Plagues in World History (25 page)

saved many lives by denying to flu its tinder of mass numbers of men in cramped quarters. But given the enormous pressure and demand for American troops to seal an Allied victory, at a time when Britain and France were exhausted and spent, there was perhaps little choice left for the president to make. However, America did learn the hard lesson that it needed to provide better medical support services to its troops and not build hospitals at its bases last.26

Even countries in the very thick of the fighting, such as France, found it was the logistics of war, rather than the war itself, that most contributed to influenza, as troops were transported to and from the front and civilian populations were starved of supplies that were sent instead to the soldiers, thus facilitating both the spread of the disease and host susceptibility to it. And yet Spain, a neutral country in the war, apparently suffered equally from influenza, to the point that the epidemic in Europe began to be called the “Spanish Flu” or the “Spanish Lady,” an unfair designation as Spain was simply one of the few countries publishing its statistics on the disease. Counterintuitively, war could even be a benefit to a country struck suddenly and unexpectedly by influenza, as was found to be the case in New Zealand where a heightened state of preparedness during wartime helped mobilize emergency relief efforts in response to the disease. The connection between flu and other factors, such as overcrowding and socioeconomic disparities, could likewise be called into question on the basis of figures from Britain, which show flu mortalities being distributed fairly equally.27 But how else to explain the fact that India’s death rate from the flu was twelve times higher than that of the United States or Europe, unless a completely different strain of the virus prevailed in Asia, which seems unlikely?28 This conundrum of flu needs to be solved if we are to draw the right lessons from 1918, to wit, if the flu’s mortality was largely biological, as was the case with plague in Europe during the Middle Ages or smallpox in the New World during the sixteenth century, when human populations had little immunity to these diseases, then experts think it quite likely, indeed almost inevitable, that another such devastating pandemic will occur. If, however, flu deaths were primarily the product of the unique historical context of 1918–1919, including the First World War and its aftermath, bad weather and widespread crop failures, inadequate medical knowledge of and preparedness for the disease, and so forth, then there is hope the disaster will not be repeated.29 I think the odds are that it was a combination of both: the emergence of an unusually virulent strain of influenza in 1918 and circumstances that greatly facilitated its spread and mortality, especially from opportunistic diseases like pneumonia. If this is the case, then at the very least we can expect to mitigate (or else amplify) any future flu’s impact, even one as deadly as that in 1918. Then there is also the possibility that, in our current climate, the two sides of the equation are inextricable: that some of our more 122 y Chapter 5

destructive social behaviors, such as environmental degradation or factory farming and food production, are in fact creating the very conditions in which new biological strains of influenza, and of other exotic viral diseases, can occur.

Historians have noted that the 1918–1919 flu pandemic broke all the rules.

In some ways, it acted like any other influenza outbreak, striking most places with high morbidity and relatively lower mortality, but in other respects it fla-grantly bucked the trend of the way flu was expected to behave. One of the more shocking things that was happening at the time was that people in the prime of life, between twenty and forty years of age, were the ones being most struck down, which wasn’t normally supposed to happen in a typical flu outbreak; as already explained, this was due to the unique cytokine response that the 1918

virus induced, which would be most expressive in robust, healthy adults. This was an anomaly noted all over the world, but it should be remembered that virtually all age groups, including the very young and the very old that were typically targeted by flu, were experiencing above-average mortality at this time.

Flu was behaving like the Black Death of the Middle Ages in this respect. Life expectancies were set back by ten years or more even in advanced industrialized countries not directly invaded by the war, such as the United States, and generally women (particularly those who were pregnant) seem to have lost their lon-gevity advantages over men.30 When influenza’s effects are combined with losses from the war, which also targeted the most productive (in this case male) members of society, it is easy to see why this became the “lost generation” of its time.

