 In 1918, I lived in Sequoia County. In 1918, my family was living in South Philadelphia. In 1918, we were living in El Paso, Texas. I was born and raised in Baltimore. In bustling cities and remote villages, in the United States and around the world, orphan children cried for their parents in 1918. People of all cultures struggled with the same terrible threat. And within a matter of months, as many as 50 million would be dead. In the United States, the death toll reached 675,000, five times the number of U.S. soldiers killed in World War I. What was that deadly threat? There were many, many people who died. We had just come from a few years before from Mexico, where we were living, on account of the revolution, the Mexican Revolution. I was about 10 years old. I was the oldest and my four brothers and sisters of the family. Only my dad and my sister, my smaller sister, did not get it. My two brothers were in one room sick. I was sick in the other bedroom with my mother, my poor dad, and sister had to be our attendants and see what they could do for us. Inflates that gave you such high fever. Mother told me that I thought her black hair was a cat, and I was afraid of it with a delirium from the high fever. People were left very weak with it, kind of that high fever. And all schools, all public places, and every place was closed, I guess nearly two or three weeks. I was eight years old. We lived near my dad's mother, and she and her daughter and two grandchildren were living close to us. And when they got the flu and got sick, my parents, we just moved in with them to where my mother could nurse all the patients and take care of them. At that time, my mother was 25 years old, and she had three children, and she was expecting another baby in May. And this was in February, and she'd taken care of eight patients at one time, very sick patients with the flu, with no convenience, no modern facilities whatsoever. And mother had to get the wood to keep peat in the house to keep all those fires going, plus do the nursing care with eight patients. My father's name is Telus Four Reina, but he always went by Telus Good Morning. Good Morning was his Indian name. At that time, he was working in Tennessee for a DuPont company. Every time anybody was sick, he would always bring up the story about how he got sick while he was in Tennessee and how a lot of people from the village that had gone were brought back sick. They were brought back in a train. He said some of them had passed away in Tennessee. In 1918, my mother was like just 11 years old, but she remembers they lived on the south side of the village. She remembers that church bell would ring every day that there's a certain bell for a notice for the death. And she said she remembers as a little girl how awful it sounded. In 1918, as now, most people didn't think of influenza as a disease that could lead to death. We suffer through the flu season every winter. In the U.S., the flu season usually peaks between January and the end of March. The symptoms of a cold are usually a runny nose, sometimes low-grade fever, and just feeling a little wiped out. Influenza, on the other hand, is much, much more pronounced than that. People will generally have a high-grade fever, absolutely no energy whatsoever. Muscle aches, headaches, a fairly dry cough. With a common cold, you may feel bad for a couple of days, but after four to five days, you're starting to feel yourself again. With influenza, it's sometimes two weeks or more. Really severe can go on to cause pneumonia. Complications from the flu cause an average of more than 200,000 hospitalizations every year in the U.S., and an average 36,000 people die from those complications. During seasonal influenza epidemics in the United States, there are certain groups that are at higher risk for complications. Young children, in particular those less than two years of age, elderly people, particularly people 65 years and older, persons of any age who may have certain underlying chronic conditions, for example, asthma, chronic lung disease, chronic cardiovascular disease. And in addition, pregnant women are at higher risk for complications from seasonal influenza. While seasonal influenza is a serious health threat for people at risk of complications, the outbreak of influenza that swept the nation in 1918 and early 1919 killed over half a million people in the U.S. when the population was only a third of what it is today. I was four years old at that time. I was living at the Rio Ranch in members of Baywood, New Mexico. My mother was the midwife, and she tended to the people, delivery of babies and all that kind of thing. She used to take me with her to go and visit the new mothers, and I loved to go see the new babies. And I cried because at that time she didn't want to take me with her because she was standing to the sick and the dying. But the miracle about it is that she didn't get it. And according to her, none of us at home got it either. She would tell me about how people would die sometimes doing the same bed and they had no funeral services or anything like that. They would just carry them off to bury them. It was very hard for them to keep up burying the dead because they were dying so fast. One thing that stayed in my mind because I used to hear it even later was the pounding of the nailing of boards together, making, I call them boxes, poppins for the people. Whether people called it influenza, the grip, or the Spanish flu, it was clear this was not the