TIME health

When Did Mandatory Vaccinations Become Common?

Smallpox Vaccination
New York Daily News Archive/Getty Images Joseph Burns, 8, grimaces as doctor vaccinates him at St. Joan of Arc Parochial School in Jackson Heights, Queens, New York, in 1947

Anti-Vaxxers are upset with mandatory Measles vaccinations. But mandatory vaccinations have a long history in the United States

History News Network

This post is in partnership with the History News Network, the website that puts the news into historical perspective. The article below was originally published at HNN.

Herbal panaceas, special cloths, strict diets, cool drinks, eschewing fireplaces, and the edict that a patient’s bedclothes be no higher than the patient’s waist—these were the prescriptions of the pre-inoculation era when someone contracted smallpox. For centuries pandemic diseases devastated much of mankind. Hardly more than a century ago, 20% of children fell to disease before the age of five, a staggering 20% more died before entering into adolescence, survivors finding little recourse in adulthood from the scourges of the age—diphtheria, yellow fever, small pox, measles, pertussis, and a deadly handful of others. It was in such a dire period that the first federal health mandates were made and bore the political origins of compulsory vaccination.

A string of yellow fever outbreaks erupted between 1793 and 1798, taking thousands of lives and leaving the nation dizzy with loss. Shortly after the outbreaks, John Adams signed and established the first federal quarantine law against the recurrent epidemics of yellow fever. According to Carleton B. Chapman, an MD, the Federal Quarantine Proposal of 1796 met “virtually no opposition.”

A couple of years later, in 1798, Congress returned to the issue after a high percentage of marine workers succumbed to yellow fever. For the first time ever,, Congress required privately employed sailors to own insurance and authorized the collection of a monthly payroll tax to fund it. John Adams promptly signed the law when it reached his desk.

Chapman states that few founders contested the federal government’s responsibility to protect the population from epidemics like yellow fever. The real issue, he reports, “was which level of government should enact and enforce quarantine.” This was the same question that arose years later when vaccination gained popularity in the medical field. Wendy K. Marine, George J. Annas, and Leonard Glantz explain that while Jeffersonians were uncomfortable with a strong federal role, Jefferson himself favored a bill that required the federal government to “guarantee and distribute effective vaccine” and signed it into law in 1813. Ultimately, Congress decided that the best approach was to leave the implementation of vaccination efforts up to state and local authorities.

America had many years of experience with vaccinations. The Puritans provided for vaccinations against smallpox after an outbreak devastated New England. But immunizations weren’t required anywhere in the United States until 1809, when Boston imposed mandatory vaccination to quell recurring outbreaks of smallpox that patchy, voluntary vaccination was permitting. Subsequently, some states adopted similar legislation. Scholars Alexandra Minna Stern and Howard Markel report that incidences of smallpox markedly declined between 1802 and 1840, but made major reappearances in the 1830s and 1870s when public memory of life imperiled by disease had dimmed and “irregular physicians” of the 1850s challenged the practice of immunization with “unorthodox medical theories.” One skeptical leader, British immigrant and reformer William Tebb, claimed, facts notwithstanding, that vaccination induced 80% of smallpox cases. Further, he alleged 25,000 children were “slaughtered” in Britain each year thanks to the program. The arguments were preposterous and contrary to evidence, but resonated with the public.

There’s a striking parallel to current anti-vaxxer scares playing on people’s fears, like the discredited and recanted study that alleged vaccination induced autism. Anti-vaccinationist Dr. J.F. Banton warned that vaccination would introduce “bioplasm” into the bloodstream and expose subjects to the “vices, passions, and diseases of the cow.” Stern and Markel relate that critics of vaccination claimed it was a “destructive and potentially defiling procedure of heroic medicine” akin to blood-letting. Many working-class people voiced the fear you hear today that the work of scientists was an “assault on their communities by the ruling class” and an “intrusion of their privacy and bodily integrity.”

The upshot? Smallpox cases surged to numbers that had not been seen in decades. Consequently, many states enacted new vaccination laws while others began enforcing existing laws. This, in turn, stirred increased opposition. California, Illinois, Indiana, Minnesota, Utah, West Virginia, and Wisconsin, repealed compulsory laws in response to the agitation.

