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

by Laura Spinney

When he rose from his sickbed, thin and weak, he went to sit by a window that gave onto the street: ‘In just one hour I saw three poorly attended funeral processions passing down Barão de Mesquita.’ A servant told him that the girl he idolised, Nair, was now seriously ill. Struggling up the stairs, he peered around her door and was shocked by what he saw. Gone was the radiance, gone the lustrous complexion. Her lips were chapped and livid, her hair dull, her temples bony and concave. ‘She was so changed it was as if she had turned into another person, as if some kind of demon were haunting her.’

  Nair died on 1 November, All Saints’ Day, by which time the epidemic was receding and life in Rio was returning to normal. It was pouring with rain. The hearse with its white curtains vanished ‘as if in an aquarium’, accompanied by Ernesto. When he returned that night, he told the others that the coffin had been lowered into a waterlogged grave. Five years later, when Aunt Eugenia went to retrieve Nair’s bones, she found her ‘completely incorrupt, only darkened like a mummy’. The gravedigger explained that her body had been preserved in its damp, anaerobic environment.

  Nair was reburied in the earth, and after two years her clean bones were transferred to the family tomb. Nava’s enduring image of her was of ‘a marble bride’ in a white dress, lying in a white coffin that the Venetian mirrors at 16 Rua Major Ávila reflected ad infinitum, her lips parted in a sad smile. ‘She belonged to the past now, as distant as the Punic Wars, as the ancient Egyptian dynasties, as King Minos or the first men, errant and miserable.’ From over fifty years’ distance, the retired doctor bade her farewell: ‘Sweet girl, may you rest in peace.’

  PART THREE: Manhu, or What is it?

  The Family, painted by Egon Schiele in October 1918

  5

  Disease eleven

  When a new threat to life emerges, the first and most pressing concern is to name it. Once it has been named it can be spoken of. Solutions to it can be proposed and either adopted or rejected. Naming is therefore the first step to controlling the menace, even if all that is conferred with the name is the illusion of control. So there’s a sense of urgency about naming; it must happen early. The trouble is that, in the early days of an outbreak, those observing the disease may not see the whole picture. They may misconstrue its nature or origin. This leads to all kinds of problems later on. The name first given to AIDS–gay-related immune deficiency–stigmatised the homosexual community. Swine flu, as we’ll see, is transmitted by humans, not pigs, but some countries still banned pork imports after a 2009 outbreak. Alternatively, the disease may ‘outgrow’ its name. Ebola is named for the River Ebola in Central Africa, for example, but in 2014 it caused an epidemic in West Africa. Zika virus has travelled even further. Named for the forest in Uganda where it was first isolated in 1947, in 2017 it is a major threat in the Americas.

  To try to prevent some of these problems, in 2015 the World Health Organization issued guidelines stipulating that disease names should not make reference to specific places, people, animals or food. They should not include words that engender fear, such as ‘fatal’ or ‘unknown’. Instead, they should use generic descriptions of symptoms such as ‘respiratory disease’, combined with more specific qualifiers such as ‘juvenile’ or ‘coastal’, and the name of the disease-causing agent. When the need arises to distinguish between diseases that lay equal claim to these terms, this should be done using arbitrary labels such as one, two, three.

  The WHO working group deliberated long and hard over this problem, which is not an easy one to solve. Take SARS, for example, the acronym for severe acute respiratory syndrome. It’s hard to imagine how it could offend anyone, but it did. Some people in Hong Kong were unhappy about it–Hong Kong being one of the places affected by an outbreak of the disease in 2003–because Hong Kong’s official name includes the suffix SAR, for ‘special administrative region’. On the other hand, names the current guidelines would rule out, such as monkey pox, arguably contain useful information about the disease’s animal host and hence a potential source of infection. The working group considered naming diseases after Greek gods (Hippocrates would have been horrified), or alternating male and female names–the system used for hurricanes–but eventually rejected both options. They might have considered a numerical system that was adopted in China in the 1960s, in an attempt to prevent panic (diseases one to four were smallpox, cholera, plague and anthrax, respectively), but in the end they decided against too radical an overhaul. The current guidelines are designed to prevent the worst naming sins, while still leaving scientists room to be creative.1

