American History, Apocalypse, Book Reviews, Charles, Science, Social Behavior
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Pale Rider: The Spanish Flu of 1918 and How It Changed the World (Laura Spinney)

Since I am an apocalypse monger, but a practical one, I do not worry about alien invasions or the reversal of Earth’s magnetic field, but I do worry about pandemics.  This book, Laura Spinney’s Pale Rider, is a recent offering in the pandemic literature that has become popular in the past twenty years.  It focuses on the only known pathogen likely to create a future pandemic, the influenza virus, through its greatest past outbreak, the Spanish Flu of 1918.  I read books like these partially for history knowledge and partially to understand what to do in a similar future situation, and Pale Rider is useful for both.

The title, though Spinney does not acknowledge it, comes from the Apostle John’s vision of the Fourth Horseman in Revelation 6:8.  “And I looked, and behold a pale horse: and his name that sat on him was Death, and Hell followed with him.”  (True, the horse, not the rider, is the pale one.  Spinney probably stole the elision from the 1985 Clint Eastwood movie of the same name.  I guess Pale Horse doesn’t have the same eerie resonance.)  The title is just an eyecatcher, not a signal of coming deep thoughts about humanity.  In practice, Spinney plays it straight, alternating between the history of the pandemic, so far as it is known, and scientific discussion, both about the pandemic itself and about the current and future state of the influenza virus.

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World War I plays a large part in the history.  The war meant that large numbers of people, mostly men, were packed together in close proximity, and it also created a lot of movement that would not otherwise have happened, such as Chinese workers being shipped through the United States on their way to Europe.  Still, while modern scholarship has figured out a lot, much of the history of the pandemic is guesswork, which Spinney freely admits.  We don’t even know where the pandemic started—Spinney notes that the major candidates are China, France, and Kansas, which is a pretty broad spread.  As a result, much of the book is anecdotes, rather than summaries of actual statistics of the time—but well-chosen anecdotes, from all around the globe, that give the reader a good flavor for the time and the events.

Though it seems close in time, 1918 is a foreign country to us.  As Spinney says, “People regarded death very differently.  It was a regular visitor; they were less afraid.”  That’s not to downplay the emotional impact of the flu and the deaths it caused on the people of 1918, but they bucked up and got on with life more than I think we would.  Parents regularly outlived their children.  Many adults died early (my great-grandfather, a Budapest journalist, died in 1908 of tuberculosis, a young man), though it’s a myth that older people were rare in any past human society.  It’s not for nothing that Psalm 90 says “The days of our years are threescore years and ten.”  More generally, most people died of infectious diseases, “not the chronic, degenerative diseases that kill most of us today.”  Leaving aside lifespan, I suspect the former is preferable—people live in fear of cancer, Alzheimer’s, ALS, and so forth, afraid of the long, slow, painful, decline.  If you have to go, better to check out with a high fever and a few days of annoyance!

The name “Spanish Flu,” as with the names of many diseases, is a misnomer, since it didn’t start in Spain at all.  All disease naming, even today, carries a propaganda element.  Perfectly reasonably, nobody wants to be tagged with responsibility or even be associated with the origin of a disease.  For example, Spinney notes that some Chinese were unhappy a decade ago with the name SARS, an acronym for “severe acute respiratory syndrome,” because Hong Kong, one of the regions affected, has the acronym SAR, for “special administrative region,” in its official name.  And AIDS was originally more accurately called GRID, for “gay related immune deficiency,” until the propagandists of both Left and Right decided to pretend it was a threat to America as a whole, a pretense that continues even today, though only halfheartedly.  Nowadays, the preferred mechanism is to name diseases mechanically, based on effects and other relevant qualifiers, which is probably a better, if less colorful, solution.  Making it worse for the Spanish, it’s not even clear whether some outbreaks of the time were the Spanish Flu at all.  Spinney mentions confusion with several other diseases, including typhus, noting that disease, spread by fleas, “has long been regarded as the disease of social collapse.”  It’s therefore indicative that, according to CNN a few weeks ago, typhus has reached “epidemic levels” in Los Angeles and Pasadena, as the derelict homeless population is allowed to expand in those areas, though kept well away from the gleaming castles of the Lords of Tech.  If we’re lucky, though, such collapse will hasten California’s breakdown and the resulting implementation of my plan to enable the underclass to flourish.

