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We Heard The Bells:  The Influenza of 1918

Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services

Post-Production Script – Final, Audio Only
Writer/Producer:  Lisa Laden
Date:  December 4, 2009

ANNAH ELNORA THURBER:

In 19 and 18 I lived in Sequoyah County.  

REBA HAIMOVITZ:

In 1918, my family was living in South Philadelphia.

MARIA PRATS GOMEZ:

In 1918 we were living in El Paso, Texas.  

RACHEL HOLLIS:

I was born and raised in Baltimore.  

NARRATOR:

In bustling cities and remote villages, in the United States and around the world, orphaned children cried for their parents in 1918.  People of all cultures struggled with the same terrible threat, and within a matter of months, as many as 50 million would be dead.  In the United States, the death toll reached 675,000—five times the number of U.S. soldiers killed in World War I.   What was that deadly threat?  

MARIA PRATS GOMEZ:

There was so many, many, people that I heard died.  We had just come from—a few years before—from Mexico where we were living, on account of the revolution, the Mexican Revolution.  I was about ten years old.  I was the oldest, and my four brothers and sisters…Out of the family, only my dad and my sister, my smaller sister, did not get it.  My two brothers were in one room sick; I was sick in the other bedroom with my mother. My poor dad and sister had to be our attendants and see what they could do for us.  Influenza gave you such high fever.  Mother told me that I thought her black hair was a cat, and I was afraid of it with the delirium from the high fever.  People were left very weak with it, on account of that high fever, and all the schools and all public places and every place was closed, I guess nearly two or three weeks.  

ANNAH THURBER:

I was eight years old. We lived near my dad’s mother, and she and her daughter, and two grandchildren were living close to us, and when they got the flu and got sick, my parents—we just moved in with them to where my mother could nurse them, all the patients, and take care of them.  At that time my mother was 25 years old and she had three children.  And she was expecting another baby in May, and this was in February, and she’d taken care of eight patients at one time, very sick patients with the flu, with no convenience, no modern facilities whatsoever.  And Mother had to get the wood to keep heat in the house, to keep all those fires going, plus do the nursing care with eight patients.

PRISCILLA REYNA JOJOLA:

My father’s name is Telesfore Reyna, but he always went by Tell-Us-Good-Morning.  Good Morning was his Indian name.  At that time he was working in Tennessee for DuPont Company.  Every time anybody was sick, he would always bring up the story about how he got sick while he was in Tennessee, and how a lot of people from the village that had gone were brought back sick.  They were brought back in a train, he said, and some of them had passed away in Tennessee. 

In 1918 my mother was like just 11 years old, but she remembers they lived on the south side of the village.  She remembers that the church bell would ring every day, that there’s a certain bell for a notice for the death.  And she said she remembers as a little girl how awful it sounded.   

NARRATOR:

In 1918, as now, most people didn’t think of influenza as a disease that could lead to death.  We suffer through the flu season every winter.  In the U.S., the  flu season usually peaks between January and the end of March.

DR. JAMES RANDOLPH FARRIS:

The symptoms of a cold are usually a runny nose, sometimes low-grade fever, and just feeling a little wiped out.  Influenza, on the other hand, is much, much, more pronounced than that.  People will generally have a high-grade fever, absolutely no energy whatsoever, muscle aches, headaches, a fairly dry cough. With a common cold, you may feel bad for a couple of days, but after four to five days you’re starting to feel yourself again.  With influenza it’s sometimes two weeks or more.  And if it’s really severe, it can go on to cause pneumonia.

NARRATOR:

Complications from the flu cause an average of more than 200,000 hospitalizations every year in the U.S., and an average 36,000 people die from those complications.

DR.TIM UYEKI:

During seasonal influenza epidemics in the United States, there are certain groups that are at higher risk for complications: young children in particular, those less than two years of age, elderly people, particularly people 65 years and older, persons of any age who may have certain underlying chronic conditions—for example: asthma, chronic lung disease, chronic cardiovascular disease.  And in addition, pregnant women are at higher risk for complications from seasonal influenza.

NARRATOR:

While seasonal influenza is a serious health threat for people at risk of complications, the outbreak of influenza that swept the nation in 1918 and early 1919 killed over half a million people in the U.S. when the population was only a third of what it is today.

CARMEN TRUJILLO PORTILLO:

I was four years old at that time.  I was living at the Trujillo ranch in Mimbres, Faywood, New Mexico.    My mother was the midwife and she tended to the people, delivery of babies and all that kind of thing.  She used to take me with her to go and visit the new mothers, and I loved to go see the new babies, and I cried because at that time she didn’t want to take me with her, because she was tending to the sick and the dying.  But the miracle about it is that she didn’t get it.  And according to her, none of us at home got it either.

