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The flu has the potential to kill millions - in 1918 it did just that

By ASHLEY HALSEY LII
The Washington Post

January 28. 2018 3:44AM
Emergency department technician Kyle Heaston, left, and Alexis Lalande, RN, work in a tent that has been set up outside of the Palomar Medical Center so that medical staff members can triage flu patients on Wednesday, Jan. 3, 2018, in Escondido, Calif. (Hayne Palmour IV/San Diego Union-Tribune/TNS)



The flu arrived as a great war raged in Europe, a conflict that would leave about 20 million people dead over four years.

In 1918, the flu would kill more than twice that number - and perhaps five times as many - in just 15 months. Though mostly forgotten, it has been called "the greatest medical holocaust in history."

Experts believe between 50 and 100 million people were killed. More than two-thirds of them died in a single 10-week period in the autumn of 1918.

Never have so many died so swiftly from a single disease. In the United States alone, it killed about 675,000 in about a year - the same number who have died of AIDS in nearly 40 years.

As the country muddles through a particularly nasty flu season - one that the Centers for Disease Control says has killed 24 children in the first three weeks of January and 37 since the start of the flu season - the 1918 nightmare serves a reminder. If a virulent enough strain were to emerge again, a century of modern medicine might not save millions from dying.

"You think about how bad it was in 1918, and you think surely our modern medical technology will save us, but influenza is the Hollywood movie writer's worst nightmare," said Anne Schuchat, CDC's deputy director, at a recent seminar on the 1918 pandemic. "We have many more tools than we had before, but they are imperfect tools."

The Spanish flu

One hundred years ago, a third of the world's population came down with what was dubbed the Spanish flu. (It got its name when the king of Spain, Alfonso XIII, his prime minister and several cabinet ministers came down with the disease.)

The flu brought life to a standstill, emptying city streets, closing churches, pool halls, saloons and theaters. Coffin makers couldn't keep up with demand, so mass graves were dug to bury the dead. People cowered behind closed doors for fear they would be struck down.

In Philadelphia, news stories described priests driving carts through the streets, encouraging people to bring out the dead so that they might be buried.

Entire families succumbed.

In Tyler County, W.Va., John Linza, his wife and two of their sons died on the same day. Two other sons died just days before them. The last Linza, an infant, died the day after his parents.

In the southwestern tip of Virginia, J.W. Trent, his wife and two sons fell ill. They were preceded in death by all four of their young daughters - Hattie, Mary, Ellen and Ruby.

In 10 weeks, the flu killed 20,000 in New York City and produced 31,000 orphans.

There is debate among historians about where the flu first surfaced - did it come from China or a British encampment in northern France or rural Kansas? But it spread worldwide practically overnight.

By the end of November, 50,000 had died in South Africa, where at its peak flu killed 600 people each day. In Egypt, the death count reached 41,000 in Cairo and Alexandria by January. In Tahiti, trucks roamed the streets of Papeete to collect the dead, and great funeral pyres burned day and night to incinerate the bodies.

Normally the most vulnerable to influenza are infants, whose immune systems are not yet up to the test, and the elderly, whose ability to fight disease diminishes with age. In 1918, more than half the people it killed were in the prime of their lives.

Many died within hours, turning blue from lack of oxygen as they coughed foamy blood up from their lungs and bled from the nose, ears and eyes.

The Spanish flu infected the upper respiratory tract and then dove deep into the lungs with viral or bacterial pneumonia. How did it kill so many young healthy adults? Their immune systems attacked the influenza invader with such force that it killed them.

One Army doctor, quoted by historian John M. Barry, author of the bestseller, "The Great Influenza," described the scene at a base hospital in Massachusetts:

"When brought to the [hospital] they very rapidly develop the most vicious type of pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see [the blueness] extending from their ears and spreading all over the face. . . . It is only a matter of a few hours then until death comes. . . . It is horrible."

Touch of flu

Then as now, the catch phrase was "a touch of the flu." The flu rolled in every winter, enveloping people in a fog and fever that lasted a few days and lingered for a week or two. It was something to be endured, but not many people died from it.

And so it began in 1918.

To comprehend what came next - and why it is possible that a deadly strain of influenza could rear up 100 years later to kill tens of millions - requires an understanding of the disease.

The world's most successful vaccinations against measles, polio, tetanus and small pox generally work in the same way. They introduce a minuscule amount of the disease so that if it ever arrives in full-blown form, the body will recognize and neutralize it with an immune system counter attack.

Influenza, however, never gives the immune system a stable target. Instead, it can transform itself into something that appears innocent to the white blood cells and enzymes intended to wage war against it.

That explains why a vaccine against the flu is a hit-or-miss proposition, based on the best guess of scientists about what flu strains are most likely to emerge six months later. This year the CDC estimates flu vaccines will be 30 percent effective against infection.

In 1918 there were no flu vaccinations, and it would not have mattered anyway. After the "touch of the flu" that proved deadly only here and there during the spring, the influenza apparently mutated into a killer.

By early autumn the public face of America and the Western world had a gauze mask on it. People wore them to church, the military marched in them, police posed for photos in them and doctors wore them to visit patients.

Pandemic fears

A century later, science has revolutionized the medical profession, producing miracle drugs and surgical procedures that no one could have imagined in 1918.

But when Thomas Frieden stepped down as head of the CDC last year he was asked in an interview what keeps him awake at night.

"We always worry about pandemic influenza because this has the potential to kill so many people," he said. "We stockpile antivirals for an emergency. But much more is needed to both track influenza better around the world and develop a better flu vaccine."

A "touch of the flu" kills up to 646,000 people worldwide each year, sometimes as many as 56,000 of them in the United States. Since 1918, there have been three flu pandemics.

"Obviously, we still have no control over the virus," said Barry, the historian who gave the keynote speech in 2004 when the National Academies of Science gathered to discuss pandemic influenza. "In a lot of ways, we're arguably as vulnerable, or more vulnerable, to another pandemic as we were in 1918 because there's more economic interdependence."


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