Johnson Evo Edu Outreach (2018) 11:5 https://doi.org/10.1186/s12052-018-0079-5

BOOK REVIEW Open Access The 1918 fu pandemic and its aftermath Norman A. Johnson*

Book details A review of L. Spinney. 2017 Pale Rider: The Spanish Flu of 1918 and How It Changed the World Public Afairs 352 pg., ISBN: 978-1610397674. Keywords: 1918 infuenza, Disease evolution, Evolutionary medicine, History, History of medicine

As I write at the start of February 2018, the United States studies could not directly test this hypothesis because the is going through a nasty infuenza season. Hospital visits sequence data they had for the virus came only from the for the fu are far above the baseline of the last decade. second wave (Taubenberger and Morens 2006). Spinney Already over 50 number of children have died from the discusses how recent studies that had obtained variants epidemic. Confounding eforts to contain the disease is from the frst wave victims illustrate that the virus had the reduced efectiveness of this season’s vaccine (Sun evolved to become better adapted to humans, though less 2018). But this most recent season pales in comparison well adapted to birds. with the 1918–1919 infuenza pandemic which killed Tis pandemic has had many names. Spinney named more people than those who died in battle in the First her book Pale Rider after a Katherine Ann Porter novella, World War and perhaps as many as 100 million people. “Pale Horse, Pale Rider”, about the relationship between a Laura Spinney, a British science journalist and a nov- solider and a journalist during the pandemic. Tis story elist, presents a fascinating and wide-ranging account of was infuenced by Porter’s personal near-death experi- this pandemic. Although several books have been written ence with this fu that had infamed her optic nerve. As about the pandemic (e.g., Berry 2005), these left consid- a result, Porter’s color vision was diminished, leaving her erable voids. Recent research in realms spanning from seeing the world in washed-out colors. Yet despite the historiography to epidemiology to phylogenetics have title, Spinney follows tradition and frequently refers to the helped fll in these gaps. As we arrive at the centennial pandemic as the “Spanish fu”. I am not sure that this was of this pandemic, Spinney’s book provides synthesis and the wisest of choices given how the common name arose. context to these new fndings. It came about not based on any evidence that the pan- Te pandemic came in three waves in quick succes- demic originated or was more severe in Spain. Instead, sion: spring 1918, fall 1918, and 1919. Some, but not it arose from media perception. Most of the other major most, accounts list a fourth wave occurring late in 1919 powers, including the United States, were engaged in the and extending into 1920. Te most severe fu occurred war. Tese countries minimized or censored news about during the second wave, leading to the hypothesis that the fu in their country. Te neutrality of Spain allowed the infuenza virus evolved to become more virulent its newspapers to fully cover the fu, unencumbered by in the intervening time was the most severe. Earlier wartime censorship. Te Spanish of the time often called the fu “Te Naples soldier” (Soldado de Napoles), not because they thought it was from soldiers from Naples *Correspondence: [email protected] but because the catchiness of the fu had been compared Department of Biology, Graduate Program in Organismic to a song of that name from the musical operetta “Te and Evolutionary Biology, University of Massachusetts Amherst, Amherst, MA 01002, USA Song of the Forgetting” (La cancion del olivido).

