horrified. “Some,” she said, “were so far gone that worms were crawling out of their mouths.”
On the streets of Philadelphia, cars bearing medical insignia were mobbed. College classes for pharmacy students were suspended so they could help fill prescriptions until drugstore shelves ran bare. Public services broke down. Nearly 500 police officers stayed off the job. About 1,800 telephone employees failed to show up for work, forcing Bell Telephone Company of Pennsylvania to take out newspaper ads warning it could handle “no other than absolutely necessary calls compelled by the epidemic or by war necessity.”
Most people stayed cooped up in their homes, often low on food, at times dying there unattended. What volunteers from Holy Name Parish discovered in one Fishtown home was not uncommon. “In the parlor were the dead bodies of the married son and his wife who had died a few days previously,” a nun wrote. “A daughter was dying in the adjoining room, alone, while her mother was seriously ill upstairs. The only attendant they had was the father who was too sick to realize what he was doing.”
During the second week of October, 2,600 people died of flu in Philadelphia. Another 4,500 died a week later. There was no longer anywhere to put their bodies. At the city morgue, abandoned corpses were stacked three and four high in the corridors and spilling out onto Wood Street. Bodies were piling up on the porches of row houses, in closets and garages, uncollected for days. “The smell would just knock you,” Elizabeth Struchesky remembered decades later.
Police wagons, mortuary trucks, and even horse-drawn carts plied the street, and people were called to bring out their dead. “They were taking people out left and right. And the undertaker would pile them up and put them in the patrol wagons and take them away,” recalled Louise Apuchase, who said her family was the only one in her neighborhood spared by the flu. “Directly across the street from us, a boy about seven, eight years old died, and they used to just pick you up and wrap you up in a sheet and put you in a patrol wagon. So the mother and father [were] screaming, ‘Let me get a macaroni box.’ ” There were no more coffins. “ ‘Please, please, let me put him in the macaroni box. Let me put him in the box. Don’t take him away like that.’ ”
Nor were there enough embalmers. Nor gravediggers. “They had so many died that they keep putting them in garages,” recounted Anne Van Dyke, whose mother had volunteered to shave the corpses.
The highways department finally dispatched a steam shovel to dig mass graves in a field at Second and Luzerne streets. Prisoners were pressed into service to bury decomposing bodies that others refused to touch. The few available caskets were priceless, and people were stealing them. A fresh supply had to be shipped in by rail under armed guard.
By the time the plague had finished claiming 12,897 Philadelphians in late November, the compassion and common decency that bound society together had been shredded. The nuns found babies without milk and adults without water. They even happened across children newly orphaned and abandoned in their homes. One nun later reflected, “It was the fear and dread of the scourge on the part of kindred and neighbors, who ordinarily would have cared for friends.”
Much of the world still knows what it is to live with death. Not to take old age for granted. To see, in fact expect, that children will die. Most Americans, by contrast, have forgotten 1918.
Yet the American health-care system, with its promise of the highest quality care for those who can afford it, is intensive, expensive, and particularly vulnerable to the extraordinary demand for medical care that would accompany even a mild flu pandemic. “It’s a more brittle system,” Fukuda told me. “The ability to meet an upsurge in patients is not one of the virtues of that kind of system. Whereas in a lot of the developing countries, where you have more flexibility in terms of the health-care system, ironically it may be those systems that are able to cope.”
In the United States, the health-care system has been under tremendous financial pressure to operate on the margin. Hospitals have been closing around the country, with the number offering critical care tumbling 14 percent between 1985 and 2000. By 2005, vacant ICU beds were rare. Some of these beds have been removed because of a severe nursing shortage. So, too, intensive care doctors have also been running short. Emergency rooms are being shuttered, about 10 percent of the national total between 1995 and 2005, and a survey of American emergency physicians revealed that almost 90 percent said their departments were routinely overcrowded. Ambulances are commonly diverted from one ER to another—on average, somewhere in the country, of once every single minute.
When researchers from the U.S. Government Accountability Office explored in 2008 whether hospitals were preparing for a mass casualty event like a pandemic, they learned that hospital executives were too preoccupied with day-to-day financial problems. The same researchers reported that federal funding for hospital emergency preparedness had decreased 18 percent from 2004 to 2007.
“Medical economics is really pushing toward downsizing of hospitals, reducing the number of staff, reducing the number of unoccupied beds,” Fukuda said. “When you look at pandemic influenza, which is a one-period-of-time occurrence, that absolute increase in cases cannot be handled so easily. You cannot handle it without having a lot of staff. You cannot handle severe cases without having hospital beds.”
Medicine would run out. Oxygen, crucial for treating those with lung disease, could be gone within days. The producers of medical oxygen are few, and the fleet of tanker trucks required to haul fresh supplies is far too small. There would be a tremendous shortage of ventilators. Most of this equipment is already being used in the everyday treatment of critical-care patients. In a severe pandemic, about 740,000 people would require ventilation, according to the U.S. Department of Health and Human Services, while studies put the existing stock at between 53,000 and 105,000.
Infectious-disease experts now debate whether the industrialized world might actually be more vulnerable today than it was in 1918. After nearly a century of medical progress, how could this be? No doubt there have been some astounding advances in hospital care. The development of antibiotics alone might save millions who would have died in 1918. Many, perhaps most, of the Spanish flu’s victims succumbed not to the virus itself but to secondary bacterial infections that are now treatable.
But consider this: In the United States, 80 percent of all prescription drugs are now produced overseas. They are delivered to drugstores just hours before they’re dispensed. In a pandemic, international shipping could come to a halt as countries impose travel bans and quarantines, companies suspend operations, and employees fall sick or stay home. Once again, pharmacy shelves would run bare. Nor would it just be flu medicine and antibiotics. Within days, medication for heart disease, high blood pressure, and depression would vanish, and insulin for diabetics would disappear. Many hospitals now maintain minimal inventories, receiving three rounds of medicine and other equipment each day. These supplies, too, could evaporate, and with them many forms of critical care.
Since the novel strain reemerged in 2003, Dr. Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, has been warning of the perils inherent in modern commerce. The economies of countries like the United States now more than ever depend on just-in-time supply chains and offshore sourcing of essential goods and services. “The interconnectedness of the global economy today could make the next influenza pandemic more devastating than the ones before it,” he wrote. “Even the slightest disruption in the availability of workers, electricity, water, petroleum-based products and other products or parts could bring many aspects of contemporary life to a halt.” With little surge capacity of their own, Osterholm projects that countries facing a major pandemic would run short on everything from soap and lightbulbs to gasoline and spare parts for municipal water pumps, and, of course, food.
Four days after lab tests had come back positive for bird flu in Vietnam, Klaus Stohr in Geneva convened an unpublicized conference call on January 15, 2004, with a half dozen of the world’s leading influenza specialists. He wanted to know what he was up against.
“A critical situation, unprecedented,” said Dr. John Wood, senior virologist at Britain’s national biological institute. “We have to behave as if it could go to pandemic.”
“Very, very serious,” said Dr. Masato Tashiro, head of virology at Japan’s national infectious-disease institute. The likelihood of human transmission is rising, and this, he said, “would be devastating. [Something we] have not yet experienced before.”
Just two months earlier, Dr. Robert Webster from St. Jude Children’s Hospital had coauthored an article for
“A very unusual event,” Webster said.
