Here are some highlights from this 2005 book:
* NOTHING COULD HAVE STOPPED the sweep of influenza through either the United States or the rest of the world – but ruthless intervention and quarantines might have interrupted its progress and created occasional firebreaks.
Action as ruthless as that taken in 2003 to contain the outbreak of a new disease called severe acute respiratory disorder, SARS, could well have had effect.* Influenza could not have been contained as SARS was – influenza is far more contagious. But any interruption in influenza’s spread could have had significant impact. For the virus was growing weaker over time. Simply delaying its arrival in a community or slowing its spread once there (just such minor successes) would have saved many, many thousands of lives.
There was precedent for ruthless action. Only two years earlier several East Coast cities had fought a polio outbreak with the most stringent measures. Public health authorities wherever polio threatened had been relentless. But that was before the United States entered the war. There would be no comparable effort for influenza.
* But nurses were harder to find than doctors. There were one-quarter fewer to begin with. The earlier refusal of the women who controlled the nursing profession to allow the training of large numbers either of nursing aides or of what came to be called practical nurses prevented the creation of what might have been a large reserve force. The plan had been to produce thousands of such aides; instead the Army School of Nursing had been established. So far it had produced only 221 student nurses and not a single graduate nurse.
* PHILADELPHIA STAGGERED under the influenza attack, isolated and alone. In Philadelphia no sign surfaced of any national Red Cross and Public Health Service effort to help. No doctors recruited by the Public Health Service were sent there. No nurses recruited by the Red Cross were sent there. Those institutions gave no help here.
Each day people discovered that friends and neighbors who had been perfectly healthy a week (or a day) earlier were dead. What should I do? People were panicked, desperate. How long will it go on?
The mayor, arrested in the early days of the epidemic and then himself ill, had done absolutely nothing. A review of five daily newspapers, the Press, Inquirer, Bulletin, Public Ledger, and North American, did not find even a single statement about the crisis from the mayor. The entire city government had done nothing. Wilmer Krusen, head of the city health department, no longer had the confidence of anyone. Someone had to do something.
* Now, in place of the city government, [Philadelphia’s bluebloods] summoned the heads of a dozen private organizations on October 7 to the headquarters of Emergency Aid at 1428 Walnut Street. There the women took charge, with Pepper adding his weight to theirs. To sell war bonds, they had already organized nearly the entire city, all the way down to the level of each block, making each residential block the responsibility of ‘a logical leader no matter what her nationality’ i.e., an Irishwoman in an Irish neighborhood, an African American woman in an African American neighborhood, and so on.
They intended to use that same organization now to distribute everything from medical care to food. They intended to inject organization and leadership into chaos and panic. In conjunction with the Red Cross (which here, unlike nearly everywhere else in the country, allowed its own efforts to be incorporated into this larger Emergency Aid) they also appealed for nurses, declaring, ‘The death toll for one day in Philadelphia alone was greater than the death toll from France for the whole American Army for one day.’
* The corpses had backed up at undertakers’, filling every area of these establishments and pressing up into living quarters; in hospital morgues overflowing into corridors; in the city morgue overflowing into the street. And they had backed up in homes. They lay on porches, in closets, in corners of the floor, on beds. Children would sneak away from adults to stare at them, to touch them; a wife would lie next to a dead husband, unwilling to move him or leave him. The corpses, reminders of death and bringers of terror or grief, lay under ice at Indian-summer temperatures. Their presence was constant, a horror demoralizing the city; a horror that could not be escaped. Finally the city tried to catch up to them.
* Pepper and Martin offered ten dollars a day to anyone who would touch a corpse, but that proved inadequate, and still the bodies piled up. Seminary students volunteered as gravediggers, but they still could not keep pace. The city and archdiocese turned to construction equipment, using steam shovels to dig trenches for mass graves. Michael Donohue, an undertaker, said, ‘They brought a steam shovel in to Holy Cross Cemetery and actually excavated’ . They would begin bringing caskets in and doing the committal prayers right in the trench and they’d line them up right in, one right after another, this was their answer to helping the families get through things.’
The bodies that were choking homes and lying in stacks in mortuaries were ready to go, finally, into the ground.
