October marks the start of a new flu season, with a rise in likely cases already showing up in Louisiana and other spots, federal statistics show.

The advice from federal health officials remains clear and consistent: Get the flu vaccine as soon as possible, especially if you’re pregnant or have asthma or another underlying condition that makes you more likely to catch a bad case.

Make no mistake: Complications from the flu are scary, says Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center in Nashville, Tenn., who is part of a committee that advises federal health officials on immunization practices.

“As we get older, more of us get heart disease, lung disease, diabetes, asthma,” Schaffner says. “Those diseases predispose us to complications of flu — pneumonia, hospitalization or death. We need to make vaccination a routine part of chronic health management.”

Federal recommendations, he says, are that “anyone and everyone 6 months old and older in the United States should get vaccinated each and every year.” People 65 and above and pregnant women, along with patients who have underlying medical issues, should make haste to get that shot, if they haven’t already, Schaffner says.

Within a typical year, about two-thirds of people over 65 get vaccinated against the flu, studies show, compared with 45% of adults overall and 55% to 60% of children. But only about half of pregnant women get vaccinated, and immunization rates for people with chronic diseases hovers around 30% to 40%.

Take the case of JoJo O’Neal, a 55-year-old radio personality and music show host in Orlando, Fla., who was diagnosed with adult onset asthma in 2004 at age 40. For years she didn’t get the flu vaccine, figuring her healthful diet, intense exercise and overall fitness would be protective enough.

“I skated along for a lot of years,” O’Neal says, “and then, finally, in 2018 — boom! It hit me, and it hit me hard.” She was out of work for nearly two weeks and could barely move. She was extremely nauseated and had an excruciating headache and aching body, she says. “I spent a lot of time just sitting on my couch feeling miserable.”

O’Neal says it takes a lot to “shut her down,” but this bout with the flu certainly did. Even more upsetting, she says, she passed the virus on to her sister who has chronic obstructive pulmonary disease. Fortunately, neither she nor her sister had to be hospitalized, but they certainly worried about it.

“We have lung issues and worry about breathing, so having the flu created lots of anxiety,” O’Neal says. This year, she’s not taking any chances: She has already gotten her flu shot.

That’s absolutely the right decision, says Dr. MeiLan Han, professor of internal medicine in the division of pulmonary and critical care medicine at the University of Michigan Health System and a national spokesperson for the American Lung Association.

If generally healthy people contract the flu, they may feel sick for a week or more, she says. But for someone with underlying lung conditions, it can take longer to recover from the flu — three to four weeks. “What I worry about most with these patients,” Han says, “is hospitalization and respiratory failure.”

In fact, Han says, 92% of adults hospitalized for the flu have at least one underlying chronic condition such as diabetes, asthma, or kidney or liver disorders.

When people with underlying lung conditions contract the flu, she says, “the virus goes right to the lung, and it can make a situation where it’s hard to breathe even harder.”

Other chronic health conditions — diabetes, HIV and cancer, among them — impair the immune system, Han explains, making people with those conditions unable to mount a robust response to the flu virus without the immunization boost of a flu shot.

That means the inflammation and infection when they get the flu can become more severe, she says.

Even many of her own patients don’t realize how bad a case of the flu can be, Han says.

“People often tell me, ‘That’s not me. I’ve never had the flu. I’m not at risk, and I’m not around people who might give me the flu.’ “

O’Neal says she’d always figured she wasn’t at risk either — until the flu flattened her.

Healthy pregnant women, too, are more prone to complications and hospitalization if they contract the flu and are strongly urged by the Centers for Disease Control and Prevention and OB-GYNs to get vaccinated against both influenza and pertussis. Yet the majority of mothers-to-be surveyed in the United States — 65% — have not been immunized against those two illnesses, according to a recent CDC Vital Signs report.

Some women mistakenly worry that the flu vaccine isn’t safe for them or their babies. “I think some of the fears about safety are certainly understandable, but they’re misinformed,” says Dr. Alicia Fry, chief of the epidemiology and prevention branch of the CDC’s Influenza Division.

The evidence is clear, Fry says: The vaccine is extremely safe. And she points to a recent study showing that immunization against flu reduces the risk of flu hospitalization among pregnant women by 40%.

As for worries that the woman’s vaccination might not be safe for her developing fetus, Fry says the opposite is true. When a pregnant woman is immunized, antibodies that fight the flu virus cross the placenta and can protect her baby in those critical months before and after birth.

“It can prevent 70% of the illness associated with flu viruses in the baby,” Fry says. “So it’s a double protection: Mom is protected, and the baby’s protected.” Infants can’t get the flu vaccine themselves until they are 6 months old.

Now, the vaccine won’t protect against all strains of the flu virus that may be circulating. But Schaffner says the shot is still very much worth getting this year and every year.

