We’re stuck fighting a 21st century public health crisis with 100-year-old medical techniques

We have emotionally and financially overinvested in the treatment of individual personal care for acute illness, while so seriously underinvesting in prevention

During the 1918 Spanish flu pandemic, newspapers carried official daily advisories. We must “keep the spread of disease gradual so that the hospitals have the chance to keep up”, declared Royal S Copeland, New York’s health commissioner. “Case reporting, inspection and quarantine regulations” needed to be “rigidly enforced”, announced his counterpart in Los Angeles. Meanwhile, headlines shouted about the need for emergency impromptu hospitals and for volunteers to help care for the overwhelming number of patients, and arguments raged around the world about the usefulness of masks, with some newspapers carrying DIY instructions and others panning them as “harmful to health,” except when “worn by people who know how to use them”.

Experts have rightly pointed out the myriad ways in which the 1918 pandemic was distinct from our current Covid-19 outbreak: the course of disease; the economic, social and political milieu; the immediate post-war context; the comparative deadliness of the complications – such as pneumonia – which were then much harder to treat. But in some important ways, there are more similarities than differences.

True, testing and reporting measures are more sophisticated, and we are perhaps more statistically savvy – the early century epidemiologist’s process of tracking disease and mortality has become a public rallying cry to “flatten the curve”. But our “Protect the NHS” is more or less a homegrown variant of Copeland’s plea to ease pressures on the health system, and our Nightingale hospitals are much the same emergency wards set up a century ago, in assembly halls or homes whose wealthy occupants had left them to wait out the plague in summer estates.

Like good 1918 citizens, we confine ourselves to our houses, cancel gatherings and discuss the inequitable ways in which contagion has impacted us. Our governments pour money into the economy and vaccine research, and explore the 18th century inoculative technique trialled during Spanish flu: the transfusion of blood plasma from the recovered to the not yet infected.

Why are we fighting a 21st century public health crisis with such old techniques? In other areas of healthcare, this would be unacceptable.

Consider the therapeutic advice that physicians offered to patients struck down by Spanish flu – to “take castor oil or a dose of salts to move the bowels”. If we were told to do this now, in the face of coronavirus, we might find it at least odd. Yet nobody seems to find it strange that we follow the equally old and far more disruptive instructions to press pause on life while we wait for the virus to have its way with us and then, in its own time, move on.

But there are no other public health solutions available to us right now. There is no better option than to do what was done in 1918. Such is our medical inheritance: we have emotionally and financially overinvested in the treatment of individual personal care for acute illness, while so seriously underinvesting in public health and prevention that in certain ways we have stood entirely still.

This is what happened to cancer. In the 19th and early 20th centuries, it was a disease of public health. Money flowed into preventive research, with investigation primarily into its distribution and its relationship with environment, pollutants, diets, and lifestyles. But in the 1930s, during change that touched all of healthcare, it became marketed as a matter of “personal care”, with individualised treatments that typified, as one physician put it in 1934, the new emphasis on “private not public health”.

This is not to deny the effectiveness of modern targeted treatments in general, nor those cases in which cancer treatments have proven effective. But when four in 10 cancers are shown to be preventable, advances in treatment alone will never be enough to reduce the rising cancer caseload. It is matter of the uneven distribution of resources and attention between prevention and treatment. And yet, in moments like this one, the celebrated arsenal of acute medical care undergirding our systems can offer little more than support for struggling bodies or, in the failure of this, palliation. And we are left in the odd situation of trying to protect our healthcare infrastructure even as it fails to protect our health – the very thing, presumably, we built it to do.

As now, vast amounts of cash poured into the 1918 effort to support the physical and economic costs of the pandemic. And in its wake there were suggestions in some places that funding ought to be continued, to facilitate further work in public health responses to epidemic disease. But this was not forthcoming, and emergency funds quickly dropped to zero once the threat had passed. As investment into acute care research increased, equivalent funding for research into the preventive, public healthcare most relevant to a pandemic dried up.

We should be shocked by how similar our public health measures are to those undertaken 100 years ago. “Flattening the curve” should not be a point of national pride, but rather a sign of how astonishingly unfit for purpose our healthcare systems are.

Coronavirus has the potential to radically transform many different aspects of our lives, from the way we work to the way we interact and consume. It has the capacity to lay bare the values we hold and expose whose work and whose knowledge we regard as socially useful. Perhaps it will also show us that our healthcare systems can be better: more inclusive, more robustly preventive, and more attentive and aware of our healthcare needs.

Dr Caitjan Gainty is a historian of science, technology and medicine and King’s College London. Dr Agnes Arnold-Forster is a postdoctoral research fellow at the University of Roehampton​