Fever Year & Invisible War

1. Fever Year: The Killer Flu of 1918, A Tragedy in Three Acts
2. The Invisible War: a Tale on Two Scales

By Kevin Wolf

There are two graphic works that take place during World War I (WWI) and provide imaginative stories of bacterial and viral diseases. The spread of these diseases was helped by those war conditions. The viral one began in the United States—misnamed the Spanish Flu because of wartime censorship (more about that later)—and spread to the world as soldier-carriers traveled to the war front. The bacterial infection was dysentery—generally water- and food-borne—and spread by unsanitary conditions which may have been common on the battlefront. I wasn’t able to find a source providing the number of Dysentery deaths in WWI; but I did find that in the developing world currently there are 120-150 million infected annually with over 1 million dying from Shigella dysentery with 60% of them children under age 5. The Spanish Flu pandemic in 1918-1919 killed 20-50 million people or more worldwide (sources vary). This Flu pandemic’s mortality rate for those infected was 4% to 20% depending on the source. Its treatment—no cure has been found—should be familiar to those who’ve learned COVID-19 prevention rules; from sporadic public health announcements 100 years ago the public should wear a mask, socially distant, stagger business openings, and wash your hands. Fever Year: The Killer Flu of 1918, A Tragedy in Three Acts by Don Brown covers the viral spread from what’s believed to be its person zero origin in March 1918 to its end in 1919. The award-winning The Invisible War: a Tale on Two Scales created by Briony Barr & Dr. Gregory Crocetti, written by Ailsa Wild with Dr. Jeremy Barr, and illustrated by Ben Hatchings covers only a ten-day period in the life of a WWI Australian battlefield nurse, Sister Anne Barnaby, infected with dysentery; and is educational and entertaining though more at the microbial level than the WWI sized level. Both excellent graphic works provide lessons for today and how much more we need to learn from our past. I highly recommend both.

Fever Year: The Killer Flu of 1918, A Tragedy in Three Acts

Fever Year provides the origin story of the 1918 flu pandemic. The first known victim found was in the United States (U.S.) March 11, 1918 in Camp Funston (part of Fort Riley near Junction City Kansas) when their cook, Albert Gitchell sickened. Within a short period over 1,000 soldiers became ill and 48 died. Symptoms included fever, coughing, severe headache, limb aches, and difficulty breathing. Because communication to the enemy in wartime was feared (the U.S. entered WWI in April 1917), information about this disease outbreak was suppressed to the detriment of U.S. citizens. More people in the U.S. died from the 1918-1919 flu pandemic than died during WWI (675,000 vs. about 53,000 combat deaths). Similar downplaying that we see by President Trump with COVID-19 today occurred in 1918 by local health officials in the Fever Year as it spread across the United States to Boston, Philadelphia, New Jersey and eventually the west coast, especially San Francisco in late 1918. Back in 1918 health officials didn’t understand how diseases spread; we don’t have that ignorance today. There were useless “cures” then and now (e.g. onion diet then, and chloroquine / hydroxychloroquine now), shortages of medical providers and equipment, and, unrealistically optimistic politicians. Germ theory was in its infancy (e.g., dust was wrongly thought to spread the disease). Like today, there were desperate requests for more medical providers—overworked with some sickening—to help treat the increasing demands.

“Within four months of its appearance in the United States, people all over the globe fell ill to influenza” (page 11, Fever Year) because ill soldiers traveled to the WWI western front. It eventually spread to Spain & since Spain was neutral (i.e. didn’t fight) in WWI, there was no press censorship—that might leak to the enemy—of the deadly disease sickening & killing their population so it became known as the Spanish Flu, though it started in the U.S.

In 1918 two ships docked in New York City with sick passengers and Royal Copeland, the NY Health Commissioner, said “The city is in no danger of an epidemic. No need for our people to worry.” (45) The case and death counts rapidly climbed. Fever Year provides many anecdotes including a young Franklin Delano Roosevelt, future President, and President Woodrow Wilson contracting the disease and recovering; anti-spitting signs were posted in New York City. (45) Everything stayed open in New York and by November 14, 2018 over 145,000 cases and 20,000 deaths occurred. “Still, it was the lowest death rate—the number of dead per 100,000 people—on the East Coast.” (49) Girls jumped rope to “I had a bird and his name was enza. I opened a window and in-flu-enza. [sic]” (29)

Fever Year provides three acts: January – July 1918, August – December 1918, and 1919 & Beyond. It’s drawn in a Ralph Steadman style without the ink spillage, emphasizing browns, and light yellows. The ill patients have pale faces. It’s mostly narration with very infrequent word balloons in red with white lettering—source notes at the back of the book only match the word balloons—but the people speaking are often not identified. Historical events are not sourced (e.g. no source for 2/3 of Civil War dead was from disease; I provide a possible hyperlink). There’s an extensive bibliography.

