"When Gen. La Grippe Declares War" - The Ogden Standard, Ogden, Utah. Library of Congress.

Forgotten Flu

America & the 1918 Pandemic

11.30.18

The CDC recommended flu shots for all this year after more than 80,000 Americans succumbed to influenza in 2017 – a four-decade high. But 100 years ago, a strain of H1N1 that was first found in soldiers in the spring of 1918 rapidly spread across the United States killing about 675,000 by 1919 and making it “the most severe pandemic in recent history,” according to the CDC. Brian, Nathan, and Joanne look back at the so-called “Spanish Flu,” how it affected the U.S., and why it’s often overlooked today.

Flu Pandemic of 1918; epidemics; public health

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Segments

In the Grip of Death

Historian Nancy Bristow and virologist John Oxford describe the horrifying effects of the influenza pandemic — as well as its “Spanish” origins.

Music:
Flood by Jahzzar
Mensa by Podington Bear
Juliette by Podington Bear
Bambi by Podington Bear

Flu Pandemic of 1918; World War I

00:00:00 / 00:00:00

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JOANNE: Major funding for BackStory is provided by an anonymous donor, the National Endowment for the Humanities, the University of Virginia, the Joseph and Robert Cornell Memorial Foundation, and the Arthur Vining Davis foundations.

BRIAN: From the Virginia Foundation for the Humanities, this is BackStory.

NATHAN: Welcome to BackStory, the show that explains the history behind today’s headlines I’m Nathan Cibbikky,

JOANNE: I’m Joanne Freeman.

BRIAN: And I’m Brian Balogh.

100 years ago, Europe was bogged down in the final years of the First World War, which had cost millions of lives. But a more deadly onslaught was to come. As early as the spring of 1918, soldiers started getting sick. Not just here in the United States, but all across the world, they were coming down with something like the flu. And historian Nancy Bristow says that the flu was nothing new.

NANCY BRISTOW: Influenza, the grippe– they used those terms interchangeably– has become a domesticated illness. It’s something they expect to see every year. And indeed they expect some people to die of it every year.

BRIAN: But as the infection spread from soldier to soldier and then soldier to civilian, doctors realized this flu was not what they were used to treating.

NANCY BRISTOW: Right away they can see that the pace of infection is very fast. It’s moving from city to city to city very quickly. The progression through a single patient is very rapid in some cases. Often, it would take a week or two for someone to die, but it could happen in less than 24 hours, literally from being healthy to being dead.

BRIAN: For military doctors nowhere was this more apparent than Fort Devens in Massachusetts. That September the epidemic struck the base, which has 50,000 soldiers. Within weeks, over 10,000 of those men came down with the virus and its horrific symptoms.

One doctor there wrote to a friend about the devastation.

MALE SPEAKER: These men start with what appears to be an attack of la grippe or influenza. We have been averaging about 100 deaths per day, and still keeping it up.

JOHN OXFORD: The first manifestation would be headaches and aches and pains and a desperate desire to go to bed. BRIAN:

BRIAN: Virologist, John Oxford.

JOHN OXFORD: Now, that can be associated with a cough as well and a sky high temperature.

NANCY BRISTOW: They may be suffering from chills and sort of what were described as nervous symptoms. And that was only the beginning.

JOHN OXFORD: Within maybe two days of you having all those symptoms, you’re lying there with your cough. You may find the cough is not getting any better. And it is a distressing cough.

NANCY BRISTOW: Leading eventually to delirium, unconsciousness, hemorrhaging taking place in the lungs, so people are really struggling to get a breath. Their bodies as a result of that absence of oxygen begin to be discolored, turning blue or purple.

JOHN OXFORD: And it’s been called a heliotrope cyanosis. And what it means, heliotrope, is lavender colored.

MALE SPEAKER: Two hours after admission they have the mahogany spots over the cheekbones. And a few hours later you can begin to see the cyanosis extending from their ears and spreading all over the face until it is hard to distinguish the colored men from the white.

