The Spanish Influenza Pandemic of 1918-19: New Perspectives (review)

December 2003 was not a good time to be reading this book. Influenza was again stalking the land, and the public health response was again inadequate. The vaccine formula chosen in the United States was only partially effective against the prevalent strain, and manufacturers had produced too few doses of even this weak shield. Public health pundits noted, supposedly in reassurance, the flu was not killing children, but that a postviral bacterial pneumonia was to blame.

Just like in 1918. Far from being the "forgotten pandemic" chronicled by Alfred Crosby, the 1918 influenza outbreak is now common fodder in the popular press. There is renewed interest in the pandemic, evidenced by Gina Kolata's popular book Flu (New York: Farrar, Straus, and Giroux, 1999), and a PBS documentary (Influenza 1918, produced by WGBH Educational Foundation, 1998). Still, the historiography of this epidemic, which probably killed more people worldwide than any other single disease outbreak before or since, has been remarkably sparse. In 1998 the editors of this volume convened a four-day conference in Cape Town, South Africa, to remedy this deficit in part, and then chose half of the thirty-two papers presented for publication.

The chapters offer analyses of an impressive array of localities. New Zealand, Japan, China, India, Europe, Africa, northern Canada, and Great Britain all come under scrutiny. There are huge gaps—nothing on Middle or South America, Russia, or the Middle East, for example—and it is hard to know whether those papers did not make the cut or no historian could be found to describe the events in these areas. The scope of the essays emphasizes the vastness of the epidemic, and the enormous task facing any historian who attempts to write a synthetic, inclusive account of it. This volume makes an admirable addition to the global story of this horrific time.

In many ways the story was the same in place after place. The epidemic flew around the world in troop ships and railroad cars, fueled by the crowding and disorder inherent in war. The epidemic struck quickly, felling large numbers of people in two or three months before burning out. Public health response often included denial, reassurance, and minimal action in rich countries with an organized sanitary infrastructure as well as in those less developed. In many places attempts were made to close public gathering places, although resistance was typical. The wearing of masks became common in countries affluent enough to afford them. In the most medically sophisticated countries, physicians advocated mass immunization against the purported cause of influenza, Pfeiffer's bacillus. (The correct viral agent was not recognized for another fifteen years.) Various remedies were tried, including regular medicines such as quinine and aspirin, patent nostrums, and herbal or folk remedies. But all told, physicians had little to offer. What did matter was nursing, and Nancy Bristow's essay emphasizes that although doctors felt helpless, nurses recognized that their services were valuable.

There were some surprising insights here that cast new light on influenza, then and now. It is well known that influenza immunity is short-lived, whether acquired naturally or via vaccination. Yet one of the peculiarities of the 1918 epidemic was the relative sparing of the elderly, whereas those between the ages of twenty and forty seemed particularly susceptible. Even if a similar strain had circulated in the late 1880s, as has been postulated, how was it that immunity from such exposure could have survived thirty years? Stephen Schoenbaum answers this question by citing the concept of "original antigenic sin," the hypothesis that the first encounter with influenza in childhood confers a long-lived immunity not replicated in later exposures. This volume also posits the theory that the first mild wave of influenza, in the spring of 1918, may have generated partial immunity among those exposed. This might explain why the more highly traveled, industrialized countries had a relatively milder experience with the deadly flu that appeared in...