Last november remarked the centennial and in november 1918 people thought relief the years of warfare and death were over. So the influenza pandemic of 1918 killed more people worldwide and was killed in combat during the war. Here in the Washington Area and other many field locations document and patient record books and telegrams and photographs of the 1918 influenza epidemic to all parts of the nation. To open a window to show us the societal costs of the pandemic and that as the information of those presentday inquiries. Jerry brown is the emergency Physician Department emergency medicine. And at the National Institutes of health. And with those peerreviewed articles and books on emergency medicine and with the cardiology emergencies to receive the nih directors award with a non addictive methods of relief jake of apple writing in the new york journal of books says clearly man not just the physiology or the epidemiology but countless fascinating and fun facts. And in the wall street journal to highlight the experience of influenza builds effectively on the scientific career making the virus itself central reads history and contemporary with the clinical practice together with zoology although the story is somber it is punctuated by humor and other advice. Ladies and gentlemen please welcome doctor brown. [applause] thank you so much for those kind words its not everyday you get introduced by the archivist of the United States. We are here to talk about influenza. And the plague that struck 100 years ago resonates all the way through today. It as you mentioned more people were killed with the influenza virus between 50 and 100 Million People worldwide in the United States 675,000 deaths and of the 116,000 combat casualties killed in world war i, over half died from disease and the majority of that was influenza. Its a sobering thought to think if you take the statistics to multiply them out by the Current Population of the United States those would turn out to be 3 million in todays number so to put it into perspective. And what that would be like to have such a thing. So the cause of this but back in 1918 there was no known cause viruses had not been discovered yet. So people were dropping from this disease called influenza but nobody knew what it was from and the force that was behind us and with the outbreak of hiv which was incredibly frightening and we knew it had to be a virus but at least we knew what we suspected back in 1918 they literally had no idea. So living through an epidemic of very different kind of an old opioid epidemic. The news over the last couple years that the death rate is so high it has dropped the average Life Expectancy in the us. If you look at the average Life Expectancy because of the large numbers of deaths the average has dropped. That is shocking. How much . Look at the data it is one tenth every year. That is a terrible statistics the 1918 breakthrough epidemic cause such a huge loss of life it dropped average Life Expectancy of us by 12 years. 120 times greater than what we have seen with the opioid crisis. So putting it into some kind of perspective, since were at the archives a thought it would be fun to actually look at archival material that actually affects and shows in the nations great capital. So this is all from the Washington Post and to tell a very brief story of a much more complicated event this is the Washington Post from 1918 on the front page that the spanish influenza was spreading across the us it wasnt reported yet in the papers in large numbers in washington dc but spread across the us. Now, the following day 19 people have died actually it was started in the midwest but they were already ramping up in the very next day that the people had died from soldiers and sailors that build momentum more people died and on the front page of the Washington Post we were told the work hours change the federal workday was staggered now washington dc was not the only city to do this by any means most of the cities that were affected so if we could stop people from mingling we didnt know what was causing this but we could understand keeping people away was a good idea. Restaurants were closed or staggered. Stores had staggered hours. In the attempt to keep people spaced from each other. And then to change around the beginning of october. So it is particularly sobering coming a couple of weeks after the announcement october 13th the Washington Post said the price of cotton skyrocketed this was an example of people taking advantage of a terrible situation. Saying it holds this people of the city of washington by the throat and extorting outrageous prices for coffins and disposal of the dead. In fact the Washington Post goes on to suggest the department of justice should step in and instantly put a stop to the high prices of coffins. It cost more to bury the dead because the coffeemakers figured they could make a buck. By the middle of october more people have died in the short amount of time and it was suggested the end was in sight and that was hopeful that there was no evidence of that that perhaps we are nearing the end of it. And throughout the epidemic people had various remedies. So we want to remember these words this is a remedy and it was thought to be very helpful. And until very recently the go to medicine for malaria has now been superseded by others. That i find it interesting