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This chapter deals with the nature of pandemic influenza, and demonstrates that in spite of the cavalier approach that frequently characterizes popular attitudes (“Oh, it’s nothing, just a touch of the flu”), influenza is a serious disease that must not be taken lightly. In fact, influenza caused the greatest pandemic in humanity’s history in terms of the actual number of deaths. The misnamed “Spanish Flu” of 1918, in contrast to most influenza pandemics that target infants and the elderly, hit especially hard among younger adults, and caused more deaths than any great war. Worldwide, it killed more than the Second World War, and did so in a brief period.
What happened before can happen again, and given the nature of influenza, it could recur in even more virulent form. Moreover, there are other viral infections that could ultimately prove to be even more of a threat.
America expends considerable resources guarding against terrorist attacks that might occur. This is appropriate, but what is not appropriate is that the country spends relatively little against pandemics that assuredly will take place at some time.
KeywordsEbola “Spanish flu” Popular culture Literature History Death toll from flu
Influenza Is Not to Be Taken Lightly
A clear understanding of the situation must first rest upon recognition that, as health professionals are well aware, influenza, even under normal circumstances, is not a benign disease. Recent attention to the possibility of an outbreak of avian flu—or “bird flu”—may to some extent have increased public awareness of its disastrous potential, but it is still common to hear influenza dismissed as little more than a mere inconvenience, as in “Oh, it’s nothing much; just a touch of the flu.”
Cavalier attitudes notwithstanding, “CDC scientists estimate that an average of 36,000 people…die from influenza-related complications each year in the United States.” 1 That is, in each normal year, and in each of those normal years, influenza results in some 200,000 hospital admissions. These figures are hardly trivial. To be sure, they are imprecise. Many of the deaths result from pneumonia and other respiratory complications that accompany influenza, thus creating ground for questioning whether so many deaths “really” result from the flu. 2 On the other hand, one does not have to search hard to discover assertions in print that in a normal year the death toll may be greater yet.
As is often the case, precision is elusive, but for our purposes, it is also unnecessary. The clear and important fact is that influenza is a serious illness that causes numerous deaths even in an ordinary year—and some years are far from ordinary. The Asian flu pandemic, for example, was responsible in 1957 for some 80,000 deaths in the USA, and around two million worldwide. 3 Even though he noted the American death toll, and wrote that the Asian flu “sickened some 25 to 30 percent of the American population,” Adam Volland in U.S. News and World Report could say that the 1957 strain “wasn’t particularly potent.” 4 Perhaps not, and certainly not in comparison with what had taken place nearly four decades before, but those who suffered and survived the 1957 pandemic can attest to the truly debilitating nature of the Asian flu while it lasted.
A personal note may be in order here. I was in graduate school, at that time, and remember being incredibly ill, probably the sickest I have ever been, and for several days. My wife was unable to eat or drink anything, even a sip of water, without vomiting. Her nausea had lasted three days. The doctor who examined her at her bedside—those were the days when physicians still made house calls—said that the next morning he would have to order her hospitalized, unless she began to be able to take fluids and nourishment. Fortunately, by then she had begun to tolerate sips of water and a few bites of a bland cookie normally sold for babies. “Debilitating” hardly describes the violent nature of the illness, as strong as that word is. It is not something that one forgets.
Influenza at Its Most Horrendous—So Far
The Asian flu pandemic was neither the worst nor the mildest of the influenza pandemics of the century. John M. Barry, historian and journalist, has produced the definitive study of the worst, the “Spanish Flu” that erupted in 1918, and swept the world quickly in three waves. Barry’s work reflects deep immersion in the subject, so great that it inspired praise from the American Medical Association, and brought him relevant academic appointments (such as the post of visiting scholar at the Center for Bioenvironmental Research at Tulane and Xavier Universities).
“Not all pandemics are lethal,” he pointed out, and described the three that swept around the world in the century that recently ended. “The most recent new virus attacked in 1968, when the H3N2 ‘Hong Kong flu’ spread worldwide, with high morbidity but very low mortality—that is, it made many sick, but killed few,” he said. “The ‘Asian flu,’ an H2N2 virus, came in 1957; while nothing like 1918, this was still a violent pandemic. Then of course there was the H1N1 virus of 1918, the virus that created its own killing fields.” 5 It was this fierce pandemic—the so-called (and misnamed) “Spanish Flu”—that led the Ford administration to launch its NIIP when a new swine flu virus was discovered that appeared to be similar to the agent that caused the 1918 pandemic.
