OUT­BREAK

The lit­tle-known story of the 1918 Span­ish Flu and how we’re pre­par­ing for the next great pan­demic

Canadian Geographic - - CONTENTS - By Alanna Mitchell

The lit­tle-known story of the 1918 Span­ish Flu and how we’re pre­par­ing for the next great pan­demic

IIT STARTED INNOCENTLY enough, with snif­fles and a cough. Then the fever pounced. Ev­ery mus­cle, ev­ery joint, ached. Blood poured from the nose. Teeth fell out. So did hair. The stench was in­de­scrib­able. Vom­it­ing and di­ar­rhea were com­mon, as was delir­ium. Ex­treme anx­i­ety led some suf­fer­ers to take their own lives. Oth­ers shrieked in ter­ror, prey to tech­ni­colour night­mares. Breath­ing be­came laboured. Then the dreaded ma­hogany-coloured patches ap­peared over each cheek­bone. The skin took on a deep plummy red colour — doc­tors dubbed it “dusky he­liotrope” — then be­gan to darken to black­ish pur­ple as the lungs filled with fluid. When fin­ger­tips and toes turned inky, the game was up. The end came swiftly. Peo­ple fought to catch a breath only to drown in their own bod­ily flu­ids. This was death by Span­ish Flu. The pan­demic that swept the world from 1918 to 1919 killed at least 50 mil­lion. It was the most lethal in­fec­tion since the Black Death of the 14th cen­tury, dis­pro­por­tion­ately tak­ing the lives of young and oth­er­wise healthy adults. In Canada, more than 50,000 peo­ple per­ished, roughly the same num­ber of Cana­di­ans who died dur­ing the four years of the First World War. The pan­demic was likely the big­gest global killing event of the 20th cen­tury. Most of the vic­tims died dur­ing 13 grim weeks be­gin­ning in Septem­ber 1918. It was a tsunami of death that left fam­i­lies, com­mu­ni­ties and na­tions reel­ing. But while dread­ful con­ta­gions such as the Black Death grasp the imag­i­na­tion, spawn­ing last­ing rec­ol­lec­tion through art, word and song, the Span­ish Flu slipped quickly from mem­ory. It was the for­got­ten plague. The first in­ter­na­tional con­fer­ence on the pan­demic, held on its 80th an­niver­sary in Cape Town, drew just 36 aca­demics. “The ef­fects of the flu got lost in the ef­fects of the war,” says his­to­rian Mark Os­borne Humphries, the Dunk­ley chair in war and the Cana­dian ex­pe­ri­ence at Wil­frid Lau­rier Univer­sity in Water­loo, Ont. To­day, the enor­mity of the tragedy is fi­nally be­ing fully ac­knowl­edged, its real toll tal­lied. The Span­ish Flu has pen­e­trated so far into pop cul­ture that it fea­tured as a plot de­vice in the hit tele­vi­sion show Down­ton Abbey and The Twi­light Saga films and has been the sub­ject of re­cent tele­vi­sion doc­u­men­taries (in­clud­ing a forth­com­ing Cana­dian Ge­o­graphic co-pro­duc­tion), sev­eral non-fic­tion books and an out­pour­ing of aca­demic re­search. Me­mo­rial events and ex­hibits are mark­ing the cen­te­nary. And re­cent foren­sic in­ves­ti­ga­tion of the virus’s in­ner machi­na­tions has helped spawn an in­tense global ef­fort to pre­pare for the next in­evitable pan­demic. Pro­vin­cial, na­tional and in­ter­na­tional pre­pared­ness plans are wait­ing to be trig­gered. Drugs are be­ing stock­piled. Sea­sonal flu viruses are un­der con­stant global sur­veil­lance. Some of the best minds in the world, spurred by Mi­crosoft bil­lion­aire and phi­lan­thropist Bill Gates, are try­ing to find a uni­ver­sal flu vac­cine. Yet the story of how the virus made its mer­ci­less ad­vance through Canada in 1918 has only be­gun to be pieced to­gether. One hun­dred years on, its lessons are still be­ing parsed. Why was it so dev­as­tat­ing? What’s changed? Most im­por­tant: How deadly will the next out­break be?

