Waiting for the Pandemic

“I have had an awful dream. My youngest sister appeared to me in deep mourning. She led me to a row of graves and named my brothers and sisters as those the graves enclosed. ‘I, too, am dead,’ she told me, ‘but God in his mercy has allowed me to spend this day with you.’ Then the dream faded and I awoke.”

Arthur Lapointe had survived fifteen months in the trenches, and the worst war in history was finally over. It was November 1918 and he would soon be going home to Canada, but he had received a letter saying that one of his brothers was dangerously ill. He was frightened by the dream, but he had lived amid death for so long that he thought it was just his imagination running wild.

It was not. What was to become known as the Spanish influenza first appeared in Haskell County, Kansas, in January 1918. A virulent new kind of influenza killed dozens of people in the sparsely populated county, and a local farm boy who was serving in the US Army carried it to Camp Funston, Kansas, where over 50,000 troops were training. The flu spread among them fast, but 1918 was the pivotal year of World War I, so troops continued to be shipped out to other camps and across the Atlantic to France. In about a month, moving mostly by rail and by sea, it spread to much of the world, but it became less virulent as it travelled. In the trenches in France they called it the “three-day fever,” and few became seriously ill.

The second wave was different. When the virus came back in September, it was a killer. It was probably worst in India, where as many as 20 million people died, but it took a terrible toll in North America, Europe, and everywhere else. Arthur Lapointe, however, had no idea what was happening because the media in the warring countries (including Canada) loyally downplayed the news or suppressed it entirely in order not to damage morale. In fact, the Spanish influenza got its name in part because newspapers in Spain, which was neutral in a world at war, were the most forthright with horrifying reports of healthy young men and women suddenly falling sick and dying in agony within a few days.

Lapointe was consumed with anxiety as the troop ship bore him home. His father and his brother Alphonse were waiting for him at the station in Mont-Joli in early February 1919 when the train pulled in from Halifax — but nobody else. “We did not tell you,” his father said, “for we wanted to spare you all the sorrow we could. The epidemic carried off your three brothers and two sisters in nine days.” It had been safer in the trenches.

In Quebec alone, the Spanish flu killed 13,800, and native people were particularly vulnerable. In Labrador, where the mail boat carried it to settlements along the coast, at least onethird of the native population died. In all, nearly 50,000 Canadians died. The worldwide second wave was followed by a third, beginning in February 1919, that killed in smaller numbers, but still in the millions.

There is good reason to fear that a similar outbreak is on its way. “The world is now in the gravest possible danger of a pandemic,” warned Dr. Shigeru Omi, the World Health Organization’s regional director for the Western Pacific, at a bird flu conference last February. In April, President Bush quietly signed an executive order adding “influenza caused by novel or re-emergent influenza viruses that are causing, or have the potential to cause, a pandemic” to the list of communicable diseases for which quarantine can be imposed in the United States.

If a flu pandemic hits, we will all suffer more or less equally whether we live in Canada or Cambodia. Viruses are not necessarily impressed by good hygiene or high living standards, and there are not enough intensive care facilities in the developed countries to make a substantial difference in the death rates if millions in those countries fall critically ill at the same time. No country has a sufficient stock of antivirals like Tamiflu to offer protection to more than a tiny fraction of its population, and vaccines would not be available for at least four months after a pandemic began.

Rich countries are now stockpiling antivirals and working on ways to massproduce vaccines much more rapidly so that by 2007 or 2008 they may well be able to protect their populations from the worst effects of a pandemic. Unless there is an unprecedented outbreak of generosity in developed countries, however, the poor parts of the world will be as defenceless as we all are now, and it could be just as bad in those regions as it was in 1918. That pandemic might have killed as many as 100 million people out of a world population of 1.8 billion — more than 5 percent of the world’s population, in other words — in less than a year. (Estimates of the death toll vary because most flu victims actually died of pneumonia and because the poorer parts of the world kept only limited public-health statistics in 1918, but as modern experts mine the old data the consensus estimate of the 1918 death toll continually rises.)

It gets even worse, because a much higher proportion of the population in poor countries is in the younger age groups. Flu epidemics normally kill the very young, the very old, and other people with weak immune systems, but the 1918 pandemic aggressively targeted healthy young adults, mainly because their strong immune systems vigorously overreacted — a so-called cytokine storm — and killed them, often within a day, by destroying the lungs so rapidly that the victims suffered from oxygen starvation, their feet, hands, and faces turning blue or even black. They bled from the nose and sometimes from the ears and eyes as well. They suffered terrible headaches and joint aches, and at autopsy their lungs resembled those of people who had died of poison gas. Over half the deaths were in the eighteen- to-forty age group.