Tag Archives: killed

Mother killed herself after ‘serious failure’ by mental health unit

A mother who killed herself while suffering from postnatal depression died as a result of a “very serious failure” that allowed her to leave a mental health unit unchaperoned, a coroner has ruled.

Despite having made multiple attempts to kill herself, 32-year-old Polly Ross was allowed to leave the Westlands mental health unit in Hull at about 8.30am on 12 July 2015, telling nurses that she was going to buy cigarettes. She was hit by a train at 11.10am and died instantly.

Speaking at the end of a four-day hearing, coroner Prof Paul Marks said he could not rule that Humber NHS foundation trust had been guilty of clinical neglect, but said the decision to allow her to leave the unit “had a direct causal effect” on her death.

Her mother, Jo Hogg, who was previously employed by the trust as an occupational therapist, thanked the coroner for conducting a “frank and fearless examination” of the circumstances surrounding her daughter’s death.

She said the trust had failed her daughter when she had needed their help the most and that care for women with postnatal depression in the region was “appalling”. She said that mental health services were “not joined up in a way that pays close regard to the complex needs of patients”.

The court heard how Ross, who ran a translation business in Paris before moving back to east Yorkshire in August 2012, had suffered from the extreme form of morning sickness, hyperemesis gravidarum, during both her pregnancies in 2012 and 2014. The condition has received media attention after it was revealed that the Duchess of Cambridge suffered from it during her pregnancies.

The condition caused Ross – who was described as “staggeringly intelligent” – to be hospitalised and put on a drip, which was said to have compounded her mental health issues. The inquest was told that she developed “drug-induced psychosis” after taking cannabis to relieve her symptoms and that when she asked to be admitted to a specialist mother and baby unit in Leeds, she was turned down.

In February 2015, the linguist was sectioned after a breakdown and her children were taken from her care. Over the coming weeks and months she regularly expressed suicidal thoughts and attended A&E on multiple occasions having self harmed or taken an overdose.

In a statement read to the court, Ross’s aunt Emma May, who acted as her carer after she was first sectioned, said she was certain that the few times her niece had left her home since February “were times she attempted to take her own life”. She said: “I cannot understand how she was allowed to leave the unit to buy her own cigarettes the morning she died.”

Giving evidence to the inquest, Dr Robert Kehoe, a Bradford-based consultant psychiatrist, said that while the overall standard of Ross’s care had been good, there were two serious failures on the part of Humber NHS foundation trust.

“One: there was a failure to clarify and state a plan for what should occur in the situation of a patient requesting to leave the unit,” he said. “Two: the effective decision to end the period of 15-minute observations allowed her to leave the unit at around 8.40am that day.”

Ross’s observations had been increased from once an hour to once every 15 minutes on 10 July after a ligature was found in her room. She was not sectioned at the time of her death, but Kehoe said there was “no logic” in increasing her observations only to allow her to leave the unit unescorted.

In a statement, Humber NHS foundation trust said: “We would like to offer our sincerest condolences to Polly’s mother, aunt, other family members and friends for their tragic loss. The thoughts of everyone associated with the trust continue to be with them at this sad time.

“We would also like to offer an unreserved apology to Polly’s family and friends and acknowledge that there were omissions in her care prior to her death on 12 July 2015. The trust acknowledges Prof Marks’ conclusion regarding the circumstances surrounding Polly’s death and has fully implemented all of the recommended improvements highlighted by our investigations.

“The trust will continue to reflect and learn and seek to continually improve the services we provide to patients.”

In October 2015, Marks ruled that Humber NHS foundation trust was guilty of neglect in the case of Sally Mays, 22, who killed herself after being turned away for inpatient mental health care. The same year, a coroner in Bristol raised concerns about mental healthcare for new mothers after 30-year-old Charlotte Bevan jumped off a cliff clutching her baby girl following a “chain of failures” by medical staff.

In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Other international suicide helplines can be found at www.befrienders.org.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Pale Rider by Laura Spinney review – the flu pandemic that killed 50 million

A high-security containment facility in Atlanta, Georgia, keeps under lock and key an organism that in the course of a few months from 1918-1919 was responsible for more deaths than the number of people killed in the first world war. Vanished until 2005, the H1N1 strain of the influenza virus was brought back to life for the purpose of better understanding its catastrophic effect on the world’s population a century ago. But as Laura Spinney points out in Pale Rider, the resurrection is not thought universally to be a good idea.

The Spanish flu pandemic, which killed at least 50 million people, has remained something of an enigma, not only because scientists are still unsure about why it was so lethal, but because it’s a hugely significant world event that for decades seemed to have been largely forgotten.

Pale Rider sets out to change this; it’s both a saga of tragedies and a detective story. At the end of the war, among weakened soldiers and undernourished populations, flu appeared as a shocking and unheralded visitor, and spread with alarming speed. Its victims reported dizziness, fevers, lethargy and coughing up blood; for at least two out of every 100 people who caught the bug, the outcome, within weeks, was death; especially vulnerable were those aged between 20 and 40.

