WEBVTT

00:01.560 --> 00:06.750
Prof: Our topic this
morning is influenza,

00:06.745 --> 00:09.765
which is timely for today.

00:09.770 --> 00:13.910
And I'd like to begin by
talking about influenza virus

00:13.906 --> 00:17.396
more in general,
and we'll concentrate our

00:17.403 --> 00:20.233
attention,
for obvious reasons,

00:20.227 --> 00:25.337
on the Spanish Lady,
the great influenza of

00:25.336 --> 00:26.866
1918,1919.

00:26.870 --> 00:31.840
Now, influenza virus was
isolated in the 1930s by

00:31.840 --> 00:37.330
Andrews, Wilson and Laidlaw,
and the mechanisms of the

00:37.329 --> 00:41.989
disease were then unraveled
subsequently.

00:41.990 --> 00:44.670
As you know,
there are three types,

00:44.668 --> 00:49.158
A, B and C, and it's A virus
that's the cause of pandemics

00:49.158 --> 00:50.968
among human beings.

00:50.970 --> 00:55.210
In terms of the structure of
the virus,

00:55.210 --> 01:00.670
as you know,
it's RNA, wrapped in a protein

01:00.670 --> 01:04.690
envelope,
with protein spikes on the

01:04.685 --> 01:09.425
surface--
you can see them--and the

01:09.427 --> 01:16.567
spikes are of two major types:
hemagglutinin and

01:16.566 --> 01:19.146
neuraminidase.

01:19.150 --> 01:24.750
The hemagglutinin enables the
virus to attach itself to a host

01:24.754 --> 01:27.944
cell,
in this case in the respiratory

01:27.938 --> 01:31.058
tract,
and it's neuraminidase that

01:31.060 --> 01:35.210
enables the fusion of the virus
with cells,

01:35.209 --> 01:40.169
so that the viral RNA can be
released into the cell's

01:40.173 --> 01:44.853
cytoplasm and then migrate to
the cell nucleus.

01:44.849 --> 01:48.629
The hemagglutinin and
neuraminidase have various

01:48.626 --> 01:53.406
strains that have been numbered,
and you have on your handout

01:53.406 --> 01:57.126
those that have been identified
for the nineteenth,

01:57.129 --> 01:59.519
twentieth and twenty-first
century.

01:59.519 --> 02:04.249
And everyone knows now H1N1,
the swine virus that's

02:04.248 --> 02:06.138
currently with us.

02:06.140 --> 02:10.160
And I'm sorry on the handout
that I've got 2010;

02:10.159 --> 02:13.659
I meant to have 2009 to 2011.

02:13.658 --> 02:17.548
So, if you could make that
correction, that would make me

02:17.546 --> 02:18.446
feel happy.

02:18.449 --> 02:25.199
The viral RNA then hijacks the
cell and transforms it into a

02:25.200 --> 02:30.120
viral factory for the
reproduction of virus,

02:30.121 --> 02:35.501
and it eventually destroys the
cell itself.

02:35.500 --> 02:39.890
This process of reproduction is
extraordinarily efficient,

02:39.889 --> 02:44.859
and nearly instantaneous,
so that the idea of measuring

02:44.855 --> 02:49.635
generations of viruses begins to
lose all meaning.

02:49.639 --> 02:54.619
We also need to point out,
about influenza virus,

02:54.620 --> 02:58.440
that the RNA combines in all
sorts of ways,

02:58.440 --> 03:04.070
making a genetic characteristic
of extreme instability,

03:04.069 --> 03:06.909
or should we say mutability.

03:06.908 --> 03:10.428
The processes involved,
that you can study up on

03:10.427 --> 03:15.957
Science Hill in more detail,
involve things called antigen

03:15.955 --> 03:18.435
drift,
antigen shift,

03:18.438 --> 03:24.138
mutation, hybridization,
giving rise to subtypes,

03:24.143 --> 03:26.653
strains and variants.

03:26.650 --> 03:31.940
All of these changes are part
of the success story of

03:31.935 --> 03:36.805
influenza as a disease,
and there is no crossover

03:36.813 --> 03:40.883
immunity from one strain to
another;

03:40.878 --> 03:46.058
acquired immunity,
that is, is strain specific.

03:46.060 --> 03:51.580
Well, mutability also explains
an epidemiological feature of

03:51.583 --> 03:56.203
influenza,
and that is that pandemics tend

03:56.198 --> 04:00.268
to arrive in waves,
each being biologically

04:00.270 --> 04:03.890
different, with different
symptoms and different

04:03.889 --> 04:04.889
virulence.

04:04.889 --> 04:10.109
And we'll see that the great
pandemic, after World War I,

04:10.114 --> 04:12.264
had four major waves.

04:12.258 --> 04:20.028
Well, influenza tends to be
reflective of the relationships

04:20.033 --> 04:24.863
also of human beings and
animals--

04:24.860 --> 04:30.450
birds, horses and pigs--in that
there's interspecies transfer

04:30.447 --> 04:35.347
from animals to humans,
and from humans in the reverse

04:35.350 --> 04:36.260
direction.

04:36.259 --> 04:39.969
And this may be the route by
which human beings first

04:39.966 --> 04:43.876
contracted the disease,
and it's known that this,

04:43.877 --> 04:49.807
the animal reservoir,
is a source of new strains.

04:49.810 --> 04:55.030
The hypothesis recently has
been that there's a reservoir in

04:55.033 --> 04:58.843
Asia, perhaps in China or
Asiatic Russia.

04:58.839 --> 05:02.729
But interestingly,
it's that very hypothesis that

05:02.732 --> 05:07.352
misled public health responses
when the swine flu pandemic

05:07.353 --> 05:12.303
first got underway,
in that surveillance was active

05:12.300 --> 05:18.010
in the Far East but the disease
arrived instead in Mexico.

05:18.009 --> 05:22.809
What's the history of human
beings and influenza?

05:22.810 --> 05:26.000
The origins simply aren't known.

05:26.000 --> 05:29.970
The earliest clear evidence,
of a literary kind,

05:29.966 --> 05:33.846
is in the fifteenth and
sixteenth centuries.

05:33.850 --> 05:38.080
But records are fragmentary and
unreliable.

05:38.079 --> 05:42.979
So, the best we can do is to
look at the last few centuries;

05:42.980 --> 05:45.870
the eighteenth,
nineteenth, twentieth,

05:45.867 --> 05:49.067
and the first years of our own
century.

05:49.069 --> 05:56.359
In the eighteenth century,
there were major pandemics:

05:56.360 --> 06:01.180
1729 to '30,
'32 to '33, '61 to '62,

06:01.175 --> 06:09.425
and then especially 1781 to
1782, and then 1788 to 1789.

06:09.430 --> 06:15.530
In the nineteenth century there
were pandemics 1830 to '31,

06:15.526 --> 06:20.356
'33, '50 to '51,
and then the great pandemic of

06:20.362 --> 06:22.152
1889 to 1890.

06:22.149 --> 06:27.139
And in the twentieth century
we've had a number of pandemics,

06:27.142 --> 06:31.322
the greatest being 1918 to '20;
the Spanish Flu,

06:31.319 --> 06:32.929
as it was called.

