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The 1918–1919 flu pandemic: lessons learned or fingers crossed?
Spotlight
Books The 1918–1919 flu pandemic: lessons learned or fingers crossed? “The term flu has consequently become probably the most abused and most meaningless term in the whole sphere of medicine….little more than a synonym for a severe cold, because it is considered a more respectable excuse for a few days off work.” Brian Inglis 1981
The influenza pandemic, known as the Spanish Flu, killed 50–100 million people worldwide, hitting an already vulnerable population at the end of World War I in 1918–19. However, it seems that only with recent outbreaks of the H1N1 swine flu and the H5N1 bird flu that crossed species to infect human beings, has public awareness been awakened, largely because of media coverage, to the possibility of a future genetic mutation infecting humanity on a significant scale. Even then, with such perceived advances in medicine, there is probably disbelief and complacency around such an event occurring. Although outbreak narratives usually end with containment, this was not the case for influenza. It was virulent and indiscriminate—a puzzling W-shaped mortality curve showed the majority of deaths were men and women aged 25–34 years, and its origin was, and to some extent still is, elusive. It was not until 1933 that the virus was successfully isolated from human beings and the bacillus Haemophilus influenzae hypothesis, proposed by Richard Pfeiffer, was finally put to rest. Two books have taken up the neglected history of the pandemic. Niall Johnson has written the “first examination of Britain’s experience” in Britain and the 1918–19 Influenza Pandemic, and a collection of essays, The Spanish Influenza Pandemic of 1918–1919, edited by Maria-Isabel Porras-Gallo and Ryan A Davis gives a perspective from the Iberian Peninsula and the Americas. Both books attempt to address unanswered questions about the 1918–19 pandemic, and both highlight the relevance of historical precedents in the understanding of current or future epidemics. Johnson describes his work as historical-cultural geography; a broad pluralistic view of environmental, political, economic, biological, and medical indices that make up the pandemic landscape. Editors PorrasGallo and Davis explain how their book builds on the historiography of the pandemic that was re-emerging at the end of the 20th century, with a proclivity to elucidate on three major gaps in Spanish flu scholarship, promoting a convincing novelty value of their collection of essays. The first is the underrepresentation of geographical areas, such as Brazil, Argentina, and Portugal. They also propose to address the lack of sociocultural richness, in
particular social control, sex and class, religion, urban development, and the relationship between military and civilian medicine that is explored in part three. Finally, the authors offer discourse on the effect of the failure of bacteriology and germ theory to explain influenza, and consider how the pandemic helped determine the future path of medical science as more than a laboratory-led discipline. Understanding the evolutionary potential of viruses and the complexity of finding effective treatments or vaccines is a thread that runs through both books. Johnson asks, “What does the virus look like?” He explains how there are eight separate RNA segments, and spikes with either haemagglutinin activity, binding the virus to the red blood cells and host cells, or neuraminidase activity that facilitates the spread of the virus. When the spikes mutate, as changes in the RNA occurs, our immune system fails to recognise them and therefore cannot fight the infection. From this recombination of RNA segments, different subtypes are identified, and within these subtypes, different strains exist. The delivery of a somewhat simplified explanation is fitting in the context of Johnson’s book. In fact, the very notion that the science has been made simple establishes a particular relationship with a reader that might prefer to gain a perspective on the threat, rather than the science of virology. Alternatively, Porras-Gallo and Davis’ first chapter by Esteban Domingo offers a scientific discourse on the mystery of virology as pertaining to the origin and the determinants of the extreme virulence of the H1N1 1918 virus. This chapter might overstretch the cognisance of a reader without a scientific background, but it ultimately leads to the same conclusion as Johnson; “Genetic variation is blind and the outcome uncertain. It is not possible to anticipate whether the virulence of a virus will increase, decrease, or remain the same…. The challenge of a potentially devastating influenza pandemic demands surveillance approaches aimed not only at detecting influenza but also at penetrating molecular and biological features of the circulating, everevolving viruses…these are not easy tasks and the threat of influenza pandemics is likely to continue indefinitely.” Why was the influenza virus of 1918–19 dubbed the Spanish Flu? Johnson explains, as does Davis, author of the essay, A Tale of Two Spains, how this stigma was unfairly attributed to Spain. Their reasoning is that Spain’s neutrality in World War I and its consequential lack of social disruption aided a proleptical and high level of media reporting, as compared to other countries,
