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

by Laura Spinney

  16

  The green shoots of recovery

  In February 1919, Adam Ebey and his wife Alice took a train into the hills of Gujarat, then trekked forty kilometres through teak and bamboo jungle to the Church of the Brethren mission at Ahwa, which they were due to take over. The third wave of the pandemic had just erupted, many of the bhagats or traditional healers had fled, and the services of the ‘surgeon sahib’, as Ebey would become known, were immediately in demand. Once the sickness had passed, however, he sat down to write to the home church in Illinois, and recounted the story of Laksman Haipat.

  Haipat was a twenty-five-year-old farmer and Christian convert who, having already been widowed once, had married for a second time in January 1919. Not long after the second wedding, he left his village on business. When he returned a few days later, he found it deserted and his new bride lying under a tree, in the terminal phase of Spanish flu. He stayed with her until she died, then he dug her grave. ‘She was a heavy woman,’ Ebey wrote. ‘He could not carry her, so he took a rope and dragged her into the grave. What else was there for him to do? He married his third wife the day after Christmas, 1919.’1

  Before the pandemic, mortality rates had been in decline the world over, partly due to advances driven by germ theory; the pandemic reversed that trend for three years. India paid a particularly high price–so high, in fact, that in 1964 the Nobel Prize-winning economist Theodore Schultz used what happened in that country to test a theory that there is surplus labour in traditional farming systems. He concluded that there isn’t, since India’s post-flu agricultural output shrunk by 3 per cent, compared to pre-1918 levels. But humans are supremely resilient, and the recovery seems to have begun almost immediately the shock had passed. Though India saw a 30 per cent reduction in births in 1919, starting in 1920, fertility not only returned to pre-flu levels, it exceeded them–triggering what has been described as the beginning of a demographic revolution.2

  It wasn’t only India that saw a rebound. Fertility rates collapsed in Europe around 1918, only to recover spectacularly two years later–briefly attaining levels higher than those seen prior to 1914. Most observers put this down to the war, and to a wave of conception that followed the men’s return. But that doesn’t explain why neutral Norway also saw a baby boom in 1920. Norwegian men did not go away to fight, but like the rest of the Norwegian population, they did suffer from flu. 15,000 Norwegians died in the pandemic, and there were 4,000 fewer conceptions in 1918 than would have been expected, but the following year saw conceptions surpass what was needed to make up for that shortfall by 50 per cent. In other words, three babies were conceived in 1919 for every two that had not been in 1918.3 Could the flu have contributed to a global baby boom? Indeed it could, and the explanation lies in the way it chose its victims.

  The pandemic took time to recede: the middle peak of the W-shaped mortality curve shrank until, between 1922 and 1928, depending on where you were in the world, the W bottomed out in a U.4 The Spanish flu had been tamed, but it had left behind a very changed humanity. By purging the less-than-fit–those who were already sick with malaria, TB and other diseases–it had created a smaller, healthier population that was now able to reproduce at higher rates. This is one theory for why fertility rebounded so dramatically: survivors like Laksman Haipat now married other survivors who were, by definition, healthier and more robust than those who had perished.

  Can we really say that humans were healthier in the wake of the Spanish flu? It seems extraordinary, but in one very crude way, we can: their biological capacity to reproduce increased, and they had more children. It’s crude, because other factors besides biology shape the number of children people have–religious and economic considerations, for example. But there are other indications that men, in particular, were healthier–namely, that their life expectancy increased. Before 1918, women had lived on average close to six years longer than men. The flu killed roughly 170 more men than women per 100,000 people, and by the time the pandemic was over the gap in life expectancy had closed to one year. Women wouldn’t regain their previous advantage until the 1930s, mainly because, by then, heart disease had become both much more prevalent, and more male.5

  Overall, therefore, it can reasonably be argued that the post-flu population was healthier. If we look more closely, however, we see a more nuanced picture, in which some groups were certainly worse off than before. First, let’s consider those who were in their mother’s womb in the latter half of 1918. Pregnant women, as we’ve said, were extremely vulnerable to the Spanish flu–and this was true the world over. They were 50 per cent more likely than women who weren’t pregnant to develop pneumonia, according to one 1919 estimate, and 50 per cent more likely to die if they did.6 It’s not clear why, but one suggestion is that the culprit was not the virus itself, but the cytokine storm it provoked–that deluge of chemical alarm signals that diverted blood and immune cells to the lungs. Already subject to the physiological stresses of carrying a fetus, pregnant women might have succumbed to this more easily, and if blood was diverted away from the womb, that might also explain why miscarriages were so common. The dent in the population left by the loss of those unborn children is only just now working itself out, as we pass their projected lifespan. But some of those children were born, so the question arises: what mark, if any, did the flu leave on them?