06:32.930 --> 06:37.490
Now, the reason I was reading
out the rather grim years of

06:37.490 --> 06:41.170
influenza pandemics was to point
out first,

06:41.170 --> 06:45.140
of course, that they're
recurrent and are still with us,

06:45.139 --> 06:48.609
as you know,
but also to note that there

06:48.607 --> 06:53.407
seemed to be something of a
pattern of more or less one

06:53.408 --> 06:56.608
major pandemic in every century.

06:56.610 --> 07:02.140
Well, influenza is a viral
infection transmitted person to

07:02.144 --> 07:04.954
person;
an airborne disease,

07:04.947 --> 07:10.827
much more contagious than say
SARS, that we remember from just

07:10.827 --> 07:12.657
a few years ago.

07:12.660 --> 07:17.310
SARS requires prolonged
face-to-face contact,

07:17.307 --> 07:19.417
but not influenza.

07:19.420 --> 07:23.960
So, a notable feature then of
the flu is its rapid

07:23.961 --> 07:25.631
communicability.

07:25.629 --> 07:30.549
It also has a short incubation
period, just twenty-four to

07:30.545 --> 07:32.265
seventy-two hours.

07:32.269 --> 07:37.879
All of that implies also that
epidemiologically it's different

07:37.884 --> 07:43.134
from a number of the infectious
diseases we've studied.

07:43.129 --> 07:48.779
As I said in the email that I
sent to you about social

07:48.779 --> 07:52.029
diseases,
it's really a spectrum,

07:52.033 --> 07:55.563
not an absolute,
when we talk about being a

07:55.564 --> 07:57.324
social disease or not.

07:57.319 --> 08:02.619
And I would submit to you that
influenza is at the far end of

08:02.620 --> 08:06.420
that spectrum,
in not really being a classic

08:06.420 --> 08:08.100
social disease.

08:08.100 --> 08:14.340
It's not very sensitive to
economic conditions,

08:14.336 --> 08:19.726
sanitation and diet;
those features that were

08:19.730 --> 08:24.150
hallmarks of malaria,
say, or tuberculosis.

08:24.149 --> 08:30.519
Its diffusion occurs wherever
human beings move in numbers and

08:30.516 --> 08:31.556
breathe.

08:31.560 --> 08:34.890
It follows networks of
communication:

08:34.890 --> 08:39.240
railroads, steamships,
airplanes in our time;

08:39.240 --> 08:44.060
and ports and railroad hub
cities, or now we would say

08:44.062 --> 08:48.162
airport centers,
tend to be foci of infection,

08:48.158 --> 08:52.708
and were first attacked with
lightening speed.

08:52.710 --> 08:57.190
So, flu was favored by the
transportation technology of the

08:57.187 --> 09:02.687
industrial revolution and since,
and once again by urbanization,

09:02.691 --> 09:07.211
and of course population growth
and overcrowding.

09:07.210 --> 09:13.390
Let's look at a precursor to
the great pandemic of the First

09:13.394 --> 09:18.644
World War, and this is the
horrible pandemic of the

09:18.635 --> 09:22.825
nineteenth century,
of 1889 to 1890.

09:22.830 --> 09:27.490
This was the first truly global
pandemic of influenza,

09:27.485 --> 09:32.665
and the most devastating one in
history, until that time.

09:32.669 --> 09:35.679
It affected every continent.

09:35.678 --> 09:40.328
The reasons were that the world
was prepared now for pandemic

09:40.331 --> 09:42.681
influenza,
as a result of the

09:42.678 --> 09:46.548
transportation revolution--
the railroad and the

09:46.552 --> 09:49.782
steamship--urbanization and
trade,

09:49.779 --> 09:53.919
demographic growth and
colonialism.

09:53.918 --> 09:59.138
Vulnerability to influenza then
seems to be, in part,

09:59.135 --> 10:04.545
a byproduct of modernization,
as we've been reminded by

10:04.553 --> 10:06.363
recent events.

10:06.360 --> 10:13.890
Studies of 1889 to 1890
demonstrate this in more detail.

10:13.889 --> 10:17.889
In cities like Moscow,
Paris or London,

10:17.890 --> 10:24.000
the first cases occurred in
October to November of 1889.

10:24.000 --> 10:25.950
And these tended not to be
noticed;

10:25.950 --> 10:31.840
there was nothing particular
about them that people noted at

10:31.841 --> 10:32.941
the time.

10:32.940 --> 10:37.210
But they occurred among very
particular sectors of the

10:37.214 --> 10:40.684
population that were most
involved in trade,

10:40.681 --> 10:44.231
commerce and the nodes of
communication;

10:44.230 --> 10:49.890
that is, the first people to
fall ill tended to be dockers or

10:49.889 --> 10:52.909
post-office workers,
railway men,

10:52.908 --> 10:54.228
policemen.

10:54.230 --> 10:58.060
Furthermore,
the less industrialized the

10:58.057 --> 11:02.867
locality, the more remote and
agricultural it was,

11:02.868 --> 11:08.168
the later and less severely the
locality suffered.

11:08.168 --> 11:13.378
In 1889 to 1890,
the Alps in Europe,

11:13.379 --> 11:17.659
Italy, Spain and Portugal,
all lagged behind Northern

11:17.663 --> 11:22.373
Europe and the United States,
and even in the great urban

11:22.374 --> 11:26.844
centers there were isolated,
small communities that

11:26.840 --> 11:30.670
sometimes survived entirely
unscathed;

11:30.668 --> 11:34.128
monasteries and convents,
for example,

11:34.125 --> 11:39.355
in both Moscow and Paris
experienced the pandemic without

11:39.356 --> 11:41.876
victims, in some cases.

11:41.879 --> 11:47.619
And this was sometimes true
also of closed institutions like

11:47.616 --> 11:48.586
prisons.

11:48.590 --> 11:51.580
Then typically,
after following the

11:51.578 --> 11:57.208
transportation network--and this
was true of 1889 to '90--the flu

11:57.206 --> 12:01.686
spread along what's called the
urban hierarchy;

12:01.690 --> 12:07.320
that is, it went first to major
cities, and from there into the

12:07.315 --> 12:12.025
hinterland of those cities,
and only later to smaller

12:12.033 --> 12:15.303
towns, villages and rural areas.

12:15.298 --> 12:18.808
And 1918 to '19,
in the United States,

12:18.806 --> 12:23.796
shows this same pattern;
that is, the flu went almost

12:23.796 --> 12:28.936
instantaneously from Boston and
New York to Cincinnati,

12:28.940 --> 12:32.260
Chicago, New Orleans,
Detroit, San Francisco,

12:32.259 --> 12:38.469
Seattle, and then at greater
leisure it moved into almost

12:38.466 --> 12:43.336
every place in between,
until there was hardly a

12:43.342 --> 12:47.832
settlement of any size that had
been entirely spared.

12:47.830 --> 12:51.030
Wherever it went,
rich and poor,

12:51.029 --> 12:54.949
educated and illiterate,
men and women,

12:54.951 --> 13:01.351
the physically fit and the
unfit, were similarly infected.

13:01.350 --> 13:04.720
But there were circumstances,
certain ones,

13:04.719 --> 13:08.569
that were especially favorable
to the disease.

