The Enemy Within: A cautionary tale of disease, indifference and devastation

The most pandemic in world history probably slipped into Washington on Sept. 17, 1918, when feverish naval recruits from Philadelphia docked at Bremerton's Puget Sound Naval Shipyard.

Less than a week later, 173 people had been stricken at what was then called Camp Lewis, south of Tacoma. Yet despite reports of devastating death tolls in the East, the Army refused to cancel the visit of 10,000 civilians to watch a review of National Guard infantry as World War I was climaxing.

Two days later, the disease appeared in Seattle, and by Sept. 28, 200 recruits at the University of Washington's Naval Training Center reported sick. It began flashing through the city's civilian population like wildfire, and on Oct. 5, Seattle's schools, theaters, dance halls, gyms and churches were shut.

What followed was the greatest health disaster since European disease nearly wiped out Native American populations in the 19th century. By late spring of 1919, 1,513 people had died in Seattle alone, according to Census Bureau estimates.

Statewide, 6,571 were counted dead: more than the state would lose in World War II, more than the toll of Pearl Harbor and the World Trade Center attack combined, and a number approaching the combat-death count on both sides at Gettysburg.

These numbers relied on the reporting of harried physicians and may be underestimates. If Washington's loss matched the national average that dread winter, the dead may actually have totaled 8,000 to 9,000.

British Columbia lost 4,400; the toll in Oregon is not known.

Three arresting facts emerge from this tragedy.

First, a pandemic that would cause media hysteria today received surprisingly subdued press attention in 1918-1919. It has since been largely forgotten, receiving scant mention in standard national, state and Seattle histories.

Second, this pandemic was not something exotic or unusual, such as bubonic plague, malaria or cholera. It was influenza: plain-old, every-year, flu. Yet this strain of flu killed more people in a shorter time than any disease in world history. In 10 months, it snuffed out somewhere between 21 million and 100 million lives, compared to the 20 million soldier and civilian deaths in all of World War I. It reached into every corner of the globe, annihilating Eskimo villages in Alaska and killing one out of five people in Western Samoa.

Nationally, 675,000 Americans died, or more than in the Civil War. The flu killed more Americans than all American wars from World War I to Iraq.

And third, the same pandemic could happen today. Most strains of flu are lethal only to the very young and very old, but in recent years a strain of the type A(H5N1) has emerged from poultry in southeast Asia that has killed 80 percent of the few people infected to date. To contain it, authorities have slaughtered more than 100 million fowl in Asia, 30 million in northwest Europe, and hundreds of thousands in British Columbia.

What has held the A(H5N1) threat in check to date is not so much the killing of farm birds but the fact that this particular virus is not yet easily transmitted from human to human. Should H5N1 ever combine with a human strain to become highly infectious, a pandemic as disastrous as 1918 could happen all over again.

Since 9/11, the Seattle-King County Public Health Office has received millions in federal aid to prepare for bio-terrorism. But at the head of nightmares for director Dr. Alonzo Plough is not man-made concoctions but lethal flu.

"If you rank what could affect Seattle and King County, pandemic flu ranks far ahead of anything," he says. "It is far ahead of smallpox, far ahead of anthrax. We're just a plane ride away from any emerging new virus. It would be like SARS squared."

Why? The answer comes every winter. Just about everybody, sooner or later, gets the flu.

WHILE FICTION posits plagues that can annihilate virtually everyone, real pandemics don't work that way. A disease that kills its host limits its own spread — dead people don't cough — and some people recover or are immune. Even the worst plagues, such as the Black Death that wiped out half of China and a third of Europe in the 14th century, didn't kill everyone.

The 1918-19 pandemic featured a flu strain more deadly than ever recorded, and many of its victims were in their 20s and 30s. Yet it is estimated only half the world's population was infected, only 25 percent exhibited flu symptoms, and just 1 to 5 percent died, the highest percentage in countries such as India. In Seattle and Washington, the death toll was closer to a quarter of 1 percent.

That was bad enough, of course. Hospitals turned people away. Sports championships were canceled. Church services were held outdoors, or abandoned altogether. Politicians had no crowds to exhort.

