"Pale Rider: The Spanish Flu of 1918 and How It Changed the World"

Laura Spinney included a lot of statistics that sent me dozing, but also dropped plenty of names.

• Between the first case recorded on 4 March 1918, and the last sometime in March 1920, it killed 50–100 million people, or between 2.5 and 5 per cent of the global population.
• The Jewish text, the Talmud, is organised in a similar way. On each page, a column of ancient text is surrounded by commentaries, then by commentaries on the commentaries, in ever-increasing circles, until the central idea has been woven through space and time, into the fabric of communal memory.
• It is often said that the First World War killed Romanticism and faith in progress, but... It ushered in universal healthcare and alternative medicine, our love of fresh air and our passion for sport, and it was probably responsible, at least in part, for the obsession of twentieth-century artists with all the myriad ways in which the human body can fail.
• For flu to spread, therefore, people must live fairly close together. This was a crucial insight, because people didn’t always live close together... The new collectives that farming supported gave rise to new diseases–the so-called ‘crowd diseases’ such as measles, smallpox, tuberculosis and influenza.
• leprosy and malaria were causing misery long before the farming revolution–but these were adapted to surviving in small, dispersed human populations. Among their tricks for doing so were not conferring total immunity on a recovered host, so that he or she could be infected again, and retreating to another host–a so-called ‘animal reservoir’–when humans were scarce... The big giveaway that a certain species plays the role of reservoir for a certain pathogen is that it doesn’t get sick from it.
• ‘Against other things it is possible to obtain security,’ wrote the Greek philosopher Epicurus in the third century BC, ‘but when it comes to death we human beings all live in an unwalled city.’
• Once the historians had realised their error, some of them started calling crowd diseases by a different name: imperial diseases.
• The Little Ice Age was probably the last time a human disease affected the global climate, however.
• Rome recorded 8,000 deaths, meaning that it was literally ‘decimated’–roughly one in ten Romans died–
• In every conflict of the eighteenth and nineteenth centuries, more lives were lost to disease than to battlefield injuries.
• Doctors were unsettled by their observation that many patients who survived the initial attack went on to develop nervous complications, including depression. The Norwegian artist Edvard Munch may have been one of them,
• but army doctors were among the first to put germ theory into practice, and their expertise trickled down to their civilian counterparts. At the beginning of the twentieth century, cities at last became self-sustaining.
• Germ theory also had profound implications for notions of personal responsibility when it came to disease.
• ‘The minds of different generations are as impenetrable one by the other as are the monads* of Leibniz,’ wrote Frenchman André Maurois,
• ‘the Black Death’, devastated medieval Europe–was still present on that continent. It seems extraordinary, but in England its last visitation coincided with that of the Spanish flu... This, then, was the world into which the Spanish flu erupted: a world that knew the motor car but was more comfortable with the mule; that believed in both quantum theory and witches; that straddled the modern and premodern eras,
• On her release from an English prison, the Irish patriot and suffragette Maud Gonne returned to Dublin to reclaim her house from the poet W. B. Yeats, to whom she had lent it. Yeats’s heavily pregnant wife being ill with flu at the time, he turned Gonne away. The woman who had for so long been his muse, to whom he had addressed the lines ‘Tread softly because you tread on my dreams’, now bombarded him with hate mail,
• On the 11th, the armistice was signed and celebrations broke out across the world, creating close to ideal conditions for a crowd disease. Thousands poured into the streets of Lima, Peru, triggering an explosion of flu in the days that followed.
• Patients would soon be having trouble breathing. Two mahogany spots appeared over their cheekbones, and within a few hours that colour had flushed their faces from ear to ear–‘until it is hard’, wrote one US Army doctor, ‘to distinguish the colored men from the white’.1 Doctors labelled this chilling effect ‘heliotrope cyanosis’.
• ‘Sitting in a long chair, near a window, it was in itself a melancholy wonder to see the colourless sunlight slanting on the snow, under a sky drained of its blue,’ wrote American survivor Katherine Anne Porter, in her autobiographical short story Pale Horse, Pale Rider.8
• It is a characteristic of flu that the period of high infectivity precedes the onset of symptoms.
• ‘It just so happens that the memories of those who lived through those days are colourless,’ wrote Nava, who may have experienced that strange distortion of colour perception reported by other patients too.
• ‘She belonged to the past now, as distant as the Punic Wars, as the ancient Egyptian dynasties, as King Minos or the first men, errant and miserable.’


• numerical system that was adopted in China in the 1960s, in an attempt to prevent panic (diseases one to four were smallpox, cholera, plague and anthrax, respectively),
• Spain was neutral in the war, and its press was not censored. Local papers duly reported the havoc that the Naples Soldier left in its wake, and news of the disruption travelled abroad.
