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Lest We Forget: Influenza Can Be Devastating

One of our readers suggested that I review the book The Great Influenza: The Epic Story of the Deadliest Plague in History, by John M. Barry. It’s not a new book (it was published in 2004) but it is very pertinent to several of the issues that we have been discussing on this blog, especially in regards to the current anti-vaccine movement. It’s well worth reading for its historical insights, for its illumination of the scientific method, and for its accurate reporting of what science has learned about influenza.

In the great flu epidemic of 1918, influenza killed as many people in 24 weeks as AIDS has killed in 24 years. It’s hard to even imagine what that must have been like, but this book helps us imagine it. It tells horror stories: children found alone and starving beside the corpses of their parents in homes where all the adults had died, decomposing bodies piling up because there was no one left who was healthy enough to bury them. Sometimes the disease developed with stunning rapidity: during one 3 mile streetcar trip, the conductor, 3 passengers, and the driver died. In another incident, apparently healthy soldiers were being transferred to a new post by train; during the trip, men started coughing, bleeding, and collapsing; and by the time it arrived at its destination, 25% of the soldiers were so sick they had to be taken directly from train to hospital. 2/3 of them were eventually hospitalized in all, and 10% of them died. The mind boggles.

The 1918 epidemic was exacerbated by politics and military considerations. Because of WWI, young men were gathered and crowded into barracks and troops were transferred to new locations, helping the disease to spread. Quarantine recommendations were rejected because they might cause panic and interfere with the war effort. Vital public health information was censored to maintain morale, so the public (and many officials) were slow to realize the extent of the problem. Falsely reassuring bulletins were issued with unhelpful advice to prevent contagion by keeping warm, keeping the feet dry, and keeping the bowels open. It was named the Spanish flu not because it originated in Spain (the author thinks it most likely originated in Kansas) but because the Spanish government was the only one that allowed the truth to be publicized.

The book explains how the flu virus works, how it mutates even during a given flu season, what antigen drift and antigen shift are, why we have to keep changing the vaccines, and how antigen shift can result in an epidemic. It explains that the killer is not the virus but the body’s massive immune response. This is why young healthy people were most susceptible: their bodies were more capable of mounting a response to the virus. Understanding this would make people less susceptible to claims that a given alternative medicine “boosts the immune system.”

Ironically, the massive immune response itself damaged the lungs so that they were susceptible to bacterial invasion. Just as some patients were recovering from the influenza virus, they developed a bacterial pneumonia and died of complications. This muddied the waters and interfered with efforts to pin down the cause of influenza. For a long time, scientists thought it was caused by B. influenzae bacteria (now known as Hemophilus influenzae) because they were often able to culture this and other pneumonia-causing bacteria from flu victims. Some laboratories found the bacteria in virtually every patient, and when other labs failed to find it their results were dismissed as due to poor technique or critics said that if the bacteria could not be found, those patients must not have had the flu.

At that point in history, there was no way to detect a virus other than to demonstrate its presence indirectly by showing that the property of infectiousness could survive filtration that removed larger elements like bacteria. The story of how scientists searched for the cause of influenza is an illuminating one, full of set-backs and mistakes. It illustrates how science progresses step by step and how errors are eventually corrected.

Desperate patients were willing to try any proposed remedy. Some opened windows while others closed them; some hung camphor and garlic around their necks. Desperate doctors tried everything from rubbing creosote into the axilla to stimulating the heart with strychnine and digitalis. Homeopaths claimed a death rate of zero, but

…the results were self-reported, making it far too easy to rationalize away those under their care who did die – to remove, for instance, from their sample any patient who, against their advice, took aspirin which homeopaths considered a poison.

The epidemic ran its course and eventually subsided, mainly because of two factors: the population developed a degree of immunity, and the virus itself became less virulent due to reversion to the mean in the mutating viral population.

This book was written before the 2009 H1N1 pandemic, so it offers a step back into a time machine. It explains the thinking that would go into the 2009 response. Critics can second-guess authorities now that the 2009 H1N1 strain has turned out not to be as serious as feared, but this book makes it clear that influenza has devastating potential and that a strong response was fully justified in 2009 and will be justified again next time. And there will be a next time. I wish anyone who questions flu vaccines or who thinks influenza is not serious because it’s “just the flu” would read this book.

Posted in: Book & movie reviews, History, Public Health

Leave a Comment (17) ↓

17 thoughts on “Lest We Forget: Influenza Can Be Devastating

  1. WilliamLawrenceUtridge says:

    Does anyone else face an ever-growing pile of library books due to Dr. Hall’s recommendations?

    An excellent review on what looks to be a very interesting topic!

  2. ConspicuousCarl says:

    to remove, for instance, from their sample any patient who, against their advice, took aspirin which homeopaths considered a poison

    In addition to Dr. Hall’s recommendation for Barry’s 1918 flu book, I suggest that everyone read a book about the horrors of the millions who died in the 1917 aspirin pandemic, and the heroic homeopaths who finally brought it to an end. If I ever find such a text, I will immediately report back here with the title.