She would tell me about how people would die, sometimes two in the same bed and they had no funeral services or anything like that.  They would just carry them off to bury them.  It was very hard for them to keep up burying the dead because they were dying so fast.   One thing that stayed in my mind because I used to hear it even later was the pounding of the nailing of boards together, making—I called them boxes—coffins for the people. 

NARRATOR:

Whether people called it influenza, the grippe, or the Spanish Flu, it was clear this was not the flu that comes every winter.  Today we know that influenza is caused by a virus, the influenza virus.  We know that the virus spreads from one person to another through droplets when people cough and sneeze, or through contact with the virus on someone’s hand or a contaminated surface.  In 1918, no one knew what caused it, where it started, or how to stop it. 

CARMEN PORTILLO

They were scared because it happened so rapidly.  They didn’t know what was going on, what was happening, why.

NARRATOR:

There were few communities in the U.S. so small or isolated that they were sheltered from the waves of deadly disease that swept around the world.  The influenza of 1918 even touched remote Inuit villages in Alaska, sometimes killing every man, woman, and child…or killing the adults and leaving the children with no one to care for them.  The 1918 influenza struck some native peoples in the Southwest very hard, too.

ALBERTA LENTE:

I don’t think the doctor resided here, but he came from Albuquerque. A lot of our people, older people, didn’t speak the English language, so my dad would interpret for him what he was asking them to do, how to take care of themselves.  They would work from—from  early morning ‘til late night trying to visit every home in the pueblo. In the morning when they got to some of the homes, they would find maybe two or three people in the family that had passed away during the night.  Every day they were burying people; the church bell would be tolling from morning to evening because of so many deaths.    

NARRATOR:

The Bureau of Indian Affairs sent Dr. D. A. Richardson to investigate the situation in the Pueblos near Albuquerque, New Mexico.  He wrote:  “The strength of the Pueblos was not taken with the aged or markedly with the infants, but from the young adult life of the tribe.”  And this was true around the world. 

With the influenza that hits us every fall and winter, most healthy adults are sick for a week or two and recover.  When people die of the flu, it’s almost always the very young and the very old.  But the influenza of 1918 was not only much more lethal than seasonal flu, the death rate was very high among young adults—strong young men and women working to support and care for their families.

REBA HAIMOVITZ:

My parents came to this country from Romania, Bessarabia.  In 1918, my family was living in South Philadelphia.  I think it was a neighborhood mostly of immigrants.  It was a hard life, it was a rough life. 

My mother and father and my two sisters all had the flu.  It was a very sad period; there was like a sadness over the city.  When you looked out, you saw hardly anybody walking around.  People stayed in their houses because they were afraid.  And they said that it seems that if it killed you, it did it fast, because I remember them telling me that a young neighbor—they saw him coming home.  They watched from the window, coming from work.  And the next afternoon, they saw him carried out.  He died. 

 NARRATOR:

Of all the cities in the U.S., Philadelphia had one of the highest rates of sickness and death, and the most disruption.  The city resisted putting measures in place that might have limited the spread of the flu—measures such as prohibiting public gatherings where the flu could spread easily.  The city allowed a large parade to take place to raise money for the troops fighting WWI.  Although the marchers and crowd wore gauze masks, many people caught the flu from those who were already infected.

Baltimore fared almost as badly as Philadelphia.   Soldiers at Camp Meade, south of the city, became sick in mid-September, and by early October there were 2,000 cases in Baltimore.  Officials hesitated to close schools and other meeting places, which would have reduced contact between the sick and the well.  Hospitals and funeral homes were overwhelmed, and the workers who kept the city and its businesses running were too sick to get out of bed. 

FLORENCE PARKS:

The Bethlehem Steel went around and got all these men from down south to operate the mills.  And there were just thousands of men coming off from the mills.  My father worked for the Bethlehem Steel Company’s bakery.  The only black baker they ever had was my father, Henry Lindsey.  The people were very kind to one another, and it was a place where everybody looked after one another.  In the barracks, nobody lived in there but the men who worked for the Bethlehem Steel.  They died, and the men who were around them didn’t even know they were dead.  Come home in there, and the man dead.  Don’t know how long he’d been dead because they went to work.  We leave him in the morning and come back, he’s dead in the evening.  My mother was sick and everything and they quarantined us.  We didn’t visit nobody, and nobody visited us except this lady.  This Mrs. Kissy Thornton, she went ‘round helping everybody who was sick, and I’m glad that lady never got sick or anything.  

RACHEL HOLLIS:

Back in 1918, I was between ten and twelve years old, I would say, and I got the flu, and it was just my mother and I.  Two of my friends, we went to elementary school together, and both of them were stricken with the flu.  And I would go out to then Bayview Hospital.  But we didn't have any carfare, so we would walk to go visit her, and they’d put her out on the porch in the cold wintertime.  And they had blankets, blankets and a hood on her, but she died, both of them died.  At that young age.  People didn't understand, and there was no vaccine.  But your parents did the best they could for you.