Never had anything in humanity’s entire history—war, famine, pestilence, or anything else—infected so many human beings, and killed so many in such a brief period. “In 1927, a scholar put the Spanish Flu’s global mortality at 21.5 million. In 1991, a systematic recalculation raised it to 30 million. A later estimate, published in the Bulletin of the History of Medicine, sets the minimum mortality at 50 million, with an upper limit of 100 million.” 6 Deaths from the Spanish Flu, a worldwide pandemic in roughly one year, were at least equal in number to the entire death toll a generation later from the greatest war humanity has ever fought, the Second World War; most likely, in fact, flu deaths in 1918 had been far greater in number than those from the later war. Note, also, that World War II took more than six times as long as the Spanish Flu to produce its total deaths. During the 1918 pandemic, an estimated one-third of the entire population of the world at the time, somewhere around 500 million people, “were infected and had clinically apparent illnesses.” 7 To be sure, the plague in the 1300s killed a far greater portion of the population (at least the European population). More than one of every four Europeans died, “but in raw numbers influenza killed more than plague then, more than AIDS today.” 8
The name “Spanish Flu” came to be applied to the disease because its toll in Spain was great. This was “to Spain’s consternation. After all, other countries of Europe, as well as the United States and countries in Asia, were hit too in that spring of 1918. Maybe the name stuck because Spain, still unaligned, did not censor its news reports, unlike other European countries. And so Spain’s flu was no secret, unlike the flu elsewhere.” 9
The point of origin almost certainly was not Spain, and in fact seems to have been in the USA. Barry traces it back to Kansas, and believes it originated early in 1918 in Haskell County. He says that the evidence suggests that from there the “virus traveled east across the state to a huge army base, and from there to Europe, through South America, through Asia and Africa, through isolated islands in the Pacific, through all the wide world.” 10
By whatever name, the influenza of 1918 was devastating. When victims of most strains of influenza die, the likely cause is pneumonia or some other secondary infection that the flu-weakened patient is too weak to withstand. The 1918 flu killed directly. Of course, it was also responsible for deaths from secondary causes. Most strains of influenza, as one would expect, cause the greatest number of casualties among the elderly and the very young. For reasons that even now are not clear, the 1918 flu tended to strike young, healthy, adults. “The attack rate and mortality was highest among adults 20 to 50 years old.” 11 And it hit quickly. Many times a strong, young, man or woman would awaken feeling healthy and well, only to become “sick by noon,” and die “by nightfall.” 12 Infants and the elderly did die, but “in 1918 the great spike came in the middle. In 1918 an age graph of the dead would look like a W.” 13
The pain was unbearable. “Patients would writhe from agonizing pain in their joints.” They would “suffer extreme fever and chills, shuddering, shivering, then huddling under blankets.” Intense pains throughout the body mimicked those from other diseases. There was often spontaneous bleeding from every orifice. Extraordinary earaches and pain seeming to come from pressure within the head were common, as was debilitating pain behind the eyes accompanied by visual disturbances. “Pockets of air leaking through ruptured lungs made patients crackle when they were rolled onto their sides. One navy nurse later compared the sound to a bowl of rice crispies [sic], and the memory of that sound was so vivid to her that for the rest of her life she could not tolerate being around anyone who was eating rice crispies [sic].” 14 Oxygen deprivation, or cyanosis, was so complete that the bodies of those who died had often turned a dark blue, so dark that it was sometimes impossible to tell whether the victim had been white or black. Many of those who survived suffered lifelong damage. The total number of American deaths resulting from the Spanish Flu has been reported to have been as high as 675,000. 15 “Nearly half of all deaths in the United States in 1918 were flu related.” 16
In view of the enormous dimensions of the tragedy, it is astonishing that it seemed quickly to have faded from popular memory. Health professionals are under no illusion regarding the danger from influenza, but even with publicity that has been given in the last decade to the possibility of an avian flu pandemic, there seems still to be a popular tendency to disregard influenza as a major threat to life. A US Navy nurse, Carla Morrisey, in 1986 wrote of the 1918 pandemic in Navy Medicine. 17 She based her article on “an oral history provided by Josie Mabel Brown, a Navy nurse who served at Great Lakes Naval Hospital during the height of the epidemic.” Morrisey was commemorating her great aunt’s—Ms Brown’s—100th birthday. She noted that the 1918 flu “now seems merely a folk memory,” and pondered why it was that “Americans took little notice of the epidemic and then quickly forgot what they did notice.” She said that “the formal histories, magazines, newspapers, and military journals notably ignored the epidemic. Little was noticed and recorded for later generations.” On the other hand, in personal papers, reminiscences, “autobiographies of people who were not in authority,” and the like, “it is apparent that the individual was frightened and his life dramatically changed.” 18 She quoted a rhyme that young girls all over the country would chant as they skipped rope:
Part of the reason for the relative lack of attention, she speculated, was that mass deaths from disease in those days prior to modern medicine were almost a way of life. Also, along with others, she pointed out that the horrors of the pandemic and those of the First World War were almost wrapped together as a single phenomenon. 20
Nevertheless, the pandemic’s effect on the people was so huge as to be difficult to exaggerate, and it did spur enormous activity “among medical scientists and their institutions.” But this was “the single great exception. It did not lead to great changes in government, armies, and corporations. It had little influence on the course of political and military events.” 21 In searching for an explanation, she quoted a comment from H. L. Mencken as the possible reason. “The human mind,” he said, “always tries to expunge the intolerable from memory, just as it tries to conceal it while current.”
