The Last Irish Plague: The Great Flu Epidemic in Ireland 1918-19, by Catriona Foley, Irish Academic Press, 240 pp, €19.95, ISBN: 978-0716531166

The past is a foreign country: they do things differently there. LP Hartley, The Go-Between

Borrowing, with some licence, from Hartley’s 1950s novel The Go-Between, a surveyor of the past might look to the publication of academic scholarship to further the quotient of common knowledge in the public domain. With an increase in such knowledge, endowed to the general reader by a scholarly go-between, we might begin to construct the history of our own lives: the esoteric, sometimes faulty, knowledge dredged from individual and familial memory creating a potentially uncertain edifice and letting it settle upon the evidence-based foundations of our collective history.

In the foreword to Catriona Foley’s book The Last Irish Plague, two UCD academics at the Centre for the History of Medicine in Ireland refer to the “great power” of this account, power that resides, they suggest,

in its author’s ability to draw the reader in to the complex and multifaceted impact of the Spanish Flu epidemic in Ireland, without ever reducing the past to clinical snapshots or distant happenings.

The chapter headings promise clarity and structure: the geography, demography and social impact of the great flu of 1918 will be addressed, as will the concept of “Fear”, of “Memory” and of the medical response to this devastating onslaught from disease. The foreword outlines the book’s priority:

While providing the reader with the important statistics, maps, and graphs of the disease and its impact on Ireland, she places the patient narrative at the heart of this telling.

More than ninety years after the first wave of the influenza pandemic, the sources to be used to ensure the delivery of such centrality may be problematic. Although extensive and diverse, such sources often state the obvious – “many parents feared for their children’s well-being during the epidemic”; or perhaps are selected to amplify the toll taken in ameliorating the most noxious aspects of the disease, as with Dr Kathleen Lynn, “the flu rages, I can do so little”. Yet is there perhaps, overall, insufficient acknowledgement of the stoicism of individual players? Does the sense of hopelessness of Dr Lynn at the end of the working day underplay the massive contribution she made at the clinic at 37 Charlemont Street, later St Ultan’s Hospital, her organisation of preventative flu vaccination and her continuing political activism with the Citizen Army? The medical profession is acknowledged as feeling a “sense of ineffectiveness and inadequacy”, but despite all of Foley’s documented limitations of a public health system, by this time also “there were doctors through the dispensary system working in the most remote and under populated parts of the country” (Burke, 2007). The dispensary doctors were also gathering information on sickness and mortality across the country and dispatching vital statistics of the impact of the influenza on the population of Ireland to the Registrar General’s office at Charlemont House in Dublin.

The sense of “the emotionally punishing nature of the epidemic” is documented throughout – but there is no equivalent sense that resistance to the seduction of despair, the deploying of strategies of survival and the meeting of individual and collective needs are also part of the canvas. Too narrow a focus on the individual patient narrative, however much the reader may sympathise/empathise, tends towards reductionism in the sense that much modern media has cultivated. To ask an individual – in the death throes of disease or walking across miles of desert leaving dead and dying children in his or her wake – how they are “feeling” may, indeed, awaken those who have no imagination. Yet even if such a crass question is asked of millions, in the absence of a structure, of some analysis of all the failed strategies that brought them to that dreadful pass, they end up being abandoned to “fate”, a mere job lot gracing the screens of the comfortable onlooker.

The bibliography to Foley’s work is extensive and with funding from the Irish Research Council for the Humanities and Social Sciences, the strategic use of important statistics would be indicative of the extent of the disease, building a framework within which the patient narrative from folklore, from newspapers, from diaries, from the records of institutions, the hospitals and prisons, workhouses and lunatic asylums – could be interpreted within the historical context of human agency. As in the midst of famine, in the face of disease on a pandemic scale -almost indecently – daily life continues, crowds gather, in Ireland an election campaign was massively conducted from street level; after travel permits had been banned for the duration of the war, hundreds of thousands of potential emigrants young Irish people had remained in Ireland and in 1918 registered a great appetite for change in the order of business. The use by Dr Foley of “such important statistics” to frame the extensive docmenting of despair and dread is underlined, but it is not deployed beyond the essentials.

The Last Irish Plague is the first published account of the impact of a disease that, between spring 1918 and early summer 1919, resulted in the sickness of over 800,000 people on this island, and the related death of almost 21,000 of them (statistics of the Registrar General of Ireland 1918-19).

This is grim material and quantifying it, graphically, does not diminish the impact of such statistics. Why Ireland, in common with so many other countries, was caught so unprepared for a silent onslaught of this magnitude, raises many questions. But first – what do we know of what happened early in spring 1918, in so many countries, including Ireland, and to such devastating effect?

