during the war. many records here in the washington area and many other field locations document the break in the united states and

letters reports, books, telegrams and photographs show the region of the 1918 influenza of the epidemic to all parts of the nation. the records open a window onto the world of 101 years ago and showed that human and societal cost of pandemic and allow us not only to look back at that time but perhaps also to look ahead at the information they contain present-day inquiries and increase our understanding of the disease. doctor jeremy brown is an emergency physician and research director in the department of medicine at the george washington university here in dc. now the director of the office of emergency care research at the national institutes of health. the author of more than 30 peer-reviewed articles and including the oxford american handbook of emergency medicine and of the handbook on the handy emergencies. he's recently received a

director's awardirector's awards on research and the non- addictive medicine. jacob writing in the new york journal of books says brown. on the scientific career making the virus central to the story he reads history and contemporary clinical practice together although his story his account is punctuated as humor and much advice. ladies and gentlemen please welcome doctor jeremy brown. [applause]

thank you so much for those kind wordwords it's not everyday thau get introduced by the united states. we are here to talk about influenza and the plague that struck us 100 years ago resonates more people were killed in the influenza virus then 50 to 100 million worldwi worldwide. of turned

out to be about 3 million deaths in today's numbers, so put that into perspective and think what it would be like to live such a thing. another way of thinking about it was to put the cause of this. i think of this as i think that the age didn't go outbreak of the hiv which was incredibly frightening and yet we knew that it had to be a virus that took three years to identify but we knew what we suspected we had a

corporate right away. one thing to put this in perspective as you all know we are sadly living through an epidemic of a different kind. the 1918 epidemic caused such a large loss of life but it

dropped the average life expectancy than what we have seen with the current opioid crisis.

builds momentum more and more people people find and buy october 2 on the front page of the "washington post" we were told the war power had changed and it's been staggered.

washington, d.c. wasn't the only city to do this by any means in fact it happened in the least of the cities that were affected. the idea it did understand it was a good idea so they were closed down in some places and restaurants were closed. stores had staggered out and in an attempt to keep people space away from each other. so the working house of the federal government changed around the beginning. i talk about this piece of the reporting in the book and this comes a couple of weeks after that.

the "washington post" reported on the headline that's the price skyrocketed and this was an example of people taking advantage of a terrible situation holding him by the throat and extorting and it goes on here to suggest the department of justice should step in and put a stop to the high prices. it costs more to bury the dead more people have died in the short amount of time and suggested that correct is now in sight. that was quite hopeful there was no evidence of that but it was

hoped that perhaps we are nearing the end of it. throughout the epidemic they had a various remedies and this was an example of the remedy that actually played well all of 1918 and we are going to come back and talk about this but i want you to remember these words. this is a remedy that contains a laxative. we will come back to that, thought to be very helpful in cases of influenza, and quinine a pill that until very recently was to go to medicines for malaria. it's now been superseded by others, but it was thought to be helpful. so people were making this and i

think it interesting that if you look at the beginning counters the following but the influenza is an exaggerated form. the templates should be tablets should be taken in larger doses and prescribed in ordinary grips ordinary gratuitously big epidemics are you better epidemic so you better take him out of this medicine. and we'll come back will come back and talk about remedies. so these and several others were advertising both to treat the disease and also of course to prevent it. so again another marketing opportunity for businesses. so lax that same quinine. the "washington post" thought we were coming to an end to, and they put this little piece that said the spanish influenza is

more deadly than the war and that is the case we know that, but what struck me is the placing of this piece of journalism. it's the back page, page 20 to an end of her dining room chairs. at the epidemic was more deadly than the worn. why was this not front page news? would have happened, and there were various suggestions some believe that there was a passive agreement is not about censorship of but about the newspapers and the government to play this down. if you're going to put a statistic like that, putting it on page 20 isn't going to get the attention it deserves, so a little bit of history and we have some smart archivists that can shed more light.

