Spanish flu—the first horseman
Authors: Talha Khan Burki
Journal: The Lancet Respiratory Medicine (2017)

Perhaps we should start with the name. Spain was neutral during the First World War; its press was uncensored. So when a wave of influenza hit the Iberian peninsula in May, 1918, it made the papers. The disease had been tearing through Allied troops on the Western Front for several weeks, and the first registered case had been two months earlier, in a military camp in Kansas, USA. But this information was not in the public domain. The authorities of the warring nations felt that letting their citizens know it was not only the enemy attacking their troops would be bad for morale. “As time went on, and it transpired that there were not many local epidemics, but one global pandemic—it became necessary to agree on a single name”, explains Laura Spinney in her scintillating new history Pale Rider. “The pandemic became known as the Spanish flu and a historical wrong became set in stone”. Many years later, the disease would be identified as influenza A H1N1, an exceptionally virulent strain that was particularly deadly for people aged 20–40 years. Those infected were vulnerable to secondary pneumonia—it was this that accounted for most of the 50–100 million deaths that the Spanish flu is thought to have caused. The disease came in three waves over the course of two years. Spinney expertly outlines the prevailing theories as to where it originated. The most compelling explanation centres on the encampment at Etaples behind the Western Front. It was teeming with soldiers from all over the British Empire. The sprawling hospital complex accommodated hundreds of men whose lungs had been ravaged by mustard gas. The Somme estuary, where millions of waterbirds stop en route from the Arctic to Africa, was 50 kilometres away. The camp itself contained plenty of live poultry. Perhaps the camp piggery was where the avian influenza virus acquired its ability to transmit directly from human-to-human; perhaps it needed no intermediary. “The virus had kept most of its bird flu-like structure, which might explain why it was so virulent”, notes Spinney. “It was a very alien invader that took the human immune system by storm in 1918, yet one that could still recognise—that is, bind to—human cells”. One tiny mutation between the first wave in the spring of 1918 and the second wave in the autumn rendered H1N1 highly contagious. “It would be hard to think of a more effective dissemination mechanism than the demobilisation of large numbers of troops in the thick of the autumn wave, who then travelled to the four corners of the globe where they were greeted by ecstatic homecoming parties”, adds Spinney. The Spanish flu did most of its killing in a few weeks in late 1918. Only the Black Death can lay claim to a greater death toll. Yet histories of the twentieth century tend to sideline the Spanish flu. It was an event of enormous consequence, but it was brief. It came at the end of a monumental conflict. Most of the infected shook it off, and it is still unclear how many people died, or how the survivors were affected. Records were scarce and diagnosis patchy—the causative agent was thought to be a bacterium and the second wave of disease was often taken for pneumonic plague. In response, Spinney avoids a stubbornly chronological narrative. Instead, she circles her subject matter, swooping down to explore the salient historical, scientific, and cultural elements of the story. The story flows freely, and characters and themes recur, sometimes in different guises. Spinney has a knack for conjuring up the chaos of the era. Colourful tales from China, Persia, Brazil, and India chart the course of the pandemic and the factors that mediated the response. One highlight is a nightmarish foray to 1918 Odessa (now in Ukraine), where the government ceded control of the streets to gangsters, and influenza vied with typhus and cholera to kill the citizens. Spinney's approach situates the reader amid a story that continues to unfold. In its barest terms, this refers to the influenza virus itself, and the ongoing attempt to unravel its mysteries. But there is far more to the Spanish flu than a pathogen. “The Spanish flu has been called the forgotten pandemic, but it is not forgotten. Our collective memory of it is simply a work in progress”, writes Spinney. She points out that the earliest surviving significant history of the Black Death dates from the nineteenth century. “The 1918 pandemic is still emerging from the shadows of the First World War, but emerge it will”, concludes Spinney. If Pale Rider is typical of scholarship in the field, her optimism is well-placed. Pale Rider: The Spanish flu of 1918 and how it changed the world Laura Spinney Jonathan Cape, 2017 352 pp. £20 ISBN 9781910702376 Pale Rider: The Spanish flu of 1918 and how it changed the world Laura Spinney Jonathan Cape, 2017 352 pp. £20 ISBN 9781910702376