Influenza Pandemic Quotes

Influenza killed more people in a year than the Black Death of the Middle Ages killed in a century; it killed more people in twenty-four weeks than AIDS has killed in twenty-four years.

Society cannot function if it is every man for himself. By definition, civilization cannot survive that. Those in authority must retain the public's trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one.

You don't manage the truth. You tell the truth.

The foundation of morality is to have done, once and for all, with lying.

The two most important questions in science are “What can I know?” and “How can I know it?

The fear, not the disease, threatened to break the society apart.

What’s true of all the evils in the world is true of plague as well. It helps men to rise above themselves.

In fact, biology is chaos. Biological systems are the product not of logic but of evolution, an inelegant process. Life does not choose the logically best design to meet a new situation. It adapts what already exists...The result, unlike the clean straight lines of logic, is often irregular, messy.

Epidemiologists have computed that measles requires an unvaccinated population of at least half a million people living in fairly close contact to continue to exist.

The influenza pandemic of 1918 killed more people than the First World War—an estimated 3 to 6 per cent of the human race.

As terrifying the disease was, the press made it more so. They terrified by making little of it, for what officials and the press said bore no relationship to what people saw and touched and smelled and endured. People could not trust what they read. Uncertainty follows distrust, fear follow uncertainty, and, under conditions such as these, terror follows fear.

So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that. Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best. A leader must make whatever horror exists concrete. Only then will people be able to break it apart.

Sit down before a fact as a little child, be prepared to give up every preconceived notion. Follow humbly wherever and to whatever abysses nature leads, or you shall learn nothing.” He also believed that learning had purpose, stating, “The great end of life is not knowledge but action.

biology is chaos. Biological systems are the product not of logic but of evolution, an inelegant process.

Emerson said that an institution is the lengthened shadow of one man,

He advised, “Whenever you fall, pick up something.

Yet institutions are human as well. They reflect the cumulative personalities of those within them, especially their leadership. They tend, unfortunately, to mirror less admirable human traits, developing and protecting self-interest and even ambition. Institutions almost never sacrifice. Since they live by rules, they lack spontaneity. They try to order chaos not in the way an artist or scientist does, through a defining vision that creates structure and discipline, but by closing off and isolating themselves from that which does not fit. They become bureaucratic.

Certainty creates strength. Certainty gives one something upon which to lean. Uncertainty creates weakness. Uncertainty makes one tentative if not fearful, and tentative steps, even when in the right direction, may not overcome significant obstacles.

Throughout the pandemic, the nation lacked a uniform policy about gathering places, and there was no central authority with the power to make and enforce rules that everyone had to obey. Each community acted on its own, doing as its elected officials thought best.12

All positive knowledge obtained . . . has resulted from the accurate observation of facts.

When the next pandemic comes, as it surely will someday, perhaps we will be ready to meet it. If we are not, the outcome will be very, very, very dreadful.

How about a global pandemic? A novel strain of influenza for which we humans have no natural defense.

I was born in 1920, during the influenza pandemic, and I’m going to die in 2020, during the outbreak of coronavirus. What an elegant name for such a terrible scourge.

Huxley did not look the warrior. But he had a warrior’s ruthlessness. His dicta included the pronouncement: “The foundation of morality is to have done, once and for all, with lying.

However, as bad as things were, the worst was yet to come, for germs would kill more people than bullets. By the time that last fever broke and the last quarantine sign came down, the world had lost 3-5% of its population.

For the influenza pandemic that erupted in 1918 was the first great collision between nature and modern science. It was the first great collision between a natural force and a society that included individuals who refused either to submit to that force or to simply call upon divine intervention to save themselves from it, individuals who instead were determined to confront this force directly, with a developing technology and with their minds.

Ebola is a zoonosis. So is bubonic plague. So was the so-called Spanish influenza of 1918–1919, which had its ultimate source in a wild aquatic bird and, after passing through some combination of domesticated animals (a duck in southern China, a sow in Iowa?) emerged to kill as many as 50 million people before receding into obscurity.

No other disease, no war, no natural disaster, no famine comes close to the great pandemic. In the space of eighteen months in 1918–1919, about 500 million people, one-third of the human race at the time, came down with influenza. The exact total of lives lost will never be known. An early estimate, made in 1920, claimed 21.5 million died worldwide. Since then, researchers have been continually raising the number as they find new information. Today, the best estimate of flu deaths in 1918–1919 is between 50 million and 100 million worldwide, and probably closer to the latter figure. 7

Should we add the 40 to 50 million victims of the 1918 influenza pandemic to the 15 million who were killed in World War I, because the flu virus would not have evolved its virulence if the war hadn’t packed so many troops into trenches?