To collect them, Archbishop Denis Dougherty, installed in office only a few weeks earlier (later he became the first cardinal from the archdiocese) sent priests down the streets to remove bodies from homes. They joined the police and a few hardy others who were doing the same.
Sometimes they collected the bodies in trucks. ‘So many people died they were instructed to ask for wooden boxes and put the corpse on the front porches,’ recalled Harriet Ferrell. ‘An open truck came through the neighborhood and picked up the bodies. There was no place to put them, there was not room.’
And sometimes they collected the bodies in wagons. Selma Epp’s brother Daniel died: ‘[P]eople were being placed on these horse-drawn wagons and my aunt saw the wagons pass by and he was placed on the wagon; everyone was too weak to protest. There were no coffins in the wagon but the people who had died were wrapped in a sort of sackcloth and placed in the wagon. One was on top of the other, there were so many bodies. They were drawn by horses and the wagons took the bodies away.’
No one could look at the trucks and carts carrying bodies (bodies wrapped in cloth stacked loosely on other bodies wrapped in cloth, arms and legs protruding, bodies heading for cemeteries to be buried in trenches) or hear the keening of the mourners and the call for the dead, and not think of another plague – the plague of the Middle Ages.
* Other professionals did their jobs as well. The police performed with heroism. Before the epidemic they had too often acted like a private army that owed its allegiance to the Vare machine. They had stood almost alone in the country against the navy’s crackdown on prostitution near military facilities. Yet when the police department was asked for four volunteers to ‘remove bodies from beds, put them in coffins and load them in vehicles,’ when the police knew that many of those bodies had decomposed, 118 officers responded.
But citizens in general had largely stopped responding. Many women had reported to an emergency hospital for a single shift. They had never returned. Some had disappeared in the middle of a shift. On October 16 the chief nurse at the city’s largest hospital told an advisory council, ‘[V]olunteers in the wards are useless’ . [T]hey are afraid. Many people have volunteered and then refused to have anything to do with patients.’
The attrition rate even where volunteers did not come into contact with the sick (in the kitchens, for example) was little better. Finally Mrs. Martin turned bitter and contemptuous: ‘Hundreds of women who are content to sit back’ had delightful dreams of themselves in the roles of angels of mercy, had the unfathomable vanity to imagine that they were capable of great spirit of sacrifice. Nothing seems to rouse them now. They have been told that there are families in which every member is ill, in which the children are actually starving because there is no one to give them food. The death rate is so high and they still hold back.’
Susanna Turner, who did volunteer at an emergency hospital and stayed, who went there day after day, remembered, ‘The fear in the hearts of the people just withered them’ . They were afraid to go out, afraid to do anything’ . You just lived from day to day, did what you had to do and not think about the future’ . If you asked a neighbor for help, they wouldn’t do so because they weren’t taking any chances. If they didn’t have it in their house, they weren’t going to bring it in there’ . You didn’t have the same spirit of charity that you do with a regular time, when someone was sick you’d go and help them, but at that time they helped themselves. It was a horror-stricken time.’
The professionals were heroes. The physicians and nurses and medical students and student nurses who were all dying in large numbers themselves held nothing of themselves back. And there were others. Ira Thomas played catcher for the Philadelphia Athletics. The baseball season had been shortened by Crowder’s ‘work or fight’ order, since sport was deemed unnecessary labor. Thomas’s wife was a six-foot-tall woman, large-boned, strong. They had no children. Day after day he carried the sick in his car to hospitals and she worked in an emergency hospital. Of course there were others. But they were few.
‘Help out?’ said Susanna Turner. ‘They weren’t going to risk it, they just refused because they were so panic-stricken, they really were, they feared their relatives would die because so many did die (they just dropped dead.’ No one could buy things. Commodities dealers, coal dealers, grocers closed ‘because the people who dealt in them were either sick or afraid and they had reason to be afraid.’
During the week of October 16 alone, 4,597 Philadelphians died from influenza or pneumonia, and influenza killed still more indirectly. That would be the worst week of the epidemic. But no one knew that at the time. Krusen had too often said the peak had passed. The press had too often spoken of triumph over disease.
