by Bryn Barnard
Under such conditions, many TB patients took only enough antibiotics to feel better but not enough to eradicate all the TB germs in their bodies. They killed off the weak bacteria, allowing the strong ones to reproduce and make them sick again. The next time they took the antibiotic, it didn’t work. The strong microbes were resistant. These resistant TB bacteria spread around the world in the bodies of refugees fleeing their crumbling societies. In 1993, the re-emergence of tuberculosis caused the World Health Organization to proclaim a global TB emergency. Today nearly two billion people on earth may host the tuberculosis bacterium. Over the next decade, ninety million will develop active TB. Eventually thirty million will die.
Tuberculosis, once the most Romantic of illnesses, is now the deadliest disease on earth. Controlling the bacterium is the twenty-first century’s greatest public health challenge.
The sausage machine
World War I extinguished ideals of chivalry that since medieval times had cloaked battle in a nimbus of glory, honor, and sacrifice. In this, the world’s first truly industrial war, battle was revealed not as a righteous conflict but as a riot of slaughter. Most of the efficient mass killing machines we are familiar with today got their start here: tanks, long-range artillery, machine guns, aerial bombardment, submarines, and poison gas. In the horrific trench warfare that characterized this struggle, tens of thousands of soldiers lost their lives to win a few feet of ground. Tens of thousands more died to win it back. The war had many names, including “the Great War” and “the war to end all wars.” President Woodrow Wilson’s favorite was “the war to make the world safe for democracy.” Poet Robert Graves called it “the sausage machine,” because “it was fed with live men, churned out corpses, and remained firmly screwed in place.” From 1914 to 1918, over fifteen million people died, nine million of them in combat.
In the last months of the war, however, a new killer appeared, far more efficient than anything devised by man. It was Spanish influenza, the single largest epidemic of the twentieth century, if not world history. As with normal flu, people who caught this illness became lethargic, feverish, and achy. But instead of recovering, many of those who were infected by this strain of influenza then progressed to a deadly pneumonia that filled the lungs with bloody froth. Oxygen was sucked from the tissues, turning the skin a sickly purple before the victim died, gasping for air.
Spanish flu had another fatal peculiarity. Most flu epidemics kill the very young or the very old. This disease, however, was most lethal among those it was most likely to encounter on the battlefields of Europe: twenty-to-thirty-year-olds. Of the one hundred thousand American soldiers who died in World War I, forty-three thousand died from the Spanish flu. Total U.S. flu deaths were about half a million. Globally, death toll estimates range from twenty million to one hundred million people. Up to twenty million may have died in India alone. In some of the isolated aboriginal populations in Alaska and the Pacific, nearly everyone perished.
“The Purple Death” didn’t just kill huge numbers of people; it shaped world events. The epidemic was a major player in the final battles of World War I and had a role in the shaping of the Versailles peace treaty. It totally overwhelmed the ability of even the best-prepared governments to care for the living and bury the dead. It catalyzed the creation of today’s global influenza surveillance system and the cycle of annual autumn flu shots. Most important of all, scientific research into the nature of the Spanish flu uncovered something totally new and unexpected that would revolutionize medicine: the first antibiotic.
In San Francisco, during the height of the epidemic, masked revelers celebrated the armistice that ended World War I.
A bloody chessboard
Politically, economically, and socially, World War I was an epochal event that demolished the existing order and created many of the conflicts we live with today. When the war started in August 1914, Europe was a patchwork of ancient, tottering monarchies and empires, stitched together by intermarriage and allied against one another by secret treaties. It ended in November 1918 with armistice: the theatrical “eleventh hour of the eleventh day of the eleventh month.” Czarist Russia had collapsed, the Soviet Union was born, and the Ottoman and Austro-Hungarian empires were dismantled. Iraq was created out of several Ottoman provinces. Palestine was made a British mandate, paving the way for the creation of the State of Israel and its attendant problems. Imperial Germany, on whom the entire disaster was blamed, was humiliated, stripped of its colonies, and saddled with crushing reparations.
