How the
Horrific 1918 Flu Spread Across America
The toll of history’s worst
epidemic surpasses all the military deaths in World War I and World War II
combined. And it may have begun in the United States
--By John M. Barry, Smithsonian
Magazine, November 2017
Haskell County, Kansas, lies in
the southwest corner of the state, near Oklahoma and Colorado. In 1918 sod
houses were still common, barely distinguishable from the treeless, dry prairie
they were dug out of. It had been cattle country—a now bankrupt ranch once
handled 30,000 head—but Haskell farmers also raised hogs, which is one possible
clue to the origin of the crisis that would terrorize the world that year.
Another clue is that the county sits on a major migratory flyway for 17 bird
species, including sand hill cranes and mallards. Scientists today understand
that bird influenza viruses, like human influenza viruses, can also infect
hogs, and when a bird virus and a human virus infect the same pig cell, their
different genes can be shuffled and exchanged like playing cards, resulting in
a new, perhaps especially lethal, virus.
We cannot say for certain that
that happened in 1918 in Haskell County, but we do know that an influenza
outbreak struck in January, an outbreak so severe that, although influenza was
not then a “reportable” disease, a local physician named Loring Miner—a large
and imposing man, gruff, a player in local politics, who became a doctor before
the acceptance of the germ theory of disease but whose intellectual curiosity
had kept him abreast of scientific developments—went to the trouble of alerting
the U.S. Public Health Service. The report itself no longer exists, but it
stands as the first recorded notice anywhere in the world of unusual influenza
activity that year. The local newspaper, the Santa Fe Monitor, confirms that
something odd was happening around that time: “Mrs. Eva Van Alstine is sick
with pneumonia...Ralph Lindeman is still quite sick...Homer Moody has been
reported quite sick...Pete Hesser’s three children have pneumonia ...Mrs J.S.
Cox is very weak yet...Ralph Mc-Connell has been quite sick this week...Mertin,
the young son of Ernest Elliot, is sick with pneumonia,...Most everybody over
the country is having lagrippe or pneumonia.”
Several Haskell men who had
been exposed to influenza went to Camp Funston, in central Kansas. Days later,
on March 4, the first soldier known to have influenza reported ill. The huge
Army base was training men for combat in World War I, and within two weeks
1,100 soldiers were admitted to the hospital, with thousands more sick in
barracks. Thirty-eight died. Then, infected soldiers likely carried influenza
from Funston to other Army camps in the States—24 of 36 large camps had
outbreaks—sickening tens of thousands, before carrying the disease overseas.
Meanwhile, the disease spread into U.S. civilian communities.
The influenza virus mutates
rapidly, changing enough that the human immune system has difficulty
recognizing and attacking it even from one season to the next. A pandemic
occurs when an entirely new and virulent influenza virus, which the immune
system has not previously seen, enters the population and spreads worldwide.
Ordinary seasonal influenza viruses normally bind only to cells in the upper
respiratory tract—the nose and throat—which is why they transmit easily. The
1918 pandemic virus infected cells in the upper respiratory tract, transmitting
easily, but also deep in the lungs, damaging tissue and often leading to viral
as well as bacterial pneumonias.
Although some researchers argue
that the 1918 pandemic began elsewhere, in France in 1916 or China and Vietnam
in 1917, many other studies indicate a U.S. origin. The Australian immunologist
and Nobel laureate Macfarlane Burnet, who spent most of his career studying
influenza, concluded the evidence was “strongly suggestive” that the disease
started in the United States and spread to France with “the arrival of American
troops.” Camp Funston had long been considered as the site where the pandemic
started until my historical research, published in 2004, pointed to an earlier
outbreak in Haskell County.
Wherever it began, the pandemic
lasted just 15 months but was the deadliest disease outbreak in human history,
killing between 50 million and 100 million people worldwide, according to the
most widely cited analysis. An exact global number is unlikely ever to be
determined, given the lack of suitable records in much of the world at that
time. But it’s clear the pandemic killed more people in a year than AIDS has killed
in 40 years, more than the bubonic plague killed in a century.