  3. Khym Chanur says:

    Homeopaths claimed a death rate of zero, but…

    Also, how exactly do they arrive at their numbers? If a patient of theirs got so sick they had to be hospitalized and then died, was their death attributed to evil allopathy? Because if a death only counts against them if their patient is so fanatical as to refuse all conventional treatment, right up until the moment they die, then their staggeringly low “death rate” is no surprise.

  4. Damned Skeptic says:

    I’ve read about how many victims there were, but I didn’t know that the flu developed so rapidly which makes it seem even more frightening. Better to have a strong response and be wrong about how deadly a flu is than have a weak response and be wrong.

    Like commenter William above, I’ll be checking this book out from the local library. Unfortunately the local branch lost the book, so I’ll be waiting a few days till it arrives from another branch.

  5. Jan Willem Nienhuys says:

    I don’t know about flu and homeopathy, but the matter of homeopathy vs. regular medicine in ordinary practice has been investigated. A serious problem is that the patient population differs between homeopathic hospitals and regular hospitals. For example, in the old time homeopathic hospitals were often private institutions for the well to do with insurance, and the public hospitals got all destitute patients, more specifically the elderly.

    The German homeopathic physician Fritz Donner wrote a paper on it: F. Donner, Statistische Probleme, Allgemeine homöopathische Zeitung,vol. 179 (1931), p. 317-337. I know only the French translation of the paper, Appendix 3 in Jean-Jacques Aulas et al., L’Homéopathie. Editions Médicales Roland Bettex, Lausanne/Paris, 1985. Donner first discusses why homeopathic hospitals had lower mortality rates. For example a report from 1910 mentions that in a certain homeopathic university hospital 70% of the beds were taken by patients with ear, nose or throat problems or eye diseases.

    Donner mentions the researches of Dr. Fritz Conrad Askenstadt of the Southwestern Homeopathic Medical College of Louisville, Kentucky, whose paper was published in 1915 in several homeopathic journals in 1915. At that time Louisville had five medical schools and one homeopathic medical school. From April 1, 1895 on the city hospital had a deal with the medical colleges. After every five patients the next one was treated by homeopaths from SHMC. This lasted until SHMC was closed in 1910.

    This arrangement made it possible to compare the death rates of homeopathy with those of ‘regular medicine’. The method of assignment to homeopathy or regular ensured that it was random; nursing and food were the same for all patients. Only the medication given differed (I think that during surgical procedures only regular anesthetics were used).

    The death rates were almost exactly the same! Lung disease exclusive tuberculosis: 18.6%, tuberculosis 100.0% (these patients were only brought to the hospital in the last stage of their disease), urology 40%, surgery 8%, cardiovascular disease about 27%, and so on. The total number of deaths was 3742, and 321 (16.6%) of these were homeopathic deaths.

    Of course, in those times there were hardly any effective medicines at all. In the same article we get a glimpse of the allopathic remedies for pneumonia (before 1921): atropine, camphor oil, whiskey, digitalis, morphine, strychnine. Allopathy (= unsuitable treatment) was an invective of Hahnemann for 18th century medicine like bloodletting and purging, but in this case of 20th century medication that term may also be appropriate.

  6. Thanks Harriet Hall, I thought you’d like the book. I thought it was compelling reading.

    What particularly struck me was how little training US medical doctors had and how poor US medical schools were at the turn of the last century. (In order to learn to use a microscope, a science-minded medical student had to leave the US to study in Europe.) It’s not at all surprising that outcomes would be no different between homeopathy and medicine.

    Even after science-based medical study had taken hold and rejected some of the old treatments like bloodletting, there was a gap of several years before science-based treatments could be developed which made it difficult for doctors who wished to study and practice scientifically to achieve much credibility.

  7. pmoran says:

    – the killer is not the virus but the body’s massive immune response.

    How does that work?

  8. Harriet Hall says:

    @pmoran – “How does that work?”

    See:
    http://www.disabled-world.com/health/influenza/flu-dangers.php

    “…first-line immune response, primed by an imperfect antibody, can overreact in a violent and uncontrolled fashion. Patients die from lung damage inflicted by their own immune system. A molecule called C4d, a product of this biochemical cascade (the complement system), is a marker for the strength of the response.
    In adults who died during the 2009 H1N1 pandemic, high levels of C4d in lung tissues suggest a massive, potentially fatal activation of the complement system.
    Pulmonary and critical care physician, Todd Rice, M.D., assistant professor of Medicine at VUMC, has seen people killed by the “exuberant” and uncontrolled response of the immune system in other diseases – like sepsis.”

  9. ConspicuousCarl says:

    Injury from excessive inflammation is one of the interesting artifacts of evolution.

    On top of the immune system’s overreaction to the flu and sepsis in response to bacteria, we have to worry about strokes prodding massive quantities of stress hormones (which, ironically, are harmful to the brain), and pericarditis after heart attacks.

    It seems like any time you need to go to a hospital to fix an initial malady, half of the battle is stopping your unintelligent body from throwing a fit and killing itself with amplified good intentions.