Viruses are themselves an enigma that exist on the edges of life. They are not simply small bacteria. Bacteria consist of only one cell, but they are fully alive. Each has a metabolism, requires food, produces waste, and reproduces by division. Viruses do not eat or burn oxygen for energy. They do not engage in any process that could be considered metabolic. They do not produce waste. They do not have sex. They make no side products, by accident or design. They do not even reproduce independently. They are less than a fully living organism but more than an inert collection of chemicals.

Another explanation for the failure of logic and observation alone to advance medicine is that unlike, say, physics, which uses a form of logic - mathematics - as its natural language, biology does not lend itself to logic. Leo Szilard, a prominent physicist, made this point when he complained that after switching from physics to biology he never had a peaceful bath again. As a physicist he would soak in the warmth of a bathtub and contemplate a problem, turn it in his mind, reason his way through it. But once he became a biologist, he constantly had to climb out of the bathtub to look up a fact.

White Christians often explained the disaster in a time-honored way: it was God's punishment of humanity for its sings. To the seven deadly sins--anger, greed, lust, envy, pride, laziness, gluttony--they added an eighth sin: 'worshiping science.

What we really need is a game-changing influenza vaccine that will target the conserved—or unchanging—features of the influenza viruses that are more likely to cause human influenza pandemics and subsequently seasonal influenza in the following years.

Most parents thought they were being good parents. They learned from their parents or their grandparents, many of whom were severely traumatized and emotionally disconnected coming out of the devastation of a 1918 influenza pandemic and two world wars.

overstate to make a point—warned, civilization could have disappeared within a few more weeks. So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that. Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best. A leader must make whatever horror exists concrete. Only then will people be able to break it apart.

In the United States, influenza death rates were so high that the average life span fell by twelve years, from fifty-one in 1917 to thirty-nine in 1918. If you were a “doughboy”—slang for an American soldier—you had a better chance of dying in bed from flu or flu-related complications than from enemy action.

Edward Jenner’s discovery of vaccination drew harsh criticism from the pulpit. Clergymen denounced the doctor for having put himself above God. Only the Almighty, they said, sends illness and only the Almighty cures it. Vaccination, critics charged, was “a diabolical operation,” and its inventor was “flying in the face of Providence

What are the odds that a killer flu virus will spread around the world like a tidal wave, killing millions? “The burning question is, will there be a human influenza pandemic,” Secretary Leavitt told reporters. “On behalf of the WHO, I can tell you that there will be. The only question is the virulence and rapidity of transmission from human to human.

Isolation is my COVID-19 insurance policy.

The 1918 epidemic came in two waves, a mild flu in the spring of 1918 followed by the killer flu in the fall.

Influenza had brought the all-conquering German army to its knees, while the Allies, stricken too, took advantage of their enemy’s weakness to regroup.

the disturbing possibility that the Spanish Lady might stage a return visit,

For instance, one reason that the Ebola virus doesn’t spread widely among humans is that it is too efficient—mortality is as high as 90 percent—which

We domesticated pigs and got whooping cough, domesticated chickens and got typhoid fever,894 and domesticated ducks and got influenza.

Despite the name, Spanish flu struck the entire world — that’s what made it a pandemic instead of simply an epidemic. It was not the first influenza pandemic, nor the most recent (1957 and 1968 also saw pandemics), but it was by far the most deadly. Whereas AIDS took roughly twenty-four years to kill 24 million people, the Spanish flu killed as many in twenty- four weeks.

With influenza and many other diseases the order is reversed, high infectivity preceding symptoms by a matter of days. A perverse pattern: the danger, then the warning. That probably helped account for the scale of worldwide misery and death during the 1918–1919 influenza: high infectivity among cases before they experienced the most obvious and debilitating stages of illness.

But even after European medicine changed, medicine in the United States did not. In research and education especially, American medicine lagged far behind, and that made practice lag as well.

In the earlier tradition from which Mrs. Post wrote, the act of dying had not yet been professionalized. It did not typically involve hospitals. Women died in childbirth. Children died of fevers. Cancer was untreatable. At the time she undertook her book of etiquette, there would have been few American households untouched by the influenza pandemic of 1918. Death was up close, at home.

Nowadays, the disease claims, on average, 36,000 Americans each year, out of a population of 320 million. Contrast this with another number: 35,092 Americans died in motor vehicle accidents in 2015.

A zoonosis is an animal infection transmissible to humans. There are more such diseases than you might expect. AIDS is one. Influenza is a whole category of others. Pondering them as a group tends to reaffirm the old Darwinian truth (the darkest of his truths, well known and persistently forgotten) that humanity is a kind of animal, inextricably connected with other animals: in origin and in descent, in sickness and in health.