The impact of the pandemic on
the United States is sobering to contemplate: Some 670,000 Americans died.
In 1918, medicine had barely
become modern; some scientists still believed “miasma” accounted for
influenza’s spread. With medicine’s advances since then, laypeople have become
rather complacent about influenza. Today we worry about Ebola or Zika or MERS
or other exotic pathogens, not a disease often confused with the common cold.
This is a mistake.
We are arguably as
vulnerable—or more vulnerable—to another pandemic as we were in 1918. Today top
public health experts routinely rank influenza as potentially the most
dangerous “emerging” health threat we face. Earlier this year, upon leaving his
post as head of the Centers for Disease Control and Prevention, Tom Frieden was
asked what scared him the most, what kept him up at night. “The biggest concern
is always for an influenza pandemic...[It] really is the worst-case scenario.”
So the tragic events of 100 years ago have a surprising urgency—especially
since the most crucial lessons to be learned from the disaster have yet to be
absorbed.
**********
Initially the 1918 pandemic set
off few alarms, chiefly because in most places it rarely killed, despite the
enormous numbers of people infected. Doctors in the British Grand Fleet, for
example, admitted 10,313 sailors to sick bay in May and June, but only 4 died.
It had hit both warring armies in France in April, but troops dismissed it as
“three-day fever.” The only attention it got came when it swept through Spain,
and sickened the king; the press in Spain, which was not at war, wrote at
length about the disease, unlike the censored press in warring countries,
including the United States. Hence it became known as “Spanish flu.” By June
influenza reached from Algeria to New Zealand. Still, a 1927 study concluded,
“In many parts of the world the first wave either was so faint as to be hardly
perceptible or was altogether lacking...and was everywhere of a mild form.”
Some experts argued that it was too mild to be influenza.
Yet there were warnings,
ominous ones. Though few died in the spring, those who did were often healthy
young adults—people whom influenza rarely kills. Here and there, local
outbreaks were not so mild. At one French Army post of 1,018 soldiers, 688 were
hospitalized and 49 died—5 percent of that population of young men, dead. And
some deaths in the first wave were overlooked because they were misdiagnosed,
often as meningitis. A puzzled Chicago pathologist observed lung tissue heavy
with fluid and “full of hemorrhages” and asked another expert if it represented
“a new disease.”
By July it didn’t seem to
matter. As a U.S. Army medical bulletin reported from France, the “epidemic is
about at an end...and has been throughout of a benign type.” A British medical
journal stated flatly that influenza “has completely disappeared.”
In fact, it was more like a
great tsunami that initially pulls water away from the shore—only to return in
a towering, overwhelming surge. In August, the affliction resurfaced in
Switzerland in a form so virulent that a U.S. Navy intelligence officer, in a
report stamped “Secret and Confidential,” warned “that the disease now epidemic
throughout Switzerland is what is commonly known as the black plague, although
it is designated as Spanish sickness and grip.”
The second wave had begun.
**********
The hospital at Camp Devens, an
Army training base 35 miles from Boston that teemed with 45,000 soldiers, could
accommodate 1,200 patients. On September 1, it held 84.
On September 7, a soldier sent
to the hospital delirious and screaming when touched was diagnosed with
meningitis. The next day a dozen more men from his company were diagnosed with
meningitis. But as more men fell ill, physicians changed the diagnosis to
influenza. Suddenly, an Army report noted, “the influenza...occurred as an
explosion.”
At the outbreak’s peak, 1,543
soldiers reported ill with influenza in a single day. Now, with hospital
facilities overwhelmed, with doctors and nurses sick, with too few cafeteria
workers to feed patients and staff, the hospital ceased accepting patients, no
matter how ill, leaving thousands more sick and dying in barracks.