* As the virus infested the Great Lakes Naval Training Station, the Associated Press reported, ‘To dispel alarm caused throughout the country by exaggerated stories’ Captain W. A. Moffat, commandant, gave out the statement today that while there are about 4,500 cases of the disease among the 45,000 blue jackets at the station, the situation in general is much improved. The death rate has been only one and one half per cent, which is below the death rate in the east.’
That report was meant to reassure. It is unlikely that it did so, even though it omitted the fact that quarantines were being imposed upon the training station, the adjoining Great Lakes Aviation Camp, and the nearby Fort Sheridan army cantonment, which, combined, amounted to the largest military concentration in the country. And military authorities of course assured both civilians nearby as well as the country at large that ‘the epidemic is on the wane.’
Over and over in hundreds of newspapers, day after day, repeated in one form or another people read Rupert Blue’s reassurance as well: ‘There is no cause for alarm if precautions are observed.’
They read the words of Colonel Philip Doane, the officer in charge of health at the country’s shipyards, who told the Associated Press, ‘The so-called Spanish influenza is nothing more or less than old fashioned grippe.’
Those words, too, ran in hundreds of newspapers. But people could smell death in them. Then they came to know that death.
Immediately outside Little Rock lay Camp Pike, where eight thousand cases were admitted to the hospital in four days and the camp commandant stopped releasing the names of the dead. ‘You ought to see this hospital tonight,’ wrote Francis Blake, one of four members of the army’s pneumonia commission at Pike. ‘Every corridor and there are miles of them with a double row of cots and every ward nearly with an extra row down the middle with influenza patients and lots of barracks about the camp turned into emergency infirmaries and the Camp closed’ . There is only death and destruction.’
The camp called upon Little Rock for nurses, doctors, linens, and coffins, all while within the city the Arkansas Gazette declared in headlines, ‘Spanish influenza is plain la grippe – same old fever and chills.’
Outside Des Moines, Iowa, at Camp Dodge, also, influenza was killing hundreds of young soldiers. Within the city a group called the Greater Des Moines Committee, businessmen and professionals who had taken charge during the emergency, included the city attorney who warned publishers (and his warning carried the sting of potential prosecution) ‘I would recommend that if anything be printed in regard to the disease it be confined to simple preventive measures – something constructive rather than destructive.’ Another committee member, a physician, said, ‘There is no question that by a right attitude of the mind these people have kept themselves from illness. I have no doubt that many persons have contracted the disease through fear’ . Fear is the first thing to be overcome, the first step in conquering this epidemic.’
The Bronxville, New York, Review Press and Reporter simply said nothing at all about influenza, absolutely nothing, until October 4, when it reported that the ‘scourge’ had claimed its first victim there. It was as if the scourge had come from nowhere; yet even the paper recognized that, without its printing a word, everyone knew of it. And even as the epidemic rooted itself in Bronxville, the paper condemned ‘alarmism’ and warned, ‘Fear kills more than the disease and the weak and timid often succumb first.’
Fear, that was the enemy. Yes, fear. And the more officials tried to control it with half-truths and outright lies, the more the terror spread.
The Los Angeles public health director said, ‘If ordinary precautions are observed there is no cause for alarm.’ Forty-eight hours later he closed all places of public gatherings, including schools, churches, and theaters.
* How could one not get panicky? Even before people’s neighbors began to die, before bodies began to pile up in each new community, every piece of information except the newspapers told the truth. Even while Blue recited his mantra (There is no cause for alarm if proper precautions are taken) he was calling upon local authorities to ‘close all public gathering places, if their community is threatened with the epidemic. This will do much toward checking the spread of the disease.’ Even if Colonel Doane had said Influenza is nothing more or less than old fashioned grippe, newspapers also quoted him saying, ‘Every person who spits is helping the Kaiser.’
And even while Blue and Doane, governors and mayors, and nearly all the newspapers insisted that this was influenza, only influenza, the Public Health Service was making a massive effort to distribute advice – nearly useless advice. It prepared ready-to-print plates and sent them to ten thousand newspapers, most of which did print them. It prepared (the Red Cross paid for printing and distribution) posters and pamphlets, including six million copies of a single circular. Teachers handed them out in schools; bosses stacked them in stores, post offices, and factories…
* In 1918 fear moved ahead of the virus like the bow wave before a ship. Fear drove the people, and the government and the press could not control it. They could not control it because every true report had been diluted with lies. And the more the officials and newspapers reassured, the more they said, There is no cause for alarm if proper precautions are taken, or Influenza is nothing more or less than old-fashioned grippe, the more people believed themselves cast adrift, adrift with no one to trust, adrift on an ocean of death.