13:08.570 --> 13:14.130
A crowded urban environment was
clearly one,

13:14.129 --> 13:18.269
where people were streaming in
and out,

13:18.269 --> 13:21.499
in closely packed milieus:
schools,

13:21.500 --> 13:24.350
theaters, barracks,
naval ships,

13:24.347 --> 13:29.567
tenement buildings,
college dormitories.

13:29.570 --> 13:34.940
In all the epidemics of
influenza, except 1918 to '20,

13:34.942 --> 13:40.212
there was also a strong
predilection of the influenza

13:40.211 --> 13:44.471
virus for the infants and the
elderly.

13:44.470 --> 13:49.360
There also tended to be an
over-representation of people

13:49.356 --> 13:53.086
with pre-existing respiratory
diseases--

13:53.090 --> 13:57.450
say tuberculosis or
bronchitis--or people with

13:57.450 --> 14:00.260
immunosuppressive diseases.

14:00.259 --> 14:04.199
The great example,
until the HIV/AIDS era,

14:04.202 --> 14:08.442
was, of course,
malaria, and malarial victims

14:08.436 --> 14:12.376
were highly susceptible to
influenza.

14:12.379 --> 14:18.959
So, the tubercular and the
malarial died massively during

14:18.956 --> 14:21.536
influenza pandemics.

14:21.538 --> 14:28.568
A typical graph then of the
influenza mortality would show a

14:28.568 --> 14:33.568
neat U-shaped curve,
spiked at both ends of the age

14:33.567 --> 14:39.907
spectrum of the population,
the very young and the elderly.

14:39.908 --> 14:44.338
Another common feature of
influenza pandemics was

14:44.335 --> 14:46.635
pronounced seasonality.

14:46.639 --> 14:51.089
In the Northern Hemisphere,
influenza almost invariably

14:51.086 --> 14:55.576
peaked in the winter months,
November to February,

14:55.581 --> 15:00.851
and ended with the coming of
warm weather in the spring.

15:00.850 --> 15:04.920
The reasons for--good
epidemiological explanations

15:04.923 --> 15:08.253
have to do partly with human
behavior.

15:08.250 --> 15:12.220
People tend to congregate
indoors in the winter,

15:12.215 --> 15:17.105
often in buildings and rooms
that are poorly ventilated.

15:17.110 --> 15:21.150
The virus itself doesn't
survive well in an environment

15:21.153 --> 15:24.453
where there's sunlight and high
humidity,

15:24.450 --> 15:29.960
and winter is a time when
people tend to sneeze and cough

15:29.955 --> 15:32.605
more than at other times.

15:32.610 --> 15:35.900
What are some other features of
flu pandemics?

15:35.899 --> 15:37.799
One is short duration.

15:37.798 --> 15:41.628
This helps to understand
societal responses as well.

15:41.629 --> 15:46.489
We know that plague and cholera
tended to lay siege to a

15:46.485 --> 15:50.715
locality for months,
and in the community it felt

15:50.724 --> 15:52.494
quite like that.

15:52.490 --> 15:59.450
But flu tended to last just a
few weeks, and then to move on.

15:59.450 --> 16:04.150
It was true also that there was
a high morbidity--that is,

16:04.148 --> 16:09.088
lots of people would fall ill
from influenza--but there was a

16:09.094 --> 16:11.324
low case fatality rate.

16:11.320 --> 16:16.560
The overall mortality would be
large simply because of the

16:16.556 --> 16:19.216
large numbers of sufferers.

16:19.220 --> 16:22.850
The kill rate was low.

16:22.850 --> 16:27.240
In the nineteenth century,
influenza, however,

16:27.240 --> 16:32.710
killed far more people than
cholera, and a stark contrast

16:32.706 --> 16:35.046
then could be drawn.

16:35.048 --> 16:39.278
Flu seems to be
quintessentially a contagious

16:39.278 --> 16:40.238
disease.

16:40.240 --> 16:43.510
But since you're interested in
the debate between--

16:43.509 --> 16:45.879
this is one of your favorites,
I'm sure--

16:45.879 --> 16:50.349
between anticontagionism and
contagionism,

16:50.350 --> 16:54.750
we might point out to you that
even although you think it seems

16:54.751 --> 16:57.381
to be self-evident that
influenza,

16:57.379 --> 17:02.309
the grippe, the flu is
contagious, that many of the,

17:02.308 --> 17:07.078
in fact the dominant current,
still in the 1890s,

17:07.078 --> 17:10.678
was that influenza was not
contagious.

17:10.680 --> 17:13.950
And the eminent British
epidemiologist,

17:13.951 --> 17:18.091
Charles Creighton,
still held to anticontagionism

17:18.086 --> 17:22.216
regarding this disease,
down into the 1890s.

17:22.220 --> 17:27.980
Well, what sorts of things held
Creighton back from accepting

17:27.978 --> 17:31.528
influenza as an infectious
disease?

17:31.528 --> 17:36.048
First he argued the disease
would affect most parts of a

17:36.049 --> 17:39.419
country in the same two or three
weeks.

17:39.420 --> 17:44.980
There simply wasn't time for a
contagious disease to spread

17:44.984 --> 17:48.924
with that extreme rapidity,
he thought.

17:48.920 --> 17:52.630
He also thought within a
smaller radius it seemed to

17:52.632 --> 17:55.182
affect everyone,
say in a household,

17:55.180 --> 17:57.510
more or less simultaneously.

17:57.509 --> 18:00.339
Everyone would fall ill at once.

18:00.338 --> 18:04.568
So, it seemed there wasn't time
for contagion.

18:04.568 --> 18:09.048
And it was this simultaneous,
sudden outbreak of influenza

18:09.046 --> 18:12.576
that gave it some of its
traditional names.

18:12.579 --> 18:16.009
It was called the grippe;
not only in French,

18:16.009 --> 18:18.819
la grippe,
but also in English in the

18:18.818 --> 18:22.148
nineteenth century it was
referred to as grippe.

18:22.150 --> 18:26.440
And partly that's because it
seemed suddenly to seize people

18:26.439 --> 18:27.529
in its grasp.

18:27.528 --> 18:31.458
Typically, you could be healthy
at breakfast,

18:31.457 --> 18:35.917
only to find yourself suffering
with chills, fever,

18:35.920 --> 18:39.580
aching bones and nausea by
lunchtime.

18:39.578 --> 18:43.058
Similarly, Moscow seemed,
to physicians,

18:43.057 --> 18:46.977
to be healthy on the first of
November, 1889,

18:46.980 --> 18:52.510
but by the middle of the month
the disease was everywhere.

18:52.509 --> 18:57.209
Shops and schools were closed,
commerce nearly ground to a

18:57.211 --> 18:57.791
halt.

18:57.788 --> 19:02.458
And this gave it--was part of
the reason it got its other

19:02.459 --> 19:03.959
name, influenza.

19:03.960 --> 19:08.240
This was an Italian word
meaning influence,

19:08.240 --> 19:12.850
and in this case people
speculated about the influence

19:12.852 --> 19:18.512
of some cosmic factor that would
disturb the microcosm as well.

19:18.509 --> 19:24.009
Perhaps it was the influence of
the stars or the heavens that

19:24.010 --> 19:28.870
poisoned or corrupted the
atmosphere and lay low whole

19:28.871 --> 19:30.981
cities all at once.

19:30.980 --> 19:35.950
What about symptoms,
effects on the individual?