flu that comes every winter. Today we know that influenza is caused by a virus, the influenza virus. We know that the virus spreads from one person to another through droplets when people cough and sneeze or through contact with the virus on someone's hand or a contaminated surface. In 1918, no one knew what caused it, where it started, or how to stop it. They were scared because it happens so rapidly and they didn't know what was going on, what was happening, why. There were few communities in the U.S. so small or isolated that they were sheltered from the waves of deadly disease that swept around the world. The influenza of 1918 even touched remote, inuit villages in Alaska, sometimes killing every man, woman and child or killing the adults and leaving the children with no one to care for them. The 1918 influenza struck some native peoples in the Southwest very hard too. I don't think the doctor resided here, but he came from Albuquerque. A lot of our people, older people didn't speak the English language so my dad would interpret for him what he was asking them to do, how to take care of themselves. They would work from early morning till late night trying to visit every home in the Pueblo. In the morning when they got to some of the homes they would find maybe two or three people in the family that had passed away during the night. Every day they were burying people. The church bell would be towing from morning to evening because of so many deaths. The Bureau of Indian Affairs sent Dr. D.A. Richardson to investigate the situation in the Pueblos near Albuquerque, New Mexico. He wrote, The strength of the Pueblos was not taken with the aged or markedly with the infants, but from the young adult life of the tribe. And this was true around the world. With the influenza that hits us every fall and winter most healthy adults are sick for a week or two and recover. When people die of the flu it's almost always the very young and the very old. But the influenza of 1918 was not only much more lethal than seasonal flu the death rate was very high among young adults. Strong young men and women working to support and care for their families. My parents came to this country from Romania, Bessarabia. In 1918 my family was living in South Philadelphia. I think it was the neighborhood mostly of immigrants. It was a hard life. It was a rough life. My mother and father and my two sisters all had the flu. It was a very sad period. There was like a sadness over the city. When you looked out you're so hardly anybody walking around. People stayed in their houses because they were afraid. And they said that it seems that if it killed you it did it fast because they were, I remember them telling me that a young neighbor they saw him coming home. They watched him from the window. He was coming from work. And the next day after noon they saw him carry it out. He died. Of all the cities in the U.S. Philadelphia had one of the highest rates of sickness and death and the most disruption. The city resisted putting measures in place that might have limited the spread of the flu. Measures such as prohibiting public gatherings where the flu could spread easily. The city allowed a large parade to take place to raise money for the troops fighting World War I. Although the marchers and crowd wore gauze masks many people caught the flu from those who were already infected. Baltimore fared almost as badly as Philadelphia. Soldiers at Camp Meade south of the city became sick in mid-September and by early October there were 2,000 cases in Baltimore. Officials hesitated to close schools and other meeting places which would have reduced contact between the sick and the well. Hospitals and funeral homes were overwhelmed and the workers who kept the city and its businesses running were too sick to get out of bed. Betham Steel went around and got all these men from down south to operate the mills and there were just thousands of men coming off from the mills. My father worked for the Betham Steel Company's bakery. The only black baker they ever had was my father, Henry Lindsay. The people were very kind to one another and there was a place where everybody looked after one another and the barrage nobody lived in there but the men who worked for the Betham Steel. The men that died and the men who were around them didn't even know they were dead. Come home and then the man dead. I don't know how long it'd been dead because they went to work. Go leave him there in the morning, come back, he's dead in the evening. My mother was sick in everything and they quarantined us. We didn't visit nobody and nobody visited us except this lady. This is Mrs. Kizzy Thornton. She went around helping everybody who was sick and other gladiators never got sick or anything. Back in 1918, I was between 10 and 12 years old, I would say, and I got the flu and it was just my mother and I. We were two of my friends. We went to elementary school together and both of them were stricken with the flu and I would go out to then Bayview Hospital to go visit her and they'd put her out on a porch in the cold wintertime and they had blankets, blankets and a hood on but she died, both of them died at a young age. People didn't understand and there was no vaccine but your parents did the best they could for you. The influenza of 1918-1919 was a pandemic, an outbreak of disease around the world which caused serious illness and death. Why was the influenza of 1918 so much more deadly than the seasonal flu we experience every