Roy Grist, a physician at the
hospital, wrote a colleague, “These men start with what appears to be an
ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they
very rapidly develop the most vicious type of Pneumonia that has ever been
seen. Two hours after admission they have the Mahogany spots over the cheek
bones, and a few hours later you can begin to see the Cyanosis”—the term refers
to a person turning blue from lack of oxygen—“extending from their ears and
spreading all over the face....It is only a matter of a few hours then until
death comes...It is horrible....We have been averaging about 100 deaths per
day...For several days there were no coffins and the bodies piled up something
fierce...”
Devens, and the Boston area,
was the first place in the Americas hit by the pandemic’s second wave. Before
it ended, influenza was everywhere, from ice-bound Alaska to steaming Africa.
And this time it was lethal.
**********
The killing created its own
horrors. Governments aggravated them, partly because of the war. For instance,
the U.S. military took roughly half of all physicians under 45—and most of the
best ones.
What proved even more deadly
was the government policy toward the truth. When the United States entered the
war, Woodrow Wilson demanded that “the spirit of ruthless brutality...enter
into the very fibre of national life.” So he created the Committee on Public
Information, which was inspired by an adviser who wrote, “Truth and falsehood
are arbitrary terms....The force of an idea lies in its inspirational value. It
matters very little if it is true or false.”
At Wilson’s urging, Congress
passed the Sedition Act, making it punishable with 20 years in prison to “utter,
print, write or publish any disloyal, profane, scurrilous, or abusive language
about the form of government of the United State...or to urge, incite, or
advocate any curtailment of production in this country of any thing or
things...necessary or essential to the prosecution of the war.” Government
posters and advertisements urged people to report to the Justice Department
anyone “who spreads pessimistic stories...cries for peace, or belittles our
effort to win the war.”
Against this background, while influenza
bled into American life, public health officials, determined to keep morale up,
began to lie.
Early in September, a Navy ship
from Boston carried influenza to Philadelphia, where the disease erupted in the
Navy Yard. The city’s public health director, Wilmer Krusen, declared that he
would “confine this disease to its present limits, and in this we are sure to
be successful. No fatalities have been recorded. No concern whatever is felt.”
The next day two sailors died
of influenza. Krusen stated they died of “old-fashioned influenza or grip,” not
Spanish flu. Another health official declared, “From now on the disease will
decrease.”
The next day 14 sailors
died—and the first civilian. Each day the disease accelerated. Each day
newspapers assured readers that influenza posed no danger. Krusen assured the
city he would “nip the epidemic in the bud.”
By September 26, influenza had
spread across the country, and so many military training camps were beginning
to look like Devens that the Army canceled its nationwide draft call.
Philadelphia had scheduled a
big Liberty Loan parade for September 28. Doctors urged Krusen to cancel it,
fearful that hundreds of thousands jamming the route, crushing against each
other for a better view, would spread disease. They convinced reporters to
write stories about the danger. But editors refused to run them, and refused to
print letters from doctors. The largest parade in Philadelphia’s history
proceeded on schedule.
The incubation period of
influenza is two to three days. Two days after the parade, Krusen conceded that
the epidemic “now present in the civilian population was...assuming the type
found in” Army camps. Still, he cautioned not to be “panic stricken over
exaggerated reports.”
He needn’t have worried about
exaggeration; the newspapers were on his side. “Scientific Nursing Halting
Epidemic,” an Inquirer headline blared. In truth, nurses had no impact because
none were available: Out of 3,100 urgent requests for nurses submitted to one
dispatcher, only 193 were provided. Krusen finally and belatedly ordered all
schools closed and banned all public gatherings—yet a newspaper nonsensically
said the order was not “a public health measure” and “there is no cause for
panic or alarm.”
There was plenty of cause. At
its worst, the epidemic in Philadelphia would kill 759 people...in one day.
Priests drove horse-drawn carts down city streets, calling upon residents to
bring out their dead; many were buried in mass graves. More than 12,000
Philadelphians died—nearly all of them in six weeks.
Across the country, public
officials were lying. U.S. Surgeon General Rupert Blue said, “There is no cause
for alarm if precautions are observed.” New York City’s public health director
declared “other bronchial diseases and not the so-called Spanish
influenza...[caused] the illness of the majority of persons who were reported
ill with influenza.” The Los Angeles public health chief said, “If ordinary
precautions are observed there is no cause for alarm.”