19:35.950 --> 19:40.180
I think we can be brief,
because it's probably very

19:40.178 --> 19:43.898
familiar to you,
from personal experience;

19:43.900 --> 19:47.310
that is, seasonal influenza.

19:47.308 --> 19:51.918
The onset, as we've said,
is normally sudden.

19:51.920 --> 19:57.640
The symptoms then are ones that
you know: a high fever,

19:57.642 --> 20:02.202
100 to 104 degrees Fahrenheit,
typically;

20:02.200 --> 20:08.190
an unproductive cough;
aching of muscles in the back,

20:08.186 --> 20:11.536
the legs;
watery eyes;

20:11.539 --> 20:16.839
sometimes nausea and vomiting;
general malaise;

20:16.839 --> 20:19.239
headache;
pain in the joints;

20:19.240 --> 20:25.130
sometimes dizziness;
and a general sense of fatigue

20:25.125 --> 20:26.915
and weakness.

20:26.920 --> 20:31.910
Typically the acute phase would
last three to five days,

20:31.907 --> 20:37.347
and for a few days more you'd
suffer from your cough and from

20:37.349 --> 20:38.529
lethargy.

20:38.529 --> 20:44.919
And then, in the vast number of
cases, there would be recovery.

20:44.920 --> 20:51.160
Flu, for young adults in good
health, enjoyed a reputation as

20:51.159 --> 20:56.669
a nasty but mercifully short,
and usually not serious,

20:56.670 --> 20:58.230
affliction.

20:58.230 --> 21:02.210
Influenza in the middle of the
nineteenth century--

21:02.210 --> 21:08.900
that is, at least before the
cataclysm of 1889 and 1890--

21:08.900 --> 21:13.870
was--people joked about it,
that it was a disease that was

21:13.872 --> 21:18.672
so unimportant that the only
physicians who gave it much

21:18.670 --> 21:23.730
attention were those who simply
had too few patients,

21:23.730 --> 21:29.200
and so started treating people
with flu as a means of enhancing

21:29.204 --> 21:30.534
their income.

21:30.528 --> 21:33.468
On the other hand,
for infants,

21:33.468 --> 21:37.968
for the elderly and those with
chronic disease,

21:37.973 --> 21:43.953
it sometimes led to serious and
even fatal complications;

21:43.950 --> 21:48.660
and it was the complications,
much more than the flu,

21:48.664 --> 21:50.664
that tended to kill.

21:50.660 --> 21:56.340
Patients who didn't recover
after three or four days then

21:56.343 --> 22:01.423
moved on to serious
complications like pneumonia or

22:01.416 --> 22:02.936
bronchitis.

22:02.940 --> 22:08.110
And about once a century,
a strain of influenza that was

22:08.114 --> 22:11.694
not seasonal but pandemic
appeared,

22:11.690 --> 22:15.190
and demonstrated that flu can
in fact,

22:15.190 --> 22:19.880
under certain conditions,
be one of the most deadly of

22:19.882 --> 22:21.212
all diseases.

22:21.210 --> 22:24.620
Well, what about treatment?

22:24.618 --> 22:29.678
Today, as in the past,
there's no specific remedy for

22:29.675 --> 22:35.115
influenza, as we've been
reminded by recent events in the

22:35.121 --> 22:36.581
newspapers.

22:36.578 --> 22:42.168
The disease is self-limiting
normally, and simply runs its

22:42.166 --> 22:43.046
course.

22:43.048 --> 22:49.168
So, therapy is supportive and
symptomatic, rest and nursing

22:49.166 --> 22:54.016
care, more than active medical
intervention.

22:54.019 --> 22:58.009
In the nineteenth century this
was also recognized,

22:58.012 --> 23:02.332
and physicians weren't inclined
to try heroic remedies,

23:02.325 --> 23:05.595
as they did say with Asiatic
cholera.

23:05.598 --> 23:10.328
But there were certain attempts
at therapeutics in the

23:10.326 --> 23:15.036
nineteenth century,
and even after World War I

23:15.038 --> 23:20.928
people were given aspirin,
cinnamon with milk to lower

23:20.930 --> 23:25.160
temperature,
fluids and nourishment,

23:25.161 --> 23:26.341
bed rest.

23:26.338 --> 23:30.528
Quinine was administered to
lower the fever.

23:30.528 --> 23:34.078
There were warm baths for
hydrotherapy;

23:34.078 --> 23:39.128
oxygen sometimes administered
to patients with respiratory

23:39.131 --> 23:40.551
complications.

23:40.548 --> 23:46.068
And some physicians recommended
caffeine to raise the flagging

23:46.065 --> 23:49.135
animal energy,
as it was called.

23:49.140 --> 23:53.480
Today the only actual
therapeutics is antibiotics,

23:53.484 --> 23:57.214
but they don't combat the
influenza itself,

23:57.210 --> 24:00.580
but its complication of
pneumonia.

24:00.578 --> 24:05.068
Well, against that background,
let's look more closely at the

24:05.067 --> 24:08.127
Spanish influenza--
the Spanish Lady,

24:08.134 --> 24:13.464
the Spanish grippe,
as it was called--from 1918 to

24:13.462 --> 24:14.162
1920.

24:14.160 --> 24:18.980
Well, first you'll probably
wonder, why this Spanish

24:18.984 --> 24:20.314
association?

24:20.308 --> 24:25.438
And the reason has actually
nothing to do with Spain itself

24:25.441 --> 24:26.681
and disease.

24:26.680 --> 24:30.950
It was simply that Spain was
not a belligerent in the First

24:30.945 --> 24:35.575
World War, and therefore was
free of censorship of the media.

24:35.578 --> 24:40.988
Hence a free press reported the
medical crisis there

24:40.992 --> 24:42.482
extensively.

24:42.480 --> 24:48.880
A popular theory in circulation
these days is that perhaps the

24:48.880 --> 24:53.390
Spanish Lady originated not in
Spain at all,

24:53.391 --> 24:55.281
but in Kansas.

24:55.279 --> 24:59.669
In any event,
on the morning of--finding the

24:59.666 --> 25:04.526
case zero is a perilous art,
but let's say that at least

25:04.534 --> 25:07.884
this much is known--
on the morning of the eleventh

25:07.878 --> 25:11.038
of March,
1918, at Fort Riley,

25:11.039 --> 25:16.709
the cook, Albert Gitchell,
reported sick.

25:16.710 --> 25:21.900
By noon, the camp infirmary had
some 100 cases,

25:21.895 --> 25:27.865
and these were the earliest
known examples of this new

25:27.871 --> 25:29.451
influenza.

25:29.450 --> 25:34.520
There's some background that
helps us comprehend the

25:34.515 --> 25:38.185
extraordinary case of 1918 to
1920.

25:38.190 --> 25:41.740
As in the past,
mutations occurred,

25:41.737 --> 25:47.887
and in this time produced a new
strain that turned out to be

25:47.893 --> 25:53.113
more virulent than any in
influenza's history.

25:53.108 --> 25:57.178
Its mode of communication was
identical to other flu

25:57.179 --> 26:01.969
pandemics, but its effects on
both the individual and society

26:01.965 --> 26:04.275
were radically different.

26:04.278 --> 26:09.028
So, let's talk about this
pandemic as coming in four

26:09.034 --> 26:09.784
waves.

