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Inside The Swift, Deadly History Of The Spanish Flu Pandemic

Scientist Johan Hultin traveled to Brevig Mission, Alaska, a town of a few hundred souls in the summer of 1997. He was searching for buried bodies, and Alaska's frozen ground was the perfect place to find them. Digging through the permafrost—with permission from the town's authorities—he eventually uncovered a woman who died almost 80 years previously and was in a state of excellent preservation. Hultin then extracted samples of the woman's lung before reinterring her. He intended to use this to decode the genetic sequence of the virus that had killed this Inuit woman along with 90 percent of the town's population.

Brevig Mission was just one place that was part of a global tragedy, one of the worst ever to befall humanity: the influenza pandemic of 1918-19. The outbreak of this influenza virus, also known as Spanish flu, spread with astonishing speed around the world, overwhelming India, and reaching Australia and the remote Pacific islands. In just 18 months at least a third of the world's population was infected. Estimates on the exact number of fatalities vary wildly, from 20 million to 50 million to 100 million deaths. If the upper end of that estimate is accurate, the 1918 pandemic killed more people than both World Wars put together. (Get the facts on influenza.)

The first official cases of the 1918 Spanish flu pandemic were recorded at the U.S. Army's Camp Funston, Kansas, where this emergency influenza ward held treated patients.

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War and pestilence

Several closely related viruses cause influenza, but one strain (type A) is linked to deadly epidemics. The 1918-19 pandemic was caused by an influenza A virus known as H1N1. Despite becoming known as the Spanish flu, the first recorded cases were in the United States in the final year of World War I. (Explore the memorials of World War I.)

A magnified view of the H1N1 virus responsible for the 1918 pandemic.

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By March 1918 the United States had been at war with Germany and the Central Powers for 11 months. During that time America's small, prewar army had grown into a vast fighting force that would eventually send more than two million men to Europe. (How the United States entered World War I.)

American forts experienced a massive expansion as the entire nation mobilized for war. One of these was Fort Riley, Kansas, where a new training facility, Camp Funston, was built to house some of the 50,000 men who would be inducted into the Army. It was here in early March that a feverish soldier reported to the infirmary. Within a few hours more than a hundred other soldiers had come down with a similar condition, and more would fall ill over the following weeks. In April more American troops arrived in Europe and brought the virus with them. The first wave of the pandemic had arrived. (What is the difference between an epidemic and a pandemic?)

Deadly speed

The Spanish flu strain killed its victims with a swiftness never seen before. In the United States stories abounded of people waking up sick and dying on their way to work. The symptoms were gruesome: Sufferers would develop a fever and become short of breath. Lack of oxygen meant their faces appeared tinged with blue. Hemorrhages filled the lungs with blood and caused catastrophic vomiting and nosebleeds, with victims drowning in their own fluids. Unlike so many strains of influenza before it, Spanish flu attacked not only the very young and the very old, but also healthy adults between the ages of 20 and 40.

Biologists at St. Bartholomew's Hospital in London are analyzing brain and lung tissue from victims of the 1918 pandemic as part of global efforts to understand the virus. Here, wax-mounted tissue samples sit on a list of children's names who fell victims to influenza in 1918.

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The principal factor in the virus's spread was, of course, the international conflict then in its last phase. Epidemiologists still dispute the exact origins of the virus, but there is some consensus it was the result of a genetic mutation that perhaps took place in China. But what is clear is that the new strain went global thanks to the massive and rapid movement of troops around the world.

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The drama of the war also served to obscure the unusually high mortality rates of the new virus. At this early stage, the illness was not well understood and deaths were often attributed to pneumonia. Strict wartime censorship meant that the European and North American press were unable to report outbreaks. Only in neutral Spain could the press speak freely about what was happening, and it was from this media coverage that the disease took its nickname.

Deadly Contact

Native Americans treat patients infected by European diseases in this 1591 engraving by Theodor de Bry.

