Pale Rider: The Spanish Flu of 1918 and How It Changed the World

by Laura Spinney

  It was in the nineteenth century that crowd diseases reached the zenith of their evolutionary success, and held dominion over the globe. This was the century of the Industrial Revolution, and accompanying it, the rapid expansion of cities in many parts of the world. These cities now became breeding grounds for crowd diseases, such that urban populations were unable to sustain themselves–they needed a constant influx of healthy peasants from the countryside to make up for the lives lost to infection. Wars, too, brought epidemics in their wake. Conflict makes people hungry and anxious; it uproots them, packs them into insanitary camps and requisitions their doctors. It makes them vulnerable to infection, and then it sets large numbers of them in motion so that they can carry that infection to new places. In every conflict of the eighteenth and nineteenth centuries, more lives were lost to disease than to battlefield injuries.

  The nineteenth century saw two flu pandemics. The first, which erupted in 1830, is said to have ranked in severity–though not in scale–with the Spanish flu. The second, the so-called ‘Russian’ flu that began in 1889, was thought to have originated in Bokhara in Uzbekistan. It was the first to be measured, at least to some extent, since by then scientists had discovered what a powerful weapon statistics could be in the fight against disease. Thanks to the efforts of those early epidemiologists, we know that the Russian flu claimed somewhere in the region of a million lives, and that it washed over the world in three waves. A mild first wave heralded a severe second one, and the third was even milder than the first. Many cases developed into pneumonia, which was often the cause of death, and this flu didn’t only claim the elderly and the very young–as in a normal flu season–but people in their thirties and forties too. Doctors were unsettled by their observation that many patients who survived the initial attack went on to develop nervous complications, including depression. The Norwegian artist Edvard Munch may have been one of them, and some have suggested that his famous painting, The Scream, sprang from his flu-darkened thoughts. ‘One evening I was walking along a path, the city was on one side and the fjord below,’ he wrote later. ‘I felt tired and ill. I stopped and looked out over the fjord–the sun was setting, and the clouds turning blood red. I sensed a scream passing through nature; it seemed to me that I heard the scream.’8 By the time Munch wrote those words, the pandemic was over, and so was the millennia-long struggle between man and flu. In the next century, the twentieth, science would conquer the crowd diseases once and for all.

  2

  The monads of Leibniz

  To us living in a world a hundred years older, a world in the grip of an AIDS pandemic, the idea that science would conquer infectious diseases for good seems nonsensical. But at the turn of the twentieth century many people believed it, at least in the west. The main reason for their optimism was germ theory–the insight that germs cause disease. Bacteria had been known about for a couple of centuries, ever since a Dutch lens grinder named Antony van Leeuwenhoek passed a magnifying glass over a drop of pond water and saw that it was teeming with life, but they had been regarded as a kind of harmless ectoplasm–nobody suspected that they could make people ill. Robert Koch in Germany and Louis Pasteur in France made the connection, starting in the 1850s. The discoveries of these two men are too numerous to list, but among them, Koch showed that TB, the ‘Romantic’ disease of poets and artists, was not inherited–as was widely believed–but caused by a bacterium, while Pasteur disproved the notion that living organisms could be generated spontaneously from inanimate matter.

  In combination with older ideas about hygiene and sanitation, germ theory now began to turn the tide on the crowd diseases. Campaigns were launched to purify drinking water and promote cleanliness. Vaccination programmes were imposed, though not without resistance–not surprisingly, people balked at the idea that they could be protected against a disease by being injected with it–and these efforts produced concrete results. If in the wars of previous centuries, more lives had been lost to disease than to combat, that trend was now reversed. Weapons had become more lethal, but military doctors had also become better at controlling infection. Those might seem like odd grounds for claiming success, but army doctors were among the first to put germ theory into practice, and their expertise trickled down to their civilian counterparts. At the beginning of the twentieth century, cities at last became self-sustaining.

