J. Stephen Morrison and Jonathan E. Hillman. "The Spanish Flu a Century Later: 2018 is Not That Different From 1918." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, March 09, 2018. Accessed December 21, 2023.

The Spanish influenza cataclysm ignited 100 years ago, and while we certainly live today in a superior state of preparedness, modernization and globalization have also driven up health security risks.

Photo Credit: PAVEL GOLOVKIN/POOL/AFP via Getty Images

A man preparing 'Anti-flu' spray for buses of the London General Omnibus Co, London, 2nd March 1920.
A man preparing 'Anti-flu' spray for buses of the London General Omnibus Co, London, 2nd March 1920. H. F. Davis/Topical Press Agency/Getty Images

The Spanish influenza cataclysm ignited 100 years ago this month. A startlingly dangerous molecular mutation, utterly unforeseen, ushered in a flu that swiftly tore through armies, public health defenses, and geographic barriers. It took full advantage of the disorder of World War I and the profound changes wrought by modernization. It leaped across oceans and sped along transportation pathways. Ultimately, it left in its wake over 50 million dead, before immunities and health systems caught up and the world eventually restabilized.

The frightening but frank truth is that it is impossible to predict when the next epochal influenza may surface and threaten human health and security. We certainly live today in a superior state of preparedness. But a hundred years of modernization and accelerating globalization also drive up health security risks, and much more work remains to build elementary defenses, especially among poorer and weaker cash-strapped states.

In 2018, the memories of 1918 have dimmed. Those who survived that distant trauma and tragedy have passed on. Still, that dark chapter of history does contain vital lessons. 1918 is not that different from 2018.

In 2018, as in 1918, pandemic influenza remains the most dangerous threat of all naturally occurring outbreaks. A virus as deadly as the Spanish flu could kill up to 81 million people, according to a 2006 study. The World Bank estimates that global economic damage could approach $3 trillion. Experts can debate specific figures and projections, but there is consensus that pandemic influenza tops the list of live health security threats, and the human and economic costs would be staggering.

In 2018, as in 1918, we remain inadequately and unevenly prepared. Consequently, we remain acutely vulnerable to surprises. As was true earlier, we cannot afford to be complacent.

The good news is that we have developed better surveillance, diagnostic, laboratory, vaccine, and antiviral capacities. New threats can be detected far more quickly, and we have a better grasp of the essential core capacities for preparedness. In 2007, the updated International Health Regulations came into force, which require countries to create the basic means to prevent, detect, and respond to outbreaks and to report events that could result in public health emergencies.

Another leap forward is the Global Health Security Agenda. Launched in 2014 by the Obama administration, this international alliance brought forward a concrete matrix of preparedness requirements and developed joint assessment tools. The World Health Organization (WHO) embraced those tools, which have guided multiple independent assessments of country preparedness.

The bad news is that, this progress notwithstanding, our collective defenses remain uneven, thin, and full of holes. An array of weaknesses has been visible in recent decades: during the early faltering international response to the HIV/AIDS crisis, stretching from the early 1980s until the launch of the President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria early in the naught decade; the successive influenza outbreaks and the SARS outbreak that unfolded over the past decade and a half; and the more recent challenges posed by Ebola and Zika.

Even after these wake-up calls, fully two-thirds of the world’s countries fall far short of the basics. The United States was able to advance the Global Health Security Agenda with $1 billion in emergency supplemental Ebola funds, which have been invested wisely and effectively in 17 partner countries. But that critical commitment appears unlikely to be renewed and sustained, if the Trump administration’s budget preferences for this next fiscal year are allowed to stand.

Responses are often exceedingly slow and at times remarkably antiquated, particularly the production of influenza vaccines. Sovereign sensitivities can impede timely sharing of samples, while panic can lead to crippling disruptions of trade and transportation. Hysteria erupted in the United States in 2014 in the face of a mere handful of Ebola cases entering the country, aggravated by 24/7 cable news and slow and ineffectual high-level communications and coordination, as laid out in the CSIS documentary, “Ebola in America: Epidemic of Fear.”

The WHO, the lead international organization charged with overseeing emerging threats globally and coordinating emergency responses, struggled with paralyzed leadership and a hollowed-out staff and budget in the face of Ebola, which gravely damaged its credibility and standing. It has recovered in significant ways, in its new leadership and strengthened emergency program, but WHO to this day requires careful, sustained support.

In 2018, as in 1918, grave disorder and historic transformations create acute new vulnerabilities.

Earlier epidemics are associated with the openings, driven by colonialism and extractive industries, of vast new tropical territories that brought humans into contact with new pathogens and the animal species that carried them. The disorder of World War I was an open invitation to a dangerous pathogen looking for cracks.

Recent outbreaks have been concentrated in areas of Asia where burgeoning animal and human populations coexist in close proximity and interaction. During the next two decades, over half of the world’s expansion in urban land will happen in Asia.

Asia’s powers have embarked on an epochal infrastructure competition that is connecting the region internally and with the world. At the center of this contest is China’s Belt and Road Initiative, which could spend upwards of $4 trillion on new roads, railways, and other connections across 70-plus countries. Japan is spending heavily as well, even more than China in Southeast Asia. India plans to build over 80 thousand kilometers of new roads over the next five years alone.

These investments could yield major social dividends, but thus far, it appears that Asia’s infrastructure push does not include commensurate investments in public health infrastructure. That is a subject of lively debate, and with developing Asia requiring some $26 trillion in infrastructure investment by 2030, there is still time to make smarter choices.

In 2018, the advent of the new field of synthetic biology, which allows widespread access to alter the genetic makeup of cells, is both raising hopes of new innovations and cures and stirring fears of the deliberate and inadvertent creation of very dangerous pathogens. Policymakers are rushing to catch up with this swiftly evolving technology. Our regulatory frameworks require refinement and new thinking to fit new realities. Those in much of the rest of the world are yet to be created.

Lastly, in 2018, as in 1918, we live in a profoundly fractured, disordered world, composed of a high number of open-ended, chronic wars and fragile states that have given rise to 65–70 million refugees and displaced persons. Across multiple conflicts, we are witnessing a surge of deliberate targeted violence—by armed states and irregular forces alike—directed against the health sector, in open defiance of the Geneva Conventions. That profound shift is destroying health infrastructure, inducing flight, and creating difficult-to-access populations, as explored in the recent CSIS documentary “The New Barbarianism.”

As should be obvious, health security has acquired multiple new meanings in the world of 2018, while wrapped in many powerful echoes from 1918. We have no choice but to be vigilant, on our toes, focused on investing in our own and others’ preparedness at home and abroad. We are fools not to concentrate our attention on the historic infrastructure transformations afoot in Asia and elsewhere, at the same time that we puzzle over synthetic biology and the transformations unfolding in do-it-yourself laboratories. And high-level political will remains essential, in 2018 as in 1918, to push back on violent disorder and the erosion of humanitarian norms that can pull our world apart.


Next Article