There were no tools available to identify the invisible agent of disease. We now know that the flu virus is a parasite that needs the host cell of another living organism in order to reproduce. In human hosts the desired cells are those lining the lung. Once reproduction is complete, the replicated virus must leave the host, be carried in the air, and infect another, if it is to thrive.

Flu’s symptoms represent the body’s immune response to the viral invasion. Antibodies are triggered and immune cells rush to the site of infection, releasing viral-killing cytokine chemicals; a consequent local inflammation is perhaps a small price to be paid by the host.

Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19.


Virus H1N1, responsible for the Spanish Flu pandemic in 1918-19. Photograph: BSIP/UIG via Getty Images

But the flu virus also shows a propensity to mutate and generate variants; hence the need to manufacture new vaccines each year for seasonal outbreaks. In the case of the variant that came to be called the Spanish flu, the viral infection triggered a cytokine storm in some victims, a massive inflammatory response throughout the lungs that was hugely damaging to the host.

Spinney, an admired science journalist, conjures the drama of the Spanish flu when “your best chance of survival was to be utterly selfish” and “jealously guard your hoard of food and water, and ignore all pleas for help”. She charts the hysteria that broke out during the three waves of infection (the second being the most deadly) which swept across the globe.

There had been pandemics before, notably the Russian flu of the 1890s, which killed a million people, but nothing on this extraordinary scale. Bloated corpses clogged rivers; bells never ceased tolling for the dead; and smoke blocked out the sunlight for days as the unburied were cremated in huge funeral pyres.

The title of Pale Rider is taken from Revelation and the apocalyptic “Pale Horse, Pale Rider”, an African-American spiritual in which the rider’s name is Death. There are pitiful stories on every page, beginning with Guillaume Apollinaire, the French poet who, having survived the trenches and surgery to remove shrapnel from his brain, succumbed weeks later to flu. Doctors might save you from injuries inflicted on the battlefield but they had little to offer these victims. The great hopes for aspirin as a wonder drug that reduced fever were unfounded; penitent Christians in Zamora, Spain, were rewarded by their God with one of the highest mortality rates; gentiles in Odessa, borrowing the ancient Jewish ritual of the “black wedding”, chose couples to be married in the cemetery in the mistaken belief, as author Mendele Mocher Sforim wrote, that with “the knots tied amidst the graves of the parish dead, the contagion would at last stop”.


People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering

If the flu could not be treated, perhaps its spread might be curtailed. Countries attempted a policy of cordon sanitaire, closing their borders as they blamed each other for the virus’s origin; it had to have started somewhere. Over the decades, suspicion has fallen on three likely candidates associated with the movement of labourers and soldiers to the trenches: Shansi in China, Kansas’s Camp Funston and Étaples in France. None is yet to be proved. One thing is certain, though: the flu, despite its name, did not emanate from Spain.

Pale Rider is not just an excavation but a reimagining of the past. As the book progresses, the flu is cast increasingly as a character that crops up Zelig-like at important moments in history, altering the course of events previously unattributed to it. Spinney makes a compelling case, for instance, for considering Britain’s medical negligence in treating flu in its Indian colony as an eventual catalyst to India’s independence movement. She also argues that the flu, by producing sickly German soldiers, had an impact on the timing of the end of the first world war.

The mystery of why the Spanish flu was so vicious appeared partly solved when decades later a rare piece of preserved lung tissue from a victim of the 1918 pandemic was examined. Gene sequencing showed that its structure bore a close resemblance to the flu virus found in birds. Until the 1990s, it had been assumed that bird flu virus could not be transmitted to humans. But the virus had mutated and jumped species. Its foreignness meant that the human immune system was vulnerable and, unprepared for the shock, triggered a violent response.

People in 1918 had been stunned by the devastation. Afterwards, they chose to protect themselves by not remembering. So severe was the impact of this “mother of all pandemics” on the community of Alaska Natives of Bristol Bay that its elders advised survivors to nallunguarluku, “to pretend that it didn’t happen”. In many other places, decisions were taken to opt for silence, if less explicitly.

The Centers for Disease Control and Prevention believes another pandemic is likely, if not inevitable. Its researchers in Atlanta reversed the genetics system to generate the 1918 flu virus. While the anxiety has been expressed that it is a blueprint for bio-terrorists “to develop and unleash a devastating pandemic on the world”, the CDC maintains that the virus’s reconstruction militates against “the potential threat posed by new strains”.

The renowned virologist John Oxford concurs: “H1N1 has a proven capacity to kill,” he says, “and we don’t need to be sitting here taking it like they did in 1918.” Spinney has ably lent her pen to the cause.