The origin of the pandemic is still debated. It was called Spanish flu only because neutral Spain escaped wartime censorship and gave it more publicity than other countries. The earliest known cases came in the spring of 1918 in Kansas and might have been a swine flu that jumped to humans from pigs.

Yet birds are the ultimate reservoir for flu, and some scientists believe the 1918 strain originated earlier in the same place most strains originate today: in the crowded poultry yards and live markets of China.

In any event, an initial wave of flu in the spring and summer of 1918 sickened so many soldiers that German Gen. Erich von Ludendorff blamed the disease for helping foil his last desperate offensive, which stalled just 37 miles from Paris. Entire divisions were temporarily laid low, and each side accused the other of germ warfare.

By the time a second, more lethal wave of the flu struck the world in August and September, American reinforcements were turning the tide of the war. But they would not escape the flu.

Flu had been ravaging Army camps and eastern cities such as Philadelphia and Boston when it appeared on Puget Sound. "It is already here," state health commissioner T.D. Tuttle announced on Oct. 4.

The next day, Seattle Mayor Ole Hanson ordered the closure of most places of public gathering, while leaving stores and restaurants open. People howled. The school superintendent called the mayor "hysterical" and the school closures "senseless." The manager of the Second Avenue Theater scoffed, too, declaring: "There is no danger of the disease spreading in the audiences."

"Some will kick, but we would rather listen to a live kicker than bury him," Hanson retorted.

NEWSPAPER COVERAGE of what followed was matter-of-fact and blind in its patriotic optimism. Deadly disease was more common than today, and war news in The Seattle Daily Times pushed most flu stories to the inside pages. Health authorities were quoted day after day as hoping the pandemic had peaked, weeks before it actually did. Far more newsprint was devoted to a Liberty-bond drive than to the worst death toll in city history.

Yet news of apocalypse crept in.

Oct. 6: 20 are dead at the Bremerton shipyard, six in Seattle, nine at Camp Lewis. Seattle's police chief has the flu. The Hotel Butler sends its café orchestra home.

Oct. 7: Hospitals are so jammed that the old courthouse is turned into a ward, with 200 beds. Tacoma closes its theaters. Aberdeen bans public gatherings.

Oct. 8: Bellingham closes its schools, military singing squads are barred from Seattle department stores. A brief item reports that in Illinois, Col. Charles Hagadorn committed suicide after 500 of his soldiers succumbed.

Oct. 12: Hoquiam, which had kept its theaters open to take business from rival Aberdeen, finally gives in and shuts them down.

Oct. 15: Three of Bremerton's five city doctors are sick, and a church is converted to a hospital. Victoria reports 231 cases. Chehalis has seven deaths in 36 hours, and every member of one family is wiped out.

Oct. 16: The Red Cross puts out a plea for a four-fold increase in women volunteers. In Missouri, divorced congressman Jacob Meeker weds his secretary at midnight and is dead from the flu by dawn.

Oct. 18: Women in Seattle adopt chiffon veils, worn like Arab dress, as the new fashion to supposedly protect against germs.

Oct. 19: Quack remedies appear in newspaper ads, 31 Seattle men are arrested for spitting in public, and state commissioner Tuttle threatens to arrest anyone participating in small, informal social gatherings.

On the toll went: in Everett, Yakima, Wenatchee, Spokane. Private nurses were asked to report to public hospitals. Ice cream was touted as a relief for fevers. The military put out a plea for magazines for hordes of sick soldiers.

By Oct. 24, Seattle barbers and dentists were ordered to wear gauze masks, an order soon extended to waiters, clerks and tellers. The Bon Marché began running ads boasting how it was protecting customers, including sterilizing telephone receivers each morning.

On Oct. 29, all Seattle workers were ordered to wear a gauze mask, available for a nickel. About two-thirds complied, but many took them off to talk, left them askew or dangled them around their necks. The most fastidious turned them inside out once smudges marred the crisp white outer layer.

In New York City, meanwhile, a steam shovel was being used to dig graves. In Vancouver, B.C., two new blocks were acquired to add to the city cemetery.

Seattle cases seemed to peak in early November just as Germany was negotiating an armistice. When peace came on Nov. 11 and celebration erupted, the gauze masks spontaneously came off, regulations be damned. Officials soon capitulated as completely as the Germans had, and schools and theaters reopened. The pandemic was declared over. Yet on Nov. 18, the same day the quarantine was lifted at Camp Lewis, the first flu cases were reported in the San Juan Islands.

