Subscribe Editor's Note | With a nation fighting a world war, the influenza virus raced through U.S. military camps like Fort Porter, New York. (Courtesy of the American Red Cross Museum) On October 1, 119 new cases were reported; on October 4, 400. Asked about closing schools and banning public gatherings, the city’s health commissioner told the Baltimore Sun, “Drastic measures…only excite people, throw them into a nervous state and lower their resistance to disease.” On October 10, the number of new cases peaked at 1,962. The rising death toll was proof, the News said, that the epidemic was reaching a “climax” and “may be expected to fall sharply soon.” Everyone was out sick. There were too few milkmen, too few firefighters, too few telephone operators and too few gravediggers. The city didn’t have enough workers to process death certificates. As it was illegal to conduct burials without one, bodies and caskets stacked up inside—and outside—funeral homes. Hospitals were overwhelmed. At Johns Hopkins Hospital, as the scope of the epidemic widened, flu patients occupied six full wards, and then the Hospital had to close its doors altogether. Three staff physicians, three medical students and six nurses died in the epidemic. Scenes of heartbreaking loss were replayed in city after city around the country—and the world. Stell Altman was 9 years old at the time and living in Rochester, New York. She, her three younger siblings, and her mother were all stricken, but, miraculously, her father remained healthy and cared for his bedridden family. “I don’t know what would have happened if my father had gotten sick,” says Altman, who is now 95 and whose nephew, Shale Stiller, is a Johns Hopkins University trustee. “There was no help to be found anywhere; everyone was too busy caring for their own families.” Altman’s mother, Sarah Salitan, died. Her father, Morris, laid his wife’s body on a bed of straw in the home, in accord with Jewish customs.
Like most other cities in the region, Baltimore slowly came around to sterner measures, closing schools and outlawing public gatherings. Whether such steps made a difference or the epidemic simply ran its course is difficult to say. The flu faded in November, then lingered into early 1919. Reporting errors and recordkeeping lapses make reliable estimates of Baltimore’s flu cases and fatalities hard to come by. By the most conservative of counts, at least 75,000 of the city’s 600,000 residents caught the flu, and more than 2,000 of those died. In an ordinary October in the early 20th century, Baltimore would suffer fewer than five deaths caused by influenza. In October of 1918, it suffered 1,464. The story of how Burke and Cummings came to mine the numbers of the 1918 flu epidemic begins in distant Thailand, where mosquito-borne dengue fever is endemic. Recently, Cummings and colleagues took data covering 850,000 cases over 15 years of dengue hemorrhagic fever, the most deadly form of the disease, and ran them through a mathematical technique originally developed by NASA to study physical waves, like in water and sound. The results were published earlier this year in Nature. “What we found is this repeating, radial pattern,” Cummings says. “Every three years, this wave moves through the country, and it comes out of Bangkok, right in the middle.” Cummings is pushing this work further, trying to identify the forces driving the spatial and temporal dynamics of the wave. But simply detecting it has important implications for public health. “It tells you two things,” Burke says. “One is, if you’re in one of the outer zones, all you’ve got to do is monitor Bangkok to know you need to prepare for an epidemic. There could be a six- or eight-month lead time. The second thing is, if we do something that succeeds in Bangkok, we may accomplish something important for the whole country.” No one has ever looked at pandemic flu data in this way before. It will be a challenge gathering reliable data in the requisite detail, but Cummings’ search is under way in Maryland—from there, he plans to fan out along the Eastern seaboard. At a minimum, pinpointing predictable ways pandemic flu rolls through space and time could offer information that helps “downstream” communities prepare for its arrival, Burke says. But it could also prove vital on the front lines. The tools in place to fight a flu pandemic today aren’t that different from the ones Welch and his colleagues employed. Hospital and isolation facilities are improved, of course. Antiviral medicines would help, but stockpiles would disappear rapidly in an event approaching the scale of 1918. So, too, would the world’s 200 million or so doses of flu vaccine. “We can use information like this in designing intervention strategies,” Burke says. “If we immunize young people, will that slow down the epidemic and give us time to make more vaccine? What if we vaccinated the more mobile sectors of society? Are there things we can learn here that would help us make the most rational use of our limited resources? My belief is yes, there are.” On the way back to Baltimore from Camp Devens, William Henry Welch fell victim to the flu. Years later, Welch told colleagues at a conference, “I could not have dreamed of going to a hospital at that time.” Instead, the 67-year-old returned to the rooms he rented in Mount Vernon, went to bed and stayed there. “The condition of Lieutenant-Colonel William H. Welch, of the Johns Hopkins University,…who for some days has been confined to his rooms, suffering from an attack of influenza, was said to be greatly improved yesterday,” the Baltimore Sun informed readers on October 14. “…It was stated last evening that he expected to sit up today and to resume his duties in Washington in the near future.” When he finally felt well enough to travel, Welch journeyed instead to his favorite vacation spot, the Hotel Dennis in Atlantic City. At least six weeks passed before he finally felt well enough to get back to his military duties and to that business of opening a new School of Hygiene and Public Health.
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