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

by Laura Spinney

  October saw the beginning of the Shi’ite holy month, Muharram, which culminates in Ashura. The most sacred event in the Shi’ite calendar, Ashura commemorates the martyrdom of the Third Imam, Hussein. Several years later, the missionary William Miller would describe the Muharram processions as he witnessed them in Mashed: ‘A group of men stripped to the waist was passing, beating their bare backs with chains,’ he wrote. ‘Then came the head-cutters, men who had made a vow to slash their foreheads with their swords until the blood streamed down their white gowns.’30 The crowd looked on, lamenting loudly. Passion plays or taziyehs were performed. Muharram is a major event that absorbs all the city’s energy for the month that it lasts, but in 1918 Grey wrote that it passed off quietly: ‘Owing to recent sickness in the city the attendance at the processions was less than usual.’

  Hoffman finally closed the American Hospital in December 1918, worn out from having run it single-handed throughout the crisis, and from his own bouts of typhus and flu. Before he took a well-earned rest, he managed to pen one last letter to the home church, asking for funds to support an expansion of the hospital and a second doctor. In the letter, he enthused about the potential for ‘medical evangelism’ in Mashed, to which all roads in the region led, and the possibility of offering pilgrims health in body and soul. The funds were duly granted.

  Qavam survived the turbulence of General Reza Khan’s British-backed coup in 1921, and finding favour with the new shah, went on to serve five terms as the country’s prime minister. The shah eventually rebuilt Mashed on a rectilinear plan, linked it to Tehran by a modern road, and demolished its graveyards. Hoffman, who stayed on there until 1947, witnessed the transformation: ‘The bones of centuries were shovelled into wheelbarrows and dumped into unmarked pits, the gravestones being used for street curbs and sidewalks.’31

  9

  The placebo effect

  Much like today, when a person was sick in Europe or America in the late nineteenth century, he could go to a ‘regular’ doctor, or he could go to a homeopath, a naturopath, an osteopath or a faith healer–or he could hedge his bets and go to all five. The difference between then and now was that the regular doctor had no special status. There was nothing ‘conventional’ about his medicine or ‘alternative’ about theirs. His was just another cult among many medical cults. In the early twentieth century, the regulars fought off the competition from the ‘irregulars’. They did this in Europe largely through increased state regulation of healthcare, and in America through a series of bitter legal battles, but the outcome in both places was the same: conventional medicine monopolised access to the masses. By 1918, it was indisputably mainstream.

  When the Spanish flu broke out, therefore, it was to the regulars that most people in the industrialised world turned for treatment. What did the doctors have to offer? No effective vaccine, of course. Certainly no antiviral drugs–the first of those didn’t enter the clinic until 1960–and no antibiotics either, for the treatment of those opportunistic bacterial infections. They wouldn’t become available until after the Second World War. Faced with wheezing, blue-faced patients, they felt they had to do something, and the approach they adopted was polypragmatism, or polypharmacy: they threw the medicine cabinet at the problem.

  What was in a conventional doctor’s medicine cabinet in 1918? It was still an era of ‘concoctions, plant extracts, and other unproven treatments’.1 Clinical drug development was in its infancy, and though some drugs had been tested in animals or humans, many had not. When human trials had been conducted, they tended to be small. The elaborate and very expensive drug trials that we read about today, with their ‘blinded’ experimenters and placebo controls, were unheard of. Legislation to ensure that medicines were pure and unadulterated was recent, in those countries that even had it. There was no real understanding of how a drug’s active components interacted with living tissues, or the conditions that turned a medicine into a poison, and even when there was, most practitioners were unaware of it; it didn’t form part of their training.

