Chapter 11 Un-remembered but Unforgettable: The ‘Spanish Flu’ Pandemic Daniel Flecknoe 1 Introduction In 1918, during the final months of the First World War, an influenza epidemic swept across the world. This strain of influenza was unusual, in that it was par- ticularly deadly among 20–40 year olds, the age group typically least at risk from flu-related mortality. Many victims of the pandemic appear to have died from respiratory failure due to secondary bacterial infections, which medicine at the time lacked the antibiotics to treat. Wartime censorship and military objectives often obstructed the public health response, and troop movements helped to spread the disease. Worldwide, during the years 1918–19, the ‘Spanish Flu’ pandemic is estimat- ed to have killed between 50 and 100 million people. Despite its massive im- pact on the world, the pandemic was largely written out of early 20th century history, possibly because of a wish to focus on the more heroic narrative of the war. The long-term repercussions of the ‘Spanish Flu’ lasted for generations, and have had both positive and negative impacts on societal resilience. This chapter discusses the pandemic, its impacts and effects, as well as its implica- tions for modern public health practice. The word ‘influenza’ was first coined during an outbreak in Renaissance-era Italy, in which it was noted that the populace attributed the disease to the ma- levolent ‘influence’ of the stars.1 Today, influenza still retains some of the mer- curial and enigmatic character lent to it by this early classification. In abbrevi- ated lay parlance it is often used to describe a mild cold (“a touch of the ‘flu’”), or the perceived malingering and tendency to exaggerate trivial symptoms by men (“don’t mind him, he’s just got man-flu”). And yet, in its pandemic form it remains at the top of public health risk registers for most developed nations.2 1 Dehner, Influenza – A Century of Science and Public Health Response. 2 nhs England, “Pandemic influenza”: www.england.nhs.uk/wp-content/uploads/2016/04/ pandemic-influenza-brief-apr16.pdf (accessed 31-8-2018); World Health Organisation, “The ten years of the Global Action Plan for influenza vaccines: report to the director-general from © koninklijke brill nv, leiden, ���� | doi:10.1163/97890044�8744_015 Daniel Flecknoe - 9789004428744 Downloaded from Brill.com09/29/2021 04:57:34AM via free access <UN> Un-remembered but Unforgettable 215 These contradictions are embodied in the largest ever recorded influenza epi- demic, which, despite being one of the single deadliest events in human his- tory was, and is still, mostly overshadowed by the First World War (which killed many fewer people).3 Not unlike a solar eclipse, when a vast object (the Sun) is obscured by a smaller one (the Moon), the explanation for this phenomenon can be found in their relative proximity to our point of view. In the case of the ‘Spanish Flu’ pandemic, which this chapter will discuss, it appears that the First World War, with all of its heroic, tragic, and stirring tales of world-changing but most importantly human agency, has always been much closer to the kind of narrative that we want to tell about ourselves, and of 20th century history. But history is not only composed of the stories that people want to tell, and there is often as much or more to learn from the times when uncaring nature collaborated with unforeseen consequences in order to humble the best efforts of medicine and society. This is one of those stories. 2 A Brief History of Infectious Disease Control Human progress towards understanding and controlling infectious diseases throughout history has been slow and uneven, with occasional flashes of im- pressively forward thinking. In the 5th century b.c., for example, the philoso- pher Empedocles is reported to have successfully rid the city of Selinus of ma- laria by diverting rivers in order to remove a stagnant swampland.4 Trial and error over the next two millennia largely established the value of isolating the sick and enacting quarantines to prevent epidemics from entering uninfected cities or towns (or confining them in infected ones).5 The famous self-imposed quarantine of the Derbyshire village of Eyam during the Great Plague of 1665 reinforces the point that knowledge of the causal organism is not always nec- essary in order to enact successful counter-measures to its spread.6 Nevertheless, the gap advisory group”: www.who.int/influenza/GAP_AG_report_to_WHO_DG.pdf (ac- cessed 17-1-2018). 3 Flecknoe, Wakefield, and Simmons, “Plagues and wars: the ‘Spanish Flu’ pandemic as a lesson from history”: doi.org/10.1080/13623699.2018.1472892 (accessed 31-8-2018). 4 Geroulanos, “Epidemics in antiquity, Byzantium and Renaissance”, p. 19. 5 Dobay, Gall, Rankin, and Bagheri, “Renaissance model of an epidemic with quarantine”, pp. 348–58; Gall, Lautenschlager, and Bagheri, “Quarantine as a public health measure against an emerging infectious disease: syphilis in Zurich at the dawn of the modern era [1496–1585]”, document 13. 