Wednesday, January 23, 2013

Giving the Flu the Respect it is Due

Over the last few weeks the media has been inundated by stories about the horrible, no good, very bad flu season that is upon us. In the United States, flu season peaks between late December and early March. We get ourselves worked up about epidemics and potentially-lethal strains, and threats thereof dominate the media each winter. This is nothing new; for example, in 1943 the Pittsburgh Post-Gazette warned that "The flu epidemic of 1943 may approach in severity the deadly one of 1918." It didn't, but that didn't stop the paper from admonishing its readership that "Without getting panicky, the public must co-operate with public health authorities in every possible way to check the spread of the disease. The best way is for each individual to safeguard his own health and treat flu, if he gets it, with the respect it deserves."

And respect it we do to this day, so much so that the good people at Google have developed a user-friendly international tracking site of flu incident reports (LINK). Caution: the site is somewhat addicting if you have epidemiological or hypochondriacal inclinations. Don't say I didn't warn you.

Truth is, we don't know what plague is like in the Western world, so the threat of an ├╝ber-illness gives us collective pause for worry. Influenza pandemics have occurred three times in the past century (1918-19, 1957-58, 1968-69), each caused by different but related subtypes. Many scientists believe it's only a matter of time until another influenza pandemic occurs, given the efficiency with which these viruses can replicate, spread, and mutate. There's no way to predict the timing or course of a pandemic, so tales about flu epidemics serve to elevate what is typically an annual annoyance that can knock us on our butts for a week to Lead Story status. It is then that we turn to history to be reminded of the devastation that widespread illness can wreak, and we start digging through our collective memory box and dusting off stories about the 1918 flu pandemic.

The influenza pandemic of 1918-19 killed an estimated 20 to 50 million people worldwide, including an estimated 675,000 deaths in the United States. That's a big gap, 20 to 50 million, and we in fact have only estimates to go by for these figures. The national Public Health Service had but recently begun to require regional health departments to report on disease incidence, and influenza wasn’t initially a reportable disease. Be that as it may, in March 1918, military health officials at Fort Riley in Haskell County, Kansas reported on the unusually virulent influenza that they were seeing there, which paralleled a concurrent outbreak in Europe among the military population. What was known as the "Spanish" flu was thusly named because Spain was the first country to be struck by the disease that was also uninvolved in World War I, and therefore did not find it necessary to censor its health reports for the good of morale as other countries (including the United States) regularly did.

The second and most virulent wave of the influenza outbreak occurred in the fall of 1918, spreading to the civilian population, while the third and final wave occurred in the spring of 1919. Influenza was made a reportable disease by state agencies at various points, and this staggered approach did little to assure accurate data collection, especially since the illness was so widespread as to render thorough record-keeping impossible, plus states had different reporting standards. Many, many cases thus went unreported, hence the uncertainty about actual statistics. Still, it's not unreasonable to imagine the worst possible scenarios, then mentally multiply them to approach reality.

Just as epidemiological data-gathering fell short of today's standards, so too were seemingly sensible precautions lacking in 1918. Since the virus spreads quickly through airborne particles, we know today that avoiding crowds is a given during flu season. But back then, public health officials thought catching the flu was the result of bacterial infection and sought to minimize exposure through the wearing of gauze masks, even passing laws requiring public wearing of such masks. We know now that masks don't effectively filter viruses in the air. Eventually people figured that out in 1918 from sorry experience, but not before thousands sickened after exposure at events like war rallies and parades. In fact, the Great War was a huge factor in the epidemiological case history of this illness. It is thought that the virus first spread to the United States on that military base in Kansas, and the subsequent incubation and widespread incidence of the illness on troop carriers is well-documented.