  One of the first phials they reached for was the one containing aspirin, the ‘wonder drug’ that was known to reduce fever and kill pain. They prescribed it in such large quantities that in 2009, a doctor named Karen Starko put forward the troubling theory that aspirin poisoning might have contributed to the deaths of a sizeable proportion of the flu’s victims. Very high doses of aspirin can cause the lungs to fill with fluid, a fact of which doctors were ignorant in 1918, and we know that they were routinely prescribing twice the maximum dose that is considered safe today. The aspirin-poisoning theory is contentious, however. Other scientists have pointed out that the drug wouldn’t have been widely available in many countries–most Indians would not have had access to it, for example–so while it may have aggravated the situation in America and other wealthy countries, it is unlikely to have contributed to the global death toll in any significant way.2

  It is nevertheless possible that many of those who suffered from Spanish flu also had to contend with the effects of overdosing of the substances that doctors gave them to try to ameliorate their symptoms. Quinine, for example, was a known treatment for malaria and other ‘bilious fevers of a paludic nature’.3 There was no evidence that it worked for flu, yet it was prescribed in large doses. ‘To the symptoms of the disease now had to be added those caused by the panacea: buzzing in the ear, vertigo, hearing loss, bloody urine and vomiting,’ wrote Pedro Nava in Brazil. Though rare, disturbed colour vision can be a side effect of taking a lot of quinine–meaning that this drug may have exacerbated the sensation that some flu victims had, of coming to in a pallid, washed-out world.

  Arsenic preparations were popular, for their tonic, painkilling action, as was camphor oil for treating shortness of breath. Digitalis and strychnine were supposed to stimulate the circulation, Epsom salts and castor oil were prescribed as purgatives, and various drugs derived from iodine for ‘internal disinfection’. When none of these things worked, doctors fell back on older techniques. Having observed that some patients seemed to take a turn for the better following a gushing nosebleed, menstruation, even–traumatically–miscarriage, some revived the ancient practice of bloodletting, or medicinal bleeding. Physicians of the Hippocratic and Galenic traditions thought that this cleansed the blood of impurities, and in 1918 it was commented upon that the blood that emerged from flu patients was unusually thick and dark. The practice provoked a certain amount of scepticism, however. ‘Although this resource did not relieve or cure anyone, it brought comfort to the patient and the family,’ wrote one Spanish doctor.4

  Even more controversial was alcohol–especially in those states where the prohibition movement was gaining force, and it couldn’t be obtained without a prescription. Some doctors claimed that alcohol in small doses had a stimulant effect, while others urged complete abstinence. Vendors seized on these slim pickings to trumpet the medicinal properties of their wares. Afraid of provoking a different kind of epidemic, health officials in the Swiss canton of Vaud circulated a memo that urged doctors to ‘vigorously oppose the idea taking root that alcohol in high doses protects against influenza’–even if, those same officials allowed, it could be useful when the patient was feverish and unable to feed himself. Some doctors claimed that inhaling cigarette smoke killed the germ, and people naturally cherry-picked the advice that suited them. The Swiss-born architect known as Le Corbusier retreated to his rooms in Paris and sipped cognac and smoked through the worst of the pandemic, while cogitating on how to revolutionise the way people lived (though he hadn’t even a diploma in architecture).

  Some enterprising ‘experimentalists’ suggested new prophylactics or therapies based on their observations. While treating patients at the New Idria mercury mine in San Benito County, California, physician Valentine McGillycuddy noticed that none of the men who operated the furnace where the metal was extracted from its ore had contracted the flu. This, he surmised, was due to mercury’s antiseptic properties, or else to the fa
ct that mercury vapour stimulates the salivary glands (McGillycuddy turns up again later in Alaska–we’ll meet him there). French military doctors observed, apparently independently, that when the flu invaded an army clinic for venereal disease, all the patients succumbed except the syphilitics, and they wondered if it was these patients’ daily mercury injections that protected them. A Viennese doctor went so far as to conduct a small trial. Since none of his twenty-one flu patients died following mercury treatment, he concluded that it was an effective therapy for flu.5 Unfortunately, as many syphilitic patients discovered, mercury is also toxic. The symptoms of mercury poisoning include loss of coordination and a sensation of ants crawling beneath the skin. The therapy, in this case, was arguably worse than the disease.