THE SPRING OF 1918 brought with it the usual yearly flu, pop­ping up here and there. Peo­ple sick­ened. Some died. Some turned a pe­cu­liar pur­ple-black and had trou­ble breath­ing. There was lit­tle alarm. In ret­ro­spect, this was the first of three waves. The world paid lit­tle at­ten­tion, as the war was all-con­sum­ing. In Canada, the mil­i­tary was the largest em­ployer, con­trol­ling much of the coun­try’s man­u­fac­tur­ing and many of its hos­pi­tals. All around the globe, troops and war sup­port work­ers were on the move, trav­el­ling in vast num­bers across land and sea, from Asia and North Amer­ica to the trenches and bat­tle­fields of Europe. News that could hurt morale or ben­e­fit the en­emy was cen­sored in most coun­tries to aid the war ef­fort. And means of mass com­mu­ni­ca­tion were lim­ited. In Canada, there were few tele­phones. And no ra­dio or tele­vi­sion. Canada’s fed­eral gov­ern­ment wasn’t keep­ing an eye on dis­ease out­breaks. In­fluenza was not a re­portable dis­ease when the pan­demic be­gan. In fact, doc­tors didn’t use the term “in­fluenza” much

at the time; in­stead, they spoke of ca­tarrhs or pu­ru­lent bron­chi­tis. Many doc­tors and nurses were also out of the coun­try, serv­ing in the war. Canada didn’t even have a fed­eral depart­ment of health. And fed­eral politi­cians who might have been able to raise the alarm weren’t gath­ered in Ot­tawa dur­ing the worst of the out­break — Par­lia­ment rose near the end of May that year, not to sit again un­til late Fe­bru­ary 1919, when the pan­demic had largely run its course. But on May 28, 1918, Cana­di­ans got their first hint of the dev­as­ta­tion that was to come. It was in a story car­ried by newswires from Spain, one of the few coun­tries whose me­dia out­lets were free from cen­sor­ship be­cause it was not a com­bat­ant in the war. The “grip” or in­fluenza had struck Madrid, the Cana­dian Press re­ported, par­a­lyz­ing the Span­ish cap­i­tal’s busi­ness world and sick­en­ing about 30 per cent of those from other parts of the coun­try. It was, the story said, a “strange dis­ease.” Within a week, read­ers of the Toronto Star dis­cov­ered that 700 had al­ready died from what it dubbed “the plague.” The Times of Lon­don was call­ing it the

Alanna Mitchell (@amitchelltweets) is a con­tribut­ing ed­i­tor to Cana­dian Ge­o­graphic. She wrote about her bi­ol­o­gist fa­ther and his re­search into pronghorn an­te­lope in the May/june is­sue. “Span­ish epi­demic.” The moniker stuck, not be­cause the pan­demic had be­gun in Spain, but be­cause the first re­ports emerged from there. A month later, when the hos­pi­tal ship Araguayan reached Hal­i­fax Har­bour from Eng­land, 23 per cent of its pas­sen­gers and crew were sick with in­fluenza, writes his­to­rian Humphries in his 2013 book The Last Plague: Span­ish In­fluenza and the Pol­i­tics of Pub­lic Health

in Canada. Rather than leap into ac­tion, fed­eral of­fi­cials dragged their feet. It was two weeks later that the of­fi­cially named “Span­ish In­fluenza” was in­cluded in Canada’s list of “the graver forms of quar­antin­able dis­ease” and steps were taken to iso­late the ship’s sick, notes Humphries. But this was still the first wave. The virus wasn’t yet on the loose in Canada. The worst was yet to come.

