Epidemics in Western Society Since 1600

HIST 234 - Lecture 20 - Pandemic Influenza

Chapter 1. Influenza [00:00:00]

Professor Frank Snowden: Our topic this morning is influenza, which is timely for today. And I'd like to begin by talking about influenza virus more in general, and we'll concentrate our attention, for obvious reasons, on the Spanish Lady, the great influenza of 1918, 1919. Now, influenza virus was isolated in the 1930s by Andrews, Wilson and Laidlaw, and the mechanisms of the disease were then unraveled subsequently. As you know, there are three types, A, B and C, and it's A virus that's the cause of pandemics among human beings.

In terms of the structure of the virus, as you know, it's RNA, wrapped in a protein envelope, with protein spikes on the surface — you can see them — and the spikes are of two major types: hemagglutinin and neuraminidase. The hemagglutinin enables the virus to attach itself to a host cell, in this case in the respiratory tract, and it's neuraminidase that enables the fusion of the virus with cells, so that the viral RNA can be released into the cell's cytoplasm and then migrate to the cell nucleus. The hemagglutinin and neuraminidase have various strains that have been numbered, and you have on your handout those that have been identified for the nineteenth, twentieth and twenty-first century. And everyone knows now H1N1, the swine virus that's currently with us. And I'm sorry on the handout that I've got 2010; I meant to have 2009 to 2011. So, if you could make that correction, that would make me feel happy.

The viral RNA then hijacks the cell and transforms it into a viral factory for the reproduction of virus, and it eventually destroys the cell itself. This process of reproduction is extraordinarily efficient, and nearly instantaneous, so that the idea of measuring generations of viruses begins to lose all meaning. We also need to point out, about influenza virus, that the RNA combines in all sorts of ways, making a genetic characteristic of extreme instability, or should we say mutability.

The processes involved, that you can study up on Science Hill in more detail, involve things called antigen drift, antigen shift, mutation, hybridization, giving rise to subtypes, strains and variants. All of these changes are part of the success story of influenza as a disease, and there is no crossover immunity from one strain to another; acquired immunity, that is, is strain specific. Well, mutability also explains an epidemiological feature of influenza, and that is that pandemics tend to arrive in waves, each being biologically different, with different symptoms and different virulence. And we'll see that the great pandemic, after World War I, had four major waves.

Well, influenza tends to be reflective of the relationships also of human beings and animals — birds, horses and pigs — in that there's interspecies transfer from animals to humans, and from humans in the reverse direction. And this may be the route by which human beings first contracted the disease, and it's known that this, the animal reservoir, is a source of new strains. The hypothesis recently has been that there's a reservoir in Asia, perhaps in China or Asiatic Russia. But interestingly, it's that very hypothesis that misled public health responses when the swine flu pandemic first got underway, in that surveillance was active in the Far East but the disease arrived instead in Mexico.

Chapter 2. Transmission [00:05:17]

What's the history of human beings and influenza? The origins simply aren't known. The earliest clear evidence, of a literary kind, is in the fifteenth and sixteenth centuries. But records are fragmentary and unreliable. So, the best we can do is to look at the last few centuries; the eighteenth, nineteenth, twentieth, and the first years of our own century. In the eighteenth century, there were major pandemics: 1729 to '30, '32 to '33, '61 to '62, and then especially 1781 to 1782, and then 1788 to 1789. In the nineteenth century there were pandemics 1830 to '31, '33, '50 to '51, and then the great pandemic of 1889 to 1890. And in the twentieth century we've had a number of pandemics, the greatest being 1918 to '20; the Spanish Flu, as it was called.

Now, the reason I was reading out the rather grim years of influenza pandemics was to point out first, of course, that they're recurrent and are still with us, as you know, but also to note that there seemed to be something of a pattern of more or less one major pandemic in every century. Well, influenza is a viral infection transmitted person to person; an airborne disease, much more contagious than say SARS, that we remember from just a few years ago. SARS requires prolonged face-to-face contact, but not influenza.

So, a notable feature then of the flu is its rapid communicability. It also has a short incubation period, just twenty-four to seventy-two hours. All of that implies also that epidemiologically it's different from a number of the infectious diseases we've studied. As I said in the email that I sent to you about social diseases, it's really a spectrum, not an absolute, when we talk about being a social disease or not. And I would submit to you that influenza is at the far end of that spectrum, in not really being a classic social disease. It's not very sensitive to economic conditions, sanitation and diet; those features that were hallmarks of malaria, say, or tuberculosis.