Cambridge, Massachusetts found itself in the throes of a smallpox outbreak in 1902. Disease beset the area and threatened to spread into a major epidemic. To stop this from happening in the future the state passed a law giving city boards of health the authority to mandate vaccinations. But some people objected. When officials ordered Henning Jacobson, a Swedish immigrant and Lutheran pastor to be vaccinated, he refused treatment on grounds of past harm, saying both he and his son had experienced “extreme suffering.” Jacobson’s status as an ethnic and religious minority likely contributed to his decision to refuse treatment. His distrust of authority is shared today by many African Americans, who well remember that racist scientists performed experiments such as the Tuskegee syphilis study on people of color.

In a sense, Jacobson represented the quintessential anti-vaxxer, which may be why his case caught the eye of the anti-vaccination league, which encouraged Jacobson’s recalcitrance and may or may not have provided the Harvard-trained James W. Pickering and Henry Ballard to represent him in court. Eventually the case made its way to the United States Supreme Court. In 1905 the Supreme Court ruled 7-2 in favor of the state against Jacobson; the Court having found that an immunization rate of 85-90 percent confers protection on the entire group. The landmark Supreme Court case Jacobson v Massachusetts served as the precedent for future court decisions and the foundation of public health laws.

The Supreme Court considered the ordinance again in 1922 when some objected to the requirement that school children be vaccinated. Once again, the principle of mandatory vaccination was upheld. By 1969 compulsory immunization laws in twelve states—Georgia, Hawaii, Illinois, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Mississippi, Rhode Island, Tennessee, and West Virginia—had expanded to include smallpox, measles, poliomyelitis, diphtheria, pertussis, and tetanus. Meanwhile, seven states—Arizona, California, Minnesota, North Dakota, South Dakota, Utah, and Washington—found it unlawful to compel citizens to be vaccinated for smallpox while still requiring pre-enrollment immunization for other diseases like measles.

Since its inception compulsory public health laws have generated skepticism and resistance. Today, recent measles outbreaks—176 affected from January 1st to March 13th, 2015—have revitalized a long-lived debate and precipitated discussion about new approaches to public education.

Cristina Valldejuli, a graduate of the University of Iowa, is an HNN intern.

TIME Infectious Disease

A New Blood Test Could Stop Doctors From Overprescribing Antibiotics

In this image provided by Duke University, lab research analyst Marshall Nichols does research relating to a new blood test on Tuesday, Sept. 17, 2013, in Durham, N.C.
Shawn Rocco—AP In this image provided by Duke University, lab-research analyst Marshall Nichols does research relating to a new blood test on Sept. 17, 2013, in Durham, N.C.

The procedure distinguishes between viral and bacterial infections

Scientists claim to have established a new blood test that can help doctors quickly distinguish between bacterial and viral infections, giving physicians the ability to prescribe antibiotics more accurately. That’s according to a study published by PLOS One on Wednesday.

Israeli-based company MeMed, along with researchers from other institutes, says that they examined over 1,000 patients and found that their ImmunoXpert blood test could distinguish between immune responses to bacterial or viral infections. The procedure is reportedly fast, taking only hours to complete when alternatives often require days.

“Antibiotic misuse is a pressing public health concern, with devastating healthcare and economic consequences,” stated MeMed CEO Eran Eden in a release to media. “Unlike most traditional diagnostics, this approach builds on an exquisitely informative system crafted by nature — the human immune system.”

While still in the laboratory stage, the test could be important because doctors have long struggled to identify the root causes of infections, meaning that antibiotics, which only attack bacteria, are often prescribed unnecessarily.

TIME medicine

A Simple 3-Part Test May Predict Alzheimer’s

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Chris Parsons—Getty Images

Dementia is a part of aging, but how do doctors separate normal brain decline from the first signs of Alzheimer’s? A new test that any physician can perform in their office may help

Diseases like Alzheimer’s start years, even decades, before the first symptoms of memory loss shows up. And with rates of those diseases rising, experts say that more primary care physicians—not neurology experts—will have the task of identifying these patients early so they can take advantage of whatever early interventions might be available.

“If we had a simple blood test, a cholesterol test for Alzheimer’s disease, that would help,” says Dr. Ronald Petersen, director of the Alzheimer’s Disease Research Center at the Mayo Clinic, “but we don’t.” But Petersen has a potential solution, and according to a new paper released Wednesday in the journal Neurology, his Alzheimer’s test has promise.

Petersen and his team wanted to develop a test that any physician can administer to patients, without the need for any new technology or expensive equipment. Petersen believes that the test they came up with could become a useful tool for any physician, even those without special training in the brain. “What we are trying to do is give them some help so they can be as efficient as possible without ignoring these important cognitive issues,” he says.