www.thelancet.com/respiratory Published online September 10, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00341-0
Lancet Respir Med 2015 Published Online September 10, 2015 http://dx.doi.org/10.1016/ S2213-2600(15)00341-0
Britain and the 1918–19 Influenza Pandemic: A dark epilogue Niall Johnson. Routledge, 2014. Pp271. £26·99 ISBN 9780415514149
The Spanish Influenza Pandemic of 1918–1919: Perspectives from the Iberian Peninsula and the Americas Edited by Maria-Isabel Porras-Gallo and Ryan A Davis. University of Rochester Press, 2014. Pp 282. £61·75 ISBN 9781580464963
1
Bettmann/Corbis
Spotlight
therefore bearing the brunt of an ensuing blame culture concerning the origin of the virus, which has never been established. It is clear that military forces in Europe, Asia, and the USA were afflicted by the virus by the middle of 1918, and ships transporting soldiers were literally carriers. Port towns were inundated by army ships and from there the virus spread into the country interiors. Liane Maria Bertucci’s chapter on Spanish flu in Brazil raises another key component of the flu debate—the uncertainty of medical opinion as to whether flu-presenting symptoms could in fact point to other diseases, such as bronchitis or pneumonia (which often followed influenza infection) and whether the flu in Brazil was in fact different from that in Europe and in Africa. Alongside the ongoing dispute about the cause of flu—a bacillus versus filterable virus—the authorities struggled to understand how, with different climates, geographical landscapes, sanitation, and living conditions, influenza showed little variation in virulence; morbidity and mortality rates were not significantly altered by demographic or environmental factors. Nor were the rates differential; the poor, the wealthy, urban and rural citizens were all affected, and this was the nature of the Spanish flu: unpredictable, indiscriminate, and rapidly fatal. There is much discussion around failures of the authorities, and Johnson raises the question; “Did the British state and medical profession fail?” At the time the British health body, the Ministry of Health’s predecessor was the Local Government Board, and political tensions presumed a lack of governance. There were additional problems; the war had depleted national resources, the world was fighting again, but this time with an unknown enemy, and the medical profession had to cope with an ever increasing quantity of patients while also suffering from loss of workforce and qualified medical personnel. 2
Infrastructure was collapsing—schools, theatres, and even pharmacies were closed, and widespread absenteeism from a flu-struck nation further compounded the pressures. Bodies were piled up in mortuaries and coffins could not be constructed fast enough. With no cure and an unpredictable pattern of attack (the virus hit in three waves), it could be argued that only vigilance; protective measures, and personal responsibility, such as using a mask, combined with a collective empathy could be employed. The role of the media and its relationship to political decision-making is discussed in Hernan Feldman’s chapter, the Spanish Flu in Argentina. Headlines are often blamed for creating widespread panic: a contagion of fear. The flu was still considered benign by some countries in the Americas, and placating alarm seemed to be the Argentinian approach. However, towards the end of October 1918, there was concern that energies had been directed towards gauging the reaction of the public in “the face of a possible epidemic rather than evaluating the escalation of the epidemic itself”. This conflict between truth and protection is one that resonates in an epidemic—both of these books offer a balanced trajectory on how the pandemic was handled by governments, scientists, and the public. Both books also mention a lack of available personal narratives, and it is difficult to interpret the general attitudes towards the management of the pandemic. A message to the Nation that Johnson alluded to was to “Carry on”—a very British response, but following a bitter and bloody war, this was perhaps the only feasible course of action. The sudden onset of toxaemic and pulmonary symptoms, with clinical heliotrope cyanosis presenting in the final stages of the short illness, and the reported cruel twist of showing signs of recovery preceding death are symptomatic of the Influenza virus type A. However, the true horror of the viral outbreak does not translate into an individualised history, but more a collective one. Johnson’s book is comprehensive and accessible, and there is a sense that most of what is known about the pandemic in Britain is included in his work. However, as with such narratives structured thematically, there is a danger of repetition and Johnson does not escape this. This is not to devalue the content, which is informative, engaging, and discursive, only to suggest the book could be condensed somewhat. Porras-Gallo and Davies’ collection from a diversified pool of writers, allows ideas and histories to overlap in different contextual landscapes so this pitfall is easier to avoid. Overall, both of these books garner valuable and thoughtful perspectives on the influenza pandemic of 1918–19, and both recognise that a future reemergence is possible. The WHO has a Global Surveillance Programme for Influenza that includes planning to mitigate future pandemics; however, the 1918–19 pandemic proved that nature is one step ahead of man.