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Biologists today name infuenza strains for the cat- Te fu didn’t just inspire development of science; iron- egories of variants that they have at the haemagglutinin ically, it also led to the propagation of pseudoscience and (H) and neuramindidase (N) genes. Fittingly, the 1918 conspiracy theories. One of the most interesting catego- pandemic strain has been designated as H1N1. Tis sub- ries of conspiracy theories was the belief that the fu was type has continued to circulate and evolve; it was the one deliberately manufactured as a biological weapon. Tere responsible for the 2009 “swine fu” pandemic, which was was even fear among the British and the Americans about widespread, but relatively mild. Te main subtype of the the fu being linked to Bayer aspirin, which was manufac- 2017/2018 fu is H3N2. tured in Germany. Of course, these fears were completely But where did the pandemic actually begin? Spinney ungrounded. Given the prevalence of conspiracy theories discusses the competing hypotheses. Some evidence and the discouragingly large proportion of the popula- points to it originating in China. An intense fu-like dis- tion who are either against or hesitant about vaccinations ease did hit the northern Chinese province Shansi in today, we should not laugh too quickly. 1917, but whether that was the same fu as the subse- Spinney also presents how the fu infuenced histori- quent worldwide epidemic is not clear. Another pos- cal events and processes. Although it caused a great deal sibility is that the pandemic evolved from the “purulent of battlefeld illness and likely sped the end of the Great bronchitis” that had been observed in military bases in War, the fu seems to have afected all sides relatively Northern France and England in early 1917. However, no equally; hence, it probably did not afect the outcome. such disease was observed in the civilian population at Te fu did afect the aftermath. Many of the participants this time. Te fnal hypothesis, one that Berry (2005) had at the peace deliberations in Paris contracted the fu. It proposed in his earlier book on the pandemic, is that it hit President Woodrow Wilson especially hard, accelerat- originated in the American heartland. Farmers in Kansas ing the physical decline he had been experiencing from had contracted a respiratory disease just a few months transient ischemic attacks (“mini strokes”) and likely con- before reports of the frst wave of the pandemic hit U. S. tributing to the massive, paralyzing stroke he sustained military bases. Spinney does not come down conclusively in October 1919. Wilson’s compromised health likely on the side of any of these hypotheses, but argues that the led to the imposition of more draconian terms for Ger- American heartland scenario is most likely. many and its allies. Moreover, a weakened Wilson was Te support for the American heartland origin comes unable to convince the United States to join Te League from recent work by Worobey et al. (2014). Teir work of Nations. Tese events helped lead to the climate that showed that all but one of the genes in the human 1918 spurred World War Two a generation later. Without the infuenza virus showed similarity to variants present in pandemic, the outcome might have been very diferent. viruses collected from birds that lived in North Amer- Spinney’s remarks about how the fu afected other his- ica. Tis study also provides evidence that H1 had been torical fgures and their ancestors provide ample grist for circulating in human viruses well before 1918, but then counterfactual histories. recombined with an N1 variant present in birds some- Te fu also had long lasting biological efects. For time between 1914 and 1917. many who contracted it, the fu became a chronic illness. As Spinney illustrates, early twentieth century medi- Te efects even extended even to the next generation. cine was a fascinating historical period in part because World War Two military records showed that recruits it rested at the border between the premodern and the born in 1919 who were in utero when their mothers had modern eras. Hence, it was replete of half steps and con- the fu were ever-so-slightly shorter on average than tradictions. Germ theory was accepted by most, though recruits who did not receive prenatal exposure to the fu. far from all medical practitioners; yet, the general public Much is still unknown about the 1918 fu pandemic. was still skeptical and many clung to older ideas of con- Reasonable estimates for how many people died still tagion. Bacteria were known and observable entities in vary at least fvefold (20–100 million). We still do not 1918. Although viruses had been postulated at the time, clearly know why the fu hit those their in 20s and early they were still abstract, hypothesized entities. Indeed, 30s especially hard. Was it because this cohort had not experimentation done during the pandemic would help had prior exposure to H1N1 as some authors, notably establish that the infuenza was due to a virus. However, Worobey et al. (2014), suggested? Alternatively, was it viruses would remain unseen until the 1930s invention that the strong immune systems of these young adults of the electron microscope. Indeed, many at the time produced violent responses (cytokine storms)? thought the infuenza was bacterial because they were Using infectious disease cases can be an efective and observing bacteria in patients that likely came through engaging way to teach the principles of evolutionary secondary infections. biology (Hillis 2007; Pai 2009). Providing sociocultural Johnson Evo Edu Outreach (2018) 11:5 Page 3 of 3

context of the history of biomedical science further References Berry JM. The great infuenza: the epic story of the deadliest plague in history. engages students and can permit them to have a deeper Extended Paperback Edition ed. New York: Penguin Books; 2005. appreciation of biology and how it relates to their per- Chamany K, Allen D, Tanner K. Making biology learning relevant to students: sonal lives (Chamany et al. 2008). Spinney’s Pale Rider integrating people, history, and context into college biology teaching. CBE Life Sci Educ. 2008;7:267–78. certainly could be used as supplemental reading in Hillis DM. Making evolution relevant and exciting to biology students. Evolu- courses on the biology of disease or the history of biology tion. 2007;61:1261–4. and medicine, in addition to appealing to professional Pai A. Evolution in action: a case study based advanced biology class at Spelman College. J Ef Teach. 2009;9:54–68. biologists. Sun LH. Here’s what you should know about the fu season this year. The Washington Post. 2018. https://www.washingtonpost.com/news/to- Authors’ contributions your-health/wp/2018/01/25/heres-what-you-should-know-about-the- The author read and approved the fnal manuscript. fu-season-this-year/. Accessed 10 Feb 2018. Taubenberger JK, Morens DM. 1918 infuenza: the mother of all pandemics. Emerg Infect Dis. 2006;12:15–22. Competing interests Worobey M, Han G-Z, Rambaut A. Genesis and pathogenesis of the 1918 pan- The author declares that he has no competing interests. demic H1N1 infuenza virus. Proc Natl Acad Sci. 2014;111:8107–12. Ethics approval and consent to participate Not applicable.

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Received: 21 February 2018 Accepted: 24 April 2018