• Following the same logic, but opting for a different solution, German doctors realised that people would need persuading that this new horror was the ‘fashionable’ disease of flu–darling of the worried well–so they called it ‘pseudo-influenza’.
• Typhus has long been regarded as the disease of social collapse.
• Governor Yen had less to fear from avaricious neighbours than other warlords, and he was able to divert his energies into an ambitious programme of reform. In 1917, he banned pigtails, the smoking of opium and foot-binding (which in Shansi meant wrappings to the knee, so that a woman’s lower legs withered).
• Biowarfare had a long and not very illustrious history. Possibly the first example of it occurred in the fourteenth century when, realising they had been infected with plague, Mongol forces laying siege to the Black Sea port of Kaffa (now Feodosia in Ukraine) hurled their dead over the city walls.
• The Austrian artist Egon Schiele left a testament to that cruelty, in an unfinished painting he called The Family. It portrays him, his wife Edith and their infant son, a family that would never exist because Edith died in October 1918, when she was six months pregnant with their first child. Schiele died three days later, having painted The Family in the interim. He was twenty-eight years old.
• Before 1919 was out, the city had awarded him the Cross of Beneficence, in recognition of his heroic efforts to end the suffering of its citizens during the epidemic, and he remained Bishop of Zamora until his death in 1927.  { :( }
• The Caribbean spiny lobster, Panulirus argus, is highly sociable by nature, but it refuses to share a den with another lobster that is infected with a lethal virus.
• A police officer in Tokyo observed that the authorities in Korea–then a Japanese colony–had banned all mass gatherings, even for worship. ‘But we can’t do this in Japan,’ he sighed, without giving a reason.
• But the pioneering head of the health department’s child hygiene division, Josephine Baker, persuaded him not to. She argued that children would be easier to survey in school, and to treat should they show signs.
• Each new wave of immigration had been associated, not only with certain racial stereotypes, but also with specific diseases... the 1830s, cholera was blamed on poor Irish immigrants. Towards the end of that century, TB became known as the ‘Jewish disease’ or the ‘tailor’s disease’. And when polio broke out in East Coast cities in 1916, the Italians were blamed.
• Odessans, who are known in Russia for their mischievous sense of humour, liked to compare their city to a prostitute who goes to bed with one client and wakes up with another. In 1918 alone, it passed from the Bolsheviks to the Germans and Austrians (under the terms of Brest-Litovsk), to Ukrainian nationalists and, finally, to the French and their White Russian allies.
• Isaac Babel’s Jewish gangster Benya Krik, in his 1921 Odessa Tales–
• After his death in 1929, (Bardakh?) was buried in Odessa’s Second Jewish Cemetery, ‘among the Ashkenazis, Gessens and Efrussis–the lustrous misers and philosophical bons vivants, the creators of wealth and Odessa anecdotes’, as Babel described it.
• ‘well’ in a crisis may warm our hearts, but it reveals a fundamental irrationality in the way we think about epidemics.
• ‘Then the flu hit us,’ wrote the poet-doctor William Carlos Williams, in Rutherford, New Jersey. ‘We doctors were making up to sixty calls a day.
• Something similar may have happened in the wake of the Black Death in the fourteenth century. ‘Nor is it the laity alone who do thus,’ wrote Giovanni Boccaccio in The Decameron, describing that interlude in Florence. ‘Nay, even those who are shut in the monasteries,
• vampires (who were supposed to have reached Transylvania from China via the Silk Road).2
• Wu obtained a second dispensation to cremate the corpses–another practice wholly contrary to Chinese custom–and the pyres burned for two days throughout the Lunar New Year at the end of January.
• The plan they came up with, in cooperation with the British and French governments, was to create a body of labourers who would not take part in combat, but who would take on the heavy lifting behind the lines–digging trenches, mending tanks and assembling shells. This was the CLC, and beginning in 1916, in a largely secret operation, as many as 135,000 men were transported to France and Belgium under its auspices, while another 200,000 went to Russia.
• an ageing Ilya Mechnikov–Russian exile, Nobel laureate, ‘lieutenant’ of Louis Pasteur and mentor of Yakov Bardakh, Wu Lien-teh and others–battled
• ‘Dujarric asked me to do him the favour of injecting him with the filtered [blood] of a flu patient, the experiment that he felt would confirm his hypothesis.