For an example of the press’s
failure, consider Arkansas. Over a four-day period in October, the hospital at
Camp Pike admitted 8,000 soldiers. Francis Blake, a member of the Army’s
special pneumonia unit, described the scene: “Every corridor and there are
miles of them with double rows of cots ...with influenza patients...There is
only death and destruction.” Yet seven miles away in Little Rock, a headline in
the Gazette pretended yawns: “Spanish influenza is plain la grippe—same old
fever and chills.”
People knew this was not the
same old thing, though. They knew because the numbers were staggering—in San
Antonio, 53 percent of the population got sick with influenza. They knew
because victims could die within hours of the first symptoms—horrific symptoms,
not just aches and cyanosis but also a foamy blood coughed up from the lungs,
and bleeding from the nose, ears and even eyes. And people knew because towns
and cities ran out of coffins.
People could believe nothing
they were being told, so they feared everything, particularly the unknown. How
long would it last? How many would it kill? Who would it kill? With the truth
buried, morale collapsed. Society itself began to disintegrate.
In most disasters, people come
together, help each other, as we saw recently with Hurricanes Harvey and Irma.
But in 1918, without leadership, without the truth, trust evaporated. And
people looked after only themselves.
In Philadelphia, the head of
Emergency Aid pleaded, “All who are free from the care of the sick at home...
report as early as possible...on emergency work.” But volunteers did not come.
The Bureau of Child Hygiene begged people to take in—just temporarily—children
whose parents were dying or dead; few replied. Emergency Aid again pleaded, “We
simply must have more volunteer helpers....These people are almost all at the
point of death. Won’t you...come to our help?” Still nothing. Finally,
Emergency Aid’s director turned bitter and contemptuous: “Hundreds of
women...had delightful dreams of themselves in the roles of angels of
mercy...Nothing seems to rouse them now...There are families 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.”
Philadelphia’s misery was not
unique. In Luce County, Michigan, a couple and three children were all sick
together, but, a Red Cross worker reported, “Not one of the neighbors would
come in and help. I ...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.” In New Haven, Connecticut, John Delano recalled, “Normally when someone
was sick in those days [people] would bring food over to other families
but...Nobody was coming in, nobody would bring food in, nobody came to visit.”
In Perry County, Kentucky, the Red Cross chapter chairman begged for help,
pleaded that there were “hundreds of cases...[of] people starving to death not
from lack of food but because the well were panic stricken and would not go
near the sick.”
In Goldsboro, North Carolina,
Dan Tonkel recalled, “We were actually almost afraid to breathe...You were
afraid even to go out...The fear was so great people were actually afraid to
leave their homes...afraid to talk to one another.” In Washington, D.C.,
William Sardo said, “It kept people apart...You had no school life, you had no
church life, you had nothing...It completely destroyed all family and community
life...The terrifying aspect was when each day dawned you didn’t know whether
you would be there when the sun set that day.”
An internal American Red Cross
report concluded, “A fear and panic of the influenza, akin to the terror of the
Middle Ages regarding the Black Plague, [has] been prevalent in many parts of
the country.”
Fear emptied places of
employment, emptied cities. Shipbuilding workers throughout the Northeast were
told they were as important to the war effort as soldiers at the front. Yet at
the L.H. Shattuck Co. only 54 percent of its workers showed up; at the George
A. Gilchrist yard only 45 percent did; at Freeport Shipbuilding only 43
percent; at Groton Iron Works, 41 percent.
Fear emptied the streets, too.
A medical student working in an emergency hospital in Philadelphia, one of the
nation’s largest cities, encountered so few cars on the road he took to
counting them. One night, driving the 12 miles home, he saw not a single car.
“The life of the city had almost stopped,” he said.
