Wednesday, January 23, 2013

Giving the Flu the Respect it is Due

Every winter we are inundated with stories about the latest horrible, no good, very bad flu season.

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. That flu-panic is nothing new; in 1943, 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."

Yup. Yinzers need to respect the flu, because it's serious business.

Though today we have no collective experiential understanding of what plague is like in the Western world, history teaches that the threat of an ├╝ber-illness ought to give us pause for concern. 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, with international communication and public health efforts struggling to keep up.

In 1918 the power of illness devastated Pittsburgh due to a complex interplay of viral and societal factors

In the Grip of La Grippe

What we call the "Spanish" flu was thusly named because Spain, the first country to be struck by the disease that wasn't involved in World War I, was not constrained for the "good of morale" during wartime to censor health reports. That's what other countries, including the United States, were doing. Since people first started hearing about the flu in Spain, that country got to claim ownership of it.

News broke in the United States in March 1918 when 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.

Newspapers duly reported on the influenza epidemic throughout 1918, but at first it seemed far away. War news and the Pirates pennant race dominated the headlines during the first half of 1918 in Pittsburgh, and the nation tried to make light of the flu even as domestic disaster loomed. See the cartoon below for an example of such flu-humor:

Reprinted in Pittsburgh Post-Gazette, 13 August 1918

The second and most virulent wave of the influenza outbreak occurred in the fall of 1918. which is when the disease truly spread to the civilian population. A third and final wave occurred in the spring of 1919.

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. In fact, we can't know for sure how many people died. The lack of accurate record-keeping might astound modern readers, but the national Public Health Service had only recently begun to require regional health departments to report on disease incidence -- and influenza wasn’t initially a reportable disease.

Influenza was made reportable by state agencies at various points, but such a 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. It's therefore not unreasonable to imagine the worst possible scenarios, then mentally multiply them to have some sense of what life was like then.

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. They 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.

National public safety advice reproduced in Pittsburgh Daily Post, 10 October 1918

In fact, the Great War was a huge factor in the epidemiological case history of this illness. The virus first spread to the United States from that military base in Kansas, with subsequent incubation and widespread incidence of the illness on troop carriers well-documented.

Warning posters like these were posted in public places
The word 'devastating' is an understatement when 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.

Try to imagine how many people died in the United States as the equivalent of ten modern football stadiums filled with dead people.

The flu took three times as many lives as did World War I itself.

And 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 socially and psychologically.

Pittsburgh Gets the Flu 

Despite the fact that Pittsburgh had higher overall death rates, stories about the effects of this city's experiences with the 1918 pandemic have been eclipsed by the health crisis in Philadelphia, which was an epicenter of the second wave of the pandemic.

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 Philadelphia's Liberty Loan Parade.

Philadelphia Liberty Loan Parade. Even as this photo was taken, all those nice people in the crowd were giving each other the flu.
U.S. National Archives photo

And then it gradually spread to the west.

Urban living conditions here provided fertile breeding grounds for disease. Pittsburgh was still the place 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. Pittsburgh's official response to the epidemic may have worsened the experience for its residents, as the political, industrial, and public health domains faced off against one another in a city already stretched to its limits due to the war effort.

Pittsburgh Daily Post, 16 September 1918
Pittsburgh certainly could not claim to be unaware of the approaching epidemic, as newspaper reports increased about its devastating spread from the eastern seaboard. The local Board of Health issued a health bulletin in mid-September with recommendations in advance of the flu's anticipated arrival. It included such sage advice as "Don't cough; don't sneeze; don't spit in public places."

But Board of Health officials attempted to minimize the flu's reach, claiming that Pittsburghers would likely suffer from the less serious "Boston variety" and not the deadly "Philadelphia strain."

Of course, there was only one flu; 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 an attempt at spin control to avoid panic? There was certainly national precedent for spin control during epidemics prior to the modern era of 24/7 investigative reporting. The New Orleans press was deliberately complicit in not reporting on its notorious yellow fever outbreak of 1853, burying the news until that city was too wretchedly affected to deny its presence any longer.

Whether it was politically expedient denial or self-denial, denial it was. Pittsburgh leadership initially refused to accept offers of aid from the state's Red Cross, even as reports from Philadelphia worsened.

The need for impression management and attempts to maintain morale by not over-stating -- or even realistically stating -- the effects of the flu may have had precedent, but denial ultimately meant death. Reluctance on the part of the media, Mayor Edward V. Babcock, and Pittsburgh's Board of Health to publicly acknowledge the full extent of the flu's impact on city residents damned Pittsburgh to suffer.

The Pittsburgh Press, 30 September 1918
The disease made its appearance in Pittsburgh by late September, although it was not locally mandated as reportable until October 4. It was said that Pittsburgh had been "passed up" -- but just in case "warnings sounded" since the danger of an epidemic was "ever prevalent."


Pittsburgh's first recorded death from influenza on 4 October 1918 was that of a 29 year old Aspinwall man named Charles N. Patterson, who succumbed at St. Francis Hospital. Patterson was home on furlough from his duties with the One Hundred and Sixth Ammunition Train. With his death, suddenly cases of the flu were mandated reportable.

