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 über-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|
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.
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.|
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:
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.
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.