  It wasn’t so difficult, in the circumstances, for the manufacturers of patent medicines to tap into a newly receptive audience, and make small fortunes selling their dubious products over the counter. Their tonics and elixirs–Dr Kilmer’s Swamp-Root was a famous formula of the time, in America–were generally plant-based too, and often claimed heritage among ancient people’s recipes. These days, research into ethnic groups’ use of native plants, ethnobotany, is a respected field in its own right, and pharmaceutical companies search for potential new blockbuster drugs in those indigenous pharmacopoeias. But in 1918, patent medicines were relatively unregulated and there was rarely any evidence that they worked. The regulars–arguably standing on shaky ground themselves–accused their makers of quackery. Those who had no truck with either turned instead to the irregulars. Having suffered the ill effects of overdosing with conventional medicines, the prospect of a ‘nature cure’ or an extremely diluted homeopathic compound might well have appealed to them. Alternatively they put their faith in home remedies: mustard poultices, sugar lumps soaked in kerosene, infusions brewed according to old family recipes, fires of aromatic plants lit twice daily in front of the house (to clear the miasma).

  Beyond the industrialised world, people sought out their traditional healers–sometimes after western-style doctors, sometimes before. Ayurveda in India, like kanpo in Japan–ancient forms of treatment that make use of herbs–were trusted and cheap alternatives to western medicine which, even if they had confidence in it, was often not available. Witch doctors in the hills of India moulded human figures out of flour and water and waved them over the sick to lure out the evil spirits. In China, besides parading the figures of dragon kings through their towns, people went to public baths to sweat out the evil winds, smoked opium and took yin qiao san–a powdered mix of honeysuckle and forsythia that had been developed under the Qing for ‘winter sickness’.

  Most of these ‘cures’ were no more effective than placebos. The placebo effect is a manifestation of the power of positive thinking. It derives from a person’s expectation that a drug or other intervention will heal them, and it can be extremely effective in itself. According to some estimates, 35–40 per cent of all medical prescriptions today are not much more than placebos.6 The interesting thing about a placebo is how sensitive it is to the trust that is established between a patient and his doctor. If a patient loses confidence in his doctor, or if he perceives that the doctor has lost respect for him, the beneficial effects of the placebo shrink–and that shrinkage doesn’t necessarily stop at zero. It can enter negative space, giving rise to a harmful or ‘nocebo’ effect.

  Some of the therapies prescribed in 1918 are described as having aggravated the symptoms. They may have actually done so, for biochemical reasons, or they may have been acting as nocebos–and this applied to western and traditional remedies alike. The term ‘nocebo’ did not enter the conventional medical lexicon until the 1960s, yet some healers may have instinctively grasped the concept. There are reports of shamans fleeing when they saw that their ministrations were having no effect. Perhaps they feared for their lives, or perhaps they understood that they risked doing more harm than good. Western doctors, adhering to a different code of conduct, stayed at their posts, trying treatment after treatment in the hope of finding one that worked. In fact, there were really only two things that any physician could do to improve his patient’s chances of survival: ensure that he didn’t become dehydrated, and that he was carefully nursed.

  People expected more, of course–in part because more had been promised. Disappointed, many turned to higher authorities. Muslims sought sanctuary in mosques, while Jewish communities all over the world performed an archaic ritual known as a ‘black wedding’–the best description of which comes from Odessa, Russia, and will be presented in the next section. In the melting pot that was New York City, this produced the intriguing juxtaposition, on the Lower East Side alone, of Italian immigrants pleading for la grazia–the Virgin’s healing grace–while their neighbours, Jews from eastern Europe, witnessed the nuptials of two of their number among the gravestones of Mount Hebron Cemetery. When God Himself proved impotent, people gave up, and like sick badgers, immured themselves in their homes.

  BLACK RITES

  When the first wave of Spanish flu struck Russia in May 1918, it went virtually unnoticed in most of the country, but not in Odessa, where a doctor named Vyacheslav Stefansky recorded 119 cases at the Old City Hospital.

  The surprise is not that this wave went unnoticed elsewhere, but that the Odessans noticed it. In 1918, Russia was in the grip of a civil war following the revolutions of the previous year. Odessa is now in Ukraine, but in 1918 it was the third most important city in the Russian Empire after Moscow and Petrograd, and a key battleground in that war in southern Russia. Odessans, who are known in Russia for their mischievous sense of humour, liked to compare their city to a prostitute who goes to bed with one client and wakes up with another. In 1918 alone, it passed from the Bolsheviks to the Germans and Austrians (under the terms of Brest-Litovsk), to Ukrainian nationalists and, finally, to the French and their White Russian allies.