In the first phase of the test, his researchers simply collected information from 1,500 patients’ medical charts—their age, family history of Alzheimer’s, factors such as diabetes or smoking that have been linked to Alzheimer’s, and whether the patient had ever reported problems with memory.

In the next phase they studied the results of the patient’s basic mental exam as well as of a psychiatric evaluation, because depression and anxiety have been connected to Alzheimer’s.

And another factor that emerged as important in developing the disease—how quickly the participant could walk a short distance. “We were a little surprised,” says Petersen. “But what’s nice about it is that it’s a nice non-cognitive, motor factor so it’s looking at another aspect of brain function.”

MORE: This Alzheimer’s Breakthrough Could Be a Game Changer

Petersen suggests that every physician should get this information on their patients at age 65; that way, they can have a baseline against which to compare any changes as their patients age. Only if they show such changes — a slower walk, for example, or worsening signs of depression or memory issues — should they move on to the third phase of the test, which is a blood analysis. That would look for known genetic factors linked to Alzheimer’s, including the presence of certain versions of the ApoE gene.

Currently, the only way to truly separate out those on the road to Alzheimer’s is to conduct expensive imaging tests of the brain, or to do a spinal tap, an invasive procedure that extracts spinal fluid for signs of the amyloid protein that builds up in the disease. “We have either expensive techniques or invasive techniques and it’s not practical to do them from a public health screening standpoint,” says Petersen.

MORE: New Test May Predict Alzheimer’s 10 Years Before Diagnosis

While his test is a possible solution to that problem, he acknowledges that the results need be repeated before it’s recommended on a wide scale to physicians across the country. But those who scored higher on the test of risk factors had a seven-fold higher chance of developing mild cognitive impairment than those with lower scores.

For now, even if doctors identify patients around age 65 who might be at higher risk of developing cognitive impairment, there isn’t much they can do to interrupt the process. But they can direct them toward clinical trials of promising new drugs to address Alzheimer’s dementia, which may slow the cognitive decline considerably.

MONEY Health Care

The Scariest Health Care Statistic of 2014

Express Scripts reports that spending on medicine surged by 13.1% in 2014.

Healthcare has no shortage of frightening statistics, but a recent review of U.S. spending on medicine last year by the pharmacy benefit manager Express Scripts EXPRESS SCRIPTS HOLDING COMPANY ESRX -0.55% contained a particularly scary revelation: Last year, Americans shelled out 13.1% more for medicine than they did in 2013. That surge in spending could put our healthcare system on a perilous path, especially given that healthcare utilization is climbing on the tailwind from aging baby boomers and healthcare reform.

Better drugs equals pricier medicine

Thanks to innovative new therapies, people are living longer, but they’re doing so at a steep cost.

A decade ago, medicines were primarily small molecule drugs that were easy to manufacture and duplicate. As a result, these drugs were less costly to prescribe and were more quickly challenged by generic alternatives once their patent protection ended.

Today, medicines are increasingly complex biologics. These biologic drugs are medicines that are developed inside living systems such as plant or animal cells. Most biologics are complicated molecules or combination molecules that aren’t easily replicated. The complexity of biologics often translates into increased efficacy over prior generation drugs, but it also makes them much more expensive to develop and manufacture. It also makes it incredibly difficult for generic drugmakers to duplicate them once their patents expire.

The ongoing shift toward these increasingly complex — and correspondingly more expensive medicines — has resulted in them accounting for an increasingly larger share of our healthcare dollars.

According to Express Scripts, despite specialty drugs like biologics representing just 1% of all annual prescriptions, they accounted for a whopping 31.8% of drug spending last year.

Unsustainable spending?

Across the tens of millions of health insurance members covered by Express Scripts pharmacy plans, spending on the average member climbed to $668.75 per year for traditional drugs and $311.11 for specialty medicines.

As you can see in the following table, annual spending per member increased by 6.4% year over year for traditional drugs and by 30.9% for specialty drugs. In both instances, higher drug prices were overwhelmingly behind the increases.

If left unchecked, drug spending growth of this magnitude could be unsustainable. In 2013, IMS Health reported that U.S. spending on medicine clocked in at about $329 billion.

If spending increases by 13.1% per year over the next 20 years, the amount spent annually on prescription medicine would surpass $3.8 trillion (yes, with a “t”).

