Original subtitles

This programme contains some scenes which some viewers may find upsetting

November 1918, Armistice Day.

Around the world, people celebrate the end of four long years of conflict.

But there's another horror unfolding in the shadow of war.

A deadly virus sweeping the world.

Schools and theatres are shut down.

Coffins are piled high.

The flu pandemic kills over 50 million people.

Many of them die cruelly.

She'd finally drowned in her profuse, thin, bloodstained sputum,

constantly bubbling froth.

CHILDREN SING

Only by going back to rare and previously unseen letters, diaries and memoirs

of those who fought the pandemic,

can we fully understand what happened.

HE COUGHS

Just try and breathe.

The heroic efforts of nurses and doctors.

Fateful decisions of key officials.

The relentless needs of warfare

justify the risk of spreading infection.

The experiences of the ill and the dying.

My grandmother tells me my mother has gone to Jesus.

But I want my mummy.

Hidden in this personal testimony are clues that can benefit us today.

What if the apocalyptic 1918 pandemic were to recur?

That's a scary prospect.

Pinpointing the lessons learned and mistakes made in 1918

will help prepare us for the next global outbreak.

Everybody would agree that another flu pandemic will happen.

And what 1918 does is illustrate to us how bad it could be.

CHILDREN SING

January 1918.

The Western Front.

Alexandra Jamieson of the Royal Scots is one of the 1.5 million British soldiers in the trenches.

He's volunteered, keen to fight for king and country.

But the talk is of death.

I feel terrible.

I'm 19.

Only been here five weeks and apparently I'm going to be killed.

But how am I going to be killed?

There's activity everywhere and shouts to put on our gas masks.

Between the smoke from the German shells,

many of which are gas shells...

..and the fog...

GUNFIRE

..it's grim.

But soldiers such as Jamieson will soon face something more lethal than war.

A horror from nature that will kill ten times those who've died fighting.

It draws no distinction between soldiers or civilians.

Take Ada Berry.

This spirited seven-year-old lives in a terraced house in Manchester.

# Smile, smile, smile...

Ada's father does all he can to protect his daughter from the hardships of war.

# Smile boys, that's the style...

Dad is in his khaki uniform and there are other soldiers visiting

and having sing songs n the parlour.

My sister Flora playing for them.

But every day intimacy will soon be fraught with danger.

Meanwhile, in London, Dr Basil Hood takes on the omnibus

to the busy hospital that he runs in Marylebone.

For Hood, the war years are exhausting,

his wards short-staffed because so many of his doctors and nurses

are in France treating the wounded.

But the deadly virus is about to rip apart all these lives

and millions like them in the trenches, on the streets and in homes across Britain.

Most scientists now believe the flu wasn't born in Europe,

but 4,000 miles away.

It all starts in a remote farm in Haskell County, Kansas.

The bird flu virus naturally lives in waterfowl.

Only with close contact between people and birds can the virus make the crucial jump into humans.

Come on, girls.

At some point, a wild bird influenza

passed their virus to a farmed animal.

Good candidates for that are ducks,

possibly chickens, possibly pigs.

And that animal is going to pass their virus onto a human.

In general, humans have a lot more contact with the farmed animals

and in it goes.

Albert Gitchell has just been conscripted into the US Army.

Gitchell arrives at Camp Funston, Kansas,

the second largest training base in America.

56,000 recruits in crowded barracks and tents.

Grub's up, boys?

Soon, Gitchell is working in the kitchens.

Being a camp cook he probably comes into contact with lots of other soldiers.

They're all queueing up to get their food and it's, eh,

almost like he can dish out his virus to them all.

Albert Gitchell is Patient Zero.

One of the very first infected,

he's thought to have kick-started the whole pandemic in March 1918.

But before the virus can become lethal,

it needs to change further, to mutate.

In every soldier it is capable of mutating and getting a little bit better.

So that's very much a random process.

The virus throws up these random mutations, like rolling a dice,

and if it gets lucky, then the right combination comes up.