6 Whittles and Didelot, “Epidemiological analysis of the Eyam plague outbreak of 1665–1666”: rspb.royalsocietypublishing.org/content/royprsb/283/1830/20160618.full.pdf (accessed 23-8-2018). Daniel Flecknoe - 9789004428744 Downloaded from Brill.com09/29/2021 04:57:34AM via free access <UN> 216 Flecknoe from the Enlightenment onwards, such knowledge was being sought with in- creasing energy and technical sophistication. This trend of historically slow progress towards understanding the true causes of disease went into abrupt overdrive in the generation prior to the First World War. Pasteur’s discovery of bacteria in the 1860s gave rise to Germ Theo- ry, which led to radically beneficial changes in medical practice relating to in- fectious disease control.7 Vaccines began to be developed, which along with improvements in clean water and sanitation, meant that many of the major scourges of the 19th century were dramatically reduced by the onset of war in 1914.8 Disease-causing protozoa and fungi had also been identified, treatments were becoming more effective, and well-reasoned guesses were beginning to be made about the existence of tiny ‘filter-passing’ organisms that were too small to see under a microscope or to be impeded by a standard bacterial filter, yet nevertheless still had the power to make people ill. These hypothesized organisms, speculatively called ‘viruses’ (meaning ‘poisons’ in Latin), were known to be rendered harmless by extremes of temperature, and so were thought to be alive in some sense, but for now their existence was only a matter of conjecture.9 Despite the growing ascendency of Germ Theory in the early 1900s, many senior doctors at the time of the First World War had done their medical training prior to its discovery, so some older ideas (such as the ‘miasma’ the- ory of disease) still persisted.10 The disciplines of bacteriology and public health were still both still in their infancy, but becoming better recognized (especially in the military) as being important for epidemic control. Pathol- ogy and laboratory sciences, which could be highly dangerous pursuits in the absence of modern biohazard precautions,11 were used to good effect in the Spanish-American war of 1898 and also during the Balkan Wars of 1912–13.12 This represented the beginning of a much needed counter-offensive in the 7 Sihn, “Reorganizing hospital space: the 1894 plague epidemic in Hong Kong and the Germ Theory”, pp. 59–94. 8 Cox, “The First World War: disease, the only victor”, www.youtube.com/watch?v=x70gZ jugLRM (accessed 13-12-2019). 9 Gordon, “The filter passer of influenza”, pp. 1–13; Dehner, Influenza. 10 Cox, “The First World War”. 11 Wever, Hodges, “The First World War years of Sydney Domville Rowland: an early case of possible laboratory-acquired meningococcal disease”, pp. 310–15. 12 Flamm, “The Austrian Red Cross and Austrian bacteriologists in the Balkan wars 1912/13 – centenary of the first application of bacteriology in theatres of war”, pp. 132–47; Wright and Baskin, “Pathology and laboratory medicine support”, pp. 1161–172. Daniel Flecknoe - 9789004428744 Downloaded from Brill.com09/29/2021 04:57:34AM via free access <UN> Un-remembered but Unforgettable 217 battle between armies and communicable diseases, in which the microbes had previously held a decisive advantage. The number of recorded deaths from infectious disease in the Peninsula, Crimean, and South African Wars, and the American Civil War (all of which occurred in the century prior to the First World War) each exceeded the recorded deaths from combat in those conflicts by a wide margin.13 The First World War would bring about some major victories for the human side of this inter-species conflict,14 and also some significant defeats, the most devastating of which is the subject of this chapter. Influenza was a disease that both gratified and frustrated practitioners of the science of medicine during this period. In its habit of mostly killing the elderly or infirm it was sometimes regarded as a merciful disease, and also a relatively congenial one for doctors who were paid per visit and could expect a bonus if their patient recovered. An illness of which many suffered but relatively few died, was therefore good for business. However, its causal organism still eluded scientific enquiry. A bacterium, now known as Haemophilus influenzae,15 had been identified as being so commonly found in the lungs of autopsied influ- enza victims that some scientists thought it was the illness’ cause, while others suggested that one of the hypothesized ‘viruses’ was a more likely candidate.16 There had been an influenza pandemic in the late 1880s, which killed roughly 1 million people around the world, and which was observed at the time to dis- proportionately affect soldiers in crowded barracks.17 At the outbreak of the war in 1914, medical personnel on all sides of the conflict were mobilized in large numbers to fight the familiar military diseases of typhus, measles, and cholera.18 No one was prepared for what they actually faced.