Its diffusion occurs wherever human beings move in numbers and breathe. It follows networks of communication: railroads, steamships, airplanes in our time; and ports and railroad hub cities, or now we would say airport centers, tend to be foci of infection, and were first attacked with lightening speed. So, flu was favored by the transportation technology of the industrial revolution and since, and once again by urbanization, and of course population growth and overcrowding.

Chapter 3. 1889-90 Pandemic [00:09:06]

Let's look at a precursor to the great pandemic of the First World War, and this is the horrible pandemic of the nineteenth century, of 1889 to 1890. This was the first truly global pandemic of influenza, and the most devastating one in history, until that time. It affected every continent. The reasons were that the world was prepared now for pandemic influenza, as a result of the transportation revolution — the railroad and the steamship — urbanization and trade, demographic growth and colonialism. Vulnerability to influenza then seems to be, in part, a byproduct of modernization, as we've been reminded by recent events. Studies of 1889 to 1890 demonstrate this in more detail.

In cities like Moscow, Paris or London, the first cases occurred in October to November of 1889. And these tended not to be noticed; there was nothing particular about them that people noted at the time. But they occurred among very particular sectors of the population that were most involved in trade, commerce and the nodes of communication; that is, the first people to fall ill tended to be dockers or post-office workers, railway men, policemen. Furthermore, the less industrialized the locality, the more remote and agricultural it was, the later and less severely the locality suffered. In 1889 to 1890, the Alps in Europe, Italy, Spain and Portugal, all lagged behind Northern Europe and the United States, and even in the great urban centers there were isolated, small communities that sometimes survived entirely unscathed; monasteries and convents, for example, in both Moscow and Paris experienced the pandemic without victims, in some cases. And this was sometimes true also of closed institutions like prisons.

Then typically, after following the transportation network — and this was true of 1889 to '90 — the flu spread along what's called the urban hierarchy; that is, it went first to major cities, and from there into the hinterland of those cities, and only later to smaller towns, villages and rural areas. And 1918 to '19, in the United States, shows this same pattern; that is, the flu went almost instantaneously from Boston and New York to Cincinnati, Chicago, New Orleans, Detroit, San Francisco, Seattle, and then at greater leisure it moved into almost every place in between, until there was hardly a settlement of any size that had been entirely spared.

Wherever it went, rich and poor, educated and illiterate, men and women, the physically fit and the unfit, were similarly infected. But there were circumstances, certain ones, that were especially favorable to the disease. A crowded urban environment was clearly one, where people were streaming in and out, in closely packed milieus: schools, theaters, barracks, naval ships, tenement buildings, college dormitories. In all the epidemics of influenza, except 1918 to '20, there was also a strong predilection of the influenza virus for the infants and the elderly. There also tended to be an over-representation of people with pre-existing respiratory diseases — say tuberculosis or bronchitis — or people with immunosuppressive diseases. The great example, until the HIV/AIDS era, was, of course, malaria, and malarial victims were highly susceptible to influenza. So, the tubercular and the malarial died massively during influenza pandemics.

A typical graph then of the influenza mortality would show a neat U-shaped curve, spiked at both ends of the age spectrum of the population, the very young and the elderly. Another common feature of influenza pandemics was pronounced seasonality. In the Northern Hemisphere, influenza almost invariably peaked in the winter months, November to February, and ended with the coming of warm weather in the spring. The reasons for — good epidemiological explanations have to do partly with human behavior. People tend to congregate indoors in the winter, often in buildings and rooms that are poorly ventilated. The virus itself doesn't survive well in an environment where there's sunlight and high humidity, and winter is a time when people tend to sneeze and cough more than at other times.

What are some other features of flu pandemics? One is short duration. This helps to understand societal responses as well. We know that plague and cholera tended to lay siege to a locality for months, and in the community it felt quite like that. But flu tended to last just a few weeks, and then to move on. It was true also that there was a high morbidity — that is, lots of people would fall ill from influenza — but there was a low case fatality rate. The overall mortality would be large simply because of the large numbers of sufferers. The kill rate was low. In the nineteenth century, influenza, however, killed far more people than cholera, and a stark contrast then could be drawn.

Flu seems to be quintessentially a contagious disease. But since you're interested in the debate between — this is one of your favorites, I'm sure — between anticontagionism and contagionism, we might point out to you that even although you think it seems to be self-evident that influenza, the grippe, the flu is contagious, that many of the, in fact the dominant current, still in the 1890s, was that influenza was not contagious. And the eminent British epidemiologist, Charles Creighton, still held to anticontagionism regarding this disease, down into the 1890s.