  A baby born in 1919, who had weathered the slings and arrows of the Spanish flu inside his mother’s womb, and who turned up at a military recruitment depot in 1941, was an imperceptible 1.3 millimetres shorter, on average, than recruits who had not been exposed to it prenatally. That may not seem like much, but it is an indication that the stresses affected every fetal organ, including the brain. As his life unfurled, this child was less likely to graduate and earn a reasonable wage, and more likely to go to prison, claim disability benefit, and suffer from heart disease after the age of sixty.7

  Only men took the draft in 1941, but the same applied to anyone unlucky enough to be conceived in the first months of 1918, regardless of their sex or colour: they were a diminished generation. The British writer Vera Brittain–who nursed at Étaples during the First World War–applied the term ‘lost generation’ to those well-born, educated young men who died while serving with the British Army, and who might have gone on to great things had they returned. But those who were in their mother’s womb when the Spanish flu struck, who are often held up as an example of why it’s important to invest in the health of pregnant women, were the twentieth century’s real lost generation.

  Others were left worse off too. There is good evidence, for example, that the Spanish flu was itself a chronic disease, and that it had a negative impact on some people’s health for months or even years after the initial flu-like symptoms had subsided. Hungarian composer Béla Bartók was left with a severe ear infection that made him fear permanent deafness–ironically, the fate of his musical hero, Beethoven. He took opiates for the pain, but they couldn’t banish the auditory hallucinations that plagued him for some time after. For American aviator Amelia Earhart, meanwhile, the legacy was a lifelong sinusitis that, some say, affected her balance and ability to fly. The first woman to fly over the Atlantic, in 1928, she vanished while flying over the Pacific nine years later.

  Previously we saw that feelings of anxiety accompanied the acute phase of the disease, and that there were instances of people killing themselves while delirious. If and when they recovered from that phase, however, some patients found themselves plunged into a lingering state of lassitude and despair. How much of this wave of ‘melancholia’ was due to the flu, and how much to the war? It’s a difficult question. The flu virus may act on the brain, causing depression, but depression is also a common response to bereavement and social upheaval. How to disentangle the two? Once again, a study from neutral Norway may help.

  Norwegian epidemiologist Svenn-Erik Mamelund studied asylum records in his country from 1872 to 1929 and found that, in every year in which there was n
o pandemic of influenza, a few cases were admitted of mental illness associated with flu. In each of the six years following the 1918 pandemic, however, the average number of such admissions was seven times higher than in those non-pandemic years. Because it’s hard to know exactly what those patients were suffering from, and impossible to retrospectively demonstrate a link between their psychiatric symptoms and flu, any conclusions drawn from these data must be tentative. With that caveat, however, Mamelund speculates that the patients admitted in those six years were survivors of Spanish flu who were suffering from what today we would call post-viral or chronic fatigue syndrome. He also believes that they were the tip of the iceberg, since in those days, most people suffering from melancholia would not have sought out a psychiatrist.