On the other side of the globe,
in Wellington, New Zealand, another man stepped outside his emergency hospital
and found the same thing: “I stood in the middle of Wellington City at 2 P.M.
on a weekday afternoon, and there was not a soul to be seen; no trams running;
no shops open, and the only traffic was a van with a white sheet tied to the
side with a big red cross painted on it, serving as an ambulance or hearse. It
was really a city of the dead.”
Victor Vaughan, formerly the
dean of the University of Michigan’s Medical School, was not a man to resort to
hyperbole. Now the head of the Army’s communicable disease division, he jotted
down his private fear: “If the epidemic continues its mathematical rate of
acceleration, civilization could easily disappear...from the face of the earth
within a matter of a few more weeks.”
**********
Then, as suddenly as it came,
influenza seemed to disappear. It had burned through the available fuel in a
given community. An undercurrent of unease remained, but aided by the euphoria
accompanying the end of the war, traffic returned to streets, schools and
businesses reopened, society returned to normal.
A third wave followed in
January 1919, ending in the spring. This was lethal by any standard except the
second wave, and one particular case would have an exceptional impact on
history.
On April 3, 1919, during the
Versailles Peace Conference, Woodrow Wilson collapsed. His sudden weakness and
severe confusion halfway through that conference—widely commented upon—very
possibly contributed to his abandoning his principles. The result was the
disastrous peace treaty, which would later contribute to the start of World War
II. Some historians have attributed Wilson’s confusion to a minor stroke. In
fact, he had a 103 degree temperature, intense coughing fits, diarrhea and
other serious symptoms. A stroke explains none of the symptoms. Influenza,
which was then widespread in Paris and killed a young aide to Wilson, explains
all of them—including his confusion. Experts would later agree that many
patients afflicted by the pandemic influenza had cognitive or psychological
symptoms. As an authoritative 1927 medical review concluded, “There is no doubt
that the neuropsychiatric effects of influenza are profound...hardly second to
its effect on the respiratory system.”
After that third wave, the 1918
virus did not go away, but it did lose its extraordinary lethality, partly
because many human immune systems now recognized it and partly because it lost
the ability to easily invade the lungs. No longer a bloodthirsty murderer, it
evolved into a seasonal influenza.
Scientists and other experts
are still asking questions about the virus and the devastation it caused,
including why the second wave was so much more lethal than the first.
Researchers aren’t certain, and some argue that the first wave was caused by an
ordinary seasonal influenza virus that was different from the pandemic virus;
but the evidence seems overwhelming that the pandemic virus had both a mild and
virulent form, causing mild as well as severe spring outbreaks, and then, for
reasons that remain unclear, the virulent form of the virus became more common
in the fall.
Another question concerns who
died. Even though the death toll was historic, most people who were infected by
the pandemic virus survived; in the developed world, the overall mortality was about
2 percent. In the less developed world, mortality was worse. In Mexico,
estimates of the dead range from 2.3 to 4 percent of the entire population.
Much of Russia and Iran saw 7 percent of the population die. In the Fiji
Islands 14 percent of the population died—in 16 days. One-third of the
population of Labrador died. In small native villages in Alaska and Gambia,
everyone died, probably because all got sick simultaneously and no one could
provide care, could not even give people water, and perhaps because, with so
much death around them, those who might have survived did not fight.
The age of the victims was also
striking. Normally, elderly people account for the overwhelming number of
influenza deaths; in 1918, that was reversed, with young adults killed in the
highest numbers. This effect was heightened within certain subgroups. For
instance, a Metropolitan Life Insurance Company study of people aged 25 to 45
found that 3.26 percent of all industrial workers and 6 percent of all coal
miners died. Other studies found that for pregnant women, fatality rates ranged
from 23 percent to 71 percent.
Why did so many young adults
die? As it happens, young adults have the strongest immune systems, which
attacked the virus with every weapon possible—including chemicals called
cytokines and other microbe-fighting toxins—and the battlefield was the lung.
These “cytokine storms” further damaged the patient’s own tissue. The
destruction, according to the noted influenza expert Edwin Kilbourne, resembled
nothing so much as the lesions from breathing poison gas.