Taking matters into hand

Such a surge in drug spending would undeniably put patients at risk. Medical costs are the biggest reason for personal bankruptcy, particularly among patients with diseases like HIV and cancer.

In an attempt to blunt the risk to the system posed by runaway drug costs, pharmacy benefit managers, or PBMs, like Express Scripts and CVS Health CVS HEALTH CORPORATION CVS -0.72% — the two largest PBMs — are rethinking how they pay for drugs.

In December, Express Scripts negotiated a steep discount to AbbVie’s ABBVIE INC. ABBV -1.63% new hepatitis C drug Viekira Pak by offering exclusivity. In January, CVS Health similarly orchestrated a discount for Gilead Sciences’ GILEAD SCIENCES INC. GILD 1.22% competing hepatitis C drugs, also in exchange for exclusivity. Express Scripts estimates that its deal with AbbVie will save its clients $1 billion annually.

In addition to more aggressive price contracts with drugmakers, healthcare payers are also developing programs that can increase patient adherence to medicine to lower the risk of costly future healthcare events, as well as programs to increase the use of generic alternatives.

PBM programs that increase the use of lower cost generics could prove to be critical. Despite biologics’ difficult-to-copy nature, technology advances are helping generic drugmakers develop biosimilars. While not exact copies, these biosimilars deliver similar efficacy to their brand name counterparts. So far, biosimilars have been a bigger story in Europe than in the U.S.; however, the FDA approved its first biosimilar this month when it gave Novartis’ Sandoz unit the go-ahead to begin marketing its biosimilar of the top-selling cancer drug Neupogen. That approval is likely to be the first of many over the coming years.

Looking ahead

The financial stakes are high for patients and drugmakers. If prices are too low, it could force drug developers to focus only on diseases that offer the biggest payoff. That could derail advances in a range of orphan diseases. However, if prices for medicine continue to grow at this rate, it’s unlikely that the system will be able to afford it. Clearly, a middle ground is not only necessary, but in the best interest of everyone. Finding that middle ground, however, may remain difficult.

TIME medicine

Here’s How 23andMe Hopes to Make Drugs From Your Spit Samples

The company is making a bold move to enter the drug-making business by using the genetic information donated by its clients

On March 12, 23andMe, the genetic testing company best known for analyzing your DNA from a sample of spit, announced the creation of a new therapeutics group. The group’s mission: to find and develop drugs from the world’s largest database of human genetic material.

That’s a huge shift for the company, which must now build a research and development arm from scratch. Richard Scheller, formerly of the biotechnology corporation Genentech, will lead the group and will also be 23andMe’s chief science officer.

Scheller admits that for now, he’s the therapeutics group’s only member. But soon after he starts on April 1, he anticipates that things will move quickly, as they do in the genetics world. That’s what attracted him to 23andMe after overseeing early drug development at Genentech for 14 years. “I’ve seen over the last couple of years how human genetics has impacted the way Genentech does drug discovery, and I thought it might be fun and interesting to work in an unrestricted way with the world’s largest human genetic database,” he says. “The questions we will ask are research based, but we could identify a drug target extremely quickly. I believe there is the real possibility to do really, really great things for people with unmet medical needs.”

MORE: Genetic Testing Company 23andMe Finds New Revenue With Big Pharma

More than 850,000 people have paid 23andMe to sequence their DNA since the company launched in 2006 until 2013, when the Food and Drug Administration requested that the company stop selling its medical genetic information services over concerns that their marketing claims weren’t supported by strong enough evidence about how the genetic information influenced human health. The company still retains that genetic information and continues to sell kits, but provides only non-medical information now while it continues to work with the FDA on further regulatory issues.

That experience “transformed” the company, as CEO Anne Wojcicki said to TIME earlier this year. Since then, the company has expanded its collaborations with pharmaceutical companies to access its database. The latest addition of drug development is a further evolution in the company’s identity.

Of those who have sent in samples, 80% have agreed to allow their genetic information to be used for research purposes. That’s the database that Scheller is eager to investigate. While at Genentech, he helped broker a collaboration between the biotech firm and 23andMe in which Genentech would have access just to the genetic testing company’s Parkinson’s disease patients, to search for any genetic clues to new therapies. Now, he says, “I plan on asking hundreds or maybe thousands of times more questions of the database than any pharmaceutical partner.”

