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INTRODUCTION: The Elephant in the Room
The brevity of the influenza pandemic of 1918 posed great problems to doctors at the time… It has posed great problems to historians ever since.
Terence Ranger, The Spanish Influenza Pandemic of 1918–19 (2003)1
Kaiser Wilhelm of Germany abdicated on 9 November 1918 and in the streets of Paris there was jubilation. 'À mort Guillaume!' they shouted. 'À bas Guillaume!' Death to Wilhelm! Down with Wilhelm! Meanwhile, high above the city's seventh arrondissement, the poet Guillaume Apollinaire lay on his deathbed. A leading light of the French avant-garde movement, the man who invented the term 'surrealist' and inspired such figures as Pablo Picasso and Marcel Duchamp, he had signed up to fight in 1914. Having survived a shrapnel wound to the head and the drilling of a hole into his skull, he died of Spanish flu at the age of thirty-eight, and was declared 'mort pour la France'.
His funeral was held four days later–two days after the armistice was signed. On leaving the Church of St Thomas Aquinas, the mourners set off eastwards towards Père Lachaise Cemetery. 'But as it reached the corner of Saint-Germain,' recalled Apollinaire's friend and fellow poet, Blaise Cendrars, 'the cortège was besieged by a crowd of noisy celebrants of the armistice, men and women with arms waving, singing, dancing, kissing, shouting deliriously the famous refrain of the end of the war: "No, you don't have to go, Guillaume. No you don't have to go…'" The famous refrain was directed with irony at the defeated kaiser, but it was filled with poignancy for the friends of Apollinaire.2
The poet's death serves as a metaphor for our collective forgetting of the greatest massacre of the twentieth century. The Spanish flu infected one in three people on earth, or 500 million human beings. Between the first case recorded on 4 March 1918, and the last sometime in March 1920, it killed 50–100 million people, or between 2.5 and 5 per cent of the global population–a range that reflects the uncertainty that still surrounds it. In terms of single events causing major loss of life, it surpassed the First World War (17 million dead), the Second World War (60 million dead) and possibly both put together. It was the greatest tidal wave of death since the Black Death, perhaps in the whole of human history.
Yet what do we see when we unravel the scroll of the twentieth century? Two world wars, the rise and fall of communism, perhaps some of the more spectacular episodes of decolonisation. We do not see the most dramatic event of them all, though it's right there before our eyes. When asked what was the biggest disaster of the twentieth century, almost nobody answers the Spanish flu. They're surprised by the numbers that swirl around it. Some become thoughtful and, after a pause, recall a great-uncle who died of it, orphaned cousins lost to sight, a branch of the family that was rubbed out in 1918. There are very few cemeteries in the world that, assuming they are older than a century, don't contain a cluster of graves from the autumn of 1918–when the second and worst wave of the pandemic struck–and people's memories reflect that. But there is no cenotaph, no monument in London, Moscow or Washington DC. The Spanish flu is remembered personally, not collectively. Not as a historical disaster, but as millions of discrete, private tragedies.
Perhaps that has something to do with its shape. The First World War dragged on for four long years, but despite its name, the bulk of the action was concentrated in European and Middle Eastern theatres. The rest of the world felt the hot wind sucking it into that vortex but remained outside it, and in some places the war seemed very far away indeed. The war had a geographical focus, in other words, and a narrative that unfolded in time. The Spanish flu, in contrast, engulfed the entire globe in the blink of an eye. Most of the death occurred in the thirteen weeks between mid-September and mid-December 1918. It was broad in space and shallow in time, compared to a narrow, deep war.
The African historian Terence Ranger pointed out in the early 2000s that such a condensed event requires a different storytelling approach. A linear narrative won't do; what's needed is something closer to the way that women in southern Africa discuss an important event in the life of their community. 'They describe it and then circle around it,' Ranger wrote, 'constantly returning to it, widening it out and bringing into it past memories and future anticipations.'3 The Jewish text, the Talmud, is organised in a similar way. On each page, a column of ancient text is surrounded by commentaries, then by commentaries on the commentaries, in ever-increasing circles, until the central idea has been woven through space and time, into the fabric of communal memory. (There may be another reason why Ranger proposed a feminised history of the Spanish flu: it was generally women who nursed the ill. They were the ones who registered the sights and sounds of the sickroom, who laid out the dead and took in the orphans. They were the link between the personal and the collective.)