Anyway, various interesting facts pop up throughout Pale Rider.  For example, recently the estimated death toll for the 1918 pandemic has been substantially revised upwards.  It might have been as many as 80 million people.  I think it’s generally known nowadays that the Spanish Flu tended to kill healthy young adults to a greater degree than most flu viruses, or, for that matter, most illnesses.  This has long been attributed to a “cytokine storm,” where a robust immune system over-responds, in this case drowning the victim from within.  But the Spanish Flu did not kill teenagers at any higher rate than normal, and their immune systems are just as robust as an adult’s.  Spinney acknowledges this, and the mystery, then drops it; I would have liked to know the current state of thinking on that disparity.  Moreover, while it’s true that relative to normal flu, healthy adults died more, it’s also true that the Spanish Flu killed the very young and very old just like a normal flu, creating a “W-shaped mortality curve.”  And it killed pregnant women most of all, in perhaps the saddest effect of the epidemic.  Still, it wasn’t like pandemics in the movies, or the Black Death, where bodies stacked up in the streets.  The death rate for those infected was 2.5% (with substantial geographic variation); most people who got the Spanish Flu experienced nothing different from a normal flu.

Deep down, most of us think that while today a new pandemic might kill quite a few people, we would soon enough, by throwing money and scientists at it, find a cure and get back to normalcy.  That confidence is misplaced, I think—one has only to see the enormous resources thrown at AIDS over the past thirty years, where a cure appears no closer, to realize that it’s not that simple.  There’s no guarantee of an effective treatment in any quick timeframe, much less a cure.  Another misapprehension, I think, is that today’s bloated government would be helpful.  At best, government is a mixed blessing in such situations.  True, sometimes the government, especially local government, is effective at organizing a response.  Spinney talks about the city’s efforts in New York to contain and treat the flu, which were reasonably successful.  But Spinney also relates how the crew of a Coast Guard vessel was sent to remote Alaskan villages, where the local Eskimo people died at high rates.  Instead of helping, the government workers mostly held dances on board and stole valuable church goods (the locals were Russian Orthodox, from the earlier Russian presence in Alaska).

Along these same lines, our thought about a pandemic today tends to be distorted by narratives of past pandemics that took place in vastly different situations.  Thus, in 1918, treatment options were extremely limited, but follow-on effects, especially food shortages due to supply chain failure, were rare.  As to treatment, in 1918 there were no antiviral drugs and there were no ventilators or other sophisticated equipment that might help those with lung failure.  Those who ended up in the hospital were little better off than those at home.  Today, in any similar pandemic, or one worse, demand for any available effective drugs and for sophisticated medical care, as well as simple hospital beds, would far outstrip supply, resulting in the need to triage such medical offerings.  As to food, even cities in 1918 had a lot more food available; they did not have food trucked in just-in-time from across the country, like we do today.  That means store shelves would be bare within a few days, and for most of us our food would run out, if the trucks stopped running, something the victims of the Spanish Flu generally did not have to face.

What would result today, from these changes in treatment and food supply, is that inequality would immediately rear its head in any really bad pandemic.  That happened in some places during the Spanish Flu.  For example, Spinney quotes the Brazilian writer Pedro Navo, who lived through the pandemic as a boy in Rio de Janeiro.  “There was talk of . . . chicken-stuffed jackfruits put aside for the privileged—the upper classes and those in government—being transported under guard before the eyes of a drooling population.”  But generally, the poor suffered more because they caught the flu at higher rates due to inferior housing conditions (children were kept in school to keep them out of their homes), not from getting worse treatment or no food.  Today, we would struggle with equitable allocations of both treatment (palliative or curative) and food.

