Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It

by Gina Kolata

“the ghost of fear walked everywhere, causing many a family circle to reunite because of the different members having nothing else to do but stay home.”

Even today, with the exquisite advances of molecular biology and the pharmaceutical industry, viral diseases—and influenza in particular—are largely untreatable.

The sickness came in the year 431 B.C. The citizens were used to illnesses and deaths but nothing had prepared them for this tragedy. For more than a year, the epidemic raged, laying waste to every structure of the carefully built society, creating a cataclysm that shook the confidence of scientists and doctors, changing history. It seemed truly a work of wrathful gods.

The answer, for the frightened Athenians, was obvious. People began holing up in their homes, afraid to visit friends, relatives, or neighbors. The sick began to perish from neglect. The order of a civil society quickly disintegrated. The epidemics, Thucydides relates, brought forth a wild recklessness, a “lawless extravagance which owed its origins to the plague.” “Men now coolly ventured on what they had formerly done in a corner,” he said. Athenians could not forget the sight of rich men dying suddenly and those who had had nothing seizing the rich men’s property. What was the use of saving or living frugally, many asked, when death could come at any moment and the poor could descend like vultures? “So they resolved to spend quickly and enjoy themselves, regarding their lives and riches as alike things of a day.”

Until the twentieth century, infectious diseases were so common and so untreatable that it was difficult for populations even to maintain their numbers in the face of epidemics. There were lulls, but each lull seemed to be followed by the fury of another terrifying infectious disease.

How could something so terrible as an infectious disease that kills half its victims, and gruesomely, be so quickly relegated to the dustbins of history? Morris ventures a guess, actually several guesses. First, he says, people had expected that the terrifying epidemic would cause a massive social disruption. That did not, in the end, occur. And second, “there were no clear ‘lessons.’” The main effect of the epidemic on British society, he claims, was to spur the efforts of a group of public health researchers who were to prevail in implementing dramatically effective measures—like cleaning up the water supply—in the coming decades.

Then came the flu epidemic, which made a mockery of the newfound optimism. And when it ended, Crosby posits, perhaps the most comforting reaction was to forget about it, to push it to the back of humanity’s collective consciousness as quickly as possible. To “see no evil, hear no evil.”

The evidence was a standard immunological test: Antibodies that cling to and inactivate swine flu viruses also clung to and inactivated this new virus. The test was to grow the virus in a fertilized hen’s egg and then remove the cloudy fluid that was brimming with virus. Mix the virus with red blood cells. If they clump, you have a flu virus. Then mix the virus with antibodies to particular strains of flu and try the red blood cell test again. When you hit on the right flu strain, the virus will be inactivated by the antibodies and the red cells will no longer clump.

There were a few obvious problems, including a logistical one: No one had ever attempted to vaccinate an entire population against the flu and it was hard to even imagine making so much vaccine. The other problem was scientific: The data thus far were so paltry that they could hardly justify making such a major decision. There were no easy answers.

Suppose there was an influenza pandemic, the meeting participant said. An immunization program was an almost certain invitation to disaster. Those who had been unable to get the flu shots in time would be angry because they would be vulnerable. Those who were immunized but who caught another virus that they thought was the flu would be annoyed because they would assume that the vaccine did not work. All in all, millions of people would be upset. Yes, a repeat of 1918 was unlikely. But, the participant said. “who could be sure?” And if it happened, “it would wreck us.” Then take the other side of the argument, supposing there was no pandemic. Then, the staff member said, the Centers for Disease Control could be accused of wasting money, of “crying wolf,” he said. Everyone, from the people who got the shots to those who administered them, would criticize the agency. “It was a no-win situation,” the participant concluded. The final decision on March 9 was predictable, however. These, after all, were people whose mission it was to protect public health and prevent disease. “Better a vaccine without an epidemic than an epidemic without a vaccine,” Kilbourne said.

Forcing experts to give odds can be one of the best methods for exposing fundamental weaknesses in an argument, they note.

“Once differing odds have been quoted, the question ‘why?’ can follow any number of tracks. Arguments may pit common sense against common sense or analogy against analogy. What is important is that the expert’s basis for linking ‘if’ with ‘then’ gets exposed in the hearing of other experts before the lay official has to say yes or no.”

Alexander’s question was brilliantly simple. He asked what information might make the group change its mind about the need to prepare to immunize the nation against swine flu?

Dr. Hans H. Neumann, who was director of preventive medicine at the New Haven Department of Health, explained the problem in a letter to The New York Times. He wrote that if Americans have flu shots in the numbers predicted, as many as 2,300 will have strokes and 7,000 will have heart attacks within two days of being immunized. “Why? Because that is the number statistically expected, flu shots or no flu shots,” he wrote. “Yet can one expect a person who received a flu shot at noon and who that same night had a stroke not to associate somehow the two in his mind? Post hoc, ergo propter hoc,” he added. In addition, Neumann wrote in his letter, within a week after receiving flu shots, 45 people will develop encephalitis and more than 9,000 will get pneumonia. Nine hundred will die of pneumonia. “Sequential to the immunizations? Yes, but not a consequence of them,” he said. “These are only a few examples of what is bound to happen the day and the week after immunizations.” Neumann cautioned: “It is one thing to see matters objectively in light of statistical expectations. It is quite another when it affects one personally. Who can blame someone for assuming the events are linked? Hence, the presumption of tort and the liability problem that is expected.”

cells. Yet if, against all odds, a bird flu

Back in England, observed John Oxford, the British virologist, hospitals had put “pandemic plans” in place. Anyone who arrived in Heathrow Airport from Hong Kong with a respiratory infection was quarantined, just in case. The H5N1 scare, he said, “was a dress rehearsal.”

That bird flu episode, Cox concluded, “was a wake-up call for a lot of people who had forgotten how devastating influenza can be. I think it was important for all of us to take heed and get our pandemic planning efforts reorganized.”