JOHN OXFORD: So if a marton, like in my own hospital, the Royal London, came into the ward, we could look down the beds in that ward and any patient lying there that had this blue, this lavender coloration of the face, blue lips, and blue ears, she could more or less say, well, hang on a minute, to the nurse. We can prepare those beds because they’re going to die.

MALE SPEAKER: It is only a matter of a few hours then until death comes. And it is simply a struggle for air until they suffocate. It is horrible.

NANCY BRISTOW: They would find that the lungs had the appearance, as one doctor says, like the lungs of the drowned. People were literally drowning in their own bodily fluids.

MALE SPEAKER: One can stand it to see one, two, or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves.

BRIAN: And there was something else about this disease which horrified doctors. Typically, flu tended to attack the very young and the elderly. But this flu was killing people in the prime of their lives.

NANCY BRISTOW: So in a regular mortality chart for influenza, you have a U with the high influenza mortality being among the very young at the left end of the chart and the very old at the right end of the chart. In 1918, you have what we call a W chart because you have a spike in the middle, those young adults, the very people who are the leaders of a society, the teachers, the politicians, the parents. And almost half of the deaths in this pandemic take place in individuals between the ages of 20 and 40, which is extraordinarily uncommon.

BRIAN: Yeah I remember my wife telling me when I told her what the topic was for BackStory that her grandmother died. And I asked how old. You know, 30 or 32 years old, right that spike in the middle of the W.

NANCY BRISTOW: Right. That’s exactly right. And when I give talks about this there are always people in the audience with those family stories.

BRIAN: Including her own. Bristow took an interest in the pandemic when she learned that her own great grandparents had died from the illness dubbed the Spanish flu.

NANCY BRISTOW: It’s a misnomer based on the reality that Spain didn’t have wartime censorship because they’re a neutral in the war.

JOHN OXFORD: And when this outbreak started, you didn’t want to let the Germans know– or the Germans didn’t want to let English know that they had a bit of a problem in the background. And so everyone kept quiet about it. In Spain, why should they keep quiet? They had nothing to do with the war really. And the King, Alfonso the second was ill. The prime minister was ill. Everyone seemed to be ill And suddenly the newspapers were full of it in Spain. And the rest of the world I think looked around and said, what’s going on in Spain? And so since that time, much to the annoyance of the Spanish and much to the annoyance of Spanish virologists, I can tell you, we’ve all called the Spanish flu ever since.

BRIAN: No matter what doctors should have called it, one thing was clear.

NANCY BRISTOW: This is just not regular influenza, that they are in the throes of something new and horrifying, and for which they are going to be a bit at sea.

Fighting the Flu

Brian and Nancy Bristow explore the medical community’s response to the pandemic, and their inability to understand the virus.

Music:
Ones Left Behind by Ketsa

Flu Pandemic of 1918; public health; quarantine

00:00:00 / 00:00:00

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BRIAN: It’s flu season and this year it’s a serious one with fatalities being reported across the country. But a century ago in 1918, America and the world was in the grip of a flu pandemic. By the time it ended, the number of deaths were estimated at between 50 and 100 billion people worldwide.

NATHAN: Today, we’re looking at the Spanish flu, tracking the impact it had on communities in the United States and across the world, hearing how some people fought back against the disease, which ravaged whole cities, and asking a disturbing question, could such a devastating flu pandemic ever happen again?

JOANNE: But first, we’re going to return to our conversation with Nancy Bristow. We’ll hear more from virologist John Oxford later in the program.

BRIAN: Scholars estimate 675,000 Americans died from the Spanish flu and that a quarter of the population was infected. This put a huge strain on the country’s medical resources and on its medical personnel who were desperate to stop the spread of this disease.

NANCY BRISTOW: On the local level, the actual fighting that takes place is at the local public health boards, so that you have in cities and towns across the country, these public health experts who are trying to impose restrictions on the behaviors of their people.

BRIAN: So what were some of the specific measures that local health boards took?