  Intriguingly, one Norwegian seems to have escaped the melancholia this time around: Edvard Munch. One might consider him unlucky to have been caught up in two flu pandemics, but we can’t be sure that he was a victim of the Russian flu, and the idea that it influenced his painting of The Scream is therefore pure speculation. On the other hand, he almost certainly did suffer from the Spanish flu, and as he recovered from it he painted a series of self-portraits, one of which shows him sitting, yellow and gaunt, in a wicker chair. Some have suggested that these paintings depict his post-viral melancholia, but his biographer Sue Prideaux disagrees. He was melancholic by nature, she says, but after the flu he entered a highly creative period. He painted at least fourteen important works in 1919, and they are striking for their optimism and celebration of nature. ‘Their colours are clear, the hand is steady, the vision and power is undiminished,’ writes Prideaux.8

  We don’t know how many people suffered from depression in the wake of the Spanish flu, but the Norwegian wave is unlikely to have been unique. Post-viral syndrome has been blamed, for example, for triggering the worst famine in a century in Tanzania, where crippling lethargy prevented an already depleted population from planting when the rains came at the end of 1918. The ‘famine of corms’, as it was known (the name refers to the root structure of the banana plant, that African women fed their families in times of hunger), lasted for two years.

  Often the psychiatric symptoms were temporary. In 1919, for example, 200 ‘recovered’ flu patients were admitted to Boston Psychopathic Hospital suffering from delusions and hallucinations. Around a third of them were diagnosed as having dementia praecox, an obsolete name for schizophrenia. Dementia praecox was supposed to be incurable, but five years later most of them had made a full recovery. The psychiatrist who followed the Boston patients, Karl Menninger, thought a new diagnostic label was called for, to describe this acute, reversible schizophrenic syndrome that had come in the wake of flu.9

  One other neurological condition has been associated with the Spanish flu, and that is encephalitis lethargica (EL), or more colloquially, ‘sleepy sickness’. EL washed over the world in a wave between 1917 and 1925, peaking in 1921. It came on with flu-like symptoms and, as its name suggests, overwhelming sleepiness. But it was a strange sleepiness: though patients showed all the outward signs of somnolence, they seemed to remain aware of their surroundings. One female patient, filmed in Germany in 1925, fell asleep while moving her finger to her nose in a test of coordination–but continued, if somewhat erratically, to complete the task.10 A third of those who contracted EL–an estimated half a million people worldwide–died within a few weeks. Another third recovered, while the remainder went on, after a delay that could stretch to years, to develop a form of paralysis that resembled advanced Parkinson’s disease.

  Was the epidemic of EL related to that of the Spanish flu? The question has been debated since the 1920s. Those who believe that it was point to the following ‘smoking guns’: although cases of EL have been reported at other times in history, the surge in the 1920s is the only recorded epidemic; some of the earliest cases in that epidemic were recorded on the Western Front in the winter of 1916, around the time of the outbreak of purulent bronchitis; Western Samoa, which suffered so badly from the flu, experienced a wave of EL, but American Samoa escaped both; and the average age of those affected was twenty-nine.

  Smoking guns are one thing, hard evidence is another, and to date scientists have failed to establish a causal link between the two epidemics. They know that the flu virus can travel up the olfactory nerve from the nose to the brain, causing inflammation there, and potentially triggering seizures and strokes (encephalitis is another name for brain inflammation), and they acknowledge that EL behaved suspiciously like a viral disease in its early stages. But they have yet to find viral RNA in brain tissue taken from EL patients post-mortem. That doesn’t mean it’s not there–it may simply be that their techniques aren’t yet sensitive enough to detect it–so for the time being, the jury is out.11

  None of those flu patients who went on to suffer long-term neurological or psychiatric conditions were ‘purged’ from the population, in the literal sense of dying, but societies often found other ways to exclude them. Nontetha Nkwenkwe, for example, was locked up for recounting her fever-fuelled dreams. We’ll tell her story in the next section, but we’ll end this one with the eloquent case of Rolando P. Mr P was one of the unfortunate third of EL patients whom the disease left imprisoned in their own bodies, and who usually ended up institutionalised and forgotten, their faces unlined even in old age. The British neurologist Oliver Sacks told the story of a group of such patients–and their temporary reprieve thanks to the Parkinson’s drug L-dopa–in his bestselling book Awakenings (1973). Rolando P was one of them.