FLU VIRUSES ARE MAGICIANS. They con­stantly re­shape them­selves, fig­ur­ing out fiendish new ways to spread, al­ways one step ahead of the body’s im­mune sys­tem. While three main types of the flu af­fect peo­ple — A, B and C — only the A type can cause pan­demics. Flu viruses also live in birds and mam­mals and by def­i­ni­tion, a pan­demic flu virus must start in an an­i­mal, typ­i­cally a wa­ter­fowl or pig. The virus breaks free from that avian or swine host, jumps to peo­ple and, ei­ther by pick­ing up some genes from an ex­ist­ing hu­man flu virus, or by mu­tat­ing its own, trans­forms from an an­i­mal flu

virus into a new type of hu­man flu virus. Be­cause it’s new, we have no im­mu­nity to it. Nov­elty alone is not enough to make it dan­ger­ous, ex­plains Arnold Monto, pro­fes­sor of epi­demi­ol­ogy and global pub­lic health at the Univer­sity of Michi­gan in Ann Ar­bor who is known as the “guru of flu.” To set the stage for a pan­demic, this new flu virus also has to be able to spread ex­ten­sively among peo­ple and cause se­vere ill­ness and death. Viruses have been wildly suc­cess­ful at that for more than 500 years. Med­i­cal sleuths track flu pan­demics back at least to the Mid­dle Ages and per­haps ear­lier. They have found ev­i­dence that sug­gests the oc­cur­rence of at least 14 flu pan­demics since 1500, in­clud­ing three since 1918. The most re­cent, in 2009, be­gan in Mex­ico, sur­pris­ing re­searchers who ex­pected it would emerge in Asia, says Theresa Tam, Canada’s chief pub­lic health of­fi­cer. “The more we un­cover about the flu virus,” she says, “the less we ac­tu­ally know.” One thing is sure. Each of the three post-1918 flu pan­demics, and al­most all mod­ern sea­sonal in­fluenza A cases around the world, evolved from that sav­age 1918 mu­ta­tion. But no ver­sion has come near the 1918 virus for sheer, ex­plo­sive vir­u­lence, writes Jef­fery K. Tauben­berger, the chief of vi­ral pathogen­sis and evo­lu­tion at the Na­tional In­sti­tutes of Health in the United States who helped se­quence its genome and later re­con­structed the virus it­self. No­body knows pre­cisely where the 1918 virus emerged — the­o­ries range from the U.S. Mid­west to China to an army camp in France — but it made a third of the peo­ple then on Earth — about half a bil­lion — clin­i­cally ill.

AT ONE TIME, his­to­ri­ans be­lieved troops returning from the bat­tle­fields of Europe car­ried the virus home. Humphries’ metic­u­lous his­tor­i­cal de­tec­tive work dis­proved that. In fact, returning troops were stuck in Europe from July un­til late Septem­ber 1918 for fear their ships would be at­tacked by Ger­man U-boats. By the time sol­diers started to ar­rive home in Oc­to­ber, the pan­demic’s sec­ond wave had al­ready spread from coast to coast. And when the ma­jor­ity of sol­diers re­turned af­ter the ar­mistice on Nov. 11, the pan­demic was al­ready rag­ing. In fact, the sec­ond wave of the pan­demic crept stealth­ily into Canada across the United States border on a fate­ful Fri­day the 13th in Septem­ber 1918, gain­ing two lethal footholds here that day. Within days, it had made two fur­ther in­cur­sions, seed­ing in­fec­tion from On­tario to Nova Sco­tia be­fore mus­ter­ing its strength and rac­ing across Canada. It ar­rived Sept. 13 at a mil­i­tary train­ing camp in Ni­a­gara-on-theLake, Ont., along with Pol­ish sol­diers re­cruited in the United States and on their way to the French army. The same day, Catholic clergy and parish­ioners from the United States reached Vic­to­ri­av­ille, just east of Mon­treal, to at­tend a huge Eucharis­tic Con­gress over the week­end that was to draw more than 25,000 par­tic­i­pants. By Mon­day, just hours af­ter the Con­gress ended, priests and stu­dents at the Col­lège Sacré Coeur, a board­ing school in Vic­to­ri­av­ille that had been the site of some of the gath­er­ings, were dead. Stu­dents still well enough to be sent home were dis­patched across the prov­ince, viruses and all. Four days later, the first flu-struck Cana­dian sol­diers be­gan re­port­ing to the

Most of the vic­tims died dur­ing 13 grim weeks be­gin­ning in Septem­ber 1918. It was a tsunami of death that left fam­i­lies, com­mu­ni­ties and na­tions reel­ing.