  These guidelines, of course, did not exist in 1918. Moreover, when influenza erupted that year, it did so more or less simultaneously all over the world, affecting populations that had embraced germ theory and others that had not. Those populations often had startlingly different concepts of disease per se. Since disease is broadly defined as the absence of health, whether or not you recognise a set of symptoms as a disease depends on your expectations of health. These might be very different if you live in a wealthy metropolis such as Sydney, or an Aboriginal community in the Australian Outback. The world was at war in 1918, and many governments had an incentive (more incentive than usual, let’s say) to shift the blame for a devastating disease to other countries. Under such circumstances, that disease is likely to attract a kaleidoscope of different names, which is exactly what happened.

  When the flu arrived in Spain in May, most Spanish people, like most people in general, assumed that it had come from beyond their own borders. In their case, they were right. It had been in America for two months already, and France for a matter of weeks at least. Spaniards didn’t know that, however, because news of the flu was censored in the warring nations, to avoid damaging morale (French military doctors referred to it cryptically as maladie onze, ‘disease eleven’). As late as 29 June, the Spanish inspector general of health, Martín Salazar, was able to announce to the Royal Academy of Medicine in Madrid that he had received no reports of a similar disease elsewhere in Europe. So who were Spaniards to blame? A popular song provided the answer. The hit show in Madrid at the time the flu arrived was The Song of Forgetting, an operetta based on the legend of Don Juan. It contained a catchy tune called ‘The Soldier of Naples’, so when a catchy disease appeared in their midst, Madrileños quickly dubbed it the ‘Naples Soldier’.

  Spain was neutral in the war, and its press was not censored. Local papers duly reported the havoc that the Naples Soldier left in its wake, and news of the disruption travelled abroad. In early June, Parisians who were ignorant of the ravages the flu had caused in the trenches of Flanders and Champagne learned that two-thirds of Madrileños had fallen ill in the space of three days. Not realising that it had been theirs longer than it had been Spain’s, and with a little nudging from their governments, the French, British and Americans started calling it the ‘Spanish flu’.

  Not surprisingly, this label almost never appears in contemporary Spanish sources. Practically the only exception is when Spanish authors write to complain about it. ‘Let it be stated that, as a good Spaniard, I protest this notion of the “Spanish fever”,’ railed a doctor named García Triviño in a Hispanic medical journal. Many in Spain saw the name as just the latest manifestation of the ‘Black Legend’, anti-Spanish propaganda that grew out of rivalry between the European empires in the sixteenth century, and that depicted the conquistadors as even more brutal than they were (they did bind and chain the Indians they subjugated, but they probably did not–as the legend claimed–feed Indian children to their dogs).2

  Further from the theatre of war, people followed the time-honoured rules of epidemic nomenclature and blamed the obvious other. In Senegal it was the Brazilian flu and in Brazil the German flu, while the Danes thought it ‘came from the south’. The Poles called it the Bolshevik disease, the Persians blamed the British, and the Japanese blamed their wrestlers: after it first broke out at a sumo tournament, they dubbed it ‘sumo flu’.

  Some names re
flected a people’s historic relationship with flu. In the minds of the British settlers of Southern Rhodesia (Zimbabwe), for example, flu was a relatively trivial disease, so officials labelled the new affliction ‘influenza (vera)’, adding the Latin word vera, meaning ‘true’, in an attempt to banish any doubts that this was the same disease. Following the same logic, but opting for a different solution, German doctors realised that people would need persuading that this new horror was the ‘fashionable’ disease of flu–darling of the worried well–so they called it ‘pseudo-influenza’. In parts of the world that had witnessed the destructive potential of ‘white man’s diseases’, however, the names often conveyed nothing at all about the identity of the disease. ‘Man big daddy’, ‘big deadly era’, myriad words meaning ‘disaster’–they were expressions that had been applied before, to previous epidemics. They did not distinguish between smallpox, measles or influenza–or sometimes even famines or wars.