• The first half of the twentieth century was an era of self-experimentation (Mechnikov had deliberately given himself cholera, among other potentially lethal diseases)
• When a virus infects a person, his or her immune cells secrete tiny morsels of protein called antibodies that attach themselves to the virus, disabling it. Antibodies can linger in the blood for years after the infection has passed, providing a record of past infections, and by the 1930s, scientists already had tests for detecting them in serum
• This was the result of their observation that chicken eggs could become infected by a disease of poultry called fowlpox, which is caused by a virus. Their achievement meant that viruses could now be grown in large quantities in the laboratory, free of contamination by bacteria.
• Essentially, it was impossible to see anything smaller than the wavelength of visible light... Two Germans, Max Knoll and Ernst Ruska, broke through that barrier in the early 1930s, when they invented the electron microscope. An electron, like a photon of light, behaves as both wave and particle, but its wavelength is hundreds of times shorter than that of a photon.
• H is the metaphorical crowbar that allows the virus to break into a cell, while neuraminidase (N), the second major antigen, is the glass cutter that allows it to exit again.
• When the flu virus reproduces itself, these genes have to be copied, but because RNA is less chemically stable than DNA, the copying mechanism is sloppy, and errors creep in. This sloppiness is the key to flu’s notorious lability–that capacity it has to generate endless new variations on itself–because errors at the genetic level translate into structural changes in the proteins they encode,
• Every flu pandemic of the twentieth century was triggered by the emergence of a new H in influenza A: H1 in 1918, H2 in 1957 and H3 in 1968.
• A viruses are classified by subtype according to which versions of these two antigens they carry. A given subtype can be further divided into strains, depending on the make-up of its internal genes... The subtype that caused the Spanish flu was H1N1–all the ones, a ghostly echo of ‘disease eleven’, as French Army doctors dubbed it, on the far side of a gulf of knowledge.
• for the virus to jump to humans, an intermediate host was required, in which it could adapt from one receptor type to another. That intermediate host was thought to be pigs. The cells lining a pig’s respiratory tract carry receptors to which both bird and human flu viruses can bind, meaning that pigs provide an ideal crucible for the mixing of a novel strain that infects people.
• Nearly five decades later, he barely skipped a beat. Back he went, alone, to the same mass grave. This time, he discovered the remains of a woman who had been overweight in life, so that the fat around her torso had protected her lungs from the worst ravages of decomposition. He packaged up her lung tissue,.. In 2005, after nine years of painstakingly ‘stitching’ the partial sequences together, he and Reid published the first complete sequence of the Spanish flu virus
• From this it became clear that the virus had undergone a small but critical change between the spring and the autumn, such that the H antigen was now less well adapted to birds, and better adapted to humans.
• there is some evidence that nutritional deficiencies in the host can drive genetic changes in the flu virus, causing it to become more virulent (while simultaneously impairing the host’s immune response).7
• different age cohorts’ previous exposure to flu. There is a school of thought that holds that the immune system’s most effective response to flu is to the first version of the virus it ever encounters. All subsequent exposures elicit variations on that response that are never a perfect match for the new strain.
• If this idea turns out to be correct, we will have to recalibrate the way we think about disease yet again: not only might infectious diseases be partly genetic, but diseases that we have long thought of as genetic or ‘environmental’ in origin might turn out to be partly infectious, too. One theory about Alzheimer’s disease holds, for example, that it is caused by ‘prions’–infectious agents that, until recently, were as shrouded in mystery as viruses were in 1918.
• Today, we know that TB is caused by the bacterium Mycobacterium tuberculosis, but that susceptibility to that bacterium is inherited.
• Could the flu have contributed to a global baby boom? Indeed it could, and the explanation lies in the way it chose its victims.
• But those who were in their mother’s womb when the Spanish flu struck, who are often held up as an example of why it’s important to invest in the health of pregnant women, were the twentieth century’s real lost generation.
• Béla Bartók was left with a severe ear infection that made him fear permanent deafness–
• For American aviator Amelia Earhart, meanwhile, the legacy was a lifelong sinusitis that, some say, affected her balance and ability to fly.
• Families were forced to recompose themselves. From a distance of a hundred years, everything seems to have happened as it should have, since many of us are alive today because of that enforced game of musical chairs. We trace ourselves in a straight line back to those of our ancestors who survived. But they, looking forward, might have imagined other futures, other families.
• Upon the death from flu of one German immigrant to America, for example, his widow and son received a sum of money. They invested it in property, and today the immigrant’s grandson is a property magnate purportedly worth billions. His name is Donald Trump.
