by The Pandemic Century- One Hundred Years of Panic, Hysteria
Lurking in the background of these initiatives is the ghost of Spanish flu. If anything has taught scientists the value of caution and the perils of hubris, it is the long shadow cast by the 1918–1919 influenza pandemic—what the WHO, an organization not known for hyperbole, calls the “most deadly disease event in the history of humanity.” Since it became possible to retrieve viral genetic material from the H1N1 pandemic virus using modern molecular pathology techniques, virologists have made huge progress in understanding the factors that made the Spanish flu so virulent. By comparing the 1918 virus to descendant H1N1 strains still in circulation, scientists have also come to a better understanding of its epidemiology and pathophysiology. Moreover, the 1997 outbreak of H5N1 bird flu in Hong Kong, and the subsequent outbreaks of other varieties of bird flu in China and Southeast Asia, have shown that it is not necessary for an avian influenza virus to transit through an intermediary mammalian host first in order for it to be the cause of morbidity and deaths in humans. At the same time, the 2009 scare over the “Mexican” swine flu demonstrated that from time to time different swine and human lineages of H1N1 can recombine to produce new pandemic viruses. However, so far, no bird flu or recombinant swine flu virus has managed the trick of wide infectivity and high virulence, as was the case in 1918. Furthermore, while it is known that the H1N1 Spanish flu was infectious to all age groups in 1918–1919, scientists are still no closer to solving the riddle of why it proved relatively more deadly to young adults, or why mortality rates were closely associated with the increased incidence of secondary bacterial infections. The result is that despite the tremendous advances in microbiology, immunology, vaccinology, and preventive medicine in the century since 1919, influenza researchers are still no closer to being able to predict when new pandemic strains will emerge or how they will impact human populations. As David Morens and Jeffrey Taubenberger put it: “In recent decades, pandemic influenza has continued to produce numerous unanticipated events that expose fundamental gaps in scientific knowledge. . . . These uncertainties make it difficult to predict influenza pandemics and, therefore, to adequately plan to prevent them.”
Reviewing the last hundred years of epidemic outbreaks, the only thing that is certain is that there will be new plagues and new pandemics. It is not a question of if, we are told, but when. Pestilences may be unpredictable but we should expect them to recur. However, what Camus could not have foreseen is that the attempt to anticipate disaster also creates new distortions and introduces new uncertainties. Twice this pandemic century, in 1976 and again in 2003, scientists thought the world was on the brink of a new influenza pandemic, only to realize that the outbreaks were false alarms and that the real danger lay elsewhere. Then in 2009 the WHO declared that the Mexican swine flu, a ressortment of two well-known H1N1 swine-lineage viruses that had circulated separately for over a decade, met the criterion of a pandemic virus, triggering the activation of global pandemic preparedness plans. On paper, this was the first pandemic of the twenty-first century and the first influenza pandemic in forty-one years. The fact that the swine flu was an H1N1, just like the Spanish flu, raised the prospect that this might be the Big One and that governments should expect a wave of illness and deaths similar to that in 1918–1919. But though the WHO’s declaration sparked widespread panic, the anticipated viral Armageddon never materialized. Instead, when it was realized that the Mexican swine flu was no more severe than a seasonal strain of flu, the WHO was accused of “faking” the pandemic for the benefit of vaccine manufacturers and other special interests. The result is what Susan Sontag calls “a permanent modern scenario: apocalypse looms . . . and it doesn’t occur.” As we look to the next one hundred years of infectious disease outbreaks, let us hope that is one prognostication that turns out to be true.
* In 2018, Sierra Leone’s Ministry of Health announced that researchers from the University of California, Davis, and the EcoHealth Alliance had identified a new species of Ebola in RNA recovered from free-tailed bats and another type of bat in Bombali, a district in the north of the country. However, at the time of writing, the study of the “Bombali virus” has not been published, and it is unclear how it might be related to other Ebola viruses and whether it can cause disease in humans.