  In the early decades of that century, therefore, faith in science and rationalism was high. The excitement over the discovery of the link between bacteria and disease had not yet abated, and there was a temptation to find bacteria responsible for every malaise. Ilya Mechnikov, the wild Russian ‘demon of science’ whom Pasteur had brought to his institute in Paris, even blamed them for old age. Mechnikov had won a Nobel Prize in 1908 for his discovery of phagocytosis–the mechanism by which immune cells in human blood swallow up harmful bacteria and destroy them. But he also suspected bacteria in the human intestine of releasing toxins that harden the arteries, contributing to the body’s ageing–a belief that brought a certain amount of ridicule down on his head. He became obsessed with villages in Bulgaria where people reputedly lived to be more than a hundred, attributing their longevity to the sour milk they drank–and in particular, to the ‘good’ bacteria that soured it. In the last years of his life, he drank huge quantities of sour milk, before dying in 1916 at the age of seventy-one.1 (These days, the microbes in our gut are generally considered to be either harmless, or good for us.)

  Viruses, however, were still a mystery. In Latin the word virus means something like poison, or potent sap, and at the turn of the twentieth century that was exactly how people understood it. When in his 1890 novel O Cortiço (The Slum), Brazilian writer Aluísio Azevedo wrote ‘Brazil, that inferno where every budding flower and every buzzing bluebottle fly bears a lascivious virus’, a venomous secretion is probably what he had in mind. But scientists were beginning to question that definition. Were they toxins or organisms? Liquid or particle? Dead or alive? The first virus was discovered in 1892, when Russian botanist Dmitri Ivanovsky identified a virus as the cause of a disease in tobacco plants. He hadn’t seen it. What he had discovered was that the disease was caused by an infectious agent that was smaller than all known bacteria–too small to see.

  In 1892, the Russian flu was raging across Europe, and it was in the same year that Ivanovsky made his discovery that a student of Koch, Richard Pfeiffer, identified the bacterium responsible for influenza. That’s right, the bacterium responsible for influenza. Pfeiffer’s bacillus, also known as Haemophilus influenzae, really exists, and it causes disease, but it does not cause flu (Pfeiffer’s error lives on in its name, like a warning to scientists, or a bad historical joke). Nobody suspected that flu could be the work of a virus, that unclassifiable thing that existed somewhere beyond the limits of observability, and they continued to not suspect it in 1918. In fact, viruses occupied only a tiny corner of the psychic universe of 1918. They hadn’t been seen, and there was no test for them. These two facts are crucial to understanding the impact of the Spanish flu. Things changed in the wake of the pandemic, as this book will explain, but it took time. When James Joyce wrote, in his thoroughly modern novel Ulysses (1922), ‘Foot and mouth disease. Known as Koch’s preparation. Serum and virus’, he probably thought of a virus in much the same way as Azevedo had.2

  The disciples of Pasteur and Koch disseminated germ theory far and wide, so that it gradually displaced Galenic concepts of disease. The psychological shift that this demanded was as troubling as the one Hippocrates had provoked more than 2,000 years earlier, and people were slow to embrace it. When two waves of cholera swept London in the mid-nineteenth century, its residents blamed miasma rising from the filthy River Thames. After a brilliant piece of detective work that involved marking fatal cases of the disease on a map, a doctor called John Snow traced the source of one outbreak to a particular water pump in the city, and deduced–correctly–that water rather than air spread cholera. He published his conclusion in 185
4, but it was only after the ‘Great Stink’ of 1858–when a spell of hot weather rendered the smell of untreated sewage on the banks of the Thames overpowering–that the authorities finally commissioned an engineer, Joseph Bazalgette, to design a proper system of sewers for the city. Their reasoning? By eliminating the miasma, they would eliminate cholera too.