Influenza transmission is legendary. The dying cells in the respiratory tract trigger an inflammatory response, which triggers the cough reflex. The virus thus uses the body’s own defenses to infect other potential hosts.

Hamer was especially interested in why diseases such as influenza, diphtheria, and measles seem to mount into major outbreaks in a cyclical pattern—rising to a high case count, fading away, rising again after a certain interval

Newspapers reported on the disease with the same mixture of truth and half-truth, truth and distortion, truth and lies with which they reported everything else. And no national official ever publicly acknowledged the danger of influenza.

THE ACTUAL WORD ‘influenza’ dates from around 1500, when the Italians introduced the term for diseases that they attributed to the ‘influence’ of the stars. Another possible origin was the Italian phrase influenza di freddo, the influence of the cold.

The CDC and three other research groups submitted a paper for publication in the journal Science detailing how they had reconstructed the 1918 H1N1 influenza virus, using virus genes that had been identified in lung samples of patients who died during the 1918 pandemic.

In the United States, no government, institution, or philanthropist even began to approach a similar level of support. As the Hopkins medical school was opening, American theological schools enjoyed endowments of $18 million, while medical school endowments totaled $500,000.

In many ways, it is hard for modern people living in First World countries to conceive of a pandemic sweeping around the world and killing millions of people, and it is even harder to believe that something as common as influenza could cause such widespread illness and death.

When we think of a pandemic, we often conjure images of deadly infectious diseases that spread rapidly across countries causing unimaginable human suffering (like the Black Death, the Spanish influenza, AIDS, or the ongoing COVID-19 crisis). The West is currently suffering from such a devastating pandemic, a collective malady that destroys people’s capacity to think rationally. Unlike other pandemics where biological pathogens are to blame, the current culprit is composed of a collection of bad ideas, spawned on university campuses, that chip away at

Surgeon General’s Advice to Avoid Influenza Avoid needless crowding. . . . Smother your coughs and sneezes. . . . Your nose not your mouth was made to breathe thru. . . . Remember the 3 Cs, clean mouth, clean skin, and clean clothes. . . . Food will win the war. . . . [H]elp by choosing and chewing your food well. . . . Wash your hands before eating. . . . Don’t let the waste products of digestion accumulate. . . . Avoid tight clothes, tight shoes, tight gloves—seek to make nature your ally not your prisoner. . . . When the air is pure breathe all of it you can—breathe deeply.

Oliver Wendell Holmes, the physician father of the Supreme Court justice, was not much overstating when he declared, “I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.

But as the program got going, the smallest details became issues, even the very name of the disease. Pig farmers complained to the Centers for Disease Control that the name “swine flu” might frighten people away from eating pork. They asked, to no avail, that the flu’s name be changed to “New Jersey

Increase in Reports of Influenza. A masterpiece of understatement, as if it were only the reporting that had increased, or perhaps the pandemic was a figment of the collective imagination. I wondered whether it was the newspaper publisher’s decision to play down the danger or if he’d received orders from above.

in a letter to the New York Times, Dr. Hans Neumann from the New Haven Department of Health noted that based on the projected scale of the immunizations, within two days of getting a flu shot, about 2,300 people would have a stroke and 7,000 would have a heart attack. “Why?” he asked. “Because that is the number statistically expected, flu shots or no flu shots.” Likewise, in the week following a flu vaccine, another 9,000 people would contract pneumonia, of whom 900 would die. These would certainly occur after a flu shot, but not as a consequence of it. “Yet,” wrote Neumann, “can one expect a person who received a flu shot at noon and who that same night had a stroke not to associate somehow the two in his mind?” Grandma got the flu vaccine in the morning, and she was dead in the afternoon. Although association does not equal causation, this thinking could lead to a public backlash against vaccinations that would threaten future programs.

On the landing yesterday’s poster hooked my attention ‘Would they be dead if they’d stayed in bed?’ I had an impulse to rip it down, but that probably constituted conduct unbecoming to a nurse, as well as treason. ‘Yes, they’d be bloody dead,’ I ranted silently. ‘Dead in their beds or at the kitchen table eating their onion a day. Dead on the tram, falling down in the street, whenever the bone-man happened to catch up with them. Blame the germs, the unburied corpses, the dust of war, the circulation of wind and weather, but Lord God Almighty, blame the stars, just don’t blame the dead, because none of them wished this on themselves.

new influenza virus emerges, it is highly competitive, even cannibalistic. It usually drives older types into extinction. This happens because infection stimulates the body’s immune system to generate all its defenses against all influenza viruses to which the body has ever been exposed. When older viruses attempt to infect someone, they cannot gain a foothold. They cease replicating. They die out. So, unlike practically every other known virus, only one type—one swarm or quasi species—of influenza virus dominates at any given time. This itself helps prepare the way for a new pandemic, since the more time passes, the fewer people’s immune systems will recognize other antigens.