This “influenza-type” infection arose, perhaps from as early as 1916 or 1917, from “causes unknown”: medical science was, despite the long human history of different types of influenza, in uncharted territory. Many advances had been made by medical science by the dawn of the twentieth century, notably in the areas of anaesthesia, bacteriology, pathology and radiology. By 1918, death from tuberculosis, still lethal, still a disease of poverty and still endemic in the tenements of Dublin, had begun a slow but measurable decline. The “transmissable agent” responsible for the 1918 pandemic, however, was “an unknown”, scientifically and medically, and was not isolated until 1933. The 1918 outbreak was recognised as presenting flu-like symptoms across the globe, but was initially considered to be “small bacteria or ultra bacteria”, a conceptual framework that “was not challenged until it failed” to deliver evidence. The experience of the great flu pandemic as an historical event in itself “weakened the bacteriological paradigm and helped to bring about the viral era" (Johnson 2006). The term virus, Greek for poison, was coined for the transmissable agent – the agent, smaller than a bacteria, and shown scientifically to be capable of the transmission of disease, first in experiments in the labs, from plant to plant, and then evident in transmission from human to human – a simple cough could spread this infection across a globe, with no cure on the horizon.

“Fear” entered the equation, but disease was not an unknown quantity and human agency, honed by previous experience, played its part in the resistance. Outlining specific cases across the island, an abundance of significant material on the attempt to resist, the disinfecting of many towns, the gradual abandoning of burial rites, on altruism amongst neighbours and the limitations of same in the face of devastating odds, Dr Foley’s book gathers to great effect much fresh historical data extracted from folklore and from contemporaneous newspaper accounts. As Cormac Ó Gráda has noted, if one lived in isolation in Co Clare, avoiding contagion might have been possible, but there were few pockets, fewer boreens where, eventually, the virus did not find a host. One of the major medical and scientific questions arising from the impact of the pandemic in Ireland as elsewhere, was why so many did not fall ill – in Ireland 800,000 did so when the population of the entire island in the 1911 census was recorded as being 4,390,219. The individual stories captured in Dr Foley’s work – the factories that closed, the towns that organised –are from sources rarely addressed in Irish historiography and she has challenged any assumption that this was – at the level of lived experience – a forgotten infestation of disease.

There are, however, problems in the “history of medicine” aspect of the book and given the imprimatur from the Centre for the History of Medicine one would have expected that inconsistency of naming/labelling/classification should reasonably have been addressed. Is the disease a plague, an epidemic, or a pandemic? A pandemic is global, but in discussion of the profound impact at the level of lived experience in Ireland it is presented throughout as “epidemic”, despite the clear reference to a distinction in the glossary. Epidemics, in an era when disease was rampant, were not entirely unusual events, which is not to trivialise the individual and collective cost of such disease. Smallpox epidemics had ravaged populations for generations, but by 1918 an effective smallpox vaccine was being systematically administered in Ireland and elsewhere. A pandemic is of a quite different order, and inconsistent use of the term can confuse. Alongside Ireland, the ongoing systematic collection of 1918 disease data from other countries in the British Empire were also recorded: in England and Wales, a calculated 200,000, and in India 2,000,000 people died from the same contagion. As with those from Ireland, they formed part of a profound and sudden spike in human mortality, where a previously largely healthy population was stalked by a disease crossing the globe with lethal speed, leaving a death list of names known and unknown – an estimated fifty to one hundred million men, women and children. The 1918 “epidemic” in Ireland is recorded in official medical classification as the record of the Irish experience of the 1918 Influenza Pandemic. The distinction in the terms “epidemic” and “pandemic” signifies that, at the very least and in such testing times, we were not alone.

The Latin plaga translates as “a blow” or “stroke”. In 431 BC Thucydides, recording “the start of the age of chronicled plagues”, witnessed order in the civil society of Athens collapse, burial ritual abandoned and the prevailing of lawlessness without honour as the magnitude of the devastation overwhelmed the citizenry. Nestling between 540 AD the first cycle of what was recognised as plague and 541 AD, is the Plague of Justinian, which may have played a part in the fall of the Roman Empire. Plague returned in the 1300s, with the beginning of a second cycle, and in 1348-49, with the unleashing of the pandemic known as The Black Death, courtesy of transmission through the black rat, although recent research suggests person to person transmission: six horrific years of global human wasteland. Through the late Middle Ages pestilence and disease led to a scarcity of human labour; in the seventeenth century, charitable and philanthropic institutions for the sick and indigent gave assistance to the stricken poor. The eighteenth century distinguished the pauper from the “wilfully idle”, the deserving poor from the other variety; the maintaining of “order” and “the preservation, upkeep and conservation of the labour force” transformed the provision of charitable and other foundations into “the state of health of a population as a general objective of policy” (Foucault, 1972). That general objective undoubtedly played a part in the early recording of the incidence and status of disease in Ireland under the Union of Great Britain and Ireland. It was a cornerstone of the administrative process of the British Empire, employing statistics as a tool to measure a population of millions across the globe, and to begin the ambitious project to define deviations from a prescribed norm of “healthy and able bodied”.

