The vaccine for the 2014–2015 flu season was only 29 percent effective against the influenza A strain. A great number of elderly patients caught the flu and died from the bacterial pneumonia that followed. In England and Wales, government statisticians saw this bump in the numbers. In January 2015, for example, there were an additional 12,000 deaths compared with the previous January. There had been a steady decline in the death rate over three decades, and yet here it was, now rising by more than 5 percent. No one was quite sure what was happening. Perhaps cuts to the National Health Service were to blame. There were fewer ambulances, longer waits to be seen in emergency departments, and more shortages in hospital staff than ever before. But there were no cuts to the Scottish health service, and the death rate there increased by more than 6 percent. Across Europe, in those older than sixty-five, there were 217,000 more deaths.
It isn’t surprising that the vaccine was off that year; sometimes the vaccine matches the strains in circulation, and sometimes it doesn’t. What is surprising is the way calculating financial institutes treated the spike in deaths. Fewer elderly people meant that fewer retirement benefits were being collected, which was a boon for those who managed retirement funds. The increase in deaths freed up more than £28 billion in pension liabilities, meaning banks and managers had a giant windfall of money to invest elsewhere. The spike was almost certainly an anomaly, but the financial sector scrutinized it for any hint of a trend. There was too much money in the game to do otherwise.
“From a pension scheme perspective, this new data is still only a snapshot,” said Andrew Ward, a partner at Mercer, one of the largest human resource companies in the world. But “some significant risks remain in a world where an extra year of life expectancy can add 5% to liabilities.”
These are dispassionate and rather cruel calculations, but business is business. I studied for an MD, not an MBA, and medical school then did not include any classes on the business of medicine. It should have. Health care and business are fused together. Health care costs money, and money can be made in health care. Influenza arrives with the regularity of the opening bell of the New York Stock Exchange. We buy insurance against it, stockpiling Tamiflu and other medicines in those warehouses at great cost, in an effort to prevent an even costlier pandemic, the ultimate liability. Flu affects business, and business in turn affects the flu.
It has been like this for at least a century. In 1918 the elderly lived on pensions and didn’t have much life insurance. Young adults, on the other hand, were more likely to have life insurance, and were also dying in greater numbers during the pandemic, meaning insurance companies stood to lose. And that’s precisely what happened. In October 1918, the Equitable Life Assurance Society paid out over seven times more claims than it had done the previous year. The Metropolitan Life Insurance Company paid out $24 million more in claims than it had expected. That’s $370 million in today’s numbers.
The life insurance business took a hit. But there were other economic effects of the 1918 pandemic, some of which benefited those who survived. Droves of working-aged men and women fell ill and stopped working, resulting in a labor shortage. Since so many middle-aged adults died, the labor supply dwindled, and workers demanded higher wages. In states and cities that had a higher flu mortality, workers experienced a higher growth in wages. The flu’s positive impact on per capita income growth was “large and robust” in the years following the pandemic, according to one economic study. What was a tragedy for one family turned into an opportunity and a better standard of living for another.
The pandemic, though, was ruinous for many businesses. In Memphis, the railway service was cut because there was no one to run the cars. In Kentucky and Tennessee, coal mining production dropped by half. In Little Rock, merchant income declined by 70 percent. New York City staggered business hours to cut down on person-to-person contact, but owners and manufacturers lodged complaints against the Board of Health, claiming it had overreached. Soon the timetable for banks, theaters, and department stores was renegotiated to allow longer opening hours.
The flu influenced economics at an individual level too. In 1918, the poor were more likely to die of the flu than the rich. Crowded living conditions were the perfect environment for the virus to spread via coughs and sneezes from person to person. Those who were socioeconomically disadvantaged were poorly nourished and more susceptible to the disease and its complications. One report found that the poor were three times more likely to die from influenza than were the “well-to-do.” Those who lived in a four-bedroom apartment had a 56 percent lower mortality compared with those who lived in a one-room apartment. The wealthy were certainly not immune—the flu killed former president Grover Cleveland’s sister, family members of Sherlock Holmes creator Sir Arthur Conan Doyle, and future president Donald Trump’s grandfather Frederick, but then, as now, socioeconomic class was a strong predictor of health and survival.