So people watched the virus approach, and feared, feeling as impotent as it moved toward them as if it were an inexorable oncoming cloud of poison gas. It was a thousand miles away, five hundred miles away, fifty miles away, twenty miles away.
* In Colorado, towns in the San Juan Mountains did not panic. They turned grimly serious. They had time to prepare. Lake City guards kept the town entirely free of the disease, allowing no one to enter. Silverton, a town of two thousand, authorized closing businesses even before a single case surfaced. But the virus snuck in, with a vengeance. In a single week in Silverton, 125 died. The town of Ouray set up a ‘shot gun quarantine,’ hiring guards to keep miners from Silverton and Telluride out. But the virus reached Ouray as well.
It had not reached Gunnison. Neither tiny nor isolated, Gunnison was a railroad town, a supply center for the west-central part of the state, the home of Western State Teachers College. In early October (far in advance of any cases of influenza) Gunnison and most neighboring towns issued a closing order and a ban on public gatherings. Then Gunnison decided to isolate itself entirely. Gunnison lawmen blocked all through roads. Train conductors warned all passengers that if they stepped foot on the platform in Gunnison to stretch their legs, they would be arrested and quarantined for five days. Two Nebraskans trying simply to drive through to a town in the next county ran the blockade and were thrown into jail. Meanwhile, the nearby town of Sargents suffered six deaths in a single day – out of a total population of 130.
Early in the epidemic, back on September 27 (it seemed like years before) the Wisconsin newspaper the Jefferson County Union had reported the truth about the disease, and the general in charge of the Army Morale Branch decreed the report ‘depressant to morale’ and forwarded it to enforcement officials for ‘any action which may be deemed appropriate,’ including criminal prosecution. Now, weeks later, after weeks of dying and with the war over, the Gunnison News-Chronicle, unlike virtually every other newspaper in the country, played no games and warned, ‘This disease is no joke, to be made light of, but a terrible calamity.’
Gunnison escaped without a death.
* In Washington, D.C., William Sardo said, ‘It kept people apart’ . It took away all your community life, you had no community life, you had no school life, you had no church life, you had nothing’ . It completely destroyed all family and community life. People were afraid to kiss one another, people were afraid to eat with one another, they were afraid to have anything that made contact because that’s how you got the flu’ . It destroyed those contacts and destroyed the intimacy that existed amongst people’ . You were constantly afraid, you were afraid because you saw so much death around you, you were surrounded by death’ . When each day dawned you didn’t know whether you would be there when the sun set that day. It wiped out entire families from the time that the day began in the morning to bedtime at night – entire families were gone completely, there wasn’t any single soul left and that didn’t happen just intermittently, it happened all the way across the neighborhoods, it was a terrifying experience. It justifiably should be called a plague because that’s what it was’ . You were quarantined, is what you were, from fear, it was so quick, so sudden’ . There was an aura of a constant fear that you lived through from getting up in the morning to going to bed at night.’
In New Haven, Connecticut, John Delano recalled the same isolating fear: ‘Normally when someone was sick in those days the parents, the mothers, the fathers, would bring food over to other families but this was very weird’ . Nobody was coming in, nobody would bring food in, nobody came to visit.’
Prescott, Arizona, made it illegal to shake hands. In Perry County, Kentucky, in the mountains where men either dug into the earth for coal or scratched upon the earth’s surface trying to farm despite topsoil only a few inches deep, a county of hard people, where family ties bound tightly, where men and women were loyal and would murder for pride or honor, the Red Cross chapter chairman begged for help, reporting ‘hundreds of cases up in mountains that they were unable to reach.’ They were unreachable not just because the county had almost no roads; streambeds in dry weather substituted for them and when the streambeds filled, transport became impossible. It was more: ‘People starving to death not from lack of food but because the well were panic stricken and would not go near the sick; that in the stricken families the dead were lying uncared for.’ Doctors were offered $100 to come out and stay there one hour. None came. Even one Red Cross worker, Morgan Brawner, arrived in the county Saturday and left Sunday, himself terror stricken. He had reason to fear: in some areas the civilian mortality rate reached 30 percent.