Well, what sorts of things held Creighton back from accepting influenza as an infectious disease? First he argued the disease would affect most parts of a country in the same two or three weeks. There simply wasn't time for a contagious disease to spread with that extreme rapidity, he thought. He also thought within a smaller radius it seemed to affect everyone, say in a household, more or less simultaneously. Everyone would fall ill at once. So, it seemed there wasn't time for contagion. And it was this simultaneous, sudden outbreak of influenza that gave it some of its traditional names. It was called the grippe; not only in French, la grippe, but also in English in the nineteenth century it was referred to as grippe. And partly that's because it seemed suddenly to seize people in its grasp.

Typically, you could be healthy at breakfast, only to find yourself suffering with chills, fever, aching bones and nausea by lunchtime. Similarly, Moscow seemed, to physicians, to be healthy on the first of November, 1889, but by the middle of the month the disease was everywhere. Shops and schools were closed, commerce nearly ground to a halt. And this gave it — was part of the reason it got its other name, influenza. This was an Italian word meaning influence, and in this case people speculated about the influence of some cosmic factor that would disturb the microcosm as well. Perhaps it was the influence of the stars or the heavens that poisoned or corrupted the atmosphere and lay low whole cities all at once.

What about symptoms, effects on the individual? I think we can be brief, because it's probably very familiar to you, from personal experience; that is, seasonal influenza. The onset, as we've said, is normally sudden. The symptoms then are ones that you know: a high fever, 100 to 104 degrees Fahrenheit, typically; an unproductive cough; aching of muscles in the back, the legs; watery eyes; sometimes nausea and vomiting; general malaise; headache; pain in the joints; sometimes dizziness; and a general sense of fatigue and weakness. Typically the acute phase would last three to five days, and for a few days more you'd suffer from your cough and from lethargy. And then, in the vast number of cases, there would be recovery.

Flu, for young adults in good health, enjoyed a reputation as a nasty but mercifully short, and usually not serious, affliction. Influenza in the middle of the nineteenth century — that is, at least before the cataclysm of 1889 and 1890 — was — people joked about it, that it was a disease that was so unimportant that the only physicians who gave it much attention were those who simply had too few patients, and so started treating people with flu as a means of enhancing their income. On the other hand, for infants, for the elderly and those with chronic disease, it sometimes led to serious and even fatal complications; and it was the complications, much more than the flu, that tended to kill. Patients who didn't recover after three or four days then moved on to serious complications like pneumonia or bronchitis. And about once a century, a strain of influenza that was not seasonal but pandemic appeared, and demonstrated that flu can in fact, under certain conditions, be one of the most deadly of all diseases.

Well, what about treatment? Today, as in the past, there's no specific remedy for influenza, as we've been reminded by recent events in the newspapers. The disease is self-limiting normally, and simply runs its course. So, therapy is supportive and symptomatic, rest and nursing care, more than active medical intervention. In the nineteenth century this was also recognized, and physicians weren't inclined to try heroic remedies, as they did say with Asiatic cholera. But there were certain attempts at therapeutics in the nineteenth century, and even after World War I people were given aspirin, cinnamon with milk to lower temperature, fluids and nourishment, bed rest. Quinine was administered to lower the fever. There were warm baths for hydrotherapy; oxygen sometimes administered to patients with respiratory complications. And some physicians recommended caffeine to raise the flagging animal energy, as it was called.

Today the only actual therapeutics is antibiotics, but they don't combat the influenza itself, but its complication of pneumonia.

Chapter 4. Spanish Influenza [00:24:00]

Well, against that background, let's look more closely at the Spanish influenza — the Spanish Lady, the Spanish grippe, as it was called — from 1918 to 1920. Well, first you'll probably wonder, why this Spanish association? And the reason has actually nothing to do with Spain itself and disease. It was simply that Spain was not a belligerent in the First World War, and therefore was free of censorship of the media. Hence a free press reported the medical crisis there extensively. A popular theory in circulation these days is that perhaps the Spanish Lady originated not in Spain at all, but in Kansas.

In any event, on the morning of — finding the case zero is a perilous art, but let's say that at least this much is known — on the morning of the eleventh of March, 1918, at Fort Riley, the cook, Albert Gitchell, reported sick. By noon, the camp infirmary had some 100 cases, and these were the earliest known examples of this new influenza. There's some background that helps us comprehend the extraordinary case of 1918 to 1920. As in the past, mutations occurred, and in this time produced a new strain that turned out to be more virulent than any in influenza's history. Its mode of communication was identical to other flu pandemics, but its effects on both the individual and society were radically different.