  Born in New York in 1917 to a newly immigrated and very musical Italian family, Mr P contracted a fever at the age of three. This illness, which was accompanied by intense drowsiness, lasted for more than four months, and when he ‘woke’ from it, his parents realised that he had undergone a profound change. His face was expressionless, and he could barely move or speak. For a few years he attended a school for the mentally defective, but his lack of balance made school increasingly problematic, and eventually his parents stopped sending him. ‘From his eleventh to his nineteenth year, he remained at home, propped before the speaker of a large Victrola gramophone, for music (as his father observed) seemed to be the only thing he enjoyed, and the only thing which “brought him to life”.’ In 1935 Mr P was admitted to the Mount Carmel Hospital in New York, and as Sacks put it, ‘The next third of a century, in a back ward of the hospital, was completely eventless in the most literal sense of this word.’12

  NONTETHA’S DREAM

  Among those who fell ill when umbathalala–the Spanish flu–reached the Ciskei region of South Africa in the autumn of 1918 was a Xhosa woman named Nontetha Nkwenkwe (umbathalala is Xhosa for ‘disaster’). Regaining consciousness after her fever, she thought she had died and come back to life. People were bending over her, holding her hands and splashing water on her face. She began to recount a series of dreams that had come to her while she was ill.13

  In one, she had seen an object wrapped in a dirty cloth hanging from the branch of a knobwood tree. A voice told her it was the Bible, but that it had rotted. When she asked Jesus for a piece of it so that she might testify to what she had seen, he refused. ‘We have already given the Bible to people,’ he said, ‘but they have neglected it.’ She was also told that people’s sons were dying in the gold mines because they had stopped praying, and she was instructed to go to the places of the great chiefs and ask them if they were ready to be liberated and to work together to rule themselves. She was to preach to them, and to persuade them to look at their own lives and to stop blaming Europeans for their woes.

  A voice then told her that umbathalala was a mere foretaste of the punishment that God would unleash on people for their sins. Judgement day had come. ‘When I looked up at the heavens, I found them shaking just like the face of a cruel man. When the sun had risen above the earth in the east, it was red like burning charcoal. There was a person inside the sun and he was shaking his fists. And the heavens were coming together
and I became afraid and cried. And there was a voice that said to me I should not cry but pray.’ It had fallen to her to lead her people out of the ruins of their old society and towards a new one.

  At the time that Nontetha fell ill she was in her forties, the widowed mother of ten children. She lived in a township called Khulile, in lands that had once belonged to her ancestors. The Xhosa had warred with Dutch and British settlers throughout the nineteenth century, and though they had scored some spectacular victories, they were now paying dearly for their ultimate defeat. The Land Act of 1913 had restricted black South Africans’ share of the country’s total land area to a risible 7.3 per cent. Squeezed into reserves in the Ciskei and Transkei (which are separated by the River Kei), many Xhosa found they were no longer able to live solely off the land. The men were forced to migrate to find work, leaving the women to run the home and family alone for six or nine months of the year. Nontetha’s husband, Bungu Nkwenkwe, had worked first at the Kimberley diamond mines, and then at Saldanha Bay, an industrial area north of Cape Town, where he had died.

  Although Nontetha was illiterate, she commanded respect in her community as an ixhwele, someone who knew the medicinal properties of plants. Part of the role of an ixhwele was to interpret events, especially traumatic ones, and there had been plenty of those in the past century. The Ciskei had known wars, famines, floods, even plagues of locusts–many of them in living memory. It was in the grip of a severe drought in the latter half of 1918, and then umbathalala arrived, coming down the train tracks with terrorised men fleeing the mines. In Nontetha’s area roughly one in ten died of the flu–more than 10,000 people–and almost every family was touched (she herself lost a child to it).

  Witnesses described bodies lying where they fell, in the bush or at the roadside. An eerie hush descended on the country. A missionary reported ‘cattle, sheep and goats straying, unherded, and no one to secure the milk, so badly needed, from the uneasy cows’. With so many sick, crops went unplanted or unharvested, exacerbating the hunger. In the circumstances, when Nontetha recounted her dreams, people listened. Some of those who heard her laughed, but others took her seriously. ‘It should be realised that Xhosa people attach great importance to dreams,’ wrote the Xhosa poet James Jolobe in his 1959 poem ‘Ingqawule’. ‘They are the means of mediation between this world and the next.’ Those who listened came back to hear her again, and gradually, she acquired a following. Nontetha had become a prophet.