The financial impact of the 1918 virus even reverberated into the future and the lives of those not yet born. Douglas Almond, an economist from Columbia University, analyzed three large populations from the time: those born in 1918 who were exposed to the pandemic as infants, those born in 1919 who were exposed to it in utero, and those born in 1920 who were not exposed at all. The in utero group had higher rates of physical disability, achieved a lower level of education, and earned lower incomes as adults. Compared with the other two cohorts, the in utero group were 5 percent less likely to finish high school and earned almost 10 percent less. They were also more likely to receive welfare benefits and to end up in jail. Another study found that those exposed to the virus in utero had 20 percent more heart disease by the age of sixty. The effects of pandemic influenza were felt for decades and in ways no one could have guessed.
Some individuals and businesses benefited from the pandemic. Mattresses were in high demand, since many of the sick were marooned at home and on bed rest. Drugstores were doing a brisk trade, as were undertakers. There was a sixfold increase in the cost of funerals in Philadelphia. The Washington Post was outraged by what it called “the ghoulish coffin trust” that was “holding the people of this city by the throat and extorting from them outrageous prices for coffins and disposal of the dead.” If your trade was death, the flu was a balm for your bottom line.
The entwining of business and health during the great flu pandemic was vividly demonstrated at the Strand Theatre in New York. In October 1918, with the pandemic now plainly in the public eye, a new Charlie Chaplin movie opened. Shoulder Arms was a Great War comedy that took place on the battlefields of France, and audiences loved it. Perhaps they wanted a distraction, and a reason to leave their homes. The crowds were so large that the Strand extended the film’s run. Harold Edel, its twenty-nine-year-old manager, took out a full-page ad in the weekly Moving Picture World. Some theaters were shunned by “panic-stricken people,” Edel wrote, so he wanted to congratulate those who “take their lives in their hands to see it.” At the bottom of the ad, double-underlined and in a huge font, was the recommendation of the Board of Health to “AVOID CROWDS.” Edel’s ad continued: “New Yorkers took their life in their hands and Packed the Strand Theatre all week.” It was splendid news for the business during a period of dark turmoil. Edel, alas, never got to see his ad in print. He died of influenza a week before it went to press.
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Nearly a century later, another man reaped rewards from the flu—or at least the fear of it—and wound up dead. In 2005, at the age of only twenty, Evan Morris was hired by the pharmaceutical giant Roche to work in its Washington office as a lobbyist. Before long Morris was in charge of a team of junior lobbyists and had a $50 million budget to influence government policy. To grease the wheels and keep politicians beholden, Morris directed $3 million in political donations to both Democrats and Republicans. He became one of the most successful lobbyists in Washington. In 2007 he bought a $1.7 million home in the suburbs of Washington. His garage contained a number of Porsches.
Washington is crawling with lobbyists. There were 11,000 of them in 2016, armed with $3.1 billion to ply lawmakers and the federal government, with the goal of supporting rules and regulations that are friendly to business. The biggest industry for lobbying that year was not the energy sector, where a paltry $301 million was spent. It wasn’t the defense sector; lobbyists there deployed only $128 million. The industry that spent the largest amount on lobbying was then—and is now—health care. In 2016, health care companies spent around $500 million on lobbying, and half of this sum came from the pharmaceutical industry. Evan Morris was a big player in a big field, and he enjoyed wild success because of the flu.
In the weeks prior to President George W. Bush’s 2005 announcement about new policies to address pandemic influenza, Morris had hired consultants with a single mission: to stir up fear about avian flu in order to sell more Tamiflu. Whether or not this actually influenced the president’s announcement, Morris was pleased with the result. The government bought more than $1 billion worth of Tamiflu for the Strategic National Stockpile. Morris continued to lobby on behalf of Roche, the manufacturer of Tamiflu, and was compensated handsomely to do so. In 2011 he paid $3.1 million in cash for a waterfront property on the Chesapeake Bay. He called it “the house that Tamiflu bought.”