NARRATOR:

The influenza of 1918-1919 was a pandemic, an outbreak of disease around the world which caused serious illness and death.   Why was the influenza of 1918 so much more deadly than the seasonal flu we experience every winter?  What was different about the influenza virus in 1918?

DR. TIM UYEKI:

The seasonal influenza viruses that cause annual outbreaks, epidemics, in the United States during our fall, winter, and early spring,  those are influenza viruses that are circulating among people worldwide, and they are evolving, they’re changing just a little bit. But they’re human viruses, and so some percentage of the U.S. population and the world’s population gets infected every year; some become ill.  Most people recover from a self-limited illness.  And all these people who survive will have some immunity.  Other people get vaccinated, and we receive some immunity through that vaccine.  So there are two ways to acquire immune protection.  One is through natural infection, in which you recover, you survive, then you have immunity.  The other is through vaccination, and vaccination stimulates our body’s immune system to produce antibodies against the specific virus strains that are contained in the vaccine.

An influenza pandemic is different.  An influenza pandemic is the emergence of a very new Influenza A virus to which most of the population has not previously been exposed and does not have any immunity, no immune protection.  And so what you see is very high numbers, very high percentage of people becoming sick worldwide.

NARRATOR:

In the last 100 years, new influenza viruses have caused four pandemics: in 1918, 1957, 1968 and 2009. 

DR. DAVID MORENS:

Ultimately, they come from birds:  wild waterfowl, ducks and geese and various other birds.  They can get into domestic poultry, chickens.  They can also, as we know, get into human beings directly, pigs, various aquatic mammals.  They can get into horses.  They can get into dogs and cats.  So they can take any of these paths and, in theory, they could end up getting into people by either coming directly from a bird or going through a circuitous route in another animal. 

DR. ANTHONY FAUCI:

By a variety of mutations that occur for a number of reasons, these types of viruses can, under certain circumstances, adapt themselves to other species.  And then as they propagate themselves in these other species, they adapt themselves better to spread from pig to pig, or from bird to bird, or from person to person.  And the host we worry about the most, obviously, from a human health standpoint, is the human species. 

ANNAH THURBER:

One of my dad’s sisters lived pretty close to us, and she had a family of four children and her husband, and she was expecting.  And she’d taken the flu, and of course, she passed away just—she was very sick.  She passed away.  The ladies that taken the flu that were pregnant, all we ever knew died, and my mother didn’t get it. 

DR. DAVID MORENS:

We don't know why pregnant women die of influenza at a high rate, but it's been documented for well over 500 years.  One of the biggest risk factors for a fatal outcome from influenza is pregnancy.  Whatever the reason, it's pretty clear that pregnant women in 1918 were at very high risk.  Pregnant women, of course, are going to be in the younger age ranges, but non-pregnant women and men in that age range were also at much higher risk of dying.  Why this happened, we don't know.  In any flu pandemic, people die from pneumonia, some percentage will always die, but it tends to be the older folks, people who have chronic conditions like heart disease and lung disease, pregnant women, infants and so on.  This time, in 1918, something very different happened.  Otherwise healthy young adults died at a very high rate and constituted a fairly large percentage of the total deaths, something that's never been seen before.  Why that happened is a mystery. 

NARRATOR:

Brevig Mission is northwest of Nome, Alaska on the Bering Sea.  The fact that Brevig exists today is remarkable, since of the 80 residents in 1918, only five adults and three children survived the flu pandemic.  Over 50 years ago, a young man with an interest in viruses found his way to the village.

DR. JOHAN HULTIN:

I was a medical student in Sweden.  And I decided to travel to the United States and get a Masters degree in virology.  And then one thing led to the next and the next, and I decided that I would go for my Ph.D.  And one day we had a visitor, a very prominent virologist.  And I remember his talking about everything that had been done to find out what was it that caused the 1918 flu.  And then he made like a 15 second comment at the end of his talk. He said somebody ought to go to the northern part of the world and try to find a victim of the 1918 Spanish flu pandemic buried in the permafrost. And that victim is likely to have been remained frozen since 1918—at that time it was something like 35 years or 40 years—and try to recover the virus. And then he went to something else. And that 15 seconds I happened to be that I heard it.  I immediately went to my faculty advisor and asked him, “Could that be a subject for my Ph.D.?” He said, “Oh yeah, why don’t you go ahead.”    I happened to have worked during the summer in 1949 for a paleontologist in Alaska.

NARRATOR:

The paleontologist, Otto Geist, had worked on the Brevig Peninsula and knew the missionaries in the villages there.   With Geist’s help, Hultin was able to review copies of mission records from the fall of 1918.  He found that the military had very good records showing the location and thickness of the permafrost in Alaska. 

