Worried about bird flu?

A book on the 1918 global flu pandemic offers some interesting lessons for our own times.
With the news that HSBC has formulated a massive contingency plan for fighting a bird flu pandemic, it is clear that the spread of the outbreak from Asia to Turkey has focused a lot of minds.

With this in mind, it probably pays to gain some perspective from the past - and the last great pandemic to hit the world. This, of course, was the 1918 flu pandemic, which killed an estimated 50 million people. And if you want to understand more about that pandemic a very good book to read is John Barry's The Great Influenza: The Epic Story of the Deadliest Plague in History.

Barry's 462 page book is an exhaustive account of the virus and is a sobering read. This virus was the deadly H1N1 - the current bird flu is H1N5 - and was especially lethal. The virus spread around the planet in less than a year, and left death in its wake.

In certain populations, its impact was truly devastating. In Nome, for example, 176 of 300 eskimos died. In Guam 10% of the population would die. "And yet the most terrifying numbers would come from India," writes Barry, "with close to 20 million dying."

The pandemic caused 675,000 deaths in the US in 1918. A comparable number in the US today (based on the same mortality rate) would be 1.75 million.

What was also strange about the 1918 influenza - and made it different from previous influenzas - was that it killed the youngest and strongest people in the population. Typically, influenza attacks the old, or the infirm. In 1918 more than half the deaths from the flu pandemic came from people between 16 and 40 years old. In South African cities, those between ages 20 and 40 accounted for 60% of the deaths.

Why was this? Well, the chief cause of death was the infection of the lungs from bacterial pneumonias and the resulting cyanosis. What made this flu so deadly was its ability to get past the immune system's first lines of defence and make it into victims' lungs.

What then happened was that the immune system was turned against the body itself. Those with the strongest immune systems - ie those between 20 and 40 - were accordingly hardest hit.

Barry explains: "When the lungs do become infected, other defences, lethal and violent defences, come into play. For the immune system is at heart a killing machine... The balance between kill and overkill is a delicate one. The immune system can behave like a SWAT team that kills the hostage along with the hostage taker... The virus was so efficient at invading the lungs that the immune system had to mount a massive response to it. What was killing young adults a few days after the symptoms was not the virus. The killer was the immune system itself."

He adds: "Victims lungs were being ripped apart as a result of, in effect, collateral damage from the attack of the immune system on the virus. The lungs became the battleground between the invaders and the immune system. Nothing was left standing on that battleground."

What happened was that the lungs could no longer transfer oxygen to the blood. As people died their bodies turned a sort of black. Symptoms could be terrible "with blood pouring from noses, ears and eye sockets."

Charles-Edward Winslow, a prominent epidemiologist and professor at Yale, noted in 1918: "We have had a number of cases where people were perfectly healthy and died within twelve hours."

Some of the tales Barry recounts are truly macabre. In Cape Town, a Charles Lewis boarded a streetcar for a three mile trip. The conductor died first, and the short journey then saw six others die, including the driver. Lewis then walked the rest of the way home.

So where did this terrifying flu originate? Barry himself discounts theories that it began in China (and more prosaically in a British trench in France) in favour of a better documented explanation that saw it derive in Kansas.

This theory postulates that the disease began in Haskell County, Kansas, with documented reports of a killer virus being recorded by Doctor Loring Miner. This flu surfaced in late January and had abated by late March. "This influenza killed. Soon dozens of his [Miner's] patients - the strongest, the healthiest, the most robust people in the country - were being struck down as suddenly as if they had been shot."

Australian, Frank MacFarlane Burnet, a Nobel laureate who studied the pandemic for years (and lived through it) also found the evidence "strongly suggestive" that the disease started in the United States and spread with the "arrival of American troops in France".

Indeed, what spread the disease so effectively was a combination of a cold Winter and America's entry into the First World War. The Winter of 1917-18 was the coldest on record (East of the Rocky Mountains) and army barracks ignored regulations on personal living space due to overcrowding and the cold.

Young men from Haskell County arrived at Camp Funston - which held 56,000 men - and very soon they had spread the virus - with eleven hundred sick with flu within weeks. However, the strain of flu the men brought to Funston was a less lethal version of the H1N1 virus than that which had devastated Haskell.

Barry notes: "All influenza viruses mutate constantly. The timing of the Funston explosion strongly suggests that the influenza outbreak there came from Haskell; if Haskell was the source, whoever carried to Funston brought a mild version of the virus, but it was a version capable of mutating back to lethality.

"Meanwhile Funston fed a constant stream of men to other American bases and to Europe, men whose business was killing. They would be more proficient at it than they could imagine."

Pandemics frequently see 50% of populations affected, and this would be the case with this one. What was also noteworthy, however, was the way in which it moved in three waves: the first relatively benign, the second lethal, and the final one, a ghastly epilogue.

The first wave went through the trenches between March and August. It had mutated into a relatively benign flu, that left people listless for 4-5 days but - much like the flu we know - was nowhere near as lethal as what was to come later in the year.