NANCY BRISTOW: Well, they started with the easiest ones, and these always make my audience smile. They outlawed spitting in public and they took away what was called the shared or public drinking cup. So today we imagine a water fountain with a stream of water. In the old days you just grabbed the same cup the person behind you and the person in front of you would use. So those are the easy things. That’s the low hanging fruit.

BRIAN: And did they actually organize shopping on different days for different people?

NANCY BRISTOW: In some communities they would have staggered work hours. They would have staggered shopping hours. What that means literally is just that if you had things open at different times, it would keep the public transportation less crowded for instance. So the purpose is just to establish sort of a calendar across the day, so that people would be in smaller numbers, so that you could stretch the public hour across the hours of the day, rather than having everybody doing the same things at the same moment.

But gradually they would impose much more interventionist measures. So they might at first just ban public meetings. And then they might move on to closing down bars and closing down public amusements. And then they might decide that even the schools and churches needed to be closed. And then they might impose a public masking where everyone in public had to wear a gauze mask, and might also engage with quarantining. Those would be the most interventionist and the most highly resisted actions that they would take.

BRIAN: Did people come to any conclusions about the effectiveness of those efforts, something like quarantine? There were places that did use it. Did they fare better in the long run?

NANCY BRISTOW: They did fare better in the long run. I’m not certain that at the time they could tell that. We know today though that quarantining and public distancing measures were really helpful. And the cities that had the earliest and longest restrictions on their publics had the best long term results. They had the lowest death rates.

BRIAN: Now, what did people do to fight the flu? And was there anything that could be done to treat this?

NANCY BRISTOW: There is nothing that can be done to treat it. In other words, you cannot address the illness itself. You can only treat the symptoms. And so they are taking good care. The nurses in particular are taking good care of the patients, not simply fluffing pillows, but keeping somebody warm, keeping them dry, keeping them clean, keeping them hydrated to the extent possible, giving them pain medication. Those were all useful things to do.

BRIAN: And I’m guessing that health care was very gendered. I’m guessing that the docs were guys an the disproportionate number of nurses were women.

NANCY BRISTOW: That’s exactly right. And it’s certainly what people expected even when there were exceptions to it. So as you read press accounts, they talk about the nurses as angels in white. And they talk about physicians and their strength and their expertise and their capacities to do the sort of manly things. But that’s a set up for trouble.

BRIAN: Yeah. How did that work out when by your description, the guys, the experts are not being terribly successful in their approach.

NANCY BRISTOW: For nurses who were primarily women, the pandemic was a positive experience of sorts. In letters and diaries and yearbooks, they write about how horrific it was to observe these illnesses, but how fulfilled they felt, how empowered they were, even the kind of camaraderie and joy they found in doing good service together. And this is a real boon to nursing as a profession. For the physicians, you can read letters and diaries casting first that horrific vision of how awful it was to see this and then the kind of defeat that this felt, the kind of meaning this carried for one’s professional identity and the kind of not embarrassment, but kind of pain of loss in their capacity to believe in what was possible.

BRIAN: And this comes on the heels of quite a bit of medical and public health optimism. Is that correct?

NANCY BRISTOW: That’s absolutely right. And I think that’s another piece of what makes this so frightening. People were unprepared. Just as we’ve said, they’re used to influenza, but they also thought that they were in an era in which infectious disease was on its way out, that medicine and public health was advancing so rapidly that they would be able to eliminate things like the yearly flu.

BRIAN: And why did they believe that? What was happening?

NANCY BRISTOW: The bacteriological revolution takes place in the late 19th century, where people in Europe, those famous doctors like Pasteur and Koch are doing the work of discovering bacteria. They can finally, for the first time identify the causal agent of illnesses.

BRIAN: Now, did people understand that the flu was not bacterial or did they figure that out?