In Norwood, Massachusetts, a historian years later interviewed survivors. One man, a newsboy in 1918, remembered that his manager would ‘tell me to put the money on the table and he’d spray the money before he’d pick it up.’ Said another survivor; ‘There wasn’t much visiting’ . We stayed by ourselves.’ And another: ‘[H]e’d bring, you know, whatever my father needed and leave it on the doorstep. No one would go into each other’s houses.’ And another: ‘Everything came to a standstill’ . We weren’t allowed out the door. We had to keep away from people.’ And another: ‘A cop, a big burly guy’ came up to the house and nailed a big white sign and on the sign it said INFLUENZA in red letters. And they nailed it to the door.’ A sign made a family even more isolated. And another survivor: ‘I’d go up the street, walk up the street with my hand over my eyes because there were so many houses with crepe draped over the doors.’ And still another: ‘It was horrifying. Not only were you frightened you might come down with it but there was the eerie feeling of people passing away all around you.’
In Luce County, Michigan, one woman was nursing her husband and three boys when she ‘came down with it herself,’ reported a Red Cross worker. ‘Not one of the neighbors would come in and help. I stayed there all night, and in the morning telephoned the woman’s sister. She came and tapped on the window, but refused to talk to me until she had gotten a safe distance away’ . I could do nothing for the woman’ except send for the priest.
* In Arizona, citizens’ committees were taken seriously. A year earlier fifteen hundred armed members of a ‘Citizens Protective League’ had put 1,221 striking miners into cattle and boxcars and abandoned them without food or water on a railroad siding in the desert, across the New Mexico line. In Phoenix another ‘citizens’ committee’ had been going after ‘bond slackers,’ hanging them in effigy on main streets. One man refused to buy a bond because of religious reasons. Nonetheless he was hung in effigy with a placard reading, ‘H. G. Saylor, yellow slacker’ . Can, but won’t buy a liberty bond!’ Saylor was lucky. The committee also seized Charles Reas, a carpenter, tied his hands behind his back, painted his face yellow, put a noose around his neck, and dragged him through downtown Phoenix streets wearing a sign that read ‘with this exception we are 100%.’
The influenza Citizens’ Committee took similar initiatives. It deputized a special police force and also called upon all ‘patriotic citizens’ to enforce anti-influenza ordinances, including requiring every person in public to wear a mask, arresting anyone who spit or coughed without covering his mouth, dictating that businesses (those that remained open) give twelve hundred cubic feet of air space to each customer, and halting all traffic into the city and allowing only those with ‘actual business here’ to enter. Soon the Republican described ‘a city of masked faces, a city as grotesque as a masked carnival.’
And yet (ironically) influenza touched Phoenix only lightly compared to elsewhere. The panic came anyway. Dogs told the story of terror, but not with their barking. Rumors spread that dogs carried influenza. The police began killing all dogs on the street. And people began killing their own dogs, dogs they loved, and if they had not the heart to kill them themselves, they gave them to the police to be killed.
* One Philadelphia doctor had another idea, logical but more reaching, and wrote in JAMA that ‘when the system is saturated with alkalis, there is poor soil for bacterial growth.’ Therefore he tried to turn the entire body alkaline. ‘I have uniformly employed, and always with good results, potassium citrate and sodium bicarbonate saturation by mouth, bowel and skin’ . Patients must be willing to forego [sic] the seductive relief by acetylsalicylic acid [aspirin]’ . My very successful experience in this epidemic cannot be dismissed as accidental or unique’ .
* Physicians injected people with typhoid vaccine, thinking (or simply hoping) it might somehow boost the immune system in general even though the specificity of the immune response was well understood. Some claimed the treatment worked. Others poured every known vaccine into patients on the same theory. Quinine worked on one disease: malaria. Many physicians gave it for influenza with no better reasoning than desperation.
