The Great Influenza by John M. Barry (Review)
Years ago, I received an enthusiastic recommendation for The Great Influenza: The Epic Story of the Deadliest Plague in History by John M. Barry. The book has Kansas connections, so I added it to my list for another time. As Covid-19 elevated from distant concern to global pandemic, it seemed like a fitting time to read how the United States responded last time disease swept across the country and the globe. Even apart from its current applicability, I have little doubt John Barry’s book would be just as gripping.
For those diving into the book, it is helpful to know that Barry builds a broad foundation that expands beyond the mere story of outbreak to conclusion. He explains the state of medicine going into the 1918 outbreak. Barry also spent time exploring the science of viruses and the transmission process, but please don’t let the prospect of scientific sidebars dissuade you from reading. Barry enfolds the science seamlessly into the story and the result is a riveting and informative read.
The following are the notes I took and comments I wrote while reading The Great Influenza:
Dr. Paul Lewis was in the navy during WWI and became one of the first medical scientists in America. Despite the horrors of the great war, the influenza pandemic was a new degree of death’s hideousness. 21-51 million deaths from influenza is the generally agreed upon estimate from 1918-19; some estimates are upward of 100 million deaths. Unlike most flu outbreaks, this strand killed more than the young and elderly. It killed people in the prime of life with great violence and speed.
As late as the 1900s, it was harder to matriculate into good undergraduate colleges than med school. Medical school required a high-school degree and no science background. It was only as the 1900s began that science began leading the medical community.
When Johns Hopkins University launched its medical school in September 1876, Thomas H. Huxley, the British scientist and evolution advocate, gave a wholly secular speech on intellectual inquiry. The absence of God scandalized the event. The questions he asked—what can I know and how can I know it—are the critical issues for science.
Barry recapped how early science relied too much on pure scientific observation. For example, medicine believed the human body had four humors (chemical systems that regulated humans): black bile, yellow bile, phlegm, and blood. When these humors were imbalanced, then counter actions were necessary—e.g. bleeding patients to purge internal illness.
I had forgotten how Rutherford B. Hayes became president over Samuel Tilden. Here’s the summary from the Encyclopedia Britannica: “Tilden led Hayes by more than 260,000 popular votes, and preliminary returns showed Tilden with 184 electoral votes (one shy of the majority needed to win the election) to Hayes’s 165.” But there were 20 disputed electoral votes from Florida, Louisiana, South Carolina, and Oregon. Congress decided the election after the Democrats relented to Hayes in exchange for the Union troops leaving the confederate states; this decision halted efforts to ensure liberties to freed slaves.
Dr. William Welch was one of the founding fathers of Johns Hopkins Medical School. He grew up in rural Connecticut in a family of physicians, yet he did not naturally gravitate to medicine. Barry commented that Welch’s commitment to Christianity did not conflict with his scientific approach to medicine. Welch’s path to medicine included a perceived detour of studying chemistry. This was a rarity in the 1800s, because medical school required no chemistry studies either as requisites before or during attendance. Despite this foundation, Welch had never learned to use a microscope by the time he passed the medical boards. Welch then trekked to Europe to study medicine in a more scientific manner. As he built his reputation as a great medical researcher, Johns Hopkins Medical School began its formation from Johns Hopkins’s estate.
This is how Barry describes Dr. Welch in relation to his body of experimentation: “Although he himself could not himself conjure, he knew the techniques of conjuring and could teach others conjury.” Welch judged people well and helped them draw out what they needed to do to advance science. This skill strikes me as an undervalued gift. It is easy to applaud the individuals who create, but this The Great Influenza emphasized how much collaboration is necessary to succeed—a fact that is true far beyond the world of medicine. It is important to have a leader who knows his or her own strengths and weaknesses and those who are sharing the same pursuit. When a leader can pull each team member together, it creates the greatest likelihood of success.
Dr. Rufus Cole was the first director at the Rockefeller Institute Hospital. He made the physicians into clinical scientists. This approach was a first in the United States, and by developing clinical scientists, he helped usher in a more scientific approach to the practice of medicine and the education of physicians.
After launching a revolution in medicine and medical education, Dr. Welch convinced the Rockefeller Family to launch the School of Public Heath under the Johns Hopkins banner. This development proved critical for addressing the coming epidemic.
Barry started the full story of the influenza outbreak in Sublette, the seat of Haskell County, Kansas. In early 1918, the new virulent strain of influenza started in Haskell County, spread to Fort Riley (specifically Camp Funston) and it’s 50,000 soldiers and then the international stage of World War I.
Dr. Loring Miner, who practiced in Haskell County, first encountered common flu symptoms with uncommon strength. Patient after patient popped up around the county. By March, however, the disease went dormant. Even today, the nature of the 1918 H1N1 virus is not well understood by the CDC. The flu virus is constantly mutating, so this mystery is perhaps unsurprising. Yet scientists have synthesized the 1918 strain without yielding much insight into its deadly nature.