Jules Morgan
www.thelancet.com/respiratory Published online September 10, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00341-0
Books The 1918–1919 flu pandemic: lessons learned or fingers crossed? “The term flu has consequently become probably the most abused and most meaningless term in the whole sphere of medicine….little more than a synonym for a severe cold, because it is considered a more respectable excuse for a few days off work.” Brian Inglis 1981
The influenza pandemic, known as the Spanish Flu, killed 50–100 million people worldwide, hitting an already vulnerable population at the end of World War I in 1918–19. However, it seems that only with recent outbreaks of the H1N1 swine flu and the H5N1 bird flu that crossed species to infect human beings, has public awareness been awakened, largely because of media coverage, to the possibility of a future genetic mutation infecting humanity on a significant scale. Even then, with such perceived advances in medicine, there is probably disbelief and complacency around such an event occurring. Although outbreak narratives usually end with containment, this was not the case for influenza. It was virulent and indiscriminate—a puzzling W-shaped mortality curve showed the majority of deaths were men and women aged 25–34 years, and its origin was, and to some extent still is, elusive. It was not until 1933 that the virus was successfully isolated from human beings and the bacillus Haemophilus influenzae hypothesis, proposed by Richard Pfeiffer, was finally put to rest. Two books have taken up the neglected history of the pandemic. Niall Johnson has written the “first examination of Britain’s experience” in Britain and the 1918–19 Influenza Pandemic, and a collection of essays, The Spanish Influenza Pandemic of 1918–1919, edited by Maria-Isabel Porras-Gallo and Ryan A Davis gives a perspective from the Iberian Peninsula and the Americas. Both books attempt to address unanswered questions about the 1918–19 pandemic, and both highlight the relevance of historical precedents in the understanding of current or future epidemics. Johnson describes his work as historical-cultural geography; a broad pluralistic view of environmental, political, economic, biological, and medical indices that make up the pandemic landscape. Editors PorrasGallo and Davis explain how their book builds on the historiography of the pandemic that was re-emerging at the end of the 20th century, with a proclivity to elucidate on three major gaps in Spanish flu scholarship, promoting a convincing novelty value of their collection of essays. The first is the underrepresentation of geographical areas, such as Brazil, Argentina, and Portugal. They also propose to address the lack of sociocultural richness, in
particular social control, sex and class, religion, urban development, and the relationship between military and civilian medicine that is explored in part three. Finally, the authors offer discourse on the effect of the failure of bacteriology and germ theory to explain influenza, and consider how the pandemic helped determine the future path of medical science as more than a laboratory-led discipline. Understanding the evolutionary potential of viruses and the complexity of finding effective treatments or vaccines is a thread that runs through both books. Johnson asks, “What does the virus look like?” He explains how there are eight separate RNA segments, and spikes with either haemagglutinin activity, binding the virus to the red blood cells and host cells, or neuraminidase activity that facilitates the spread of the virus. When the spikes mutate, as changes in the RNA occurs, our immune system fails to recognise them and therefore cannot fight the infection. From this recombination of RNA segments, different subtypes are identified, and within these subtypes, different strains exist. The delivery of a somewhat simplified explanation is fitting in the context of Johnson’s book. In fact, the very notion that the science has been made simple establishes a particular relationship with a reader that might prefer to gain a perspective on the threat, rather than the science of virology. Alternatively, Porras-Gallo and Davis’ first chapter by Esteban Domingo offers a scientific discourse on the mystery of virology as pertaining to the origin and the determinants of the extreme virulence of the H1N1 1918 virus. This chapter might overstretch the cognisance of a reader without a scientific background, but it ultimately leads to the same conclusion as Johnson; “Genetic variation is blind and the outcome uncertain. It is not possible to anticipate whether the virulence of a virus will increase, decrease, or remain the same…. The challenge of a potentially devastating influenza pandemic demands surveillance approaches aimed not only at detecting influenza but also at penetrating molecular and biological features of the circulating, everevolving viruses…these are not easy tasks and the threat of influenza pandemics is likely to continue indefinitely.” Why was the influenza virus of 1918–19 dubbed the Spanish Flu? Johnson explains, as does Davis, author of the essay, A Tale of Two Spains, how this stigma was unfairly attributed to Spain. Their reasoning is that Spain’s neutrality in World War I and its consequential lack of social disruption aided a proleptical and high level of media reporting, as compared to other countries,
www.thelancet.com/respiratory Published online September 10, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00341-0