Fever Year provides the source of the word “influenza,” namely, “ex influential colesti” meant “the sick were under a celestial influence” and later known as “una influenza” (12) and now shortened to “influenza” or “flu.” Symptoms included fever, pain in head/back/limbs, cough and trouble breathing. Coffins awaiting burial piled up. To his credit, Surgeon General, Rupert Blue, said, “No specific cure for influenza … and that many of the alleged cures and remedies … being recommended by neighbors, nostrum vendors, and others do more harm than good. “ (55) “On October 24 [1918], the city [of San Francisco] passed an ordinance requiring the wearing of masks.” (56) Josie Brown, nurse working 16 hour days, was quoted, “We wrapped [the dead] in a winding sheet and left nothing but the big toe on the left foot out with a shipping tag on it to tell the man’s rank, his nearest kin, and hometown.” (61) Fever Year provides the life cycle of the virus. This work brings the research to 1995 when a WWI dead soldier’s rediscovered tissue led to a breakthrough in finding the viral source of this pandemic. (87)

Other non-fiction graphic works by Don Brown include The Great American Dustbowl (2013), Drowned City: Hurricane Katrina and New Orleans (2015), The Unwanted: Stories of the Syrian Refugees (2018), and Big Ideas That Changed the World: Rocket to the Moon! (2019).

While Fever Year takes place mostly in the U.S., Invisible War occurs over ten days starting 23 August 1916 with the Battle of Pozières at a war front British Casualty Clearing Station, a field clinic. Such clinics were used to stabilize war casualties before being moved to better equipped facilities further behind the lines. This CCS included British, Australian, and New Zealand nurses. (Endnotes 1-4) The authors, publisher, and funding support for this graphic work are from Australia.

The Invisible War: a Tale on Two Scales

In The Invisible War: a Tale on Two Scales (Two Scales) the WWI scale—though covered in reasonable depth—primarily provides a segue to the more important story about dysentery at the microbial scale. Even today, dysentery’s impact is much worse than on the Western Front of WWI. After all, as mentioned earlier, dysentery still sickens over 100 million and kills about 1 million people annually in developing countries. Good sanitation prevents the spread; and its cure is fluids to replenish water loss from diarrhea and antibiotics which hadn’t been developed until Alexander Fleming (1881-1955) found penicillin in 1928 (Plagues page 60). The endnotes at the back of Two Scales are at least as important as the body of Two Scales. If there’s one take away from this book: our digestive system is filled with bacteria and viruses which are mostly beneficial though when invaders (e.g. Shigella flexneri bacteria) arrive the system can collapse if no countermeasures are taken; and the system tries to provide those counters.

The front cover of Two Scales provides the only color image with Sister Anne Barnaby shown in her military uniform with dysentery (Shigella flexneri) swimming in the background in a grey soup. The word “WAR” in the title has the center of the A be a myophage virus. At the back of the graphic work there’s a page (70) showing the “scales” (i.e. sizes) of the WWI events from 1,500 kilometer (km) length of the Western Front to 50 picometers (pm; 1 meter = 1,000,000,000,000 picometers or 10¹²) for hydrochloric stomach acid (HCI). Other scaled entities discussed include white blood cell—15 micrometers (μm; I couldn’t find this word and believe that the book means “micron” where 1 meter = 1,000,000 microns or 10⁶), Shigella flexneri (bacteria)—3 μm, and deoxyribonucleic acid (DNA) —2 nm (nanometer, where 1 meter = 1,000,000,000 nm or 10⁹ wide). Shigella flexneri is the primary cause of bacterial dysentery (there’s also a form of amoebic dysentery).

The story starts at the WWI scale where we see Sister Anne working at a British CCS. She’s an Australian nurse among about 2,300 in the Australian Army Nursing Service. We learn Australian soldiers weren’t conscripted (meaning “drafted” in the U.S; i.e., compulsory enlistment) for battle outside of Australia. Australian women’s battlefield roles were only as nurse volunteers; and they had to be widowed or single and childless.