The blame on Spain
World War I was a disease-conscious war. Only nine years before, the Russo-Japanese War (the first major conflict that occurred after the discoveries of Pasteur and Koch) had shown that with proper sanitation among the troops, deaths from disease could be less than those from combat. This was significant: in nearly all past military conflicts, more soldiers died from infectious disease than from battle. With this example in mind, military leaders on both sides in the Great War took extraordinary precautions to prevent epidemics among their troops. They were especially concerned about typhus, a bacterial disease carried by fleas and human body lice. It thrives in conditions where people cannot bathe regularly or change their clothes. At the beginning of the war, both armies were especially vigilant about delousing soldiers returning from the front lines. In Serbia, however, sanitation broke down. During 1914 alone, a typhus epidemic there killed over two hundred thousand people. After the war, that disease spread to the freshly minted Soviet Union, where in four years it killed ten million people. Lenin is said to have remarked, “Either socialism will defeat the louse or the louse will defeat socialism.” (Socialism won.) As bad as typhus was, however, the flu was worse. No army had ever encountered a disease as murderous as the “Spanish Lady.”
The flu was called Spanish not because it started in Spain but because it was first reported in newspapers there. Why? Because Spain remained neutral in the war and therefore its military didn’t censor the press. People were getting sick everywhere, but in the nations at war—including the United States—any news that might help the enemy was suppressed.
The first recorded incidence of Spanish flu was in the United States at Fort Riley, Kansas, in March 1918. This first spring wave of the flu epidemic was a mild three-day illness that caused aches, fever, chills, a red face, and a weeklong hangover. As it spread to the war zone, doctors called this spring flu a “delightful disease” (everybody ill, nobody dying), but the soldiers weren’t nearly so grateful. The French griped about la grippe. The British suffered from “three-day fever.” The Italians complained of “sand fly fever.” The Americans came down with “knock-me-down fever.”
Mild it might have been, but the first wave arrived at a critical time for Germany. When General Erich Luden-dorff first heard that the enemy was suffering from what the Germans called Blitzkatarrh (“lightning flu”), he in-formed Kaiser Wilhelm II that it might help the war effort. But when German soldiers started coming down with the very same complaint, General Ludendorff blamed the failure of his July Friedensturm, or “peace offensive,” on the disease. This decisive battle had been Germany’s last real chance at victory. Afterward, American soldiers poured into Europe, ensuring victory for the Allies. Though the conflict would rage on for many more months in 1918, the outcome was essentially decided.
Gauze, laws, and paws
By July 1918, the first mild wave of the epidemic had faded around the world. In August, the second lethal wave of the disease appeared simultaneously among troops in Sierra Leone, France, and Massachusetts. It quickly spread. In the United States, though thousands started dying every week from the flu, Americans were more interested in war than illness. They took many actions that unwittingly spread the disease. Thousands of soldiers were shuttled around the country from base to base. Tens of thousands of men lined up to register for the draft. Hundreds of thousands packed together for Liberty Loan Bond parades to raise money for the war. By September, nearly every
major American city was infected. In most cities the epidemic lasted for a month or so. Some cities had two or three waves of illness.
San Francisco had ample warning to prepare for the worst. The height of the West Coast epidemic lagged about a month behind that on the eastern seaboard. Officials were able to read newspaper accounts from unprepared cities like Philadelphia. Understaffed hospitals there had been flooded with patients. The city morgue (capacity thirty-six) had overflowed, with hundreds of decomposing bodies stacked four deep in the halls. The bereaved were made to dig the graves of their dead, and funeral homes doubled their fees. In preparation for the inevitable, San Francisco ordered extra coffins and prepared the cemeteries. In order to slow infection, a “mask ordinance” required all citizens—even babies—to wear gauze masks in public at all times. This rhyme was a reminder: “Obey the laws / And wear the gauze / Protect your jaws / From Septic Paws.”
At the Philadelphia morgue during the flu epidemic, bodies were stacked four deep in the halls.