“Although it’s not perfect, the vaccine we have today actually prevents a lot of disease completely,” he says. “And even if you do get the flu, it’s likely to be less severe, and you’ll be less likely to develop complications.”

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Editor’s note: This story includes images that some readers may find disturbing.

When photojournalist Lynsey Addario was awarded the MacArthur Fellowship in 2009, she took it as a chance to work on a topic that many photographers and editors shied away from: maternal mortality. Her photos of overcrowded hospitals, bloody delivery room floors and midwives in training illustrate the challenges women face in childbirth and what the global health community is doing to overcome it. The series was featured at this year’s Visa Pour L’image festival in Perpignan, France.

Addario has borne witness to some of the most intense global conflicts of her time. She has worked for publications like The New York Times, National Geographic and Time Magazine and has covered life under the Taliban in Afghanistan and the plight of Syrian refugees. She has been kidnapped twice while on assignment, most recently in Libya in 2011 while covering the civil war.

Every two minutes, a woman dies from childbirth or pregnancy-related causes, and many of these deaths are entirely preventable. While the global health community has made great strides bringing down the rate of these maternal mortalities since efforts intensified in the early 1990s, the reality for many mothers is still harrowing.

We spoke to Addario, author of the 2015 memoir It’s What I Do: A Photographer’s Life of Love and War, about what drives her work and what she’s witnessed over a decade of reporting on this topic. The interview has been edited and condensed for clarity.

How did you get interested in the topic of maternal mortality?

In 2009 I was named a MacArthur Fellow. It was the first time in my career where I was given money to work on a project without an assignment, so I could choose something that I felt was important to cover. I started learning about the incredible number of women who were dying in childbirth every year. It wasn’t a story that was easy to get published — I think most editors felt it wasn’t a sexy topic. Most people just don’t realize what a big deal this is.

[Early in the project,] in the very first hospital I walked into outside of Freetown, Sierra Leone, I literally watched a very young woman, Mamma Sessay, hemorrhage in front of me on camera and die. And I knew that it was a story I had to continue with.

You write in your book Of Love & War that what compels you to do photojournalism is “documenting injustice.” How does that apply in this series?

If you’re a poor woman living in a village where there are no medical professionals around, and you don’t have enough money to get to a hospital, then you run the risk of dying in childbirth. That’s injustice. I think everyone is entitled to a safe delivery. In 2019 there should be medical facilities within reach for anyone to be able to access them, or mobile clinics.

Were you a mother when you started the project?

No. In fact I always used to joke around on the delivery ward that I would never become a mother because I had photographed so many women delivering, and I knew it was such a painful and difficult experience. Then in 2011 I gave birth to my first son, so I ended up doing it anyway. Even though this project made me more scared to actually deliver because I know how many things can go wrong.

Ironically my own delivery in 2011 was not a great experience. I moved to London when I was 32 weeks pregnant and delivered at 37 weeks. I had no doctor, basically just showed up at the hospital nine centimeters dilated and delivered with whatever midwife was on duty. Now that I’ve been doing this project for 10 years, there are so many things I would suggest to first-time mothers — or second-time mothers.

Like what?

Like maybe have a doula or have someone with you who can be an advocate — who can explain to you what’s going on with your body, who can help you navigate the pain. Someone who can understand if something’s going wrong, like the symptoms of preeclampsia: headaches, sweating, swelling. There’s so much that we just don’t know, that we’re not taught. People take childbirth for granted.

What is it like talking to your male colleagues about this project?

Most of them just haven’t paid attention to this work. Colleagues have said things to me about some stories — like the woman giving birth on the side of the road in the Philippines and the Mamma Sessay story — because they’re sensational, but no one really asked me about the work, which is interesting in and of itself. I think people sort of shy away from talking about birth, you know? Unless it’s something happy and positive.

What has surprised you while photographing this series?

How much access people give me. I’ve photographed — I can’t even count how many — probably three or four dozen births. The women invite me into very intimate spaces. I obviously try to be very respectful of how I photograph something like this. It’s one of the most beautiful things I’ve ever witnessed, watching a baby be born. It’s something delicate to photograph because it’s so incredible and at the same time it’s very graphic. It’s hard, and it’s always surprising to me how many people have let me in.

That word “graphic” jumps out at me. I’m looking at one of your photos now, where there’s blood on a delivery room floor, and it’s uncomfortable in a way that’s different than looking at blood from violence.

It is different. It’s different because no one thinks of childbirth like that. They think of childbirth as Hallmark pictures, but there’s a lot that’s not beautiful about it.

You’ve been working on this project for 10 years now. What has changed?

The statistics [for maternal mortality] have gone down, which is incredible, and there’s a lot more awareness. There are so many organizations — like Every Mother Counts, which is Christy Turlington’s organization, and UNFPA and UNICEF — working to fight maternal death. There’s more information, but it’s still too many — one woman a day is too many.

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