The spectacle of corpses stacked like “cordwood” in hospital corridors and bodies lying unburied due to lack of space or a shortage of gravediggers naturally evoked memories of plague, as did reports of panicked flight and scapegoating early in the pandemic, which quickly subsided once it was realized that no one was exempt and there was nowhere to run. Like the Black Death, the influenza pandemic of 1918–1919 was both an urban and a rural phenomenon. Doctors once again found themselves utterly impotent for all their recent advances in bacteriology. Discovery of a potential cause of the disease in “Pfeiffer’s Bacillus,”

a bacterium allegedly found in flu patients by the German physician Richard Pfeiffer, proved premature and discouragingly anticlimactic; the first flu virus was not to be isolated from human subjects until 1933. On the other hand, female nurses found themselves empowered due to the fact that simple bed rest and nursing care proved the most effective remedy, or at least provided some comfort to suffering victims in their last hours, especially in an age that preceded antibiotics as a “miracle cure” for pneumonic infections.31

Campaigns to improve sanitation and hygiene, such as local laws that forbade coughing and spitting, were reminiscent of what was tried during cholera epidemics in Europe in the previous century. In an even earlier throwback to Influenza y 123

the time of plague, authorities also proscribed communal spaces—now to include schools and movie theaters in addition to churches (but not bars, since alcohol and tobacco were believed to be prophylactic against the flu!). And predictions of the apocalypse, or end of the world, once again came into fashion, as they had been in the Middle Ages. Influenza even inspired its own nursery rhyme, comparable to the “ring around the rosy” ditty composed during the London plague of 1665, which was sung in 1918 by my grandmother-in-law and which proved remarkably prescient, given what we now know about the probable avian origins of the virus:

I had a little bird

And its name was Enza

I opened up the window

And in-flu-enza!

Some aspects of the 1918–1919 pandemic also foreshadowed future concerns about disease: for example, some American cities mandated the wearing of gauze masks, but when these proved ineffectual, civil liberty suits were brought because they were uncomfortable or embarrassing for some. The millions of dollars in business losses, such as were sustained by the life insurance industry, as death rates soared in 1918 added an economic dimension on a scale that was to become a familiar one in the calculations of the impact of all subsequent pandemics.32

Above all, the influenza outbreak of 1918–1919 is unique in terms of how contemporaries chose to historicize this disease. In contrast to the plague, for example, it became the “forgotten pandemic” and not just in the United States or Europe but also in other countries around the globe, such as Senegal. Why this is so has been variously explained. For much of the Western world, the unprecedented violence and brutality of the previous four years of war perhaps in-ured it to the “just another millions” more deaths from influenza, which did not produce the political and diplomatic legacy of Versailles, or maybe the quiet deaths from disease were not heroic or dramatic enough even for a generation that had lost its romantic love affair with war. The nature of influenza itself also encouraged collective amnesia about it. As Crosby notes, it came and went relatively quickly, and compared to a more deadly disease per incidence like plague, it did not inspire the same degree of terror when most people who contracted it could still expect to survive, even in 1918. In the end, people may simply have wished to forget its horrors, after everything else they had been through, and remember it just like any other influenza.33 Yet, this is now no longer the case.

Since 1976, the recovered memory of what happened in 1918–1919 has cast a long shadow, as dark and ominous as the Black Death, over every real and potential pandemic of the flu.

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After 1919, influenza pandemics seemed to subside for the next three decades: During that time, viruses were successfully scanned by the new technology of electron microscopes, antibiotics were discovered and first tested on humans, and the World Health Organization (WHO) was formed in 1948, with a World Influenza Center established the following year, in order to coordinate worldwide responses to disease and share information from laboratories in forty-five countries around the globe. Thereafter, an influenza pandemic looked set to be occurring once a decade with the advent of airline travel and an ever-shrinking world: pandemics occurred in 1946–1949—in the aftermath of World War II; in 1957; and in 1968—the so-called Hong Kong Flu. All these pandemics were considerably milder than the one in 1918–1919, conforming once again to flu’s typical pattern of targeting the very young and the very old, and WHO demonstrated that vaccination programs could be coordinated on a global scale, experience it was to use to good effect in its smallpox eradication campaign of the 1970s. But the disturbing thing about these pandemics was that they demonstrated the rapidly mutating capability of the flu virus. The one of the 1940s was a H1N1 strain to which many must have had some immunity from the 1918