Flu pandemics are nothing new. Medical historians think the first one struck in 1510, infecting Asia, Africa, Europe, and the New World. Between the years 1700 and 1900, there were at least sixteen pandemics, some of them killing up to one million people. Yet these were tame compared to the 1918 calamity. It was by far the worst thing that has ever happened to humankind; not even the Black Death of the Middle Ages comes close in the number of lives it took. A 1994 report by the World Health Organization pulled no punches. The 1918 pandemic, it said, “killed more people in less time than any other disease before or since.” It was the “most deadly disease event in the history of humanity.

relationship with nature, modern humanity has generally been the aggressor, and a daring one at that, altering the flow of rivers, building upon geological faults, and, today, even engineering the genes of existing species. Nature has generally been languid in its response, although contentious once aroused and occasionally displaying a flair for violence. By 1918 humankind was fully modern, and fully scientific, but too busy fighting itself to aggress against nature. Nature, however, chooses its own moments. It chose this moment to aggress against man, and it did not do so prodding languidly. For the first time, modern humanity, a humanity practicing the modern scientific method, would confront nature in its fullest rage.

Influenza is caused by three types of viruses, of which the most worrisome and widespread is influenza A. Viruses of that type all share certain genetic traits: a single-stranded RNA genome, which is partitioned into eight segments, which serve as templates for eleven different proteins. In other words, they have eight discrete stretches of RNA coding, linked together like eight railroad cars, with eleven different deliverable cargoes. The eleven deliverables are the molecules that comprise the structure and functional machinery of the virus. They are what the genes make. Two of those molecules become spiky protuberances from the outer surface of the viral envelope: hemagglutinin and neuraminidase. Those two, recognizable by an immune system, and crucial for penetrating and exiting cells of a host, give the various subtypes of influenza A their definitive labels: H5N1, H1N1, and so on. The term “H5N1” indicates a virus featuring subtype 5 of the hemagglutinin protein combined with subtype 1 of the neuraminidase protein. Sixteen different kinds of hemagglutinin, plus nine kinds of neuraminidase, have been detected in the natural world. Hemagglutinin is the key that unlocks a cell membrane so that the virus can get in, and neuraminidase is the key for getting back out. Okay so far? Having absorbed this simple paragraph, you understand more about influenza than 99.9 percent of the people on Earth. Pat yourself on the back and get a flu shot in November. At

For propagandists, whatever promoted the Allied cause was true, whether factual or not. What counted was the noble end--victory--not the sordid means of achieving it. 'Truth and falsehood are arbitrary terms,' declared a CPI official. 'There is nothing in experience to tell us that one is always preferable to the other....There are lifeless truths and vital lies....The force of an idea lies in its inspirational value. It matters very little if it is true or false.

As poorly transmissible as it was, however, SARS exposed the absence of “surge capacity” in the hospitals and health-care systems of the prosperous and well-resourced countries it affected. The events of 2003 thereby raised the specter of what might have happened had SARS been pandemic influenza, and if it had traveled to resource-poor nations at the outset instead of mercifully visiting cities with well-equipped and well-staffed modern hospitals and public health-care systems.

In 1918 fear moved ahead of the virus like the bow wave before a ship. Fear drove the people, and the government and the press could not control it. They could not control it because every true report had been diluted with lies. And the more the officials and newspapers reassured, the more they said, There is no cause for alarm if proper precautions are taken, or Influenza is nothing more or less than old-fashioned grippe, the more people believed themselves cast adrift, adrift with no one to trust, adrift on an ocean of death.

We follow what is happening with influenza virus strains in the Southern Hemisphere when it is their fall (our spring) to predict which influenza viruses will likely be with us the next winter. Some years that educated guess is more accurate than others. So is it worth getting the vaccination each year? I give that a qualified yes. It might or might not prevent you from getting flu. But even if it is only 30 to 60 percent effective, it sure beats zero protection. What we really need is a game-changing influenza vaccine that will target the conserved—or unchanging—features of the influenza viruses that are more likely to cause human influenza pandemics and subsequently seasonal influenza in the following years. How difficult would such a game-changing influenza vaccine be to achieve? The simple truth is that we don’t know, because we’ve never gotten a prototype into, let alone through, the valley of death. We need a new paradigm—a new business model that pairs public money with private pharmaceutical company partnerships and foundation support and guidance.