And then ramps up into a full-blown airborne transmissible

pandemic flu virus.

The new virus, more deadly and more contagious, rips through the camp.

Within three weeks 1,100 men are seriously ill.

38 young soldiers die.

Way more than expected from normal flu.

One of the officers thought, "There's something wrong here,

"this is not the kind of flu that I'm used to dealing with."

And so the officer wrote to the government in Washington and said,

"This is more sinister than anything I have seen before."

But his warnings were ignored.

The new virus can now spread from Kansas,

hiding inside infected troops,

to ports on the eastern seaboard.

25 transport ships carry US troops across the Atlantic in March 1918.

At least one incubates the deadly disease on board.

The ships dock at Brest in France.

Trains take soldiers to the front.

By April, flu breaks out in the trenches.

Soldiers and medical staff are taken by surprise.

Nurses like Sister Katharine McPhee.

HE COUGHS

Just try and breathe. That's it.

Almost immediately we start taking in the wounded and people that have flu.

We're kept very busy and it's a most depressing time.

Sister McPhee is at a casualty clearing station just behind the front.

She's seen plenty of war wounds, but this is different.

Patients' faces, their ears, their lips,

turn blue as the flu destroys the lungs from inside.

Many die rapidly.

It's been just 40 days since Patient Zero caught the flu in Kansas.

Scottish Private Alexander Jamieson is nervous.

There's an epidemic of flu.

People are being carried away steadily from the signal section,

being carted away to hospital.

In the crowded trenches, he himself is at risk of catching it.

Either from the breath of an infected comrade,

or touching a contaminated object.

They didn't even know what a virus was, really, in 1918.

But, of course, today we now know that influenza,

as the respiratory disease, is caused by this virus

we call Influenza A, erm,

and this is what it looks like.

These things are so tiny that I could get 100,000 of them

across my fingernail.

Each one of these little round balls is an influenza virus,

and once one of these gets inside your nose or throat,

inside a single cell of your body, it will generate perhaps a thousand,

10,000, 100,000 of itself, copies.

As the virus replicates inside Jamieson's airways,

he shows the classic signs of flu - headache, fever, clogged lungs.

HE COUGHS

I feel terrible.

My head is bursting.

He struggles to stay conscious.

Calling Company HQ. Calling Company HQ.

My head feels like a threshing machine.

The next thing there is a voice saying,

"You know what happens to a man who's found asleep on duty?"

We shoot them at dawn!

"He's shot at dawn."

To save his neck, Jamieson has to persuade his captain

that he is genuinely ill.

Ill with a disease that's killing more people than the fighting.

Over 300,000 British troops will become infected and 10% die.

Horrifying figures repeated across all the armies.

We can't send them down the line because they're too ill to move

and we've ever so many deaths.

The boys are coming in with colds and a headache

and are dead within two or three days.

Great big, handsome fellows,

healthy men just come in and die.

Some of the seriously ill in France are sent back to Britain for treatment.

Other apparently healthy soldiers on leave also carry the virus.

They're contagious, even before any symptoms appear.

Starting in the Channel ports and then to London, the virus follows

railways and roads, crisscrossing Britain.

Hidden inside its human host.

Two months after the flu hits the trenches,

the first cases appear in Manchester.

It is June 1918.

The doctor responsible for the health of the city

is James Niven.

Niven worries about the children because they, and the elderly,

are usually the most vulnerable.

An epidemic of influenza is bursting on the city of Manchester,

flaring up with extraordinary rapidity.

The children are simply dropping on their desks,

as if their roots are poisoned.

If you are in very close contact, or touching somebody,

of course you can directly exchange some secretion, saliva etc.

You then have the fairly close contact through droplets,

large droplets, which are exhaled or coughed and sneezed out.

And for those to actually infect another person you'd need

the person to be pretty close, less than one metre for sure.

And therefore, it's not surprising that people living

in very densely populated areas are much more likely to catch flu from one another.