26:09.778 --> 26:17.048
The first was in the spring of
1918, and was relatively mild,

26:17.046 --> 26:19.586
in March and April.

26:19.588 --> 26:23.148
It soon passed,
and it attracted little

26:23.153 --> 26:24.283
attention.

26:24.278 --> 26:28.118
Wartime press censorship was
partly a factor,

26:28.118 --> 26:33.408
but people were simply
preoccupied with the war and not

26:33.413 --> 26:38.813
with the presence of a mild
outbreak of a well-known and

26:38.807 --> 26:40.667
common disease.

26:40.670 --> 26:48.900
The second wave was the fall of
1918, which was the worldwide

26:48.900 --> 26:50.410
disaster.

26:50.410 --> 26:55.540
It began in August with
simultaneous explosions in

26:55.542 --> 27:01.722
places as far apart as Sierra
Leone, Boston in this country,

27:01.723 --> 27:05.953
Brest in France;
a common feature being that

27:05.952 --> 27:10.302
these were all port cities,
and had an important role in

27:10.298 --> 27:13.458
the movements of troops and
supplies.

27:13.460 --> 27:17.000
In this case,
one could argue that not only

27:17.000 --> 27:20.710
the war itself,
but also the coming of peace,

27:20.711 --> 27:24.171
contributed to the spread of
the flu.

27:24.170 --> 27:30.100
Armistice Day itself produced
huge crowds and gatherings,

27:30.102 --> 27:35.932
which were not propitious for
stopping the spread of the

27:35.928 --> 27:37.198
disease.

27:37.200 --> 27:42.880
Then came the spring of 1919,
a less, much less,

27:42.882 --> 27:46.512
mercifully less severe wave.

27:46.509 --> 27:50.649
And then finally January,
February of 1920,

27:50.652 --> 27:55.682
the fourth wave of the Spanish
Lady, which was mild,

27:55.682 --> 27:59.432
and limited in its morbidity
even.

27:59.430 --> 28:03.610
Partly, of course,
because by then so many people

28:03.605 --> 28:05.515
were already immune.

28:05.519 --> 28:09.669
Well, there are a number of
features of the Spanish Lady

28:09.673 --> 28:11.413
that made her unique.

28:11.410 --> 28:17.330
The first was that it possessed
an extraordinary mortality and

28:17.334 --> 28:18.504
morbidity.

28:18.500 --> 28:22.770
Comparing it with normal
outbreaks of influenza,

28:22.769 --> 28:27.219
it's impossible to generate
precise statistics.

28:27.220 --> 28:31.440
But there are speculations that
this was perhaps,

28:31.440 --> 28:35.380
in absolute terms,
the greatest demographic shock

28:35.384 --> 28:39.414
that humanity had ever
experienced from infectious

28:39.411 --> 28:40.481
diseases.

28:40.480 --> 28:46.250
More people died of influenza
than of casualties in the First

28:46.246 --> 28:47.396
World War.

28:47.400 --> 28:52.190
Worldwide, some estimates--the
estimates vary widely,

28:52.192 --> 28:56.342
so one has to take them with
great caution.

28:56.338 --> 29:01.398
But they ranged from 25,000,000
people perishing,

29:01.397 --> 29:07.507
upwards to--the highest
estimates are about 100,000,000.

29:07.509 --> 29:13.009
In the United States it's
pretty well known that at least

29:13.007 --> 29:18.057
675,000 people perished;
more than American casualties

29:18.057 --> 29:23.777
in all twentieth-century wars;
ten times the numbers killed in

29:23.784 --> 29:25.464
First World War.

29:25.460 --> 29:30.890
In a normal--if there is such a
thing--influenza outbreak,

29:30.894 --> 29:36.524
a case fatality rate might be
something like 0.1 percent.

29:36.519 --> 29:39.499
In the case of the Spanish
influenza,

29:39.500 --> 29:45.090
the case fatality rate was just
above 2.5 percent,

29:45.088 --> 29:50.088
and this yielded a vast total
mortality,

29:50.088 --> 29:52.548
because indeed,
as it seemed at the time,

29:52.549 --> 29:55.859
almost everyone was infected.

29:55.858 --> 30:00.788
Let's look at a slide of the
death rates.

30:00.788 --> 30:06.158
You can see the influenza,
the great wave in October,

30:06.163 --> 30:09.163
November, December of 1918.

30:09.160 --> 30:16.860
The black is 1918--rather,
sorry, is the average 1911 to

30:16.858 --> 30:20.918
1917, and the grey is 1918.

30:20.920 --> 30:25.830
So, this compares influenza
then with what we might call

30:25.832 --> 30:27.532
normal influenza.

30:27.528 --> 30:31.708
You can see the extraordinary
new mortality.

30:31.710 --> 30:36.120
Another feature of this
influenza was the lack of

30:36.124 --> 30:40.634
understanding of the disease
when it broke out.

30:40.630 --> 30:43.810
Indeed, I'd like to quote
Victor Vaughan,

30:43.808 --> 30:48.498
who directed public health in
the United States Army against

30:48.500 --> 30:50.170
the Spanish Lady.

30:50.170 --> 30:52.940
And he said,
and I'm quoting:

30:52.941 --> 30:57.301
"Doctors know no more
about the flu than

30:57.297 --> 31:03.927
fourteenth-century Florentines
did about the Black Death."

31:03.930 --> 31:09.290
And I think it's important to
understand this idea of a sense

31:09.290 --> 31:13.760
of helplessness facing this
medical catastrophe.

31:13.759 --> 31:17.669
Some physicians indeed,
in 1918, termed what they were

31:17.674 --> 31:20.634
facing "epidemic
pneumonia."

31:20.630 --> 31:24.440
And then, as now,
there was no effective

31:24.438 --> 31:25.608
treatment.

31:25.609 --> 31:28.519
The symptoms were distinctive.

31:28.519 --> 31:32.189
As you now know from reading
Crosby,

31:32.190 --> 31:38.000
this influenza was fulminant,
and post-mortem lung

31:37.997 --> 31:44.867
examinations revealed things
that were unlike anything that

31:44.869 --> 31:49.729
examining physicians had seen
before.

31:49.730 --> 31:55.030
Enormous quantities of bloody
fluid, like a froth,

31:55.034 --> 31:57.204
filling the lungs.

31:57.200 --> 32:00.630
Some physicians,
on their first encounter,

32:00.627 --> 32:05.057
suspected that this was a kind
of pneumonic plague.

32:05.058 --> 32:08.718
Right here in New Haven,
in the New Haven Hospital,

32:08.720 --> 32:13.650
pathologists wrote that the
devastation caused to the lungs

32:13.651 --> 32:17.651
more than anything else
resembled the effects of

32:17.647 --> 32:22.067
poisonous gases used in World
War I,-like phosgene or

32:22.068 --> 32:25.738
chlorine,
were the comparisons that came

32:25.736 --> 32:26.886
to their mind.

32:26.890 --> 32:30.310
Furthermore,
although other organs of the

32:30.307 --> 32:35.107
body could be affected--
the spleen, for example--the

32:35.107 --> 32:40.447
impact of the Spanish Lady on
the lungs was so overwhelming

32:40.448 --> 32:44.958
that that alone was often the
cause of death,

32:44.960 --> 32:49.720
and pulmonary effects were
almost the only ones that people

32:49.719 --> 32:50.539
noticed.