Sta­tion Hos­pi­tal in St-jean, Que., likely in­fected by re­cruits from Bos­ton where the pan­demic was in full, grue­some swing. From St-jean, the virus swiftly made its way to Mon­treal, launch­ing a cas­cade of death there. On Sun­day, Sept. 22, the virus made land­ing in Syd­ney, N.S., along with 500 des­per­ately ill Amer­i­can sol­diers who had been try­ing to sail to France and had to go to shore for med­i­cal help. From those four strate­gic land­ings, the sec­ond wave of the virus surged piti­lessly across the coun­try with east­ern­ers head­ing west by rail. One prime dis­sem­i­na­tor of in­fec­tion was the Cana­dian Siberian Ex­pe­di­tionary Force troops, who were headed to Rus­sia to bol­ster Al­lied ef­forts on the Eastern Front. In late Septem­ber, just two weeks af­ter the virus ar­rived in Canada, SEF re­cruits left Sus­sex Camp in New Brunswick to travel by train to Van­cou­ver, then across the sea to Rus­sia. The same day, flu broke out at the camp. By the time their train hit Mon­treal, some sol­diers were so ill they had to be hos­pi­tal­ized. It was the same story at stops in Win­nipeg, Cal­gary and Van­cou­ver. “Like an in­vad­ing army rav­aging a for­eign coun­try, re­cruits from the Cana­dian Siberian Ex­pe­di­tionary Force spread dis­ease to the towns they passed through on their way west,” writes Humphries. On Wed­nes­day, Oct. 2, just 19 days af­ter it first hit Cana­dian soil in the east, the “Span­ish Lady” reached the West Coast. By mid-oc­to­ber, the pan­demic was in full strength in Canada, as well as other parts of the world. Hal­i­fax had 500 cases by then, and Mon­treal, 20,000, ac­cord­ing to front-page head­lines in the Hal­i­fax Her­ald. Six hun­dred new cases emerged in Ot­tawa overnight. New York had seen more than 25,000 cases and Cape Town re­ported 140 buri­als in a sin­gle day.