Lancet Respir Med 2015 Published Online September 10, 2015 http://dx.doi.org/10.1016/ S2213-2600(15)00341-0
Britain and the 1918–19 Influenza Pandemic: A dark epilogue Niall Johnson. Routledge, 2014. Pp271. £26·99 ISBN 9780415514149
The Spanish Influenza Pandemic of 1918–1919: Perspectives from the Iberian Peninsula and the Americas Edited by Maria-Isabel Porras-Gallo and Ryan A Davis. University of Rochester Press, 2014. Pp 282. £61·75 ISBN 9781580464963
1
Bettmann/Corbis
Spotlight
therefore bearing the brunt of an ensuing blame culture concerning the origin of the virus, which has never been established. It is clear that military forces in Europe, Asia, and the USA were afflicted by the virus by the middle of 1918, and ships transporting soldiers were literally carriers. Port towns were inundated by army ships and from there the virus spread into the country interiors. Liane Maria Bertucci’s chapter on Spanish flu in Brazil raises another key component of the flu debate—the uncertainty of medical opinion as to whether flu-presenting symptoms could in fact point to other diseases, such as bronchitis or pneumonia (which often followed influenza infection) and whether the flu in Brazil was in fact different from that in Europe and in Africa. Alongside the ongoing dispute about the cause of flu—a bacillus versus filterable virus—the authorities struggled to understand how, with different climates, geographical landscapes, sanitation, and living conditions, influenza showed little variation in virulence; morbidity and mortality rates were not significantly altered by demographic or environmental factors. Nor were the rates differential; the poor, the wealthy, urban and rural citizens were all affected, and this was the nature of the Spanish flu: unpredictable, indiscriminate, and rapidly fatal. There is much discussion around failures of the authorities, and Johnson raises the question; “Did the British state and medical profession fail?” At the time the British health body, the Ministry of Health’s predecessor was the Local Government Board, and political tensions presumed a lack of governance. There were additional problems; the war had depleted national resources, the world was fighting again, but this time with an unknown enemy, and the medical profession had to cope with an ever increasing quantity of patients while also suffering from loss of workforce and qualified medical personnel. 2
Infrastructure was collapsing—schools, theatres, and even pharmacies were closed, and widespread absenteeism from a flu-struck nation further compounded the pressures. Bodies were piled up in mortuaries and coffins could not be constructed fast enough. With no cure and an unpredictable pattern of attack (the virus hit in three waves), it could be argued that only vigilance; protective measures, and personal responsibility, such as using a mask, combined with a collective empathy could be employed. The role of the media and its relationship to political decision-making is discussed in Hernan Feldman’s chapter, the Spanish Flu in Argentina. Headlines are often blamed for creating widespread panic: a contagion of fear. The flu was still considered benign by some countries in the Americas, and placating alarm seemed to be the Argentinian approach. However, towards the end of October 1918, there was concern that energies had been directed towards gauging the reaction of the public in “the face of a possible epidemic rather than evaluating the escalation of the epidemic itself”. This conflict between truth and protection is one that resonates in an epidemic—both of these books offer a balanced trajectory on how the pandemic was handled by governments, scientists, and the public. Both books also mention a lack of available personal narratives, and it is difficult to interpret the general attitudes towards the management of the pandemic. A message to the Nation that Johnson alluded to was to “Carry on”—a very British response, but following a bitter and bloody war, this was perhaps the only feasible course of action. The sudden onset of toxaemic and pulmonary symptoms, with clinical heliotrope cyanosis presenting in the final stages of the short illness, and the reported cruel twist of showing signs of recovery preceding death are symptomatic of the Influenza virus type A. However, the true horror of the viral outbreak does not translate into an individualised history, but more a collective one. Johnson’s book is comprehensive and accessible, and there is a sense that most of what is known about the pandemic in Britain is included in his work. However, as with such narratives structured thematically, there is a danger of repetition and Johnson does not escape this. This is not to devalue the content, which is informative, engaging, and discursive, only to suggest the book could be condensed somewhat. Porras-Gallo and Davies’ collection from a diversified pool of writers, allows ideas and histories to overlap in different contextual landscapes so this pitfall is easier to avoid. Overall, both of these books garner valuable and thoughtful perspectives on the influenza pandemic of 1918–19, and both recognise that a future reemergence is possible. The WHO has a Global Surveillance Programme for Influenza that includes planning to mitigate future pandemics; however, the 1918–19 pandemic proved that nature is one step ahead of man.
Jules Morgan
www.thelancet.com/respiratory Published online September 10, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00341-0