32:50.538 --> 32:56.408
Let me read a passage from
Katherine Anne Porter,

32:56.406 --> 33:00.316
the famous writer,
Pale Horse,

33:00.317 --> 33:05.817
Pale Rider,
where she was herself a victim

33:05.817 --> 33:08.627
of the influenza.

33:08.630 --> 33:11.540
And she writes here in the
third person,

33:11.538 --> 33:14.268
but she's describing her own
symptoms,

33:14.269 --> 33:17.409
and I think it's worth noting
how she felt:

33:17.413 --> 33:21.483
"Silenced,
Miranda sank easily through

33:21.482 --> 33:27.072
deeps upon deeps of darkness,
until she lay like a stone at

33:27.071 --> 33:32.371
the farthest bottom of life,
knowing herself to be blind,

33:32.372 --> 33:35.912
deaf, speechless,
no longer aware of the members

33:35.913 --> 33:39.213
of her own body,
entirely withdrawn from all

33:39.208 --> 33:42.878
human concerns,
yet alive with a peculiar

33:42.884 --> 33:45.034
lucidity and coherence.

33:45.029 --> 33:48.649
All notions of the mind,
the reasonable inquiries of

33:48.651 --> 33:51.451
doubt,
all ties of blood and desires

33:51.451 --> 33:54.561
of the heart,
dissolved and fell away from

33:54.561 --> 33:57.411
her, and there remained only a
minute,

33:57.410 --> 34:02.150
fiercely burning particle of
being that knew itself alone,

34:02.150 --> 34:06.450
that relied upon nothing beyond
itself for its strength,

34:06.450 --> 34:10.370
not susceptible to any appeal
or inducement,

34:10.369 --> 34:14.509
being itself composed entirely
of one single motive,

34:14.510 --> 34:17.140
the stubborn will to live.

34:17.139 --> 34:22.659
This fiery, motionless particle
set itself unaided to resist

34:22.664 --> 34:26.024
destruction,
to survive, and to be in its

34:26.023 --> 34:30.413
own madness of being,
motiveless and planless,

34:30.414 --> 34:34.014
beyond that one essential end.

34:34.010 --> 34:39.160
She felt, without warning,
a vague tremor of apprehension,

34:39.157 --> 34:42.947
some small flick of distrust in
her joy.

34:42.949 --> 34:47.279
A thin frost touched the edges
of this confident tranquility.

34:47.280 --> 34:49.080
Something, somebody was missing.

34:49.079 --> 34:50.469
She'd lost something.

34:50.469 --> 34:53.199
She had left something valuable
in another country.

34:53.199 --> 34:55.369
What could it be?

34:55.369 --> 34:58.409
'There are no trees,
no trees here,' she said in

34:58.407 --> 34:58.987
fright.

34:58.989 --> 35:01.359
'I've left something
unfinished.'

35:01.360 --> 35:04.680
A thought struggled at the back
of her mind, came clearly as a

35:04.684 --> 35:05.724
voice in her ear.

35:05.719 --> 35:06.879
'Where are the dead?

35:06.880 --> 35:08.210
We've forgotten the dead.

35:08.210 --> 35:10.530
The dead, where are they?'

35:10.530 --> 35:14.420
At once, as if a curtain had
fallen, the bright landscape

35:14.422 --> 35:14.982
faded.

35:14.980 --> 35:19.430
She was alone in a strange
stony place of bitter cold,

35:19.434 --> 35:23.724
picking her way along a steep
path of slippery snow,

35:23.722 --> 35:26.752
calling out,
'Oh I must go back.

35:26.750 --> 35:29.250
But in what direction?'

35:29.250 --> 35:32.330
Pain returned,
a terrible compelling pain,

35:32.327 --> 35:35.627
running through her veins like
heavy fire.

35:35.630 --> 35:39.630
The stench of corruption filled
her nostrils.

35:39.630 --> 35:43.430
The sweetish,
sickening smell of rotting

35:43.429 --> 35:44.989
flesh and pus.

35:44.989 --> 35:49.119
She opened her eyes and saw
pale light through a coarse

35:49.121 --> 35:53.371
white cloth over her face,
and she knew that the smell of

35:53.367 --> 35:58.267
death was in her own body,
and she struggled to lift her

35:58.273 --> 35:59.523
hand."

35:59.518 --> 36:05.398
There are also pictures
of--this is a famous painting of

36:05.400 --> 36:09.250
Edvard Munch,
After the Influenza,

36:09.248 --> 36:10.958
in 1919.

36:10.960 --> 36:15.860
Or this is also--in fact,
this is called After the

36:15.862 --> 36:18.412
Flu, painted in 1919.

36:18.409 --> 36:21.869
A doctor wrote that his
patients died,

36:21.871 --> 36:27.111
struggling to clear their
airways of a blood-tinged froth

36:27.112 --> 36:31.232
that gushed from their noses and
mouths.

36:31.230 --> 36:35.030
The fluid then filled the
respiratory system,

36:35.034 --> 36:40.054
from the trachea to the tiniest
alveoli and bronchioles.

36:40.050 --> 36:44.970
And at post-mortem examination
the lungs were greatly

36:44.974 --> 36:48.864
distended, and when pressed,
even lightly,

36:48.858 --> 36:53.498
oozed with blood-tinged fluid
and yellow pus.

36:53.500 --> 36:57.760
The walls of the alveoli
collapsed under the pressure,

36:57.760 --> 37:02.910
leaving a formless mass where
neither blood nor air could flow

37:02.905 --> 37:05.525
freely,
and the patient died of

37:05.527 --> 37:09.547
asphyxia, or the blockage of
pulmonary circulation.

37:09.550 --> 37:14.720
Let me show you two pictures of
the lungs of a young woman who

37:14.715 --> 37:19.285
died of the Spanish Lady at the
New Haven Hospital,

37:19.289 --> 37:24.379
and I think you can see the
enormous and terrifying

37:24.376 --> 37:28.546
destruction of the lungs that
occurred.

37:28.550 --> 37:33.570
Well, in addition,
there were important sequelae.

37:33.570 --> 37:38.840
One feature of the Spanish Lady
was the distinctive length of

37:38.835 --> 37:40.235
convalescence.

37:40.239 --> 37:44.239
And also there were
neurological aftereffects,

37:44.239 --> 37:48.519
protracted depression,
and there is speculation that

37:48.523 --> 37:53.313
throughout the 1920s there was
an outbreak of neurological

37:53.311 --> 37:56.901
afflictions,
that Oliver Sacks deals with in

37:56.900 --> 37:59.340
his famous book
Awakenings.

37:59.340 --> 38:03.730
There's some dispute about
whether this was an authentic,

38:03.730 --> 38:07.570
among authentic sequelae of the
Spanish influenza,

38:07.572 --> 38:10.162
but it is at least plausible.

38:10.159 --> 38:15.779
Another feature that made this
pandemic distinctive was the age

38:15.775 --> 38:18.035
profile of the victims.

38:18.039 --> 38:22.099
We've seen how normally in
influenza there's a U-shaped

38:22.097 --> 38:22.697
curve.