All that had ended was a war-weary public's willingness to pay attention to flu. Soon after crowds recongregated, the flu accelerated again, and the disease killed as many Seattle residents in December as it had in October. Still, all that city health commissioner J.S. McBride could win from politicians was agreement to quarantine the sick. By Dec. 11, 984 Seattle homes bore yellow warning placards. Christmas shopping ads shared space with those for flu remedies.

The disease lingered through the winter months of early 1919 before gradually burning out and disappearing as mysteriously as it had arrived. The dead were buried, orphans adopted, and life went on with a determination to forget this strange last episode of Great War horror.

Future novelist Mary McCarthy, for example, was 6 when her flu-stricken Seattle family boarded the train on Oct. 30, 1918, to visit Minneapolis. Both parents were dead shortly after arrival, a bereavement that sent her to two different homes of relatives and stamped her with experiences that made her an author.

There were a million American stories like McCarthy's, yet most went unrecorded. With the exception of Katherine Anne Porter and Thomas Wolfe, no major American writers of the flu generation wrote anything about the worst plague in American history. Historians ignored it as well, until Alfred W. Crosby, then at Washington State University, became curious.

"When I was a kid in the 1930s, there was a blanket in the back seat of our car," the University of Texas historian recalls. "I asked my father about it, and he said that he got it off the cot of a fellow soldier who died of the flu at Fort Devens, Mass., in 1918. Then, 30 years later, I came across a graph of life expectation that falls like a brick in 1918. The cause was the flu that my father survived." The result was the first full history, "America's Forgotten Pandemic," in 1976.

And Mayor Hanson, whose draconian measures may have helped keep Seattle's death rate to a third that of Philadelphia's? He was criticized for crippling business. He left for California, resigning before his two-year term was completed.

LIKE AIDS, FLU is caused by a virus, a tiny packet of genes in a protein coat so simple, and so inert, that most biologists don't consider viruses truly "alive" until they invade a host cell. Then they hijack the cell's machinery and use its energy to turn out 100,000 to 1 million copies of themselves in just 10 hours. Eventually they swell so thick that they burst the cell from within, flooding out to further infect the body.

They are spread from respiratory passages, the cough and sneeze droplets deposited on doorknobs, desktops, coat sleeves and food tables. Kleenex and hand washing remain two of the most reliable methods to contain flu.

A virus is much smaller and simpler than bacteria and, unlike bacteria, cannot be killed by antibiotics. Trying to fight a cold or flu with antibiotics is as misguided as trying to battle mosquitoes by shooting elephants.

The flu of 1918-19 appears to have been particularly deadly for two reasons: It provoked an unusually violent immune response from the body, particularly those in the prime of life, and the resulting battleground ravaged the lungs where flu viruses reside. It is the body's immune system, not the virus itself, that creates most of the miserable symptoms of ordinary flu. Fever, for example, is useful because the virus doesn't like heat.

The 1918 strain's toll on the body's defenses also opened the door to pneumonia, which often finished victims off.

The cause of flu was unknown in those years — the virus wasn't isolated until 1933. As a result, most of the measures Seattle took to fight the plague were ineffectual. The city concocted its own flu vaccine, based on bacteria found in the dead, and inoculated thousands. Yet the serum did nothing to ward off or lessen the disease. Gauze masks were equally unlikely to contain or intercept viruses far smaller than the weave, although they may have contained some cough spittle.

What may have helped most was the decision to close public gathering places, particularly schools. Seattle did have a lower rate of infection than cities where crowds persisted too long.

In Temple, Texas, Dr. Paul Glezen of the Baylor College of Medicine is in the midst of an interesting experiment to see if immunizing children against flu, using a new flu mist vaccine that doesn't require needles, helps prevent its spread to the vulnerable elderly. The theory is that classrooms are particularly good flu incubators, and that children then transmit the disease to their elders.

Early results, he says, suggest school vaccinations have produced a decline in flu of 15 to 18 percent among people over 35, preventing about a thousand adult cases.

Yet the experiment has been hampered because vaccines have come too late or have been ill-designed for recent flu strains.