Warning posters like these were posted in public places
The word 'devastating' is an understatement in describing the effects of this pandemic. Whereas normally the influenza virus is most threatening to the very young, very old, or those with compromised immune systems, the 1918 mutations struck people under 35 in the prime of life. There are some theories that this age cohort suffered disproportionately because those folks had not been alive to develop antibodies to a similar flu virus that circulated in the 1890s. Entire families sickened and died within days, with no one to care for them due to the widespread nature of the illness, fear of contagion, and decimated medical corps due to wartime service needs. Even if you somehow escaped being infected (and there were many who did, perhaps having developed antibody resistance from the aforementioned 1890s flu outbreak), you were still affected. Imagine the worst case scenarios: garbage piling up on the sidewalk outside of your house because there weren't enough healthy workers to collect the trash; businesses shutting down because there were no healthy employees; schools emptied as children sickened and died; a communication vacuum leaving the fates of your friends and families unknown due to inconsistent telephone and postal service. In some cities, funeral parlors ran out of caskets, bodies went uncollected in morgues, and trenches were dug for mass civilian burials. Try to imagine how many people died in the United States as the equivalent of ten modern football stadiums filled with dead people. In fact, the flu took three times as many lives as did World War I itself.

Despite the fact that Pittsburgh had higher overall death rates, stories about the effects of the 1918 pandemic here were eclipsed by the health crisis in Philadelphia, an epi-center of the second wave of the pandemic. A ship from infected Boston had docked in Philadelphia in September 1918 and cases of influenza were diagnosed soon thereafter at the Navy base. Within 24 hours 600 sailors had been diagnosed, and the virus quickly spread to the civilian population through exposure at large-scale gatherings such as the Liberty Loan Parade. The disease made its appearance in Pittsburgh in mid September, although it was not locally mandated as reportable until October 4.
Irene Kaufmann Settlement House for the Jewish immigrant community, Hill District, May 1922. Pittsburgh settlement houses overflowed with the afflicted since hospitals were filled to capacity. This one was designated as an emergency hospital during the pandemic, and treated 1047 cases of influenza/pneumonia in 42 days. Photos courtesy of Archives Service Center, University of Pittsburgh.

Professor of History at Kutztown State University Jim Higgins, Ph.D. detailed in a July 2010 article for the Pennsylvania Magazine of History and Biography how Pittsburgh's experience of the 1918 pandemic both mirrored and differed from that of other hard-hit urban areas. Although accurate estimates are impossible, Higgins' sources indicate that the city lost between 4800 to 6600 people to the flu, or roughly one percent of its total population. To visualize this, imagine the Byham Theater, Benedum Center, and Heinz Hall for the Performing Arts all filled to capacity with dead bodies.

Higgins further details how Pittsburgh's official response to the epidemic largely worsened the experience for its residents because the city's political, industrial, and public health domains were at loggerheads with one another. This could but bode ill in a city already stretched to its limits due to the war effort and with habitually dismal living conditions. Pittsburgh was still the place that writer James Patton had described in 1866 when looking down from Mount Washington as "hell with the lid taken off," a place where "...we inhale death while enjoying every breath we draw." The abysmal environmental and overcrowded, sub-standard housing conditions that characterized Pittsburgh contributed to its vulnerability to and mortality rate from the influenza outbreak.

So, too, did reluctance by political and public health officials to acknowledge and define the scope of the disaster. It's hard to reconcile the reasons for this reluctance, because Pittsburgh was not caught unawares of the approaching epidemic as it moved westward. The local Board of Health even announced that it was predicted the flu would make its appearance in Pittsburgh on September 17! Why that date was chosen is unknown, and there is no word as to whether there was an official welcoming committee on hand to greet the flu with the key to the city upon its arrival. But in what was likely an attempt to control panic, Board of Health officials claimed that while Pittsburgh would be hit the culprit would be the less serious Boston variety of flu, not the deadly Philadelphia strain. Except there were no different strains; sick was sick no matter what you called it. Did officials really believed the stories they were telling in an orgy of self-reassurance and denial, or whether this was mere spin control? There was always spin control during epidemics prior to the modern era of 24/7 investigative reporting. For example, the New Orleans press was famously complicit in not reporting on its notorious yellow fever outbreak of 1853 until the city was too wretchedly affected to deny its presence any longer. Pittsburgh leadership's impression management and attempts to maintain morale by not over-stating -- or even realistically stating! -- the case was understandable in that context of the times.