finally we hit the record but unfortunately, no. 16 deaths from the flu in a single day. again this is tucked away into the real estate and record reporting. so, again, it was reported. it wasn't hidden, but you have to sort of look for this to understand what was going on. the the finals why i want to share with you at reporting from our "washington post" was exactly this day, march 5, 1919 exactly a century ago. exactly 100 years ago today this was a small report was in the "washington post" cited two boys

who volunteered to go to boston and take part in some experiments that were trying to understand the cause and methods of the mission. during the recent epidemic we read them voluntarily submitted to experiment to determining the cause and method of transmission of the disease and preventative measure. they were involved in this epidemic that wasn't understood in which there was no cure other than the tablets which i doubt people really look for. everyday heroism putting their lives on the line in order to

try to understand what was actually going on, what was this terrible disease. so, these are just a few examples from the "washington post" that tell us a little bit about what happened here in washington, d.c.. i'm just going to switch to a second slideshow, and this one will run itself. if it works fine you will see the images as we talk through. for today what i would like to do is focus on three areas of research that i describe in the book the first is how the treatments have evolved and you

will find it's changed less than. the second focus is going to be our understanding of the virus and how it's changed over the last century. what was it 100 years ago so we know about the same virus today and they are we agree it's been an absolutely remarkable leap in our understanding of what is going on. and finally, how we can prevent ourselves from catching the flu in the first place and where we are today but we still have a lot of work to do. so let's start with the treatments. they were not terribly

effective. inhaling factory gases, yes that happened people reported taking their families and children to factories where the toxic fumes would somehow reduce the likelihood of getting influenza. it's not as crazy as it sounds because many of these contained chlorine and we never disagreed antiseptic and tells everything, including people. so very likely it shows the factory workers had influenza and similar rates than other people because guess they were inhaling little bits of chlorine and that's probably reduced the amount going around so that wasn't a completely crazy thing to take your children to inhale factory gases.

there was an upside to the treatment back then that wasn't extremely popular as it has been described by physicians so not everything was difficult. as we said they were used to treat everything back then. they were quite popular and one of the most remarkable things like letting which is the process by which it is removed from the body. the senior doctors suggested that we like blood. now the junior people were listening to this idea and there give us a little bit of

resistance but the senior people as he lay dying on his bed and he passed out and within a few hours, he was dead. president george washington underwent this procedure. the doctor then try to think about reanimating george washington by using and i'm not joking, using sheep's blood. enough was enough and they finally let him rest in peace. but it was used in the epidemic of 1918 and not just by what we might call a quack today but by mainstream physicians, and this was one of the things that sparked my interest then and

now. as was reported by one of the leading medical journals in the world and in the united kingdom and if you think about it it was named after the device. the leading medical journal today the report mentions that in 1916, that is two years before this great flu pandemic there was another epidemic and some in some of the military camps and great britain and the doctors had tried everything including bloodletting 71916 this was the time of my grandfather positions were trying to bloodletting and of course it didn't work but we think it didn't work because we tried it too late. had he tried it a little bit

sooner maybe it worked, and then there were reports in 1918 at the height of the epidemic of bloodletting and in fact the reports were that yes sometimes it works for influenza. so you can see if it was in the enema bag a few of the bloodletting might get here and it was quite a nasty array of medicines we had to try to treat this. please call earlier and add four quinine into it is a useful drugs for malaria but useless as a treatment for the flu because it is useful in in mall area it reduces the fever cycle and the idea was if it reduces fever and malaria, it will reduce fever in

malaria through different mechanisms but that's the thought process behind it. a completely useless drugged and incidentally dangerous and inappropriate purpose. everybody was prescribed enemas and one of my favorite discoveries when i was researching the book was from a published paper from the grandchildren of a patient who had influenza in 1936, soapy teen years almost two decades after the pandemic the family had preserved the nursing records of grandfather and actually published them. i'm going to read a little bit, a passage that describes what this person went through. over a period of three, he was treated with mustard plaster, a home remedy wrapped on the skin, aspirin for fever, codeine for

the cough, a cancer-causing laxative, oriole, seven enemas, rectal tubes, don't ask, milk of magnesia another laxative, god help him, a blood antiseptic. these were all administered in 1936 and in a in the paper that published you can see the arrows on the timeline when these things were given. the patients received at least five doses of whiskey so there is at least that and 14 doses of castor oil. actually, the seven enemas may have been medically necessary because he was given at least 39 doses of codeine which suppresses coughing but also causes constipation.