• The most important of these was an emphasis on prevention that went beyond hygiene, to sport, body consciousness and diet. These ideas reached the masses with the blessing and encouragement of the elites, who saw in them a convenient way of distracting the lower classes from the dangerous allure of communism. Thus the King of Spain–the same Alfonso XIII whose high-profile case of flu had contributed to the pandemic’s naming–gave his regal imprimatur to the Madrid Football Club in 1920, creating Real (Royal) Madrid FC, and turned football into a national pastime.
• But Africans weren’t the only ones undergoing intellectual crises. ‘Victorian science would have left the world hard and clean and bare, like a landscape in the moon,’ wrote Sir Arthur Conan Doyle in 1921, ‘but this science is in truth but a little light in the darkness, and outside that limited circle of definite knowledge we see the loom and shadow of gigantic and fantastic possibilities around us, throwing themselves continually across our consciousness in such ways that it is difficult to ignore them.’5
• Conan Doyle, the British creator of that most scientific of detectives, Sherlock Holmes, stopped writing fiction after he lost his son to the Spanish flu, and devoted himself instead to spiritualism–
• By then, however, thanks to his success in publishing nature cure journals, American naturopath and wrestler Jesse Mercer Gehman had accumulated a larger fortune than the press baron William Randolph Hearst
• And the Nazis, in power in Germany, had appropriated the notion of nature as clean to legitimate purification of the German population,
• In 1920, therefore, Russia was the first to implement a centralised, fully public healthcare system.
• Rockefeller Foundation signed a deal with the Spanish government that put in place the building blocks of a modern health system in that country. It was also influential in helping Wu overhaul medical education in China–notably through the Peking Union Medical College, which it financed.
• Perhaps the most significant victim of the flu in Paris that spring, however, was the American president, Woodrow Wilson... because it rendered him unable to persuade the US government to ratify the Treaty of Versailles, or to join the League. Germany was forced to pay punitive reparations, stoking its people’s resentment–something that might not have happened had the US had a say in it. By turning Wilson into the greatest obstacle to his own goals, the Spanish flu may therefore have contributed, indirectly, to the Second World War.
• his vow not to drink milk–the result of his disgust at the practice of phooka, in which air is blown forcefully into a cow’s vagina to induce her to lactate.
• Gandhi’s promise turned out to be premature; the bitter struggle for independence would drag on until 1947. But in 1921, thanks in no small part to the Spanish flu, he was the undisputed head of the independence movement, and he had grass-roots support.
• All across the arts, the 1920s saw a desire to sever the link with Romanticism, to strip back, pare down, and slough off the exuberance of an earlier, misguided age. Painters and sculptors revisited classical themes. Architects jettisoned ornament and designed buildings that were functional. Fashion did something similar, dismissing colours and curves,
• Saneatsu Mushanokōji–a member of the avant-garde Shirakaba or White Birch literary society in Japan–wrote a story about a young man returning from his travels in Europe, who learns that his girlfriend has died of influenza. Entitled Love and Death (1939)... One of the bestselling European novels of the 1920s, that caught the imagination of a generation, was Michael Arlen’s The Green Hat (1924). .. Another detached loner from the period is Sam Spade, the private detective in Dashiell Hammett’s The Maltese Falcon (1929).
• The Spanish flu arrived in China at a time when the New Culture movement was challenging traditional Chinese values... New Culture poured scorn on traditional Chinese medicine, which they saw as emblematic of all that was wrong with Chinese society, and they urged those in power to embrace western scientific ideas. One of the leaders of the movement was a little-known writer called Lu Xun.
• Nobody yet knows why La Niña should make a pandemic more likely, but it may have something to do with the effect those changes in air currents have on the paths taken by migratory birds–and hence the populations of domesticated birds with which they come into contact.
• But the world’s population has also aged. Though age weakens the immune system, the elderly also have immune ‘memories’ of more varieties of flu,
• the ‘friendship paradox’. This is the idea that, on average, your friends have more friends than you have, and it arises because of a bias inherent in the way we count our friends (essentially, popular individuals get counted more often than less popular ones... During the 2009 swine flu outbreak, Christakis and Fowler tracked infection in two groups–one randomly chosen group of Harvard undergraduates, and a second group whom the first had nominated as friends. They found that the friends fell sick on average two weeks earlier than their randomly picked counterparts–presumably because they were more likely to come into contact with carriers of infection.
• he realised that another part of the H antigen does not change from year to year: the stem. That’s because it has to anchor the head in place, meaning it is subject to certain mechanical constraints. His group, among others, is now focusing on this essential but relatively unchanging component of the virus,
• The sixth-century Plague of Justinian is remembered better today than the eighth-century An Lushan Rebellion in China, though to the best of our knowledge, they killed comparable numbers.
• Memory is an active process. Details have to be rehearsed to be retained, but who wants to rehearse the details of a pandemic?