One upshot of this first 'benign' wave was that it disrupted the last German push of the war under von Ludendorff. The Ludendorff offensive had been successful in April and had been timed to make a decisive breakthrough in the Entente lines before fresh American troops could arrive. It flagged thanks to flu.

"Ludendorff himself blamed influenza for the loss of initiative and the ultimate failure of the offensive, stating: 'It was a grievous business having to listen every morning to chief of staff's recital of the number of influenza cases, and their complaints about the weakness of their troops.'"

However, the flu continued to mutate as it passed through various human hosts, and when it reached Spain in May it began to gain media attention. Strict censorship had led other fighting powers to keep news of the flu out of newspapers so as to uphold morale. In Spain, no such censorship existed - given it was a non-combatant in the war.

"The disease soon became known as Spanish influenza," writes Barry, "very likely because only Spanish newspapers were publishing accounts of the spread of the disease."

Those who caught the 'benign' flu that Spring - and survived - were fortunate in that they built up immunities to the second and third waves - both of which were the more deadly strains.

And it soon became clear that the second wave had begun. On September 22, US Army Camp Devens (near Boston) found that 19.6% of the entire camp was on sick report, and 75% of those were hospitalized.

The disease quickly passed from US army bases to major cities. Due to its location, Philadelphia was particularly hard hit. With a population of 1.75 million, at least a third of citizens got sick, totally overwhelming the local medical services. On a single day on October 10, the epidemic killed 759 people. During the week of October 16 alone, 4,597 Philadephians died from influenza or pneumonia.

Notes Barry: "Routinely two people in a family would die. Three deaths in a family were not uncommon... But the most terrifying aspect of the epidemic was the piling up of bodies. Undertakers, themselves sick, were overwhelmed... The director of the city jail offered to have prisoners dig graves, then rescinded the offer because he had no healthy guards to watch them."

Susanna Turner, who was a medical volunteer in 1918 said: "People were afraid to go out, afraid to do anything. You just lived from day to day. It was a horror-stricken time."

At virtually every large employer, huge percentages of employees were absent. Thirty-eight hundred Pennsylvania Railroad workers were off sick.

The panic spread across America. In a description that recalls the terrible SARS era in Hong Kong, Barry quotes a Daniel Tonkel from North Carolina remembering: "We were actually almost afraid to breathe, the theatres were closed down so you didn't get into crowds... People were actually afraid to talk to one another... You never knew from day to day who would be next on the death list."

Masks came out. Prescott, Arizona even made it illegal to shake hands.

The only good news was that the virus was so lethal that it burned out its host (people), very fast. Wherever it was possible to measure, the virus seemed to have ravaged a city and dissipated within six weeks.

What seemed to occur, with the process of human 'passage' was that the virus would mutate from its more lethal aspects back to a more 'normalised' mean. For example, at Camp Sherman in Ohio - which was hit in the early stages - 35.7% got pneumonia and 61.3% of those died. In the last five camps hit, only 7.1% got pneumonia and only 17.8% of those died. The virus had clearly weakened in the interim.

By November the second wave had burned out. Then in December and January a third wave began, albeit less lethal than the second. This hit Australia particularly hard.

The epidemic caused sproradic outbreaks through 1920, but more and more of the surviving population had built up immunity, which eventually led to this particular flu's demise.

And yet when you read this book, you realise that 1918 was a horrible year to be alive and take your chance of just surviving - a particular irony since the war itself was ending. During the course of the 1918 influenza epidemic, 47% of all deaths in the US came from the flu and its complications.

So what do we learn from this? Well, Barry's book does point out that no matter how much quarantining you do, the sheer virulence of the flu makes it hard to contain - which is unlike SARS which is substantially less contagious (indeed, unlike flu it is not airborne, and cannot survive on surfaces such as door handles for anywhere near so long).

In conclusion, he states: "The only good news seems to be that an increasing number of virologists now doubt that H5N1 [bird flu] will be the next pandemic virus. (And if it does provide the seed for the next pandemic virus, it might become mild after adapting to humans.)

Their reasoning is simple. Large numbers of people - vastly more than confirmed infections - have by now been exposed to it. Yet the virus has not become easily transmissible from person to person. These virologists believe if H5N1 could transmit this way, it would have done so already."

But Barry is not entirely convinced by the so-called good news: "Never before in history has there been such a combination of so many people and animals. In 1968, for example, China had only 5.2 million pigs and 12.3 million poultry; now it has 508 million pigs and 13 billion poultry. And H5N1 is adapting itself to more and more animals."

So in a mathematical world of probabilities, the deck seems stacked against us. If we do see a repeat of the 1918 virus, our improvements in living standards, communications and medicine, will be mitigating factors. However, just the experience of SARS has taught us that any such disease will lead to massive economic and social dislocations - and that will be especially so if this virus spreads in three waves like the 1918 H1N1 virus did, making the impact reverberate globally for at least 18 months.

The Great Influenza: The Epic Story of the Deadliest Plague in History is available from Amazon.com.

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