winter? What was different about the influenza virus in 1918? The seasonal influenza viruses that cause annual outbreaks, epidemics in the United States during our fall, winter and early spring, those are influenza viruses that are circulating among people worldwide and they are evolving, they're changing just a little bit but they're human viruses and so some percentage of the U.S. population and the world's population gets infected every year, some become ill, some percent recover from a self-limited illness and all these people who survive will have some immunity. Other people get vaccinated and we receive some immunity through that vaccine so there are two ways to acquire immune protection. One is through natural infection in which you recover, you survive, then you have immunity. The other is through vaccination and vaccination stimulates our body's immune system to produce antibodies against the specific virus strains that are contained in the vaccine. An influenza pandemic is different. An influenza pandemic is the emergence of a very new influenza A virus to which most of the population has not previously been exposed and does not have any immunity, no immune protection and so what you see is very high numbers, very high percentage of people becoming sick worldwide. In the last 100 years, new influenza viruses have caused four pandemics in 1918, 1957, 1968 and 2009. Ultimately they come from birds, wild waterfowl ducks and geese and various other birds. They can get into domestic poultry, chickens. They can also, as we know, get into human beings directly. Pigs, various aquatic mammals. They can get into horses, they can get into dogs and cats. So they can take any of these pests and in theory, they could end up getting into people by either coming directly from a bird or going through a circuitous route in another animal. By a variety of mutations that occur for a number of reasons, these types of viruses can, under certain circumstances, adapt themselves to other species. And then as they propagate themselves in these other species, they adapt themselves better to spread from pig to pig or from bird to bird or from person to person. And the host we worry about the most, obviously, from a human health standpoint is the human species. One of my dad's sisters lived pretty close to us and she had a family of four children and her husband and she was expecting and she'd taken the flu and of course she passed away just... she was very sick, she passed away. The latest at taking a flu that we're pregnant or we ever knew died and my mother didn't get it. We don't know why pregnant women die of influenza at a high rate, but it's been documented for well over 500 years. One of the biggest risk factors for a fatal outcome from influenza is pregnancy. Whatever the reason, it's pretty clear that pregnant women in 1918 were at very high risk. Pregnant women, of course, are going to be in the younger age ranges, but non-pregnant women and men in that age range were also at much higher risk of dying. Why this happened, we don't know. In any flu pandemic, people die from pneumonia. Some percentage will always die, but it tends to be the older folks, people who have chronic conditions like heart disease and lung disease, pregnant women, infants and so on. This time in 1918, something very different happened. Otherwise, healthy young adults died at a high rate and constituted a fairly large percentage of the total deaths, something that's never been seen before. Why that happened is a mystery. Brevik Mission is northwest of Nome, Alaska, on the Bering Sea. The fact that Brevik exists today is remarkable. Since of the 80 residents in 1918, only five adults and three children survived the flu pandemic. Over 50 years ago, a young man with an interest in viruses found his way to the village. I was a medical student in Sweden and I decided to travel to the United States and get a master's degree in virology. And then one thing led to the next and to the next, and I decided to go for my PhD. And one day, we had a visitor, a very prominent virologist, and I remember he's talking about everything that had been done to find out what was it, what was it that caused the 1918 flu in energy? Like a 15-second comment at the end of his talk, he said, somebody ought to go to the northern part of the world and try to find a victim of the 1918 Spanish flu pandemic buried in the permafrost. And that victim is likely to have been remained frozen for since 1918. At that time, it was something, you know, 35 years or 40 years. And tried to recover the virus. And then he went to something else. And that 15 seconds, I happened to be there and heard it. I immediately went to my faculty advice and asked him, could that be a subject for my PhD? I said, oh yeah, why don't you go in? I happened to have worked during the summer of 1949 for a paleontologist in Alaska. The paleontologist, Otto Geist, had worked on the Brevik Peninsula and knew the missionaries in the villages there. With Geist's help, Halton was able to review copies of mission records from the fall of 1918. He found that the military had very good records showing the location and thickness of the permafrost in Alaska. On the basis of that, I came and decided on three villages. I showed up in June. And I went to the first village that's called Nome, it's a rather large city actually, Nome. I went into the mass grave at the cemetery and discovered that the river that normally had flowed on the side of the village at some