ACKNOWLEDGMENTS
This book is the product of over a decade of research and thinking about infectious disease. My interest in epidemics and pandemics began in 2005 when I went to speak to John Oxford, then Professor of Virology at Queen Mary and Westfield School of Medicine in East London, about avian influenza. A few months earlier a strain of the H5N1 bird flu virus had sparked a spate of deaths in Vietnam, and I had asked John to give me a tutorial on the ecology and virology of influenza before heading to Hanoi to write a feature article for The Observer. Very quickly our conversation turned to other notable outbreaks of infectious disease, including the 1918–1919 Spanish influenza pandemic. It was the beginning of an obsession with influenza that has led, by way of a PhD and a research fellowship, to a deeper engagement with the history of bacteriology and disease ecology. That research has been generously supported by the Wellcome Trust, allowing me to visit archives in the United States and Australia, where I was able to consult primary documents on the Spanish flu as well as several of the other epidemics canvassed in this book. In 2015, the Wellcome Trust also funded my travel to Sierra Leone to document the impressions of patients, clinicians, and research scientists swept up in the Ebola epidemic, and in chapter seven I have drawn on several of these interviews.
Since 1918 there has been a huge change in the scientific understanding of infectious disease and of virology in particular, and I am acutely aware of the scope for error in seeking to summarize this shifting scientific knowledge in relation to such a wide range of infectious pathogens. I have been fortunate in being able to consult some of the leading experts in their fields to help me avoid more obvious errors and summarize past and current scientific knowledge of these pathogens accurately (any errors that remain are mine). In particular, I would like to thank the following for their comments on specific chapters and passages: Wendy Barclay, Kevin De Cock, David Fraser, David Heymann, Michael Kosoy, Ernesto Marques, Joe McDade, David Morens, Malik Peiris, Celina Turchi, and Liana Ventura.
I would also like to thank the librarians and archivists who helped me locate key documents and who directed my attention to collections that I might otherwise have missed. In particular: Diane Wendt, Curator of Medicine and Science at the National Museum of American History; Louise E. Shaw, Curator of the David J. Sencer CDC Museum; and Polina E. Ilieva, the Head of Archives and Special Collections at the University of California San Francisco. My thanks also to the staff at the Wellcome Library in London, the National Library of Medicine and National Archives in Bethesda, Maryland, and the librarian in the Library of Congress’s newspaper room, who helped me locate the January 1930 report in Hearst’s American Weekly about the outbreak of parrot fever in the theatrical troupe in Buenos Aires.
Writing a book—especially one of this size—is not a task to be undertaken lightly, and for urging me on and encouraging me that my initial proposal would find an enthusiastic editor, I would like to thank my agent, Patrick Walsh. I would also like to thank Anne Bogart for her knowledge of Los Angeles and her comments on the pneumonic plague chapter, and my wife, Jeanette, who perhaps missed her vocation as a copy editor but has more than made up for it since. No one has read more drafts than she has, and I cannot thank her enough for her intellectual and emotional support. Finally, I am very pleased that the editor who “got” this book and wanted to publish it was John Glusman, whom I had previously worked with at Farrar, Straus and Giroux.
ABBREVIATIONS
AFRO Africa Regional Office
AIDS Acquired Immune Deficiency Syndrome
ARDS Acute Respiratory Distress Syndrome
CDC Centers for Disease Control and Prevention
CMV Cytomegalovirus
CSF Cerebrospinal Fluid
&nb
sp; CZS Congenital Zika Syndrome
DRC Democratic Republic of the Congo
EID Emerging Infectious Disease
EIS Epidemic Intelligence Service
ELISA Enzyme-Linked Immunosorbent Assay
ELWA Eternal Love Winning Africa
ETU Ebola Treatment Unit
GOARN Global Outbreak Alert and Response Network
GPHIN Global Public Health Intelligence Network
GRID Gay-Related Immune Deficiency
HIV Human Immunodeficiency Virus
HTLV Human T-cell Leukemia Virus
IAM Instituto Aggeu Magalhães
KS Kaposi’s Sarcoma
LAV Lymphadenopathy Associated Virus
LCL Levinthal-Coles-Lillie
MSF Médecins Sans Frontières
NGO Nongovernmental Organization
NIAID National Institute of Allergy and Infectious Diseases
NIH National Institutes of Health
PAHO Pan American Health Organization
PCP Pneumocystis carinii pneumonia
PCR Polymerase Chain Reaction
PHS Public Health Service
ProMED Program for Monitoring Emerging Diseases
RT-PCR Reverse Transcriptase Polymerase Chain Reaction
SIV Simian Immune-Deficiency Virus
UNMEER United Nations Mission for Ebola Emergency Response
USAMRIID United States Army Medical Research Institute of Infectious Diseases
WHO World Health Organization
NOTES
PROLOGUE: SHARKS AND OTHER PREDATORS
1 in 1891: Richard Fernicola, Twelve Days of Terror: A Definitive Investigation of the 1916 New Jersey Shark Attacks (Guilford, CT: Globe Pequot Press, 2001), xxiv–xxx.