Today, we share no fewer than 300 diseases with domesticated animals. For example, humans get 45 diseases from cattle, including tuberculosis; 46 from sheep and goats; 42 from pigs; 35 from horses, including the common cold; and 26 from poultry. Rats and mice carry 33 diseases to humans, including bubonic plague. Sixty-five diseases, including measles, originated in man’s best friend, the dog. We can still get parasitic worms from pet dogs and cats. That is why it is not a good idea to kiss a pet on the mouth or sleep with it in bed.4

No medicine and none of the vaccines developed then could prevent influenza. The masks worn by millions were useless as designed and could not prevent influenza. Only preventing exposure to the virus could. Nothing today can cure influenza, although vaccines can provide significant—but nowhere near complete—protection, and several antiviral drugs can mitigate its severity. Places that isolated themselves—such as Gunnison, Colorado, and a few military installations on islands—escaped. But the closing orders that most cities issued could not prevent exposure; they were not extreme enough. Closing saloons and theaters and churches meant nothing if significant numbers of people continued to climb onto streetcars, continued to go to work, continued to go to the grocer. Even where fear closed down businesses, where both store owners and customers refused to stand face-to-face and left orders on sidewalks, there was still too much interaction to break the chain of infection. The virus was too efficient, too explosive, too good at what it did. In the end the virus did its will around the world.

If they would have acknowledged this [SARS] early, and we could have seen the virus as it occurred in south China, we probably could have isolated it before it got out of hand,” explained one infectious disease expert. “But they completely hid it. They hide everything. You can’t even find out how many people die from earthquakes.”2438 The foundation of the theoretical models is openness and cooperation for rapid detection of outbreaks of influenza. “Would they admit to it if it was here?” one Asian diplomat asked. “That’s the big question, since they deny everything left, right and center.

increases of the infectivity rate may lead to large epidemics.” This quiet warning has echoed loudly ever since. It’s a cardinal truth, over which public health officials obsess each year during influenza season. Another implication was that epidemics don’t end because all the susceptible individuals are either dead or recovered. They end because susceptible individuals are no longer sufficiently dense within the population. W. H. Hamer had said so in 1906, remember? Ross had made the same point in 1916. But the paper by Kermack and McKendrick turned it into a working principle of mathematical epidemiology.

Capps did write the JAMA article. He reported finding the masks so successful that after less than three weeks of experimenting he had abandoned testing and simply started using them as “a routine measure.” He also made the more general point that “one of the most vital measures in checking contagion” is eliminating crowding. “Increasing the space between beds in barracks, placing the head of one soldier opposite the feet of his neighbor, stretching tent flags between beds, and suspending a curtain down the center of the mess table, are all of proved value.” To prevent a few arriving individuals from infecting an entire camp, he also repeated Welch’s recommendation to isolate transferred troops.

As Einstein once said, “One of the strongest motives that lead persons to art or science is a flight from the everyday life. . . . With this negative motive goes a positive one. Man seeks to form for himself, in whatever manner is suitable for him, a simplified and lucid image of the world, and so to overcome the world of experience by striving to replace it to some extent by this image. This is what the painter does, and the poet, the speculative philosopher, the natural scientist, each in his own way. Into this image and its formation, he places the center of gravity of his emotional life, in order to attain the peace and serenity that he cannot find within the narrow confines of swirling personal experience.

One nurse at Great Lakes would later be haunted by nightmares. The wards had forty-two beds; boys lying on the floor on stretchers waited for the boy on the bed to die. Every morning the ambulances arrived and stretcher bearers carried sick sailors in and bodies out. She remembered that at the peak of the epidemic the nurses wrapped more than one living patient in winding sheets and put toe tags on the boys’ left big toe. It saved time, and the nurses were utterly exhausted. The toe tags were shipping tags, listing the sailor’s name, rank, and hometown. She remembered bodies “stacked in the morgue from floor to ceiling like cord wood.” In her nightmares she wondered “what it would feel like to be that boy who was at the bottom of the cord wood in the morgue.

Since the body does a better job of fighting infection when it is a few degrees hotter, might reducing the fever lead to a worse outcome for the patient? A group from McMaster University in Canada looked at what happens in a large group of people when some of them—infected with, say, influenza—take medicine to reduce their fever. Once they feel better, patients with the flu get out of bed and start to socialize, spreading the virus. On a population level the effect is rather drastic. The McMaster group concluded that the practice of frequently treating fevers with medication enhances the transmission of influenza by at least 1 percent. I know that doesn’t sound like a lot, but remember that as many as 49,000 people die from the flu each year in the United States. If you plug the McMaster estimates into these flu numbers, almost 500 deaths per year in the U.S. (and perhaps many more elsewhere) could be prevented by avoiding fever medication during the treatment of influenza.