What makes flu such an annual irritant, and so potentially deadly, is that like the HIV virus that causes AIDS, it is a moving target. Made of RNA instead of the more stable DNA, it mutates like a movie monster, making vaccinations obsolete in a year or so.

Many disease viruses and bacteria don't change much. If you get measles you are generally immune for life because your antibodies have learned to detect and kill that virus. Each successful human virus has protuberances called antigens that successfully snag victim cells, and our blind antibodies are constantly relearning which protuberances indicate enemies. Imagine a darkened room full of angels and demons, the defenders recognizing foes by their horns and friends by their wings.

Flu, however, is subject to genetic "drift." One study counted 19 new flu mutations, or strains, appearing in just 33 years. Medical authorities are constantly trying to forecast the next strain to make effective vaccine. Last winter, a severe one, the vaccine that was prepared was late, in short supply, and turned out not to be the right type, preventing flu in only about half the patients who received it. A more normal success rate is 70 to 90 percent.

Earlier this month, the U.S. vaccine supply was cut roughly in half when regulators suspended the license of the California-based Chiron Corp., after they found problems at a plant in Liverpool. Health officials are recommending rationing the remaining supply, giving high-risk groups priority. They're also calling for money to develop faster cell-culture technologies to bolster the traditional vaccine-manufacturing method using eggs. It's too early to say how the sudden shortage will affect this flu season. "One thing we know about the flu is that we can't predict it," said Dr. Julie Gerberding, head of the U.S. Centers for Disease Control and Prevention.

In part that's because occasionally the flu will change radically in what is called a "shift" and take humans by such complete surprise that a pandemic erupts. An estimated three to six shifts occurred in the 18th century, four in the 19th, and three in the 20th: the 1918 pandemic, the 1957 Asian flu and the 1968 Hong Kong flu. Because it can take six to nine months to make enough effective vaccine, a lethal "shift" that explodes around the world is what gives health authorities nightmares.

THE FEDERAL GOVERNMENT'S Centers for Disease Control and Prevention has roughly estimated up to 1.2 million King County residents would become infected in the first six weeks of such a pandemic, up to 612,000 would get sick, up to 4,896 would become hospitalized and up to 2,666 would die.

"What concerns us here is that we are so close to Asia," says Dr. Jeffrey Duchin, chief of Seattle-King County's communicable-disease section. Planes and ships make Seattle a natural port of entry.

These kinds of numbers can leave people with feelings of helpless dread, but there is a sophisticated global network to try to stop such a pandemic in its tracks. More than 80 countries and 121 U.S. cities belong to a reporting system to track flu. In King County, 12 to 15 clinics and practices report on cases and send virus samples to help detect anything unusual.

And now, doctors know what causes flu, they have decades of experience with vaccines to combat it, and they even have anti-viral drugs, though those are expensive and of limited effectiveness.

Still, as University of Washington and Veterans Hospital researcher Dr. Kathy Neuzil says, "There's a lot we don't know." Where did the 1918 flu come from? Why exactly was it so deadly? Where did it go?

The UW and four other institutions have just started a five-year, $12.5 million study that will infect monkeys with separate genes from the virus, exhumed from the dead buried in Alaskan permafrost, to try to discover why it was so lethal.

Meanwhile, public indifference, fear of needles or parental resistance to vaccinating their children hamper efforts to get the vulnerable vaccinated, says Dr. Janet Englund of Seattle's Children's Hospital. "The reason kids don't get it (at low cost or for free) is because they don't have a lobbying group like AARP. One of these days there will be a severe flu" and schools could become a "cesspool" of infection.

She hopes the nasal-mist vaccine just entering the market might be key to making childhood vaccination more acceptable.

King County is benefiting from an infusion of federal health-planning money prompted by bio-terrorism fears: $3 million this year, $4 million next. Public-health authorities are increasingly sophisticated, Dr. Plough says.

But we're also much more vulnerable, he warns. Global warming, deforestation that puts humans in contact with new animal diseases, urbanization, population growth, air travel and shipping of food supplies around the world all make pandemics easier.

Cover your mouth, he advises.

"It's a much smaller world than in 1918."

William Dietrich is a Pacific Northwest magazine staff writer.