At the root of every pandemic is an encounter between a disease-causing microorganism and a human being. But that encounter, along with the events that lead up to it and the events that ensue from it, is shaped by numerous other events taking place at the same time–as well as by the weather, the price of bread, and ideas about germs, white men and jinns. The pandemic in its turn affects the price of bread, ideas about germs, white men and jinns–and sometimes even the weather. It is a social phenomenon as much as it is a biological one; it cannot be separated from its historical, geographical and cultural context. The way African mothers and grandmothers recount an event gives weight to that contextual richness, even if the event it impinges on lasts no longer than a historical heartbeat. This book sets out to do the same.
The time is right. In the decades immediately after the pandemic, the only people who studied it–besides actuaries employed by insurance companies–were epidemiologists, virologists and medical historians. Since the late 1990s, however, Spanish-flu historiography has exploded, and this recent burst of attention has been noticeable by its multidisciplinary nature. Now economists, sociologists and psychologists are interested in it too, along with 'mainstream' historians. Each has trained their gaze on a different aspect, and between them they have transformed our understanding of it. All too often, though, their conclusions are buried in specialist journals, so this book attempts to bring them together; to weave all the different strands into a more coherent picture of the beast, in all its multifaceted glory–or horror.
The information that is available today is not only more academically diverse, it is also more geographically diverse–capturing the global reach of the disaster. Most accounts of the Spanish flu to date have focused on Europe or North America. They had to, because for a long time it was only in those places that data had been collected systematically. In 1998, when Spanish-flu experts from around the world met in Cape Town to mark its eightieth anniversary, they acknowledged that almost nothing was known about what happened in large swathes of the globe–South America, the Middle East, Russia, South East Asia and inland China. But Europe- and North America-centred accounts distort the picture for two reasons. First, those continents reported the lowest death rates, on average, so their experiences were atypical. And second, by 1918 they were both heavily implicated in a war that would devastate Europe. War was undoubtedly the main event on that continent: France lost six times more souls to the war than to the flu, while in Germany the multiple was four, in Britain three and in Italy two. But on every other continent–with the possible exception of Antarctica, which both disasters left pristine–more died of flu than war. At the time of writing–nearly twenty years on from the Cape Town summit, and as we approach the centenary of the catastrophe–it is possible to begin to reconstruct what happened in those other parts of the world.
This book takes a different approach to telling the flu. It moves in on it–from prehistory to 1918, from the planet to the human, from the virus to the idea and back again. At the heart of it is the story of how the Spanish flu emerged, swept the planet and receded, leaving humanity transformed. But that story pauses, at times, to look at what set communities apart in their experiences of it, as well as what brought them together. In 1918, the Italian-Americans of New York, the Yupik of Alaska and the residents of the Persian shrine city of Mashed had almost nothing in common except the virus, and in each place cultural and other factors moulded their encounter with it. A series of portraits therefore tracks the disaster as it unfolded in societies located at different points on the globe, highlighting the profoundly social nature of a pandemic.
These portraits shine a light into areas of the map that were previously dark, and give an indication of how the Spanish flu was experienced in parts of the world where 1918 was the year of the flu, not the year the war ended. They are not comprehensive, because millions of stories remain untold, so they come with caveats. It surely wasn't only in Rio de Janeiro that a post-flu orgy produced a spike in births, or only in Odessa, Russia, that people performed archaic religious rituals to ward off the scourge. It wasn't only Indians who temporarily transgressed strict social boundaries to help each other, or only in South Africa that people of one colour blamed those of another. A Catholic bishop may have frustrated efforts to contain the disease in Spain, but missionaries were often the only ones bringing relief to remote tracts of China. There is one overarching caveat: the narrator is, once again, European.