The very rich would certainly get treatment and food.  Steve Jobs famously jumped the line to get a liver transplant by having a private jet ready to take him at an instant’s notice to get a new liver.  (He needed one because he initially refused to have surgery to cure his pancreatic cancer, one of a small percentage of such cancers curable by early surgery, preferring to try herbs and meditation first.  He chose poorly, and he doubly ripped off someone poorer than him.)  The very rich could also hire private doctors, nurses and machines.  And, of course, with enough money you can always get food.  Everybody else would have to fight for a space in the ICU or for limited doses of whatever drugs might be effective, and wonder where their next meal was coming from.

It wouldn’t be anarchy—people won’t abide anarchy, and individuals are often less selfish in practice during disasters.  But some mechanism of allocation of both treatment and food would arise.  I suspect treatment would be allocated along two axes.  The first would be through personal or class connections, just as under any non-free market system.  When my aunt, not an English citizen but the widow of an Englishman, though she had not lived in England in decades, was diagnosed with cancer, she returned to England from Asia, was illegally entered into the NHS, then moved to the front of the line with the best oncologists—all because she knew the right people in the professional-managerial class.  Communism had similar mechanisms of allocation:  the nomenklatura got the good stuff, and the top echelon of the nomenklatura got medical treatment in the West (like Fidel Castro), since their medical systems were so terrible.  (Spinney credulously takes at face value Lenin’s pronouncements that he was going to offer great medical care to all Russians; she probably believes that the Soviet Constitution meant what it said too.)  Allocation through connections is not a great system, and would in practice benefit the professional-managerial elite that has already dragged down America, but it’s the kind of thing that characterizes every human society, as Francis Fukuyama has noted.

The second axis, the group that would really jump the line on treatment allocation, is far more pernicious.  That’s government workers.  The process would start with Congress, which would pass laws ensuring they and their families were prioritized—for the good of the country, you know.  Naturally, Congressional staffers and their families would also have to be included.  And, of course, executive and judicial branch workers.  Then, logically, administrative agencies—how could the country survive if EPA and EEOC drones died, or had to see their families die, or even had their work hampered by having to worry about their health?  So most, if not all, federal government employees would be deemed essential and jump in line before the general population.  (A few government workers might not want to so benefit at the expense of the more deserving, but they would be kept silent, directly or by peer pressure, since to question this process might result in its crumbling.)  Sometimes the country just has to make hard choices; if prioritizing bureaucrats in Imperial City means the average Joe in Iowa City has to die, that’s unfortunate, but what else can we do?

The same process would probably flow downwards to the state and local level, though for treatment allocation, that would not result in much additional allocation to such government workers, since the federal government would hog all available resources.  On the local level, food would be the real problem, and I expect many local governments, if food was short and not obviously coming anytime soon, would attempt to steal food from any place they could find it—stores, farmers, and individuals—to “ensure equitable distribution,” and then give it to their friends.  Another reason to make sure you have enough guns.

Maybe this is all too cynical.  It’s possible that government workers (other than Congress, which is irredeemable) would not take advantage of their power.  Spinney notes that, somewhat surprisingly, in the Spanish Flu most people did not just “shelter in place,” which would have maximized their chances.  Instead, they tended to try hard to help each other.  As I say, you see this same pattern in most disasters—average people tend to view others as more, rather than less, deserving of help, even at personal risk.  Selfishness decreases, when you think it would increase.  Spinney calls this “collective resilience,” and I have no doubt it’s the reality, even in today’s more atomized society where intermediary institutions that were the primary administrative mechanisms of such have disappeared.  I just don’t think that in practice it applies to the federal government, whose workers are taught to feel themselves superior and who show themselves incompetent in most disasters—see, e.g., Hurricane Katrina (though there the local government was even worse).  But, in fairness, maybe I’m wrong and in practice the government would be a help, rather than a selfish hindrance, in a fresh pandemic.  Let’s hope we don’t find out.

