Shrugs Over Flu Signal Future Attitudes About Covid

When Dr. Arnold Monto, a public health researcher at the University of Michigan, lectures about influenza, he starts by saying: “Flu is bad.”

“You don’t have to start a lecture about hypertension by saying, ‘Hypertension is bad,’” he noted. It’s self-evident.

But he has to convince his audiences that flu is, in fact, bad.

In good years, it kills Americans in the low tens of thousands and sickens many times more. Yet even in the time of Covid, flu, the other respiratory killer caused by a virus, is underestimated. Almost half of American adults don’t bother to get vaccinated against it. Despite the ongoing Covid experience, researchers and historians don’t expect Americans’ attitudes toward flu to change much.

“Statistics on flu have been given to the public; the public has been beaten to death with them for decades,” said Dr. David Morens, a flu researcher and senior adviser to the director of the National Institute of Allergy and Infectious Diseases. “And they just don’t care.”

Some researchers and historians are examining attitudes toward flu for clues about how Americans will deal with Covid in the years to come. Will Covid, like flu, be a serious infectious disease that the public shrugs off even as it continues to cause large numbers of deaths each year?

Public attitudes toward flu, historians and public health experts say, are revelatory — and illustrate the paradoxical thinking about risks and diseases.

“It’s a story of how we get used to living with the toll of a virus and don’t count it or see it or care or fear it too much,” said Dr. Robert Aronowitz, a historian of science at the University of Pennsylvania.

Americans have taken flu’s toll for granted, Dr. Morens said, despite the fact that it’s “not so far behind heart disease and cancer.”

“People get excited about acute things, shocking things that happen all at once,” he said, citing Covid or Ebola or, when the disease first emerged in the 1980s, AIDS.

Just over half of Americans get vaccinated against influenza. And despite the fear of respiratory viruses that Covid might have instilled, the percentage of all Americans vaccinated during this latest flu season was about the same as it was in the 2019-2020 season. It was only because of lockdowns and the avoidance of crowds and other gatherings that flu nearly disappeared last year.

Rapid tests for flu are widely available, but sick patients are not often tested. Antiviral drugs help if taken soon after symptoms begin, but they are taken infrequently.

“I think, for the public, ‘flu’ means minor illness,” Dr. Monto said. But in bad flu years, hospitals are filled, and elective surgeries are postponed. “People forget that,” he said.

In typical flu seasons, the virus kills mostly older people and babies. But when new strains emerged, flu killed an estimated 70,000 Americans in 1957 and an estimated 100,000 in 1968. More than half of those who died in those two pandemics were under 65.

Yet flu almost never shows up on death certificates, even when it is the proximate cause of death. And with little testing, the federal government is forced to use statistical manipulations to make estimates of infections and deaths that have wide error bounds. Even with those uncertainties, the Centers for Disease Control and Prevention estimates that at least 24,000 to 36,000 Americans die of flu in an average year, and nearly 100,000 die in really bad years. Most recently, in 2018, the year before the coronavirus emerged, 380,000 Americans were hospitalized with flu and an estimated 28,000 died.

And that is just the tip of an iceberg. As with Covid, many get a mild respiratory disease that they do not recognize as flu or they get a symptomless flu. Unaware that they are infected, they can then spread the virus.

In years like this one, when the flu vaccine was at best minimally effective, many are skeptical about getting the shots, which are widely available. Dr. Monto said there are efforts underway to produce much better flu vaccines. But, he said, because Congress is not very interested in seasonal flu, the National Institutes of Health had to tie requests for funds for flu vaccine research to pandemic preparedness.

Historians say a nonchalance about flu dates back to at least the 19th century.

Nancy Bristow, chair of the history department at the University of Puget Sound, looked at newspaper articles and other sources from the end of the 19th century and into the 20th century and found “a perennial refusal to pay attention to flu as a serious illness.”

Flu was not frightening, Dr. Bristow said, “because it was so familiar.” It was not even a reportable disease until the 1918 pandemic.

People made light of the flu in advertisements. One published in the Atlanta Constitution in 1890 said: “Kerchew! Achew!-Hew!!! Most every one has the Grippe in some form, and we would like to get Our Grip on your purchase of Furniture, Carpets, Mantels, Etc.” (Flu was once referred to as Grip or Grippe — the French word for influenza.)

An ad from the Golden Eagle Clothing Company suggested a “doctor’s prescription” for a “poorly-clad boy” who “was suffering from la grippe,” writing, “The doctor has influenz-ed his mother to purchase one of those $2.50 all wool boys’ suits.”

Occasionally, public health officials issued warnings. One that Dr. Bristow found was published in 1916 in the Journal of the American Medical Association. It said: “Don’t laugh at the grip. It is a deadly and dangerous thing.”

The laughter stopped in 1918, when a new influenza strain caused a pandemic with a frightening mortality rate. But when that pandemic ended, Dr. Bristow said, complacency resumed. People wanted to put that awful period behind them.

Margaret O’Mara, a professor of history at the University of Washington, said that even though masks were common and mandatory during the pandemic, when she looked at photographs from 1920, nobody was wearing one.

Attitudes toward serious diseases are so unpredictable and inconsistent, said Tom Ewing, a flu historian at Virginia Tech.

“From the perspective of a historian, this question of when diseases become noticeably significant really varies,” he said.

“Why do we become fascinated and obsessed by certain diseases that are seemingly out of proportion to their effects?” Dr. Ewing asked.

He does not think today’s fears of Covid will spill over into similar concern about flu. Instead, he said, attitudes toward Covid will become more like attitudes toward flu.

“Historians hate to prognosticate about the future,” Dr. Bristow said. But, she said, she sees a shift in views about Covid taking place already.

President Biden told the nation in his State of the Union address this month, “COVID-19 no longer need control our lives.”

“It’s fascinating,” Dr. Bristow said. “We are in the process of being told how to live with something we were told to be afraid of.”

He added, “We are watching the culture trying to teach us not to be terrified.”