics occurred in
waves, with the second and third waves frequently resulting
in more severe disease, and more deaths, than the first.
Forearmed with this knowledge, medical officers of health
could alert populations to the pandemic threat ahead of
time and issue advice on isolation and social distancing
Daily Herald Archive/SSPL/Getty Images

measures designed to reduce the peaks or, as we would say

today, flatten the curve.
Another crucial factor was the media: thanks to the
expansion of telegraphic communications and the growth
of mass market newspapers in the late Victorian period, it
now became possible to telegraph news of the spreading
infection ahead of its arrival, hence The Lancet’s claim A typist in Manchester, UK, during the 1957 influenza pandemic

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 Perspectives

Not everyone was happy with the UK Government’s

passivity, however. “The public seems under the impres­
sion that nothing can be done to prevent the calamity that
is threatened by the advance of influenza in the Far East”,
argued Dr Kitching in a letter to the BMJ in June, 1957. “On the
contrary there is a great deal that the Government can do; by
acting at once they may save hundreds of thousands of lives.”
But the ministry of health was not listening. Instead,
fearing that the press would have a field day if it issued
a prominent warning about the pandemic, it left it to
local medical officers of health to decide on the most
appropriate course of action. “The general assessment
seems to be that eventually [the influenza] will affect up to
20 percent of the population”, wrote the then junior health
Bettmann/Getty Images

minister John Vaughan-Morgan. “This is a heaven-sent

topic for the press during the ‘silly season’”.
Vaughan-Morgan was right to be concerned about the
Nurse Nadyne Weber at Cleveland’s Grace Hospital, USA, during the influenza pandemic, December, 1968 press’s reaction. At the end of July, 1957, the Daily Mail issued
a dire warning about a “new outbreak of Asian flu” when a
many thousands more people will most likely have died 1-year-old girl fell ill in Fulham. The Guardian surrendered
from COVID-19. However, critics of the UK Government’s its cool editorial tone for a headline reading: “Crash Fight
response are perhaps right to point to the role of Against Asian ‘Flu’”.
epidemiology and statistical modelling in propagating fear. However, such headlines were the exception and for
Unlike today, in 1957 epidemiologists did not have the the most part newspapers seem to have behaved respon­
ability to track the emergence of a novel pathogen in China— sibly during the pandemic. Publishers were also reluctant to
indeed, the initial signal was missed by WHO, meaning be seen to be stoking public fears, a reflection perhaps of
that the first that influenza experts knew of the “Asian flu” heightened anxieties due to the Cold War and the launch
pandemic was when The New York Times published the report of Sputnik, as well as greater respect for medical experts
about the outbreak in Hong Kong. In 1957, virologists and deference to authority.
did not understand the genetic mechanisms behind the Indeed, Charles Graves, the brother of the novelist
emergence of new pandemic strains, hence the initial Robert Graves, recalled how when news of the influenza
confusion as to whether this influenza virus was a variation outbreak reached his publisher, Icon, it put the publication
of the H1N1 influenza virus of 1918. of his book Invasion by Virus on hold, citing concerns
More importantly, realising that influenza was usually about “frightening the public”. The result was that it was
associated with mild or inapparent infections and that not until 1968 that Icon finally agreed to release the title,
quarantines were impractical, public health authorities in having been reassured in the meantime that influenza
the USA and the UK made no effort to mitigate the spread in 1957 “was no real killer”. In his book Graves compared
Further reading
of the infection by, for instance, introducing border checks the 1957 and 1968 pandemics to that of the 1918–19
Dehner G. Influenza: a century of
science and public health
or strict isolation measures. Nor did governments consider influenza pandemic and asked “Could it happen again?”
response. Pittsburgh: University suppressing the basic reproduction number to buy time for His answer was yes and that the UK had been lucky
of Pittsburgh Press, 2012 hospitals and front-line health workers: as Hugh Pennington, that the recent pandemics had been of a “mild type” of
Giles C. UK deaths since virus then a young medical student at St Thomas’ Hospital, London, influenza. He closed by reassuring readers that history
struck almost 55,000 above
average, says ONS.
UK, recalled in a recent article in the London Review of Books, was unlikely to repeat itself before 1998, “by which time
The Financial Times, this was because intensive care units were not yet established the medical profession will know a great deal more about
May 19, 2020 in 1957 and ventilator technology was rudimentary. Nor, immunisation that it did in 1918—or does now.”
Honigsbaum M. A history of when the second wave of the pandemic arrived in the autumn Graves was right on both counts, but wrong to think
the great influenza pandemics:
death, panic and hysteria,
of 1957, were hospitals overwhelmed by patients. Similarly, that better medical knowledge of vaccines and statistical
1830–1920. London: Bloomsbury a review of hospital admissions in Pittsburgh, Baltimore, modelling would reduce public anxiety about pandemics.
Academic, 2020 and New York, USA, during the 1968 pandemic found that
Kilbourne E. Influenza pandemics although patient numbers increased by 3%, hospitals coped Mark Honigsbaum
of the 20th century.
with the influx. Indeed, the only real strategy considered by http://www.markhonigsbaum.co.uk/
Emerg Infect Dis 2006; 12: 9–14
health authorities in the UK and the USA was vaccination, Mark Honigsbaum is a medical historian and author of The Pandemic Century:
Pennington H. Memories of the
1957 flu. London Review of Books, but the vaccines arrived too late in both the 1957 and 1968 A History of Global Contagion from the Spanish Flu to Covid 19 (published by
W H Allen on June 4, 2020).
April 21, 2020 influenza pandemics to make a difference.

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