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  1. Richard says

    This article was prescient! No guarantee of a quick cure… certain jobs deemed essential… more effective local response.
    Fortunately no problems with the food supply.

    • Charles says

      Thanks! Now we can just wait, when and if there is a vaccine, to see who gets it first–those at risk, or the categories I identify. Although given by that time the problem will likely be less acute, the question may not arise in the same way.

  2. Carlos Danger says

    Excellent review. (And indeed, as Richard says, prescient.) This review got me interested in reading about the 1918 Spanish Flu pandemic, starting with this book Pale Rider and moving on to some other books. Here are some I liked:

    1. America’s Forgotten Pandemic: The Influenza of 1918, by Alfred W. Crosby (Cambridge University Press, 1989). (first published as Epidemic and Peace, 1918, by Greenwood Press, 1976)

    Alfred Crosby (who died two years ago) was a history professor, but this book is written for a general audience–the tone is not scholarly and the book tells a lot of personal stories, some of suffering. As the title indicates, Alfred Crosby explores how the pandemic had largely been ignored by historians and the public. The title of the first edition of the book illustrates another focus: the effects of the pandemic on the peace process after World War I.

    The pandemic did have an effect on the war, as it may have ended it early by striking the Germans harder. And it had an effect on the peace, as the flu struck president Woodrow Wilson while he was in Paris negotiating the terms of the treaty ending the war. But though war and flu both raged and took their toll in blood and horror, the war gets all the attention, with the pandemic barely mentioned. That makes some sense, as the war lasted longer and its effects were much more weighty. Still, it’s nice to have a corrective giving the pandemic some attention.

    Alfred Crosby dedicates the book–“To Katherine Anne Porter, who survived”, impressed by her exceptional depiction in fiction of the personal suffering caused by the flu. Journalist and author Katherine Anne Porter caught the flu while working as a 28-year-old for a newspaper in Denver. She was hospitalized for months (her paper apparently prepared her obituary just in case) and emerged frail and completely bald. Her hair, when it grew back, was white instead of black. She wrote the short novel Pale Horse, Pale Rider largely about her experience. That story is the next book on my list.

    2. Pale Horse, Pale Rider, by Katherine Anne Porter (1939).

    Katherine Anne Porter caught the flu in 1918 and nearly died from it. This short novel (as she called it–she hated the term novella) seems largely autobiographical (it’s unclear whether Katherine Anne Porter actually had a fiance then as the main character in the book did). The story gives a gripping feel for the suffering of ordinary people as the flu pandemic took its toll. It’s a powerful read and rather unique, as there are few works of fiction about the pandemic. (Poet Robert Frost was also felled by the flu, but did not write about it.)

    Laura Spinney took the title of her book Pale Rider from Katherine Anne Porter’s title Pale Horse, Pale Rider (she says this on page 301, note 8 of Pale Rider). Katherine Anne Porter had taken the title from an African-American spiritual she references in the story, which begins “Pale horse, pale rider, done taken my lover away. . .” The pale rider is Death, who Katherine Anne Porter said took away an entire era. (Death is, of course, one of the Four Horsemen of the Apocalypse: the Conqueror on a white horse, War on a red horse, Famine on a black horse, and Death on a pale horse. As Charles notes, it is Revelations 6:8 that refers to the pale horse ridden by Death.)

    It’s interesting in that regard that the 1918 Spanish flu pandemic largely left black Americans untouched. No one really knows why–blacks would seem likely to suffer disproportionately due to their relative poor public health, as they are suffering disproportionately now with the coronavirus. Some speculate that perhaps due to poor health and living conditions so many blacks caught the flu in the mild first wave that most were immune when the deadlier second wave hit–a lucky break.