GRANGER/ALBUM

Epidemics are as old as civilization: Signs of smallpox appear on 12th-century B.C. Egyptian mummies. Increased contact led to the spread of disease. In the sixth century A.D. The Plague of Justinian moved along trade routes, killing 25 million people across Asia, Africa, Arabia, and Europe. Eight centuries later, the Black Death wiped out 60 percent of Europe's population. When Europeans settled in the Americas in the 16th and 17th centuries, they introduced smallpox, influenza, and measles to the native peoples, killing an estimated 90 percent of the population. Here, Native Americans treat patients infected by European diseases in a 1591 engraving by Theodor de Bry.

The second wave

The overcrowded trenches and encampments of the First World War became the perfect hosts for the disease. As troops moved, so the infection traveled with them. The wave that had first appeared in Kansas abated after a few weeks, but this was only a temporary reprieve. By September 1918 the epidemic was ready to enter its most lethal phase.

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It has been calculated that the 13 weeks between September and December 1918 constituted the most intense period, taking the greatest number of lives. At least 195,000 Americans died in October alone. In comparison, total American military casualties for the whole of World War I came in at just over 116,000. Once again, it was the crowded military encampments where the second wave initially gained a hold. In September an outbreak of 6,674 cases was reported at Camp Devens, a military base in Massachusetts.

As the crisis reached its zenith, the medical services began to be overwhelmed. Morticians and gravediggers struggled, and conducting individual funerals became impossible. Many of the dead ended up in mass graves. The end of 1918 brought a hiatus in the spread of the illness and January 1919 saw the beginning of the third and final phase. By then the disease was a much diminished force. The ferocity of the autumn and winter of the previous year was not repeated and mortality rates fell.

Although the final wave was much less lethal than its predecessors, it was still able to wreak considerable damage. Australia, which had quickly enacted quarantine restrictions, managed to escape the worst of the flu until the beginning of 1919, when the disease finally arrived and took the lives of several thousand Australians.

The Spanish flu did not strike in Australia until 1919. Quarantine camps like this one, in Wallangarra, Queensland, were set up to treat and contain the illness.

PAUL FEARN/ALAMY/ACI

The general trend of mortality, however, was downward. There were cases of deaths from influenza—possibly a different strain—as late as 1920, but by the summer of 1919 health care policies and the natural genetic mutation of the virus brought the epidemic to a close. Even so, its effects, for those left bereaved or suffering long-term health complications, were to last decades.

Lasting impact

The pandemic left almost no part of the world untouched. In Great Britain 228,000 people died. The United States lost as many as 675,000 people, Japan some 400,000. The south Pacific island of Western Samoa (modern-day Samoa) lost one-fifth of its population. Researchers estimate that in India alone, fatalities totaled between 12 and 17 million. Exact data in the number of deaths is elusive, but global mortality figures are estimated to have been between 10 and 20 percent of those who were infected.

In 1997 the samples taken by Johan Hultin from the woman found in the frozen mass grave in Brevig Mission added to scientists'  knowledge as to how flu viruses mutate and spread. Drugs and improved public hygiene—in conjunction with international institutions such as the World Health Organization and national bodies such as the Centers for Disease Control and Prevention in the United States—put the international community in a much better position to meet the challenges of a new outbreak. However, scientists know a lethal mutation could occur at any time, and a century on from the mother of all pandemics, its effects on a crowded, interconnected world would be devastating.

From The Black Death To Spanish Flu And Smallpox, A Brief History Of Plagues

No matter where you look up the meaning of the word "plague", it's never a good thing. It can be confusing, because as a verb, plague means "to cause continual distress", yet as a noun, it means a deadly disease that spreads very quickly – what we would today call a "pandemic". It can also refer to one specific disease, Yersinia pestis. 

On top of that, a plague can refer to a large number of insects or animals in one place that are causing a lot of damage, like the locusts currently swarming in east Africa. 

