Editor’s note: Earlier this month the Nisqually Valley News printed the story “Flu Activity Picking Up Across State.” We take a look back 201 years to 1918 when the Spanish flu swept through the nation, including Washington state. It killed about 5,000 Washingtonians during the final four months of 1918. The following is the final Part II.
A Dearth of Data
For several reasons, tracking the progress of the pandemic in the state in 1918 with much accuracy was impossible.
First, influenza was not a disease that had to be reported to state health authorities, at least not during its most virulent phase in the fall of 1918. Voluntary reporting was extremely sporadic, as will be seen. Deaths needed no diagnosis and were faithfully recorded, but overall tallies of the infected must be considered rough estimates, even when impressively specific.
Second, the flu in 1918 and early 1919 came in three distinct waves — a usually mild form in the spring and summer of 1918, followed by the deadly strain in the closing months of that year, and ending with a return of usually (but not always) milder disease in the early months of 1919, not fully tapering off until 1920. Not everyone who became ill was infected with the virulent Spanish flu, some had a more mild form, which still could be lethal to the very young and the elderly.
To further frustrate public-health authorities, the Spanish flu killed both directly and by leaving victims vulnerable to secondary infections with bacterial pneumonia, which was often fatal even in the absence of the flu, particularly in the elderly or infirm. This muddled the causality picture. But because the Spanish flu had proven so stunningly contagious and pneumonia was so often found during autopsies of flu victims, the federal Census Bureau decided to use a single category in its mortality statistics for 1918: “deaths from influenza and pneumonia (all forms).” As frustrating as it is to epidemiologists and life-insurance actuaries, all statistical studies of the effects of the 1918 pandemic are riddled with uncertainty and approximations.
What the Record Shows
Washington was one of 30 “registration states” deemed by the U.S. Census Bureau to have reasonably reliable recordkeeping in 1918, but the state’s epidemiologist, in a January 1919 Board of Health biennial report to Governor Ernest Lister, emphasized the unprecedented nature of the pandemic and the difficulty of gathering accurate information:
“This pandemic made its appearance in Washington in the first week of October. In the history of the State Board of Health no such calamity has afflicted the State nor has so serious an emergency ever arisen. In the five years 1913-1917 inclusive, from the five most common contagious diseases ... there have been 1768 deaths. From influenza alone we have had to date well over 2,000 deaths and the end is not yet. The toll will probably be double or triple 1,768.
“City health officers, except in Seattle, Tacoma, Spokane and Yakima, are part-time men. Their salary is often nothing or five dollars a month. They are appointed by their mayors and change frequently. They are not of our making and do not feel as if they have much responsibility to us. Their jobs pay little and their policy is to do as much as the pay justifies.”
The report was prepared in December 1918, when the full extent of the catastrophe was unknown. The health board’s next biennial report was not issued until January 1921 and was almost silent on the 1918 pandemic. There appears to be no available compilation, state or federal, of infection rates or deaths on a county-by-county basis, much less for individual communities, although census data does exist for Washington’s two largest cities, Seattle and Spokane, and Yakima’s experience is relatively well documented.
In its Mortality Statistics 1918 the U.S. Census Bureau compared the state’s total 1918 flu deaths with those from 1915, contrasting the first eight months of each year with the last four. Between January and August of 1915, 605 Washington residents died of influenza and pneumonia; in the first eight months of 1918, 838 Washingtonians died, a sizable but not shocking increase.
In the last four months of 1915, only 381 people in Washington succumbed to the flu, but in the last four months of 1918, the pandemic killed 4,041 in the state, 10.6 times the 1915 count for the same period. The state epidemiologist’s pessimism about the final toll proved fairly accurate.
Other facts from the mortality tables demonstrate the unprecedented nature of the Spanish flu. Perhaps most surprising, slightly more than half, or 2,461 of the 4,879 flu fatalities in Washington in calendar year 1918, were men and women between the ages of 20 and 39, the demographic group that normally enjoyed the highest disease survivability. The same rough proportions held true in the state’s two largest cities. In Seattle 708 of 1,441 flu deaths recorded between Oct. 12, 1918, and March 15, 1919, fell into that age range, while in Spokane the count was 252 of the 428 flu deaths.
These numbers alone illustrate just how unique this pandemic was in comparison to any other disease outbreaks for which records exist. This mystery has never been fully resolved, but the leading theory is that the 1918 virus triggered catastrophic immune reactions in young adults with robust immune systems.
Comparative numbers were not calculated for Yakima, but roughly one-third of the population, or about 6,000 people, were infected there. Of these, 120 died — 32 percent of the city’s total 1918 death toll from all causes. So contagious was the disease that Yakima’s only hospital, St. Elizabeth, run by the Sisters of Providence, for a time refused to admit influenza patients.
There is only one statistic in the 1918 mortality tables from which some comfort may be taken. Of the 30 registration states relied upon by the Census Bureau, with the single exception of Oregon, Washington by a significant margin had the lowest number of influenza/pneumonia deaths per 1,000 residents. Nevertheless, 4.1 of every 1,000 Washingtonians were killed by influenza/pneumonia in 1918 (more than five times normal) and 1.9 of every 1,000 in 1919 (more than twice normal). In contrast, the state’s mortality rate from those causes in each of the three preceding years was less than one per 1,000.
