John Barry’s lively, artful, and very well informed account of the flu epidemic in 1918–1919, which killed more people than the guns and bayonets of World War I, ought to attract unusual interest in a year when a lethal form of “avian flu” has begun to spread from birds to people in East Asia, and may (or may not) be about to spread as widely around the world as its predecessor did. If that happens, the medical profession and public health authorities will be far better prepared than anyone was in 1918, since they now know how to immunize human populations against a flu virus, whereas in 1918 no one knew what caused the flu and efforts to find a cure proved ineffective. Yet despite all the expert knowledge and skills accumulated since 1918, it is far from sure that our contemporary medical establishment could deliver enough of the necessary vaccine in time to forestall another march of illness and death comparable to what occurred eighty-six years ago.
The story of the 1918 plague and how a few American doctors mounted frantic yet futile efforts to find a cure for it are the themes of Barry’s book. Chapters shift back and forth between evocative accounts of local outbreaks in the United States and the laboratory efforts of a handful of experts who sought to find the germ that caused the disease and hoped to develop a vaccine against it. In the end, the epidemic subsided of its own accord—or more accurately, through age-old ecological processes, as levels of resistance in human bloodstreams rose and genetic mutation deprived the virus of its initial lethality.
None of that was understood at the time, but Barry’s account profits from subsequent discoveries and his own impressively up-to-date understanding of the dynamics of infection and epidemic. This imparts a magisterial detachment to his portrait of the career of the virus and of a few of the doctors and public health officials who tried to counter its ravages. For in those far-off times, the parasitical virus and the human host still interacted in the natural fashion, and the process was little affected by anything that anyone could do. Nonetheless, current levels of scientific understanding allow Barry plausibly to reconstruct the course of the infection, while admiring the effort and recognizing the mistakes of the doctors and administrators who tried to cope with it.
Barry tells us that it took him seven years to write The Great Influenza, more than twice as long as he had expected. Partly that was because he expanded his theme by deciding to explore the sorry state of American medicine before 1918 in order to better understand the situation that medical scientists faced when the flu struck. But he was also delayed because
finding useful material on the epidemic proved remarkably difficult. It was easy enough to find stories of death, but my own interests have always focused on people who try to exercise some kind of control over events. Anyone doing so was far too busy, far too overwhelmed, to pay attention to keeping records.
Record keeping is undoubtedly one of the first things to crumple under epidemic conditions; but it seems to me there was another factor at work. For those who survive such an epidemic have their own reasons to suppress nasty memories of what they went through. That, I believe, is why the 1918–1919 flu, despite its statistical magnitude—about 675,000 deaths in the United States and between 20 and 50 million deaths worldwide, most of which came “in a horrendous twelve weeks in the fall of 1918”—scarcely figures in public or private recollection. This is the case, even though almost everyone living through those twelve weeks must have experienced mortal fear, and perhaps a majority of the world’s human inhabitants fell ill and endured acute suffering for the ten to twelve days it took for the disease to run its course.
I myself am a survivor of that flu epidemic, but have no memory of it since I was thirteen months old when my mother came down with the disease in Chicago and, under circumstances I can only imagine, gave birth to my sister on December 4, 1918. The birth was some weeks premature; and both I and my father were then also suffering from the flu. At the time, my father was an impecunious graduate student, and my parents found themselves alone in a paralyzed city with no relatives close by, and little or no outside help. My parents made no written record and never spoke about what they had endured afterward. The most dreadful experience of their entire lives was therefore systematically expunged from family memory, so that exactly what happened and how they survived remain completely unknown to me.
But I learned from Barry’s book that by December 1918, when the flu came to Chicago, the infection was far less lethal than it had been during its initial outbreaks in East Coast army camps and cities nearby. “The East and South, hit earliest, were hit the hardest. The West Coast was hit less hard. And the middle of the country suffered the least.” This undoubtedly is why my mother and sister both survived, though my sister’s first six months were precarious. That fact did enter family oral tradition because the story had a happy ending. For my sickly sister turned the corner and began to thrive when the family returned to my father’s birthplace on a farm in Canada for the summer. That was where, under sunny skies, my grandmother’s care rescued both mother and daughter from the sha-dow of December. Such a story was worth repeating, whereas mention of the lonely fear, despair, and suffering of December, however poignant it may have been, was merely depressing. Accordingly, selective memory prevailed, deliberately deleting all mention of the greatest crisis of my par- ents’ lives.