DR. JOHAN HULTIN:

On the basis of that I came—decided on three villages.  I showed up in June, and I went to the first village; it’s called Nome—a rather large city actually, Nome.  I went to the mass grave at the cemetery and discovered that the river that normally had flowed on the side of the village at some distance away, it had changed course since 1918 and had come into the village and melted this permafrost. I could just see it.  And then I engaged a bush pilot to fly me to another village called Wales at the Bering Strait.  I found where the mass grave was, clearly marked with a large cross.  And the bluff had fallen onto the beach and almost excavated or invaded the mass grave.  So I figured there is no permafrost here.  So the bush pilot flew me to what today is Brevig, but there was no way to land there. I had to land on the beach at some distance away in another village.  And then I had to cross some water with a whaleboat.  Got across this really sizable water.  And then I had to walk about six miles in soggy tundra that was just beginning to melt, then on to Brevig.

They had a village council, the council of the elders. And it’s a matriarchal society. So the eldest woman of the largest family makes decisions or heavily influences decisions. And little did I know that that was going to be very important later on.  Fortunately for me there were three survivors of the 1918 pandemic still alive.  So I asked them to please tell the other members, the elder council, what it was like in that November week when 90 percent of the village died.  Then I said, “If you allow me to enter the grave, and if I’m fortunate enough to find the right specimens, I will take it back, the specimen, back to my laboratory. And if everything works out well, it will be possible for us to develop a vaccine.  So in the next pandemic coming, threatening you, we will have a vaccine to immunize you, protect you.”  They understood what vaccine was because they had been immunized against smallpox.  The matriarch, Jenny Olanna, was in favor of that. So that influenced the decision.  So they allowed me to open the grave. 

So I went out on the gravesite and started to dig. And about a foot down I came onto permafrost, a very hard frozen ground.  And I started a fire, got driftwood from the beach and climbed up on the bluff, there where the mass grave is, and started to melt the permafrost.  And on the end of the second day I came down about four feet. And there I found the first victim, young child, a girl I estimated 12 years of age.  But the condition of her body at four feet from the surface was so good that I was confident that down deeper there will be, even be better—better preserved adults and so on. Seventy-two bodies in that grave.

Now I didn’t come alone to Alaska. I had my faculty advisor, an influenza virologist.  I had a pathologist, one of the professors in the department in Iowa, to perform the post mortem examinations; and then Otto Geist.  So there were four. I was out there ahead of them to scout the grave, to scout the test dig.  A day later they came to the same beach where I had landed earlier, and we traveled the same way back to Brevig.

Now there were four of us digging, so we could do it very rapidly.  About three days later we were down six feet. And then we found three perfectly preserved bodies, and the pathologist performed post mortems on them. And the lungs were perfectly preserved.  Then we left, thanked the villagers, closed the grave. And I took some pictures of course all the time.

So eventually we got to Iowa with this. And I started to try to grow the virus, trying to find an alive influenza virus.  Week after week after week after week, I got more and more discouraged. And eventually I had no more specimen.  And the virus was dead.  And there went my Ph.D.  I could see it fly off through the window in the non-air conditioned office, by the way, the lab I had.  I decided to go back to Sweden to continue my medical education.  And I was exceeding—extremely fortunate.  I was offered to continue medical school at Iowa.  And then I got my M.D. there, became a pathologist.  But back in my mind, I had this memory of not getting my Ph.D. and all the effort that went into that, and it was just, kind of collapsed.

DR. JEFFERY TAUBENBERGER:

Molecular pathology is a specialty of medicine, where pathologists use the tools of molecular biology and molecular genetics to make diagnoses and provide insight into patient care decisions.  You can make diagnoses of infectious diseases by looking for the genetic material of the infectious organism, the virus or the bacteria, for example. 

I was in the National Cancer Institute as a pathologist in the '80s, and in 1993 I moved to the Armed Forces Institute of Pathology to set up a new group devoted to molecular pathology, both for clinical molecular pathology as well as research.  And one of the things we had to do for both sides of that is to work out ways to recover genetic material from typical biopsy material.

The tissue repository at the AFIP goes back to the Civil War, so they have a huge collection of millions of tissue samples reflecting all aspects of clinical disease, tumors and infectious disease, including autopsies of soldiers who died of flu in 1918. I wanted to think of a project that would highlight the utility of having such an old tissue archive as well as our new molecular techniques in which we could do analyses.  And the way those two things came together in my mind was to go after the 1918 flu.  We thought that it might be possible to recover fragments of the genetic material of the virus still preserved in autopsy tissues of people who died in 1918. 

When we started the project there were really two fundamental questions that we wanted to answer.  That is, one, why was this virus so particularly virulent?  Why did it kill so many people, especially young, healthy adults?  And secondly, where did this virus come from?  We were hoping to learn from what we see in 1918 to apply it to the future, that we could understand how pandemics form and why particular flu viruses cause more disease than others. 

