Trivia

Mental health during the 1918-1919 Spanish Flu
March 20, 2021 - 10:44 pm

As we all try to acclimate ourselves to the rapidly changing circumstances brought about by the COVID-19 pandemic, comparisons are being made between this pandemic and the so-called Spanish flu pandemic of 1918-1919. (The reason it was referred to as the Spanishflu was that Spain was one of the only countries at the time to not censor reports of cases, and so it was widely publicized there by late-fall 1918.) The Spanish flu proved to be peculiar for several reasons, most noteworthy of course due to the high morbidity (as many 500 million were infected) and mortality (around 50 million deaths). It also came in waves. In the US, there were four such waves: first in spring 1918, again in August 1918 (epidemiologically the most devastating of the four), yet again in winter 1918/1919, and a final return in early 1920. Finally, the disease was unlike most flus in that it decimated even the traditionally more robust segments of the population (ages 20-40), taking the lives of many within 3 days of showing symptoms.

Exploring the pandemics

Since the pandemic of the Spanish flu, researchers dedicated themselves to identifying the origins and nature of the virus. It took decades, however, before virologists succeeded. Starting in the mid-1990s, Jeffrey Taubenberger, MD, PhD, and his team were able to carry out a sequence and phylogenetic analysis of 1918 influenza virus genes and identified it to be an H1N1 virus of avian origin.1

Until around 1970, historical research about the pandemic had been virtually non-existent. Some novels and popular histories appeared over the decades, but it was Alfred Crosby’s 1976 book Epidemic and Peace, 1918 (reissued in 1989 under the title America’s Forgotten Pandemic: The Influenza of 1918) that paved the way for international research about the subject.2 One of the book’s major achievements was to draw attention to the fact that the pandemic quickly disappeared as a topic of public conversation soon after it was over, ignored by periodicals and textbooks for decades. To many historians, this collective silence is as much a part of the pandemic’s story as the course of the disease itself.

The mental health links

In comparison to other aspects of the pandemic, little research has been done on the long-term impact of the Spanish flu on mental health. One of the few researchers to investigate the subject was historical demographer Svenn-Erik Mamelund, PhD. Looking at asylum hospitalizations in Norway from 1872 to 1929, Mamelund found that the number of first-time hospitalized patients with mental disorders attributed to influenza increased by an average annual factor of 7.2 in the 6 years following the pandemic.3 In addition, he pointed out that Spanish flu survivors reported sleep disturbances, depression, mental distraction, dizziness, and difficulties coping at work, and that influenza death rates in the United States during the years 1918-1920 significantly and positively related to suicide.4

Mamelund is among a number of scholars who have noted what many suspect to be a connection between the Spanish flu and a pronounced increase in neurological diseases. By 1919 and 1920, physicians and researchers in Great Britain were already reporting a marked rise in nervous symptoms and illnesses among some patients recovering from influenza infection; among other symptoms, depression, neuropathy, neurasthenia, meningitis, degenerative changes in nerve cells, and a decline in visual acuity were cited.5

Encephalitis lethargica: another connection or vulnerability?

Encephalitis lethargica coincided with the Spanish flu; it reached epidemic proportions alongside the Spanish flu. As Hoffman and Vilensky have recently described, the syndrome was characterized by two, often, blended phases:6

During the acute phase, patients typically experienced excessive sleepiness, disorders of ocular motility, fever, and movement disorders, although virtually any neurological sign or symptom could be exhibited, with day-to-day, and even hour-by-hour shifts in symptomatology. The chronic phase could occur months to years later and was most commonly characterized by parkinsonian-like signs.

Psychiatrists and neurologists first reported encountering encephalitis lethargica symptoms in 1916 and 1917 in Austria and France. By 1919, cases had become common throughout Europe, the United States, Canada, Central America, and India. All told, approximately 1 million people worldwide were affected by encephalitis lethargica between its outbreak in 1916 until the early 1930s. While many clinicians (both at the time and since then) have surmised an association between encephalitis lethargica and the Spanish flu,7 there is no conclusive evidence of causality.

Collateral damage

Some medical and social historians have been tracing connections between the pandemic and the other catastrophic global event of the time-World War I. In this regard, historians have flagged the ways in which the war efforts depleted medical personnel, helped disseminate the virus through the mobilization of troops, and created the conditions for the mutation of an otherwise mild flu virus.8

When it comes to mental health, the historical record shows that the pandemic, like the war, took a toll on the emotional resilience of those not (or not yet) in harm’s way. The massive and sudden loss of life plunged many into a chronic state of helplessness and anxiousness. A large portion of the population were affected by the loss of loved ones. Parents had to come to grips with losing a child (or even several children), while some children suddenly found themselves parentless. In November 1918, 31,000 children in New York City alone had lost one or both parents. For others, the experience left them feeling a mix of guilt, anger, confusion, and abandonment. Surviving health professionals were not immune to such sentiments, with many of them noting that they were haunted by a sense of frustration and grief, even years later.9

Like all mass encounters with infectious disease, the Spanish flu pandemic had its own unique features. If history teaches us anything, it is that we should always be measured in how we glean lessons from the past. That said, the example of the influenza of 1918-1920 gives us reason to expect that the present pandemic will carry in tow its own set of mental health challenges.

Source: Psychiatric Times

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Vaccine Passports: what we need to know

The COVID-19 pandemic has killed more than half a million people in the US and has seriously impacted our daily lives. The granting of Emergency Use Authorizations for COVID-19 vaccines has been a game changer in helping to reverse the pandemic onslaught. Demand for the vaccines currently far exceeds supply nationwide. They have become the golden ticket that can transport us back to a time when routine activities, such as attending school or taking vacations, didn’t seem fraught with danger. What’s the best way to go about re-establishing these activities? One idea that’s getting discussed seriously is giving those who have been immunized a vaccination passport (VP).