  Odessa did not witness the violence known as the Red Terror that ruptured the northern cities–though it did not entirely escape the killings, torture and repression instigated by the Bolshevik secret police, the Cheka–but it did experience a breakdown in the bureaucratic underpinning of life, resulting in food and fuel shortages and a security vacuum into which local crime lords sharply stepped. One nicknamed Misha Yaponchik–the model for Isaac Babel’s Jewish gangster Benya Krik, in his 1921 Odessa Tales–took control of the streets with a gang that allegedly consisted of 20,000 bandits, pimps and prostitutes, and like a latter-day Robin Hood proceeded to terrorise the better-off.

  Odessa differed from the two northern cities in other ways, too. It was warm, pleasure-loving, cosmopolitan and open to the west. It had a large Jewish contingent–a third of its 500,000-strong population according to official figures, more than half according to unofficial ones. And it was more advanced in the understanding and surveillance of infectious diseases. This Black Sea port, known as the ‘Russian Marseilles’, had for centuries provided a stop on the route by which silks and spices from the east were transported westwards to Constantinople and beyond. It had always been vulnerable to pathogens arriving by sea, and almost since Catherine the Great gave it city status in 1794, had operated a quarantine system. Quarantine had rarely kept disease out entirely, however, as the city’s many plague cemeteries testified. The most visible of these, a plague mound known as Chumka, still stands on its outskirts.

  It was logical, therefore, that in 1886, Ilya Mechnikov should choose Odessa as the site of Russia’s first plague control facility–the Odessa Bacteriological Station. This was set up as a result of Pasteur’s development–with Émile Roux–of a rabies vaccine, and it had the mission of producing and perfecting vaccines of all kinds. Within its first six months of existence, it administered anti-rabies shots to 326 individuals from all over Russia, Romania and Turkey, who had been bitten by rabid animals. Mechnikov soon fell out with his Russian colleagues, however. Unlike them, he was a bench scientist, not a medic, and he found it difficult to impose his authority on
them. When he moved to Paris two years later–desolate at having to leave his beloved Russia–he bequeathed the station to his capable (and medically qualified) assistant, Yakov Bardakh.

  Under Bardakh’s direction the station carried out important research into anthrax, typhoid, cholera, malaria and TB. When he introduced the inspection of drinking water and the tests revealed typhoid bacteria, the sanitarians responsible for the city’s water supply attacked him, refusing to believe that the disease was waterborne. He was later vindicated, but when poor people started lining up outside the station for treatment, it was too much. Odessa had long been regarded as a hotbed of revolutionary dissent, and the authorities placed the station under police surveillance.

  Perhaps on account of those bedraggled lines, perhaps because he had experimented with deadly diseases, or perhaps because he was Jewish, Bardakh was removed from his post in 1891. Russian law barred Jews from the headships of certain institutions, and strict quotas governed how many of them could enter education and employment. Some Jews took Russian names to circumvent these restrictions, but not Bardakh. ‘I am a Jew’ he wrote proudly on every official document that required him to state his ethnic origin. Mechnikov lamented his departure: ‘Science lost a gifted worker.’ But when Pasteur offered Bardakh a post in Paris, he refused, preferring to stay and serve his country.7

  The directorship of the station passed to his student, Stefansky, and Bardakh entered private practice. The authorities could not stop his reputation from growing, however. He saw patients at the city’s Jewish Hospital and in his own home. Though he came from humble stock–he was the son of a Jewish scholar and teacher–his wife, Henrietta, was the daughter of a banker, and they received a constant stream of visitors in the large, oak-panelled dining room of their home on Lev Tolstoy Street, where Henrietta served tea from a samovar. So many people arrived at Odessa train station asking for Bardakh that the coach drivers all knew his address by heart. He taught bacteriology at the city’s university–the first such courses in Russia–and he launched the Odessan tradition of lecturing the public on science. Large audiences came to hear him talk about the origins of plague and Pasteur’s discoveries, and he regularly kept them glued to their seats until midnight. By 1918, Bardakh was the most famous doctor in southern Russia, and his name was mentioned with respect in capitals further west, too.