These tissues were extremely old, and it was not clear that we could actually recover any genetic material at all from these samples.  We had to work out techniques and continue to refine the techniques to extract nucleic acids, DNA and RNA, from these samples.  We had started this project in 1995, and it took over a year to find a first positive case to work out our techniques to make sure that we actually could find influenza.  Once we had found a first positive case and we started to generate sequence and compare it to known influenza viruses, we were convinced that we had really found the 1918 virus.  But we were really concerned that there would be inadequate amounts of material available to us to sequence the whole virus from that material.  

DR. JOHAN HULTIN:

In March of 1997 in Science News, there it was: “1918 Pandemic Virus Found.”  A small sequence had been discovered by Jeffery Taubenberger.  I wrote a letter saying, “If you need more specimen, let me know, and I will go back to Alaska.  I’ve been there before. I know where it is. I can go back.”  And I didn’t hear anything, I didn’t hear anything.  And I thought, well, he knows, he thinks I’m a nut.   He happened to be on vacation so he didn’t get his mail. 

DR. JEFFERY TAUBENBERGER:

We were extremely excited about the possibility.  We, we had hoped that if we could recover material from a frozen victim that the quality of genetic material of the virus might be improved over what we had in these formalin-fixed blocks.  

DR. JOHAN HULTIN:

And he called me here. And he asked me, “When can you go?”  So I said, “I can’t go this week. But I can go next week.”  And I called up to Brevig.  Now this time when I come, the second visit in 1997, it so happened it was in August.  And that is a much better time to dig in the permafrost. 

I went to see the missionary, another one now, Pastor Brian Crockett is his name.  He’s still there.  And he knew of the excavation that I had carried out in 1951.  And he also knew that I had to get the permission to do it again.  So he said it was very difficult. “You may not be able to get a permission this time. But I will introduce you to Rita Olanna.”  She was the matriarch in 1997. And little did I know that her grandmother was Jenny Olanna. That was it. It would never have happened otherwise.  Everything doesn’t go wrong all the time. It just looks like that, but it didn’t.  There it is—crucial.

NARRATOR:

Dr. Hultin presented his case to the Brevig Village Council, including Rita Olanna.  He made sure they understood that the virus was dead and could not cause disease.

DR. JOHAN HULTIN:

I also told them how important it is because—“Your participation, this is where it begins. And you’re part of the team now, the villagers of Brevig.  And I’m the specimen collector. And then Dr. Taubenberger in the Armed Forces Institute of Pathology, these are the three. But it begins with you.”  And I got the permission to go.  I figured no one wants to go in a grave and dig with bodies. So I was all set to do it myself. And so one of the members said, “Would you like to have some help?”  Four young men, Eskimos, assigned by the village council to help me.

Because I had the photograph with me, I knew where the grave was. So I marked it off.  At the end of the first day we were down about four feet, and I didn’t see anything at all, and five feet the following day.  I noticed there were some bodies at seven feet, found a skeleton and then next to the skeleton was a woman, and perfectly preserved with—clothing had fallen off, rotted away, but I could see the skin, and it was of an obese woman.  I started to do the post-mortem.  And then I took the rib cage off and there exposed the lungs, and they were the textbook picture of a person who had died from acute viral pneumonitis, exactly what I needed.

The subcutaneous fatty layer of Lucy and fat inside of course also, that had protected the lungs from the occasional thaws of the permafrost that had reached seven feet down.  The Eskimos are not obese, there’s not that much food around, and they were active and hardworking, particularly in 1918.  To find one who had extra calories, storage calories, that was just remarkable.  And here was a woman who had ample food, had a good husband, good seal hunter, walrus hunter, brought all this food for her.  Can you imagine how fortunate?

Then I decided before I leave I’ve got to make new crosses to show my gratitude to the village.  I had photographs of the original crosses, I knew how tall they were, the widths, everything.  I finished my work with the crosses at 1:00, and by 8:00 the next morning the high school kids came, and they helped me put the crosses in.  And about an hour later the bush pilot landed, and I got all my specimen on board and I shipped them to Jeffery Taubenberger.

DR. JEFFERY TAUBENBERGER:

The advantage that we had was that the formalin-fixed autopsy tissue samples were extremely tiny, just the size of a fingernail, and so were very limiting, where he was able to provide us large sections of an entire lung, so that even though the quality of RNA was lower, we had so much more material to work with.  It became absolutely clear that we would be able to sequence the rest of the virus from that material. 

DR. JOHAN HULTIN:

I figured it would take weeks and weeks before he had any inkling that the specimens were good. Like, 10 days later he called, and he said, “Johan, we have it. The specimen is good. We have lots of specimen, great material, and this is going to be wonderful.  It was a great day for me because I had started in 1955 [sic], and finally in ’97, there it is, made it. But, again, without the Eskimos in Brevig nothing would have come.