NANCY BRISTOW: No. So there is a theory about something that’s even smaller than the bacteria they’re able to see. There are people who are aware that that is existing, but they can’t see it. They just can’t see it yet. The technology is not available. So they can only operate on a theory. And this is one of the problems that I think the scientists and the physicians are facing during the pandemic. And people write about, I will never again talk about my profession being capable of doing everything and anything.

Victor Vaughn who was a very important distinguished leader of American medicine. He was Dean of the University of Michigan Medical School. He had already completed a term as the president of the American Medical Association. And he writes in his memoir in 1926 this about his experience during the pandemic, the saddest part of my life was when I witnessed the hundreds of deaths of soldiers in the army camps and did not know what to do. At that moment I decided never again to parade about the great achievements of medical science and to humbly admit our dense ignorance in this case.

BRIAN: That’s unbelievably horrible.

NANCY BRISTOW: It is.

BRIAN: If we step back a little bit and look at the optimism about stamping out infectious diseases at the turn of the 20th century, there’s a real parallel there. And the parallel is to the optimism, believe it or not, of stamping out great wars. People believed very strongly that better transportation, more trade was bringing the world together. Do you see any parallels between the optimism on the war front and the disease front and then in fact what World War I and this pandemic led to?

NANCY BRISTOW: I do. What’s interesting for me is the way it plays in the aftermath, which is that in the aftermath of both the flu and the war, the nation is able to retain its optimism. And it retains it, I think, because of that war and what it does. So that in the public sphere, Americans feel bigger, stronger, and more important in the aftermath of the war, despite the disappointment and the disillusionment that the war brought. We see it in the 1920s with the explosion of the American economy and a great deal of belief that the way we are doing things is the way we should do things, and the withdrawal in fact from government activism, for instance. But in the aftermath of the pandemic, it’s much harder to draw kind of optimistic picture.

BRIAN: Does that mean that the war eclipses the pandemic quite quickly in people’s memory?

NANCY BRISTOW: That’s exactly what happens. The pandemic, as you know, is referred to by many and most famously by Alfred Crosby, the great historian, as the forgotten pandemic. And there are a number of reasons that that happens. But certainly the war eclipses it, and in part because the war is a better story. The pandemic is the wrong story for where the nation sees itself in the aftermath of World War I. And I think it’s much easier to subsume it under this glorious victory of the war. And as a result, to simply forget it in terms of its place in the public eye. There are no memorials. There are no anniversaries held for those who died or for those who quote, fought the pandemic. It just disappears.

BRIAN: Nancy Bristow is a historian at the University of Puget Sound, and the author of American Pandemic– the Lost Worlds of the 1918 Influenza Epidemic.

Tomb of the Unknown Nurse

Brian, Joanne, and Nathan consider why the Spanish flu became a “forgotten pandemic.”

Music:
Seven Up by Podington Bear

Flu Pandemic of 1918; memorialization; nursing

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I think that Nancy Bristow raised a really great point. I mean why is it we don’t have memorials to those who died in the pandemic and those who fought that pandemic? We’ve got memorials for the soldiers who died in World War I. Well, medical professionals and volunteers knew that they were risking their lives by taking care of the sick, just like soldiers knew they were risking their lives by fighting in the war.

JOANNE: They knew that. The question is if you’re talking about how he remember those people, that’s a different question. That’s a question of how do other people perceive what they’re doing and that risk. And do they understand that there’s literally an invader that’s being attacked?

BRIAN: Right So I get it. So you’re saying that today in an age of antibiotics and where some people of course do die from the flu every year, but where we don’t have millions of people dying, today we just don’t recognize the heroism or those public health officials. Got it.

JOANNE: Or the threat, right? Or the threat. I mean, the fact of the matter is even just this year, there’s this sort of low hum of a refrain this year, of like, hey guys, like this year is a little more serious. Like, it’s a little more serious. People are actually dying. And it’s taken quite a lot for that message to even sort of begin to whisper its way into the public. I mean I just think maybe we do sort of take for granted, just as you’re saying, that well, it’s a disease and diseases have cures.

