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ICU and You  ·  Historical Snapshots  ·  Number 1

Twenty pounds of serum

Nome, Alaska, 1925 — a diphtheria outbreak, twenty mushers, about 150 dogs, and the wrong dog on the statue

A new column

Historical Snapshots is for the history buffs, and for anybody who has ever wondered how we got here. One moment, held still, and the question of what was different afterwards. Not a potted history of medicine — more often a story that happens to have medicine in it, or people in it who were doing their best with what the year had given them. Some of it will be about children. Some of it will be uncomfortable. All of it is chosen because it is worth knowing and because it is a good story, which are not the same test but are a good pair to apply together.

The Great Race of Mercy  ·  Nenana to Nome, Alaska  ·  27 January – 2 February 1925  ·  674 miles (1,085 km)  ·  20 mushers, about 150 dogs  ·  cargo: 300,000 units of diphtheria antitoxin, about 20 pounds, wrapped in a quilt

On 22 January 1925 the only doctor in Nome, Alaska, sent a telegram that read like a man who had already worked out how this ended. He had a confirmed case of diphtheria in a three-year-old boy, at least twenty more children he was worried about, a town of some 1,400 people iced in until spring, and not one vial of antitoxin that had not expired.

Curtis Welch was a United States Public Health Service officer running a small hospital with four nurses. He had ordered fresh antitoxin the previous summer. It had not arrived before the port froze, and the port would not open again until June. He asked for a million units.

What made the telegram urgent rather than merely bad was something Welch did not have to spell out to anyone in Alaska. Seven years earlier the 1918 influenza pandemic had gone through Nome and killed roughly half of the town's Alaska Native population. Everybody remembered. An epidemic arriving in a community with that in its recent memory was not an abstraction about case fatality rates. It was a thing they had watched happen.

The argument about the aeroplanes

There was a modern option, and it was taken seriously.

The editor of the Fairbanks Daily News-Miner, who also happened to have founded the Fairbanks Airplane Corporation, pushed hard to fly the serum in. He had a willing pilot. Roald Amundsen, of all people, publicly agreed. It was 1925, aviation was the future, and here was the future's obvious moment.

What the future actually consisted of, in Fairbanks that January, was three surplus open-cockpit biplanes with water-cooled engines, dismantled for the winter, which had never been flown below about −10°F. The longest flight anyone had managed locally was around 260 miles. Nome was 674 away.

Nome's Board of Health voted unanimously for dogs. The Territorial Governor, Scott Bone, made the final call and agreed. Hold that decision in your mind, because it gets tested later in a way that is almost too neat.

The relay

Three hundred thousand units were found in a hospital in Anchorage — not enough, but something — wrapped, padded, packed into an insulated quilt, and sent north on the Alaska Railroad to Nenana, which was as far as any train went. The parcel weighed about twenty pounds.

At Nenana on the evening of 27 January it was handed to Wild Bill Shannon, who ran the first fifty-two miles in something around −50°F, dropping to perhaps −62°F. He arrived with frostbite on his face and had lost dogs to the cold. Then he handed the parcel on, and so did the next man, and the next.

Twenty drivers ran it in relay, each covering his own stretch of country in the dark. There was no coordination in any modern sense — roadhouse to roadhouse, a man waiting, a parcel changing hands, a team going out again. On the exposed coastal sections the wind chill was reckoned at something near −85°F.

The stretch everybody remembers belonged to Leonhard Seppala and his lead dog Togo, who was about twelve years old. Seppala had driven 170 miles out from Nome to meet the relay coming the other way, then turned around and carried the serum ninety-one miles back — the longest single leg of the whole run, at the end of a journey of some 261 miles in total.

Part of it went straight across the sea ice of Norton Sound, in a blizzard, at night, because going around would have cost a day. The ice they crossed broke up about three hours behind them.

What was in the parcel, and why hours mattered

Diphtheria kills two ways. The organism sits in the throat and builds a tough grey membrane that can spread down and block the airway outright — with the swelling of the neck that the textbooks still call a bull neck. And it releases a toxin that shuts down protein synthesis in whatever tissue it reaches, which in practice means heart muscle and nerve.

Antitoxin is not an antibiotic and it is not a vaccine. It is borrowed antibody, and it neutralises toxin that is still circulating. Toxin that has already bound to tissue is beyond its reach — nothing brings that back. So the whole desperate arithmetic of the run had a precise pharmacological basis: every hour of delay moved more toxin from the column marked neutralisable to the column marked fixed. Untreated, the case fatality runs somewhere around five to ten per cent, and higher in small children.

If you have never seen it, that is the point of vaccinating. If you ever do see it, you will want the airway sorted early and the antitoxin given on suspicion rather than on confirmation, for exactly the reason above.

The names that did not make the papers

At least ten of the twenty mushers were Alaska Native — Athabascan and Inupiat — and between them they covered about two-thirds of the 674 miles. Edgar Kalland. Johnny Folger. Sam Joseph. Titus Nikolai. Harry Pitka. Jackscrew. Charlie Evans. Tommy Patsy. Victor Anagick. Myles Gonangnan.

The newspapers of the time were not much interested. This is worth sitting with for a moment, because the population most at risk in Nome was Inupiat, the people who carried the serum most of the way were Alaska Native, and the figure who ended up in Central Park was a dog.

Kalland, asked about it long afterwards, said that it was just an everyday occurrence as far as they were concerned.

The dog on the plinth

Gunnar Kaasen took the final leg, fifty-three miles from Bluff, and reached Nome at half past five in the morning on 2 February. Not a vial had broken. He had gone through Point Safety without waking the musher waiting there to take over, and run the last twenty-five miles himself — a decision people have been arguing about ever since.