distance away, it had changed course. Since 1918, it had come into the village and melted the permafrost. I could just see it. And then I engaged a bush parlor to fly me to another village called Wales at the Bearing Strait. I found them where the mass grave was, clearly marked with a large cross. And the bluff had fallen down through the beach and almost excavated or invaded the mass grave. So I figured there is no permafrost here. So the bush parlor flew me to what today is Brevik. But there was no way to land there. I had to land on the beach at some distance away in another village. And then I had to cross some water with a whale boat. Got to cross this really sizable water and then I had to walk about six miles in soggy tundra. It was just being to melt and then on to Brevik. They had a village council, the council of the elders. And it's a matriarchal society. So the eldest woman of the largest family makes decisions or heavily influences decisions. And little did I know that that was going to be very important later on. Fortunately for me, there were three survivors of the 1918 pandemic still alive. So I asked them to please tell the other members here of the council what it was like that November week when 90% of the village died. Then I said, if you allow me to enter the grave and if I am fortunate enough to come find the right specimens, I will take it back to specimen back to my laboratory. And if everything works out well, it will be possible for us to develop a vaccine. So in the next pandemic coming threatening you, we will have a vaccine to immunize you, protect you. They understood what vaccine was because they had been immunized against smallpox. The matriarch Jenny Ollana was in favor of that. So that influenced the decision so they allowed me to open the grave. So I went out on the grave site and started to dig and about a foot down I came onto permafrost. Very hard enough frozen ground and I started a fire. Drift was from the beach and climbed up on the bluff and there were the masquerade and started to melt the permafrost. And on the end of the second day I came down about four feet and there I found the first victim. Young child, a girl, I estimated 12 years of age, but the condition of her body at four feet from the surface was so good that I was confident that down deeper there will even be better preserved of an adult's assault. 72 bodies in that grave. Now I didn't come alone to Alaska. I had my faculty advisor, influenza virologist, I had a pathologist, one of the professors in the department in Iowa to perform the post-mortem examinations and then auto-guised, so there were four. I was out there ahead of them to scout the grave, to scout the test dig. The day later they came to the same beach where I had landed earlier and we traveled the same way back to Bravig. Now there were four of us digging, so we could do it very rapidly. About three days later we were down six feet and then we found three perfectly preserved bodies and the pathologists performed the post-mortems on them and the lungs were perfectly preserved. Then we left, thanked the villagers, closed the grave and I took some pictures of course all the time. Eventually I got to Iowa with this and I started to try to grow the virus, trying to find an alive influenza virus. Week after week after week after week I got more and more discouraged and eventually I had no more specimen and the virus was dead and there went my PhD. I could see it fly out through the window in the Northern Air Conditioned Office by the way, lab I had. I decided to go back to Sweden to continue my medical education and I was exceedingly fortunate I was offered to continue medical school at Iowa. Then I got my MD there, became a pathologist but back in my mind I had this memory of not getting my PhD and all the effort went into that and it was just kind of collapsed. Molecular pathology is a specialty of medicine where pathologists use the tools of molecular biology and molecular genetics to make diagnoses and provide insight into patient care decisions. You can make diagnoses of infectious diseases by looking for the genetic material of the infectious organism, the virus or the bacteria for example. I was in the National Cancer Institute as a pathologist in the 80s and in 1993 I moved to the Armed Forces Institute of Pathology to set up a new group devoted to molecular pathology both for clinical molecular pathology as well as research. One of the things we had to do for both sides of that was to work out ways to recover genetic material from typical biopsy material. The tissue repository at the AFIP goes back to the Civil War so they have a huge collection of millions of tissue samples reflecting all aspects of clinical disease, tumors and infectious disease including autopsies of soldiers who died of flu in 1918. I wanted to think of a project that would highlight the utility of having such an old tissue archive as well as our new molecular techniques in which we could do analyses and the way those two things came together in my mind was to go after the 1918 flu. We thought that it might be possible to recover fragments of the genetic material of the virus still preserved in autopsy tissues of people who died in 1918. When we started the project, there were really two fundamental questions that we wanted to answer. That is one, why was this virus so particularly virulent? Why did it kill so many people, especially young healthy adults? And secondly, where did this virus come