To fight the flu, James Niven tracks the outbreak.

The flu spreads across the entire city simultaneously.

But the North is most severely affected,

more crowded and industrial.

In just six weeks, over 100,000 are infected.

This report on the epidemic of influenza is written by James Niven.

It's clear that he sees this as being something exceptional.

He says the epidemic flared up with extraordinary rapidity.

So, what this suggests is this is not the kind of ordinary influenza,

if you like. It's not the kind of influenza one sees most winters.

James Niven wants to close down schools and Sunday schools

to slow it down.

But some feel this is an overreaction.

There are managers who decline to close the schools.

An announcement is also given in the press that Sunday schools should be closed.

It is difficult to understand the perversity of those who withstand this request to close.

It's quite clear that he was incredibly frustrated with people

who continue to keep these schools open

or continue to send their children there, regardless of the risk of being infected.

I issue a leaflet of precautions, 30,000,

distributed to a number of works in the city, to the press and in houses.

500 large posters are put up in conspicuous positions throughout the city.

In Manchester, James Niven is doing more than anyone in the country

to actively fight this deadly pandemic.

But for the young Ada Berry, the warnings come too late.

It's Sunday. I'm put to bed.

I have this great, big headache

and I tell my mother to stop the others crying.

It's making my head hurt.

At St Marylebone Hospital in London,

Dr Basil Hood does his best to fight the pandemic.

Hood worries his staff will catch it from patients.

Doctors already know conventional flu is infectious, so rightly assume

masks also help stop the new influenza.

Where are your masks? Come on.

When a mask is taken off it is thrown away at once

and a new mask used.

Better masks can be used, but there is no-one left to make them.

This is a memoir by Basil Hood.

And I've always found this profoundly moving.

He really shows what it was like to deal with the thick of the action.

Because while he was doing his work as a doctor,

trying to run a busy hospital, that was overwhelmed,

he was also losing friends and colleagues.

And that, to me, is very moving.

The corridors are now swamped by 200 new patients

from nearby Paddington Hospital.

The place literally reels.

We could not be worse placed to deal with an epidemic. The sick,

the labour, the distress, it's horrific

and it hardly bears thinking about.

Not only is there an influx of cases,

some are critically ill because of the influenza pneumonia,

but the staff are dropping like ninepins, nurses, domestic porters,

practically none of which can be replaced.

As chaos sweeps through the hospitals,

the question is how the government will respond.

Sir Arthur Newsholme is the most senior medical officer at Whitehall.

He's the person best placed to help protect the whole country.

In my official capacity I have prepared a memorandum for public use.

It listed the official advice, what to do in the event of

a recurrence of what they then called epidemic influenza.

To isolate yourself at home if you're sick,

avoid crowded public gatherings where you might spread the disease to other people.

And they were also very big on not sort of spitting and coughing in the street.

But on the balance of consideration,

its distribution is not considered expedient at this time.

There are...

..national circumstances in which the major duty is to carry on.

The main reason he gave for not issuing this memorandum was because of the war.

We need to keep munitions workers in these factories,

we need to keep the trains, the Postal Service, the omnibuses running.

So Arthur Newsholme used this phrase which you now see emblazoned

on T-shirts to this day - carry on. We have to carry on.

The relentless needs of warfare

justify the risk of spreading infection,

and the associated creation of a more virulent type of disease.

Whichever way you cut it, there's no doubt Arthur Newsholme's decision

not to issue that advice cost lives.

I think you could say safely, thousands.

By summer, the flu virus has already spread through France,

Germany and Britain.

It invades other European countries, including Spain,

and an early victim is the king himself, King Alfonso XIII.

Spanish newspapers started speculating about it and talking about it openly.

They were able to do this because Spain was neutral.

There was no censorship.

It was impossible to discuss in Britain because it was felt

by the authorities that an open discussion of the new flu

could lead to damage to morale.

So very quickly, foreign correspondents based in Madrid

labelled the flu, the Spanish flu. OK?