The story of the Spanish flu is told in Parts Two to Six of the book. But that story is embedded in a larger one–the one that tells how man and flu have cohabited, and co-evolved, for 12,000 years–so Part One, 'The Unwalled City', recounts that story up to 1918, while Part Seven, 'The Post-Flu World', explores the traces of the Spanish flu with which we live today. Since man and flu are still co-evolving, Part Eight, 'Roscoe's Legacy', looks forward to a future battle–the next flu pandemic–envisaging what new weapons we will carry into it, and what is likely to be our Achilles heel. Together, these stories comprise a biography of the flu–a human story, that is, in which the fil conducteur is flu. An afterword addresses the question of memory, asking why, when its impact was so profound, we call it 'forgotten'.
It is often said that the First World War killed Romanticism and faith in progress, but if science facilitated industrial-scale slaughter in the form of the war, it also failed to prevent it in the form of the Spanish flu. The flu resculpted human populations more radically than anything since the Black Death. It influenced the course of the First World War and, arguably, contributed to the Second. It pushed India closer to independence, South Africa closer to apartheid, and Switzerland to the brink of civil war. It ushered in universal healthcare and alternative medicine, our love of fresh air and our passion for sport, and it was probably responsible, at least in part, for the obsession of twentieth-century artists with all the myriad ways in which the human body can fail. 'Arguably' and 'probably' are indispensable qualifiers when discussing the Spanish flu, because in 1918 there was no way of diagnosing influenza, and hence no way of knowing for sure that that was what it was–any more than we can be certain that the bubonic plague (or one of its variants, pneumonic plague) caused the Black Death in the fourteenth century. What isn't arguable is that the 1918 pandemic accelerated the pace of change in the first half of the twentieth century, and helped shape our modern world.
If all of this is true, how come we still think of the Spanish flu as a footnote to the First World War? Have we really forgotten it? Terence Ranger thought we had, but if he were still alive today he might hesitate before repeating that claim. If so, then credit must go to a vast collaborative effort. The Spanish flu can no longer be told without the contributions of both historians and scientists, including social scientists. Science tells the tale up to the threshold of history, across the acres of prehistory that look empty but are, in fact, covered in an invisible scrawl–and that moulded events in 1918 just as much as what came later. History takes it up where the scrawl becomes legible, and science sheds some light back from the present. In another hundred years, science and history will themselves have been transformed. There might even be a science of history, in which theories about the past are tested against computerised banks of historical data.4 That kind of approach will likely revolutionise the way we understand complex phenomena such as pandemics, but it's still in its infancy. There is one thing we can already say for sure, however: by the bicentenary of the 1918 pandemic, historians will have filled in more of the blanks, and the light shed by science will be brighter.
PART ONE: The Unwalled City
Coughs and sneezes
Sometime around the winter solstice of 412 BC, a cough wracked the people of Perinthus, a port city on the Sea of Marmara in what was then northern Greece. The Perinthians reported other symptoms too: sore throat, aches, difficulty swallowing, paralysis of the legs, an inability to see at night. A doctor called Hippocrates jotted them all down, and the 'Cough of Perinthus' became the first written description–probably–of influenza.
Probably, because certain of those symptoms don't seem to fit: impaired night vision, paralysis of the limbs. Their inclusion troubled historians of medicine, until they realised that Hippocrates defined an epidemic differently from us. Indeed, Hippocrates was the first to use the word epidemic (literally, 'on the people') in a medical sense. Before that, it had referred to anything that propagates in a country, from fog to rumour to civil war. Hippocrates applied it specifically to disease, and then he redefined disease.
The ancient Greeks thought of disease as spiritual in origin, a punishment from the gods for any kind of misdemeanour. Doctors were part priests, part magicians, and it was their role to mollify the irascible divinities with prayer, spells and sacrifices. Hippocrates argued that the causes of disease were physical, and that they could be divined by observing a patient's symptoms. He and his disciples introduced a system for classifying diseases, which is why he is often referred to as the father of western medicine: he was responsible for the notions of diagnosis and treatment that still underpin medicine today (he also left us with a code of medical ethics, the Hippocratic Oath, from which we have the promise made by newly qualified doctors to 'do no harm').