In this article, we'll talk about the plagues, or pandemics, that humans have battled with throughout history. 

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Black Death

The worst plague in history was the Black Death, which may have killed up to 200 million people. This was caused by a bacteria, Yersinia pestis, that first hit Europe in the 1340s. 

People still disagree over where it came from, but the most common theory is that it first emerged in Asia, in a certain type of flea that lived on rats. In fact, when scientists in the 1900s were looking for the cause of a similar disease, they came to Hong Kong as part of their investigation. 

Back in the 1300s, life was pretty dirty, as people didn't know anything about hygiene. They also didn't have much medical knowledge – they had never heard of antibiotics or quarantine. This meant that the plague killed around 90 per cent of the people it infected, and in some cases, it killed everyone it infected. But this didn't wipe it out.

Several waves of the Black Death swept the globe and killed hundreds of millions of people.

Photo: Shutterstock

Two more deadly waves of the plague hit in the 1500s and 1800s. In fact, scientists think that it may have been around before the 1300s, as there are records of a similar disease in Rome in 146AD, known as the Justinian plague.

The symptoms of the plague were awful. It started with a swelling in the lymph nodes under the armpit or in the groin, until they were about the size of an apple. Once the swellings burst, people had a fever, vomited blood, and soon died.

Spanish flu

After the devastation of the first world war came the Spanish flu. It did not actually come from Spain, but this was where it first became bad enough to be noticed. It killed up to 40 million people – more than all the deaths of the first world war. It spread across the world, aided by the movement of  hundreds of thousands of soldiers to far-off battlefields. 

It started out like a normal cold, so people were not too worried about it. But then those who were infected developed pneumonia, a lung condition which makes breathing difficult. After that, victims eventually suffocated. 

No one knows where the Spanish flu started, but recent studies show that the virus may have emerged when strains of pig and human flu infected the same host, and their genes combined to create a new mutation. 

Medical workers wore masks to avoid the Spanish flu at a US Army hospital in 1918.

Photo: Shutterstock

Smallpox 

There is no doubt that plagues changed the course of history. They caused empires to fall and new ones to arise. Smallpox first emerged around 68,000 years ago. We have no idea how many people it has killed, but we do that in the 20th century alone it killed around 500 million people. 

Smallpox was introduced to the Americas by European colonisers in the 1400s. It was responsible for the fall of the Aztec and Incan empires, and killed up to 90 per cent of the Northern Native American population – allowing the Europeans to steal the land and claim it as their own.

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Smallpox was the leading cause of death in the 18th century. And, like all good plagues, it was awful, causing sufferers to break out in small blisters all over their bodies that caused them great pain.

People did notice, however, that once someone had survived smallpox, they never got it again. So, in the 10th century, people in China began taking some pus from the infected blisters and scratching it into their own skin. This allowed the body to learn the virus' code and build immunity to defeat it. In 1798, an British doctor, Edward Jenner, developed a vaccine. In 1966, the World Health Organisation began a global vaccination campaign to wipe out smallpox for good. The last-ever case was diagnosed in 1977. Smallpox is one of only two infectious diseases to have been completely stopped. Hooray for vaccines!

Flu: The Story Of The Great Influenza Pandemic Of 1918 And The Search For The Virus That Caused It

Farrar, Straus and Giroux, 256 pages, $25.00, 1999 0374157065ISBN: 0-374-15706-5

There is a cemetery in a small railroad town in northern Ohio where I grew up that tells a sliver of the story of the great 'Spanish' influenza pandemic of 1918. One section of the cemetery is full of simple, rough, limestone markers that tilt willy-nilly in the perpetually damp sod of the graveyard. These unembellished memorials mark the graves of unfortunate souls who died one week during the fall of 1918 from the flu. In other towns all over the country there are similar hastily prepared grave sites. At least 10,000 people died in the city of Philadelphia during one three-week period during the month of October, overwhelming doctors, hospitals and undertakers.

