The (Not so) Spanish Flu, and How it Became the Deadliest Epidemic in Modern Time.


I had a little bird,

its name was Enza.

I opened the window,

and in flew Enza.

     ~Children’s rhyme of 1917

In early March 2018 a mess cook at an Army base in Kansas reported to the infirmary complaining of sore throat, headache, and fever. After being checked over, the doctor could find no cause for alarm, and returned him to duty. By lunch time the infirmary was filled with soldiers complaining of similar symptoms, and by the end of the month the number of sick soldiers had grown beyond the capacity of the base hospital and a make-shift infirmary was created using an airplane hanger. By the end of the first month, 38 men had died. Influenza routinely killed 30% of those infected if they were under age 2. This influenza was killing health young men in the twenties. The soldiers were suffering with would become known as the Spanish Flu. You can imagine the worst place to have an infectious disease would be a place where tens of thousands of people were crowded together, as they were in training camps, where they prepared to go to war. The disease would spread to other training camps and eventually overseas.

Laura Spiney, in her book Pale Rider: The Spanish Flu of 1918 and How It Changed the World called the 1918 influenza epidemic, “The greatest wave of death since the Black Death.” A bit dramatic perhaps, but nevertheless accurate. What made this epidemic even more deadly, brought groups of infected and uninfected people together, and greatly helped the spread of this deadly disease, was the denials by those in power that anything was wrong.

In 1917, California Senator Hiram Johnson, an isolationist Progressive-Party-member-turned-Republican, states the first casualty when war comes is truth. At the time, Congress passed a measure, signed into law by President Woodrow Wilson, that made it punishable by up to 20 years in prison to “utter, print, write or publish any disloyal, profane, scurrilous, or abusive language about the government of the United States.” A clear violation of the First Amendment. Yet because Spain was neutral, its press was not under morality laws, so the pandemic they reported on became known as the Spanish flu.

In the cities of Minneapolis, St. Paul, Chicago, Philadelphia, New York, San Francisco, and several others, parades and events considered “important to the war effort” were not cancelled, even though they brought great numbers of people together. When public health experts demanded that such events (parades, rallies, etc.) would help spread the disease, they were reminded of the Morality Law, and the notion that “Fear kills more than the disease.”

The flu pandemic of 1918 to 1919 infected an estimated 500 million people worldwide, and claimed the lives of between 50 and 100 million people. More than 25 percent of the U.S. population became sick, and 675,000 Americans died during this pandemic, more than 10 times the number killed in Vietnam. The 1918 flu was first observed in Europe, the U.S. and parts of Asia before swiftly spreading around the world. By the time the disease had burned itself out, the total number of dead outnumbered those killed in both World Wars.

Why so deadly. Although many people had been exposed to H3N8 virus that had been circulating in the human population for about a decade, the human virus picked up genetic material from a bird flu virus just before 1918, creating a novel virus. The new virus had surface proteins that were very different, thus people’s immune system would have made antibodies, but they would have been ineffective against the virus. The high fatality was brought about by a combination of refusing to warn the public about exposure, refusing to allow newspapers to print stories of the epidemic, the novel makeup of the virus, the opportunistic bacteriological infections that thrived in weakened immune systems of many, and a process known as hypercytokinemia, or cytokine storm. Cytokines are molecules that aid cell-to-cell communication in immune responses and trigger inflammation. It is the overreaction of immune system (like fever and inflammation) that caused the high lethality of this influenza.

While most influenza viruses are dangerous for children, the elderly, or those with compromised immune systems, the 1918 strain was deadliest for those in their 20’s and 30’s in good health with a robust immune systems. The Spanish influenza strain provoked a manic immune response creating a potentially fatal immune reaction with highly elevated levels of various cytokines. In recreating the pandemic of 1918, medical research scientists used reconstructed 1918 influenza virus and injected in mice and monkeys to try to understand why it was so lethal. The animals’ immune systems responded so violently, the lungs filled with blood and fluids, essentially drowning them. Scientists have deduced that what made the Spanish flu so deadly was that it used the body’s own immune system to flood the lungs with fluid, and destroy the lining of the respiratory system, making it much easier for bacteria to infect the lungs. In this case, the healthier you were, the more violent the immune response to the virus.

In the end, the 1918 influenza virus pandemic was due to a combination of a novel virus, an official disregard for honesty to avoid damaging morale and the war effort, a cowardly press that refused to challenge this veil of secrecy that was the government’s propaganda machine. Let us home the government and those at the highest levels of power will treat the next influenza epidemic more honestly and openly.

Could it ever happen again? Could it happen again where a novel influenza virus becomes epidemic then pandemic killing millions? According to an article in The Lancet, flu pandemic like that of 1918-1919 were to break out today, it would likely kill 60-80 million (This is more than the total number of people that die in a single year from all other causes combined). The estimate stems from a new tally of flu deaths from 1918 to 1920 in different countries, which varied widely. To gauge the potential threat from the H5N1 avian influenza currently circulating among birds in Asia and Africa, the researchers reviewed the toll of the most severe previous case from 1918 as a benchmark.

Worried? You should be. If anything, the new estimates may be optimistic, according to epidemiologist Neil Ferguson of London’s Imperial College in an editorial published in The Lancet. High incomes may not protect rich countries as much as some writers have suggested. In 1918 pandemic influenza, being young, fit, and healthy was no protection. Public health researchers and epidemiologists warn that it is not a matter of if the next influenza pandemic strikes, but when.

Meanwhile, national governments slash public health funding and funds needed for health research.


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