BRIAN: So your answer, Joanne, is that we’ve failed as historians.

JOANNE: Oh gosh.

NATHAN: That’s a nice optimistic note.

JOANNE: Gee, thanks, Brian.

BRIAN: I’m taking part of the blame. I mean the point is we have not been successful at letting people understand that first of all, more people died globally from this than World War I, for instance, and that the quote soldiers fighting it were risking their lives.

NATHAN: No. But I mean– but I think there is something to the effect that you get these diseases kind of every year. It’s now factored into being part of the rhythm of Americans’ lives.

JOANNE: Right. And you get a shot.

NATHAN: You get a shot. Exactly. And we feel as if it’s something that we kind of manage in the way that you manage an ulcer or something like that on a kind of societal level. But just to be very clear, I mean there aren’t many monuments to doctors, period, right? We tend to like building monuments to–

BRIAN: What do you mean, Nathan? You teach at one of them.

NATHAN: Well, [INAUDIBLE]. But even the Johns Hopkins University is not about the physicians necessarily. It’s about Johns Hopkins, the philanthropist, right?

BRIAN: Absolutely.

NATHAN: Yeah. But I think it’s also really key that you have a country that at a broad level of commemoration in its culture well build monuments to generals who lost the war, as we’ve been talking about for quite some time, rather than having the kinds of things that might reflect broad commitments by many thousands of people trying to fight back the ravages of a pandemic like flu.

And I think it’s also I think– as you point out, Brian, the tens and hundreds of thousands of people that are losing their lives to these diseases in some ways also become through the passage of time kind of faceless casualties, right? We don’t have a way of talking about the ravages of public health in K through 12 education. This isn’t part of the fables that we talk about America and how it’s able to conquer this or that. Even the eradication of polio, that word eradication it’s almost like a moment in time. But people don’t go back and think about how polio was really dealt with as part of the general education of most people. It ends up having to be a kind of flashpoint in more specialized conversation.

So all this to say, I think scholars certainly have, I think, been doing their work to try to get that narrative out there. But I think it’s also a heavier lift in terms of what kinds of things count as events for most Americans. And things like pandemics, for lack of a better word, really do fly under the radar for most of the time.

JOANNE: Well, an what’s a victory in that kind of a war?

BRIAN: Well, antibiotics and vaccines. That strikes me as every bit as much a victory as the one won in World War I, which most scholars would say led pretty directly to World War II.

JOANNE: Yeah. I mean I think there are victories like that. And we could name Jonas Salk. I mean we could name medical professionals who’ve done things that we remember. And we remember the person who created or innovated that particular discovery. But the–

BRIAN: Although you’re right, Joanne. No sooner is victory declared, then we completely forget about it because people don’t worry about that disease anymore. You take a pill. And what’s the big deal?

NATHAN: That’s the point. That’s the point of curing it.

BRIAN: Exactly.

NATHAN: To be forgotten.

JOANNE: Right, right. That’s exactly true. We’re trying really hard to forget about this thing.

BRIAN: So if I hear you correctly, you’re calling for the Tomb of the Unknown Doctor, or better, The tomb of the Unknown Nurse.

Rest in Peace

Historian James Higgins describes how influenza devastated Philadelphia’s population, and how the city recruited the Catholic Church to help bury the thousands of dead.

Music:
Dark Water by Podington Bear
Gnossienne 1 by Podington Bear
Black is the Color by Podington Bear

Flu Pandemic of 1918; Philadelphia; burial; death

00:00:00 / 00:00:00

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JOANNE: When the flu took hold, it was so devastating it could overcome whole cities and their civic structures. In Philadelphia, the flu’s progress was aided by a massive gathering on the 28th of September 1918. Americans across the country were gathering in support of the liberty loan drive. They were encouraged to buy bonds to support the war effort. And many cities held patriotic celebrations. Historian James Higgins says the largest one was in Philadelphia.