so, that's what life was like when you had influenza back 100 years ago or so. what about today? for the vast majority of us, influenza is a little bit of an convenience -- inconvenience. it's something we generally deal with at home. friends or family come around to give us hot soup, a couple of days in bed and usually that's it at some of us end up in the emergency department and over my time as a physician i got to treat many possibly hundreds who knows, maybe thousands of patients with influenza over the many years and there we have things we didn't have 100 years ago, we had an emergency department, a blood test that can tell us what's happening, x-rays so we can get a good look to see any evidence of secondary

pneumonia or primary pneumonia and we can get people intravenous fluids. we can get people intravenous fluids and treat them in that way and of course we have antibiotics today. let's be very clear antibiotics should be given to patients with influenza. they do not work and we all know this even though they are prescribed unnecessarily even today. they don't work but they do work to help treat the secondary infections, the bacterial pneumonia that comes as a result of the primary viable influenza and we have those antibiotics today. they were not available until the early 30s, and it's a remarkable thing today we believe the majority of deaths that occur in the great flu epidemic caused by secondary pneumonia he would be able to

treat today so that's good news. we also have other medications to treat fevers, we have medications like aspirin or motrin or tylenol, but i can across an interesting study that suggests perhaps we shouldn't be giving medications to people's fevers quite as often as we do. this was a study out of mcmaster university in canada. they looked at the modeling and said what happens if you give tens of thousands of people with the flu medicine to reduce the fever while many of them will feel better quicker. having a high fever and shivers and shakes and chills as miserable. so they will get out of bed quicker and what will happen? they will come downstairs and cough on their friends and children and go to work and cost over them. the suggestion from this group was by treating a fever for patients and save the emergency

department you might increase transmission rates by about 1% and given the enormity of the disease they suggested you might get an additional 500 deaths per year in the united states as a result of treating people speakers. if you come to the emergency department with influenza today and your doctor sees you have a fever of 103 and suggests that you probably shouldn't get something for your fever because she says there's a paper from mcmaster university that theoretically this could increase the death rate by 100 you will probably say doctor please give me the medicine. i know i would command i would prescribe and probably continue to prescribe something for people speakers in the presence of influenza but there is at least this other way of thinking globally about what we are doing

locally and how that might affect transmission and spread, so we have those medications as well to help us. then there are some specific medications that treat the flu by things like tema flu and the new case direct antiviral medications to go directly now and perhaps we can talk about them later, but they are also out there. they probably don't work anywhere nearly as efficiently as they could but we will leave that for later. so that is the treatment. the enemas, bloodletting, laxatives, whiskey. 100 years ago today the emergency department of course connected to this was the intensive unit for the sickest of the sick go to be supported and i opened up with a story of a young lady, a young mother of

two who came down with influenza extremely quickly and ended up in a matter of hours being taken from personal town to pittsburgh where she was put on a machine for several weeks until she recovered from the flu. that is the marvelous medicine today that clearly wasn't around 100 years ago. so, the treatment. let's now think about the cause of influenza. what do we know about the cause today and what did they know 100 years ago? i think in many respects this is the most frightening aspect of the great influenza pandemic. they just didn't know what it was caused by. there were some suggestions and among the suggestions included the conjunction of jupiter and saturn, in fact the conjunction of the patterns.

that's where. as for the defending that's where we get the main influenza from is from the italian word meaning influence into the earliest thoughts were and this is an 15 and 16 hundreds was this disease, an entity that you could identify was caused by something up in the stores, so there was a theory going around and we still have this. in our history when we refer to influenza today so perhaps conjunction of jupiter and saturn rotting animal carcasses were thought to be one possible explanation, earthquakes and volcanic eruptions were suggested as possible causes. they discharge into the air into the bowels of the earth. people really didn't know what it wasn't that was in fact at a meeting that occurred in chicago public health officials early in the epidemic of 19181 public-health officials of the following we may as well admit and call it germ x..