So, let's talk about this pandemic as coming in four waves. The first was in the spring of 1918, and was relatively mild, in March and April. It soon passed, and it attracted little attention. Wartime press censorship was partly a factor, but people were simply preoccupied with the war and not with the presence of a mild outbreak of a well-known and common disease. The second wave was the fall of 1918, which was the worldwide disaster. It began in August with simultaneous explosions in places as far apart as Sierra Leone, Boston in this country, Brest in France; a common feature being that these were all port cities, and had an important role in the movements of troops and supplies. In this case, one could argue that not only the war itself, but also the coming of peace, contributed to the spread of the flu.

Armistice Day itself produced huge crowds and gatherings, which were not propitious for stopping the spread of the disease. Then came the spring of 1919, a less, much less, mercifully less severe wave. And then finally January, February of 1920, the fourth wave of the Spanish Lady, which was mild, and limited in its morbidity even. Partly, of course, because by then so many people were already immune. Well, there are a number of features of the Spanish Lady that made her unique. The first was that it possessed an extraordinary mortality and morbidity. Comparing it with normal outbreaks of influenza, it's impossible to generate precise statistics. But there are speculations that this was perhaps, in absolute terms, the greatest demographic shock that humanity had ever experienced from infectious diseases.

More people died of influenza than of casualties in the First World War. Worldwide, some estimates — the estimates vary widely, so one has to take them with great caution. But they ranged from 25,000,000 people perishing, upwards to — the highest estimates are about 100,000,000. In the United States it's pretty well known that at least 675,000 people perished; more than American casualties in all twentieth-century wars; ten times the numbers killed in First World War. In a normal — if there is such a thing — influenza outbreak, a case fatality rate might be something like 0.1 percent. In the case of the Spanish influenza, the case fatality rate was just above 2.5 percent, and this yielded a vast total mortality, because indeed, as it seemed at the time, almost everyone was infected.

Let's look at a slide of the death rates. You can see the influenza, the great wave in October, November, December of 1918. The black is 1918 — rather, sorry, is the average 1911 to 1917, and the grey is 1918. So, this compares influenza then with what we might call normal influenza. You can see the extraordinary new mortality. Another feature of this influenza was the lack of understanding of the disease when it broke out. Indeed, I'd like to quote Victor Vaughan, who directed public health in the United States Army against the Spanish Lady. And he said, and I'm quoting: "Doctors know no more about the flu than fourteenth-century Florentines did about the Black Death." And I think it's important to understand this idea of a sense of helplessness facing this medical catastrophe.

Some physicians indeed, in 1918, termed what they were facing "epidemic pneumonia." And then, as now, there was no effective treatment. The symptoms were distinctive. As you now know from reading Crosby, this influenza was fulminant, and post-mortem lung examinations revealed things that were unlike anything that examining physicians had seen before. Enormous quantities of bloody fluid, like a froth, filling the lungs. Some physicians, on their first encounter, suspected that this was a kind of pneumonic plague.

Right here in New Haven, in the New Haven Hospital, pathologists wrote that the devastation caused to the lungs more than anything else resembled the effects of poisonous gases used in World War I,-like phosgene or chlorine, were the comparisons that came to their mind. Furthermore, although other organs of the body could be affected — the spleen, for example — the impact of the Spanish Lady on the lungs was so overwhelming that that alone was often the cause of death, and pulmonary effects were almost the only ones that people noticed.

Let me read a passage from Katherine Anne Porter, the famous writer, Pale Horse, Pale Rider, where she was herself a victim of the influenza. And she writes here in the third person, but she's describing her own symptoms, and I think it's worth noting how she felt: "Silenced, Miranda sank easily through deeps upon deeps of darkness, until she lay like a stone at the farthest bottom of life, knowing herself to be blind, deaf, speechless, no longer aware of the members of her own body, entirely withdrawn from all human concerns, yet alive with a peculiar lucidity and coherence. All notions of the mind, the reasonable inquiries of doubt, all ties of blood and desires of the heart, dissolved and fell away from her, and there remained only a minute, fiercely burning particle of being that knew itself alone, that relied upon nothing beyond itself for its strength, not susceptible to any appeal or inducement, being itself composed entirely of one single motive, the stubborn will to live. This fiery, motionless particle set itself unaided to resist destruction, to survive, and to be in its own madness of being, motiveless and planless, beyond that one essential end. She felt, without warning, a vague tremor of apprehension, some small flick of distrust in her joy. A thin frost touched the edges of this confident tranquility. Something, somebody was missing. She'd lost something. She had left something valuable in another country. What could it be? 'There are no trees, no trees here,' she said in fright. 'I've left something unfinished.' A thought struggled at the back of her mind, came clearly as a voice in her ear. 'Where are the dead? We've forgotten the dead. The dead, where are they?' At once, as if a curtain had fallen, the bright landscape faded. She was alone in a strange stony place of bitter cold, picking her way along a steep path of slippery snow, calling out, 'Oh I must go back. But in what direction?' Pain returned, a terrible compelling pain, running through her veins like heavy fire. The stench of corruption filled her nostrils. The sweetish, sickening smell of rotting flesh and pus. She opened her eyes and saw pale light through a coarse white cloth over her face, and she knew that the smell of death was in her own body, and she struggled to lift her hand."