JAMES HIGGINS: There was a mock bombing raid. Anti aircraft guns were hidden throughout the city with dud anti aircraft shells that they’ fire off. It is a huge celebration. And the parade marches 23 blocks from north Philadelphia to South Philadelphia. And that day there are singalongs numbering in their hundreds throughout the city. People are packed cheek by jowl on the trolleys and the sidewalks to get to the parade. And then of course, people are standing there for hours watching the parade go by.

JOANNE: There had been scattered cases of influenza in Philly, which had been brought to the city by sailors from the naval base in Boston. But the liberty loan celebration exposed almost the entire population of the city to the virus, and almost all at once.

JAMES HIGGINS: And that night, I like to suggest that the half of the city that went to the parade went home to the half of the city that didn’t go to the parade.

Within one week of the parade, Philadelphia officially logs 1,100 deaths.

JOANNE: Many doctors and nurses had been called away to war and the city’s hospitals were quickly overwhelmed. Funeral homes ran out of coffins. And grave diggers who had to dig everything by hand couldn’t keep up with the number of bodies. The morgue for the city of Philadelphia only had room for 36.

JAMES HIGGINS: We have a couple of photographs from inside that morgue. And there are bodies with towels and sheets and a bit of cloth over the faces strewn on the floor. They’re on embalming tables. We know from written records that they are stacked on desks and they’re piled in corners. And the atmosphere inside the city morgue becomes so cloying that the back doors are thrown open and the liquid that’s running out of people moves across the floor and onto the sidewalk. And little boys had to be shooed away by adults because they’re gawking through the doors at all the bodies inside.

JOANNE: Even more horrifying, as the morgues filled up, deceased family members were left around the home, stretched out on couches, set up in chairs, and put under tables. Panic spread throughout the city, along with the smell.

JAMES HIGGINS: People are walking down the street, and they can tell which house has a body laying in it by the smell alone. And so it is a terrifying sort of realization that you are walking down a street in metropolitan Philadelphia and you’re passing a home where you know there’s a body laying. And when you walk through some of the most densely packed of the neighborhoods, people’s senses are assaulted by it. And this adds to such a great deal of the fear that people already feel, as everyone around them gets sick and as you wait for your own symptoms to develop.

JOANNE: This was a city in crisis. Its systems couldn’t cope with the sheer number of the dead. When it was clear that the city was unable to keep up, they turned to the largest charitable organization in Philadelphia, the Roman Catholic Church. On October 14, young men from St. Charles Borromeo Seminary removed more than 400 bodies from the city morgue.

JAMES HIGGINS: And this must have been like untangling the bodies at Dachau and other concentration camps that American and British soldiers liberated at the end of World War II. Some people are stacked like cordwood and others are thrown into heaps. And they’ve been there for days.

JOANNE: Those bodies along with others from homes around Philadelphia were buried in Potter’s Field.

JAMES HIGGINS: Where the poor, the indigent, and the unknown are buried by the city of Philadelphia.

JOANNE: Many of Philadelphia’s immigrants who died from the flu, Irish, Italian, Polish, were Catholic and had been left on the grounds of Holy Cross Cemetery.

JAMES HIGGINS: The seminarians who go there, and there are dozens, report that there are bodies lying all over the cemetery grounds. They’ve been pushed into sheds and horse sheds. They’ve been pushed into the office. They’re laying on the grounds of the cemetery itself amongst tombstones. Bodies are brought in coal carts, children’s wagons. One of the seminarians recalls a pitiful scene of an Italian father with his 1-year-old or 2-year-old baby has been put in a pasta box. Another father brings one of his children and they are in a citrus fruit bag, a burlap sack because even if he could afford a coffin, there are no coffins to be found in the city of Philadelphia anywhere by the second week of October.

JOANNE: The seminarians spent the first day digging individual graves until 10:00 at night, but the numbers of bodies were so great that it became clear that this wouldn’t be sustainable.

JAMES HIGGINS: And so the decision is made to begin excavating large communal graves, trench graves. These are not holes where you toss bodies. That’s not what they do.