MORE: 23andMe Finds Genes for Motion Sickness

He will be looking, for example, at whether patients who develop a certain disease tend to have specific hallmark genetic changes in their DNA, which could serve as potential launching points for new drugs. Or he might focus on the extreme outliers: people who have advanced cancer, for example, but somehow survive, or those who seem to succumb early. Mining their genomes might yield valuable information about what makes diseases more or less aggressive, and might become targets for drugs as well.

To do this, Scheller will have to create a drug development team from the ground up. The company is not divulging how much it intends to invest in this effort, but is soliciting another round of financing in the coming months. Initially, Scheller anticipates that even before the company has labs set up, he and his team will take advantage of labs-for-hire, or contract research organizations, to start doing experiments within weeks. Because his drug candidates will be more targeted and designed to address specific mutations or processes in the body, he anticipates that the cost of developing drugs that patients might eventually benefit from may be “substantially reduced” from the average $1 to $2 billion most pharmaceutical companies now spend.

MORE: Time Out: Behind the FDA’s Decision to Halt Direct to Consumer Genetic Testing

As for which disorders or medical issues he will tackle first, Scheller is being democratic. “We are going to be opportunistic,” he says. “That’s the nice thing about being part of 23andMe. We don’t really have a say. We can look generally at the database, and try and let it teach us what we should be working on.” In other words, anything is game.

TIME medicine

First Successful Penis Transplant ‘Massive Breakthrough’, Doctors Say

The operation took 9 hours to perform

A 21-year-old man has received the world’s first successful penile transplant, surgeons say.

The man, whose name was not revealed for privacy reasons, had his organ amputated three years ago after a circumcision went wrong. Doctors at Stellenbosch University and Tygerberg Hospital in South Africa operated for nine hours in December, and just a few months later they say he’s already regained full function in the transplanted organ —a much faster recovery than they had hoped for.

“It’s a massive breakthrough. We’ve proved that it can be done – we can give someone an organ that is just as good as the one that he had,” Prof Frank Graewe, head of the Division of Plastic Reconstructive Surgery at Stellenbosch University, said. “It was a privilege to be part of this first successful penis transplant in the world.”

While at least one other attempt has been made at penile transplant, the surgeons say this is the first such operation to succeed.

In their announcement, the doctors emphasized the psychological trauma of penile amputation, a problem they say is particularly acute in South Africa.

TIME ebola

Why West Africa Might Soon Have 100,000 More Measles Cases

Now more than ever: Measles vaccinations have dramatically cut disease rates in Africa
Spencer Platt; Getty Images Now more than ever: Measles vaccinations have dramatically cut disease rates in Africa

One lethal epidemic could give rise to another

Correction appended, March 12

There’s not a war college in the world that couldn’t learn a thing or two from the way viruses operate. They’re stealthy, they’re territorial, they seek and destroy and know just where to hit. And, just when you think you’ve got them beat, they forge an alliance with another of your enemies. That, according to a new paper published Thursday in Science, is what’s poised to happen with Ebola and measles—and it’s the babies and children of Africa who will overwhelmingly pay the price.

The Ebola epidemic is by no means over, but it is being contained and controlled. With nearly 24,000 cases and more than 9,800 fatalities so far—mostly in Guinea, Sierra Leone and Liberia—the epidemic is still claiming new victims, though more slowly. The crisis, however, has disrupted health-care delivery across the entire affected region, preventing children from receiving badly needed measles vaccines. That, the new study reports, could result in an additional 100,000 measles cases over the next 18 months, leading to an additional 2,000 to 16,000 deaths. Rates of vaccination against other diseases—particularly polio and tuberculosis—have fallen too. But measles’ ease of transmission makes it especially worrisome.

“When there’s a disruption of medical services, measles is always one of the first ones in the door,” says Justin Lessler, of the Johns Hopkins Bloomberg School of Public Health, a co-author of the paper. “The Ebola epidemic significantly increases the likelihood of a major measles outbreak occurring.”

Lessler and his co-authors arrived at their numbers painstakingly. First, they used health data to map and estimate the share of vaccinated and unvaccinated children in 5 km by 5 km (3.1 mi. by 3.1 mi.) squares across the three affected countries. They then estimated a 75% reduction in vaccination rates during the epidemic and projected forward by 6, 12 and 18 months. They factored in the transmissability of the virus within each region and estimated the likely number of deaths using what’s known as a Case Fatality Ratio—a mathematical tool that, as its name suggests, estimates lethality for any particular disease under any particular set of circumstances.