His lead dog was Balto, and Balto is the one who became famous, because Kaasen's was the team the photographers met.

Seppala was scathing. He had bred Balto, judged him second-rate, had him neutered at six months and put him on the freight teams; he later described him in print as a scrub freight dog who had never been in a winning team. There is even a decent argument, made by people who were there, that the dog actually leading Kaasen's team that night was one called Fox.

None of which stopped New York. A statue went up in Central Park on 17 December 1925 — within the year — and Balto attended his own unveiling, which is said to make him the only subject of a Central Park monument ever to turn up for it.

And here is the part almost nobody notices. Read the inscription and it does not honour Balto at all. It is dedicated to the indomitable spirit of the sled dogs that relayed the antitoxin — all of them, plural, the whole relay. The plinth says ENDURANCE · FIDELITY · INTELLIGENCE. The monument got it right. The retelling is what narrowed it to one animal.

The sideshow, and the children who bought him back

Fame lasted about two years. Kaasen toured with the dogs, then sold them on, and by February 1927 Balto and six of his teammates were chained to a sled in a dime museum in Los Angeles, underfed, ribs showing, exhibited for a dime.

A Cleveland businessman named George Kimble walked in, recognised them, and would not let it go. He got the owner to name a price. Back in Cleveland a committee formed, a newspaper and three radio stations took it up, and the city was given about ten days to raise roughly two thousand dollars.

They did it in a week and a half, largely in small change. Schoolchildren gave their milk money. Coins came in by the handful from people who had nothing much to give.

Children in Nome were the reason the serum ran. Children in Cleveland were the reason the dogs came home.

Balto and his team arrived by train and were paraded through Public Square on 19 March 1927. They went to live at Brookside Zoo, and about fifteen thousand people came to see them on the first day. He died there in 1933, at about fourteen, and Cleveland raised another subscription to have him mounted. He is still on display at the Cleveland Museum of Natural History, where anyone can go and look at him.

Togo, who had done the hard part, retired to a kennel in Maine, founded a bloodline, and died in 1929 at sixteen. He is also still with us, in two pieces and two places: his mounted skin at the Iditarod headquarters in Wasilla, his skeleton at Yale.

What the films did with it

Two animated and dramatised versions have shaped what most people think they know, and it is worth being precise about which is which, because they are usually muddled together.

Balto (1995) is the cartoon, and it is not a Disney film — it was made by Spielberg's Amblimation and released by Universal, which is a small fact that gets mangled constantly. Its liberties are large and cheerful: Balto is a half-wolf outcast shunned by the other dogs, there is an invented rival who sabotages the run, an invented love interest, a Russian-accented goose and a pair of comic polar bears, and by the end Balto is more or less finding the serum single-handed. The twenty mushers are essentially gone.

Togo (2019) is the Disney one, made for Disney+ with Willem Dafoe as Seppala, and it exists more or less to correct the first film. It puts Seppala and Togo at the centre, gets the Norton Sound crossing close to the record, and ends by pointedly contrasting the statue in New York with what Alaskans have always thought. It takes its own liberties — it keeps Togo in Alaska when he in fact went to Maine, and gives him the lead alone when he shared it — but it is arguing with the record rather than ignoring it.

Balto settles it himself, ninety-eight years later

In 2023 a team sequenced Balto's genome from tissue taken from the mounted specimen in Cleveland, as part of a comparative genomics project, and published it in Science.

He had no meaningful wolf ancestry. The central dramatic premise of the 1995 film is not merely invented but disproved — by the dog. What he did have was an unusually mixed inheritance: Alaskan sled dogs, village dogs, Greenland dogs, something of Tibetan mastiff. He was more genetically diverse than any modern breed, which is very likely part of why he could do what he did.

A museum specimen mounted in 1933 answering a question raised by a cartoon in 1995 is, on any view, a good day for keeping things.

Two postscripts, one of them very hard to read

Three hundred thousand units were never going to be enough. A second consignment of 1.1 million units was assembled on the west coast and shipped north, and this time Governor Bone changed his mind and authorised half of it to go by air.

On 8 February and again on 9 February 1925, the aircraft would not start. The dogs took it. Ed Rohn — the musher Kaasen had gone past at Point Safety without stopping — ran the last ninety miles of the second relay through another blizzard and delivered it on 15 February.

Officially, the outbreak killed five to seven people. It is almost certainly an undercount: Welch himself estimated at least a hundred further cases among Alaska Native families that were never reported to him, and gave the reason plainly, which was that families were burying children without telling anyone. What the true figure was, nobody knows and nobody now can.

And the one that stings

On 10 December 1923, thirteen months before Welch sent his telegram, Gaston Ramon had presented the diphtheria toxoid to the French Academy of Sciences. Canada was manufacturing it at scale through 1924.

It existed. It was simply not yet anywhere near Nome, and in the United States it would not be in routine use until the 1930s. The epidemic fell into the narrow window between a thing being invented and a thing being distributed — which is, if you think about it, still where most of the world's preventable child deaths occur.

One thing that is not true

The Iditarod is not a commemoration of the serum run. This is stated flatly by the Iditarod itself, which says on its own education pages that the founders did not have the serum run in mind, and quotes founding mushers saying the two have nothing to do with each other. The race began in the 1960s and 70s to get the Iditarod Trail protected and to keep sled dogs in Alaskan life as snowmobiles took over. The two routes share only the last third, from Ruby to Nome.

There is a commemorative run — the Serum Run, founded in 1997, which retraces the real route and delivers immunisations to the villages along the way. Which is a considerably better memorial than a race, and almost nobody has heard of it.

Over to you

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