we had no idea. we don't know what causes it and where we are. now an example of a cause that wasn't really a cause was a discovery in 1982 berlin by a microbiologist and they found a bacteria on both samples of people who died from the flu and they said this must be the cause of the flu because it's everywhere and they called it to the influenza physalis. the problem was that wasn't the cause of the disease, it was the secondary pathogen that was found. it is a secondary bacteria and that thought that they found the bacteria and it turned out not to be correct happened in several different influences to think of instances. the physalis later changed its

name. it was called the this influenza fortunately we now have vaccines against it but for many years i have no idea as a physician why am i looking at treating this person with h. flu that has nothing to do with the flu, it turns out 100 years ago it was thought to have been the cause of the flu and was inappropriately named. one of the historians, ask red cross be called an authoritative sign pointing in the wrong direction. so that was a secondary pathogen. in et and 89 there have been a small epidemic and it was so severe parliament commissioned a

report on the epidemic and this was reported in 1889 by henry parsons she was a very smart person and we will see if i. he spoke of various theories that may have caused this epidemic. one of the theories of the time was tainted brush and oats. the suggestion is they were bringing their disease from the east through europe in these russia notes. every society actually blamed an outsider. but it strikes me as kind of weird today we are still going to be explaining the russians for pretty much everything back in the great flu epidemic in earlier perhaps they were behind it as well. but as i said he was smarter than that and he dug a little deeper so he suggested it could be the weather.

perhaps there's something floating around in the air and that is of course partially true there is something in the air although he suggested maybe it is a nonliving particulate matter which is a remarkably accurate description of what a virus turned out to be a nonliving particulate matter so prissy and in describing the possible cause of the flu, so it could be rushing tainted votes or a poison in midair and then he suggested what if it is a person-to-person contact box spread by for volcanoes were stuck in the air that one person gets it to another, and here i think henry parsons really showed the right way for us to think about things. he said this gets some data. what he did is look to the illness rate of the british railway system and compared the rate of the engineers who were

outside far away from people and he compared those and how many people reported and he compared that to the rate of influenza among the clouds and sites selling the tickets and of course they are inside and in constant contact with people. he simply compared to two and found of course it was the clerks that had an increased illness because they were in contact with people and the railway engineers driving the train standing outside, the flu was much lower even though they were outside exposed to who knows what from volcanoes and from here he suggested it is probably nothing to do with the atmosphere is more to do with

person-to-person contact. from a simple look at the records he figured out we are onto something it had something to do with the spread and of course we know today it is related to the spread of influenza 89, henry parsons was onto something when he discussed the possibility that birds were involved. so there is an example of people trying to think this through in a logical way there's no doubt it is a viral particles which is

many times more than the bacteria the microscope was developed and not able to be used around 1859, and so we have pictures of the influenza virus, pictures, diagrams. in fact scientists today know the genetic code of a work together and with those proteins do so the degree of advantages to something that we can see and identify and know a lot about i think is a remarkable example of the progression of science. now we can identify the viral particles onto its genetic

makeup, its genetic construction. so, in that respect, we have come a long way in understanding the cause of the disease which brings us to the last part. the way we've changed in terms of vaccines and prevention. there were attempts to produce early vaccines to influenza. back in the 80s he developed his own set of vaccines and if that doesn't necessarily mean he knew what the virus was that he had a suggestion that it was something in the system and he managed to propagate and take samples and then the care and weaker until he figured out what he had now was a weekend thing and that is how he produced the rabies, so that's how we know people were producing vaccines back then but of course they

were using his bacteria secondary pathogens and not the primary that was influenza so per instance there was a bacteria from the patients and they mixed them all together and managed to inoculate over 100,000 people with his vaccine. we are not sure what the clinical outcomes were, but he certainly tried to do something. now at the medical college of doctor timothy leary needed vaccine using the chelsea hospital and the infected or not far from boston and he made a concoction and gave them to

people and his vaccine ended up being sent to san francisco where a team teamed thousand people were inoculated with the vaccine. in case you're wondering, yes the answer is the same as doctor timothy leary. they were to drop out and it's his uncle that created this 100 years ago. so those are the attempted vaccines back then. what we have today? we will take them every year and those of us involved in healthcare we have to get the flu vaccine. makes sense to try to prevent the transmission, but if really not a very good vaccine. if you think about it, mumps,

measles, you get them once or twice and you are done. finished. that's it. you are good to go. in terms of the flu we are told we need to get it every year. i had it last year and the year before. we we're dealing with a vaccine that is not on the same level as effectiveness it was in the 20 to 30% range, so why is this, why is it so hard to create and the answer is the eight genes of the virus and make the proteins on the surface the vaccine is