The final numbers—especially the potential 16,000 deaths—rightly alarmed the researchers, though lessler does admit that they are by no means a certainty. “The 75% decrease in vaccinations is a little too pessimistic,” he concedes. But the critical word in that admission is “little,” and the investigators did consider 25%, 50% and 100% rates too, before settling on 75% as at least the most plausible. No matter what, the odds are still high of a five figure death rate and a five to six figure additional case rate—and the Ebola epidemic, which led to the problem in the first place, has not even fully abated.

Lessler and his colleagues are not waiting until it does to sound the alarm, urging global health groups to mobilize a vaccination campaign now so it can be ready to launch in the affected areas the moment the Ebola all-clear sounds. The new push would first target children who were born during the Ebola epidemic since they would have likely received almost no medical attention at all up until that point, and then expand to all children in the most measles-susceptible age group—about 6 months to 5 years.

“The best time to start the campaign would be as soon as it’s logistically feasible,” says Lessler. “For every month no campaign begins, the risk of an outbreak occurring and the impact of such an outbreak worsens.”

The happy news, Lessler believes, is that done right, the campaign could not only prevent the measles epidemic from beginning, but could actually put West Africa in a better position than it was before Ebola, with vaccine coverage for measles and other diseases exceeding the pre-outbreak rates. “Previous campaigns have reached coverage in excess of 90%,” he says.

Victory in the battle against Ebola—to say nothing of the battle against measles—is by no means yet assured. But, again as the war colleges would teach, with the right cooperation and the right deployment, the good guys can win.

Correction: An earlier version of this story misidentified an assistant professor at the Johns Hopkins Bloomberg School of Public Health. He is Justin Lessler.

TIME health

What Made the Spanish Flu so Deadly?

Red Cross 1918
APIC / Getty Images Red Cross volunteers fighting against the spanish flu epidemic in United States in 1918

Mar. 11, 1918: A soldier in Fort Riley, Kans., reports to the infirmary with what will become known as Spanish flu

Nearly a century after it made its grisly debut, the mysteries surrounding Spanish flu continue to plague epidemiologists. In 2005, as Slate has reported, scientists succeeded in sequencing the virus’ RNA — eight years after exhuming a flu victim’s frozen corpse from an Alaskan grave to obtain a sample. But they still don’t know exactly where the virus came from or how it achieved such staggering lethality, killing more than half a million Americans and an estimated 50 million people worldwide in a single year.

Some researchers believe the story began on the morning of this day, Mar. 11, 1918, when a soldier in Fort Riley, Kans., went to the camp infirmary with a fever. According to the PBS documentary Influenza 1918, more than 100 soldiers had reported to the infirmary by noon. Within a week, that number had quintupled. Several dozen soldiers died there that spring, before the contagion seemed the ebb; the official cause was pneumonia.

As soldiers fanned out to fight World War I, however, the virus made its way around the globe, from European battlefields to remote areas of Russia and Greenland, spawning two more pandemic waves that were even deadlier than the first. (It became known as Spanish flu only because the Spanish news media was the first to widely report the epidemic, which had been hushed by wartime censors elsewhere in Europe.)

What made this flu different from all other flus was a dramatically higher fatality rate, plus the fact that while ordinary flus claimed casualties among the very young and the very old, this virus was especially deadly to young adults between the ages of 20 and 40. And their deaths weren’t pretty. As Slate tells it, “Many sufferers came down with severe nosebleeds — some spewed blood out of their nostrils with such force that nurses had to duck to avoid the flow. Those unable to recover eventually drowned in their own bodily fluids.”

Why Spanish flu was so fatal, especially to people in the prime of their lives, is what scientists are striving to understand, as TIME reported in the wake of Hong Kong’s 1997 avian flu outbreak. It was during that outbreak that a pathologist named Johan Hultin collected an intact, long-frozen sample of the Spanish flu virus from a mass grave in a tiny Alaska town called Brevig Mission, where 85 percent of the population had been felled by the flu in a single week. Research on that sample has shown that one way Spanish flu worked was by overstimulating the immune system and turning it against its owner — so having a strong immune system to begin with may have been a disadvantage.