Other authorities also speculate on the virtual vanishing of the pandemic from the collective memory. The thoughtful and insightful historian and geographer Alfred W. Crosby pointed out that because of the flu’s death toll, the average American life expectancy in the year 1918 tumbled by 20 years. 22 He thought it remarkable that despite the vast toll in health and even life, the pandemic seemed suddenly to disappear from consciousness. As he pointed out in an extended musing that he called “An Inquiry into the Peculiarities of Human Memory,” there was little mention of the tragedy in either history or literature. 23 He believed the war to have been the major cause. He, too, said that many thought of the pandemic as simply a subdivision of the war. 24
Only occasionally does a writer of that rich literary period allude even briefly to the flu, and it took the traumatic death of his brother, Benjamin Harrison Wolfe, to induce Thomas Wolfe to craft a chapter in his novel Look Homeward Angel using the illness as its theme. 25 There was, however, one major exception in literature, Katherine Anne Porter’s Pale Horse, Pale Rider. Crosby accurately describes it as a “masterpiece of short fiction.” 26
Porter’s work is a brief trilogy of novellas, the third of which is “Pale Horse, Pale Rider,” from which the whole takes its name. Crosby writes, correctly, that it is “the most accurate depiction of American society in the fall of 1918 in literature. It synthesizes what is otherwise only obtainable by reading hundreds of pages of newspapers.” Regardless of that, historians have paid it no attention at all. 27
Porter based her portrait of the time on her own experience as a victim of the flu who nearly died. She was so ill that “her obituary was set in type. She recovered. Her fiancé did not.” Barry describes her “haunting novella” as one of the best—and one of the few—sources for what life was like during the disease.” 28
It is even more than that. Porter also presented a glimpse of what life was like in Wilson’s wartime America, which at least on a national scale probably came closer to totalitarianism than the country has ever been, before or since. (On a regional basis the ante-bellum South had also closed ranks to impose a relentless conformity in its efforts to defend slavery, and it continued its solidarity for a century afterward.) In the Wilson era, this authoritarianism in no way reflected a proto-fascist ideology, but rather a malady that can easily affect democracies: a determined effort to direct all attention to a war effort. The Espionage and Sedition Acts are reasonably well-known, as are some of the period’s other governmental excesses such as the Palmer Raids, but the authoritarian dynamics were not exclusive to government; they existed also at the personal level, and sometimes mixed the personal with the official as in the case of the American Protective League, “a secret service volunteer division of the Department of Justice.” 29 Porter’s main character in Pale Horse, Pale Rider, Miranda, was a young and underpaid journalist making only $18 a week. She was berated, and feared for her job or worse, because she could not afford to pay $50 to buy a Liberty Bond. 30
The novelist Alice McDermott praised Porter’s fine work in a brief segment on NPR’s “All Things Considered.” She had assigned the book to her graduate students at Johns Hopkins University, she said, and one student obtained a lovely, hardbound edition of the 1939 work online. It turned out to be a library discard, stamped “Out of Date, Low Demand.” McDermott titled her presentation, “Why Libraries Should Stock Pale Horse, Pale Rider.” 31
Porter figured prominently in the 1998 PBS documentary “Influenza 1918,” for the series This American Life, in 1998, 32 but the emphasis was on her life, not its fictional portrayal in Pale Horse, Pale Rider. The documentary mentioned the obituary for which her newspaper “quietly set the type.” It even said that “her fever rose so high that her hair turned white, then fell out.” Crosby mentioned that as well. 33 The dramatic production was powerful (if incomplete), using photographs and visual images along with skillful narrative. It quoted Dr. Victor Vaughn, Surgeon General of the Army, who feared that the disease could cause civilization “to disappear from the face of the earth within a few weeks.” But something happened: “just as suddenly as it struck, the calamitous disease abruptly began to vanish.” Why? A Los Angeles County public health official, Dr. Shirley Fannin, provided a likely explanation based on modern understanding of influenza. She said that the disease “probably ran out of fuel. It ran out of people who were susceptible and could be infected.” Although it noted that the tragedy changed the lives of survivors, such as Porter, forever, this documentary, too, marveled that “World War I and painful memories associated with the epidemic caused it to be mostly forgotten.”