Eh, and, you know, that name just stuck.

Only a small proportion of the people infected with this strain of flu actually die.

The majority recover, including young soldier Alexander Jamieson.

My flu must have cleared up. I don't remember any more about it,

but, I mean, you're so tough physically, you just throw these things off.

During August 1918, the pandemic finally appears to be receding.

The flu no longer terrorises soldiers.

And the tide of war turns in favour of the Allies.

We go up again to Ypres. We don't suffer a great many casualties.

At the end of the first day you can look ahead and see the trees

and all the rest of it that's never been affected by the war.

It is just unbelievable.

We know then that things are going well.

Back in Manchester, James Niven,

the doctor doing so much to counter the flu,

tracks the slow-down of the pandemic.

Niven actually had a degree in mathematics, so I think

probably even more than most medical officers of health

who had to keep statistics, he was very attuned to those statistics

and it's clear he recorded them with some accuracy and also with some flair.

Niven turns individual tragedies into valuable statistics.

Cases like Ada Bury, who's been seriously ill but is now on the mend.

The disease appears to have sunk into quiescence by the 3rd of August.

There'd been this sort of sudden outbreak of flu at an unusual time

of year, in the May and early summer.

But then, you know, the case numbers drop right down.

And people thought they'd dodged a bullet.

The war governments feel fully justified in censoring news of the pandemic.

Civilian life returns to normal. But for how long?

In September, the flu virus returns.

And it's mutated into an even more dangerous form.

For the second time a US army camp is the crucible.

Just outside Boston is a massive training camp, Camp Devens.

The flu starts in the barracks.

Soon the infirmary is overflowing.

This time the virus kills more quickly and violently.

To investigate the outbreak, the army calls in brilliant research scientist Dr William Welch.

This is from the second specimen.

Many more fatalities may be expected before the epidemic has run its course.

The deaths at Camp Devens will probably exceed...500.

He's intrigued by a soldier who came in coughing up blood

and dies in less than a day.

23-year-old male.

Welch has the body opened up to try to find out more.

Tray.

The lung is heavier than normal. Mm.

Must be at least a cup and a half of fluid there. No wonder he asphyxiated.

He's shocked. The lungs are even more destroyed than those damaged by poison gas.

This must be some new kind of infection.

Or plague.

They saw all this fluid in the lung spaces.

The main function of the lung is to take oxygen and deliver it

to the blood, and then the blood pumps it around the body.

And if blood does not have any oxygen in it, it goes bluer.

So this blueness of the lips, the ears, was very obvious.

And then their outcome is going to be fatal, more or less.

William Welch argues the camp should be immediately isolated,

but his commander overrules him.

The experience at Camp Devens may be fairly expected to occur at every large cantonment.

New men will almost certainly contract the disease.

Once again, blinkered officialdom fails to contain the virus,

and this second version of the flu is unleashed on the world.

The second wave was more deadly because the virus had become

a better human virus. And I think that allowed it to transmit

more efficiently to more people.

But also the change in the virus sequence,

making it better at infecting human cells, beefing it up,

is probably contributing to the increased lethality in the second wave.

29th of September 1918.

More, ever larger transport ships are setting sail for Europe.

The Leviathan, a converted cruise liner,

is ready to depart from New Jersey with 9,000 troops.

A deadly cargo is hidden on board.

The second wave of flu.

What we have here is an image of the American doughboys sailing over to France.

What's striking about this image is the number of men

that these ships carried.

They were generally over capacity by 50%.

So these were stacked with soldiers,

and the ideal conditions for the spread of influenza, a disease ship.

Down below. Keep coming, keep coming.

Colonel Ernest Gibson commands the 57th Vermont Pioneer Infantry.

Stow your gear where you can.

He's worried even before the ship sails.

The victims of this epidemic fall,

as they are unable to carry their heavy packs.

On board the transport, men continue to be stricken.