    3. American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic, by Nancy K. Bristow (University of Oxford Press, 2012)

    Nancy Bristow is a history professor whose grandfather was orphaned by the 1918 Spanish flu. She didn’t learn this until she was an adult, and decided to look into why few family stories seemed to be told about the pandemic. She focuses on the social and cultural effects of the pandemic, telling many stories about how the pandemic affected lives, including her own.

    The writing is sometimes a tad dry as the author tends to overexplain; the book has an academic bent and 70 pages of footnotes. Still, the book mostly reads well and pages turn easily. Photographs help with that too. And a few times the writing is stellar. Nancy Bristow refers to Katherine Anne Porter’s book Pale Horse, Pale Rider as the best account from a flu survivor, and summarizes her dark story with pith and poignancy: “Porter’s narrative was infused not with rebirth but with death, not with optimism but with despair, not with opportunity but with loss.”

    Aside from Katherine Anne Porter and a few others, the book focuses on public health professionals–nurses, doctors, bureaucrats–more than patients. For that and other reasons, the book may be better as a supplement to other books on the pandemic than a stand-alone book by itself.

    4. The Great Influenza: The Epic Story of the Deadliest Plague in History, by John M. Barry (Viking, 2004)

    Bill Gates gushes about this book, as he does with so many others. His praise seems off in its specifics, but on in general. John Barry did a good job researching and writing this book (though it has its faults). I don’t see much helpful insight from Bill Gates on the current pandemic, nor from John Barry (he was on CNN the other day and in the New York Times a day or two before that). But the book helps one draw one’s own insights. In that, it’s helpful.

    John Barry talks a lot about Paul Lewis, a physician turned scientist who played a role in the 1918 fight of man against nature. Paul Lewis was one of those who helped create modern virology, only to perish in 1929 in the Brazil Amazon of the yellow fever virus he went there to study. John Berry dedicates this book to his own wife Anne and “to the spirit that was Paul Lewis”.

    The Great Influenza is an ambitious book, and a bit overblown in parts, but it does do a good job tracing the history of medicine and putting the 1918 pandemic in that history. It traces too the social and political trends that the war was twisting and torturing, and how they all affected the response to the pandemic. That gives us lots to think about in our day fighting our own virus.

    • Charles says

      All those sound interesting. I actually had an interchange with Spinney on Twitter, in which she pointed out the derivation of the name, and the footnote mentioning it. Ah well. I changed it briefly, but then she insulted me (how escapes me now), so I changed it back to the original. Too bad for her. (She also had a few other objections to my review, all incorrect, in response to which I made no changes.)

      The Wuhan Plague won’t produce good books. But the next plague probably will, unfortunately. Some time after.

  3. Carlos Danger says

    5. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It, by Gina Kolata (Farrar, Straus and Giroux, 1999) (updated edition published in 2001)

    Gina Kolata is a medical writer at The New York Times, and she does a pretty good job at it (though the articles I’ve seen from her on the current coronavirus crisis did not impress me much). This book on the 1918 Spanish flu pandemic reads well and has some good insights. On the other hand, it jumps around a bit, gets some things wrong, and has a lot of stories that seem important but then go nowhere. So it’s a bit of a mixed bag, but worth reading.

    One thing Gina Kolata understands that a lot of people don’t is that our knowledge of how pandemics evolve is limited. She points out that Americans in 1918 were pretty proud of how many diseases had been conquered and how medicine had become a helpful profession. She says that people started calling parlors “living rooms” because they no longer had to be kept ready to display the dead. Then the flu struck and all the progress seemed a sham.

    We are in the same boat today. We have the genetic sequence for the coronavirus and can see it with our electron microscopes. We have sophisticated tests to see who has been infected and intensive care units to treat the worst cases. None of that seems to matter much. Indeed, our leaders tell us that masks are the most important tool we have!

    Gina Kolata tells how puzzled public health officials were by how the pandemic just seemed to fester and then explode. That continues to puzzle people today. We just don’t know how that happens.

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