  Germ theory also had profound implications for notions of personal responsibility when it came to disease. Hippocrates had some surprisingly modern ideas about this. People were responsible for their diseases, he believed, if they did not make lifestyle choices conducive to good health, but they could not be blamed if a disease was hereditary. Even in that case, however, they had choices. He gave the example of cheese, arguing that one should choose whether or not to eat cheese in the light of knowledge about the constitution one had inherited. ‘Cheese,’ he wrote, ‘does not harm all men alike; some can eat their fill of it without the slightest hurt, nay, those it agrees with are wonderfully strengthened thereby. Others come off badly.’3

  By the Middle Ages, people had shifted most of the responsibility for disease back onto the gods, or God, and a sense of fatalism persisted for centuries, despite the rise of science. In 1838, the French writer George Sand took her tubercular lover Frédéric Chopin to the Spanish island of Majorca, hoping that the Mediterranean climate would ease the symptoms of her ‘poor melancholy angel’. She didn’t expect it to cure him, because to her mind TB was incurable. Nor did it occur to her that she could catch it from him. By then, however, ideas about what caused TB were already in flux, and when the pair arrived in Palma, they discovered that its inhabitants wanted nothing to do with them. As an outraged Sand wrote to a friend, they were asked to leave, TB ‘being extremely rare in those latitudes and, moreover, considered contagious!’4

  In the nineteenth century, epidemics were still regarded–like earthquakes–as acts of God. Germ theory forced people to consider the possibility that they could control them, and this revelation brought another new set of ideas into play: the theory of evolution that Charles Darwin had introduced in his On the Origin of Species (1859). When Darwin had talked about natural selection, he had not meant his ideas to be applied to human societies, but his contemporaries did just that, giving birth to the ‘science’ of eugenics. Eugenicists believed that humanity comprised different ‘races’ that competed for survival. The fittest thrived, by definition, while the ‘degenerate’ races ended up living in poverty and squalor because they lacked drive and self-discipline. This line of thinking now dovetailed insidiously with germ theory: if the poor and the working classes also suffered disproportionately from typhus, cholera and other killer diseases, then that too was their fault, since Pasteur had taught that such diseases were preventable.

  Eugenics informed immigration and public health policies across the world in the late nineteenth century. German anthropologists were busy classifying human ‘types’ in their colonies in Africa, while in some American states, people judged mentally ill were forcibly sterilised. Ironically, though American eugenicists saw the Japanese as racially inferior, and tried to keep them out of their country, eugenics was also popular in Japan–where, of course, the Japanese race was regarded as superior.5 Eugenics is taboo today, but in 1918 it was mainstream, and it would powerfully shape responses to the Spanish flu.

  ‘The minds of different generations are as impenetrable one by the other as are the monads* of Leibniz,’ wrote Frenchman André Maurois, but we can at least highlight some obvious differences between 1918 and now. The world was at war, and had been since 1914. The reasons for that war lay mainly in Europe–in tensions between that continent’s great imperial powers. The age of discovery had borne fruit by 1914, when more of the globe was colonised by Europeans than at any other time. From that apogee, a long process of decolonisation would break up those empires and liberate their colonies. But 1918 also saw one of the last battles in one of the last colonial wars–the American Indian Wars, in which the European settlers of North America fought, and ultimately defeated, its indigenous peoples.

  Future heads of state Nicolae Ceau¸sescu and Nelson Mandela were born in 1918, as was the future dissident writer Aleksandr Solzhenitsyn, the film director Ingmar Bergman and the actress Rita Hayworth. Max Planck won the Nobel Prize in Physics for his work on quantum theory, while Fritz Haber won the chemistry prize for inventing a way of producing ammonia, which is important in the manufacture of fertilisers and explosives (the Nobel committees decided not to award prizes in medicine, literature or peace that year). Gustav Holst’s The Planets was lauded at its premiere in London, while Joan Miró’s work was lampooned at the artist’s first solo exhibition in Barcelona.