JOANNE: They dig 60 foot long trenches 10 feet deep where dozens of boxes would lay on top of each other. They meticulously record the location of every body in case family members wanted to exhume it later for burial in an individual plot.

JAMES HIGGINS: An eyewitness recalls in the evening when the the sun is down that she hears Latin being spoken.

MALE SPEAKER: [SPEAKING LATIN]

JAMES HIGGINS: And she comes around some tombstones and finds a number of seminarians in one of these mass graves. And they are reciting the De Profundis from the Old Testament. And it goes in part from, the depths oh lord I cry out to you. It’s a lamentation psalm. And they are saying the prayers over the dead, blessing them with holy water, and stacking the coffins two high.

JOANNE: Higgins says that there is evidence that up to 3,400 people were buried by the Philadelphia seminarians in just about three weeks time. The trench graves at Holy Cross Cemetery are still there today. And Potter’s Field has been turned into a parking lot. And that’s a fitting image because most Americans have forgotten about the Spanish flu and know nothing about the way it could ravage whole American cities. But James Higgins is not surprised.

JAMES HIGGINS: It’s not exceptional, I don’t think, for the public to forget about epidemics. I wager if you ask most Americans, even most Philadelphians, tell me a little something about the yellow fever epidemic of 1793 that killed 10% or 15% of the entire city of Philadelphia, most won’t be able to tell you anything about it. What I find more exceptional is that the historical community, the professional historians, the scholars, the professors, the writers, the researchers, they too have forgotten it. They have somehow missed, they have somehow overlooked and ignored an event that kills more Americans than the Civil War in just a couple of months time.

BRIAN: James Higgins is a historian at The University of Houston Victoria. He id the author of A Brief History of Pennsylvania Medicine.

Once and Future Flu

Brian returns to his conversation with virologist John Oxford, who explores how the 1918 influenza pandemic spread worldwide, and why scientists think we should prepare for another pandemic.

Music:
Live With No Fear by Ketsa

Flu Pandemic of 1918; virality

00:00:00 / 00:00:00

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NATHAN: The impact of this disease was felt across the globe. Spanish flu didn’t respect national boundaries and would travel with soldiers headed home on boats and trains along the connective tissue of the modern world of 1918. Today’s world is connected in ways undreamed of at the beginning of the 20th century. And today’s doctors and public health officials are acutely conscious of pandemic threats in a world bridged by international air travel, subway systems, conferences, and pop concerts.

BRIAN: Earlier in the show, we heard from virologist John Oxford. He spoke to us from London. And I asked him about the international impact of the Spanish flu.

JOHN OXFORD: The deaths varied quite a lot in different countries. In some countries, for example in Labrador, nearly 100% of people in some of the villages died. And yet, in one place on this planet actually organized by the United States that is in Samoa, there was a complete quarantine. And as far as I know, no one died.

BRIAN: Unbelievable. What was it about this particular flu that caused so many deaths? Was it the strain of the flu virus or something else?

JOHN OXFORD: It’s probably a combination of things. I mean groups in the states have resurrected the virus. They’ve tested it in little animal models, in mice, in cell culture. It does look slightly more virulent, maybe five times. But I don’t think that really explains the deaths in 1918. And then you come onto the most recent possibility, which has always been in the background, that it sort of depends on our immune history. What was the history of an old person? How many strains had they been infected with before 1918? Had they been infected with anything at all?

So you’ve got that combination. You’ve got what the past immune history, the past infection history has been. On top of that, you’ve got a virus which is perhaps a little bit more virulent than a common old garden one. But on top of that again, you’ve got one other factor that, of course, 1918 was very much a bacteriological world. There were bacteria all over the place pre-antibiotic. So we know now that that must have made– that was another factor that comes into it.

BRIAN: How to explain the global reach of this pandemic? I understand it made it as far as the Arctic Circle.