"While the embarkation troops were lined up on the big pier,

"some of the dropped helpless on the deck.

"A number of men had fallen by the wayside, limp and listless,

"on their march from the camp to the scene of the transportation.

"Our first death was recorded on the next day out."

Hundreds of men on the ship would never reach the front,

never get to write home of their fears and hopes.

Casualties not of war, but the pandemic.

Also travelling to France are 200 nurses.

US Army nurse Mary Dobson catches the flu as the ship departs.

You've terrific pain all over your body,

especially in your back and in your head, and you just feel

your head is going to fall off.

The odour is terrible in the ship's infirmary.

I've never smelt anything like it.

There is no-one spare to look after us

because hundreds of troops go down with it as well.

THEY COUGH

The new virus is spreading to the rest of the world.

It's truly a global pandemic now.

This flu often hits the colonies of the Imperial powers first,

emerging where ships arrive.

The pandemic in India begins in the port city of Bombay and,

thanks to the railways, quickly spreads through the rest of the country.

India was one of the worst affected countries, if not THE worst affected.

Probably killed about 70 million people.

Compared to, certainly to Britain,

the mortality rate was about four times greater in India.

This flu is turning out to be more deadly than any other pandemic in history.

Scientist William Welsh is desperate to find out exactly what this flu is.

There was a lot of confusion.

Scientists really didn't know what agent was causing this disease.

But the favourite candidate at the time was a bacteria,

Pfeiffer's bacillus.

If I could just ask you to spit in here, sir. That's it.

So, in 1918, they took sputum and they cultured

whatever was in it on an agar plate in their laboratory.

And all sorts of bacteria grew in it,

because there's all sorts of bacteria in our nose and throat the whole time.

The bacteria they find are only responsible for secondary infections,

such as pneumonia, not the actual flu.

The real culprit, a virus, is a thousand times smaller than bacteria,

making it extremely hard for scientists of the time to study the flu.

People didn't really know much about what a virus was.

They didn't have the methodologies, the technologies,

everything was a little bit hit and miss.

And so if you don't even know what the causative agent is,

erm, how scary must that be?

Without identifying the true killer, scientists can't develop effective drugs or vaccines.

And doctors and nurses rely on the most basic of treatments.

Hot drinks such as Bovril, bed rest and opium to suppress coughs.

Meanwhile, the second wave of flu spreads unchecked

through the Leviathan, as it voyages across the Atlantic.

By October the 3rd, they're halfway, taking the southern convoy route.

As the epidemic rapidly progressed, the hospital was immediately filled up.

So, they started trying to find isolation beds,

separate from the healthy population in other parts of the ship.

First in E deck then in other cargo holds such as F deck.

In F deck, In the Leviathan report,

there are up to nearly 900 men in there.

The U-boat menace means that every portal has to be shut at night.

And the air below decks, where the men sleep,

grows hot and heavy.

The number of sick increases rapidly.

COUGHING You'll be all right, son.

You have to remember that the Leviathan,

like any ship going across to France, was blacked out.

Inside, outside, no lights on, not even a cigarette.

COUGHING

Pools of blood from severe nasal haemorrhages of many patients

are scattered throughout the compartments.

And the attendants are powerless to escape trekking through the mess

because of the narrow passages between the bunks.

The decks become wet and slippery.

Groans and cries of the terrified

add to the confusion of the soldiers,

clamouring for treatment.

And altogether, a true inferno reigns supreme.

HE READS: "Things seem to grow worse instead of better.

"Cleaning details were demanded of the army, but few men responded.

"There is no organisation for control.

"The nurses made a valiant effort to clean up,

"but always against tremendous odds."

As it becomes evident that this ship is being engulfed by a terrible

plague, this also explains the fear.

To see your fellow soldiers suffering from something

that had never been encountered before...

Flu was a mild disease -

it's not supposed to do this.

If this is influenza, it's a strange kind of influenza.

Many die.

They want to take the bodies to Brest

and bury them in military graves,

but we are on the southern group, and it is very hot.