Barry gave a helpful description of how the influenza virus differs from other viruses—its mutations and rapidity of change as an RNA virus. Even a virus produced from a single cell will produce many mutated versions of itself; it acts like a swarm emerging from the host cell. HIV and Coronavirus are also RNA viruses.
Similarly, Barry gave a helpful overview of antigenic shift to describe how viruses spread and can spawn an epidemic. Over time, the flu virus mutates, and small viral changes accumulate to create a new strain that the immune system fails to recognize. The immune system’s antibodies produced in response to having the flu in the past do not protect against the new strain. Our bodies can typically handle small mutations, but larger mutations fool the body.
Walter Lippmann, the writer and political commentator, submitted a memo to Woodrow Wilson advocating for the creation of a publicity bureau. He believed in rule by elites: “The real environment is altogether too big, too complex, and too fleeting for direct acquaintance. We are not equipped to deal with so much subtlety, so much variety, so many permutations and combinations. And although we have to act in that environment, we have to reconstruct it on a simpler model before we can manage it.” Further, he noted, “the mass of absolutely illiterate, of feeble-minded, grossly neurotic, undernourished and frustrated individuals, is very considerable, much more considerable there is reason to think than we generally suppose. Thus a wide popular appeal is circulated among persons who are mentally children or barbarians, people whose lives are a morass of entanglements, people whose vitality is exhausted, shut-in people, and people whose experience has comprehended no factor in the problem under discussion.”
After submitting this memo to President Wilson, the administration launched the bureau, which soon captured and directed the nation’s attention—launching unprecedented volunteerism for the war effort. It also swelled the military ranks in an unprecedented manner, which ultimately caused influenza to spread worldwide.
Even going into WWI, there were many in the Wilson Administration and leaders outside the government who were focused on preventing disease. They knew that disease killed far more in wars than the fighting itself. Unfortunately, the efforts did not result in the medical community effectively changing habits in the military community. The Spanish-American War revealed how poorly equipped the army was to prevent disease, which led to thousands of deaths. The medical community sought a different approach going into WWI.
Because of military resistance to the medical community, Simon Flexner proposed enfolding the Rockefeller Institute into the military. This, it became Army Auxiliary Laboratory #1, which provided military clout to the Institute’s scientific and medical efforts.
Surgeon General Victor Vaughan warned that the military’s treatment of recruits in barracks was foolishly planned. The response was that “the purpose of mobilization is to convert civilians into trained soldiers as quickly as possible, and not to create a demonstration in preventive medicine.”
The 1918 Influenza Epidemic came in waves. There are three theories for the waves. The first is that is that it was two separate viruses, but this theory is undermined by the resistance of those who experienced the first wave. The second theory is that a mild virus caused the spring epidemic, and then a second virus infected the same cells and combined to cause a new lethal virus. This theory is widely rejected. The third theory is that the virus adapted to man, which is the prevailing idea.
In the late 1800s, French scientist C.J. Davaine discovered the concept of viral passage, which is the process of viruses increasing or decreasing on virility as it moves from carrier to carrier. He tested the concept with anthrax in rabbits. There, the potency needed to kill grew exponentially. After twenty-five passages, the bacteria in the blood had become so virulent that less than 1/1,000,000 of a drop killed the rabbits.
When influenza reached Camp Deven, Massachusetts in September 1918, the doctors reported averages of 100 deaths per day with a total of 850 previously healthy men turning blue and dying in great pain.
Treasury Secretary William Gibbs McAdoo was the progenitor of the WWI War Bond, which the United States unveiled with a broad marketing campaign to link patriotism with bond contributions. As part of this plan, leaders planned a massive Liberty Loan Parade in Philadelphia as the influenza epidemic spread through the city. Health officials urged canceling the parade, but Philadelphia took no action to respond. William Vare was Philadelphia’s political boss who eventually was ousted for corruption. He took a cut from endless city contracts, and the political machine wanted the parade to go forward. Dr. Wilmer Krusen was the Director of Public Health and a political appointee who disregarded the advice to cancel the parade. By moving forward, the parade created the same dire conditions found in the military barracks with packed streets, close conditions, and plenty of influenza carriers. Influenza spreads even when victims do not yet show or feel symptoms. This parade led to influenza moving beyond military ranks to civilians, and 12,000 Philadelphians died from the flu. In the days following the parade as the flu spread and the daily death tolls were in the hundreds, Krusen continued telling the public that “today is the high-water mark and the worst is behind us.” And day after day, the death tolls kept rising.
As the influenza spread, it largely proved itself to be the normal influenza. For the majority, the sickness prompted up to ten days of fever, headache, exhaustion, and coughing. But for 20%, the virulence was so extreme, it caused horrific death with extreme fevers, air pockets below the skin, bulging eardrums, cyanosis, and blood pouring from bodily orifices. Perhaps worst of all was the damage to the lungs and eventual suffocation. Normal lungs when removed for autopsy will deflate. Lungs removed for autopsy in 1918 influenza victims remained full—not of air but blood. Despite the severity in deaths, perhaps was the most unique nature of the 1918 influenza to attack the young and strong.