Hippocrates thought that disease was the result of an imbalance between the four 'humours' or fluids that circulate in the human body–black bile, yellow bile, phlegm and blood. If you were lethargic, you had too much phlegm, and the treatment was to eat citrus fruit. Galen, another Greek physician who lived about 500 years after Hippocrates, elaborated on that model, suggesting that people could be categorised by temperament according to which humour dominated in them. Black bile was associated with melancholy types, yellow bile with choleric or hot-tempered ones. A phlegmatic person was laid-back, a sanguine one hopeful. We retain the adjectives, but not the understanding of anatomy and bodily function that produced them. And yet, the Galenic concept of medicine dominated in Europe for a good 1,500 years, and his notion that 'miasma' or noxious air could trigger a humoral imbalance was still popular, in some parts of the world, in the twentieth century.
Hippocrates' definition of an epidemic didn't survive either. For him, an epidemic was all those symptoms experienced in a given place over a given period of time, during which its population was in the grip of sickness. In those circumstances, he did not distinguish between separate diseases. Later the term epidemic came to be associated with one disease, then with one microbe, then with one strain of microbe, but this process of refinement didn't get underway until the Middle Ages, when the great plague epidemics forced a rethink. In modern terms, therefore, the people of Perinthus were probably suffering from influenza, diphtheria and whooping cough combined–perhaps with a deficiency of vitamin A thrown in.
Why should we care about a 2,400-year-old outbreak of flu in Greece? Because we would like to know how long flu has been a disease of humans, and what caused it to become one in the first place. Understanding more about its origins might help us to pinpoint the factors that determine the timing, size and severity of an outbreak. It might help us to explain what happened in 1918, and predict future epidemics.
The Cough of Perinthus probably wasn't the first flu epidemic. And though the historical record is silent on the subject before 412 BC, that doesn't mean there's nothing to be said about flu in earlier times. Like humans, flu carries information about its origins within itself. Both of us are living records of our evolutionary past. An example is the human tail bone or coccyx, which is a vestige of our tree-dwelling ancestors. As the tail became less useful, natural selection favoured individuals in whom a chemical signal during embryonic development switched off spinal elongation before the tail grew. Very occasionally, a glitch occurs and that signal doesn't get turned off in time. The medical literature contains around fifty reports of babies born with tails–a glimpse of the arboreal primate in all of us.
The flu virus has no tail, but it harbours other clues to its origins. It is a parasite, meaning that it can only survive inside another living organism, or 'host'. Unable to reproduce on its own, it must invade a host cell and hijack that cell's reproductive apparatus. The offspring of the virus must then leave that host and infect a new one. If they don't, then the virus expires with the original host, and that is the end of flu. Just as our ancestors' survival depended on their ability to swing through trees, so flu's survival depends on its ability to jump from one host to another. This is where the flu story becomes interesting, however, because being a parasite, its survival depends both on its own behaviour and on that of its host. And though for a long time scientists were in the dark about flu's past, they knew a few things about what humans were doing before 412 BC.
Flu is transmitted from one person to another in tiny infected droplets of mucus that are flung through the air by coughs and sneezes. Snot is a fairly effective missile–it should be, it was designed in a wind tunnel–but it can't fly further than a few metres. For flu to spread, therefore, people must live fairly close together. This was a crucial insight, because people didn't always live close together. For most of the human story they were hunter-gatherers and far apart. That all changed about 12,000 years ago, when a hunter somewhere in the vastness of Eurasia erected a pen around a couple of wild sheep and invented livestock. Plants were domesticated too, for crops, and these two developments meant that the land could now support a higher density of people, who could thus come together to compete, collaborate, and generally display all the ingenuity characteristic of human societies. The hunter's innovation, known as the farming revolution, ushered in a new era.
The new collectives that farming supported gave rise to new diseases–the so-called 'crowd diseases' such as measles, smallpox, tuberculosis and influenza. Humans had always been susceptible to infectious disease–leprosy and malaria were causing misery long before the farming revolution–but these were adapted to surviving in small, dispersed human populations. Among their tricks for doing so were not conferring total immunity on a recovered host, so that he or she could be infected again, and retreating to another host–a so-called 'animal reservoir'–when humans were scarce. Both strategies helped ensure that they maintained a sufficiently large pool of susceptible hosts.