Plague, in its many forms, is not new, and in Ireland as elsewhere ancient plague pits digest the remains of the unnamed legions. It marks grim territory, fully warranting the application in Foley’s work of the labels “horrific”, “fearful” and “catastrophic”. Much academic work on the impact and analysis of the 1918-19 pandemic in the United States, England and Wales, Scotland and other countries where resources have facilitated research, have revealed similarities, consistencies and inconsistencies in the extent and intensity of the illness across the globe. In Ireland this research has only just begun.

Most recently, and serving as “go-between” in addressing the deficit in common knowledge of “disease”, science journalism has, at its best, been to the fore in an insistence, for that reader, of accessibility to distilled scientific knowledge. Drawing on academic sources, it has absorbed complexity and, in large part, has deployed journalistic skills to inform the population most vulnerable to such onslaughts, ourselves, but not ourselves alone. It may be cliché but the adage “forewarned is forearmed” is perhaps pertinent: “we cannot out-evolve or out-adapt a virus. An evolutionary ‘race’ with a virus is not one humanity is going to win.” (Johnson, 2006). We need a Plan B: an informed population might be a useful point of departure. The publication in an accessible form of tales of cholera, of plague and of the 1918 influenza pandemic has endeavoured to map a route to the “upping” of such common knowledge.

The Ghost Map (Johnson, 2006) borrows from cartography and maps the streets of the city of London, circa 1854, “a city of scavengers”, in pursuit of a “deadly bacterium”. Recorded since the first millenium BC in ancient Sanskrit, Chinese and Greek texts, as “a cholera-like diarrhoel disease”: this bacterium isvibrio cholerae: cholera, from the Latin cholera morbus, noting “sporadic diarrhoel affliction”, and the Greek khol, meaning bile. (Dobson, 2007). Utterly grim, daunting and deadly – and yet, a complexity addressed in a bestselling book of non-fiction, hailed as a New York Times “Notable Book”, “a paean to city life”. The push to address the complexity of a collision of elements is introduced by the author, distinguished writer-in residence at New York University’s Department of Journalism, as

an attempt to tell the story of that collision in a way that does justice to the multiple scales of existence that helped bring it about: from the invisible kingdom of microscopic bacteria, to the tragedy and courage and camaraderie of individual lives, to the cultural realm of ideas and ideologies, all the way up to the sprawling metropolis of London itself.

A map is created by a man – it is the dawn of the the art of dot mapping, “representing the spatial path of an epidemic by marking each case with dots ... on a map”. Autumn 1854, and sanitation for the sprawling mass of human life in the city of London is a policy priority. In Broad Street, Soho, an outbreak of cholera presents many contenders for the primary role of vector: dots mark the excavation of sewer lines, the site of an ancient plague burial pit, the thirteen water pumps serving the Soho area, black bars marking the concentration of deaths. Fetid air, rising in the imagination from the pest house and the decay of ancient bodies, from a local slaughter house, from the workhouse off Poland Street: all feed old theories of transmission by miasma, “the intellectual equivalent of a contagious disease”, the vector of choice for the intelligensia. But not all of them. The anaesthesiologist John Snow, whose name was established on “the predictable physiological effects of inhaled vapours”, resists, from the evidence, the diagnosis of transmission by miasma. As dot mapping was in its infancy, he draws upon other disciplines, “a centuries old mathematical tool ... later termed the Voronoi diagram”, using the thirteen pumps of the Soho area as points, distance to be calculated on foot-traffic ... the map acquired “iconic status”, the epidemic continued, but more knowledge was gathered at street-level – lives as lived in a metropolis, the dangers lurking in population density, the mapping, tracking and the genesis of the water-borne theory of disease.

The Plague Race (Marriot, 2002), begins another tale from science journalism with daunting intent. It is 1894, half a century on from the Broad Street epidemic, half a world away from Soho. In the Victorian era of imperial outreach, at the dawn of the twentieth century in a British colony, an isthmus of the Chinese mainland.