To a great extent, and in spite of recent books, documentaries, and warnings about avian flu, the general public still appears to have little knowledge of the horrors in our relatively recent past. Barry agrees with others regarding the reason, saying that “the relative lack of impact it left on literature may not be unusual at all. It may not be that much unlike what happened centuries ago.” One scholar of medieval literature, Barry wrote, said that “while there are a few vivid and terrifying accounts, it’s actually striking how little was written on the bubonic plague. Outside of these few very well-known accounts, there is almost nothing in literature about it afterwards.” Barry speculates that writers deal well with the horrors that people inflict on people, but that they apparently “forget the horrors that nature inflicts on people, the horrors that make humans less significant.” 34
Perhaps he is correct. Despite the recent, and short-lived, near hysteria about Ebola, can there be any doubt that after years of propaganda following 9/11, Americans have been far more worried about possible actions from terrorists than about any threat from a pandemic? This is true even though terrorists at their worst likely present a danger that pales into insignificance beside the 1918 flu, or beyond the real possibility of an even more virulent disease.
CDC (Centers for Disease Control and Prevention), 2003, “CDC Finds Annual Flu Deaths Higher Than Previously Estimated,” Press Release (7 January 2003).
See, e.g., Anita Manning, “Study: Annual Flu Death Toll Could be Overstated.” USA Today, (11 December 2005); http://usatoday30.usatoday.com/news/health/2005-12-11-flu-deaths_x.htm; retrieved 7 June 2015.
Mike Davis, The Monster at Our Door: The Global Threat of Avian Flu. New York: Henry Holt, 2006. p. 36.
Adam Volland, “Lessons From a Bug: A Pandemic Filled Beds but Offered Important Insights,” U.S. News and World Report (20 August 2007), p. 69.
John M. Barry, The Great Influenza. New York: Penguin Books, 2005, p. 115.
See David Brown, 2002, “A Shot in the Dark: Swine Flu’s Vaccine Lessons.” Washington Post (27 May 2002), p. A 9; see also Niall Johnson, and Müller Jürgen, 2002, “Updating the Accounts: Global Mortality of the 1918–1920 ‘Spanish’ Influenza Pandemic,” Bulletin of the History of Medicine, 76:1, (2002), pp. 105–115.
Jeffry K. Taubenberger, and David M. Morens, “History: 1918 Influenza: The Mother of all Pandemics,” Emerging Infectious Diseases (CDC), 12:1 (January 2006); p. 1; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291398/; retrieved 7 June 2015.
Barry, p. 4.
Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused it, New York: Touchstone (Simon and Schuster), 2005, p. 10.
Barry, p. 92.
“Pandemics and Pandemic Scares in the 20th Century,” National Vaccine Program Office, Department of Health and Human Services (12 February 2004); p. 1; http://archive.hhs.gov/nvpo/pandemics/flu3.htm ; retrieved 7 June 2015.
Barry, p. 239.
Ibid., pp. 234–235.
Jeffry K. Taubenberger, “Chasing the Elusive 1918 Virus: Preparing for the Future by Examining the Past.” The Threat of Pandemic Influenza: Workshop Summary. Washington: National Academies Press (Institute of Medicine), (2005), pp. 69–89; reference, p. 73.
Laurie Garrett, “The Next Pandemic?” Foreign Affairs (July/August 2005), p. 2; also available at http://www.foreignaffairs.org.
Carla R. Morrisey, “The Influenza Epidemic of 1918.” Navy Medicine 77:3 (May–June 1986), pp. 11–17; http://www.history.navy.mil/research/library/online-reading-room/title-list-alphabetically/i/influenza/the-influenza-epidemic-of-1918-by-carla-r-morrisey-rn-bsn.html; retrieved 7 June 2015.
Ibid., pp. 11–13.
Ibid., p. 14.
Ibid., p. 12.
Ibid., p. 14.
Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918, Cambridge, England: Cambridge University Press, 2003. P. xi.
Ibid., pp. 311–328.
Ibid., p. 320.
Thomas Wolfe, Look Homeward Angel, New York: Simon and Schuster, 1929; mentioned Ibid., pp. 315–317.
Crosby, p. 318.
Barry, p. 394.
See Max J. Skidmore, Moose Crossing: Portland to Portland on the Theodore Roosevelt International Highway, Lanham, Maryland: Hamilton Books, 2007, p. 106.
Katherine Anne Porter, Pale Horse, Pale Rider, New York: Harcourt Brace, 1939, pp. 144–148.
McDermott, Alice, 2006. “Why Libraries Should Stock Pale Horse, Pale Rider.” NPR, All Things Considered, 23 October 2006.
“Influenza 1918,” This American Life, PBS, 1998; program description, complete transcript, etc., at http://www.pbs.org/wgbh/americanexperience/films/influenza/; retrieved 7 June 2015; available on DVD from PBS.
Crosby, pp. 317–318.
Barry, p. 394.