38:22.699 --> 38:27.609
It does what seems normal to
people, attacking the very young

38:27.614 --> 38:29.094
and the elderly.

38:29.090 --> 38:34.160
The Spanish Lady instead had a
preference for adults in the

38:34.157 --> 38:37.037
twenty to forty-year age group.

38:37.039 --> 38:41.439
And so it produced something
that seemed highly unnatural,

38:41.442 --> 38:44.842
a W-shaped curve,
with a spike in the middle,

38:44.840 --> 38:48.470
afflicting the people in the
prime of life.

38:48.469 --> 38:53.869
Victor Vaughan again observed
that the Spanish flu imitated

38:53.871 --> 38:57.511
the war itself,
and that it killed young

38:57.505 --> 38:58.525
adults.

38:58.530 --> 39:03.290
Like war, he said,
this infection kills young,

39:03.289 --> 39:06.039
vigorous, robust adults.

39:06.039 --> 39:08.819
The reasons are still
mysterious.

39:08.820 --> 39:12.240
But one could point to a couple
of partial factors.

39:12.239 --> 39:17.989
Perhaps the elderly had some
immunity left over from the

39:17.985 --> 39:21.325
great pandemic of 1889 to '90.

39:21.329 --> 39:25.329
And it was the young,
of course, epidemiologically,

39:25.326 --> 39:29.956
who most directly experienced
the war and military service,

39:29.961 --> 39:35.301
in close, crowded conditions;
just the young population,

39:35.297 --> 39:36.747
most at risk.

39:36.750 --> 39:41.180
And for those of you who think
that working out at the gym

39:41.175 --> 39:44.355
protects you from influenza
pandemics,

39:44.360 --> 39:49.720
I would point out that the
physically fit also fell ill in

39:49.715 --> 39:51.685
comparable numbers.

39:51.690 --> 39:53.930
John Hellum, the U.S.

39:53.929 --> 39:59.499
pentathlon champion--that is,
someone who did the broad jump,

39:59.501 --> 40:02.751
discus, javelin,
200-meters and 1500

40:02.753 --> 40:06.843
meters--died in October 1918 of
the flu.

40:06.840 --> 40:10.450
As did Jackie O'Shaughnessy,
who was the U.S.

40:10.449 --> 40:13.049
National quarter-mile champion.

40:13.050 --> 40:17.560
So, physical fitness had
nothing to do with survival from

40:17.561 --> 40:18.851
the influenza.

40:18.849 --> 40:21.829
Let me show you a graph.

40:21.829 --> 40:27.349
This is the notorious U-shaped
curve of the influenza.

40:27.349 --> 40:29.639
And you see the two curves
together.

40:29.639 --> 40:35.439
The dotted line is normal
influenza, and this solid line,

40:35.443 --> 40:41.143
with the terrible W in the
middle, is the mortality from

40:41.143 --> 40:43.323
the Spanish Lady.

40:43.320 --> 40:46.460
Well, meanwhile,
what happened with public

40:46.460 --> 40:47.150
health?

40:47.150 --> 40:51.780
And here a major feature is to
point out--

40:51.780 --> 40:55.870
and we should think of this in
terms of lessons for

40:55.869 --> 40:59.699
preparedness today--
was the way that the public

40:59.697 --> 41:02.097
health service was overwhelmed.

41:02.099 --> 41:07.259
It was overwhelmed in part
because of the extreme rapidity

41:07.255 --> 41:11.235
with which this disease,
through its airborne

41:11.235 --> 41:13.855
transmission,
was spread;

41:13.860 --> 41:21.230
by the speed of transportation,
and the short incubation period

41:21.228 --> 41:23.248
of the disease.

41:23.250 --> 41:27.590
It was also true that there is
a percentage--perhaps ten

41:27.592 --> 41:32.252
percent, in the Spanish Lady--of
people who are asymptomatic

41:32.253 --> 41:33.283
carriers.

41:33.280 --> 41:39.830
Influenza also was not a
reportable disease.

41:39.829 --> 41:44.879
It was maximized also because
of the unavoidable and

41:44.876 --> 41:50.416
uncontrollable movement of
troops, because of the war.

41:50.420 --> 41:53.560
But in addition,
there was a lack--and we might

41:53.556 --> 41:58.006
think about this--
of preparation for just such an

41:58.005 --> 42:01.905
emergency,
a shortage of doctors,

42:01.914 --> 42:08.214
nurses, hospital beds and space
on hospital wards.

42:08.210 --> 42:13.080
Influenza also has the terrible
feature,

42:13.079 --> 42:17.999
unlike cholera for example,
that it creates chaos within

42:17.996 --> 42:23.466
the health system itself,
by striking down caregivers who

42:23.474 --> 42:27.414
are among those who are most
vulnerable.

42:27.409 --> 42:31.379
And then there was the war
itself, in which doctors and

42:31.380 --> 42:35.200
nurses were mobilized to deal
with the victims of the

42:35.204 --> 42:36.164
conflict.

42:36.159 --> 42:40.009
So, there were drastic
shortages of healthcare

42:40.012 --> 42:44.212
personnel available to the
civilian population.

42:44.210 --> 42:47.840
Rupert Blue,
whom you will remember from the

42:47.840 --> 42:51.620
Barbary Plague,
was a director of public health

42:51.623 --> 42:55.773
services during the crisis,
and he was forced to lure

42:55.771 --> 42:58.941
doctors and nurses out of
retirement,

42:58.940 --> 43:05.240
to help deal with the emergency;
to recruit even from old-age

43:05.244 --> 43:06.034
homes.

43:06.030 --> 43:12.390
Well, what were the measures
adopted to deal with the crisis?

43:12.389 --> 43:14.969
Anti-flu measures,
by this time,

43:14.971 --> 43:20.301
were based on the premise that
this was a contagious disease,

43:20.300 --> 43:24.230
and the understanding that
influenza was spread somehow

43:24.230 --> 43:25.540
through the air.

43:25.539 --> 43:30.589
A first major goal was to
prevent those who were healthy

43:30.590 --> 43:35.460
from inhaling the contaminated
air of the infected.

43:35.460 --> 43:38.880
To that end,
public gatherings and

43:38.880 --> 43:45.000
assemblies of large numbers of
people at close quarters were

43:44.998 --> 43:46.138
banned.

43:46.139 --> 43:50.079
Public institutions were
closed: schools,

43:50.081 --> 43:53.531
dancehalls, movie theaters,
bars.

43:53.530 --> 43:58.090
Churches in this country were
allowed to remain open,

43:58.090 --> 44:02.390
but the number of services was
greatly reduced.

44:02.389 --> 44:06.239
In many cities,
people seen by the police to be

44:06.239 --> 44:10.509
coughing and sneezing,
without covering their faces,

44:10.509 --> 44:12.769
were stopped and fined.

44:12.768 --> 44:16.998
The New York City Department of
Health posted some 10,000

44:17.003 --> 44:20.953
placards around the city,
bearing a message that was

44:20.954 --> 44:24.974
familiar to the public,
because of its similarity to

44:24.967 --> 44:28.977
the urgings of the campaign
against tuberculosis.

44:28.980 --> 44:32.390
So, one can see the
anti-tuberculosis campaign

44:32.389 --> 44:35.799
preparing people,
in a sense, for dealing with

44:35.798 --> 44:36.858
influenza.