the spanish influenza is the exaggerated form that should be taken in larger doses to be subscribed so it is a big epidemic see you should take a lot of this medicine well talk about these particular remedies they were advertised both to treat the disease and also prevent it. Another marketing are opportunity for the businesses laxative bromo quinine. The Washington Post that we were coming to an end that said spanish influenza is more deadly than war. We know that but it is the placing of this piece of journalism. The back page on page 20 next to the dining room chairs why was this not frontpage news . What happened . There are some various suggestions not censorship but tacit agreements and then on page 20 it doesnt get the attention that it deserves. And then to shed some more light on this that on the back of the papers. And more than any time of the record 16 deaths from flu in a single day in the city of washington. So you have to look for this to understand what was going on. And the final slide to share from the Washington Post is exactly this day march 5t march 5th, 1919 exactly one century ago. And with those boys who volunteered and to take part in experiments to understand the cause and the methods of the transmission. And with those for those naval doctors to determine the course of transmission of the disease and preventative measures. There is another remarkable side of the story those involved in research on this very deadly epidemic that was not understood and there is no cure for the laxative bromo quinine tablets so the example of every day for our System People putting their own lives to understand what is going on of this terrible disease it is a few examples from the Washington Post about what happens here in washington dc. To a second slideshow in this one will run itself. You will see some images as we talk through. So today what i would like to do is focus on three areas of research that i describe in the book and how treatments of influenza had default one evolved. And what do we do today . And you will find actually it has changed less than you have thought and how the understanding of the influenza virus has changed over the last century. What was it that caused influenza and what do we know about that same virus today. So that was a remarkable evolution to understand exactly what was going on. And then how we can prevent ourselves from catching the flu in the first place and where we are today there still a lot of work to do. The treatments were not effective mercury, tree bark and inhaling factory gases. South bend of england they would take their families and their children to the munition factories were the toxic fumes were thought to reduce the likelihood of influenza actually is not as crazy as it sounds because many they actually contain chlorine gas we know that chlorine is a great antiseptic and killing everything including people so very likely the factory workers had influence at slightly lower rates because yes they were inhaling little bits of chlorine in the atmosphere that probably reduce the amount of free virus floating around that wasnt completely crazy to take your children to inhale factory gases. There was an upside. Whiskey was extremely popular and champagne prescribed by senior physicians and not everything was difficult and enemas were used to treat everything back then. So an enema was thought to clean everything out so that was quite popular and one of the most remarkable things. Now bloodletting is the process by which blood is removed from the body and with that you are taking out the bad things in the blood causing the disease. It dates back to at least fifth century bc and George Washington was probably killed by bloodletting as he lay dying the doctor suggested we let the blood other people were less into the idea there was a little bit of resistance but the senior people one and blood was taken from George Washington as he lay dying on his bed and he passed out. And within a few hours he was dead. So her own president George Washington underwent this procedure. And then to think about reanimating George Washington by using sheeps blood but fortunately by that time they said enough is enough and let him rest in peace. But what is remarkable is bloodletting was used in the great flu epidemic of 1918. And not just by . Today but by mainstream physicians and what sparked my interest in the story of influenza, there is a report one of the leading medical journals in the United Kingdom and it is named after that device leading medical journals today is called the lancet and that is 1916, two years before the great flu pandemic, there was another epidemic in the military camps in Great Britain and the doctors had tried everything including bloodletting they said. So in 1916 in the lifetime of my own grandfather, in 1916 physicians were trying bloodletting on these poor patients and of course it did not work. They said but it was because we tried it too late. Had we tried it sooner, that maybe it worked and then there were thoughts in 1918 that are highly epidemic that yes sometimes it does work for influence up. So you can see if that didnt get you the bloodletting would and it was the nasty array of medicines that we had to try to treat this. We saw earlier the concoction that contained bromo quinine a useful drug for malaria but useless as a treatment for flu because it is