To meet the demand for masks, merchants offered several fashion options. There was the classic hospital-style mask (a half yard of gauze folded over like a triangular bandage), a more comfortable extended-muzzle version that gave the wearer a piglike appearance, or a veil that hung loose below the chin. All would prove essentially useless: in homes, where people congregated closely, masks were not required; they could also remove them to eat. Moreover, as the flu virus was as yet undiscovered, no one understood that millions of the tiny pathogens could slip through a single hole in the coarsely woven gauze. People died at about the same rate in San Francisco as in other cities. City services were unable to cope. Still, it must have been a surreal sight: thirty thousand masked San Franciscans singing, dancing, and waving flags in the Civic Center on November 11 to celebrate the armistice that marked the end of the war.
Losers and winners
The flu had numerous repercussions. Many people who caught the flu and survived later developed encephalitis lethargica, an illness that caused victims to fall into an around-the-clock sleep punctuated by comas. About five million people died from this ailment before it disappeared in 1928. Those who survived never fully recovered—they were aware of their surroundings but unable to move.
In Europe, during the postwar peace negotiations at Versailles, President Woodrow Wilson caught the flu. At the time he was the most popular leader in the world: American troops had provided the needed manpower to end the war. If anyone could have rammed through an agenda, it was Wilson. Indeed, he had come to the conference to push his Fourteen Points, a plan to prevent future Great Wars. But while Wilson was too sick and weak to have much influence, the other Allies forced unpayable reparations on Germany and gained territory for themselves. In the end, the Versailles treaty was not the blueprint for a better world that Wilson had hoped for. It was “legal robbery,” a treatise on revenge. Worse, the United States Senate rejected Wilson’s greatest creation, a League of Nations to guarantee the peace. In the years between the wars, unemployment and hyperinflation so crippled Germany that people would listen to anyone with a plan, even the hate-filled fantasies of Adolf Hitler. World War II was virtually guaranteed.
Just the flu
Influenza is an Italian word meaning “influence.” The name may spring from the astrological idea that the stars and planets influence humanity, including human health. It is an ancient disease that probably first evolved in birds. Today the main reservoir of the virus resides in the flocks of wild waterfowl like ducks, geese, and gulls that spread it around the world as they migrate. They ingest the virus when they eat and excrete it in their feces. It doesn’t make them sick, suggesting a long relationship between parasite and host. Domestic birds like chickens, however, are not so well adapted to the virus. It kills them. Once one chicken is infected, the disease explodes through flocks, often with devastating effects. As the virus sickens the birds, their immune systems try to make antibodies to overwhelm it. Under this kind of pressure, flu viruses are unstable. Each generation is slightly different from the last. This helps the virus outmaneuver the immune systems of some hosts, which can cause a local epi-demic. Every few decades, a flu virus may morph into a form to which nearly all hosts are susceptible. This causes a global pandemic. Such was the case with Spanish influenza.
The influenza virus
How did the flu virus start infecting us? People living in close proximity to animals have given many pathogens an opportunity to switch hosts. At some point in the past, the influenza virus jumped from birds to people, either directly or via an intermediate host. Pigs are the most probable “mixing vessel,” an animal susceptible to avian viruses whose internal environment pressures the unstable flu parasite to change just enough to be able to infect us, too. One of the places where people, domestic birds, and pigs live in close proximity is rural China. It is no surprise that most of the major flu pandemics have started there. Even the 1918 Spanish flu may have had a Chinese origin: thousands of Chinese laborers were imported to Europe during World War I to dig trenches and could have carried the disease with them.