Then Morris’s employer received an anonymous warning of his “unusual financial arrangements,” according to a riveting story about him in the Wall Street Journal. Morris allegedly embezzled millions of dollars to fund his extravagant lifestyle, and gave illegal kickbacks to clients. On July 9, 2015, he was summoned to a meeting with the head of legal affairs at his Washington office. Morris, realizing that he was in trouble, cut the meeting short and left quickly. He bought a gun, drove to his favorite golf course, ate a steak dinner, and bought everyone a round of drinks. He walked to a fire pit a few hundred yards from the clubhouse, a bottle of expensive champagne in his hand. He texted his wife the details of his life insurance provider and financial planner. Then he shot himself.
It’s impossible to say whether one man caused the United States government to buy $1 billion worth of Tamiflu. But it’s clear that one man became disproportionately wealthy marketing a flu-related product. When profit is as much of an incentive as is the public good, you get a story like Evan Morris’s.
Lobbying, of course, can be a force for good, especially against pandemics. Many groups over the last few decades advocated for more HIV research. As a result, 10 percent of the budget of the National Institutes of Health was eventually set aside for that purpose. That’s about $3 billion each year—a huge amount, especially given that less than 1 percent of the U.S. population is infected with the virus. Activists and lobbyists brought a neglected disease to the attention of lawmakers, which resulted in more research dollars. While HIV is still a serious disease, antiviral medications have turned it from a life-threatening plague into a chronic but largely manageable condition. Those medications would not exist without people lobbying their government.
There are several sectors that gain from lobbying about pandemic influenza. Scientists want support for their research into better drugs and better vaccines. Federal agencies like the NIH and the CDC may receive more funding. Pharmaceutical companies want to make and sell vast quantities of their products. Without a government commitment to purchase millions of vaccines and antiviral medications for the stockpile, companies wouldn’t invest billions to bring them to market.
We are directing money to the problem. Nearly $213 million, in the case of one particular office in the Department of Health and Human Services. Brace yourself for more acronyms. The department’s Office of the Assistant Secretary for Preparedness and Response (ASPR), created in 2006 in the wake of Hurricane Katrina, is charged with preparing for and responding to natural disasters and public health emergencies. And 11 percent of its budget goes to planning for outbreaks of infectious diseases and pandemic influenza. Is that enough?
Not according to one former ASPR official. “We are better prepared than we have ever been in the past, but we are not fully prepared for a flu pandemic,” he told me. He pointed out that, unlike natural disasters, epidemics have “a slow rollout.” The slow but steady manner in which influenza arrives means that we often lose focus on it; federal dollars are directed to more pressing and visible disasters, like a flood or an earthquake that strikes with no warning and causes immediate and urgent humanitarian needs.
The allocation of federal resources toward preparedness is cyclical. Something bad happens, or a function of government fails, and dollars are sent to fix the problem. As time goes by without a major recurrence, a kind of preparedness fatigue takes over. New priorities are set, and money is directed to other areas—until there’s another disaster, at which point the whole cycle starts again. It’s either panic or neglect. As a result, monetary support for influenza preparedness varies from budget cycle to budget cycle. In 2014, ASPR received $111 million for pandemic flu preparation. A year later the budget dropped by 60 percent, to $68 million. But the news was better in 2017; the budget for pandemic influenza increased to $121 million. Such wide swings make it very challenging to plan for more than one year at a time, and make it almost impossible to fund multiyear research programs. We need to bake influenza preparedness into the health care system, so that we can focus on the bugs and not on the budget.
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Spending on preparedness is only one piece of the influenza pie. The NIH is heavily invested in influenza research. Each year it spends about $220 million on research projects that cover everything from investigating how the virus evolves to creating better vaccines and the next generation of influenza medications. The NIH estimates that every one dollar it spends on research stimulates private industry to spend eight. In that respect, influenza is not a drain on our economy. It’s a steroid. It supports jobs and businesses across the country, including a start-up that will test for influenza from your living room couch.