CANA­DI­ANS SCRAM­BLED to re­spond. There was no treat­ment. No cure. The in­ven­tion of an­tibi­otics to com­bat the deadly bac­te­rial pneu­mo­nia that came in the flu’s wake was still more than a decade away. Even aspirin, that ef­fi­cient queller of fevers, was un­com­mon. Vac­cines were im­per­fectly un­der­stood and in­ef­fec­tive. It would be 15 years be­fore vi­rol­o­gists would iso­late and cul­ture any hu­man flu virus in a lab, and even longer be­fore they dis­cov­ered how a virus could evolve to be­come so deadly. Peo­ple re­sorted to folk reme­dies and su­per­sti­tion. Some wore cot­ton bags filled with cam­phor or moth­balls about the neck, re­ported jour­nal­ist Eileen Pet­ti­grew, who in­ter­viewed sur­vivors and scoured news­pa­per re­ports for her 1983 book The Silent En­emy: Canada and the Deadly Flu of 1918. “Some peo­ple put their faith in vi­o­letleaf tea, goose-grease poul­tices, gar­lic buds, cas­tor oil, salt wa­ter snuffed up the nose, or hot coals sprin­kled with sul­phur or brown su­gar and car­ried through the house ac­com­pa­nied by clouds of bil­low­ing smoke,” she writes. First Na­tion reme­dies in Saskatchewan and Al­berta in­cluded wild gin­ger and the barks of cot­ton­wood, wild cran­berry and poplar. Some of­fi­cials and in­di­vid­ual cit­i­zens took ac­tion, clos­ing schools, church ser­vices and the­atres, and sus­pend­ing pub­lic gath­er­ings. In Hal­i­fax, for a short time the homes of suf­fer­ers were plas­tered with plac­ards to warn of the flu lurk­ing within. Priests in Mon­treal ad­min­is­tered last rites on the streets and of­fered com­mu­nion to cit­i­zens on their doorsteps, her­alded by bu­gles or bells. Toronto ho­tels were pressed into duty as makeshift in­fir­maries. Cal­gar­i­ans had to wear face masks by law. Leth­bridge, Alta., quar­an­tined it­self. Forty-five prairie towns along the Cana­dian Pa­cific Rail­way lines re­fused to al­low trains to stop. But in other places, of­fi­cials turned a blind eye. On Oct. 5, T.J. Minnes, chair­man of the board of health in Brant­ford, Ont., down­played the fe­roc­ity of the virus, re­fused to im­ple­ment the re­quests of the med­i­cal of­fi­cer of health and, four days later, claimed the Span­ish In­fluenza had by­passed his city. At the time, the hos­pi­tal was turn­ing away pa­tients and a doc­tor had died. The fol­low­ing week, Brant­ford had 2,500 cases of flu and the med­i­cal of­fi­cer of health had re­signed in frus­tra­tion. Saska­toon’s med­i­cal of­fi­cer of health, Arthur Wil­son, was equally dis­mis­sive, say­ing the flu’s in­flu­ence had been ex­ag­ger­ated by me­dia re­ports — the 1918 ver­sion of “fake news.” The mil­i­tary, more con­cerned with sup­port­ing the war ef­fort, con­tin­ued to en­cour­age pub­lic events in Win­nipeg to buoy war-weary spir­its. Of­fi­cers sent sol­diers from the St-jean bar­racks to Mon­treal for the fu­neral of Que­bec’s lieu­tenant-gov­er­nor even though the bar­racks were un­der quar­an­tine.

Flu viruses are magicians. They are con­stantly re­shap­ing them­selves, fig­ur­ing out fiendish new ways to spread, al­ways one step ahead of the body’s im­mune sys­tem.