pandemic; those of 1957 and 1968, however, were caused by entirely new strains (antigenic shift) of H2N2 and H3N2 respectively, which successively crowded out earlier ones. These pandemics are also believed to have come from the Far East, specifically China, and to have come on in waves, like in 1918, with the second wave seemingly more virulent (both in terms of morbidity and mortality) than the first, showcasing an evolutionary process whereby the virus was evidently adapting itself more successfully to humans. Yet, as in 1918, those who caught the flu in the first, milder wave seem to have acquired some immunity to later incidences of the disease, and it is thought that the strains of 1957 and 1968

may have circulated in the late nineteenth century, conferring some protection to the older generation who were most susceptible. This time the viruses responsible are thought to have arose through “reassortment” of human and avian strains in a third host, such as pigs, rather than making a direct leap from birds to humans as in 1918, which means that these later pandemics would act less like “virgin soil” diseases in human populations and were less likely to provoke in them uncontrolled immune responses, such as a cytokine storm. Yet, all was not smooth sailing, as Communist China under Chairman Mao Zedong maintained a closed-door policy with respect to reporting flu cases, a pattern that has continued recently with avian flu; to this day, we still do not know how many Chinese died in 1957, with some scholars believing that a good proportion of the thirty million who died during the “Great Leap Forward” collectivization program between 1958 and 1961 may be attributed to flu. Even in Western democratic developed countries, such as Britain, authorities were slow to follow Influenza y 125

WHO recommendations and close schools, which has been proven to halt epidemics, and hospital facilities and staff were at times overwhelmed.34

The postwar experience of a flu pandemic occurring once every decade looked set to continue when in January 1976 more than two hundred army recruits at Fort Dix in New Jersey came down with an H1N1 “swine flu” strain, although several dozen victims were also infected with the H3N2 virus that had last circulated in 1968. Of great concern at the time was that the swine flu virus was demonstrated to be transmissible from person to person and that it seemed to be related to the exceptionally virulent strain of 1918, since serum obtained from individuals over fifty years of age, who were likely to have been exposed to the earlier virus, contained antibodies to the present one. This also meant that much of the population, particularly the younger generation, would have no immunity to this virus since they had been born after the strain of 1918 had ceased circulat-ing, which raised the specter of another “virgin soil”–type pandemic. As it turns out, we have already seen that recent biomolecular archaeology on autopsy samples from victims of the 1918 flu indicate that it was an avian strain, not a swine one, yet this information was simply not available in 1976; in fact, this “epidemic that wasn’t” was the first to demonstrate that a major antigenic shift can occur in an influenza virus without producing a widespread outbreak. This was probably because the virus passed directly from pigs to humans without recombination or reassortment in swine with a human viral strain, which would have made it far more transmissible person to person.35

However, while doing nothing was simply not an option, some at the time did counsel caution: Albert Sabin, who helped develop the polio vaccine in the 1950s, recommended to the Centers for Disease Control (CDC) and in testimony before Congress that only high-risk groups be initially targeted for vaccination and that in the meantime extra doses be stockpiled, while WHO failed to report any further outbreaks of flu cases around the world. Yet, dissenting voices were deliberately excluded from the blue-ribbon panel advising U.S.

president Gerald Ford. As a consequence, an ambitious, $135 million program to mass vaccinate the entire U.S. population of roughly two hundred million people was quickly signed into law by Ford in April, and implementation began with the first shots administered in October. A number of factors went into this decision to vaccinate on such an unprecedented scale. Chief among these seem to have been fears of a repeat of 1918, with its huge potential losses in lives and treasure, this time ranging in the millions of deaths and billions of dollars. Historical writing about the flu also played its part. It was said that the secretary of the Department of Health, Education, and Welfare, David Mathews, read Crosby’s new book about the 1918 pandemic,
Epidemic and Peace
, and warned his colleague, James Lynn, director of the Office of Management and Budget, 126 y Chapter 5