* Places that isolated themselves (such as Gunnison, Colorado, and a few military installations on islands) escaped. But the closing orders that most cities issued could not prevent exposure; they were not extreme enough. Closing saloons and theaters and churches meant nothing if significant numbers of people continued to climb onto streetcars, continued to go to work, continued to go to the grocer. Even where fear closed down businesses, where both store owners and customers refused to stand face-to-face and left orders on sidewalks, there was still too much interaction to break the chain of infection. The virus was too efficient, too explosive, too good at what it did. In the end the virus did its will around the world.
It was as if the virus were a hunter. It was hunting mankind. It found man in the cities easily, but it was not satisfied. It followed him into towns, then villages, then individual homes. It searched for him in the most distant corners of the earth. It hunted him in the forests, tracked him into jungles, pursued him onto the ice. And in those most distant corners of the earth, in those places so inhospitable that they barely allowed man to live, in those places where man was almost wholly innocent of civilization, man was not safer from the virus. He was more vulnerable.
In Alaska, whites in Fairbanks protected themselves. Sentries guarded all trails, and every person entering the city was quarantined for five days. Eskimos had no such luck. A senior Red Cross official warned that without ‘immediate medical assistance the race’ could become ‘extinct.’
* One process involved immunity. Once the virus passed through a population, that population developed at least some immunity to it. Victims were not likely to be reinfected by the same virus, not until it had undergone antigen drift.
The second process occurred within the virus. It was only influenza. By nature the influenza virus is dangerous, considerably more dangerous than the common aches and fever lead people to believe, but it does not kill routinely as it did in 1918. The 1918 pandemic reached an extreme of virulence unknown in any other widespread influenza outbreak in history.
But the 1918 virus, like all influenza viruses, like all viruses that form mutant swarms, mutated rapidly. There is a mathematical concept called ‘reversion to the mean’ this states simply that an extreme event is likely to be followed by a less extreme event. This is not a law, only a probability. The 1918 virus stood at an extreme; any mutations were more likely to make it less lethal than more lethal. In general, that is what happened. So just as it seemed that the virus would bring civilization to its knees, would do what the plagues of the Middle Ages had done, would remake the world, the virus mutated toward its mean, toward the behavior of most influenza viruses. As time went on, it became less lethal.
* The disease has survived in memory more than in any literature. Nearly all those who were adults during the pandemic have died now. Now the memory lives in the minds of those who only heard stories, who heard how their mother lost her father, how an uncle became an orphan, or heard an aunt say, ‘It was the only time I ever saw my father cry.’ Memory dies with people.
The writers of the 1920s had little to say about it.
Mary McCarthy got on a train in Seattle on October 30, 1918, with her three brothers and sisters, her aunt and uncle, and her parents. They arrived in Minneapolis three days later, all of them sick (her father had pulled out a gun when the conductor tried to put them off the train) met by her grandparents wearing masks. All the hospitals were full and so they went home. Her aunt and uncle recovered but her father, Roy, thirty-eight years old, died on November 6, and her mother, Tess, twenty-nine years old, died November 7. In Memories of a Catholic Girlhood she spoke of how deeply being an orphan affected her, made her desperate to distinguish herself, and she vividly remembered the train ride across two-thirds of the country, but she said almost nothing of the epidemic.
John Dos Passos was in his early twenties and seriously ill with influenza, yet barely mentioned the disease in his fiction. Hemingway, Faulkner, Fitzgerald said next to nothing of it. William Maxwell, a New Yorker writer and novelist, lost his mother to the disease. Her death sent his father, brother, and him inward. He recalled, ‘I had to guess what my older brother was thinking. It was not something he cared to share with me. If I hadn’t known, I would have thought that he’d had his feelings hurt by something he was too proud to talk about’ .’ For himself, ‘[T]he ideas that kept recurring to me, perhaps because of that pacing the floor with my father, was that I had inadvertently walked through a door that I shouldn’t have gone through and couldn’t get back to the place I hadn’t meant to leave.’ Of his father he said, ‘His sadness was of the kind that is patient and without hope.’ For himself, ‘the death of my mother’ was a motivating force in four books.’
Katherine Anne Porter was ill enough that her obituary was set in type. She recovered. Her fiancé did not. Years later her haunting novella of the disease and the time, Pale Horse, Pale Rider, is one of the best (and one of the few) sources for what life was like during the disease. And she lived through it in Denver, a city that, compared to those in the east, was struck only a glancing blow.
