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.
In every previous war for which statistics can be reconstructed more soldiers had died of infection than of wounds; but in 1917 recent advances in bacteriology meant that effective vaccines against longtime killers like typhoid and cholera now existed. This and this alone allowed millions of men to survive in the trenches of France for years on end, when Russian soldiers were dying on the eastern front of typhus and similar infections in the age-old way. But Crawford Gorgas, recently appointed surgeon general of the US Army, knew this well, since he had made his reputation by control-ling yellow fever in Havana and the Canal Zone. Accordingly, he set out to stockpile “huge quantities of vaccines, antitoxins and sera” and organized large-scale production of more. Yet when a localized epidemic of measles broke out in Georgia and Texas between September 1917 and March 1918, his preparations proved inadequate. A total of 5,741 deaths from measles in the affected camps was recorded. That figure, however, was immediately dwarfed by the onset of flu, beginning in the month when the measles subsided.
The fact was that no one knew any cure for either measles or influenza when this second viral epidemic broke out in Camp Funston, Kansas, in March 1918. But initially deaths were few. Widespread concern and accompanying fear only came in July, when a second wave of the flu infection, with far higher mortality rates, and extreme symptoms that did not look the least like ordinary flu, manifested themselves almost simultaneously in Brest, France, Freeport, Sierra Leone, and Boston, Massachusetts. Thanks to ships and railroads, the resulting epidemic soon became worldwide, reaching its climax in September and October; then, despite recurrent local flare-ups, it gradually subsided across the ensuing several years.
Recent detective work suggests that (at least within the United States) a virulent new strain of influenza first afflicted human beings in rural Kansas in February 1918, and was carried to Camp Haskell by three men reporting for military service at the end of that month. But some dispute the claim that the epidemic started in Kansas. Recent flu epidemics have usually originated in rural East Asia where birds, pigs, and people live far closer together than they do in Kansas; and some believe that the flu of 1918 originated there, unnoticed as usual, some-time before cropping up in Kansas. The exact origin of the epidemic will never be established for sure; but its spread around the world and within the United States is comparatively well documented. Barry accordingly concentrates his attention upon selected episodes from its course within the United States.
The most notable early outbreak took place at the end of August and during the first days of September at Camp Devens in Massachusetts, where about 45,000 men were crowded into temporary quarters. On the peak day, 1,543 soldiers reported ill, and approximately 200 deaths were occurring daily. Doctors and nurses were especially at risk and many fell ill or died. The camp hospital soon col- lapsed under the strain and on September 21 a spokesman officially announced that it would not admit any more patients, no matter how ill they might be. Care was almost nonexistent when Dr. William Henry Welch, the principal American champion and organizer of a novel German style of laboratory-based scientific medicine, arrived on the scene. He was, according to Barry, the leader of “the movement that created the greatest scientific medical enterprise, and possibly the greatest enterprise in any of the sciences, in the world.”
More than six thousand soldiers were crammed into a hospital designed to accommodate no more than 2,500 patients; and, above all, “there were no nurses.” More alarming still, many symptoms—bleeding from nostrils and ears, bluish faces, and lungs damaged in unfamiliar ways, as well as “dead bodies…stacked…like cord wood,” convinced Welch and his colleagues that “this must be some new kind of infection or plague.” But Welch and other experts soon abandoned that idea, agreeing that the epidemic was a very virulent form of flu, compounded by a variety of other infections.
But what caused the flu? Recent triumphs in dealing with tuberculosis and other bacterial infections dictated how to find out by taking swabs of mucus from the dead and dying, and then trying to grow bacteria collected on such swabs in laboratories in the hope of identifying the organism responsible. The idea that something smaller might cause disease—so-called filterable viruses, too small to see under a microscope—was already in circulation. In fact, one of Barry’s heroes, Dr. Paul Lewis, had “proved that a virus caused polio,” and was predisposed to to suspect that influenza might also be a viral infection.