Doing Their Best
The health board’s Twelfth Biennial Report documented both a realistic apprehension of the danger Spanish influenza presented and a recognition of the futility of efforts to prevent it. It recounted the efforts of Dr. Thomas D. Tuttle, the state’s health commissioner and the report’s lead author, to get advice from the federal government:
“This epidemic was very prevalent in the Eastern states during the month of September, and, realizing that in all human probability it would rapidly spread over the entire country, your commissioner of health took up with the United States Public Health Service the question of the advisability of quarantining individual cases.”
Specifically, the board reported, Tuttle sent a telegram to U.S. Surgeon General Rupert Blue asking “Intrastate quarantine Spanish influenza under consideration. What period of quarantine if any do you recommend?” and Blue replied, “Service does not recommend quarantine against influenza.”
In the report Tuttle provided the health board’s opinion on how the Spanish flu came to Washington. It is but one theory among several, but as credible as any:
“The epidemic struck our state in the early part of October. The immediate introduction of the disease was through a shipment from Pennsylvania to the United States Naval Training Station at Bremerton of about 1,500 men, a large percentage of whom were afflicted with influenza when they reached their destination. From this location the disease spread widely (but) many outbreaks were not directly traceable to the infection at or near Seattle.”
Tuttle’s account of a Chicago meeting of state health authorities could not conceal a tone of desperation:
“The outstanding feature of the discussion of the subject at this conference was the evidence that whatever efforts were made the spread of the disease was only retarded and not prevented. As one health officer very aptly expressed the situation: ‘One can avoid contracting the disease if he will go into a hole and stay there, but the question is how long he would have to stay there? The indications are that it would be at least for a year or longer.”
Desperate Measures, Mostly Futile
Despite its early concerns, the Washington State Board of Health did not impose statewide measures to combat the pandemic until it was well under way, probably because it had very limited resources and little or no control over local health authorities.
The only preventive regulation of statewide application that the board issued came on Nov. 3, 1918, when it required that surgical masks of a specified size and thickness “entirely covering the nose and mouth” be worn in virtually all public places where people came into close contact with one another; the order also required that the proprietors of stores, restaurants, and cafes “keep their doors open and their places well ventilated” and that one-third of the windows in streetcars be opened when in use by the public.”
Vancouver in Clark County was one of the first cities in the state to aggressively address the pandemic. On Oct. 7, 1918, acting on a report from the chief health officer, the city council ordered that “all places of public gathering, such as schools, churches, dances etc.” be closed (Vancouver City Council minutes). Two days later the town council of Monroe in Snohomish County approved a similar measure, as did Yakima, which later joined with Yakima County to lease a building owned by St. Michael’s Parish “for the purpose of establishing same as an Isolation Hospital.” On October 31 the ban on gatherings in Yakima was widened even further to include “all places where any kind of business is transacted ... with the exception of drug stores, meat markets, restaurants, eating places, hotels and fruit warehouses,” the last an apparent concession to the town’s leading industry.
Similar bans on public assembly were imposed in counties, cities, and towns across the state. A small sample would include Seattle (Oct. 6); Spokane (Oct. 8); Pullman (Oct. 10); Anacortes in Skagit County (Oct. 15); Ferry County in Northeast Washington (Nov. 17); tiny Wilson Creek in Grant County, where all children under age 16 were ordered confined to their homes (Dec. 7); and Chelan, although it exempted schools (Dec. 10). No corner of the state was spared, nor did the ordeal end with the new year. The Cowlitz County Council did not even impose similar restrictions until Jan. 16, 1919, and White Salmon to the east was at that time still under siege.
These and similar measures probably helped to limit the spread to some extent, but perhaps the most telling reason for the eventual ebbing of the pandemic was that it simply ran out of vulnerable victims. In this regard it is important to remember that most people did not become infected, despite nearly universal exposure, nor did it kill but a fraction of those it did infect.
What Was It? Where Did It Go?
In the 1990s researchers, using archived autopsy samples from 1918, mapped the virus’s genome and determined it to be Type A, the most common, which can infect both humans and some animals.
More specifically, the investigation revealed that the virus was a strain of Type A known as H1N1. The “H” represents a protein molecule on the surface of a virus that is the usual target for the immune system. When random mutations alter that molecule, the virus can become virtually invisible to the body’s defenses. As researchers explained in 2006, “Recently published ... analyses suggest that the genes encoding surface proteins of the 1918 virus were derived from an avian-like influenza virus shortly before the start of the pandemic and that the precursor virus had not circulated widely in humans or swine in the few decades before.”
Because it had not circulated widely, humanity had developed no “herd immunity” to it. This explains its rapid spread but not its lethality, which remains a mystery.
As to where it went, the answer is that it went nowhere. Almost all cases of type A influenza since 1918 have been caused by less-dangerous descendants of that lethal virus. Viruses do not have intentions, only random mutations. Some mutations will enable them to sicken birds, pigs, people, or other animals. Some will make them unusually lethal, others will render them totally harmless to humans.
But inevitably a strain will emerge that is as infectious and deadly as the 1918 variety. Viral mutation is ongoing, endless, and unpredictable. In any new flu pandemic the toll will likely be lower due to advances in immunology and other countermeasures, but as with death itself, the question is not whether it will come, but rather when.