3 to this day: The best narrative account of the New Jersey shark attacks is Michael Capuzzo’s Close to Shore (London: Headline Publishing, 2001). The attacks also inspired Peter Benchley’s best-selling novel 1974 novel Jaws, the basis for the Steven Spielberg film of the same name. In both the book and the film, the shark attacks are transposed to the fictional Long Island resort of Amity.
5 hospitalizations: David Oshinsky, Polio: An American Story (Oxford: Oxford University Press, 2005), 19–23.
5 one child in four: John Paul, A History of Poliomyelitis (New Haven, CT: Yale University Press, 1971), 148–60; Naomi Rogers, Dirt and Disease: Polio before FDR. Health and Medicine in American Society (New Brunswick, NJ: Rutgers University Press, 1992), 2–6.
9 “will strike back”: René Dubos, Mirage of Health: Utopias, Progress and Biological Change (New Brunswick, NJ: Rutgers University Press, 1996), 266–67.
12 blind spots in the future: On February 12, 2002, five months after the 9/11 attacks and a year before the invasion of Iraq, the then–US secretary of defense Donald Rumsfeld appeared at a Pentagon news conference to field questions about the purported threat posed by the Iraqi dictator Saddam Hussein’s secret weapons program. Asked by a journalist what evidence he had that Iraq had supplied or was willing to supply terrorists with weapons of mass destruction, Rumsfeld responded: “Reports that say that something hasn’t happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know.”
At the time, Rumsfeld’s comments were widely lampooned for their “Alice in Wonderland” quality, but, as many of Rumsfeld’s critics subsequently acknowledged, he was drawing on well-known scholarship in the philosophy of knowledge and the social construction of scientific facts. Indeed, much scientific research is based on investigating known unknowns, where scientists develop a hypothesis and then design experiments to test the null hypothesis, or the commonly held view. At the outset the researcher does not know whether or not the results will support the null hypothesis. However, it is common for the researcher to believe that the result that will be obtained will be within a range of known possibilities. Occasionally, however, the result is completely unexpected, making it an unknown unknown.
Historians of Science also routinely apply these ideas to capture the uncertainty surrounding natural events from earthquakes, to climate change, to pandemics, that pose a catastrophic threat to modern societies and where knowledge may be partial and incomplete. However, in addition to the three types of knowledge described by Rumsfeld, they also propose a fourth category—the “unknown known.” This captures a situation in which experimenters think they have discovered everything there is to know about a scientific object but are unaware of their ignorance as regards certain important aspects of it (it is sometimes also described as “uncomfortable knowledge”). Pneumonic plague, Psittacosis, Ebola, and Zika belonged to this category. By contrast, Legionnaires’ disease, SARS, and HIV were unknown unknowns. To the extent that no one had a way of studying the influenza virus before 1918, Spanish flu could also be considered an unknown unknown, though many researchers had begun to suspect it might be a filter-passer and had become uncomfortable with the state of bacteriological knowledge of the disease. For the background and context of Rumsfeld’s remarks, see Errol Morris, “The Certainty of Donald Rumsfeld,” New York Times, March 25, 2014, accessed September 1, 2017, https://opinionator.blogs.nytimes.com/2014/03/25/the-certainty-of-donald-rumsfeld-part-1/?mcubz=1. For further discussion of Rumsfeld’s parsing of the philosophy of knowledge and unknown knowns, see Steve Rayner, “Uncomfortable Knowledge: The Social Construction of Ignorance in Science and Environmental Policy Discourses,” Economy and Society 41, no. 1 (February 1, 2012): 107–25.