  Some people reserved judgement. In Freetown, a newspaper suggested that the disease be called manhu until more was known about it. Manhu, a Hebrew word meaning ‘what is it?’, was what the Israelites asked each other when they saw a strange substance falling out of the sky as they passed through the Red Sea (from manhu comes manna–bread from heaven). Others named it commemoratively. The residents of Cape Coast, Ghana called it Mowure Kodwo after a Mr Kodwo from the village of Mouri who was the first person to die of it in that area.3 Across Africa, the disease was fixed for perpetuity in the names of age cohorts born around that time. Among the Igbo of Nigeria, for example, those born between 1919 and 1921 were known as ogbo ifelunza, the influenza age group. ‘Ifelunza’, an obvious corruption of ‘influenza’, became incorporated into the Igbo lexicon for the first time that autumn. Before that, they had had no word for the disease.

  As time went on, and it transpired that there were not many local epidemics, but one global pandemic–it became necessary to agree on a single name. The one that was adopted was the one that was already being used by the most powerful nations on earth–the victors in the Great War. The pandemic became known as the Spanish flu–ispanka, espanhola, la grippe espagnole, die Spanische Grippe–and a historical wrong became set in stone.

  6

  The doctors’ dilemma

  The flu had been named; the foe had a face. But what did doctors mean by influenza in 1918? The most forward-thinking of them meant a constellation of symptoms that included cough, fever, aches and pains, that was caused by a bacterium named for its discoverer, Richard Pfeiffer. If a patient came to a doctor’s consulting rooms complaining of feeling under the weather, the doctor might perform a clinical examination. He might take the patient’s temperature, interrogate him about his symptoms, and look for the telltale mahogany spots over his cheekbones. This might be enough to convince him that the patient was suffering from flu, but if he was a rigorous type who wanted to be certain, he would take a sample of the patient’s sputum (a polite word for coughed-up phlegm), grow its bacterial inhabitants on a nutritious gel, and then peer at them under a microscope. He knew what Pfeiffer’s bacillus looked like–Pfeiffer himself had taken a photograph of it in the 1890s–and if he saw it, that would clinch the matter.

  The trouble is, Pfeiffer’s bacillus, though it is commonly found in the human throat, does not cause flu. In 1918, doctors found it in some of their cultures, but not in all. This violated the first of the great Robert Koch’s ‘postulates’, the four criteria he had laid down for establishing that a particular microbe causes a particular disease: the microbe must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms. Flu is, of course, caused by a virus. A virus is roughly twenty times smaller than a bacterium–too small to see under an optical microscope. Even if they had suspected that a virus caused flu, in other words, they had no way of detecting it. This was the doctors’ dilemma in 1918: they did not know the cause of flu, so they could not diagnose it with certainty. And this dilemma bred others.

  People were fairly easily convinced that the spring wave of the pandemic was influenza, but when the autumn wave erupted, there were serious doubts that it was the same disease. Even Americans and Europeans who had never seen a case of plague began to fear that that deadly disease had entered their midst. In hot countries it was mistaken for dengue fever, which also starts with a fever and headache. Cholera, which lends a blue tinge to the skin, was whispered, while a doctor at Constantinople’s Hamidiye Children’s Hospital claimed that it was worse than all of those, ‘a disaster which isn’t called plague but actually is more dangerous and more fatal than that’.1

  Some doctors thought they were dealing with typhus, which starts out with flu-like symptoms–fever, headache, general malaise. Typhus has long been regarded as the disease of social collapse. It ravaged Napoleon’s troops during their retreat from Moscow, and broke out in the Bergen-Belsen concentration camp in 1945–probably killing the young diarist, Anne Frank. In 1918, when Russia was in the grip of a civil war, a doctor in Petrograd wrote that it ‘follows Lenin’s communism like the shadow follows the passer-by’.2 That country experienced simultaneous epidemics of typhus and influenza, and Russian doctors were often at a loss to tell the two apart–at least until the patient broke out in the telltale typhus rash.

  In Chile, doctors did not even consider the possibility of influenza. In 1918, Chilean intellectuals were gloomily convinced that their country was in a state of decline. The economy was faltering, labour disputes were on the rise, and there was a belief that the government was too much under the sway of foreign powers. When a new disease invaded the country, even though they had read reports of a flu epidemic in neighbouring states, a cabal of eminent Chilean doctors assumed that it was typhus. They blamed it on the poor and the workers, whom they referred to as los culpables de la miseria (makers of their own misery), because of the abject sanitary conditions in which they lived, and they acted accordingly.