But calling an invisible infectious agent by a new name was much the same as attributing the disease to an invisible miasma, as the most up-to-date European doctors had done before the 1880s, when the German doctor Robert Koch proved the rival germ theory by showing that two formid-able infections, tuberculosis and cholera, were caused by specific kinds of bacteria, visible under a microscope. Moreover, he developed ways to grow these bacteria in his laboratory and then killed them to make protective vaccines. As long as viruses remained invisible nothing like that could be done; so the scientific medical experts, seeking a cure for the flu in 1918, concentrated on finding some kind of bacillus responsible for causing the disease.
As a matter of fact, this had already been done in Germany where, during a minor flu epidemic in 1889–1890, a respected doctor named Richard Pfeif- fer discovered a new kind of bacillus in flu sufferers’ throats and named it Bacil- lus influenzae, because he believed it caused the disease. As director of the Institute for Infectious Disease in Berlin, Pfeiffer’s claim sufficed to make his discovery plausible, even though his new bacillus was often hard to find in flu-infected throats, and failure to find ways of growing it in laboratories (it required a very narrow range of temperatures) had inhibited making experimental vaccines that could have put Pfeiffer’s conclusion to a practical test.
In 1918 a variety of different bacteria stood ready to invade the throats and lungs of persons whose mucous membranes had been riddled or destroyed by the virulent flu virus. Pneumococci predominated; and their ravages, together with overreaction by human immune systems, flooding the lungs with cell and viral detritus, were the proximate causes of most deaths. Pfeiffer’s bacillus was inconspicuous among the secondary invaders and in fact irrelevant. But when improved methods discovered it on more and more swabs, Paul Lewis abandoned his idea that a virus was at work, and joined the crowd of other experts in assuming that Pfeiffer’s bacillus was the real cause of the disease. As a result, preparing a useless vaccine based on the dead bodies of Pfeiffer’s bacillus turned out to be the principal achievement of the American scientific effort to combat the flu.
The ineffectiveness of that vaccine and of every other effort to find a bacterial basis for the flu revived the notion that a virus might be responsible. But only in the 1940s, when electron microscopes made viruses visible, did it become possible to distinguish different viruses and study their behavior. Contemporary understanding of the flu virus and our current ability to make effective vaccines against it had to wait for the electron microscope.
A parallel effort in 1918–1919 to find a vaccine against pneumonia was more successful, even though it was effective only against some strains of pneumococci, and difficulties in its manufacture meant that only trivial amounts of the new vaccine became available before the epidemic ended. Nonetheless, Barry tells us, Oswald Avery’s experimental studies of pneumococci eventually led in 1943 to the initial discovery of the role of DNA in genetics.
Barry’s stories of Pfeiffer’s bacillus and of the laboratory efforts to find a cure for the flu are instructive and very well told. Barry admires and dramatizes each of the leading doctors and scientists involved and describes their every move. Nonetheless, his book suffers from two significant limitations. First, his account of the flu epidemic is episodic and radically incomplete. Barry concentrates almost entirely on what happened in the United States, and in practice only tells us about what actually happened in two places. His account of the disastrous situation in Massachusetts at Camp Devens is accompanied by a longer, equally interesting, account of what happened in Philadelphia. But he skips other cities like New York and Boston, where the flu was equivalently paralyzing and lethal; while his references to outbreaks in other parts of the country are scattered and scant.
He has, moreover, almost nothing to say about Europe. And what he does tell us is skewed by a desire to magnify the flu’s impact. For example, he says that the German offensive in the spring of 1918 may have been halted by an outbreak of flu. “Ludendorff himself,” he writes, “blamed influenza for the loss of initiative.” But then he backpedals, writing that, since Allied soldiers were also falling sick, Ludendorff “may have simply seized upon it as an excuse.” Similarly, his claim that an attack of flu in 1920 weakened President Wilson in mind and body to such a degree that he gave up struggling against Clemenceau and Lloyd George over the terms of the Versailles peace treaty makes flu responsible for political and military decisions that were surely influenced as well by other, more urgent considerations.
Barry also shortchanges the scope and sweep of the epidemic around the rest of the world. Two sentences are all he devotes to the world’s most populous country, China. That is followed by a page of exaggerated description of the plague in India. For example: “Throughout the Indian subcontinent, there was only death. Trains left one station with the living. They arrived with the dead and dying, the corpses removed as the trains pulled into station.” In another overdramatized passage he writes: “The virus ripped through Senegal, Sierra Leone, Spain, and Switzerland, leaving each devastated and keening with a death toll that in some areas exceeded 10 percent of the overall population.” Such information is so random and vague that it is almost meaningless. His choice of countries to mention is apparently governed by the first letter of their names rather than any other affinity.