There are also pictures of — this is a famous painting of Edvard Munch, After the Influenza, in 1919. Or this is also — in fact, this is called After the Flu, painted in 1919. A doctor wrote that his patients died, struggling to clear their airways of a blood-tinged froth that gushed from their noses and mouths. The fluid then filled the respiratory system, from the trachea to the tiniest alveoli and bronchioles. And at post-mortem examination the lungs were greatly distended, and when pressed, even lightly, oozed with blood-tinged fluid and yellow pus. The walls of the alveoli collapsed under the pressure, leaving a formless mass where neither blood nor air could flow freely, and the patient died of asphyxia, or the blockage of pulmonary circulation.

Let me show you two pictures of the lungs of a young woman who died of the Spanish Lady at the New Haven Hospital, and I think you can see the enormous and terrifying destruction of the lungs that occurred. Well, in addition, there were important sequelae. One feature of the Spanish Lady was the distinctive length of convalescence. And also there were neurological aftereffects, protracted depression, and there is speculation that throughout the 1920s there was an outbreak of neurological afflictions, that Oliver Sacks deals with in his famous book Awakenings. There's some dispute about whether this was an authentic, among authentic sequelae of the Spanish influenza, but it is at least plausible.

Chapter 5. Epidemiology and Responses [00:38:09]

Another feature that made this pandemic distinctive was the age profile of the victims. We've seen how normally in influenza there's a U-shaped curve. It does what seems normal to people, attacking the very young and the elderly. The Spanish Lady instead had a preference for adults in the twenty to forty-year age group. And so it produced something that seemed highly unnatural, a W-shaped curve, with a spike in the middle, afflicting the people in the prime of life. Victor Vaughan again observed that the Spanish flu imitated the war itself, and that it killed young adults. Like war, he said, this infection kills young, vigorous, robust adults. The reasons are still mysterious. But one could point to a couple of partial factors.

Perhaps the elderly had some immunity left over from the great pandemic of 1889 to '90. And it was the young, of course, epidemiologically, who most directly experienced the war and military service, in close, crowded conditions; just the young population, most at risk. And for those of you who think that working out at the gym protects you from influenza pandemics, I would point out that the physically fit also fell ill in comparable numbers. John Hellum, the U.S. pentathlon champion — that is, someone who did the broad jump, discus, javelin, 200-meters and 1500 meters — died in October 1918 of the flu. As did Jackie O'Shaughnessy, who was the U.S. National quarter-mile champion. So, physical fitness had nothing to do with survival from the influenza.

Let me show you a graph. This is the notorious U-shaped curve of the influenza. And you see the two curves together. The dotted line is normal influenza, and this solid line, with the terrible W in the middle, is the mortality from the Spanish Lady. Well, meanwhile, what happened with public health? And here a major feature is to point out — and we should think of this in terms of lessons for preparedness today — was the way that the public health service was overwhelmed. It was overwhelmed in part because of the extreme rapidity with which this disease, through its airborne transmission, was spread; by the speed of transportation, and the short incubation period of the disease.

It was also true that there is a percentage — perhaps ten percent, in the Spanish Lady — of people who are asymptomatic carriers. Influenza also was not a reportable disease. It was maximized also because of the unavoidable and uncontrollable movement of troops, because of the war. But in addition, there was a lack — and we might think about this — of preparation for just such an emergency, a shortage of doctors, nurses, hospital beds and space on hospital wards. Influenza also has the terrible feature, unlike cholera for example, that it creates chaos within the health system itself, by striking down caregivers who are among those who are most vulnerable. And then there was the war itself, in which doctors and nurses were mobilized to deal with the victims of the conflict.