Still, the refusal by Mayor Edward V. Babcock and the city's Board of Health to publicly acknowledge and recognize the potential danger the epidemic posed to city residents proved disastrous. Their initial refusal to accept offers of aid by the state's Red Cross is mind-boggling, even as reports from Philadelphia worsened and the Army commandeered the 150-bed Magee Women's Hospital on October 4 for care of military flu victims.  Pittsburgh's political leadership even balked at enforcing the state's mandatory gathering ban under pressure from local businesses that relied upon monies earned at local watering holes, hotels, restaurants, theaters, sports events and the like. Enforcers thus looked the other way as these establishments continued to operate. There were no mandatory closures of churches but many Catholic churches and Jewish synagogues did voluntarily close. City public schools remained open until October 24, far into the epidemic, ostensibly so that the public health director could monitor and track the rate of transmission of the illness among school children!

The official and willful deception, inveigling and obfuscation is exemplified by this response by William H. Davis, local Board of Health director, as described by Dr. Higgins:
Davis summed up officials' reluctance to deal with the epidemic when he answered a reporter's question about whether there was an influenza epidemic in Pittsburgh by stating, "You must draw your own conclusion. What constitutes an epidemic is a matter of opinion."
American Red Cross training class, Fifth Ave High School, June 1918. Little did they know what was to come.
City officials could and should have done so much better for residents. Fortunately, private groups stepped to the fore where the initial administrative response was lacking. Pittsburgh was thus spared the trauma of having corpses overflowing its morgues for the local Red Cross was particularly instrumental in securing coffins and organizing the removal and burial of remains.

The trajectory of the illness in Pittsburgh was prolonged over the course of many months, rather than isolated in intense bursts as in Philadelphia. This also helped to alleviate some infrastructure burdens, in spite of administrative failures.

As the aftermath of domestic disasters like Hurricane Katrina has illustrated, there are reasons why we should even today question the confidence that we place in official abilities to effectively and efficiently manage large-scale relief efforts. We can but hope that enlightened minds will prevail if faced with pandemic conditions in the modern era. Because the big fear, of course, is whether a 1918-like pandemic could happen again.

Exposure to the 1918 virus (which itself has been reconstructed and studied by the federal Centers for Disease Control and Prevention) is thought by some microbiologists to have conferred protective status on those exposed through the development of antibodies that neutralized the effect of subsequent related viruses. Those antibodies, coupled with modern public health policies and a collectively enlightened understanding about infection precautions that developed once the disease process of influenza was recognized in the 1930s, rendered the other two influenza pandemics of the 20th century less virulent. Viruses like the one responsible for the 1918 pandemic circulated among humans until 1957 and then seemed to die out, although a related virus re-emerged as 'swine flu' in 1976. It stands to reason that anyone exposed to those viruses may have developed some resistance, but no one is naturally immune to influenza and of course other new strains of viruses develop that have potentially devastating lethal capabilities. Fortunately so far the dreaded H1N1 and H5N1 flu viruses have not shown themselves capable of adapting so as to enable transmission between humans, as this great video from the folks at NOVA explains:

Watch 1918 Flu on PBS. See more from NOVA scienceNOW.

We are so fortunate to live in an age when health care and vaccines are readily available and research can be conducted on identifying and eradicating new diseases. I know that there are those who have carefully considered objections to flu vaccines, and it is certainly true that no vaccine can be effective against all virus strains. But the lessons of 1918 seem to me to speak to the need for each of us to do everything we can as individuals to prevent widespread disease-spread devastation. I do worry that lack of personal experience leads to complacency in the face of danger. If you've known even one person who suffered from polio, for example, you'd be hard-pressed to forgo a polio vaccination for your child. But as our population ages and there are fewer polio survivors as a result of natural attrition, this still very-much-living disease seems to retreat into the past. Complacency can make its eradication seem less of an immediate concern, vaccination less important, and reliance on herd immunity more of a temptation. While I don't think that influenza is subject to the same kind of complacency, given the infinite variations of viruses that can make us sick, I do think we have to resist the temptation to think "Meh, flu! No big deal. This too shall pass."

Yes, it will pass. But it might take you with it.  