44:36.860 --> 44:39.660
And in New York City the
placards said:

44:39.659 --> 44:43.049
to prevent the spread of
Spanish influenza,

44:43.050 --> 44:48.650
sneeze, cough or expectorate,
if you absolutely must,

44:48.650 --> 44:54.110
into your own handkerchief;
you're in no danger if everyone

44:54.112 --> 44:56.582
should heed this warning.

44:56.579 --> 45:03.669
Another widespread measure was
a practical application also.

45:03.670 --> 45:08.970
One was masking with gauze
masks, and some municipalities

45:08.971 --> 45:13.801
required their whole populations
to put on masks.

45:13.800 --> 45:18.110
San Francisco did so,
and so did San Diego.

45:18.110 --> 45:22.380
Another was disinfection
practices, applied in hospital

45:22.380 --> 45:25.070
wards, sickrooms and ambulances.

45:25.070 --> 45:29.450
Trains too were washed down
with antiseptic solutions.

45:29.449 --> 45:37.209
You can see a picture of the
properly masked police.

45:37.210 --> 45:39.710
I think this is San Francisco.

45:39.710 --> 45:46.370
And here you can see the
general masking of the whole

45:46.373 --> 45:48.043
population.

45:48.039 --> 45:53.049
And this was a public notice,
a public health poster from

45:53.054 --> 45:58.164
Kingston, New York or--and it
says about the measures I've

45:58.157 --> 46:01.427
told you about;
theaters, churches,

46:01.425 --> 46:04.225
schools, hospitals,
and so forth.

46:04.230 --> 46:09.240
Or you can see here another
poster for public health.

46:09.239 --> 46:13.889
State boards of health also
isolated the ill through

46:13.887 --> 46:18.987
quarantine, as far as possible,
and the military tried to

46:18.990 --> 46:22.090
quarantine its training camps.

46:22.090 --> 46:26.830
On hospital wards,
sheets were hung between beds.

46:26.829 --> 46:31.719
Ambulance trains were washed
down with antiseptic.

46:31.719 --> 46:36.449
People were urged to avoid
nervous and physical exhaustion.

46:36.449 --> 46:39.739
You can see a long legacy of
this idea.

46:39.739 --> 46:43.709
You remember Laennec talking
about the passions

46:43.706 --> 46:48.316
tristes, the sad passions,
and their influence on your

46:48.322 --> 46:49.702
constitution.

46:49.699 --> 46:53.509
So, some of the advice had a
really long history that you'll

46:53.505 --> 46:54.275
recognize.

46:54.280 --> 47:00.050
And they also cautioned you to
avoid chills.

47:00.050 --> 47:04.340
They urged people to gargle
with warm water and salt,

47:04.344 --> 47:07.904
and to spray saline solutions
up their nose,

47:07.896 --> 47:09.876
to wear gauze masks.

47:09.880 --> 47:14.620
And legislation was passed to
prevent the use of common

47:14.623 --> 47:16.033
drinking cups.

47:16.030 --> 47:20.170
Some people sprayed their
nostrils with carbolic acid

47:20.172 --> 47:23.232
spray,
and some towns set up fines to

47:23.226 --> 47:27.286
punish people they called--
this was one of the jargons at

47:27.289 --> 47:30.889
the time--
the open-face sneezer.

47:30.889 --> 47:35.579
New York City modified the
opening hours of stores and

47:35.577 --> 47:39.467
businesses in order to stagger
rush hour,

47:39.469 --> 47:44.549
so that subway trains and trams
would not be so crowded and not

47:44.545 --> 47:46.015
be so dangerous.

47:46.018 --> 47:51.238
Congress voted special funds to
enable Surgeon General Rupert

47:51.237 --> 47:56.627
Blue to recruit thousands of
doctors and hundreds of nurses.

47:56.630 --> 48:01.400
But, as I said,
the war effort complicated his

48:01.400 --> 48:06.280
task, and he turned to people
who'd retired.

48:06.280 --> 48:12.470
And those were other--I wanted
to show you a camp.

48:12.469 --> 48:17.129
The fact that it was wartime
made it easy for the government

48:17.128 --> 48:20.838
to induce people to accept
rigorous measures.

48:20.840 --> 48:24.070
People by this time had grown
used, by 1918,

48:24.074 --> 48:27.014
to invasive and restrictive
measures.

48:27.010 --> 48:30.680
They already knew all about the
draft, or rationing,

48:30.684 --> 48:32.634
or daylight savings time.

48:32.630 --> 48:37.710
But existing facilities were
inadequate to cope with a sudden

48:37.706 --> 48:41.506
surge, and so the general
public, one can see,

48:41.512 --> 48:44.392
suffering as a result of that.

48:44.389 --> 48:48.689
I wanted to mention that there
were also popular remedies that

48:48.688 --> 48:51.858
people adapted,
and especially in rural areas,

48:51.860 --> 48:54.680
recourse to folk remedies and
magic.

48:54.679 --> 48:57.509
Onion soup was thought to be a
preventative.

48:57.510 --> 49:01.860
People stuffed salt up their
nostrils to ward off danger.

49:01.860 --> 49:05.760
They wore garlic around their
neck, as they had in Florence in

49:05.764 --> 49:07.624
the time of bubonic plague.

49:07.619 --> 49:11.749
They burned hot charcoals with
sulfur or brown sugar,

49:11.751 --> 49:15.251
to give off a reassuring
protective aroma;

49:15.250 --> 49:18.290
you can recognize this too from
the plague.

49:18.289 --> 49:22.629
There were rumors that the
disease perhaps was an act of

49:22.632 --> 49:23.662
bio-terror.

49:23.659 --> 49:27.519
There were thoughts that there
were mysterious German agents

49:27.521 --> 49:30.731
who landed on U-boats and
started the epidemic.

49:30.730 --> 49:35.890
There were suspicious too that
poisonous gases associated with

49:35.887 --> 49:40.367
the war effort had escaped and
caused the disaster.

49:40.369 --> 49:45.029
Well, I will run out of time
now, and just say that one of

49:45.034 --> 49:50.194
the things to think about then
are what are possible lessons?

49:50.190 --> 49:52.790
And I just wanted to leave us
to think,

49:52.789 --> 49:58.129
as we deal with our own H1N1,
and possibly whatever its

49:58.128 --> 50:02.178
successor is,
that clearly in 1918 and '19,

50:02.184 --> 50:07.484
there's a collective memory in
the public health service of the

50:07.478 --> 50:12.428
vulnerability of a society of
critically ill patients,

50:12.429 --> 50:16.169
turned away from hospitals,
that were full to bursting,

50:16.170 --> 50:21.230
with no care available because
the system was overwhelmed.

50:21.230 --> 50:26.850
And there's a fear then of what
about the effects now of the

50:26.853 --> 50:30.383
impact of organized care
medicine,

50:30.380 --> 50:35.350
on a managed care basis,
with cost-cutting search for

50:35.347 --> 50:39.627
savings in our system;
the commitment to ridding

50:39.628 --> 50:43.208
hospitals of excess capacity and
spare beds.

50:43.210 --> 50:48.270
And so this approach raises the
question of what would happen in

50:48.269 --> 50:52.929
another time when the system
might once again be tested?

50:52.929 --> 50:57.999