from? We were hoping to learn from what we see in 1918 to apply it to the future that we could understand how pandemics form and why particular flu viruses cause more disease than others. These tissues were extremely old and it was not clear that we could actually recover any genetic material at all from these samples. We had to work out techniques and continue to refine the techniques to extract nucleic acids, DNA and RNA, from these samples. We had started this project in 1995 and it took over a year to find a first positive case to work out our techniques to make sure that we actually could find influenza. Once we had found a first positive case and we started to generate sequence and compare it to known influenza viruses we were convinced that we had really found the 1918 virus but we were really concerned that there would be inadequate amounts of material available to us to sequence the whole virus from that material. In March of 1997, in science news, there it was 1918 pandemic virus found. A small sequence had been discovered by Jeffrey Torrenberger. I wrote a letter saying, if you need more specimens, let me know and I will go back to Alaska. I've been there before, I know where it is. I can go back and I didn't hear anything, I didn't hear anything. And I thought, well, he knows things I may not but he happened to be on vacation so he didn't get his mail. We were extremely excited about the possibility. We had hoped that if we could recover material from a frozen victim that the quality of genetic material of the virus might be improved over what we had in these formal and fixed blocks. And he called me here. He asked, when can you go? I said, I can't go this week, but I can go next week and I called up to Braving. Now this time, when I come the second visit in 1997, it so happened it was in August and that is a much better time to dig in the permafrost. What is he the missionary? It's another one now, Pastor Brian Crockett is his name is still there. And he knew of the excavation that I had carried out in 1951 and he also knew that I had to get a permission to do it again. So he said it was very difficult. You may not be able to get a permission this time but I will introduce you to Rita Olana. She was a matriarch at 1997 and little did I know that her grandmother was Jenny Olana. That was it. It would never have happened otherwise. Everything doesn't go wrong all the time. It just looks like that, but it didn't. Here it is, crucial. Dr. Holton presented his case to the Brevik Village Council including Rita Olana. He made sure they understood that the virus was dead and could not cause disease. I also told him how important it is because your participation, this is where it begins and you're part of the team now, the villagers of Braving and the specimen collector and then Dr. Taubrenberger and the Armed Forces Institute, the Pathology. These are the three, but it begins with you and I got the permission to go. I figured no one wants to go in the grave with bodies. So I will do it myself. And so one of the members said, would you like to have some help? Four young men, Eskimos, assigned by the village council, assigned to help me because I had a photograph with me. I knew where the grave was, so I marked it off. At the end of the first day, we were down to about four feet and I didn't see anything at all and five feet and the following day, I noticed that some bodies at seven feet found a skeleton and then next to the skeleton was a woman and perfectly preserved. The clothing had fallen off, rotted away, but I could see the skin and it was an obese woman. I started to do the post-mortem and then I took the rib cage off and there exposed their lungs and they were the textbook picture of a person who had died from acute viral nominitis. Exactly what I needed. The subcutaneous fatty layer was loose and fat inside of course also. That had protected the lungs from the occasional thaws of the permafrost that had reached seven feet down. The skin was not obese. There's not that much food around and they were active in their hard work, in particular in 1918. So fine, one who had extra calories, storage calories, it was just remarkable. And here was a woman who had ample food, had a good husband, good seal hunter, Walrus Hunter brought all this food for her. Can you imagine how fortunate? Then I decided before I leave I'm going to make new crosses to show my gratitude to the village. I had photographs of the regional crosses. I knew how tall they were, the width of everything. I finished my work with the crosses at one o'clock and by eight o'clock the next morning the high school kids came and they helped me put the crosses in. About an hour later the bush pilot landed and I got all my specimen on board and then I shipped it to Jeffrey Thorneberger. The advantage that we had was that the formalin fixed autopsy tissue samples were extremely tiny, just the size of a fingernail. And so we're very limiting, where he was able to provide us large sections of an entire lung, so that even though the quality of RNA was lower we had so much more material to work with it became absolutely clear that we would be able to sequence the rest of the virus from that material. I figured it would take weeks and weeks before he had any inkling and that the specimens were good, like ten days later he called and he said, Yo, we have it, specimen is good. He had lots of specimen, great material and this is going to be wonderful. It was a great day for me because I started