They have to take all the food out of the refrigerator

and put bodies in.

COUGHING

Even before the Leviathan completes her voyage,

the second deadly wave of flu is reaching London.

It's now autumn 1918,

and conditions at Basil Hood's hospital have deteriorated further.

At the end of October, we lose our first nurse to the influenza,

nurse Armitage.

And by November the 7th,

I have to record the death of four more nurses.

Sister Walker....

..Nurse Hunt...

..Nurse Ireland...

..Nurse Giles...

The last of whom was with us for just four days.

The new strain of flu kills rapidly.

CLATTERING

One poor nurse with a terribly acute influenza and pneumonia had become

so distressed that she cannot stay in bed

and insists on being propped up

against a wall by her bed.

Until she finally draws in her profuse, thin, bloodstained sputum,

constantly bubbling forth.

I know she is doomed and that her end is near,

so we do as she urgently desires us,

making her as comfortable as possible.

Back in Manchester, young Ada Berry has recovered,

but her mother is now critically ill with flu.

And since Ada's father has caught it too,

there is no-one left at home to look after her.

My mother is watching me as I get dressed and go with Auntie Annie.

She looks so sad.

I thought because I am leaving,

but now I think it is because she probably knows

she might never see me again.

Ada's mother dies the next day.

Unlike other types of flu,

this time children often recover while adults are more likely to die.

Also in Manchester, James Niven tracks the flu casualties,

far higher than the first wave.

A real calamity has befallen the city.

Great difficulty occurs in getting the dead buried,

partly due to the lack of grave-diggers,

partly due to the difficulty in getting coffins.

Bodies are left as long as a fortnight unburied.

Niven continues to pioneer ways of fighting the pandemic.

We are also loaned a film on influenza called Dr Wise.

This is shown in a number of cinemas in Manchester.

Precautions like this ensure Manchester is less severely hit

than other cities.

I think it's probably likely that hundreds of lives,

possibly thousands of lives

would have been saved by what Niven was doing.

All around the world,

people do their best to cope with the flu pandemic.

Public entertainment is curtailed.

If people go out, they wear masks.

People are keeping calm and carrying on,

but they are still wearing these strange white gauze masks.

It reminded me of early sci-fi,

as if some strange alien virus had arrived on Earth,

and everybody was just trying to carry on as normal.

WHISTLE BLOWS

The Leviathan is approaching the coast of France,

but the situation onboard is anything but normal.

Of the 9,000 soldiers, 2,000 are seriously ill.

Nearly 100 are dead.

The Leviathan arrived on the 7th of October.

In Brest, there was, well, continuing chaos.

There was an urgency around dealing with the dead.

Now, some of the dead had already been embalmed and put into caskets.

A few of the dead had been put overboard.

And the sick, when they disembarked, had to make their way to a hospital,

which was a full two miles away from the port.

And of course many died.

When we get to France, I am put in charge of the flu cases.

Because I've had the flu,

they thought I'd be immune to the infection.

But half the men we are nursing

have been brought in straight off the boat.

They just die within 24 hours after they get there.

The cemetery is just up the hill,

and every morning you can hear the bugle blowing

as they bury the bodies.

It is gruesome.

It really is. BUGLE BLOWS

But one country on the other side of the world

decides to take drastic action.

The government of Australia nervously observes the tentacles

of the virus spread towards them.

In October 1918,

they seal the entire country off from the outside world.

The Australians made sure that any ship that was arriving from other

countries was kept in quarantine for a long period in time,

and they maintained a very strict vigilance over the people who were

embarked from the ships into the quarantine station,

to make sure there was no cases of influenza.

The quarantine is the first international attempt

to stave off the flu and saves thousands of lives.

But elsewhere, the flu continues to rage.

The armistice is declared at 11am, on the 11th of November, 1918.

Alexander Jamieson, still at the front,

has survived the horrors of battle and the Spanish flu.