Colin Grant’s A Smell of Burning: The Story of Epilepsy is published by Cape.

Pale Rider: The Spanish Flu of 1918 and How It Changed the World is published by Cape. To order a copy for £15 (RRP £20) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

Thai doctor fights against carcinogenic raw fish dish that killed his parents

A doctor in Thailand whose parents died from liver cancer after eating a much-loved raw fish dish is travelling the country’s rural north-east to warn people off the recipe.

Koi pla, a cheap plate of raw fish ground with spices and lime, is eaten by millions of Thais, especially in one of the nation’s poorest provinces, Isaan.

But the meal often contains parasites that cause a type of liver cancer believed to be killing up to 20,000 Thais per year. Isaan has the highest reported instance of cholangiocarcinoma, or bile duct cancer, in the world.

The aggressive cancer is often caused by a parasitic flatworm – or liver fluke – native to fresh water fish in the Mekong region.

“It’s a very big health burden around here,” Narong Khuntikeo, who went on to become a liver surgeon after he lost his parents, told Agence France-Presse.

“But nobody knows about this because they die quietly, like leaves falling from a tree.”

Without surgery, the disease has one of the lowest survival rates of all cancers, according to cholangiocarcinoma charities.

Narong has brought together scientists, doctors and anthropologists in his fight against the “silent killer”.

His team has spent four years driving ultrasound machines and urine testing kits around the Isaan region, testing villagers for the parasite. Up to 80% of the inhabitants of some communities were found to have ingested the parasite. At a recent testing visited by AFP, a third of villagers showed abnormal liver symptoms and four were suspected to have cancer.

“I’ve never been checked before, so I think I will probably have it because I’ve been eating [koi pla] since I was little,” said Thanin Wongseeda, a 48-year-old queueing up for the screening in Kalasin province.

Thanin’s test came back negative, but he said he would stay away from the uncooked fish salad from now on.

Narong is encouraging others to do the same but it is proving difficult, especially in a country famed for and proud of its treasured local dishes, their recipes passed down across generations.

Local health officials have introduced a school curriculum of colourful cartoons that aims to teach children about the risks of raw foods.

But older generations are harder to convince, says Narong.

“They’ll say: ‘Oh well, there are many ways to die,’” he said. “But I cannot accept this answer.”

Doctors recommend frying the mixture of chopped fish but many villagers say cooking the pink flesh gives it a sour flavour.

“I used to come here and just catch the fish in the pond,” said Boonliang Konghakot, a farmer from Khon Kaen province. “It’s so easy to eat raw.”

Thai doctor fights against carcinogenic raw fish dish that killed his parents

A doctor in Thailand whose parents died from liver cancer after eating a much-loved raw fish dish is travelling the country’s rural north-east to warn people off the recipe.

Koi pla, a cheap plate of raw fish ground with spices and lime, is eaten by millions of Thais, especially in one of the nation’s poorest provinces, Isaan.

But the meal often contains parasites that cause a type of liver cancer believed to be killing up to 20,000 Thais per year. Isaan has the highest reported instance of cholangiocarcinoma, or bile duct cancer, in the world.

The aggressive cancer is often caused by a parasitic flatworm – or liver fluke – native to fresh water fish in the Mekong region.

“It’s a very big health burden around here,” Narong Khuntikeo, who went on to become a liver surgeon after he lost his parents, told Agence France-Presse.

“But nobody knows about this because they die quietly, like leaves falling from a tree.”

Without surgery, the disease has one of the lowest survival rates of all cancers, according to cholangiocarcinoma charities.

Narong has brought together scientists, doctors and anthropologists in his fight against the “silent killer”.

His team has spent four years driving ultrasound machines and urine testing kits around the Isaan region, testing villagers for the parasite. Up to 80% of the inhabitants of some communities were found to have ingested the parasite. At a recent testing visited by AFP, a third of villagers showed abnormal liver symptoms and four were suspected to have cancer.

“I’ve never been checked before, so I think I will probably have it because I’ve been eating [koi pla] since I was little,” said Thanin Wongseeda, a 48-year-old queueing up for the screening in Kalasin province.

Thanin’s test came back negative, but he said he would stay away from the uncooked fish salad from now on.

Narong is encouraging others to do the same but it is proving difficult, especially in a country famed for and proud of its treasured local dishes, their recipes passed down across generations.

Local health officials have introduced a school curriculum of colourful cartoons that aims to teach children about the risks of raw foods.

But older generations are harder to convince, says Narong.

“They’ll say: ‘Oh well, there are many ways to die,’” he said. “But I cannot accept this answer.”

Doctors recommend frying the mixture of chopped fish but many villagers say cooking the pink flesh gives it a sour flavour.

“I used to come here and just catch the fish in the pond,” said Boonliang Konghakot, a farmer from Khon Kaen province. “It’s so easy to eat raw.”