  Typhus is transmitted by lice, which means that it spreads much less easily than breath-borne flu. The Chilean doctors therefore saw no reason to ban mass gatherings. After ace pilot Lieutenant Dagoberto Godoy completed the first flight over the Andes in December 1918, ecstatic crowds greeted the hero in the streets of the capital, Santiago. Soon enough, the city’s hospitals were turning away sick people for lack of space. Meanwhile, sanitary brigades went into battle against the imaginary typhus epidemic, invading poor people’s houses and ordering them to strip, wash and shave body hair. In the cities of Parral and Concepción, they forcibly evicted thousands of workers and torched their homes–a strategy that probably exacerbated the epidemic, since it left crowds of homeless people exposed to each other and to the elements.

  In 1919, while the country was still in the grip of the pandemic, a young woman entered the order of Discalced Carmelites in the township of Los Andes. Within a few months Teresa of Jesus–as the novice called herself–had fallen ill, and she died in April 1920 having taken her religious vows in periculo mortis (in danger of death). Teresa would later be canonised–English-speakers know her as Teresa of the Andes, Chile’s patron saint. History books tell us that she died of typhus, but there is good reason to believe that she actually died of Spanish flu.3

  The case of the Chinese province of Shansi (Shanxi) illustrates the doctors’ dilemma most clearly, however, because it shows how difficult it was to identify a respiratory disease in a place where–as in many other parts of the world at that time–villages were isolated and hard to reach; where people were poor, often malnourished and suffering simultaneously from other diseases; and where they were opposed to ‘foreign’ medicine, creating conditions that were far from conducive to careful scientific work.

  A TENTATIVE DIAGNOSIS

  Shansi lies on China’s frontier with Inner Mongolia. Surrounded on all sides by mountains and rivers, it is a landscape of precipices, ravines and rocky plateaus–the natural habitat of wolves and leopards. The Great Wall meanders through, a relic
of attempts to keep out nomadic tribes and a reminder, along with the sandstorms that blow in from the Gobi Desert, of Shansi’s position at the edge. In 1918, the people of the province lived in villages, but also in caves dug into cliffs. Their towns were fortified and protected by antique cannon. They were isolated by their geology, their geography and their history of conflict with outsiders, and all of this had left its mark. Fiercely proud of their ancient civilisation, they were considered conservative even by other conservative Chinese.

  In 1911, revolution had overthrown the last imperial dynasty, the Qing, and ushered in a new republic. In the great cities of Peking, Shanghai and Tientsin, things were changing. The New Culture movement was challenging the rules by which Chinese society had organised itself for 4,000 years, and reserving particular scorn for traditional Chinese medicine. ‘Our doctors do not understand science,’ wrote Chen Tu-hsi (Chen Duxiu), one of New Culture’s leaders, in 1915. ‘They not only know nothing of human anatomy, but also know nothing of the analysis of medicines; as for bacterial poisoning and infections, they have not even heard of them.’4 By 1918, however, these ideas had yet to percolate beyond the metropolises. Many in Shansi still recognised the Qing as their only legitimate rulers, and believed that illness was sent by demons and dragons in the form of evil winds. When disease scythed through them, as it did with dismal regularity, their first instinct was to appease the disgruntled spirits.

  Though the revolution had given birth to a new republic, in reality the country had passed into the hands of rival provincial warlords. Yuan Shikai, the leader of the republic, had managed to keep these warlords more or less in check from Peking, but his death in 1916 ushered in a turbulent period during which they struggled to dominate one another. The governor of Shansi was a former revolutionary soldier named Yen Hsi-shan (Yan Xishan). Before the revolution, Yen had spent time in Japan which, unlike China, had embraced ‘western’ scientific ideas. On one occasion he had been admitted to a Japanese hospital, where he had encountered drugs and X-rays for the first time. He had seen with his own eyes how far his own country had fallen behind the rest of the world, and he had come to believe that Confucian values were toxic to it, hooks in its flesh anchoring it to the past. This ‘enlightened’ warlord was determined to remove those hooks, and to drag Shansi, bleeding if necessary, into the twentieth century.