It kept people apart. . . . It took away all your community life, you had no community life, you had no school life, you had no church life, you had nothing. . . . It completely destroyed all family and community life. People were afraid to kiss one another, people were afraid to eat with one another, they were afraid to have anything that made contact because that’s how you got the flu. . . . It destroyed those contacts and destroyed the intimacy that existed amongst people. . . . You were constantly afraid, you were afraid because you saw so much death around you, you were surrounded by death. . . . When each day dawned you didn’t know whether you would be there when the sun set that day. It wiped out entire families from the time that the day began in the morning to bedtime at night—entire families were gone completely, there wasn’t any single soul left, and that didn’t happen just intermittently, it happened all the way across the neighborhoods, it was a terrifying experience. It justifiably should be called a plague because that’s what it was. . . . You were quarantined, is what you were, from fear, it was so quick, so sudden. . . . There was an aura of a constant fear that you lived through from getting up in the morning to going to bed at night.

Because the second wave was so much more severe than the first, a lot of people refused to believe it could be the same disease. It had to be terrorism. They didn't care what medical experts kept telling them, about how it was the nature of influenza to occur in waves and that there was nothing about this pandemic, terrible though it was, that wasn't happening more or less as had long been predicted. No, not bioterrorism, others said, but a virus that had escaped from a laboratory. These were the same people who believed that both Lyme disease and West Nile virus were caused by germs that had escaped many years ago from a government lab off the coast of Long Island. They scoffed at the assertion that it was impossible to say for sure where the flu had begun because cases had appeared in several different countries at exactly the same time. Cover-up! Everyone knew the government was involved in the development of bioweapons. And although the Americans were not the only ones who were working on such weapons, the belief that they were somehow to blame--that the monster germ had most likely been created in an American lab, for American military purposes--would outlive the pandemic itself. In any case, according to a poll, eighty-two percent of Americans believed the government knew more about the flu than it was saying. And the number of people who declared themselves dead set against any vaccine the government came up with was steadily growing.

A highly regarded infectious-disease epidemiologist named Donald S. Burke, presently dean of the Graduate School of Public Health at the University of Pittsburgh, gave a lecture (later published) back in 1997 in which he listed the criteria that might implicate certain kinds of viruses as likeliest candidates to cause a new pandemic. “The first criterion is the most obvious: recent pandemics in human history,” Burke told his audience. That would point to the orthomyxoviruses (including the influenzas) and the retroviruses (including the HIVs), among others. “The second criterion is proven ability to cause major epidemics in non-human animal populations.” This would again spotlight the orthomyxoviruses, but also the family of paramyxoviruses, such as Hendra and Nipah, and the coronaviruses, such as that virus later known as SARS-CoV. Burke’s third criterion was “intrinsic evolvability,” meaning readiness to mutate and to recombine (or reassort), which “confers on a virus the potential to emerge into and to cause pandemics in human populations.” As examples he returned to retroviruses, orthomyxoviruses, and coronaviruses. “Some of these viruses,” he warned, citing coronaviruses in particular, “should be considered as serious threats to human health. These are viruses with high evolvability and proven ability to cause epidemics in animal populations.” It’s interesting in retrospect to note that he had augured the SARS epidemic six years before it occurred. Much more recently, Burke told me: “I made a lucky guess.” He laughed a self-deprecating hoot and then added that “prediction is too strong a word” for what he had been doing.