in 1955, finally in 97. Here it is, made it. But again, without the eskimos in Brevik nothing would have come. The effort to sequence the entire genome of the 1918 virus from beginning to end took ten years. It was a very laborious process. More than 13,000 pieces of genetic information that had to be put together as a total. If he gets a sequence or a stretch of the gene a little piece, so he has it looking at it here and the gene is this long and it's fully built and this piece, what is it fitting here? Or is it in this end here? Or is it this way? And what comes to the left and the right? And day after day, month after month put in these things together, year after year. So 13,000 pieces plus pieces had to form this proper place. And it's incredible. It's clearly a virus that was human adapted but genetically it's very bird-like in its sequence, it's very avian-like. And so what we think is that it is an entirely avian-like influenza virus that somehow adapted to humans. We now know that there are a number of mutations in several of the genes that are absolutely crucial in the adaptation to humans. And so you could imagine using these mutations as a screening tool to assess the significance of a bird strain as to whether it was actually moving along the path that would make it adapt to humans. If we identify changes that were crucial to allow a bird virus to replicate in humans you could particularly design drugs that might block or bind to that particular change to prevent a bird virus from actually functioning in humans. The 1918 flu had as its most unique feature the fact that it had a high propensity to kill young adults ages 15 to 40. Even having the entire sequence of the virus in front of us we do not yet understand why it behaved in that manner. I've favored the idea that people in that particular age group might have had the wrong sort of immunity to the 1918 virus. Some kind of immune response that actually made them more susceptible to die in people older than about age 45 or 50 in 1918. There might have been pre-existing immunity to viruses similar to the 1918 virus. We're trying to identify influenza virus positive autopsy tissue samples from before 1918 to try to help us figure out this problem. Jeffrey Torbenberger's right-hand woman, Ann Reed, very accomplished, she was sent up with a plaque from the AFRP to present it to the Village Council. If this Torbenberger's work brings antiviral drugs and good vaccines and the savings of hundreds of millions of lives it began with Rita, Olana, and Jenny Olana. Another question about the death toll in the 1918 flu pandemic was how people died after they became ill with the flu. Dr. Torbenberger and Dr. Morins examined not only the autopsy tissues in the AFIP collection but also autopsy reports from all over the world of people who had died of pandemic influenza. We find that the vast majority of people dying died because of secondary bacterial pneumonia. What we think happened is that a very virulent influenza virus caused such an extensive inflammatory response in the lungs and caused such tissue damage that bacteria like strep or pneumococcus that are very commonly carried in the throat of normal individuals could spread down into the lung and cause disease that would ultimately actually kill the person. The evidence of the bacterial pneumonias I think helps explain why you had such high mortality in military camps particularly. While this is very important in trying to understand what happened in 1918, it also has significant implications for pandemic planning in the future. We've really seen an explosion in information about influenza in the last 10 or so years because primarily I think of sequencing of the 1918 virus but also the unusual events associated with the H5N1 virus, the bird flu virus. We've been watching this particular avian influenza virus for over 10 years now. These viruses are highly transmissible from bird to bird and they can destroy a flock of birds but the most important thing from the public health perspective is that humans who have very close contact with the infected birds occasionally can become infected by this virus. Over 60% of those who have become infected have died. Many more people have been exposed to the virus than have become infected. In order for this avian influenza virus to cause a pandemic we would have to see a number of changes that would occur in the virus so that the virus could be transmitted easily from human to human to human. The fact that the avian influenza viruses that we're monitoring so closely have been circulating for 10 years and still haven't caused a pandemic doesn't mean that these viruses will not cause a pandemic. We don't know for past pandemics how long those viruses actually circulated, caused infections in humans and then gained that ability to be transmitted efficiently so we don't know enough about past history to predict the future. I think the biggest lesson is that we can't predict what influenza will do. As scientists continue to look for answers in the 1918 flu virus we can also learn from the men and women who responded to the health crisis by taking it upon themselves to care for their relatives, their neighbors and their communities. Dr. John Tappin was a physician with the Public Health Service in El Paso, Texas. He wrote to a colleague serving at an army field hospital in France. We have all been awfully busy with the flu. I made on an average of 30 calls a day for about a month, and everyone else did