I had a little bird
Its name was Enza
I opened the window
And in-flu-enza

BRITISH schoolchildren skipping to this rhyme during the Great Influenza pandemic of 1918 and 1919 might have been simply pleased that schools had been closed to reduce contagion. But many would have been aware of its more ominous meaning.

By the end of 1918, influenza was killing an average of 95 children a week in London alone. In all, one third of the British population were infected and 228,000 died. Around the world, the 1918 virus killed more than ten times as many people as died in the First World War. The victims were tormented by high fevers and excruciating headaches and, just before dying, their skin would turn the colour of wet ashes and they would drown in fluids filling their lungs. As an editorial in The Times lamented on February 2, 1921, that influenza was a “monster” with a mighty appetite.

It is a monster that could return today. Three years ago, Sir Liam Donaldson, Britain's Chief Medical Officer (CMO) admitted that a new pandemic was a question of “when, not if”. Avian flu could arrive in the UK by migrating birds, or on any number of commercial airliners. In 2002, public health officials feared the worse when severe acute respiratory syndrome (Sars) was spread via passengers on aircraft from China to 26 countries around the world, causing 8,500 infections and killing 916 people. The microbiologist Malik Peiris was not exaggerating when he said that “nature remains the greatest bioterrorist of all”.

The UK Government has taken note. Fearing the spread of the nasty avian virus known as H5N1, it has stockpiled antiviral drugs. In 2007, Exercise Winter Willow reviewed the UK's preparedness for dealing with a flu pandemic. If a new pandemic is a “biological inevitability”, as the CMO alleged, then might the 1918-19 catastrophe teach us some lessons?

In this book Mark Honigsbaum shows how the history of medicine can inform policymaking today. In 1918, he tells us, medical officers were unprepared. They were not helped that bacteriologists at the time were at a loss to explain what caused the disease. It took until 1933 for scientists to realise that influenza was transmitted by a virus. Equally significant is that in 1918 responsibility for dealing with crises of such magnitude lay in the hands of local authorities. The Ministry of Health was established only in 1919. Even so, the authorities were slow to respond. Sir Arthur Newsholme, the CMO of the Local Government Board, explained his own ineptitude by referring to the war. The “relentless needs of warfare”, he insisted, required the nation to “carry on”, regardless of any risk.

Not everyone was as resigned. People besieged chemists insisting that they be given quinine. Sneezing, spitting, and “indiscriminate expectoration” in public were forbidden. Some people panicked, especially when funeral parlours ran out of coffins and bodies remained unburied in the front parlour, sometimes for weeks. Suicide rates soared. Survivors all agreed that the “feeling of misery and utter helplessness” was something they would “never forget”.

But we have forgotten. What if a lethal strain of the virus emerged today? The UK Government has plans to stockpile 14 million doses of oseltamivir, but this would cover only a quarter of the British population. In the event of an outbreak, would the manufacture of further doses of the drug be completed in time? Given lim-ited supplies of the drug, who would be given priority? Would people panic? What would be the effect on the economy if between a quarter and half of all workers decided to stay at home?

During the Sars outbreak, nearly a third of those infected were healthcare professionals. Surely the NHS would be overwhelmed? In 1918, a quarter of people in the UK were infected: if the same proportion were to fall ill today, some 15 million people would need medical attention. If only 10 per cent of these infected people were admitted to hospital, Honigsbaum reminds us that this would total 1.5 million patients - yet there are only 111,800 acute and intensive care beds in England. Even more worrying is that British society today lacks the voluntarist ethic and community spirit that dominated the early decades of last century. Honigsbaum's prognosis is glum. The legendary “stiff upper lip” was greatly exaggerated during the 1914-18 war. It would be highly unlikely during a 21st-century pandemic.

Living with Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918 by Mark Honigsbaum

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