useful drug for malaria it reduces the fever cycle and the idea that bromo quinine reduces fevers and malaria it will reduce and influenza through different mechanisms of the disease but that was the thought process behind it of course a completely useless drug and incidentally dangerous and inappropriate. Everyone was prescribed enemas. One of my favorite discoveries when i was researching the book was from a published paper from the grandchildren of one who had influence and not an 181 1918 but 19362 decades after the great pandemic the family had preserved the medical records of grandfather and publish them. I will read a little bit of a passage that describes what they went through. Over a period of three weeks he was treated at the punishing battering of poems home remedy rubbed on the skin with aspirin for fevers , codeine for cough. A cancercausing laxative, laxative, castor oil a laxative, seven enemas, milk of magazine asia one milk of magnesia another laxative this was given to the patient in 1936 but the patient received at least five doses of whiskey and 14 doses of castor oil seven enemas may have been medically necessary because he was given at least codeine which suppresses coughing but also causes constipation. So that is what life was like when you had influenza 100 years ago. But what about today . For the vast majority of us influenza is a little bit of an inconvenience it is not lifethreatening and with friends and family and then a couple days in bed and then that is it as my time as an emergency physician i taught one saw many of patients with influenza over the years we had an Emergency Department now we have xrays so we could get a good look at the lungs to see if there is any pneumonia we could give people intravenous fluids. And treat them in that way and of course, we have antibiotics today. To be very clear antibiotics should not be given to patients with influenza. They do not work. They are prescribed unnecessarily often but they do work to help treat the secondary infections the bacterial pneumonia that come as a result of the primary viral influenza and we have those today. They were not available until the early thirties and its a remarkable thing that today that the majority of deaths that occurred in the great flu epidemic were caused by secondary pneumonia which we could treat today. Thats good news. We also have other medications to treat fevers like aspirin or motrin or tylenol but a study that suggests we should be giving medication for fevers quite as often as we do theres a study out of canada they looked at modeling and said what happens if you give tens of thousands of people with the flu medicine to reduce fever . Many will feel better quicker. So then they will get out of bed quicker. So that they come downstairs and cough on the children and the suggestion is that by treating a fever and the Emergency Department you may increase transmission rates by 1 percent and given the enormity of this disease you could get an additional 500 deaths per year in the United States as a result of treating people as you come to the Emergency Department with influenza and the doctor sees you have a fever of 103 and suggests because theoretically to increase the death rate you would say please give me the medicine and i would continue to describe but at least there is this other way of thinking globally what we are doing locally and how that affects transmission and spread. We have those medications as well. And then there are specific medications to treat the flu. They are antiviral medications but they are also out there. So we will leave that for later. That is the treatment. Anime, bloodletting. And the Emergency Department and then the young mother of two came down with influenza quickly it is matter of hours was medevac from a small town in pittsburgh and on a ventilator for several weeks until she recovered that is the miracle of modern medicine today that clearly was not around 100 years ago. And what do they know if 100 years ago . This is the most frightening aspect that they just did not know there was some suggestion with the conjunction of the planet thats very get influenza from the italians the influence that this disease that you could identify was up in the stars so there was a theory going around and still in our history referring to influence the today. So rotting animal carcasses earthquakes and volcanic corruptions and the discharge into the air from the bowels of the earth. And people really didnt know what it was. So what occurred early in the influenza epidemic of 19181 Public Health official said the following, we may as well admit it and call it germ x. They had no idea. That now the example of the cause was the discovery in 1892 by a microbiologist and found a bacteria from those who died from the flu this could be the cause because its everywhere they call it influenza but the problem was it was a secondary pathogen the secondary bacteria and that thought it turned out not to be correct but later they changed its name and some of you may have heard of it and now we have some vaccines so why recalling this fluid has nothing to do with the flu. It was thought to have been the cause of the flu and was inappropriately named one of the historians that this discovery was the authority to sign in the wrong direction. The secondary pathogen. Now in 1889 a small epidemic so severe in Great