DR. JEFFERY TAUBENBERGER:

The effort to sequence the entire genome of the 1918 virus from beginning to end took ten years.  It was a very laborious process.   

DR. JOHAN HULTIN:

More than 13,000 pieces of genetic information that had to be put together as a total, so if he gets a sequence or a stretch of a gene, a little piece, so he has it, looking at it here and here, gene is this long and fully built, and this piece, where does it fit in? Here? Fit in here? Or is it in this end, here? Or is it this way? What comes to the left and the right? And day after day, month after month, putting these things together year after year. So, 13,000 pieces, plus pieces, had to find its proper place, and it’s incredible.

DR. JEFFERY TAUBENBERGER:

It's clearly a virus that was human adapted.  But genetically it's very bird-like in its sequence; it's very avian-like.  And so what we think is that it is an entirely avian-like influenza virus that somehow adapted to humans.  We now know that there are a number of mutations in several of the genes that are absolutely crucial in the adaptation to humans.  And so you could imagine using these mutations as a screening tool to assess the significance of a bird strain as to whether it was actually moving along the path that would make it adapt to humans.  If we identify changes that were crucial to allow a bird virus to replicate in humans, you could particularly design drugs that might block or bind to that particular change to prevent a bird virus from actually functioning in humans.  The 1918 flu had as its most unique feature the fact that it had a high propensity to kill young adults ages 15 to 40.  Even having the entire sequence of the virus in front of us, we do not yet understand why it behaved in that manner.  I favor the idea that people in that particular age group might have had the wrong sort of immunity to the 1918 virus, some kind of immune response that actually made them more susceptible to die.  In people older than about age 45 or 50 in 1918, there might have been preexisting immunity to viruses similar to the 1918 virus.  We're trying to identify influenza virus positive autopsy tissue samples from before 1918 to try to help us figure out this problem.  

DR. JOHAN HULTIN:

Jeffery Taubenberger’s right hand woman, Ann Reid—very accomplished—she was sent up with a plaque from the AFIP to present it to the village council.  If this Taubenberger’s work brings antiviral drugs, and good vaccines, and the savings of hundreds of millions of lives, it began with Rita Olanna, and Jenny Olanna.

NARRATOR:

Another question about the death toll in the 1918 flu pandemic was how people died after they became ill with the flu.  Dr. Taubenberger and Dr. Morens examined not only the autopsy tissues in the AFIP collection, but also autopsy reports from all over the world of people who had died of pandemic influenza.

DR. JEFFERY TAUBENBERGER:

We find that the vast majority of people dying died because of secondary bacterial pneumonia.  What we think happened is that a very virulent influenza virus caused such an extensive inflammatory response in the lungs and caused such tissue damage, that bacteria like strep or pneumococcus that are very commonly carried in the throat of normal individuals, could spread down into the lung and cause a disease that would ultimately actually kill the person.  The evidence of the bacterial pneumonias, I think, helps explain why you had such high mortality in military camps particularly.  While this is very important in trying to understand what happened in 1918, it also has significant implications for pandemic planning in the future. 

DR. DAVID MORENS:

We’ve really seen an explosion in information about influenza in the last 10 or so years, because primarily I think of sequencing of the 1918 virus, but also the unusual events associated with the H5N1 virus, the Bird Flu virus. 

DR. NANCY COX:

We’ve been watching this particular avian influenza virus for over ten years now. These viruses are highly transmissible from bird to bird, and they can destroy a flock of birds. But the most important thing from the public health perspective is that humans who have very close contact with the infected birds occasionally can become infected by this virus.  Over 60 percent of those who have become infected have died.  Many more people have been exposed to the virus than have become infected.  In order for this avian influenza virus to cause a pandemic, we would have to see a number of changes that would occur in the virus so that the virus could be transmitted easily from human to human to human.  The fact that the avian influenza viruses that we’re monitoring so closely have been circulating for 10 years and still haven’t caused a pandemic doesn’t mean that these viruses will not cause a pandemic. We don’t know for past pandemics how long those viruses actually circulated, caused infections in humans, and then gained that ability to be transmitted efficiently.  So we don’t know enough about past history to predict the future.

DR. DAVID MORENS:

I think the biggest lesson is that we can’t predict what influenza will do. 

NARRATOR:

As scientists continue to look for answers in the 1918 flu virus, we can also learn from the men and women who responded to the health crisis by taking it upon themselves to care for their relatives, their neighbors, and their communities.

Dr. John Tappan was a physician with the Public Health Service in El Paso, Texas.  He wrote to a colleague serving at an army field hospital in France.