Barry described the lung damage with great clarity. He started by discussing the 2003 coronavirus that caused SARS (Severe Acute Respiratory Syndrome). SARS typically kills through ARDS (Acute Respiratory Distress Syndrome). ARDS is sometimes described as burning the lungs—the disintegration of the lung tissue. Barry noted that because coronavirus replicates more slowly than influenza, death comes more slowly, sometimes weeks after showing symptoms. The immune-system response is what kills previously healthy victims. ARDS will cause death in varied and painful ways:
(1) organs fail due to lack of oxygen;
(2) the blood that fills the right ventricle of the heart causes so much strain, that the victim drowns;
(3) the strain on the heart pumping can cause heart failure; and
(4) exhaustion simply causes breathing to stop.
There is some belief that more people died from secondary bacterial pneumonia that could have been treated with antibiotics. Yet the army’s follow-up study and one other scientific study showed ARDS as the cause of death, which is alarming when considering the prospect of another pandemic. Further, bacterial resistance means that even secondary pneumonia can be a death sentence.
Avery Bradley described Alfonse Douchet (and perhaps also himself) upon receiving the Kober Medal: “results are not random products of chance observations. They are the fruit of years of wise reflection, objective thinking, and thoughtful reflection.” In a modern culture that values immediacy, perhaps it is little surprise that results seldom match with original pursuits.
Barry looked at the societal effects of the epidemic and observed that institutions are a strange mix of the mass and the individual. Creating institutions provides a barrier between the mass and the individual. Institutions tend not to sacrifice or act with spontaneity. Institutions reflect the individuals that compose the institutions. Institutions become bureaucratic because of the rules established to run the organization. In 1918, the premier institution was the federal government, which was almost wholly focused on winning WWI—not dealing with the flu epidemic.
In the description of Philadelphia’s incredible death toll, Barry commented how many citizens turned inward both out of sickness and fear: “But by now, the city had heard enough pleas, and had turned into itself. There was no trust, no trust, and without trust, all human relations were breaking down.” Later Barry reported one Philadelphian’s comment: “the fear in their hearts withered them.”
The nationwide message as the influenza spread was “don’t give in to fear” and a theme of reassurance—even as more people got sick and died. It’s interesting how similar the message is today facing the United States and Corvid-19. Also similar between now and then was the xenophobic race-blaming. Much like President Trump has blamed China, American leadership and subsequently citizens blamed Germany as the progenitors of the virus who were intentionally spreading the disease.
The American Medical Society contested the government publications that emphasized clean clothes and clean mouths. The publications encouraged not being afraid, chewing your food well, and keeping the bowels open. Yet the this was also the time of snake-oil salesmen who peddled ineffective tonics as cure-all medicines. Thus, medicine was not yet a respectable or trusted profession, so it is perhaps unsurprising that people did not know who to trust.
Fear destroyed neighborliness and the hope that shared humanity would cause people to help each other. Washington D.C. citizen William Sardo put it like this: “It kept people apart. It took away all your community life. You had no community life. You had no school life. You had no church life. You had nothing. It completely destroyed all family and community life...It destroyed those contacts, that intimacy between people.” People just left neighbors alone regardless of their sickness, suffering, or death.
Quinine—an anti-malaria drug—was given to influenza patients in hopes it would help. This medicine was just one of many given in desperate hope that it would help. Despite doctors’ insistence that it does not treat the coronavirus, President Trump has suggested Chloroquine, a descendent of quinine, as a potential cure for Covid-19. There is nothing new under the sun.
In the conclusion, Barry commented that his original intent when he began writing changed as he researched the subject and more influenza outbreaks occurred around the world. Much like the stories he told of the scientists who investigated the 1918 outbreak, he followed where the facts led him.
Barry wrote this book fifteen years ago and emphasized how much a pandemic of any severity would stretch the American healthcare system beyond its capacity. He noted presciently that we have inadequate hospital beds and respirators.
The fear of the unknown causes the greatest panic. “The public could trust nothing so they knew nothing...The fear, not the disease threatened to break the society apart.” Further, “The final lesson of 1918…those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one.”
As I suggested earlier, The Great Influenza is a book you’ll be glad to have read. It does not read like a textbook but wonderfully tells a story with interesting information as an added benefit. That said, some of the general sections on the spread of the virus and the failure to act (Surgeon General Rupert Blue) occasionally dragged. Details like the spread of the virus in Philadelphia effort might have been better served as a stand-alone appendix or a supplemental story. But these are minor quibbles in a book that I wholly endorse. Whether you read The Great Influenza as part of your Covid-19 quarantine reading or read it when the current pandemic passes, be sure to add Barry’s book to your reading list. Any concerns over the topic’s dreariness are overwhelmed by the tales of doctors and scientists who battled the disease in the most inspirational of ways.