There are few people alive today who remember the 1918 pandemic. There are, however, countless recorded histories and stories about that time that can make what happened 'real' to us as individuals, which in turn can help us to process current discussions and incidences of influenza.  That certainly has been the case for me. Mostly out of sheer laziness, I have not always been a flu shot advocate. That changed due to an odd convergence of experiences. When my youngest child was born I passed the time in the wee hours between his nocturnal feedings by researching my family history. I made many late night discoveries, including documenting a family whose members had all died within days of one another in the fall of 1918.  At the time, I was reading Mary Doria Russell's Dreamers of the Day, a book revolving around the 1921 Cairo Peace Conference which defined the modern Middle East.  The protagonist of this book comes into her own following her family's demise as a result of the 1918 influenza pandemic. Russell's descriptions of the personal and communal trauma inflicted by the pandemic, and the contrasts that her dazed protagonist drew between her past and present were so gripping that they have stayed with me long past the reading of the rest of the book. Because of the stage Russell set, I knew immediately what had happened to my little family. That hit me hard, and I got a flu shot the next day.

Such is the power of narrative to inform and transform, even the narrative of well-researched and written historical fiction.  I think this is a prime example of why we owe it to ourselves to pay attention to stories from the past.  Along those lines, if you have a family story about an experience related to the 1918 influenza pandemic, I hope you will share it here in the comments section of this blog (you can do so anonymously), especially if you are from Western Pennsylvania.

And please, think seriously about getting a flu shot. Give the flu the respect it is due.


Further Reading:
10 Things to Know about the Flu
1918 Spanish Flu Pictures
Digital Encyclopedia: The American Influenza Epidemic of 1918-1919
NOVA: 1918 Flu Expert Q&A
Studies on epidemic influenza :comprising clinical and laboratory investigations, University of Pittsburgh, 1919.
Springdale memorial remembers those who died in 1918 flu epidemic
The Great Pandemic
The Great Pandemic: Pennsylvania
The Real Reasons Kids Aren't Getting Vaccines

Bristow, Nancy K. American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic.
Higgins, James. “With every accompaniment of ravage and agony”: Pittsburgh and the Influenza Epidemic of 1918–1919." The Pennsylvania Magazine of History and Biography, Vol. 134, No. 3 (July 2010), pp. 263-286. Published by: The Historical Society of Pennsylvania
Iezzoni, Lynette. Influenza 1918: The Worst Epidemic in American History
Russell, Mary Doria. Dreamers of the Day.

Friday, January 11, 2013

Whistling While I Work

"You know how to whistle, don't you, Steve? You just put your lips together and... blow."
~Lauren Bacall in To Have and Have Not 

I've been thinking about whistling this week after reading performer and musical anthropologist Michael Feinstein's latest book, The Gershwins and Me

Feinstein has never been shy about expressing his opinions and I found his observations about music in today's culture fascinating. While giving modern technology high praise for its role in making music accessible and for providing tools for innovation, Feinstein regrets the proliferation of isolationist listening because of its potential to break down shared experience, which in turn contributes to a de-emphasis of music because of the lack of communal relating points. A corollary to this idea is that when there's so much music out there that we're spoilt for choice, it's difficult to find common cultural ground.

It's an arguable point, I think, because there is conversely much joy to be found with so many songs to choose from, so many iterations of those songs, and so many artists making so much different music.

The bottom line is that a plethora of choices requires us to be discerning consumers of art, and arts education makes us wise shoppers.
George and Ira Gershwin

Feinstein of course argues that a good place to start with such education is with the standards, those classics of sublime composition and lyricism such as those the Gershwin brothers produced. "Bringing people together is what...the Gershwin songs have always done," wrote Feinstein. He's preaching to the choir with me on that point. Just as I love history for the continuity of life's lessons it illustrates, I've loved the standards from the Gershwin songbook for ever and a day. I see them as illustrative of musical continuity and community-building. As a wee Sue back in the late 60s and 70s I absorbed the ubiquitous television variety hours and specials that featured the standards, later trying to replicate the amazing phrasing and timing of their performers. My success at that is why I'm here writing a blog while others are out there performing the music with verve and precision! And that's fine, because some of us have to be the listeners while others perform.