So, there were drastic shortages of healthcare personnel available to the civilian population. Rupert Blue, whom you will remember from the Barbary Plague, was a director of public health services during the crisis, and he was forced to lure doctors and nurses out of retirement, to help deal with the emergency; to recruit even from old-age homes. Well, what were the measures adopted to deal with the crisis? Anti-flu measures, by this time, were based on the premise that this was a contagious disease, and the understanding that influenza was spread somehow through the air. A first major goal was to prevent those who were healthy from inhaling the contaminated air of the infected. To that end, public gatherings and assemblies of large numbers of people at close quarters were banned. Public institutions were closed: schools, dancehalls, movie theaters, bars. Churches in this country were allowed to remain open, but the number of services was greatly reduced.

In many cities, people seen by the police to be coughing and sneezing, without covering their faces, were stopped and fined. The New York City Department of Health posted some 10,000 placards around the city, bearing a message that was familiar to the public, because of its similarity to the urgings of the campaign against tuberculosis. So, one can see the anti-tuberculosis campaign preparing people, in a sense, for dealing with influenza. And in New York City the placards said: to prevent the spread of Spanish influenza, sneeze, cough or expectorate, if you absolutely must, into your own handkerchief; you're in no danger if everyone should heed this warning.

Another widespread measure was a practical application also. One was masking with gauze masks, and some municipalities required their whole populations to put on masks. San Francisco did so, and so did San Diego. Another was disinfection practices, applied in hospital wards, sickrooms and ambulances. Trains too were washed down with antiseptic solutions. You can see a picture of the properly masked police. I think this is San Francisco. And here you can see the general masking of the whole population. And this was a public notice, a public health poster from Kingston, New York or — and it says about the measures I've told you about; theaters, churches, schools, hospitals, and so forth. Or you can see here another poster for public health.

State boards of health also isolated the ill through quarantine, as far as possible, and the military tried to quarantine its training camps. On hospital wards, sheets were hung between beds. Ambulance trains were washed down with antiseptic. People were urged to avoid nervous and physical exhaustion. You can see a long legacy of this idea. You remember Laennec talking about the passions tristes, the sad passions, and their influence on your constitution. So, some of the advice had a really long history that you'll recognize. And they also cautioned you to avoid chills. They urged people to gargle with warm water and salt, and to spray saline solutions up their nose, to wear gauze masks. And legislation was passed to prevent the use of common drinking cups. Some people sprayed their nostrils with carbolic acid spray, and some towns set up fines to punish people they called — this was one of the jargons at the time — the open-face sneezer.

New York City modified the opening hours of stores and businesses in order to stagger rush hour, so that subway trains and trams would not be so crowded and not be so dangerous. Congress voted special funds to enable Surgeon General Rupert Blue to recruit thousands of doctors and hundreds of nurses. But, as I said, the war effort complicated his task, and he turned to people who'd retired. And those were other — I wanted to show you a camp. The fact that it was wartime made it easy for the government to induce people to accept rigorous measures. People by this time had grown used, by 1918, to invasive and restrictive measures. They already knew all about the draft, or rationing, or daylight savings time. But existing facilities were inadequate to cope with a sudden surge, and so the general public, one can see, suffering as a result of that.

I wanted to mention that there were also popular remedies that people adapted, and especially in rural areas, recourse to folk remedies and magic. Onion soup was thought to be a preventative. People stuffed salt up their nostrils to ward off danger. They wore garlic around their neck, as they had in Florence in the time of bubonic plague. They burned hot charcoals with sulfur or brown sugar, to give off a reassuring protective aroma; you can recognize this too from the plague. There were rumors that the disease perhaps was an act of bio-terror. There were thoughts that there were mysterious German agents who landed on U-boats and started the epidemic. There were suspicious too that poisonous gases associated with the war effort had escaped and caused the disaster.

Well, I will run out of time now, and just say that one of the things to think about then are what are possible lessons? And I just wanted to leave us to think, as we deal with our own H1N1, and possibly whatever its successor is, that clearly in 1918 and '19, there's a collective memory in the public health service of the vulnerability of a society of critically ill patients, turned away from hospitals, that were full to bursting, with no care available because the system was overwhelmed. And there's a fear then of what about the effects now of the impact of organized care medicine, on a managed care basis, with cost-cutting search for savings in our system; the commitment to ridding hospitals of excess capacity and spare beds. And so this approach raises the question of what would happen in another time when the system might once again be tested?

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