Today, such studies are illegal. Medical scientists cannot offer inducements like pardons to persuade prisoners to take part in their studies. Although they can award small cash payments to research subjects, they are forbidden from giving anyone so much money or such tempting favors that their compensations might constitute what ethicists term an inappropriate inducement, an irresistible temptation to join the study. Now, more than eighty years after the 1918 flu, people enter studies for several reasons—to get free medical care, to get an experimental drug that, they hope, might cure them of a disease like cancer or AIDS, or to help further scientific knowledge. In theory at least, study participants are supposed to be true volunteers, taking part in research of their own free will. But in 1918, such ethical arguments were rarely considered. Instead, the justification for a risky study with human beings was that it was better to subject a few to a great danger in order to save the many. Prisoners were thought to be the ideal study subjects. They could offer up their bodies for science and, if they survived, their pardons could be justified because they gave something back to society. The Navy inmates were perfect for another reason. Thirty-nine of them had never had influenza, as far as anyone knew. So they might be uniquely susceptible to the disease. If the doctors wanted to deliberately transmit the 1918 flu, what better subjects? Was influenza really so easily transmitted? the doctors asked. Why did some people get it and others not? Why did it kill the young and healthy? Could the wartime disruptions and movements of troops explain the spread of the flu? If it was as contagious as it seemed, how was it being spread? What kind of microorganism was causing the illness? The normal way to try to answer such questions would be to study the spread of the disease in animals. Give the disease to a few cages of laboratory rats, or perhaps to some white rabbits. Isolate whatever was causing the illness. Show how it spread and test ways to protect animals—and people—against the disease. But influenza, it seemed, was a uniquely human disease. No animal was known to be susceptible to it. Medical researchers felt they had no choice but to study influenza in people. Either the Navy doctors were uncommonly persuasive or the enticement of a pardon was overwhelmingly compelling. For whatever reason, the sixty-two men agreed to be subjects in the medical experiment. And so the study began. First the sailors were transferred to a quarantine station on Gallops Island in Boston Harbor. Then the Navy doctors did their best to give the men the flu. Influenza is a respiratory disease—it is spread from person to person, presumably carried on droplets of mucus sprayed in the air when sick people cough or sneeze, or carried on their hands and spread when the sick touch the healthy. Whatever was causing the flu should be present in mucus taken from the ill. The experiments, then, were straightforward. The Navy doctors collected mucus from men who were desperately ill with the flu, gathering thick viscous secretions from their noses and throats. They sprayed mucus from flu patients into the noses and throats of some men, and dropped it into other men’s eyes. In one attempt, they swabbed mucus from the back of the nose of a man with the flu and then directly swabbed that mucus into the back of a volunteer’s nose.

Early on it is clear that Addie has a rebellious streak, joining the library group and running away to Rockport Lodge. Is Addie right to disobey her parents? Where does she get her courage? 2. Addie’s mother refuses to see Celia’s death as anything but an accident, and Addie comments that “whenever I heard my mother’s version of what happened, I felt sick to my stomach.” Did Celia commit suicide? How might the guilt that Addie feels differ from the guilt her mother feels? 3. When Addie tries on pants for the first time, she feels emotionally as well as physically liberated, and confesses that she would like to go to college (page 108). How does the social significance of clothing and hairstyle differ for Addie, Gussie, and Filomena in the book? 4. Diamant fills her narrative with a number of historical events and figures, from the psychological effects of World War I and the pandemic outbreak of influenza in 1918 to child labor laws to the cultural impact of Betty Friedan. How do real-life people and events affect how we read Addie’s fictional story? 5. Gussie is one of the most forward-thinking characters in the novel; however, despite her law degree she has trouble finding a job as an attorney because “no one would hire a lady lawyer.” What other limitations do Addie and her friends face in the workforce? What limitations do women and minorities face today? 6. After distancing herself from Ernie when he suffers a nervous episode brought on by combat stress, Addie sees a community of war veterans come forward to assist him (page 155). What does the remorse that Addie later feels suggest about the challenges American soldiers face as they reintegrate into society? Do you think soldiers today face similar challenges? 7. Addie notices that the Rockport locals seem related to one another, and the cook Mrs. Morse confides in her sister that, although she is usually suspicious of immigrant boarders, “some of them are nicer than Americans.” How does tolerance of the immigrant population vary between city and town in the novel? For whom might Mrs. Morse reserve the term Americans? 8. Addie is initially drawn to Tessa Thorndike because she is a Boston Brahmin who isn’t afraid to poke fun at her own class on the women’s page of the newspaper. What strengths and weaknesses does Tessa’s character represent for educated women of the time? How does Addie’s description of Tessa bring her reliability into question? 9. Addie’s parents frequently admonish her for being ungrateful, but Addie feels she has earned her freedom to move into a boardinghouse when her parents move to Roxbury, in part because she contributed to the family income (page 185). How does the Baum family’s move to Roxbury show the ways Betty and Addie think differently from their parents about household roles? Why does their father take such offense at Herman Levine’s offer to house the family? 10. The last meaningful conversation between Addie and her mother turns out to be an apology her mother meant for Celia, and for a moment during her mother’s funeral Addie thinks, “She won’t be able to make me feel like there’s something wrong with me anymore.” Does Addie find any closure from her mother’s death? 11. Filomena draws a distinction between love and marriage when she spends time catching up with Addie before her wedding, but Addie disagrees with the assertion that “you only get one great love in a lifetime.” In what ways do the different romantic experiences of each woman inform the ideas each has about love? 12. Filomena and Addie share a deep friendship. Addie tells Ada that “sometimes friends grow apart. . . . But sometimes, it doesn’t matter how far apart you live or how little you talk—it’s still there.” What qualities do you think friends must share in order to have that kind of connection? Discuss your relationship with a best friend. Enhance

The pandemic may have originated in the American military post at Fort Riley, Kansas, where a dust storm whipping about tons of incinerated manure had sent hundreds of coughing, stumbling doughboys diagnosed with influenza into the post hospital, where many died. Soon after, American troopships disembarked at Brest and Saint-Nazaire, and French poilus began to fall ill, then British soldiers. Then, as the malady rolled across France, German troops were stricken. The fatality rate was appalling. In the AEF, roughly one out of every three soldiers with influenza died, far worse odds than a man faced in battle.