The crowd diseases were different. They burned rapidly through a farming population, either killing their victims or leaving them immune to re-infection. They might infect other animals, but not as well as they infected humans, and some of them were so well adapted to humans that they became exclusively parasitic to our species. They needed a pool of thousands or even tens of thousands of potential victims to sustain them–hence the name, 'crowd disease'. They would not have survived prior to the farming revolution, but after it, their evolutionary success was index-linked to the growth of human populations.
But if they would not have survived before farming, where did they come from? The clue is those animal reservoirs. We know that there are disease-causing microbes that only infect animals. There are forms of malaria, for example, that infect birds and reptiles but can't be transmitted to humans. We know that there are microbes that infect both animals and humans (influenza falls into this category), and we know that there are microbes that infect only humans. This is the case, for example, with measles, mumps and rubella. According to current thinking, these different categories of infectious disease represent steps on the evolutionary path by which an exclusively animal disease becomes an exclusively human one. To be precise, scientists recognise five steps that a disease-causing microbe has to go through to complete this transition.1 Some diseases, like measles, have gone all the way; others have stuck at intermediate points on the path. But we shouldn't think of this process as fixed. It's highly dynamic, as illustrated by Ebola.
Ebola virus disease is primarily a disease of animals. Its natural reservoir is thought to be fruit bats that inhabit African forests, and that may infect other forest-dwelling animals that humans prize as bushmeat (humans eat the bats, too). Until recently, Ebola was considered a disease that infected humans poorly: it might be transmitted via contact with bushmeat, for example, but a person who was infected by that route would only infect a few others before the 'outbreak' fizzled out. That all changed in 2014, when an epidemic in West Africa revealed that Ebola had acquired the ability to pass easily between people.
It isn't easy for, say, a virus to jump the species barrier. In fact 'jump' is entirely the wrong word–it would be more helpful, though still a metaphor, to think of it 'oozing' across. Cells are built differently in different hosts, and invading them requires different tools. Each step along the path to becoming a human disease is therefore accompanied by a specific set of molecular changes, but acquiring those changes is a very hit-and-miss affair. The virus will likely have to pass through many, many rounds of reproduction before a mutation arises that confers a useful change. But then, if the virus's evolutionary fitness improves as a result–if by infecting humans better, it manages to produce more of itself–then natural selection will favour that change (if it doesn't, it won't). Other changes may follow, and their cumulative effect is that the virus moves another step along the path.
The natural reservoir of influenza is generally considered to be birds, especially waterbirds. The big giveaway that a certain species plays the role of reservoir for a certain pathogen is that it doesn't get sick from it. The two have co-evolved for so long that the virus manages to complete its life cycle without causing too much damage to its host, and without unleashing an immune response. Ducks, for example, can be heavily infected with flu without showing any signs of disease. After the farming revolution, ducks were among the animals that humans domesticated and brought into their villages. So were pigs, which are regarded as potential intermediaries in the process by which a bird disease became a human disease, since pig cells share features of both human and bird cells. For millennia, the three lived cheek by jowl, providing flu with the ideal laboratory in which to experiment with moving between species. Flu infected humans, but probably not very well at first. Over time, however, it accumulated the molecular tools it needed to make it highly contagious, and one day there was an outbreak deserving of the name 'epidemic'.
Epidemic here is meant in its modern sense–that is, as an increase, often sudden, in the number of cases of a given disease in a given population. An 'endemic' disease, in contrast, is always found in that population. A crowd disease can be both endemic and epidemic, if it is always present in a region but also produces occasional outbreaks there. This is where the definitions of the two terms become a little blurred and vary according to the disease in question. We might say, for example, that the relatively mild outbreaks of seasonal influenza that we see each winter are the endemic form of the disease, and reserve the term epidemic for when a new strain emerges, bringing a more severe form of flu in its wake–though not everybody would agree with that distinction.