  10. JCloth says:

    Thanks Harriet for a really interesting book review, which does make me want to go out and find a copy of the book.

    Aside from that, I’m a newcomer to this blog, and this part struck a chord with me:

    It explains that the killer is not the virus but the body’s massive immune response. This is why young healthy people were most susceptible: their bodies were more capable of mounting a response to the virus. Understanding this would make people less susceptible to claims that a given alternative medicine “boosts the immune system.”

    My first degree was a BSc in one of those “CAM” subjects which you guys are here to debunk. The day I knew I was really in the wrong place in studying it was when one of the lecturers was teaching us how to ‘treat’ hayfever by “boosting the immune system”. I was confused and asked why we would want to boost the immune system for what I understood to be viewed as an overreaction of the immune system to various types of pollen… the subsequent confusion, backtracking and irritation from the lecturer told me that nodoby had bothered to even question this before and that questioning was not really welcome.

    So – thanks for the review, and to the others for the rest of the blog too.

  11. Rick says:

    Sounds like a book I need to pick up. What is maddening, when debating the anti-vax crowd, is their utter lack of logic. When they say that the HN1N pandemic overblown, I point out to them that according to CDC statistics that if you had the flu last year it was 99.9 % likely to have been H1N1. Of course the never believe government statistics.

  12. wales says:

    Regarding the 1918-19 influenza, aberrant immune responses to viruses were just part of a complex problem. As the authors of this paper http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600384/ explain:

    “We endorse a sequential-infection hypothesis. This hypothesis is consistent with the known epidemiologic and clinical characteristics of the 1918-19 influenza pandemic, reflects the consensus views of firsthand observers and contemporaneous experts, and incorporates current knowledge regarding the effects of influenza on physical and immune respiratory tract defenses and physiologic interactions between influenza and respiratory bacteria.”

    “A novel strain of influenza spread rapidly throughout the world in 1918. For most patients, infection with the virus was clinically expressed as an “influenza-like illness” that was transiently debilitating but rarely fatal. In addition, however, the virus induced aberrant immune responses, including excessive and prolonged production of interferons, proinflammatory cytokines, and chemokines, particularly among young adults. The pathophysiologic effects included inflammation and destruction of respiratory epithelium; immune cell infiltration of lung tissue with edema and hemorrhage; and ultimately, degradation or destruction of virtually all physical and immune defenses of the lower respiratory tract. Increased susceptibility of the lower respiratory tract enabled invasion by preexisting or newly acquired colonizing strains of bacteria. The synergistic effects of infection with the virus, aberrant immune responses to the virus, and secondary opportunistic bacterial pneumonias were severe and often fatal.”

    To prepare for future pandemics, the authors caution against relying solely upon preventative actions such as vaccination, citing the high mortality from secondary and tertiary bacterial infections and emphasizing the importance of effective antibiotics.

  13. Panthera spelaea says:

    @WilliamLawrenceUtridge [I]Does anyone else face an ever-growing pile of library books due to Dr. Hall’s recommendations?[/I]

    No, but Amazon.com is very happy with me. :-)

  14. weing says:

    “To prepare for future pandemics, the authors caution against relying solely upon preventative actions such as vaccination, citing the high mortality from secondary and tertiary bacterial infections and emphasizing the importance of effective antibiotics.”

    Do they give any evidence that vaccination induces an aberrant immune response similar to the one caused by the actual virus? I don’t think so.

  15. dt says:

    Last year around the time H1N1 was starting up, the BBC had a wonderful film about the Spanish flu and one public health doctor’s efforts in Manchester UK to deal with the waves of flu outbreaks sweeping the city.

    It was called “The Forgotten Fallen”, starring Bill Patterson.
    It was beautifully acted and filmed.
    http://www.bbc.co.uk/programmes/b00lz31y
    I don’t know if its still viewable anywhere.

  16. Calli Arcale says:

    wales:

    To prepare for future pandemics, the authors caution against relying solely upon preventative actions such as vaccination, citing the high mortality from secondary and tertiary bacterial infections and emphasizing the importance of effective antibiotics.

    One of the reasons, I would think, is because influenza vaccine tends to be only about 80% effective, with the actual rate varying depending on how closely the vaccine matches the circulating strains — it can be as low as 10% or as high as 95%. If we rely exclusively on vaccination, then we are essentially gambling on having picked the right vaccine this year. If this turns out to be a year of an especially bad match *and* and especially infectious *and* especially virulent influenza, then we are basically screwed. And even if it’s not a bad year, *some* people are going to catch the flu even if we have very good vaccine compliance and a good antigenic match, and some will get seriously ill. Doctors need to be able to treat them, and that’s where antivirals and antibiotics and other therapies can come into play.

    So I’d agree — while preventative actions are extremely important (it’s best not to catch it in the first place, after all), we cannot rely on them alone. Not until someone invents a universal flu vaccine, anyway, and while there’s some interesting work in that area, it’s not anything we can plan on using right now.

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