And it was getting worse. On that same day that Patterson died, the Army commandeered the 150-bed Magee Women's Hospital for care of military flu victims.

The papers noted that 25/30 reported cases of flu in Pittsburgh were also being treated at the same hospital where Paterson died, but emphasized that the only afflicted patients were military members.

Surely no one was fooled: on the eastern seaboard, the flu was not confined to members of the military. Knowing this, watching the flu devastate Philadelphia, and doing its best to contain contagion, Pennsylvania state government instituted a mandatory gathering ban almost immediately. Across the state, people were ordered to stay at home.

Staying Well vs. Making Money
Pittsburgh's political leadership balked at what it felt was arbitrary and unnecessary interference from the state.

The local media duly reported on this city-versus-state power struggle. Pittsburgh Mayor Babcock peevishly declared in a statement to the press:
Edward V. Babcock, Mayor of Pittsburgh 1918-1921
"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."
But they really didn't want to.

Why? Because, money.

Pittsburgh businessmen who relied upon revenue earned at local watering holes, hotels, restaurants, theaters, dance halls, pool rooms, and sports events exerted pressure for their establishments to stay open. Ban enforcers were encouraged to look the other way as these businesses continued to operate, and there was talk about unified resistance to the state ban. Local papers didn't quite seem to know who to believe, as this equivocal editorial indicates.

The Pittsburgh Press, 4 October 1918

But at the same time it was expressing doubt about the need for a gathering ban, the press reported on the city's compliance with the state order in tones that praised obedience for the sake of public health.

Pittsburgh Post-Gazette, 5 October 1918

A month later, Mayor Babcock lifted the public gathering ban in Pittsburgh earlier than recommended by the State -- just in time for election day.

Pittsburgh Post, 2 November 1918

"Our darkened streets and deserted assembling places, by reason of this ban has thrown over the community a depression and a pall that seriously retards the recovering to normal conditions of health, business and recreation and can but enhance further dangers from the affliction through which we have passed,"  wrote Babcock in his proclamation. Meanwhile, the State Health Commissioner called this "an invitation to lawlessness and disorder" and impugned the Mayor's actions as being influenced by "liquor interests".  He was probably right, because Babcock weathered insistent pressure from closed bars and booze whole-sellers to lift the ban.

The city and state exchanged testy words throughout the epidemic, each struggling to assert authority whilst containing the disaster. The State won out in the end, prosecuting Pittsburgh businesses that defied the ban with stiff fines.

Meanwhile, more people got sick. And more people died.
The official deception, inveigling and obfuscation rhat occurred is exemplified by this response by William H. Davis, local Board of Health director, on 10 October 1918. After reporting on various alarming statistics, including that 659 new cases of the flu had been reported in the previous 36 hours, the Post-Gazette reported:
Asked if the disease is to be regarded as having reached the epidemic stage, Health Director W.H. Davis said: "You must draw your own conclusions. What constitutes an epidemic is a matter of opinion."
Never mind that three days earlier, his department had ordered city hospitals to operate on an emergency epidemic basis, admitting only the sickest patients and postponing nonessential surgeries.

Two weeks after Charles N. Patterson's death, this was the 18 October 1918 headline in the Pittsburgh Post:

But hey, what constitutes an epidemic is a matter of opinion.

Giving the flu the respect it was due by telling the truth about its virulent hold on the city might have helped contained the spread of the disease. City officials could and should have done better for residents. Initially there were no mandatory closures of churches, though many did voluntarily shut their doors. Eventually the city caught up and ordered church closures. But 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!

A City Afflicted

Imagine these Pittsburgh scenarios: garbage piling up on the sidewalk outside 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.

American Red Cross training class, Fifth Ave High School, June 1918. Little did they know what was to come.
Historic Pittsburgh Image Collection
Fortunately, organized volunteerism by private groups stepped in when the initial government response was lacking. Pittsburgh was spared the trauma of having corpses overflowing its morgues because the local Red Cross was instrumental in securing coffins and organizing the removal and burial of remains. The Red Cross even secured promises from Pittsburgh-based National Casket Company to keep its products in Allegheny County, and made sure requisite craftsmen were available so the company could meet demand.

It was Red Cross networking that organized railroad delivery to Pittsburgh of caskets made elsewhere, and Red Cross requisitioning of city street-cleaners to fill in as gravediggers. Red Cross ambulances and trucks were lent to the city to transport bodies, and Red Cross workers arranged for enough hospital supplies, drugs, and vaccines for Pittsburghers.

Red Cross nurse, Pittsburgh flu hospital, early 1900s. Historic Pittsburgh Image Collection

Trained medical care was hard to come by, since WWI had left many communities short of doctors and nurses. Pneumonia was the shadow-killer of this epidemic, attacking flu suffers at the point of their weakest immunity. In an age without antibiotics, people had to rely on luck, prayers, and solicitous care by their loved ones. Problem was, during this epidemic many families were left with absolutely no healthy members to care for their afflicted.