But 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 says, ‘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.’
People write about war. They write about the Holocaust. They write about horrors that people inflict on people. Apparently they forget the horrors that nature inflicts on people, the horrors that make humans least significant. And yet the pandemic resonated. When the Nazis took control of Germany in 1933, Christopher Isherwood wrote of Berlin: ‘The whole city lay under an epidemic of discreet, infectious fear. I could feel it, like influenza, in my bones.
* Yet, despite such occasional harshness, the 1918 influenza pandemic did not in general demonstrate a pattern of race or class antagonism. In epidemiological terms there was a correlation between population density and hence class and deaths, but the disease still struck down everyone. And the deaths of soldiers of such promise and youth struck home with everyone. The disease was too universal, too obviously not tied to race or class. In Philadelphia, white and black certainly got comparable treatment. In mining areas around the country, whether out of self-interest or not, mine owners tried to find doctors for their workers. In Alaska, racism notwithstanding, authorities launched a massive rescue effort, if too late, to save Eskimos. Even the very Red Cross worker so nauseated by filth continued to risk his own life day after day in one of the hardest-hit areas of the country.
During the second wave, many local governments collapsed, and those who held the real power in a community (from Philadelphia’s bluebloods to Phoenix’s citizens’ committee) took over. But generally they exercised power to protect the entire community rather than to split it, to distribute resources widely rather than to guarantee resources for themselves.
Despite that effort, whoever held power, whether a city government or some private gathering of the locals, they generally failed to keep the community together. They failed because they lost trust. They lost trust because they lied. (San Francisco was a rare exception; its leaders told the truth, and the city responded heroically.) And they lied for the war effort, for the propaganda machine that Wilson had created.
It is impossible to quantify how many deaths the lies caused. It is impossible to quantify how many young men died because the army refused to follow the advice of its own surgeon general. But while those in authority were reassuring people that this was influenza, only influenza, nothing different from ordinary ‘la grippe,’ at least some people must have believed them, at least some people must have exposed themselves to the virus in ways they would not have otherwise, and at least some of these people must have died who would otherwise have lived. And fear really did kill people. It killed them because those who feared would not care for many of those who needed but could not find care, those who needed only hydration, food, and rest to survive.
* Every expert on influenza agrees that the ability of the influenza virus to reassort genes means that another pandemic not only can happen. It almost certainly will happen.
For influenza is not like SARS, which was contained and (as this book goes to press) may have been completely eliminated. SARS, although more lethal even than the 1918 influenza virus, is less dangerous for several reasons.
First, SARS requires fairly close contact to spread, while influenza is among the most contagious of all diseases.
* If a new influenza virus does emerge, given modern travel patterns it will likely spread even more rapidly than it did in 1918. It will infect at least several hundred million, and probably more than a billion, people. In the United States alone, the Centers for Disease Control estimates that a new pandemic would make between 40 and 100 million people sick.
* In 1918 the world’s population was 1.8 billion, less than one-third today’s. Yet the 1918 influenza virus killed a likely 50 million and possibly as many as 100 million.
* The U.S. Centers for Disease Control (CDC) estimates that the annual death toll in the United States from influenza now averages 36,000 in a nonepidemic year. The 1918 virus killed 675,000 people in the United States, out of a population not much more than one-third the size of today’s.
* A vaccine offers far better protection, especially for the elderly. But to make the vaccine, investigators have to aim at a moving target. Every year they try to predict which virus strains will dominate and the direction of antigen drift. Then they design a vaccine for these antigens. When the investigators are right, when they hit their target, the vaccine protects very well for an entire flu season, preventing many attacks and reducing the severity of others. But the vaccine needs to be produced in huge quantities, which takes months, and in that time the virus can mutate in a direction different from the one anticipated. And even if the vaccine includes the right antigens, given the ‘mutant swarm’ nature of the virus, some viral strains will escape it.
* The real danger, though, is that it may not be possible to develop and distribute a vaccine in time to protect against a new virus.
* So even with all the medical advances since 1918, the CDC estimates that if a new pandemic virus strikes, then the U.S. death toll will most likely fall between 89,000 and 300,000. It also estimates a best case scenario of 75,000 deaths and a worst case scenario in which 422,000 Americans would die.