But there is more to it than that, other scientists say. And understanding the full story of Spanish flu could help develop vaccines to protect us from the next flu epidemic — an epidemic that is inevitable, as Hultin told TIME in 1998. In the meantime, there’s only one surefire method of surviving pandemic flu, according to Hultin: Isolate yourself in a mountain hideaway until the outbreak subsides. TIME explains: “It was a tactic… successfully used in 1918 by a village just 30 miles from Brevig. Its elders, after learning of the advancing plague, stationed armed guards at the village perimeter with orders to shoot anyone who tried to enter. The village survived unscathed.”

Read original coverage of the Hong Kong outbreak, here in the TIME archives: The Flu Hunters

Read next: Why the Government Has Legal Authority to Quarantine

Listen to the most important stories of the day.

TIME Innovation

Five Best Ideas of the Day: March 6

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. India has banned a documentary on the 2012 gang rape that rocked the country. That was a huge mistake.

By Shashi Tharoor at NDTV

2. Berkeley decided to give campus departments a real incentive to cut power consumption by charging them directly — and energy use went down.

By Meredith Fowlie in The Berkeley Blog

3. Pakistan is helping Afghanistan’s president make peace with the Taliban. Other powers should back him.

By the Economist

4. Ukraine’s military will never be strong enough to beat Russia outright. But it doesn’t have to be.

By Alexander J. Motyl in Foreign Policy

5. Micro-bubbles — guided with magnets, deployed with sound waves — could revolutionize the delivery of medicine and even chemotherapy.

By Charvy Narain at the Oxford Science Blog

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME medicine

Chain of Kidney Transplants Begins at San Francisco Hospital

Kidney donor Zully Broussard speaks at California Pacific Medical Center on March 4, 2015 in San Francisco
Leah Millis—AP Kidney donor Zully Broussard speaks at California Pacific Medical Center in San Francisco on March 4, 2015

This is the largest kidney-donation chain in the transplant center's history

(SAN FRANCISCO) — Zully Broussard thought she was going to help one person by donating a kidney.

Instead, she helped six.

The Sacramento woman’s donation to a Benicia man set off an organ swap that resulted in five more sick people getting new kidneys at a San Francisco hospital. Three transplants were completed Thursday, and the remaining three will be done Friday.

“I thought I was going to help this one person who I don’t know. But the fact that so many people can have a life extension, that’s pretty big,” Broussard said.

Domino-like kidney swaps are still relatively new, but they are becoming increasingly common.

With a total of a dozen patients and donors, this week’s surgeries at the California Pacific Medical Center represent the largest kidney donation chain in its transplant center’s 44-year history, hospital spokesman Dean Fryer said. The patients at are between 24 to 70 years old, and most of them are from the San Francisco Bay Area.

Transplant chains are an option when donors are incompatible with relatives or friends who need kidneys.

In this case, six donors are instead giving kidneys to strangers found through a software matching program developed by 59-year-old David Jacobs, a kidney recipient whose brother died of kidney failure. Its algorithmic program finds potential matches using a person’s genetic profile.

Jacobs, of San Francisco, said he understands firsthand the despair of waiting for a deceased donor.

“Some of these people might have waited forever and never got the kidney,” he said. “But because of the magic of this technology and the one altruistic donor, she was able to save six lives in 24 hours.”

Fewer than 17,000 kidney transplants are performed in the U.S. each year, and between 5,000 and 6,000 are from living donors, considered the optimal kind.

Kidney swaps are considered one of the best bets at increasing live-donor transplants, and they are becoming more common as transplant centers form alliances to share willing patient-donor pairs. The United Network for Organ Sharing has a national pilot program underway.

In 2001, Johns Hopkins Hospital in Baltimore, Maryland, performed a transplant chain that started as a two-way kidney exchange and grew to 30 pairs.

Jacobs’ kidneys failed in early 2000 from a genetic disease. In late 2003, a living unrelated donor provided an organ for a transplant.

A new chance at life got him thinking.

“I talked to my doctor about kidney-paired donation. He was excited about the idea but didn’t know how to do it,” he recalled. “I was a tech person. I’ve been in technology my whole professional career. I thought of it as an enterprise software problem I could solve.”

He said the two months he imagined it would take to take to develop the software stretched into six years.

The National Kidney Foundation reports more than 100,000 people in the United States are awaiting kidneys, and 12 people die a day while waiting.

Broussard said her son died of cancer 13 years ago and her husband passed away 14 months ago, also from cancer.

Asked why she volunteered to donate a kidney to a stranger, the 55-year-old said: “I know what it feels like to want an extra day.”

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