Mean­while, Indige­nous Cana­di­ans in some iso­lated com­mu­ni­ties across the North died in num­bers so vast none were left to dig graves. The death toll in the Inuit com­mu­nity of Okak, Labrador, was so large that the place was aban­doned. While deaths were high ev­ery­where, a fed­eral re­port pub­lished in 1919 cal­cu­lated that Indige­nous Cana­di­ans liv­ing on re­serves died from the pan­demic at more than five times the na­tional av­er­age. “While a lot of em­pha­sis is placed on the virus it­self, I don’t be­lieve you can ex­plain what hap­pened in 1918 with­out con­sid­er­ing the so­cial cir­cum­stances of that time,” says his­to­ri­anan­thro­pol­o­gist Kan­dace Bo­gaert, Cleghorn Fel­low in war and so­ci­ety at Wil­frid Lau­rier Univer­sity i n Water­loo, Ont. She points to the move­ment of mil­lions around the world for the war, crowded liv­ing con­di­tions, in­equal­ity and even chil­dren returning to school in the fall as rea­sons the sec­ond wave was so deadly. Fi­nally, in De­cem­ber, the sec­ond wave pe­tered out. A smaller, less vir­u­lent third wave washed through Canada and other parts of the world in early 1919. It hit the Mon­treal Cana­di­ens so hard dur­ing the Stan­ley Cup fi­nal in April that the sixth game of the se­ries with the Seat­tle Metropoli­tans was can­celled and no cup was awarded that sea­son. Cana­di­ens de­fence­man Joe Hall died of the flu in a Seat­tle hos­pi­tal on April 5. Be­tween the war and the three waves of the Span­ish Flu, peo­ple were numbed. One sur­vivor told Pet­ti­grew: “We got so we didn’t even mourn.” ONE HUN­DRED YEARS later, a new flu pan­demic is con­sid­ered in­evitable by pub­lic health of­fi­cials around the world, says Tam, Canada’s chief doc­tor. Will it prove as deadly for Cana­di­ans? Or the world for that mat­ter? No one knows. To be sure, much has im­proved over the cen­tury. Peo­ple’s health was gen­er­ally poorer then and, in Canada, they died an av­er­age of nearly 22 years ear­lier. Other in­fec­tious dis­eases, such as tu­ber­cu­lo­sis, were com­mon, low­er­ing re­sis­tance when the pan­demic ar­rived. Now, in place of face masks and goose grease, we have an­tibi­otics, flu vac­cines, daily an­tivi­ral med­i­ca­tions and me­chan­i­cal res­pi­ra­tion. A uni­ver­sal flu vac­cine, long promised, could be on the hori­zon in the next few years, says guru of flu Monto. And, thanks to the pan­demic, we also have dif­fer­ent at­ti­tudes to­ward health it­self, says Humphries. Un­til 1918, health was seen as a per­sonal and lo­cal re­spon­si­bil­ity. Now, it’s col­lec­tive. That has led to a pub­lic health in­fra­struc­ture, hos­pi­tal care and de­tailed global pan­demic plan­ning. As part of the plan­ning, re­searchers across the world, in­clud­ing those at Win­nipeg’s Na­tional Mi­cro­bi­ol­ogy Laboratory, rou­tinely ex­am­ine flu viruses as they ap­pear, shar­ing knowl­edge if some­thing is amiss, Tam says. It’s a global early warn­ing sys­tem. And when the next pan­demic virus emerges, labs will know how to se­quence its genome swiftly, let­ting them cal­cu­late how lethal it will be. In Canada, that knowl­edge will trig­ger an in­for­ma­tion cam­paign to tell Cana­di­ans what to do. It’s a far cry from the wartime me­dia cen­sor­ship and out­right pro­pa­ganda of 1918. Still, the world has changed in ways that could let a new pan­demic flu virus thrive. To­day, there are far more po­ten­tially in­fectible peo­ple on Earth — about 7.6 bil­lion com­pared to about 1.5 bil­lion in 1918. Far more are el­derly and vul­ner­a­ble. And we travel swiftly in vast num­bers by air, great con­duits for dis­ease as the world dis­cov­ered in 2003 when the se­vere acute res­pi­ra­tory syn­drome, or SARS coron­avirus, ar­rived, and in 2009 when the lat­est pan­demic flu virus be­gan to spread. “We need to be as adapt­able as the flu virus,” says Tam. But the legacy of the once for­got­ten plague is still be­ing cal­cu­lated. Deaths from the war and the three waves of pan­demic hol­lowed out a whole gen­er­a­tion of young Cana­di­ans, a ma­jor de­mo­graphic “catas­tro­phe,” says Humphries. What did it mean for Canada? That’s a project Lau­rier’s Bo­gaert is ea­ger to take on. Now, more cen­tury-old records are be­ing dig­i­tized and made pub­lic, and she is us­ing them to mea­sure how those in­ti­mate fam­ily losses re­ver­ber­ated through the gen­er­a­tions and through Canada’s cul­tural mem­ory. As much as the Span­ish In­fluenza has al­ready told us, it still has tales to tell.

A new flu pan­demic is con­sid­ered in­evitable. Will it prove as deadly for Cana­di­ans? Or the world for that mat­ter?no one knows.

Clock­wise from op­po­site bot­tom: A hos­pi­tal ship at Hal­i­fax on June 29, 1917; teach­ers tend to chil­dren sick with Span­ish Flu at Col­lège La Salle in Thet­ford Mines, Que.; the 15th Bat­tal­ion of the Cana­dian Ex­pe­di­tionary Force ar­rives at Toronto’s Ex­hi­bi­tion Camp in 1919; A head­line from the Ot­tawa Jour­nal on Oct. 8, 1918.

A post­card de­pict­ing the ar­rival of Span­ish Flu in Bel­gium. The card was one of the few art­works cre­ated dur­ing the pan­demic.

The Inuit com­mu­nity of Okak, N.L., in 1902. The flu’s death toll was so high in the set­tle­ment that it was aban­doned in 1919.

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