The Next Pandemic?

Laurie Garrett

From Foreign Affairs, July/August 2005

Summary:  Since it first emerged in 1997, avian influenza has become deadlier and more resilient. It has infected 109 people and killed 59 of them. If the virus becomes capable of human-to-human transmission and retains its extraordinary potency, humanity could face a pandemic unlike any ever witnessed.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and is the author of The Coming Plague and Betrayal of Trust.

Nearly half of all deaths in the United States in 1918 were flu related. Some 675,000 Americans -- about 0.6 percent of the population of 105 million and the equivalent of 2 million American deaths today -- perished from the Spanish flu. The average life expectancy for Americans born in 1918 was just 37 years, down from 55 in 1917. Although doctors then lacked the technology to test people's blood for flu infections, scientists reckon that the Spanish flu had a mortality rate of just less than one percent of those who took ill in the United States. It would have been much worse had there not been milder flu epidemics in the 1850s and in 1889, caused by similar but less virulent viruses, which made most elderly Americans immune to the 1918-19 strain. The highest death tolls were among young adults, ages 20-35.

The Spanish flu got its name because Spain suffered from an early and acute outbreak, but it did not originate there. Its actual origin remains uncertain. The first strain was mild enough to prompt most World War I military forces to dismiss it as a pesky ailment. When the second strain hit North America in the summer of 1918, however, the virus caused a surge of deaths. First hit was Camp Funston, an army base in Kansas, where young soldiers were preparing for deployment to Europe. The virus then spread swiftly to other camps and on troop ships crossing the Atlantic, killing 43,000 U.S. military personnel in about three months. Despite the entreaties of the military's surgeons general, President Woodrow Wilson ordered continued shipments of troops aboard crowded naval transports, which soldiers came to call "death ships." By late September 1918, so overwhelmed was the War Department by influenza that the military could not assist in controlling civic disorder at home, including riots caused by epidemic hysteria. Worse, so many doctors, scientists, and lab technicians had been drafted into military service that civilian operations were hamstrung.

Under these conditions, influenza swept from the most populous U.S. cities to extraordinarily remote rural areas. Explorers discovered empty Inuit villages in what are now Alaska and the Yukon Territory, their entire populations having succumbed to the flu. Many deaths were never included in the pandemic's official death toll -- such as the majority of victims in Africa, Latin America, Indonesia, the Pacific Islands, and Russia (then still in the throes of revolution). What is known about the toll in these regions is staggering. For example, influenza killed 5 percent of the population of Ghana in only two months, and nearly 20 percent of the people of Western Samoa died. The official estimate of 40-50 million total deaths is believed to be a conservative extrapolation of European and American records. In fact, many historians and biologists believe that nearly a third of all humans suffered from influenza in 1918-19 -- and that of these, 100 million died.

In the last years of the nineteenth century and the early years of the twentieth, a series of important scientific discoveries spawned a revolution in biology and medicine and led pioneers such as Hermann Biggs, a New York City doctor, to create entire legal and health systems based on the identification and control of germs. By 1917, the United States and much of Europe had become enthralled by the hygiene movement. Impressive new public health infrastructures had been built in many cities, tens of thousands of tuberculosis victims were isolated in sanatoriums, the incidences of child-killing diseases such as diphtheria and typhoid fever had plummeted, and cholera epidemics had become rare events in the industrialized world. There was great optimism that modern science held the key to perfect health.

Influenza's arrival shattered the hope; scientists still had virtually no understanding of viruses generally, and of influenza in particular. The hygienic precautions and quarantines that had proved so effective in holding back the tide of bacterial diseases in the United States proved useless, even harmful, in the face of the Spanish flu. As the epidemic spread, top physicians and scientists claimed its cause was everything from tiny plants to old dusty books to something called "cosmic influence." It was not until 1933 that a British research team finally isolated and identified the influenza virus.

Most strains of the flu do not kill people directly; rather, death is caused by bacteria, which surge into the embattled lungs of the victim. But the Spanish flu that circulated in 1918-19 was a direct killer. Victims suffered from acute cyanosis, a blue discoloration of the skin and mucous membranes. They vomited and coughed up blood, which also poured uncontrollably from their noses and, in the case of women, from their genitals. The highest death toll occurred among pregnant women: as many as 71 percent of those infected died. If the woman survived, the fetus invariably did not. Many young people suffered from encephalitis, as the virus chewed away at their brains and spinal cords. And millions experienced acute respiratory distress syndrome, an immunological condition in which disease-fighting cells so overwhelm the lungs in their battle against the invaders that the lung cells themselves become collateral damage, and the victims suffocate. Had antibiotics existed, they may not have been much help.

OOPS

In January 1976, 18-year-old Private David Lewis staggered his way through a forced march during basic training in a brutal New Jersey winter. By the time his unit returned to base at Fort Dix, Lewis was dying. He collapsed and did not respond to his sergeant's attempts at mouth-to-mouth resuscitation.

In subsequent weeks, U.S. Army and CDC scientists discovered that the virus that had killed Lewis was swine flu. Although no other soldiers at Fort Dix died, health officials panicked. F. David Matthews, then secretary of health, education, and welfare, promptly declared, "There is evidence there will be a major flu epidemic this coming fall. The indication is that we will see a return of the 1918 flu virus that is the most virulent form of flu. In 1918, a half million people died [in the United States]. The projections are that this virus will kill one million Americans in 1976."