  Movies were silent and telephones were rare. Long-distance communication was mainly by telegraph, or, in parts of China, by carrier pigeon. There were no commercial airplanes, but there were submarines, and steamships plied the oceans at an average speed of a little under twelve knots (about twenty kilometres per hour).6 Many countries had well-developed rail networks, but many did not. Persia, a country three times the size of France, had twelve kilometres of rail. It also had only 300 kilometres of road and a single car–the shah’s. Ford had issued his affordable Model T, but cars were a luxury, even in America. The most common mode of transport was the mule.

  It was a world that was both familiar to us, and terribly foreign. Despite the inroads made by germ theory, for example, human populations were far less healthy than they are now, and even in the industrialised world, the main cause of ill health was still, overwhelmingly, infectious diseases–not the chronic, degenerative diseases that kill most of us today. After America entered the war in 1917, it undertook a mass examination of army draftees–the first national physical exam in its history. The results came to be known as ‘the horrible example’: of 3.7 million men who were examined, around 550,000 were rejected as unfit, while almost half the remainder were found to have some physical deformity–often one that was preventable or curable.

  ‘Plague’, for us, means something very precise: bubonic plague–as well as its variants, pneumonic and septicaemic plague–all of which are caused by the bacterium Yersinia pestis. But in 1918, ‘plague’ referred to any dangerous disease that attacked by storm. ‘Real’ plague, meanwhile–the disease that, under the alias ‘the Black Death’, devastated medieval Europe–was still present on that continent. It seems extraordinary, but in England its last visitation coincided with that of the Spanish flu.7 Nor did ‘middle-aged’ mean what it does today: life expectancy at birth in Europe and America did not exceed fifty, and in large parts of the globe it was much lower. Indians and Persians, for example, were lucky to celebrate their thirtieth birthdays.

  Even in wealthy countries, the vast majority of births took place at home, bathtubs were reserved for the rich, and a significant minority of the population was illiterate. Ordinary people grasped the concept of contagion, but not the mechanism, and if that seems surprising–given that germ theory had already been around for half a century by then–consider a modern parallel. The discovery of the structure of DNA in 1953 gave birth to the field of molecular genetics, which once again radically altered our understanding of health and disease. But a survey of ordinary Americans conducted half a century later, in 2004, revealed high levels of confusion as to what a gene actually is.8

  Doctors’ training was patchy in 1918, though from 1910 Abraham Flexner had begun campaigning for rigorous, standardised medical education in the US. Health insurance was almost unheard of, and in general healthcare was paid for privately or provided by charities. Antibiotics had yet to be invented, and there was still relatively little people could do once sick. Even in Paris and Berlin, therefore, disease filled the interstices of human lives. It lurked behind the column inches devoted to the war. It was the dark matter of the universe, so intimate and familiar as not to be spoken about. It engendered panic, followed by resignation. Religion was the main source of comfort, and parents were used to surviving at l
east some of their children. People regarded death very differently. It was a regular visitor; they were less afraid.

  This, then, was the world into which the Spanish flu erupted: a world that knew the motor car but was more comfortable with the mule; that believed in both quantum theory and witches; that straddled the modern and premodern eras, so that some people lived in skyscrapers and used telephones, while others lived much as their ancestors had in the Middle Ages. There was nothing modern about the plague that was about to be unleashed on them, however; it was thoroughly ancient. From the first fatality, it was as if the entire population of the globe, some 1.8 billion people, had been transported back several millennia, to a city like Uruk.

  * A monad, according to the German philosopher Gottfried Leibniz (1646–1716), was an elementary particle or simple substance–something indivisible.

  PART TWO: Anatomy of a Pandemic

  Emergency hospital created to accommodate Spanish flu patients at the US Army’s Camp Funston, Kansas, 1918

  3

  Ripples on a pond

  On the morning of 4 March 1918, a mess cook at Camp Funston in Kansas, Albert Gitchell, reported to the infirmary with a sore throat, fever and a headache. By lunchtime the infirmary was dealing with more than a hundred similar cases, and in the weeks that followed so many reported sick that the camp’s chief medical officer requisitioned a hangar to accommodate them all.