Wednesday, January 23, 2013

Giving the Flu the Respect it is Due

Every winter we are inundated with 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, which is when we work ourselves up about potential epidemics and lethal strains just like we've been doing for decades. In 1943, for example, the Pittsburgh Post-Gazette warned readers 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: "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."

Respect is called for indeed. Truth is, we don't know what plague is like in the Western world, so the threat of an ├╝ber-illness rightfully 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. Modern science has yet to figure out how to predict the timing or course of a pandemic, and the ramifications of that makes folks nervous. It is then that we turn to history to be reminded of the power of illness, and then that dig through our collective memory box and dust off stories about the 1918 flu pandemic.

A Case of the Flu, 1918-style
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 in fact we can't know for sure as these are only estimates. The lack of accurate record-keeping might astound modern readers, but 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, but this staggered approach did little to assure accurate data collection, especially since the illness was so widespread as to render coordinated record-keeping impossible (not to mention different state 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.

Pittsburgh Gets the Flu
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. Here's how it started: a ship from infected Boston docked in Philadelphia in September 1918, and cases of influenza were diagnosed soon thereafter at the local Navy base. Within 24 hours 600 sailors had been diagnosed. The virus quickly spread to the civilian population through exposure at large-scale gatherings like that city's 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 struggling with habitually dismal urban 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." Overcrowded, sub-standard housing and abysmal environmental conditions contributed to the city's vulnerability and escalated the influenza mortality rate.

So, too, did reluctance by the media, political and public health officials to acknowledge and define the scope of the disaster. War news and the Pirates pennant race dominated the local headlines. It's hard to reconcile the reasons for this information void, because Pittsburgh could not claim to be unaware of the approaching epidemic as it moved westward. The local Board of Health even announced that it predicted the flu would make its appearance in Pittsburgh on September 17th.  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.

Whenever it arrived, Board of Health officials claimed that Pittsburghers would likely suffer from the less serious "Boston variety" and not the deadly "Philadelphia strain." Problem was, there was only one flu and sick was sick no matter what you called it. Did officials really believe such strain-parsing in an orgy of self-reassurance and self-denial, or was this merely an attempt at spin control to avoid panic? There was certainly a precedent for 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 that 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, denial ultimately meant death. The initial reluctance on the part of the media, Mayor Edward V. Babcock and the city's Board of Health to publicly acknowledge and recognize the dangers that the coming flu epidemic posed to city residents would prove disastrous. They initially refused to accept offers of aid from the state's Red Cross, even as reports from Philadelphia worsened. The Board of Health's prediction wasn't far off, as flu cases began being reported in local papers by mid-September. Pittsburgh's first recorded death from influenza was that of a 29 year old Aspinwall man named Charles N. Patterson, who succumbed at St. Francis Hospital on 4 October 1918 while home on furlough from his duties with the One Hundred and Sixth Ammunition Train. The papers duly reported that 25/30 reported cases of flu were at the same hospital, but emphasized that all afflicted patients were military members. On the same day, the Army commandeered the 150-bed Magee Women's Hospital for care of military flu victims.

Experience on the eastern seaboard showed that the flu would not remain confined to members of the military, and the state instituted a mandatory gathering ban in early October. Local media and Pittsburgh's political leadership balked at what they felt was an arbitrary declaration, effectively grumbling that things weren't THAT bad here. Mayor Babcock
Edward V. Babcock, Mayor of Pittsburgh 1918-1921
peevishly declared in a statement to the press:
"The State Department of Health has full power. Personally, it appears to me, in view of local conditions and in the absence of any epidemic of influenza, that the orders of the Department are too drastic. However the State is in command, and the city authorities will enforce its order to the strictest letter."
Except they didn't. Businessmen who relied upon monies earned at local watering holes, hotels, restaurants, theaters, sports events and the like exerted pressure for their establishments to stay open. Ban enforcers were rumored to look the other way as these businesses continued to operate -- flu be damned.  Two months later, Babcock lifted the public gathering ban earlier than recommended by the State, just in time for election day. The State Health Commissioner and Pittsburgh's Mayor exchanged testy words throughout the epidemic, each struggling to assert his authority whilst containing the disaster.

Initially there were no mandatory closures of churches but many Catholic churches and Jewish synagogues did voluntarily close. Eventually the city caught up and ordered closures. 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!

Two weeks after Charles N. Patterson died, this was the headline in the Pittsburgh Post on 18 October 1918:

The official and willful deception, inveigling and obfuscation was 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.

On 20 October 1918, city hospitals reached their full capacity and new cases were sent to the Kingsley House, which opened its doors for overflow

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.
White, Kenneth A. Pittsburgh and the Great Epidemic of 1918.

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