Late one afternoon, as the mango and banana sellers were beginning to count their day’s takings and the Hong Kong street lights were stuttering to life, a monstrous rat surfaced at the intersection of Aberdeen and Bridges. The size of a small cat, it emerged from the drain on one side of the road and climbed up and out, its fur glistening and matted ... shifting its weight old-mannishly ...

By the end of a nine-page prologue, the reader has been transported back in time – to late nineteenth century China, to Hong Kong and to the genesis of the third plague pandemic. Two scientists, the renowned Japanese bacteriologist Shibasaburo Kitasato, responding to a global call for assistance by the governor of the British colony, sets sail from Japan; and the less established Swiss born Frenchman, Dr Alexandre Yersin, late of the Pasteur Institute, knowledge tempered by incursions beyond the lab as ship’s doctor bound for the Far East, with shore leave forays into the interior of Vietnam, a man becoming familiar with tribes unfamilar with ‘pale-skinned witchcraft’. En route, now, responding to the call emanating from the fog-filled waters on the shore of Hong Kong. This ‘plague race’ tracks science, human fraility, ambition, achievement, disappointment, disaster and death –competing theories, wilful reluctance in the bureaucracy of political access: the plague bacillus straddles an account of epic medical and scientific struggle set in an historic era when, ‘if ever there was a time to be a scientist’, it was this time.

Such tales, non-fiction but with authoritative research cast akin to the mode of the detective novel, deploy the art of the story-teller to advance public education but are neither overly worthy nor tediously heroic. They place the practice of the scientific method in the heart of the spaces where people live – in cities, in tribes, in mountains, in valleys – all residents, for a time, on a finite globe. Fear can travel like a plague, can infect hope of better outcomes, undermine human agency and the capacity to resist. ‘Fear’ has become the bon mot of choice, across all media, in these interesting times we are all required to live through – fear of an economic crash; fear of change; fear of, and for, the future. That fear became manifest in the first flu pandemic of the twenty first century, Pandemic H1N1, c. 2009, just over ninety years after the Great Influenza Pandemic of 1918.

Between two pandemics, much had changed. At the turn into the third millenium, journalism presented a case to be considered: a science reporter from The New York Times, formerly at Science magazine, ‘...a microbiology major...took a course in virology’. The most infamous virus of the modern era, responsible for the death of the uncharacteristically wide statistical calculation of ‘between 50-100 million deaths across the world’, was simply not mentioned. The book Gina Kolata was prompted to write, published in 1999, travels with informed ease through historical data embellished with case histories on the continuing enigma of the 1918 pandemic, tracking the isolating of the H1N1 virus in 1934, the subsequent development of the vaccine and the search for samples of tissues containing the virus to further molecular and genetic research on specific characteristics that explained the level of mortality and the vulnerability of the young – particularly young healthy men – to this influenza virus. She is at ease with the science and engaged with the Centres for Disease Control in the US in the competitive and potentially highly commercial world of researchers pursuing answers and prevention of the means through which any return of this virus or a similarly potent mix, could have such catastrophic results in a highly globalised world.

The same concerns – with a pre-2009 pandemic concern focusing on the potential for an outbreak of H5N1 avian flu – inform the work of another journalist and social historian where the level of detail, across centuries of emerging knowledge, is brought to bear on formulating a comprehensive understanding of the impact of the 1918 influenza on a world already exhausted by the ravages of WWI (Quinn, 2008). The impact of that war cannot be ignored, and an area of weakness in the impressive scholarly sources that Dr Foley has considered, involves research on the entry of the United States on the side of the Allies in 1917, and the related role allocated to Ireland as sister nation under the Union of Great Britain and Ireland. That we were part of an Empire, with decisions made to serve the interests of that Empire is not a novel observation but it is often ignored. Foley is aware of the possibility that an infection of the lungs evident in British military camps, ‘at Brest and Aldershot in 1916 and 1917 ...may have been earlier strains of the 1918 virus’, but has taken no account of the British Army and Naval base at Queenstown, County Cork, and the strategic importance of that base from 1917 onwards.

By 1918, Europe had been at war for almost five years. A virulent influenza, causes still unknown, was rampant in the armed forces of the Allies and was rumoured to have laid waste to legions of the German Army. The initial transport of troops across America, despite advice from American doctors that such a strategy would ‘lead to a rapid and disastrous spread of influenza across the country’, was underway. The consequence of ignoring such advice was compounded by the further transport, by ship, of thousands of young American men to the European theatre of war. President Woodrow Wilson refused to permit publication of reports on the virulence of the outbreak ‘in case it weakened the war effort’(Quinn, 2008). Young men, followed by young women, were the greatest casualties in the Great Flu Pandemic of 1918 - a finding which was contrary to the bulk of medical and scientific experience of disease at the time.