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Editorial Reviews
From The New England Journal of Medicine, August 26, 1999
By conservative estimates, the influenza pandemic of 1918 killed 21 million to 40 million people around the world, 675,000 of them in the United States. After only 17 months, the mortality was half that attributed to the 4-year span of the Black Death in 14th-century Europe and Asia. To many, "Spanish" influenza ranks as the deadliest plague to afflict human beings in recorded history. Its origins were obscure, its pathologic features unique, and its consequences, coming in the midst of the American entry into World War I, almost unendurable. In the panic that ensued, churches and schools were closed, the Army canceled the draft, corpses overflowed mass graves in Philadelphia, and black wreaths hung from virtually every door. Influenza 1918 recounts these statistics with the clarity of a tocsin.
By conservative estimates, the influenza pandemic of 1918 killed 21 million to 40 million people around the world, 675,000 of them in the United States. After only 17 months, the mortality was half that attributed to the 4-year span of the Black Death in 14th-century Europe and Asia. To many, "Spanish" influenza ranks as the deadliest plague to afflict human beings in recorded history. Its origins were obscure, its pathologic features unique, and its consequences, coming in the midst of the American entry into World War I, almost unendurable. In the panic that ensued, churches and schools were closed, the Army canceled the draft, corpses overflowed mass graves in Philadelphia, and black wreaths hung from virtually every door. Influenza 1918 recounts these statistics with the clarity of a tocsin.
Even more affecting are the stories of children, now in their 80s and 90s, whose pastoral reminiscences about Sunday picnics and Thrift stamps darken at the memory of lost friends, parents, siblings, and entire families. This book, adapted in part from the information televised in The American Experience, examines with a documentarian's eye the portraits of individual Americans against the canvas of the global pandemic.
The tracing of the nearly simultaneous eruptions of influenza in coastal Spain (in February 1918) and Fort Riley, Kansas (in March 1918), is complicated by the disease's wildfire proliferation across Europe as troops in trenches, hospitals, and overloaded transports spread the infection. In April and May 1918, the disease spread through Spain and the rest of Europe, but it remained quiescent in the United States until September, when explosive illness ravaged the East Coast. Continental epidemics in Africa, South America, India, and Australia followed. A time line summarizing these outbreaks might have been helpful to the reader; although they make for an effective journalistic portrayal of the simultaneity of foci, the book's rapid-fire shifts from Europe to the United States, then to India and Australia may be confusing to some readers. The book reads like a modern newscast, with rapid cutting from one scene to the next and brief but memorable sound bites from witnesses.
However, many of the scientific questions that would occur to the lay reader, not to mention the medical expert, are left unanswered. For example, what was the origin of the virus? The book breathes mystery: "A chance encounter occurred. Perhaps between a duck and a pig. Perhaps between a duck and a man, woman, or child. Perhaps between a pig and a man." But scientific evidence has demonstrated that partial sequences from 5 of the virus's 10 genes and the entire hemagglutinin sequence are much more akin to mammalian than to avian clades (J.K. Taubenberger, et al. Initial Genetic Characterization of the 1918 "Spanish" Influenza Virus. Science 1997;275:1793-6; and A.H. Reid, et al. Origin and Evolution of the 1918 "Spanish" Influenza Virus Hemagglutinin Gene. Proceedings of the National Academy of Sciences 1999;96:1651-6). Some of this work is summarized in the epilogue, but at times a tendency toward sensationalism displaces fact.
Other readers might wish to know more about the manifestations of illness, which were described as horrifying, even in contemporaneous medical reviews. Much is made of the awful premonitions that heralded imminent collapse, of the cutaneous, genital, and pulmonary hemorrhages that appalled medical personnel, and of the astounding rapidity of death, but no extracts from medical reports published at the time are provided. In other examples, we are told variously that workers in gas and cordite factories, blacks in the South, and those with tuberculosis were mysteriously spared, but without precise footnoting, these statements appear undocumented.
Finally, almost all readers will ask, "Can this happen again?" No facts are presented to dispel this very reasonable concern. A brief discussion of international surveillance organizations -- even without mention of the nearly immediate identification of the avian variant of the Hong Kong flu in 1998 -- would have been appropriate.
The book vividly evokes the fear and terror sparked by the pandemic but discusses its clinical, epidemiologic, and virologic correlates cursorily. This is a great read for those attracted to the "you are there" approach, but in the end a dissatisfying one for those who want to know why, how, and whether again.
Reviewed by Margaret K. Hostetter, M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to an out of print or unavailable edition of this title.
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