14 between one-quarter and one-third: Thucydides, History of the Peloponnesian War (Harmondsworth, UK: Penguin, 1972); David Morens et al., “Epidemiology of the Plague of Athens,” Transactions of the American Philological Association 122 (1992): 271–304.
CHAPTER I: THE BLUE DEATH
18 “huge city of soldiers”: Roger Batchelder, Camp Devens (Boston: Small Maynard, 1918), 11.
19 “the out-door life”: Batchelder, Camp Devens, 94.
20 several southern states: Carol R. Byerly, “The U.S. Military and the Influenza Pandemic of 1918–1919,” Public Health Reports 125, suppl. 3 (2010): 82–91.
21 “Captain of the Men of Death”: William Osler, Henry A. Christian, and James G. Carr, The Principles and Practice of Medicine: Designed for the Use of Practitioners and Students of Medicine, 16th edition (New York and London: D. Appleton-Century, 1947), 41.
22 “material in the camp”: Victor Vaughan, A Doctor’s Memories (Indianapolis: Bobbs-Merrill, 1926), 424–25.
23 “admixture of air”: J. A. B. Hammond et al., “Purulent Bronchitis: a study of cases occurring amongst the British troops at a base in France,” The Lancet 190, no. 4898 (July 14, 1917): 41–46.
23 “effects of gas poisoning”: A. Abrahams et al., “Purulent Bronchitis: its influenzal and pneumococcal bacteriology,” The Lancet 190, no. 4906 (September 8, 1917): 377–82.
24 a type of influenza: A. Abrahams et al., “A Further Investigation into Influenzo-pneumococcal and Influenzo-streptococcal Septicæmia: Epidemic influenzal ‘pneumonia’ of highly fatal type and its relation to ‘purulent bronchitis,’ ” The Lancet 193, no. 4975 (July 5, 1919): 1–11.
25 group of draftees: E. L. Opie et al., “Pneumonia at Camp Funston,” Journal of the American Medical Association (January 11, 1919): 108–16.
25 camp in Valdahon: Byerly, “The U.S. Military and the Influenza Pandemic of 1918–1919,” 125.
26 “falls on unaffected officers”: “Letter to Susan Owen, June 24 1918,” in Wilfred Owen Collected Letters, ed. H. Owen and J. Bell (London: Oxford University Press, 1967).
27 Koch’s fourth postulate: This stipulates that in order for a microorganism to be considered the etiological agent of a disease, the organism must be constantly present in all clinical cases of the disease, and when grown and isolated in pure culture and ino
culated into healthy test animals must be able to reproduce the same disease.
27 from rural areas: E. L. Opie et al., “Pneumonia at Camp Funston,” Journal of the American Medical Association 72, no. 2 (January 11, 1919): 108–16.
28 “that’s Fort Riley, Kansas”: Dorothy A. Petit and Janice Bailie, A Cruel Wind: Pandemic Flu in America, 1918–1920 (Murfreesboro, TN: Timberlane Books, 2008), 83.
28 “hick town”: Batchelder, Camp Devens, 16.
28 “I will get it”: Letters and postcards form Pvt. Clifton H. Skillings, Bangor Daily News, accessed July 6, 2017, https://bangordailynews.com/2009/05/15/news/letters-postcards-from-pvt-clifton-h-skillings/.
29 British naval vessels: F. M. Burnet and E. Clark, Influenza: A Survey of the Last Fifty Years. Monographs from the Walter and Eliza Hall Institute of Research in Pathology and Medicine, no. 4 (Melbourne: Macmillan, 1942); Anton Erkoreka, “Origins of the Spanish Influenza Pandemic (1918–1920) and Its Relation to the First World War,” Journal of Molecular and Genetic Medicine: An International Journal of Biomedical Research 3, no. 2 (November 30, 2009): 190–94.