as much or more. The Public Health Service and the Red Cross opened a hospital in the old Hau'i School where we treated the Mexican part of town. The epidemic here was fierce. We had about 10,000 cases in El Paso and the Mexicans died like sheep. Whole families were exterminated. The white population fared almost as badly. I was three days behind in my calls. Good doctors all had the same experience, of course. When the people living in other parts of El Paso learned of the many deaths in the southern part of the city near the border with Juarez, many volunteered to use their cars as ambulances, picking up the sick and delivering them to hospitals in other parts of town. When the Hau'i School in the Chihuahuita neighborhood was turned into a hospital for flu patients, El Pasoans from all over the city volunteered as nurses, drivers and clerks. So you see we have been serving our country right here at home. That epidemic helped the community to get together because everybody helped the good, gave their houses or their help or whatever the people needed that needed it. So that's helped the community both lotters and here. There was a shortage of doctors and nurses during the 1918 influenza pandemic because so many of the physicians and nurses were serving in the war effort. So you had a mixture of both trained medical personnel and those with some training and those who basically were very civically minded individuals who wanted to participate in tending to the ill. The women who volunteered during the 1918 influenza pandemic were literally putting their lives on the line. They were stepping into a deadly pandemic because they believed that it was their calling and they wanted to do what they believed was their duty. I would say that the activities of volunteers and particularly women volunteers who rose to the challenge was absolutely crucial. This is a story of unsung heroes, of forgotten people who really rose to the gravity of the moment. In villages in Alaska, for example, the whole village would become sick at once. There would be nobody to provide food, nobody to provide shelter. These things can make a difference and even in wealthy nations like the United States, the conclusion at the end of 1918 and 1919 was that the single most important thing that could save your life from flu was good nursing care. Not medicines, not doctors, not hospitals, but good nursing care. When you first read those things, you're likely to say, that can't be true. What could they do in those days? What's chicken soup going to do? What's a blanket going to do? I believe the data, they're strong and some of the best and smartest physicians, nurses and other observers set it again and again, good nursing care. Even though no one knew what caused influenza in 1918, some communities took steps to prevent the spread of the disease. In our group at the Center for the History of Medicine, we have been looking at 43 American cities during that pandemic to see exactly what they did to stave off the epidemic or what they didn't do for that matter, what worked, what didn't work, and what were their records. And what we find is that those that acted very early with a suite of classical public health interventions, things like quarantine, closure of schools, banning public gatherings, if they acted very early before the epidemic had a chance to spread to a lot of people, kept these measures on for a long time and used more than one of these measures at the same time, those cities had a much better record in terms of cases and deaths than those cities that did not. I think there's a mountain of stuff that we're learning from the 1918 pandemic that applies to people today or in the near and distant future. We have learned from the experiences of the 1918-1919 pandemic, but that's only one of the factors that makes us better prepared to deal with influenza pandemics than the world was in 1918. There are extraordinary advantages. Some of them are pretty simple like experience of what seemed to work in some cities, like social distancing and avoiding crowded places, things that were not necessarily fully appreciated. Some cities did it and did well, but most importantly, we have biomedical and healthcare and technical advances that we didn't have. We have vaccines. We didn't have vaccines then for flu. We didn't even know what the microbe was. When they were dealing with it, many people thought it was some strange form of a bacteria and not necessarily a virus. Number two, we have antiviral drugs. For example, tamaflu and relenzia and others. We didn't have it then. We had antibiotics to treat the secondary complications, the bacterial complications of influenza. We have much better technologies to treat acutely and seriously ill individuals like efficient good respirators, intensive care units, people who have expertise in medicine that's acute care medicine. All of these things we did not have back then. We have them now. Our parents and grandparents had a little warning or chance to prepare. But we know now that influenza has caused pandemics at intervals for at least the last 500 years. Public health officials have been preparing for the next flu pandemic, knowing that it could be a mild pandemic as in 1968 or a severe as in 1918. The world is watching a new pandemic flu virus. The novel H1N1 flu virus, emerged in the spring of 2009. We know that the new 2009 H1N1 virus is in almost every country of the world already. Fortunately, so far, the 2009 H1N1 virus doesn't appear