JOHN OXFORD: There the war, I think, has a lot to answer for. Well, all the troops, including American troops, in Europe by the autumn of 1918, British troops and colonial troops from all the colonies. And in November 1918, certainly the whole thing finishes and they all want to go home. There was a huge movement of young men, 18, 19, 20-year-olds. They were some of them carrying the influenza. And the boat comes into South Africa. They go home at the railway lines. The railway lines were quite important in carrying this virus, as a transport mechanism in 1918.

They go to the furthermost spots in South Africa. Their parents, that we can call their friends in from a range of about 10 miles. They come in by horse and cart to celebrate the young men coming home and they all catch it. So it’s a question of people movement. And there were a lot of people moving, probably more than had ever been moved before, probably 10, 15 million young people on the move. And that had a lot to do with it, I think.

BRIAN: Well, you mentioned the war as a crucial factor in transmitting this disease. Obviously, the war killed tens of millions of people. How do the casualties from World War I compare to the totals from the influenza pandemic?

JOHN OXFORD: Well, very much. They were very much smaller. I mean it’s bad enough, isn’t it, to have 10 million, as you say 12 million young men dying because of the war. But I feel myself now, that whoever was responsible for that– and I myself put it at the feet of politicians. It was their job to try and stop all this. That is their job. And they failed. So not only did that result in 10 million or more young people dying in that conflagration, but I think myself if it had not been for that war, the pandemic would not have arisen. So I think now those responsible are responsible for 10 plus 50 million, 60 million. So it tells in modern terms, you can start things off with these war things, but you never know when they’re going to end.

BRIAN: And were there things that could be done to help?

JOHN OXFORD: The doctors and nurses tried and tried and tried. And in the group of doctors and nurses I’m particularly involved in looking back on– I mean I read their papers in The Lancet. It’s as though they’re talking to you now. Right in the middle of those battles when they were within 10 miles of the western front day and night, all they got were explosions going off and shells and everything else, they were trying to look after these first patients coming in with what was the first kind of wave, the early wave of the Spanish flu.

They even set up– to try to help these soldiers, they even set up tents. And they had aromatic compounds and oils in those tents, so it’s kind of a steam tent. And that I find so admiring. I mean those [INAUDIBLE] were risking their lives. They were pretty close to the western front, all this going on, and they were making these tents of canvas and steam so they could persuade these ill soldiers to get up and sit in there and get some relief from it. So I think they were really into it. But all they could do in reality was that sort of thing, the nursing care, a lot of care, and try and bring their temperatures down with aspirin. And there’s not much else they could– if their heart began to fail, they had belladonnas and had [INAUDIBLE] so they could tackle that a little bit. But overall, again and again, you feel how helpless they felt at the time.

BRIAN: Well, whether it’s that strain or not, what are your thoughts about the possibility for another global pandemic on the scale of the Spanish flu?

JOHN OXFORD: Well, I think all virologists, when we look at the past, there have been been pretty, not regular exactly, but they’ve been they’re coming out at us. And remember the theory is that they’re spread– these pandemic viruses come from the great migrating geese and ducks and swans of this world. And they’ve got all of the viruses, the mutating influenza virus. All of them are in those migrations not normally causing any problems. So they go on their business around the world on the big migration routes, come into contact with domesticated ducks and creatures and turkeys. And then they’re pressurized, the domesticated ones, because [INAUDIBLE] like factory farming. And there you begin to get the symptoms if they catch it from a migrator and then push on the symptoms and the virus on to their keepers.

So we know which way the virus comes now. We didn’t know that before. So it’s [INAUDIBLE] to say, well, that’s not going to happen again because it happened in– we know from recent history– in 1845, there was a big outbreak that was almost certainly flu. 1889, so called Russian influenza was kind of big one. The 1918, 1957, 1968, 1976, and then 2009. So they’re coming after us. And there’s every reason. Given the global population increasing and everyone on the move, there’s every reason to anticipate and plan from the next one.

NATHAN: John Oxford is a virologist at the Royal London Hospital.

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