Britain that parliament commissioned a report in 1889 by Henry Parsons who was a very smart professor. Because one of the theories at the time was tainted russian oats. Suggesting that the russian was bringing the disease from the east because every society blame the outside of this. But it strikes me kind of weird as we still blame the russians for everything through the epidemic perhaps the russians were behind it as well. And then he dug a little deeper and said it could be the weathe weather. Something floating around in the air and that is partially true. And he suggested it is a nonliving particulate matter that is a remarkably accurate description of what of my wrist turned out to be. On particulate matter. So a little question to describ describe. It could be russian tainted oats. It is a spread by oats or volcanoes but from one person to another. And then say lets get some data. And looking at the illness rates of the Railway System and compare the rates of the engineer and then outside but far away from people and with those influenza rates and then you compare those to the rates of influenza to those that are selling the tickets. They are inside exploiting the outside. He compared it and found and with an increased rate of influenza they are in contact with people and the Railway Engineers standing outside the rates of flu even though they were exposed to volcanoes and that is nothing to do with the atmosphere. So from the simple records that probably we were on to somethin something. And then said the following and also suggested perhaps animals had something to do with it and here hes really on the money that birds or horses or dogs had something to do with the spread. And of course we know today it is intimately red with on spread. Work togetherl code looks like and the proceeds on that and what the proteins do and how they make us sick so the degree of advances from the suggestion to something we can see and identify and know a lot about. Its the progression of science over a century and now we can identify the particle down to its genetic makeup and genetic construction. So, in that respect, i think weve come a long way in understanding the cause of the disease which brings us to the last part now. So there were attempts to produce early vaccines to influenza. He would have developed his own set of vaccine he knew of the viruat thevirus was suggested is something he managed to propagate and make it weaker and weaker until he figured out what they have now is a weekend thing called a virus thats how he produced the rabies vaccine. But of course what they were using were bacteria that were secondary pathogens and not the primary pathogen that was influenza so in early 1919, edward from the clinic. With his vaccine we are not sure what the political outcomes were but they certainly tried to do something. Now in boston at the medical college, doctor Timothy Leary made a vaccine. She made a blended vaccine from the chelsea hospital, a nurse from the carney hospital and infected more camp devens not far from boston. He made a concoction and gave them to people, and this is his vaccine that ended up being sent to San Francisco where 18,000 people were inoculated with his vaccine. And in case your you were wond, yes the answer is it is the same doctor Timothy Leary. In fact this is the uncle of the famous doctor Timothy Leary in boston, he wanted us to drop out. His uncle created this attempt at a vaccine in a hundred years ago. So that his attempts at vaccines back then. What do we do today . We do have vaccines against the flu. Many of us in this room take them every year and those of us that are involved in healthcare we have to get the vaccine. It makes sense to trick to prevent thtreat andprevent the t its really not a very good vaccine. If you think about it, mumps, measles, you get it once or twice as a kid and you are done, thats it, you are good to go you wont get the disease ever but in terms of the flu, we need to get it every year. I just had it last year and the year before. We are dealing with a vaccine that is not on the same level of effectiveness as these others. In fact in a good year with the wind blowing in the right direction to flu vaccine is about 50 to 60 effective at best. Last flu season was in the 20 to 30 range. So, why is this so hard to create . The answer is it contains the eight genes of the flu virus and it makes these proteins on the surface. The problem is the flu is a master of disguise and changes the makeup of the proteins very quickly and mutates from one kind to another so when we think weve got it and figured out what flu its going to be around it turns out its been sort of mutates and the vaccine is no longer effective. And by the way we didnt realize b. And c. You wer were going toe so we didnt include them in the vaccine and therefore we were not vaccinated against those which is the reason incidentally some of us get the flu vaccine and end up with the flu. Its not because i didnt work against that particular strain but there were others who were not vaccinated against were the original changed its surface structure just enough that its a changing an overcoat from brown to black and the immune ie system didnt recognize it and thats whats going on with the flu vaccine. It stays one step ahead of us all the time and there is a similar story with it. The promise of an hiv vaccine