**********
Seasonal influenza is bad
enough. Over the past four decades it has killed 3,000 to 48,000 Americans
annually, depending on the dominant virus strains in circulation, among other
things. And more deadly possibilities loom.
In recent years, two different
bird influenza viruses have been infecting people directly: the H5N1 strain has
struck in many nations, while H7N9 is still limited to China (see “The Birth of
a Killer”). All told, these two avian influenza viruses had killed 1,032 out of
the 2,439 people infected as of this past July—a staggering mortality rate.
Scientists say that both virus strains, so far, bind only to cells deep in the
lung and do not pass from person to person. If either one acquires the ability
to infect the upper respiratory tract, through mutation or by swapping genes
with an existing human virus, a deadly pandemic is possible.
Prompted by the re-emergence of
avian influenza, governments, NGOs and major businesses around the world have
poured resources into preparing for a pandemic. Because of my history of the
1918 pandemic, The Great Influenza, I was asked to participate in some of those
efforts.
Public health experts agree
that the highest priority is to develop a “universal vaccine” that confers
immunity against virtually all influenza viruses likely to infect humans (see
“How to Stop a Lethal Virus”). Without such a vaccine, if a new pandemic virus
surfaces, we will have to produce a vaccine specifically for it; doing so will
take months and the vaccine may offer only marginal protection.
Another key step to improving
pandemic readiness is to expand research on antiviral drugs; none is highly
effective against influenza, and some strains have apparently acquired
resistance to the antiviral drug Tamiflu.
Magisterial in its breadth of
perspective and depth of research and now revised to reflect the growing danger
of the avian flu, “The Great Influenza” is ultimately a tale of triumph amid
tragedy, which provides us with a precise and sobering model as we confront the
epidemics looming on our own horizon.
Buy
Then there are the less
glamorous measures, known as nonpharmaceutical interventions: hand-washing,
telecommuting, covering coughs, staying home when sick instead of going to work
and, if the pandemic is severe enough, widespread school closings and possibly
more extreme controls. The hope is that “layering” such actions one atop
another will reduce the impact of an outbreak on public health and on resources
in today’s just-in-time economy. But the effectiveness of such interventions
will depend on public compliance, and the public will have to trust what it is
being told.
That is why, in my view, the
most important lesson from 1918 is to tell the truth. Though that idea is
incorporated into every preparedness plan I know of, its actual implementation
will depend on the character and leadership of the people in charge when a
crisis erupts.
I recall participating in a
pandemic “war game” in Los Angeles involving area public health officials.
Before the exercise began, I gave a talk about what happened in 1918, how
society broke down, and emphasized that to retain the public’s trust,
authorities had to be candid. “You don’t manage the truth,” I said. “You tell
the truth.” Everyone shook their heads in agreement.
Next, the people running the
game revealed the day’s challenge to the participants: A severe pandemic
influenza virus was spreading around the world. It had not officially reached
California, but a suspected case—the severity of the symptoms made it seem
so—had just surfaced in Los Angeles. The news media had learned of it and were
demanding a press conference.
The participant with the first
move was a top-ranking public health official. What did he do? He declined to
hold a press conference, and instead just released a statement: More tests are
required. The patient might not have pandemic influenza. There is no reason for
concern.
I was stunned. This official
had not actually told a lie, but he had deliberately minimized the danger;
whether or not this particular patient had the disease, a pandemic was coming.
The official’s unwillingness to answer questions from the press or even
acknowledge the pandemic’s inevitability meant that citizens would look
elsewhere for answers, and probably find a lot of bad ones. Instead of taking
the lead in providing credible information he instantly fell behind the pace of
events. He would find it almost impossible to get ahead of them again. He had,
in short, shirked his duty to the public, risking countless lives.
And that was only a game.
………….
About John M. Barry –He is the
author of The Great Influenza and Rising Tide: The Great Mississippi Flood of
1927 and How It Changed America, which received the 1998 Francis Parkman Prize
for the best book of U.S. history.
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