VOICE OF DR. JOHN TAPPAN:

“We have all been awfully busy with the ‘flu’ - I made on an average of 30 calls a day for about a month and everyone else did as much or more.  The Public Health Service and the Red Cross opened a hospital in the old Aoy School where we treated the Mexican part of town.  The epidemic here was fierce.  We had about 10,000 cases in El Paso and the Mexicans died like sheep.  Whole families were exterminated.  The white population fared almost as badly.  …I was three days behind in my calls. …The other doctors all had the same experience of course.”

NARRATOR

When the people living in other parts of El Paso learned of the many deaths in the southern part of the city near the border with Juarez, many volunteered to use their cars as ambulances, picking up the sick and delivering them to hospitals in other parts of town.  When the Aoy School in the Chihuahuita neighborhood was turned into a hospital for flu patients, El Pasoans from all over the city volunteered as nurses, drivers and clerks.

VOICE OF DR. JOHN TAPPAN:

“So you see we have been serving our country right here at home.”

MARIA PRATS GOMEZ:

That epidemic helped the community to get together because everybody helped that could, gave their houses or their help, or whatever they had people needed—that they needed it.  So that helped the community, both Juarez and here.

ALEXANDRA MINNA STERN:

There was a shortage of doctors and nurses during the 1918 influenza pandemic because so many of the physicians and nurses were serving in the war effort. So you had a mixture of both trained medical personnel and those with some training, and those who basically were very civically minded individuals, who wanted to participate in tending to the ill.  The women who volunteered during the 1918 influenza pandemic were literally putting their lives on the line.  They were stepping into a deadly pandemic, because they believed that it was their calling, and they wanted to do what they believed was their duty.  I would say that the activities of volunteers, and particularly women volunteers who rose to the challenge, was absolutely crucial.  This is a story of unsung heroes, of forgotten people, who really rose to the gravity of the moment.

DR. DAVID MORENS:

In villages in Alaska, for example, the whole village would become sick at once.  There would be nobody to provide food, nobody to provide shelter—these things can a make a difference.  And even in wealthy nations like the United States, the conclusion at the end of 1918 and 1919 was that the single most important thing that could save your life from flu was good nursing care.  Not medicines, not doctors, not hospitals, but good nursing care.  When you first read those things you’re likely to say, “That can’t be true, what could they do in those days?”  You know, what’s chicken soup going to do?  What’s a blanket going to do?  I believe the data, they’re strong, and some of the best and smartest physicians, nurses, and other observers said it again and again, “good nursing care.”

NARRATOR:

Even though no one knew what caused influenza in 1918, some communities took steps to prevent the spread of the disease. 

DR. HOWARD MARKEL:

In our group at the Center for the History of Medicine, we have been looking at 43 American cities during that pandemic to see exactly what they did to stave off the epidemic or what they didn't do, for that matter.  What worked, what didn't work.  And what were their records?  And what we find is that those that acted very early with a suite of classical public health interventions—things like quarantine, closure of schools, banning public gatherings—if they acted very early, before the epidemic had a chance to spread to a lot of people, kept these measures on for a long time and used more than one of these measures at the same time, those cities had a much better record in terms of cases and deaths than those cities that did not.  I think there’s a mountain of stuff that we’re learning from the 1918 pandemic that applies to people today or in the near and distant future. 

NARRATOR:

We have learned from the experiences of the 1918-1919 pandemic.  But that’s only one of the factors that make us better prepared to deal with influenza pandemics than the world was in 1918.    

DR. ANTHONY FAUCI

There are extraordinary advantages.  Some of them are pretty simple, like experience of what seemed to work in some cities, like social distancing and avoiding crowded places—things that were not necessarily fully appreciated.  Some cities did it and did well.  But most importantly we have biomedical and health care and technical advances that we didn't have.  We have vaccines.  We didn't have vaccines then for flu.  We didn't even know what the microbe was.  When they were dealing with it, many people thought it was some strange form of a bacteria and not necessarily a virus. 

Number two, we have antiviral drugs, for example Tamiflu and Relenza and others; we didn't have it then.  We have antibiotics to treat the secondary complications, the bacterial complications of influenza.  We have much better technologies to treat acutely and seriously ill individuals like efficient, good respirators, intensive care units, people who have expertise in medicine that's acute‑care medicine.  All of these things we did not have back then.  We have them now. 

NARRATOR:

Our parents and grandparents had little warning or chance to prepare, but we know now that influenza has caused pandemics at intervals for at least the last 500 years.  Public health officials have been preparing for the next flu pandemic, knowing that it could be a mild pandemic, as in 1968, or as severe as in 1918.  The world is watching a new pandemic flu virus—the novel H1N1 flu virus—which emerged in the spring of 2009. 