within a year or two we were told in 1980 and its still not there. The viruses are clever and changing their service and arriving at the immune system and so we still dont have a good influenza vaccine. The way we make incidentally is we have 120 or so across the world in the World Health Organization that lookout for samples that are sent to the lab and try to get exactly the kind of two species that is prevalent. We look at australia and what thedid whatthey had in their mot and we try to figure that out and incidentally they look to see what happened in the northern hemisphernorthern hemit them so to the oncoming flu season in the summer. Then doctors make the best educated guess they can and they say based on the evidence that they have come at the most likely are going to be this and this and to this day the majority is produced using eggs. Its hard to grow so it is the same thing that was just a century ago. There is a vaccine that is made using Soap Technology that allows us to have a vaccine that is not created in eggs but still, those are simply the methods that we have today that are left from 100 years ago so the majority of the vaccine is still to this day something to do with eggs and needed to be grown in medium so in many respects, we are at the beginning of the fight against influenza by preventing and creating a vaccine. Now, while that is all true and its not very effective, we must remember that in certain groups its extremely important to get a vaccine tthe vaccine, the higk people suppose our children, the elderly, those with immune compromised conditions, people taking steroids that have undergone chemotherapy, pregnant women, extremely important for pregnant women to get the influenza vaccine. For some reason they are slightly more increased risk of complications from influenza and so those are some of the high risk groups that certainly should be vaccinated no question. In terms of everybody else the data is hard to find an effect on the flu in fact in the United Kingdom as high risk groups are targeted and everybody else if you want when you can get one talk to your primary care doctor but theres no campaign. Here in the u. S. We have a campaign the cdc says everybody over the age of six months should get vaccinated, period. Thats the advice weve given here in the United States. Its worth pointing out this is not the advice given overseas and we can talk about why that might be at another time but its an important difference in the way we think about the flu. Super high risk groups important for otherwise healthy adults the evidence of the vaccine doesnt really do a whole lot. So what we need instead . A universal flu vaccine that will work from yea yeartoyear without havinyear to yearwithoun each year, a vaccine that will work in old age groups and both will work in all geographic areas regardless of what specific strain of the flu is running rampant in your area. So, that is the goal of the universal vaccine. And to do that, we have to target the flu virus and find a bit of it that doesnt change that we can target and then our immune systems will recognize and kill the virus no matter what particular strain was. It sounds easy but its a hard thing to do in reality. We are still not there yet but i will say from the National Institute of health where i work they want to pause and let you know im not here representing the federal governments views on the epidemic of 1918. Im here on my own personal time and views of where i work we are very focused on trying to find a universal flu vaccine. Weve put a lot of money and research ointoresearch of time o that. Theres a sponsored trial of a possible candidate produced by a company from israel and theres other companies out there doing this underway right now from the nih and who knows wil what this worker will not. Will we see the universal flu vaccine, i dont know but that is certainly the goal of what we are trying to do. We have a long way to go. If we look at where we were hundred years ago and where we are today, the treatments are very different thankfully the we still lack good treatment for influenza. We understand the virus in a remarkable deep profound way in a way that was unimaginable a century ago. Arbut are we able to use that knowledge in them dont vaccine clinics not quite yet although that is where the Research Efforts are going. My hope in looking forward is that we really will be able to see influenza not just has a asa story of the past but the disease of the past and the way we think about smallpox as a disease of the past that was eradicated. Its important to try to move towards this goal. The cdc estimates anywhere between 30 to 50,000 people each year in the u. S. Died of influenza. A soft number. Its not a great accurate number but that is a figure. A lot of people still get the disease and die from it. Its in a risk groups the high s predominantly whether that happens. We really have to try to think about ways that we can improve our own decisions so that we will be able to hopefully make when they influenza a thing of the past. Thank you for your time. [applause] any questions . Somebody made a lot of money with face masks back then if we see those today. In this culture we do not see them as commonly as a show whenn they would get a call. My question is how effective are they. That would be uncomfortable and potentially dangerous. Is