We don't have variety hours these days, and it's increasingly difficult to secure funding for arts education. But we can choose to pay attention to the music of yesteryear, for sheer enjoyment and to provide a foundation of musical knowledge. 

And there's one thing we can pretty much all do: whistle. That's right, just put your lips together and blow. Unless you're in India or Russia, that is, where whistling is considered rude. Or in Korea where it's considered to be bad luck for women to whistle. Or in a theatre during a production, lest you want to accidentally trigger the stage crew to bring down the rigging. 

Presuming that his readers were not out to sabotage shows or traveling to Korea, India or Russia to whistle away their cares, Feinstein noted:
One friend of mine observed that people no longer whistle. After pondering that thought I went out to roam the streets to see if it was true. The thought alarmed me, because my father always whistled and that sound was of seminal comfort. So I spent what seemed like an eternity wandering around, strolling the streets in search of any whistler, anywhere. Exhausted and disheartened by the sea of silent iPods, I was ready to surrender and head home.
Fortunately over-hearing a stray whistled phrase from "The Man I Love" restored Feinstein's faith in humanity that day, but his story got me thinking about this phenomenon.

Whither, whistling? Is it really a lost art? With its piercing quality, whistles have most often been associated with attention-getting and used as warnings. Personally, I never mastered the art of a two-fingered loud whistle but was always impressed by kids in grade school who could manage that sound.  Warnings aside, whistling has mostly served to amuse and pass the time. Echoing Feinstein's concerns, some musicologists posit that whistling as an art form is in its death throes because music isn't being shared communally and performed socially at home, a phenomenon ushered in by the age of radio then pushed along in the modern era with music piped into our heads vis-a-vis electronic devices.  If you've got the radio or an iPod handy, why learn music? Why even whistle to entertain yourself if there's always someone else to sing to you?

Now there are plenty of folks who find whistling to be loud and obnoxious and who'd say good riddance to it.  I, like Feinstein, find it to be a comforting sound (provided it's done melodically, and probably sparingly depending upon the skill and repertoire of the whistler). And I do believe that the ability to reproduce a song, whether by singing or whistling a tune, builds community through shared experience and arts appreciation. I can't imagine how those could be anything but positive things. 

All this has served to provide me with a New Year's resolution of sorts. That's right: I've resolved to whistle more.

There. You can't say you've not been warned.

I don't have the time or level of dedication that Feinstein has, so you're not likely to see me roaming the streets and lurking in back alleys searching for whistlers. With my luck I'd be more likely to find flashers and meth dealers back in there, although I suppose they're as entitled to whistle as is anyone else. So no whistling quests for me, but I do intend to pay informal attention to the incidences of whistling I come across this year and take note of the ages and genders of said whistlers. I figure I'll find older, male whistlers for the most part. Whistling has typically not been culturally considered an appropriately feminine pastime, despite its treble range, and I also suspect that very few people younger than my generation bother to whistle. I'm happily willing to be proven wrong on these points.

Whistler's Mother, who'd look more cheerful if she'd only whistle
I don't think I'll be heading down to the annual International Whistler's Convention in North Carolina, but I might check out this year's winners come April for inspiration. It's probably impossible to feel down-in-the-dumps and whistle at the same time so, hey, Intentional Daily Whistling could become a stress reduction movement if it catches on.  Remember, you read it here first, so make sure you attribute the movement to me in the Wikipedia article.

Mostly, though, I think paying attention to the wanton whistlers around me and contributing a few warbles of mine own is a feasible way that I can help assure the continuity of an art form that contributes to musical accessibility.

Unless you've got some motor skills issues (which can be worked on) or regularly wear a space suit, you, too, can whistle. So pucker up, and let me know how many whistlers you come across this year. I'll be one of them. 

And for more whistling trivia than you can possibly absorb in one sitting, check out the thorough Wikipedia article on whistling HERE. I am actually a decent pucker whistler but exclusively rely on the less common 'blowing-in method."  Right, that's me, rebel whistler.