The pandemic occurred just at the moment in history when the nightmare of World War I was finally ending, and it killed far more than the Great War itself. The death toll from the flu of 1918 was more than a half-million people in the United States, and more than 20 million people worldwide. This modern day plague is the topic of a new book by Gina Kolata, a science writer for the New York Times. Although the subject of the 1918 flu pandemic is certainly compelling stuff, there is little in this new book that has not already been said better by others, most notably by Alfred Crosby in a book entitled America's Forgotten Pandemic, originally written in the 1970s but since updated. In that book the student of flu can find the primary data underlying many of Kolata's generalizations.

It is unfortunate that much of the book reads like a newspaper article written on a tight deadline. The reader often feels that only the most lurid anecdotes are mentioned, apparently precluding any in-depth description of our burgeoning understanding of the structure and function of the virus itself. The virus is, after all, the 'mass murderer' in this detective story. There are no thoughts here about how viruses propagate or kill or evolve. There is not a word about the molecular virology underlying the phenomena of antigenic drift (a change in surface protein, usually resulting from a base pair mutation) or antigenic shift (which for flu is usually the acquisition of a whole new segment of RNA). Any scientist or physician interested in the influenza virus itself, and all its fascinating efficiencies and complexities, will be sorely disappointed with this book.

The author does, however, vividly illustrate how the great devastation wrought by the flu pandemic continues to affect more recent history. Two chapters of ten in this new book concern the swine flu fiasco of 1976. A series of unfortunate events was started with the death of a single soldier at Fort Dix, New Jersey. The causative agent in the soldier's case was determined to be an influenza virus of a type that normally infects pigs. Because of work in the decades after the 1918 flu pandemic that suggested a link between flu in humans and flu in pigs, scientists feared that the soldier's case was only the first in a deadly pandemic that could engulf the nation and the world. Using scant evidence, and what seems in retrospect to be numerology, a small group of prominent vaccinologists convinced President Gerald Ford to immunize the entire nation. The swine flu epidemic never occurred, but 43 million Americans were vaccinated, leading to scores of lawsuits of patients who claim to have been injured after being immunized.

The most original part of the book is where the author describes recent efforts Jeffery Taubenberger and his team at the Armed Forces Institute of Pathology to sequence the 1918 influenza virus using polymerase chain reaction (PCR)-based techniques. These careful workers have successfully isolated fragments of RNA from the 1918 influenza virus. The acquisition of the tissues for these experiments, either from paraffin-embedded specimens recovered from a government warehouse or from snippets of tissue obtained from bodies buried in the permafrost, is the stuff of high drama.

Even after the latest round of PCR analysis of the flu genome, it remains a mystery why the flu virus of 1918 was so deadly. The most pressing question remains: Can such a deadly virus ever emerge again? On one hand it seems unlikely, given the rapid advances in our medical knowledge. New drugs, such as zanamivir (Relenza), can inhibit the ability of the flu virus to proliferate by blocking the activity of the neuraminidase enzyme. When the Spanish flu pandemic hit, doctors around much of the globe were still using venesection as a treatment.

On the other hand, drug-resistant variants of the flu virus could emerge. Furthermore, the flu virus of 1918 killed quickly—there are many cases of documented mortality in under 48 hours. A large-scale epidemic could overwhelm our modern, sophisticated medical system. Because our overcrowded cities are massively interconnected by commerce and travel, an emerging virus could be spread today at a rate that is orders of magnitude faster than the rate of spread eight decades ago.

So the questions remain: Can such a pandemic happen again? How will we deal with the deadly viruses that will undoubtedly emerge in the future? Greater knowledge about what happened in the 1918 flu pandemic and a deeper understanding of the virus that caused it would be useful. And although Kolata's book provides a lot of heat, it does not shed much light on the questions that really matter.

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