created, the problem though is it is such a good master of disguise but it changes the makeup of things very quickly. and it mutates from one kind to another so that when we think we've got, we figured out what is going to be around, when it turns out that this would've mutates would have mutates and the vaccine is no longer effective. and by the way, we didn't realize b. and c. were going to be the ones, so we didn't include those in the vaccine and you were not vaccinated against those which is the reason incidentally some of us get the vaccine and end up with the flu. it's because mocked because it didn't work against that particular strain but there were others that we were not vaccinated against were because the original changed its surface structure sits like changing a

black overcoat and a brown overcoat and the system didn't recognize it. it stays one step ahead of us all the time. there's a similar story with hiv. within a year or two we were told and it's still not there. they are very clever at changing their service and hiding from the immune system. we still don't have a good influenza vaccine. that way we make the vaccine incidentally is we have about 120 or so laboratories around the world by the world health organization. they look at samples that are sent to their lab and try to figure out exactly bus glue of species that is prevalent. we look at australia and what they had in the most recent

outbreak and we try to figure that out and they do the same for us to see what happened in the northern northern hemisphere and adjust themselves to the oncoming flu season of the summer. then doctors make the best educated guess they can. they say based on the evidence we have come at the most, the most likely are going to be this and this and we are going to make the vaccine. to this day much is produced using eggs and it is hard to grow. it's the same thing that is used a century ago. there is a vaccine that is made using cellular technology that allows a vaccine. still those are the methods we have today that are left over from us 100 last 100 years ago, so the majority is still to this

day something to do with eggs and needing to be grown in that medium. in many respects, we are at the beginning of the fight here against influenza by preventing it and creating a vaccine. now, while that is all true and it's not very effective, we must remember that in certain groups, certain age groups it is important to get the vaccine. the high risk people, so those were children, the elderly, those with immune compromised concessions, people taking steroids or have undergone a chemotherapy, pregnant women, extremely important to get the influenza vaccine. for some reason there is an increased risk of complications from influenza. and so those are some of the high risk groups that should be vaccinated there is no question. in terms of everybody else the data out there is harder to find

in effect. a risk groups are targeted. if you want one go get one, but there's no campaign. here in the u.s.. that is the advice they've given here in the united states it's just worth pointing out and we can talk about why that maybe another time, but it's an important difference in the way we think about the flu. for a risk groups it's important and for otherwise healthy adult's it doesn't do a lot. so what do we need, a universal flu vaccine from year to year without having to get it again each year. a vaccine that will work in all

age groups and a vaccine that will work in all geographic areas regardless of one specific strain of the flu running rampant in your area so that is the goal of universal flu vaccine. and to do that, we have to target the virus we understand very well and find a bit of it doesn't change. find some that we can target and then our immune systems will recognize and kill it no matter what particular strain it was. it sounds easy but it's a hard thing to do in reality. we are still not there yet but i will say the national institutes of health where i work and i want to pause and let you know i'm not here representing the views of the great influenza epidemic of 18. i'm here on my own time and personal views, but the nih where i work is actually very

focused on trying to find a universal flu vaccine for a lot of money and a lot of research time and effort into that. there are other companies out there that are doing doing this because under way right now from the nih and who knows what will this work or not work well we see a universal flu vaccine i don't know if we'll see one that is the goal. we certainly have a long way to go. so, if we look at where we were 100 years ago and where we are today, the treatments are very different, thankfully. but we still lack good treatment for influenza. we understand the virus in a remarkably deep profound way in a way that was unimaginable a

century ago but are we able to use the knowledge and build the vaccine plaques not quite yet although that is where the research efforts are going. my hope then going forward is we will be able to see it's not just as a story of the past or disease of the past and the way they think about smallpox as a disease that was eradicated it's important to move towards this goal they estimate anywhere between 30 to 50,000 people each year in the u.s. died die of influenza. it's a soft number. it's not an extremely accurate number but that is the ballpark figure. a lot of people still get get the disease and die from it. it's in the high numbers predominantly whether that happens, so we have to think about ways that we can improve our own vaccinations so that we will be able to make one day influenza a thing of the past.