Again, it was the Red Cross that stepped in to organize and coordinate nurse recruitment and emergency patient care, even providing hot meals when desperate family situations were identified.

Sketch of Red Cross Nurse by Childe Hassam, 1918, from Carnegie Museum of Art

On 20 October 1918, city hospitals reached their full capacity. Pittsburgh's settlement houses were called into service.

Kingsley House, c. 1913. From Kingsley house annual report, Historic Pittsburgh Image Collection.

New cases were sent to the Kingsley House, a settlement house which voluntarily suspended its normal operations to operate as an emergency hospital. Resources and equipment were brought from Kingsley's satellite Lillian Convalescent Rest and Fresh Air Homes. Its large urban complex in the expanded former Montooth mansion in the Hill District opened its doors for some 300 sick Pittsburghers.

Irene Kaufmann Settlement House for the Jewish immigrant community, Hill District, May 1922.

The Irene Kaufman Settlement House in the Hill functioned as an emergency hospital as well, caring for 1047 cases of influenza/pneumonia in 42 days.

But even that wasn't enough.

The city set up a tent to house an additional 300 recuperating flu sufferers just below Kingsley House and old Central High School, on the Washington Park playground. This was in accordance with the popular idea that exposure to open air helped thwart progression of the disease.

Washington Park and field house, facing downtown, a few years later.
A canvas tent served as a hospital for some 300 Pittsburghers here during the 1918 flu epidemic.
Pittsburgh City Photographer Collection, Historic Pittsburgh Image Collection

Even the Courthouse annex on Ross Street was commandeered as an emergency influenza hospital on 26 October. A week earlier, the criminal court and grand jury rooms had been fumigated with formaldehyde candles as a preventative and sealed for 24 hours, with guards stationed at the doors to explain why the rooms had been closed. Justice would have to wait a little longer while those rooms served another purpose for a few weeks.

While Pittsburgh's officials were reluctant to declare a medical emergency, local businesses had no hesitation at capitalizing on the concerns of residents. The daily papers were filled with ads that October for products referencing influenza, like these from the Pittsburg Press:

Excerpt from Rosenbaum department store ad

The disease trajectory in Pittsburgh was prolonged over the course of many months, rather than isolated in intense bursts as in Philadelphia. Pittsburgh's sustained course actually helped to alleviate some infrastructure burdens, in spite of administrative failures.

Jim Higgins, Ph.D., Professor of History at Kutztown State University, 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.

Cautionary Tales and Future Concerns

As the aftermath of domestic disasters like Hurricane Katrina has illustrated, there are good reasons why we must constantly assess the confidence 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, and at the very least make sure disaster relief agencies are fully funded.

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. Two other influenza pandemics of the 20th century were rendered less virulent by a likely combination of collective 1918 antibodies, coupled with modern public health policies and a subsequent enlightened understanding about infection precautions once the influenza disease process was recognized in the 1930s.

Viruses like the one responsible for the 1918 pandemic circulated among humans until 1957, but then seemed to die out (though 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 other new strains of viruses develop that have potentially devastating lethal capabilities. Indeed, new strains appear every year, and modern medicine struggles to keep up with it all. Health officials must choose influenza strains for vaccine makers to target months in advance, which makes it difficult to know precisely what strains will be circulating. And even when flu vaccines are well-matched to that year's circulating viruses, effectiveness is about 60% at best. Vaccines tend to work better against influenza B and influenza A (H1N1) viruses, offering lower protection against influenza A (H3N2). The 1918 pandemic involved a strain of the influenza A (H1N1) virus.

Yinzer Herd Immunity Won't Protect You

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 considered objections to flu vaccines. And certainly no vaccine is effective against all virus strains, or even wholly against the ones it targets. But the lessons of 1918 speak to the need for each of us to do everything we can as individuals to prevent widespread disease-spread devastation...including getting vaccinated.

I 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, logic and compassion dictate that 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, the devastation of that disease is less immediate. Complacency makes its eradication seem less of an immediate concern, and vaccination seems less important. Reliance on herd immunity becomes a temptation.

But the 1918 pandemic has lessons to teach those who are tempted to forego a flu shot.

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

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 time in the wee hours between his nocturnal feedings by researching my family history. I made many late night discoveries, including documenting a young 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. The protagonist of this book comes into her own following her family's demise as a result of the 1918 influenza pandemic. Russell's eloquent descriptions of the personal and communal trauma inflicted by the pandemic were wrenching. And the connection became obvious; I knew immediately what had happened to my vanished family members in 1918. I remember cuddling my baby, who had egg allergies and was unable to receive a flu vaccine (most influenza vaccines contained small amounts of egg protein). Herd immunity wasn't failsafe; I could get the flu and be miserable, but he could get it from me and die.

I got a flu vaccine the next day and have had one every year since, even though my son has long since outgrown his egg allergies. It's just the responsible, sensible thing to do.

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. There's no one today who remembers the lived experience of 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.

With the centennial of this deadly epidemic in 1918, those stories are resurrected and analyzed. We must listen. We must 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
White, Kenneth A. Pittsburgh and the Great Epidemic of 1918

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