to have that level of severity that the 1918 one had. The 2009 H1N1 virus is affecting people differently than seasonal flu strains. The illness is most common in young people, children and young adults, but we're also seeing hospitalizations and deaths, in particular in people who have conditions that increase their risk of complications. Pregnant women have really been heavily hit by this virus. In the United States, and reports around the world suggest that native populations may have a higher risk of severe illness caused by the 2009 H1N1 strain. We want to be ready and we want to make sure that they are served and that they have good access to healthcare and to the vaccination. Everyone has the experience throughout the world that the best way to contain influenza is by getting a very efficient and safe vaccine. Vaccines given the current technology and even in more modern technology, you don't make a vaccine overnight. You have to first find out what the virus is you're dealing with and then you go through the process in order to get enough vaccine to protect the population. That multi-step process generally takes several months, usually along the line of six or more months. Vaccination is a really important part of our response to the 2009 H1N1 virus, but it's important to say it's not the only part of it. We have a whole series of mitigation efforts and a whole series of communication efforts. Public health officials are fighting the spread of influenza with the health hygiene we learned as children. Stay home when you're sick, wash your hands frequently with warm water and soap for 20 seconds, practice cough and sneeze etiquette and avoid touching your eyes, nose or mouth. At the start of a pandemic, that's the most efficient tool we all have in addition to obviously social distancing, like staying home when you're sick and so on. But we are a community that hugs, that shakes, that have elevators that you need to ride on to go to different parts of a building. We go grocery shopping and we need to push our cards. Everything you do basically needs to touch something that other people touch. And so that hand-washing bit will be very critical. These good habits and vaccination also prevent the spread of seasonal flu. An annual immunization for the seasonal flu helps people stay healthy and helps health workers prepare to vaccinate the population during a pandemic. These immunizations are widely available every year. It's very important for people, particularly people who are 65 and over, to take the influenza immunizations. It's important to have the vaccine every year and the vaccine is a covered Medicare benefit. There's absolutely no way you will get the flu from the flu shot. Based on what I know and what I have been observing with this 2009 H1N1 virus and based on what I know about influenza vaccines, the risk of getting influenza or having a complication from influenza is much higher than any theoretical risk from the vaccines. It's important for people to know that not getting vaccinated also puts you at risk. 100 million people get influenza vaccine every year in the United States. They have a strong safety track record. And the 2009 H1N1 influenza vaccines are being made exactly the same way that the seasonal flu vaccines are made. A long-term goal for scientists working on flu vaccine is to develop a vaccine that would protect against all seasonal and pandemic influenza. We generally refer to that as a universal influenza vaccine. And I think there's a real possibility to that. I don't think it's going to be easy to do what we're working on. When I say we, I mean the scientists in the field is to identify the components of all influenza viruses that don't change as the virus drifts or even shifts. And then you've got to put that in what we call an immunogenic form, namely a form that when you inject it into a person or you spray it into the nose of a person that that person will make an immune response that's very robust. There are a lot of people working on it. It's a high priority project. Every year we have fewer elders to remind us of the terrible time they, their families and their communities endured in 1918 and 1919. But we need to keep those memories alive. There's a lot of things to be learned from continuing to study the 1918 flu. I think the important lesson is that pandemics can be very serious, but also pandemics can be widespread but not that serious. There's a gradation of severity of pandemics. You always must prepare for the worst case scenario, even though you might have a mild pandemic like occurred in 1968 or an intermediate pandemic that occurred in 1957. The current pandemic is much less severe so far than the planning scenarios that most of us had had. It could be that it becomes less severe and doesn't affect a lot of people. It could be that it becomes more severe and mutated to a deadlier virus which would be terrible and very difficult to manage. It could be that it continues along the way it's been so far. Only time will tell we have to be ready to pivot and respond differently if the virus changes. The one thing you could predict about influenza is that it's unpredictable. We still know much less than we'd like about influenza, but the experiences of the individuals who endured the pandemic of 1918 and the research into that pandemic continue to contribute to our understanding of the disease. We are infinitely better prepared now than we were 100 years ago back in the beginning of the 20th century.