this a reality of something that can help prevent the spreading of the . That is that is a wonderful question. Thank you. Of course masks do something. The question is what is stopping. It might be stopping your secretion if it catches with your spitting out. After a short amount of time they become caught and are completely useless. Dont sneeze and cough all over people. But the suggestion if we are going to stop this by wearing a face mask i think that you may see the picture of the happily married couple, husband and wife hugging each other wearing face masks. We do know one of the most important things that you can do to prevent the flu isnt to go out and get an antiviral medicine from your doctor, not turn up for work when youre sick, wash your hands if you were helping somebody and what we need to do wha when we have e flu thank you for the talk. I would be interested to hear you say more about the cultural differences between whether the u. S. Encourages everyone to get vaccinated, whereas sometimes they dont. So, why is that and what do you think is correct . I got into this in go into te detail. So, to be clear in the United States, the cdc recommendation is everybody over the age of six months get vaccinated. In the uk and parts of europe the high risk groups and everybody else you can if you want but its really not being pushed. I think the difference in how they approach the flu. Its a serious disease with complications that includes death. Since that is the case, everybody over the age of six months should get the vaccine. If you go on the website and start looking at them i got to paraphrase again, it basically says the following. Influenza is it a nuisance. You will feel unwell for a couple of days. You dont have to see a primary care doctor about it because there isnt a whole lot to do that if you need to uni to stayo stay indoors and youre going to be fine. That is the view of influenza and if you have these different approaches at the potentially dangerous disease that could universes a bit of a nuisance but it will be all right. Those are different ways of approaching what we should do about the disease. If it is a potentially deadly disease even the influenza vaccine isnt terribly good, lets use it whereas in the United Kingdom they say what yod at where we need to use it. Influenza is indeed a deadly disease that is. 1 of the people that are going to get it and theres a tiny number of people that are going to get it its only those that are at increased risk from the disease. Those highrisk populations and the United Kingdoms approach is a bit of a nuisance. Thats also correct for which these two messages drives us to to how we respond to the vaccine and weve decided in the United States this is the best publichealth approach. Lets talk about that group as the Young Healthy middleaged adults. Its a bit of a nuisance and of course its a bit of a larger discussion. If it works, put it out there even though it might suffer terribly welcome even though there are problems with it. In the uk program does not discuss it and he said in the United Kingdom they think about how it works and include things like does it make sense economically to do this and if you add up the numbers it doesnt make sense economically to have a big campaign when so few of them are going to end up getting sick and taking time off work. So we will just leave it with a different approach and different cultures separated. Good afternoon. My name is eric and im a by the history graduate student at george mason university. I was just curious what the sampling of services you use. I know you had mentioned in newspaper articles and medical diaries but im more interested in your use of secondary sourc sources. The truth is i use both. I began with one of the second resources and pretty much everything that has been published in the last decade or so. There were several very good books out there on influenza and i was actually talking before we came in. Now we have the resource resours thing called the internet, and i dont know if this was available to the degree that it is with the others that came out. You can do a search for hundreds through hundreds of newspapers for the keyword influenza. You can get these gems of information. The Washington Post reported the death rate for influenza was greater than the death rate in world war i and was on that page and ive never seen that as it is reported and what it was us about how they approach works so thankfully im sure you are also grateful for this in the remarkable archives where w we have a lot that is available to us politically simple tools to. I think you and others are going to get back and reading the oril articles. They were mentioned in the primary literature and you could get a different view on things. Thank you for that question. We are out of time, ladies and gentlemen. I hope each and every one of you will stay healthy. [applause] i would like to introduce the distinguished author of the rising tide and the winner of the francis prize for outstanding books on American History 1997. He is current New York Times bestseller is the great influenza. Hes here to talk about that with us today. Hes currently a consultant with the World Health Organization on the subject of influenza. When hes done speaking, if you would like to ask questions, there will be two microphones in the back of the room