We have in-home kits to measure our cholesterol, to tell us if we are pregnant, and to detect HIV infection. But there is not a home flu detection kit—yet. A California company called Cue hopes to provide such a kit as part of a suite of medical tests so that, in the words of its infomercial, “you can hold the power of your health in your hands.” The infomercial then cuts to a child of perhaps four or five having his nose swabbed. Mom inserts the swab into the Cue machine, a silver box that sits on the desk, and then a message pops up on her iPhone: FLU DETECTED! Mom stays calm as she presses the CONTACT PHYSICIAN link. And presto: a doctor pops up on the screen to say that he’s sending a prescription to the local pharmacy. Meanwhile, an alert is sent to Dad: FLU DETECTED IN YOUR FAMILY NETWORK.
Cue’s two founders first thought of home influenza testing in 2009, during the swine flu outbreak. Given the publicity and media frenzy at that time, it was inevitable that a business opportunity would present itself. Cue initially received $2 million from angel investors, and another $7.5 million in 2014.
“The business is based on the razor-and-blade model,” explained one of the founders. “We don’t plan on making a profit on the razor.” The razor, in this case, is the sleek silver testing unit ($199). The blades are the test cartridges, which are priced at four dollars apiece but must be replenished.
In general, similar rapid influenza tests are not very sensitive. They vary greatly, and the best have a sensitivity of only 75 percent. This means that if you have influenza, the test will detect it only 75 percent of the time. Or, put another way, 25 percent of people with influenza will not be told by the test that they have it. That’s not very reassuring, and shows how limited these tests can be.
Cue also makes a rapid vitamin D test. Might that be useful in the fight against influenza? A better question is why measure your vitamin D level at all? All you need is fifteen minutes of sunshine on your face or arms three times a week, and your body will make all the vitamin D it needs. If you are really worried, you could take a vitamin pill each day. Just to be sure. If you did that, your vitamin D levels would be perfect. And there would be no need to measure levels every day.
If you have a couple of hundred dollars to spare and you like shiny products with a Bluetooth connection, Cue might be for you. But for the majority of us, getting a message on your smartphone that your symptoms are caused by influenza is going to be of little benefit. I doubt the elderly or chronically ill would invest in technology like this, which might be just as well. When they come down with symptoms of influenza, these at-risk groups are more likely to really need medical care—which they should seek without waiting for an app to tell them to do so.
Even though flu provides business opportunities, no one wants to see a 1918-style outbreak to help the economy. In fact, the opposite is likely to occur. To understand the scope of the economic mayhem that could result from a bad influenza outbreak, a paper aptly titled “Total Economic Consequences of an Influenza Outbreak in the United States” is a good place to look. And the news isn’t reassuring. The paper’s three authors, all economists, built a complex model that took into account some of the largely overlooked consequences of an influenza epidemic. Consider tourism, for example. Pandemic flu would frighten off domestic and international tourists, and all the associated industries would suffer, from airlines to hotels. Travel restrictions might decrease sales at the gas pump, at movie theaters, and on public transportation. Truck drivers would be out sick, hampering the supply of everything from heating oil to potatoes. Each of these sectors would see an economic downturn. When these and many more scenarios are factored in, the estimated cost of a severe influenza outbreak in the United States is between $20 billion and $25 billion. That’s about the same as the economic loss that would result from a two-week total electricity blackout in Los Angeles County.
But it’s a two-way street between the flu and business. Airlines would suffer from a pandemic, but air travel might have helped cause it. Just as passenger ships brought the 1918 virus to vulnerable communities, the confined metal tubes that carry us through the skies are perfect flu incubators. We had no idea of just how big a part they played in the spread of influenza until another devastation occurred: the terrorist attacks on 9/11. There was a dramatic reduction in flights following the attacks, and a decrease in air travel persisted for some time. That year, the peak activity of the influenza virus came two weeks later than usual.
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Perhaps no big business is more quintessentially American than the yearly spectacle that is the Super Bowl. But don’t encourage your favorite team too much. It turns out that if your local team makes it all the way, your risk of catching influenza back home increases.