What is a vaccination passport?

Let’s start by clarifying some terminology. VPs are documents that show that someone has been given a vaccine(s) and is therefore presumed to be immune from getting and sharing that disease. These are distinct from diagnostic tests to determine if a person is or is not infected with a particular virus (PCR and viral antigen tests) or has been exposed to a virus (antibody tests). VPs are the modern day equivalents of the “letters of transit” that played a key role in the film Casablanca. They’ll enable you to travel freely.

Why give vaccine passports?

Vaccinated people are unlikely to transmit the virus that causes COVID-19 with others, though this has yet to be definitely proven. So, what’s the primary rationale for giving vaccination passports? It seems the goal is to incentivize people to get vaccinated. Folks might be more likely to seek out the vaccine if it bestows upon them certain privileges, such as being able to travel freely. While the idea might sound appealing at one level, the road to vaccine passports is pockmarked with political potholes and littered with logistical land mines.

Administrative issues

There are a lot of important questions that need to be answered before VPs can become widespread; it’s unlikely there will be a “one size fits all” solution. What might VPs look like? Pieces of paper (that could easily be lost or counterfeited), or a digital key or document you store on your smartphone (that many older folks still don’t have)? If you lost one, how would you get it replaced? Would your vaccination records be tied to your other medical records, and if so, what kind of privacy and security protections would be needed to safeguard your data? How would the passport administrator verify that you got vaccinated in the first place? Who is responsible for correcting any errors that crop up? Given how much we’ve struggled as a nation to simply solve the scheduling of vaccinations, VPs might be significantly more difficult to manage.

Who’s going to run the program?

A coalition of health tech leaders (including Epic, the Mayo Clinic, Microsoft and Salesforce) has started the Vaccination Credential Initiative to create an internationally accepted digital health card. Its vision – as stated on its website – is “to empower individuals to obtain an encrypted digital copy of their immunization credentials to store in a digital wallet of their choice. Those without smartphones could receive paper printed with QR codes containing World Wide Web Consortium (W3C) verifiable credentials.” Some European countries (e.g. Denmark) are working on developing their own immunization passports, and the President of the European Union Commission has voiced support for them.

We already have a hodgepodge system designed to keep folks with COVID-19 from traveling. Many airlines are requiring proof of non-infectivity to board a plane – these are distinct from VPs. The methods adopted vary from airline to airline: United uses Travel Ready Center, American uses VeriFly while others use Common Pass. Saga cruises are the first in the UK to demand proof of vaccination, but not everyone is on board with the concept. The World Travel and Tourism Council stated its opposition to allowing travel only by those who have been vaccinated, on the grounds that it is discriminatory.

Discrimination concerns

The concept of gaining advantage from one’s immunological status is not a new one. In New Orleans in the mid 19th century, great economic value was attached to those who survived the onslaught of epidemic waves of yellow fever. A mix of structural racism and a system valuing “immunocapital” ranked men and women highly if they were yellow fever survivors. Those that had not had the disease yet found it difficult to obtain work or obtain credit and women could not marry. Slaves were similarly revalued, with larger assessments attached to survivors. This legacy of viral discrimination casts a long shadow over current discussions surrounding vaccination passports.

Also problematic is the fact that not everyone will be eligible for VPs. Some people can’t be vaccinated for medical reasons but would still like to participate in whatever activities the passports enable (such as travel opportunities). These individuals will likely file complaints if they are denied VPs, arguing that they’re discriminatory in nature. Vaccine opponents will no doubt also file lawsuits seeking to block the use of VPs, claiming they represent an attack on their freedoms and personal choice.

Others may be shut out of VP programs because they don’t have the computer skills to register online, a problem that’s turned out to be widespread with the vaccinations. Don’t have any ID? In some places this prevents the most vulnerable from getting the COVID-19 vaccine, and therefore VPs as well. Many Black and marginalized communities are already deeply suspicious of the medical establishment, and wary of receiving a COVID-19 vaccine. Restrictions that prevent these groups from participating in various societal activities because they don’t have VPs will echo the Jim Crow days of poll taxes and literacy tests that were required to vote.

Enforcement issues

VPs bring up a similar issue as mask mandates: who is going to enforce them? It is one thing for a cruise line to do so, since reservations are required and extensive paperwork needs to be filled out in advance. Who is going to keep non-vaccinated people out of restaurants or concerts that require proof of vaccination? We’ve already seen anti-maskers storm department stores, ignore requirements to wear masks on planes and even kill a security guard who confronted them.

Black market for vaccine passports

Many airlines are now requiring proof of a negative COVID-19 test before they will let their customers fly. This has led to a black market for fake negative COVID-19 test results for those who are looking to game the system. Similarly, bogus cards claiming that the cardholder was exempt– for medical reasons – from having to wear a mask, have been manufactured and distributed. It’s not hard to imagine that a similar market will emerge for VPs.

Overcoming vaccine hesitancy

Given the multitude of issues and concerns listed above, moving forward with issuing vaccination passports seems highly problematic. If the primary purpose of having VPs is to drive up immunization rates, that can be better accomplished by running public service announcements and ads illustrating how liberating it is to start doing normal activities once vaccinated. A nationwide campaign to do just that is already in the works. I personally can think of a better use for the time and money that will be spent on establishing VPs: use them to focus efforts on overcoming vaccine hesitancy in concert with combatting the high tide of online vaccine misinformation and disinformation.

Source: Technology Networks

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