We've gone to bed in a hayloft,

and a sergeant comes in and shouts that the war is over.

Everybody gets up, we go into this wee village, and it's inhabited.

The owner opens up his pub and issues free drinks.

MERRYMAKING

What they don't realise is that the killing is about to accelerate.

COUGHING

CHEERING

The crowded streets,

the hugging and kissing are perfect vectors for the virus.

Armistice celebrations,

instead of celebrating the fact that the war was over,

were simply making it possible for the Spanish flu to spread.

Some families suffered the cruellest of blows,

losing loved ones to war and then the pandemic.

Catherine Garvin is in London with her mother for Armistice Day.

Fantastic news.

As the crowds celebrate,

for the Garvin family, a tragedy unfolds.

SHE COUGHS

On Armistice Day,

she's crying and crying through all the rejoicing and saying,

"It is too late for me."

The doctor had been in the morning and said she was better.

But on the eve of her 43rd birthday...

..her heart gives up and she goes.

My father finds her as she lies in bed.

The flu piles tragedy upon tragedy.

He has lost a son at the Battle of the Somme.

He is inconsolable.

Ada Berry has already lost her mother to the flu.

Now her father dies, too.

And her young brother, Noel, also perishes.

Two more of her close-knit family killed by the flu in as many days.

There were the black horses with the plumes made from ostrich feathers,

then the gun carriage with Dad's coffin covered with the Union Flag.

My mother's coffin was in a big glass hearse,

with Noel's coffin under the driver's seat.

My grandmother tells me my mother has gone to Jesus.

And I say,

"Jesus has got plenty of people.

"I want my mummy."

In London, Doctor Basil Hood struggles to keep his hospital

running through this terrible pandemic.

I am finding it increasingly difficult to get about the place,

as some 15 or 16 rounds a day are required of me.

All the work has to be done at top speed.

And the stress and distress, all coming at the end

of four and a quarter years of war.

I become incapable of continuing.

Hood's collapse turns out to be exhaustion rather than influenza.

But his time away leads to important changes.

In my absence, my deputy feels it necessary to engage

three more medical officers, and two of these are women.

This is the first time women doctors have ever been engaged

in the infirmary.

He was not only impressed by this, but proud.

The importance of this occasion demands their names be recorded.

Elizabeth and Marcella Kelly.

The Spanish flu brought around an enormous amount of social change.

Not only did it bring women doctors into hospitals,

but the organised response required to deal with the pandemic led to the

creation of the Ministry of Health.

In January 1919, the flu starts to decline.

And over the first half of the year, the number of victims falls.

500 days after the virus first appears,

the pandemic is ending.

The pandemic killed at least 50 million people,

possibly as many as 100 million,

which, compared with any pandemic,

is, you know, absolutely staggering.

The death toll of the pandemic

dwarfs the death toll from the First World War.

We're probably talking about ten to one, I would say,

at the very least.

In terms of death,

there are few comparisons.

I mean, the standard comparison is with the Black Death,

but the Black Death really affected continental Europe.

This affected the globe, and it did so in the speed of...

..of months rather than years or decades.

The success of the disease has become its own worst enemy.

By July 1919,

the virus has infected pretty much everyone in the world it can.

But as time goes by,

the number of vulnerable or susceptible people decreases

because they have already had that virus and their immune system

remembers that and protects them against it when they encounter it.

So the pandemic itself will almost burn itself out.

Take Alexander Jamieson.

Once he's had the flu, he's protected.

Survivors help end the spread of the disease.

The virus has also changed, evolving to become less deadly.

To be good at transmitting,

it's no good if you kill your host,

because that host is not going to transmit on,

so actually what you see with nearly all viruses is,

as they become accustomed to their new host, they calm down,

they become less dangerous in the new host,

because that gives them a longer chance of transmitting onwards,

and they are better adapted.

The virus has mutated into a form similar to normal flu.

The pandemic type has all but disappeared.

But could the killer return 100 years on?