Charles Stoecker is a health economist at Tulane University and has taken a deep dive into the effect of the Super Bowl on influenza. Several years ago, he was attending a research conference in Houston when he heard a news report about a shortage of exotic dancers. Huge crowds of young testosterone-charged men descended on the city when it hosted the Super Bowl, and there were not enough exotic dancers to meet the demand at local strip clubs. There was a suggestion to bus these entertainers in to fill the gap in the workforce. This got Stoecker thinking about the health consequences that might occur as a result. Might it lead to more cases of sexually transmitted diseases? Stoecker quickly realized that it would be impossible for him to access the data he would need to answer that question, but a research seed had been planted.
The Super Bowl takes place every year in February, which is often a peak influenza month. How, he wondered, might participation affect influenza deaths? Stoecker had a theory: If your local team makes it to the Super Bowl, there will be more people back home watching the game at sports bars and restaurants. More fans will hang out in close contact at Super Bowl parties, sharing food and drinks. This increased social mixing would spread more influenza, which would, so the theory went, increase the number of deaths, especially in the elderly.
To test his hypothesis, Stoecker analyzed twenty-five years’ worth of data on flu deaths and on Super Bowl appearances. The title of his paper was “Success Is Something to Sneeze At”; sending a local team to the Super Bowl, he found, causes an 18 percent increase in influenza deaths in the elderly in the team’s hometown. In the years in which the Super Bowl was scheduled closer to peak flu activity, the effect was even greater; there was a sevenfold increase in influenza deaths back home. Even if they did not attend Super Bowl events at the same rate as the younger crowd, the elderly were at risk because the number and mobility of people carrying the virus increased.
To be sure that the effect was real and not just a statistical fluke, Stoecker analyzed influenza deaths back home in the seasons right before and right after a city sent a team to the Super Bowl. If the flu bounce was really due to the Super Bowl, the mortality rates over these periods, when the local team was not in the Super Bowl, should have stayed the same. And they did. There was no significant change in the usual deaths from influenza. As a control for his experiment, Stoecker looked at deaths from other causes, like heart attacks, cancer, accidents, and suicides. If the mixing theory was correct, it should affect only transmissible diseases like influenza, and not any of these other conditions. And when he looked at the numbers, there was no bump in local deaths from, say, cancer in the year that a city sent a team to the Super Bowl. That is precisely what you would expect if the mixing theory was really the cause of the increased influenza mortality.
The data also showed that in the cities that hosted the Super Bowl, rather than the ones that sent a team there, the influenza rate was unchanged. Travelers to the Super Bowl were not infecting the local population. This, too, makes sense. Cities that host the event are generally warm despite the wintry season. That’s the reason they are chosen to host in the first place. But influenza likes it cold. The weather in the host cities mitigates any effect on the rates of influenza deaths that social mixing might have.
“Your Team Made the Super Bowl?” asked a headline in the New York Times when Stoecker’s results were published. “Better Get a Flu Shot.”
Health care experts often talk about the burden of diseases in our society, and rank them in order of how deadly they are. That’s why you’ve heard that the number one killer is heart disease, and cancer the number two. Influenza and pneumonia, which are listed together, come in at number eight, just below diabetes but higher than kidney disease. But digging a little deeper into the effects of influenza reveals a story far more complex than a top ten list of deadly diseases. The virus infects so many aspects of society, from secret stockpiles to Super Bowls, from the global economy to average life expectancy.
The 1918 pandemic had serious economic consequences, some of which were apparent only decades later. A century after the great pandemic, influenza threatens our economy in unpredictable ways, and we have entire industries and government offices dedicated to battling it. They consume and generate millions of dollars each year, sometimes for the greater good, and sometimes in a wasteful or corrupt fashion. Our lives—not just our personal health—are interwoven with the flu, in ways that we are only beginning to understand. Just when we think we’ve got a handle on its behavior, the virus dodges our grasp and defies our expectations. It is an invention of nature that so far outmatches the cunning of humanity. When will our intellect outpace the ingenuity of the flu? Not soon enough.