We have no written accounts of the first epidemics of the first crowd diseases, but they are likely to have been very deadly (witness the 2014 epidemic of Ebola, which might yet go on to earn the title 'crowd disease'). We know, for example, that one of the deadliest crowd diseases of all, smallpox, was present in Egypt at least 3,000 years ago, because mummies have been found with pockmarked faces, but the first written account of a (probable) smallpox epidemic doesn't turn up until 430 BC, when a contemporary of Hippocrates, Thucydides, described corpses piled up in the temples of Athens.
When did the first flu epidemic occur? Almost certainly in the last 12,000 years, and probably in the last 5,000–since the first cities arose, creating ideal conditions for the disease to spread. It too must have been horrific. We find this hard to understand, because today, in general, influenza is far from lethal. Yet even today, a small proportion of people come off badly each flu season. These unlucky individuals develop acute respiratory distress syndrome (ARDS): they become short of breath, their blood pressure drops, their faces take on a bluish tinge, and if they aren't rushed to hospital they will very likely die. In a few cases, their lungs may even haemorrhage, causing them to bleed from their noses and mouths. ARDS is a glimpse of the carnage that first flu epidemic wrought.
- "Impressive...Set against the devastating backdrop of global contagion, it is individual lives and deaths, discovered in letters, diaries, biographies and memoirs, that epitomize this rich account. Spinney invokes potent images...Along with exemplary research, Spinney's narrative is packed with fascinating, quirky detail...As the centenary of this monumental event approaches, other volumes on the pandemic will undoubtedly appear. Pale Rider sets the bar very high."—Nature
- "A saga of tragedies and a detective story... Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it.... Compelling."—The Guardian
- "A book about the Spanish flu could so easily be dreary-complex pathology interwoven with pervasive tragedy. Not so Pale Rider. I've seldom had so much fun reading about people dying. Laura Spinney, a science journalist, is adept at explaining arcane scientific research in an entertaining, comprehensible way. ...With superb investigative skill and a delightfully light-hearted writing style, Spinney extends her analysis far beyond the relatively short duration of the plague....Spinney finds it odd that we know so little about the worst calamity to affect the human race. So do I. There are tens of thousands of books about the First World War, yet that flu is, arguable, more relevant to our world. While global war is, we hope, a thing of the past, global pestilence hovers like a vulture."—The Times
- "Spinney argues that almost a century later, the Spanish flu is 'still emerging from the shadows of the First World War' in our collective memories. She sets out to rectify this, knowing just which medical mysteries and haunting vignettes will give the pandemic full purchase on our imaginations."—New York Times Book Review
- "Wide-sweeping... Spinney is a storyteller with a science writer's cabinet of facts. Retracing influenza's death trail over nine continents, she attempts to show how the flu affected not only the war-torn West but also remote communities in South Africa, China, and Brazil. The book reveals how desperately and differently people reacted and how gravely the flu influenced the modern world, touching everything from medicine to business and from politics to poetry."—Science
- "Influenza, like all viruses, is a parasite. Laura Spinney traces its long shadow over human history... Ms Spinney ties the virulence of Spanish flu to its genetic irregularities and does a good job of explaining containment strategies through epidemiology... In Europe and North America the first world war killed more than Spanish flu; everywhere else the reverse is true. Yet most narratives focus on the West... Ms Spinney's book goes some way to redress the balance."—The Economist
- "Spinney's book is intensely readable, and instead of a strictly chronological account she circles around history, epidemiology and culture to give a panoramic portrait of the previous century's most deadly pandemic. We are probably due another one of these any day now, this is a great way to see what the future holds."—TheAwl
- "A page turner that should easily satisfy armchair historians and epidemiologists and anybody who likes a good, if gruesome, yarn."—Foreign Policy
- "A vividly recreated, grimly fascinating book...Coolly, crisply and with a consistently sharp eye for the telling anecdote...Spinney demonstrates how Spanish flu cast a long, dark shadow over the 20th century."—The Daily Mail
- "One of the many strengths of Pale Rider is to show its readers the regional variations that combat took throughout the world, from Bristol Bay to Zamora to Unalaska Island... For all the tragedies and upheavals, the book portrays, Pale Rider actually paints an oddly hopeful picture of a population more sensitized to early warnings and largely more willing to heed them."—TheNational
- On Sale
- Sep 12, 2017
- Page Count
- 352 pages