There are many fascinating medical topics at least touched upon in the end notes. Casualties at CCS’s had numerous causes, such as wounds from bayoneting, shot off limbs, and gangrene (Note 4). Sister Anne treats a soldier suspected of dysentery (intestinal inflammation); based on his symptoms of bloody diarrhea and dehydration. Dysentery was known to be highly infectious so the patients were isolated and often resulted in death. Treatments were rudimentary; often disposing of soiled clothes and cleaning the soldier of fecal matter (Note 6 and pages 6-9) and providing clean drinking water, if available, to replenish water loss. There was a sophisticated—for its day—mobile lab (Note 7) to look at stool samples microscopically. Early 20^th century doctors were reluctant to accept germ theory or microscopic study as a diagnostic tool (note 11). Though Germany, Britain & France had signed an anti-poison-gas agreement before WWI, the German’s violated this agreement which led to both sides gassing each other. Gases included chlorine, phosgene and mustard gases with unpredictable distribution—Note 18 and according to The Secret History of the War on Cancer—pages 199-200—by Devra Davis (2007) mustard gas in WWI was found to kill off white blood cells and with leukemia being the overproduction of white blood cells this poisonous “discovery” later led to the first chemotherapy treatments. Gas masks might be available to survive a gas attack. Note 43 provides a brief discussion of war-related post-traumatic stress disorder (PTSD; though it was actually called “shell shock” in WWI). Spanish Flu is mentioned in Note 26 as “The most lethal virus ever documented” spread at the end of WWI “… with infected troops returning to their various homes in different countries …” There’s an Italian editorial cartoon provided as “Ůltima Hora” in that same Note.

At the microbial scale the illustrations are amazingly realistic. There’s an interesting sequence of magnifications—1x to 4000x—of a bloody rag from dysentery patient to see Shigella flexneri bacteria anthropomorphized along with red blood cells and mucus strands. The anthropomorphized dysentery bacteria provides some humorous commentary (e.g. “we just got carried away …” (15) when a riding on a fly) which reduces some of the seriousness of the bacteria’s destructive effect. The nurses don’t know a fly is carrying the dysentery bacteria and it lands on hard cheese—leaving some Shigella flexneri—that Sister Anne eats, which moves the story to the microbial scale.

Note 13 provides a flowchart from how a casualty might move from health facility to facility; and possible returning to the front if healthy enough to fight or nearby burial if dying. Other notes include how nutritionally poor the military rations were (note 14); our digestive system (pages 22-38, and notes 19-23 and notes 25-36) which explains the Shigella flexneri bacteria moving toward Sister Anne’s gut and battling toxic-to-them stomach—hydrochloric—acid; with a few survivors reaching the large intestines (aka, the gut) to try to wreak havoc. Oddly some notes are out of order from where the text locates them (e.g. text’s note order includes: 14, 17, 15, 16, 20, 18, 19, 21). One medical anecdote I had learned in the past was wrong; that was that the human appendix was useless. Note 25 provides a use for our human appendix—to restore good gut bacteria “after heavy bouts of diarrhea” or other destruction of our gut biome. Our intestines have trillions of bacterial & viral microbes with much to still learn about this essential microbiome (e.g. one gram of feces has more bacteria than there are humans on earth). (80) Viruses are discussed in Note 26. The book includes some of the authors’ theories (e.g., “Dr. Jeremy Barr proposed the Bacteriophage Adherence to Mucus (BAM) … protecting … their animal hosts from invading bacteria; … a beneficial symbiosis” (84 in Note 32).

Deep in Annie’s gut at magnification of 10,000x shows Bacteroides & Prevotella are enemies of Shigella flexneri. (39-40) Shows a Shigella flexneri reaching the lining (epithelial cell) of Annie’s gut and enters one cell—as invader the cell tries to self-destruct to kill the Shigella flexneri while the Shigella flexneri stops the self-destruction—to multiply and invade nearby epithelial cells and spread along the lining(41-43). Neutrophils, type of white blood cell—part of the immune system—try to destroy and stop the spread of the Shigella flexneri. (44 and Note 41) Mucosal cells erupt trying to flush the Shigella flexneri out of the gut (Note 42) which requires liters of water to be consumed by the human to prevent a dehydration death. The microscopic battle plays out in Sister Anne’s gut as a war with death and destruction, good and bad fighters all beyond her control. Two Scales provides a battle poem (50) of the phages:

Hunting fails … fear prevails

They tip the scales … Our world derails

This lock [Shigella virus] is new. We need a key.

That breaks into this enemy.

We must be clever. We must be wary.

We have to change. We have to vary.

Adapt, mutate …

Before it’s too late …

To hunt this new and deadly foe,

We learn from hosts … we already know.

No new key then

Try again, try again …

Will Sister Anne survive or will the Shigella?

The 2017 honors given to Two Scales include the Award for Excellence in Educational Publishing: Most Outstanding Resource of the Year and Best Secondary Reference Resource (Educational Publishing Awards Australia); Best Designed Educational Primary/Secondary Book (Australian Book Design Awards); Small Press Network MUBA (Most Underrated Book Award); and DeBary Children’s Science Book Award. The Two Scales website includes tools to use this graphic work in the classroom.

Both Fever Year about the 1918-19 flu pandemic and Two Scales occur nearby in space and time. They are both worthwhile additions to the pantheon that is Graphic Medicine. After reading this review, you might be interested in a review of two other highly recommended pandemic-related graphic works (The Great Hanoi Rat Hunt & Plagues) at graphicmedicine.org.