DR. ANNE SCHUCHAT:

We know that the new 2009 H1N1 virus is in almost every country of the world already.  Fortunately so far, the 2009 H1N1 virus doesn’t appear to have that level of severity that the 1918 one had.  The 2009 H1N1 virus is affecting people differently than seasonal flu strains.  The illness is most common in young people: children and young adults.  But we’re also seeing hospitalizations and deaths in particular in people who have conditions that increase their risk of complications.  Pregnant women have really been heavily hit by this virus.  In the United States, and reports around the world, suggest that native populations may have a higher risk of severe illness caused by the 2009 H1N1 strain.  We want to be ready and we want to make sure that these populations are served and that they have good access to health care and to the vaccination.

DR. TONY FAUCI:

Everyone has the experience throughout the world that the best way to contain influenza is by getting a very efficient and safe vaccine.  Vaccines, given the current technology and even in more modern technology, you don't make a vaccine overnight.  You have to first find out what the virus is you're dealing with, and then you go through a multi- step process in order to get enough vaccine to protect the population.  That multi-step process generally takes several months, usually along the line of six or more months. 

DR. ANNE SCHUCHAT:

Vaccination is a really important part of our response to the 2009 H1N1 virus, but it’s important to say it’s not the only part of it.  We have a whole series of mitigation efforts and a whole series of communication efforts.  

NARRATOR:

Public health officials are fighting the spread of influenza with the health hygiene we learned as children:  stay home when you’re sick, wash your hands frequently with warm water and soap for 20 seconds, practice cough and sneeze etiquette, and avoid touching your eyes, nose, or mouth. 

DR. GLORIA ADDO-AYENSU:

In the start of a pandemic, that's the most efficient tool we’ll have in addition to, obviously, social distancing—like staying home when you're sick and so on. But we are a community that hugs, that shakes, that have elevators that you need to ride on to go to different parts of a building. We go grocery shopping, and we need to push our carts. Everything you do basically you need to touch something that other people touch, and so that hand washing bit would be very critical.

NARRATOR:

These good habits and vaccination also prevent the spread of seasonal flu.  An annual immunization for the seasonal flu helps people stay healthy and helps health workers prepare to vaccinate the population during a pandemic.

DR. JAMES RANDOLPH FARRIS:

These immunizations are widely available every year.  It’s very important for people, particularly people who are 65 and over, to take the influenza immunizations. It’s important to have the vaccine every year, and the vaccine is a covered Medicare benefit.  There’s absolutely no way you will get the flu from the flu shot.

DR. ANNE SCHUCHAT:

Based on what I know and what I have been observing with this 2009 H1N1 virus, and based on what I know about influenza vaccines, the risk of getting influenza or having a complication from influenza is much higher than any theoretical risk from the vaccines.  It’s important for people to know that not getting vaccinated also puts you at risk.  A hundred million people get influenza vaccine every year in the United States.  They have a strong safety track record.  And the 2009 H1N1 influenza vaccines are being made exactly the same way that the seasonal flu vaccines are made. 

NARRATOR:

A long-term goal for scientists working on flu vaccine is to develop a vaccine that would protect against all seasonal and pandemic influenza.

DR. ANTHONY FAUCI:

We generally refer to that as a universal influenza vaccine.  And I think there’s a real possibility to that.  I don’t think it’s going to be easy to do.  What we’re working on—when I say “we” I mean the scientists in the field—is to identify the components of all influenza viruses that don’t change as the virus drifts or even shifts.  And then you’ve got to put it in what we call an immunogenic form, namely a form that when you inject it into a person or you spray it into the nose of a person, that that person will make an immune response that’s very robust.  There are a lot of people working on it.  It’s a high priority project.

NARRATOR:

Every year we have fewer elders to remind us of the terrible time they…their families…and their communities endured in 1918 and 1919.   But we need to keep those memories alive.

DR. ANTHONY FAUCI:

There's a lot of things to be learned from continuing to study the 1918 flu.  I think the important lesson is that pandemics can be very serious.  But also, pandemics can be widespread but not that serious.  There's a gradation of severity of pandemics.  You always must prepare for the worst-case scenario, even though you might have a mild pandemic, like occurred in 1968, or an intermediate pandemic that occurred in 1957. 

DR. THOMAS FRIEDEN:

The current pandemic is much less severe so far than the planning scenarios that most of us had had.  It could be that it becomes less severe and doesn’t affect a lot of people.  It could be that it becomes more severe and mutates to a deadlier virus, which would be terrible and very difficult to manage.  It could be that it continues along the way it’s been so far.  Only time will tell.  We have to be ready to pivot and respond differently if the virus changes.  

DR. ANTHONY FAUCI:

The one thing you can predict about influenza is that it's unpredictable.

NARRATOR:

We still know much less than we’d like about influenza, but the experiences of the individuals who endured the pandemic of 1918, and the research into that pandemic, continue to contribute to our understanding of the disease. 

DR. ANTHONY FAUCI:

We are infinitely better prepared now than we were a hundred years ago, back in the beginning of the twentieth century.

NARRATOR:

For more information about pandemic influenza, visit www.flu.gov and www.medicare.gov