thank you for your time. [applause] any questions? happy to take them. somebody made a lot of money with face masks back then and we see them today but not as commonly as an asia and they get a cold or they don't want to get a cold to give a cold to somebody else. my question is how effective are those because there was a picture you showed us that causes death and if you spit in your eye i assumed i would be uncomfortable as well as potentially dangerous. can you talk about the perspective and the filtering is it a comfort of all of ours and back then did they use masks or is it a reality of something that can help prevent the spreading of that? >> that is a wonderful question. thank you. of course they do something. even the cheap ones you can buy at the local pharmacy have a

filtered -- so if you cover it you will be breathing through that match that's going to stop something. the question is what is stopping. it might be stopping your secretion if you cost and the mask catches what you are coughing out. does it stop the viral particles with someone else coughed out almost certainly not. the other thing is after a short amount of time they become clogged and then they are completely useless and not doing anything. i think what we are seeing is an interesting idea. in other words, don't sneeze over people, please, don't cough over people that the suggested we are going to stop this by using a face mask think you may have seen the picture of the husband and wife hugging each other wearing a face mask.

it's something that probably does very little that we but we do know that one of the most important perhaps the most important thing you can do. they remind us of what we need to do when we have the flu but in terms of an intervention, these small paper masks are almost getting very little. >> thank you for the talk. i would be curious to hear you say more but the cultural differences. in the united states the

recommendation is everybody over the age of six months gets vaccinated in the uk and parts of europe high-risk groups only everybody else you can if you want but it's not being pushed but the difference is how we approach the flu. if you look at the website you will see that influenza is a serious disease with complications that include death. since that is the case everybody over the age of six months should get the vaccine. if you go on the website command by looking at them recently from the health service in england and i've got to paraphrase again it basically says the following, it is a bit but a new sense. you will feel unwell for a couple of days but you don't have to see a primary care doctor for about it because there isn't a whole lot they can

do. you can stay indoors and you are going to be fine. that is what the national health service is and if you have these two different approaches it's a potentially dangerous disease that can kill you versus it's a bit of a nuisance but you will be all right. those are two different ways so they say if it is a potentially deadly disease even though the vaccine isn't typically good, let's use it as at least something whereas in the united kingdom they say let's use it where we need to use it but most people won't need it. it is indeed potentially deadly disease but that is only from .001% of the people who are going to get it and the tiny number of people that are going to get it proportionately how many get sick it's only those with increased risk from the

disease, those high-risk populations and the united kingdom's approach so which of these are going to decide how we respond to the vaccine, and we've decided in the united states, the cbc decided that this is the best public-health approach. the data is in high risk groups it's still not terribly effective but it does something they probably do very, very little. and yet as you know the beginning of august you will see signs in the pharmacy saying we are ready to get the flu vaccine, come and get it and we will give you a coupon.

this is a bit of a larger discussion. if it's kind of works we should use it that seems to be the approach of many aspects of the american health system. the united kingdom they are much more circumspect. i talked to the chief medical officer of the uk program who was the person that sort of leads the discussion and he said they think about things beyond how well it works like this make sense economically to do this and if you add up the numbers it doesn't make sense to have a big campaign for healthy adults to get the vaccine when so few of them proportionately are going to end up getting sick and taking time off work so a very

different approach. >> i in a history graduate student at george mason university. suffice it to say i'm quite a stickler on sources. i was just curious what sampling of services you use. i know you mentioned newspaper articles and some medical diaries but i was more specifically interested in your use of secondary sources to bolster your own medical knowledge that you already have. >> it's a good question but i might get in trouble now there's a historian in the room. the truth is i use both. i read pretty much everything published in the last decade or

so there are several very good books out there and i was talking just before we came in but now you have the resource of this thing called the internet and i don't know that this was a pivotal to the degree that it is that other books that came out and you can do the research for hundreds of newspapers for the keyword influenza you can get this information like i showed you now so those are primary sources i've never seen that fact that the "washington post" reported the death rates for influenza were greater than that in world war i and it was on the back pages i had never seen that as a report of observation and what it tells us about how to approach the flu, so thankfully and i'm sure you are grateful for this also in the archives

this history where we have a lot that is available to us with relatively simple tools. the nice thing of course is when the historian discovers something no one else has found hidden away in a box and of course as the historian you and others are very keen to find that, but a lot going back reading the original articles and teasing up a medicine like out the medicine like there's other reports of bloodletting in 1916 they were of course mentioned in literature but when you read you can get a different view on things, such thank you for that question. we are out of time ladies and gentlemen so thank you for your time and attention and i hope each and every one of you will stay healthy as we end this season. ..

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