Nearly everyone who suffered and recovered from the flu must have had similar, if less extreme, memories to suppress. Barry notes that “writers of the 1920s had little to say about it.” And in the circle within which I grew up the only person I remember who ever mentioned the epidemic to me was a boy whose father had died in an army camp; and what his mother had conveyed to him was not so much about the flu as about the war she blamed for her husband’s death.
Barry nonetheless has discovered a quasi-autobiographical account of what it was like to have the flu, Pale Horse, Pale Rider by Katherine Ann Porter, herself a survivor, which was published in 1939. Here is part of what he quotes:
She sank easily through deeps and deeps of darkness until she lay like a stone at the farthest bottom of life, knowing herself to be blind, deaf, speechless, no longer aware of the members of her own body, entirely withdrawn from all human concerns,…and there remained of her only a minute fiercely burning particle of being …composed entirely of one single motive, the stubborn will to live. This fiery motionless particle set itself unaided to resist destruction, to survive and to be in its own madness of being, motiveless and planless beyond that one essential end.
This sounds bogus to me. When I suffered pneumonia (the actual killer of most of those who died during the flu epidemic) in the 1950s I remember Porter’s “deeps of darkness” all right, and “withdrawal from all human concerns”; but no fiery “will to live.” Instead blank unconsciousness and then, thanks to penicillin, awakening next day in a state of muscular weakness, the like of which I had never experienced before, and of surprise at being painlessly stretched out in my hospital bed. The aches and pains of high fever, followed by unconsciousness and then either recovery or death: that I suspect was what most people experienced in 1918–1919. There is nothing much to say or remember after such an experience; and that, too, may help to explain why what Barry chose to call “The Great Influenza” left so few traces in human memory.
His book therefore cannot tell us much about what it was actually like to have the flu in 1918–1919, but with unusual literary panache and admirable mastery of the latest epidemiological findings, he explains what probably happened in 1918–1919 vividly and, yes, memorably, at a time when threatening new forms of the virus have emerged to worry experts and the public at large.
The fact is that flu is one of the most formidable infections confronting humankind. The virus mutates constantly as it circulates among birds, pigs, and human beings, so each new flu season now challenges experts who must decide what exact strains of the virus to use for making the vaccine of the year. When they guess right, the flu shots that millions of American children and old people have recently become accustomed to take do in fact prevent infection. But that does not stop flu from becoming life-threatening from time to time, whenever a particularly lethal form of the virus suddenly emerges and is different enough from its predecessors to evade existing vaccines and all the accumulated antibodies in bird, pig, and human immune systems.
In short, just like human beings, influenza viruses specialize in changeability, thus sporadically expanding their access to the energy that sustains all forms of life by preying unmercifully upon the cells of our bodies. We humans are uniquely versatile, capable of attacking an enormous range of other life forms (including influenza viruses) as well as exploiting inanimate sources of energy. In comparison, the influenza virus is narrowly restricted, depending, as it does, on suddenly and successfully becoming parasitic on birds (the virus’s principal food source) and various mammals, primarily pigs and people.
Barry gives the clearest explanation I have read of how the exact shape of a flu virus allows it to penetrate a human cell, and then replicate itself there until, after about ten hours, thousands of new viruses emerge from the dying cell, ready and able to repeat the cycle. His discussion of how the virus mutates by what is called “antigen shift” in the chapter that follows is equally precise and easy to understand. The rapidity with which successful flu viruses multiply and spread throughout our bodies is what makes the disease so formidable; and even though human antibodies usually check the multiplication of flu viruses within about ten days, by then secondary bacterial invaders regularly proliferate in the vulnerable throat and lungs, and are what actually kill most flu victims.
Many of Barry’s observations about how America’s strenuous mobilization for war contributed to the epidemic of 1918–1919 are equally persuasive. Above all, scores of thousands of young soldiers, concentrated in the cramped quarters of improvised training camps, were exceptionally vulnerable to infection. This was well known ahead of time to the small company of medical men whose careers Barry follows: William Henry Welch, Simon Flexner, William Crawford Gorgas, William Park, Oswald Avery, and Paul Lewis. Some of them—Gorgas, Welch, and Flexner in particular—were in a position to make their voices heard in high places of the American government, even though real or imagined imperatives of the war effort overrode their efforts to isolate initial outbreaks of infectious disease.