* If a new pandemic struck, people suffering from ARDS would quickly overwhelm intensive care units; those with ARDS who did not get true intensive care would have a mortality rate approaching that in 1918. A new virus would also feast on a population that did not exist in 1918 – those with compromised immune systems, including people undergoing radiation or chemotherapy for cancer and transplant recipients, not to mention anyone with HIV.
No one has attempted to estimate the worldwide death toll of another influenza pandemic, but one could easily imagine a lethal virus (even one less virulent than that of 1918) killing tens of millions. No disease, including AIDS, poses the long-term threat of a violent explosion that influenza does.
* Some medical historians and epidemiologists have hypothesized that the 1918 pandemic began in China. Most pandemics whose origin is known did begin in Asia or Russia. There is no scientific reason for this; it is only a question of probabilities. There large numbers of people live in close contact with pigs and birds, so more opportunities exist for a virus to cross over from animals to humans.
* But before the first notification of WHO, [SARS] existed for months in China. For political and commercial reasons mainland Chinese authorities kept the disease secret and then initially lied about it. Once they did recognize the threat they moved aggressively and successfully to contain it, but had it been a new influenza virus, the months of silence would have made it impossible for public health authorities to have any chance either to contain the virus or develop a vaccine before a pandemic exploded across the world. Possibly the Chinese government (and other governments) learned a lesson they will not forget; possibly they will be both open and aggressive in the future whenever any indication of a new disease surfaces. One hopes so.
* …a small plane spraying anthrax spores over New York City could, under theoretically perfect conditions, kill 120,000 people, while improving distribution of antibiotics alone would slash the death toll from an identical attack to 1,000.
* Public health officials will need the authority to enforce decisions, including ruthless ones. If, for example, unvaccinated individuals threaten not only themselves but others by providing a reservoir in which pathogens can breed, officials might decide to order mandatory vaccination. Or, if there is any chance to limit the geographical spread of the disease, officials must have in place the legal power to take extreme quarantine measures. A centralized system should exist to allocate all resources including professionals as well. The utter waste of resources in 1918 in New York City (when doctors repeatedly crossed each other’s paths entering and leaving the same building because no centralized system was used to dispatch them) should not be tolerated.
Questions about who will have the authority to make and enforce such decisions, and under what circumstances, must be settled in advance. Neither an epidemic nor an attack will leave time for debate.
* There was terror afoot in 1918, real terror. The randomness of death brought that terror home. So did its speed. And so did the fact that the healthiest and strongest seemed the most vulnerable.
The media and public officials helped create that terror – not by exaggerating the disease but by minimizing it, by trying to reassure.
Terror rises in the dark of the mind, in the unknown beast tracking us in the jungle. The fear of the dark is an almost physical manifestation of that. Horror movies build upon the fear of the unknown, the uncertain threat that we cannot see and do not know and can find no safe haven from. But in every horror movie, once the monster appears, terror condenses into the concrete and diminishes. Fear remains. But the edge of panic created by the unknown dissipates. The power of the imagination dissipates.
In 1918 the lies of officials and of the press never allowed the terror to condense into the concrete. The public could trust nothing and so they knew nothing. So a terror seeped into the society that prevented one woman from caring for her sister, that prevented volunteers from bringing food to families too ill to feed themselves and who starved to death because of it, that prevented trained nurses from responding to the most urgent calls for their services. The fear, not the disease, threatened to break the society apart. As Victor Vaughan (a careful man, a measured man, a man who did not overstate to make a point) warned, ‘Civilization could have disappeared within a few more weeks.’
So the final lesson, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that.
Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best.
Leadership must make whatever horror exists concrete. Only then will people be able to break it apart.
In the summer of 2005, President George W. Bush was on vacation at his ranch in Crawford, Texas, when he began flipping through an advance reading copy of a new book about the 1918 flu pandemic. He couldn’t put it down.
When he returned to Washington, he called his top homeland security adviser into the Oval Office and gave her the galley of historian John M. Barry’s “The Great Influenza,” which told the chilling tale of the mysterious plague that “would kill more people than the outbreak of any other disease in human history.”
“You’ve got to read this,” Fran Townsend remembers the president telling her. “He said, ‘Look, this happens every 100 years. We need a national strategy.'”