After the Spanish influenza subsided, a worldwide flu surveillance network was developed to try to head off another pandemic. Scientists in the network now monitor the nature of yearly flu outbreaks and provide this information to pharmaceutical companies so that they can develop effective vaccines. Particular attention is paid to China and Southeast Asia. Several deadly flu epidemics have been controlled this way, including the 1957 Asian flu and the 1968 Hong Kong flu. The 1991 Hong Kong bird flu and the 2004 Asian bird flu, both of which jumped to people, were stopped by slaughtering chicken flocks that might harbor the disease. Nineteen million birds were killed in Canada’s Fraser Valley alone in 2004. Since 2001, the United States Centers for Disease Control has stepped up flu surveillance with the establishment of the International Emerging Infections Program. In 2003, the group’s office in Thailand was among the first to alert the world to a pandemic of a novel flulike disease, severe acute respiratory syndrome (SARS). The pandemic was controlled, in part, by unprecedented cooperation among scientists around the world, which the flu network had made possible. That cooperation will be essential in the future. Knowledgeable scientists say that with the instability of the influenza virus, it is only a matter of time—not if, but when—until another lethal Spanish-style flu emerges. Officials at the World Heath Organization estimate that when that happens, up to a billion people around the world could fall ill. Without an effective response, they suggest, 180 million people could die. Unlike in 1918, however, we know this pandemic is coming. We can prepare for the worst.
Possibly the most important outcome of the Spanish flu was its immunological aftermath: the discovery of penicillin. Flu wasn’t definitively understood to be a virus until 1933. Before that, many scientists agreed with eminent German biologist Richard Friedrich Johannes Pfeiffer that flu was caused by a bacterium. In 1928, Scottish scientist Alexander Fleming was trying to isolate that bacterium, known as Pfeiffer’s bacillus. While Fleming was on vacation, a spore from a neighboring lab contaminated one of his bacterial cultures with the rare mold Penicillium notatum. Fleming noticed that the mold released a poison that inhibited the growth of bacteria. He had stumbled across the world’s first antibiotic: a substance that could kill pathogenic bacteria. He called the substance “penicillin.”
Alexander Fleming was searching for a bacterial cause of the Spanish flu when he discovered the first antibiotic. A stray spore of a mold, Penicillium notatum, floated onto one of his petri dishes that was already infected with a culture of staphylococcus bacteria. Fleming noted that the mold produced a substance that inhibited the growth of the bacteria. He called it “penicillin.”
Fleming didn’t follow up on his discovery, but ten years later, two other British doctors, Howard Florey and Ernst Chain, tried to find out if penicillin had medical potential. When World War II created a huge need for drugs to treat wounded soldiers, these experiments were ac
celerated. At the time, soldiers were losing limbs and dying from even tiny wounds that festered and progressed to gangrene. Penicillin, though useless against viruses, stopped many bacterial infections with near-miraculous power. Soldiers who would have died from infection in previous wars could now return to the battlefield, giving the Allies a significant advantage over their enemies. Penicillin production was transferred to the United States and ramped up a millionfold, from petri dishes and lab trays to huge brewery vats. The strain of Penicillium changed, too, from the low-yield fungus in Fleming’s petri dish to a more productive strain discovered on a moldy cantaloupe in Peoria, Illinois. (A mutated version of that species, Penicillium chrysogenum, is still used today.) By 1945, the United States was producing enough penicillin to treat a quarter million patients a month. The age of antibiotics had begun.
I wish I hadn’t said that
“It is time to close the door on infectious disease.”
When United States surgeon general William Stewart made that pronouncement in 1967, it seemed neither hubris nor naïveté. It was a bold declaration in an age when anything seemed possible. At the time, smallpox was well on the way to being eliminated. Polio could be cured. Tuberculosis was in decline. Malaria and yellow fever were controlled. Measles was disappearing. Sexually transmitted diseases could be squelched. With infection nearly bested, chronic diseases like cancer and heart ailments seemed to be the focus of the future.
By century’s end, however, nearly all of those immunological gains had been reversed. Once-proud public health care systems were faltering, victims of their own success: as fear of infectious disease faded, many governments had slashed public health funding. Parents had begun to weigh the slightly possible adverse side effects of immunizations—from autism to death—against what they perceived as the dimming chance of disease. More and more people started opting out of vaccination programs. Diph-theria, pertussis, mumps, measles, and yellow fever reemerged as health problems. Meanwhile, bacterial infections that had been disappearing at midcentury not only had returned but had proved increasingly invulnerable to antibiotics. Worried infectious-disease professionals warned that unless something changed, even our most powerful antibiotics would eventually be useless.