What if the apocalyptic 1918 pandemic were to recur?

That's a scary prospect.

Of all the major disasters that could befall the human race,

I think pandemic is the most likely.

And it's growing more likely all the time.

This is a copy of the UK Pandemic Influenza Response Plan,

and the impact could be a 1918-type pandemic with severe illness

in young, healthy adults, which of course would be pretty devastating,

or it could be a pretty mild pandemic.

And in some ways, you have to plan for the worst case scenario,

because if that one comes and you're not ready for it,

then, you know, then you're in big trouble.

Planning for a modern pandemic has built on the work of pioneers

such as James Nevin.

More might have been done to limit the spread of the disease,

and the public health authorities

might be expected in future outbreaks to press

for further precautions to be taken.

Contrast Nevin's approach in Manchester

to that of Sir Arthur Newsholme,

responsible for the whole of Britain.

You tend to be remembered for the big mistakes, and, you know,

his failure to intervene more vigorously in 1918,

in the pandemic, was a mistake.

Even today, there is always a risk of someone making a catastrophic

mistake because other factors cloud their judgment.

Some aspects of a modern pandemic

will make it more dangerous than the one of 1918.

Colonel Gibson's hellish voyage across the Atlantic

took eight long days.

The story of the Leviathan is a microcosm

of how soldiers converging in Europe brought the virus with them.

But the flu will not travel by ships any more,

it will travel by planes and by other means.

So the potential for a virus to travel fast and further

is a reality here and now.

A new virus could crisscross the globe in 24 hours...

..making a quarantine like that of Australia in 1918

almost impossible to sustain.

But medicine has improved enormously in the last 100 years.

Doctor Basil Hood had no effective drugs to counter flu.

Most of what he and his nurses did was palliative.

If we look back from 2018 to 1918,

some significant things have changed.

The vaccines we have against it and the therapeutics that we have -

antibiotics against things like pneumonia,

which killed most of the soldiers at the time.

The science of influenza has also advanced.

Back in 1918,

William Welch couldn't possibly know

the cause of human flu was a virus

that originated in waterfowl...

..and that it jumped from a farm animal to a patient zero.

Nor did doctors understand why the flu killed healthy adults,

yet so often spared the children.

Ada represents in many ways a typical demographic.

Her mother got ill,

and eventually her father also got ill,

and they both died.

Ada survived. Although children fell ill,

they tended to survive,

whereas adults might get more serious illnesses,

but all were exposed to the same virus.

Science now has an answer.

What we do know about the 1918 virus is that it's a virus which can kick

off a thing called the cytokine storm,

so this is where your own immune system does more damage than good.

It ends up damaging organs,

and people with the very fittest and best responding immune systems -

young, healthy adults -

were the people who reacted worst to the virus.

This cytokine storm is driven by high levels of virus replication,

and today we have anti-viral drugs that help calm this storm.

So how bad could a modern pandemic be?

In 1918, about 3% of all the people infected with flu died.

This is called the fatality rate.

A worst case modern pandemic is estimated to be 1%.

It's reassuring to say that we do have ways of dealing with influenza

pandemics today, which were not available in 1918.

But I think that if we saw anything like, you know,

a 1% case fatality rate,

then it would be a terrible experience for everyone.

If a third of the British public caught a deadly new flu,

then a 1% fatality rate results in about 200,000 deaths.

We hope that with the various plans in place,

with the mitigating strategies, antibiotics, antivirals, vaccines,

good communication,

public health plans in place to stop spread of disease,

even with a serious virus emerging,

the idea behind all of these plans

is that that sort of case fatality rate would not be seen.

But the ever mutating nature of the bird flu virus means the threat of a

killer flu enveloping the world

will long remain our number one health risk.

# I opened up the window and in flew Enza... #

This nursery rhyme, influenza, they talked about it being a bird.

They had no idea, of course, that influenza was an avian virus.

So history doesn't always echo, but it rhymes.

So here's a great example of history rhyming, in a way.