Ironically, it was not the flu that actually killed people but the way in which it weakened them in ways that allowed pneumonia or meningitis could set in.

As the early outbreak at Fort Riley suggested, the primary breeding ground for the influenza consisted of army camps that were springing up all over America in the early days of 1918. America had entered World War I the previous October, and many young men were anxious to do their part and join the fight.  As a result, the camps soon became overcrowded with recruits and service veterans brought in from all over the country to train them.

Since that time there have been numerous epidemics of the disease. In 1889 and 1890 the disease was epidemic over practically the entire civilized world. Three years later there was another flare-up of the disease. Both times the epidemic spread widely over the United States. Although the recent epidemic is called ‘Spanish influenza,’ investigation has shown that it did not originate in Spain.  We now know that there was an undue prevalence of influenza in the United States for several years preceding the recent great pandemic. Because the disease occurred in mild form, and because the public mind was focused on the war, this increased prevalence of the disease escaped attention. Not until the epidemic appeared in severe form in Boston in September, 1918, did it excite any special interest.” - U.S. Public Health Service Report, prepared by Surgeon General Rupert Blue

the Indians who were our neighbors, they were only six miles away. So Dad and the city marshal rode up there one day to see how things were going at the Indian camps and they were horrified at what they saw. After an Indian died, his family and friends would sit around chanting him to the Happy Hunting Grounds and they’d spend all night there. And, by that time, they were all exposed, everybody had the flu. Ultimately, it killed about half the Indians.

The 1918–19 influenza virus strain, a pandemic which killed forty million people in Europe, Asia and America, was not confined to the war areas, though it struck them hardest.

Still, this particularly virulent and infectious strain of the flu virus is thought to have killed as many as 40 million people around the world between 1918 and 1919.

In 1918 and 1919 came the Great Influenza, the Spanish Flu.  The only global pandemic in modern times.  Fifty million to a hundred million dead.  How did Tibet fare this time, you ask?” McAlister’s face was stoic, immobile. Suddenly angry, Undertaker said, “No. You don’t ask, Dr. McAlister; you don’t ask because you already know.  Tibet was barely touched.  A few sick, no one reported dead.

Because influenza viruses continually evolve, new influenza strains continually threaten human populations.

It worries the flu scientists because they know that H5N1 influenza is (1) extremely virulent in people, with a high lethality though a relatively low number of cases, and yet (2) poorly transmissible, so far, from human to human. It’ll kill you if you catch it, very likely, but you’re unlikely to catch it except

RNA viruses because I already had that list in my mind: Hendra and Nipah, Ebola and Marburg, West Nile, Machupo, Junin, the influenzas, the hantas, dengue and yellow fever, rabies and its cousins, chikungunya, SARS-CoV, and Lassa, not to mention HIV-1 and HIV-2. All of them carry their genomes as RNA. The

Swine influenza is not even a reportable disease, a classification saved for diseases deemed a threat to the entire industry, such as foot-and-mouth disease. On the other hand, pig flu viruses can be a big problem for the general population. That is because pigs are a genetic crucible for new flu viruses. They can be infected with flu viruses from birds, other pigs and people, creating opportunities for a melding of genes in new combinations known as reassortants. The fear is these new hybrids will prove capable of infecting people readily, while being sufficiently foreign to cause serious illness once they do.

These alterations arise through small mutations in the gene that constitutes the blueprint for that protein. Sometimes a mutation makes little difference in the protein’s stability or activity. Sometimes it damages the protein and reduces the viability of the virus. Other times, though, it enhances survival, such as by reconfiguring a site on hemagglutinin that was formerly recognized by an antibody.

When the hemagglutinin or neuraminidase genes and proteins accumulate several alterations, they can become virtually unrecognizable to most of the antibodies in a population and may initiate a new epidemic.

The elderly, normally the group most susceptible to influenza, not only survived attacks of the disease but were attacked far less often. This resistance of the elderly was a worldwide phenomenon. The most likely explanation is that an earlier pandemic , so mild as to not attract attention, resembled the 1918 virus closely enough that it provided protection. (p. 408 paperback edition)