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widespread typhus epidemic, which was taking its toll in both urban and rural areas. Consequently,
the flu came into an environment already beset by the calamities of war, famine and disease. 46
But Akfhami argues that the principal multiplier of influenza mortality in Iran, even more than hunger,
was malaria. He finds dramatic correlations between malaria incidence and influenza mortality, both
among the local population and the Indian troops of the British Army. Cities with chronic malaria, such
as Mashhad, had influenza death rates triple those of cities with low malaria rates, such as Tehran. The
climax of pandemic mortality in November coincided with the usual “peak period of malignant tertian
malarial fevers among Iranians.” Akfhami also observes that malaria sufferers, including both Iranians
and Indians, were afflicted with anemia and were notoriously susceptible to pulmonary infections. 47
Poverty, malnutrition, chronic illness, and co-infection were thus powerful determinants of the precise
tax that the 1918 influenza exacted from different populations. Indeed, the global pandemic itself was
really a constellation of individual epidemics, each shaped by local socioeconomic and public-health con-
ditions. In some countries, such as India and Iran, the co-factors (hunger, malaria, anemia) formed deadly
nonlinear synergies with influenza and its secondary infections. Although most of the literature on the
1918 pandemic has focused on its unusual preference for young adults, including the robust and well-fed
young soldiers of the American Expeditionary Force in France, the correlation between social class and
lethality in virtually every country was no less striking. In the most sophisticated analysis of pandemic
mortality yet undertaken—a case-study of the 1918 virus in Sydney—Kevin Cracken and Peter Curson
found that “the working class and blue-collar workers experienced the heaviest death rates,” particularly
in the inner city, and that unemployment was as consistent a predictor of mortality as more conventional
epidemiological factors such as persons per room density. 48
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