Barry seizes upon a handful of medical men as heroes for his tale. Their laboratory approach proved useless against the flu, but its later success at finding the virus blinds Barry to the equally ineffectual yet comforting and helpful efforts others made to cope with the disease and stabilize it. He scorns doctors who did what the medical profession had done for centuries by administering useless remedies. But they nevertheless reassured people that something was being done, and Barry’s scientific doctors did no better.
Barry also deplores the way government officials and journalists sought to minimize or deny the reality of the flu, contemptuously quoting the Chicago public health commissioner for claiming: “It is our duty to keep the people from fear. Worry kills more people than the epidemic.” Yet lies and half- truths designed to reassure the public may have allowed American society to continue to function before and after the epidemic outbreaks temporarily brought all ordinary behavior to a standstill in many unaffected towns and cities.
Barry thinks that such official policies backfired by creating distrust. Perhaps so; but I wonder. In 1918 American society was already committed to an economy that depended on complex flows of goods and services throughout the entire country. All but the briefest interruptions in such movements were quite literally life-threatening. No city could long survive without uninterrupted delivery of food and other essential commodities from afar. And the war effort magnified all such vulnerabilities by putting millions of persons in improvised army camps. To keep urbanized American society—and the army—going, it was necessary to maintain daily routines of work, and official denials that deadly infection was raging close at hand may have helped assure that result.
Barry also says nothing about religion. Priests and ministers traditionally helped to reassure their flocks in times of crisis and certainly rallied around in 1918–1919, doing so in traditional fashion through prayer, ritual, and, not least, burial services for the dead. Such actions brought no cures any more than government lies and half-truths did. Yet both perhaps comforted frightened people and contributed to preventing American society from breaking down more than sporadically, locally, and for short periods of time.
Barry’s book is very artfully constructed. It begins and ends with snapshots of Paul Lewis confronting the dismaying new disease in a Philadelphia hospital in 1918, and then himself dying of yellow fever in Brazil in 1929. One of his associates once said that Dr. Lewis was the smartest man he knew, and each time Barry introduces him afresh that tag is repeated like one of Wagner’s leitmotifs. In effect, he makes Lewis into an archetype and symbol of the futile effort to find a cure through laboratory science. Similarly, he punctuates the chapter in which he reviews the flu’s unusual symptoms with almost choral repetition of the ironic phrase “This was influenza, only influenza,” and this or similar phrases recur from time to time in other chapters. Other phrases—“The war was over there. The epidemic was here” and “There was no time”—recur in other passages of the book.
Such devices are reminiscent of Homer’s fixed epithets and impart a portentous, quasi-epic tone to the book. Not for nothing did Barry choose “The Epic Story of the Deadliest Plague in History” as the book’s subtitle. And as this phrase illustrates, Barry regularly resorts to hyperbole. Heroes and knaves alike are portrayed grandiosely, and in a sense this is true of the flu itself. The flu may have killed more people than any previous epidemic, but this was because there were so many more people for the virus to feed upon. In its consequences, the flu of 1918–1919 was almost trivial when measured against the Black Death of the fourteenth century and the Antonine plagues of the second. Both of these disasters had far greater long-lasting effects on human society and killed far larger proportions of the affected populations than the flu did in 1918–1919.
Throughout, Barry wants his readers to shudder at death and suffering, admire his chosen heroes of the lab, and scorn those who tried to hush things up or comfort people with words and inadequate remedies. He sometimes sounds a little like the ad writers who clutter our TV screens with exaggeration. This is regrettable, especially because his understanding of contemporary epidemiology and his masterful explanation of how the virus functions in human bodies more than make up for such stylistic extravagances. Moreover, his message for our time is clear and makes his book all the more worth reading: the recurrence of widespread death from flu is still possible, despite all the scientific knowledge and the international organization that exist to counter it.
April 8, 2004