The Great Influenza: The Epic Story of the Greatest Plague in History

By John Barry, Feb/2004 (560p.)


The Great Influenza: The Epic Story of the Greatest Plague in History was a New York Times Best Seller that won the 2005 Keck Communication Award from the United States National Academies of Science for the year’s outstanding book on science or medicine. The author, John M. Barry, is a distinguished scholar and professor at Tulane University who has served on a federal government’s Infectious Disease Board of Experts and on the advisory boards at MIT and John Hopkins.

In this March 27, 2020 article, Professor Barry did an email interview with a CNN reporter, where he states his opinion that Covis-19 will hit in waves, much like the Spanish Flu did:  “In 1918, we had a generally mild spring wave, which was hit or miss. New York, Chicago and Louisville, among other places here and around the world, had pronounced but localized outbreaks yet Los Angeles did not record a single spring death from influenza. Although it was generally mild, there were plenty of hints that it could be very deadly. In one small Army post, for example, it killed 5% of the soldiers. In Louisville, it was pretty bad. Then came the lethal second wave that hit in September. Probably two-thirds of the deaths worldwide occurred between late September and late December. Then came a third wave in March and April 1919, lethal by any standard except the second wave. There is absolutely no indication — zero, not the slightest hint anywhere in the world — that Covid-19 will become more virulent than it is now, so we can relax on that question. Don’t worry about it. However, I do expect it to come and go in several waves, and I expect it to become endemic — it will be here forever. But that is not necessarily scary. Right now no human’s immune system has ever seen it before. As our bodies become familiar with it, there’s a very good chance we will be able to deal with it much better naturally, even without a vaccine or drugs. As far as lessons, this is a marathon. We can’t wait out the virus. But we also need to get ahead of it, get all sorts of things in place, before we restart the economy or we will be in big trouble.”

Further down in the same interview, Professor Barry praises George W. Bush and Obama to suggest he is not being political, before he throws Donald Trump under the bus (common in CNN interviews):  “Whenever someone quotes Santayana, I quote Hegel: what we learn from history is that we learn nothing from history. The George W. Bush administration was determined to prove Hegel wrong and to learn the lessons of 1918. Led by an assistant secretary of Health and Human Services named Stewart Simonson, and backed up by the President himself, they created an infrastructure to prepare for a pandemic. President Barack Obama continued it and did in fact respond well both to H1N1 and Ebola. Trump spent January, February, and part of March forgetting every lesson. Hopefully his change of tone, now 11 days old, continues — although his desire to start everything up again in a few weeks suggests otherwise.”

Barry makes the scary prediction that Covid-19 will infect more people than the Great Influenza, but then he ends the interview on a somewhat more positive note:  “Eventually people’s immune systems did become accustomed to the virus and became capable of dealing with it more effectively. In addition the virus itself seemed to change. Eventually it morphed into a seasonal flu.” … “I agree with Tony Fauci. This virus is likely to be around from now on. It’s not going away. My hope is natural immunity along with drugs and vaccines will significantly diminish the threat of Covid-19.”

In addition to informative, Barry’s 560-page book was a fascinating tale of scientific discovery and progress.  He profiles the lives of the great doctors and laboratory researchers of the time, who were able to change history, even though none succeeded to change it in time to avoid the calamities that Barry also profiles.  The book is also inspirational in that it reveals how life goes on and humans manage to thrive, even when civilization is driven to its knees (perhaps because of it).  The 1918 influenza was unique in that it hit as World War I was coming to an end, crushing people who had already been devastated by nearly 4 years of War.  In most countries, the media was being controlled by war propaganda, which had little interest in reporting the truth.  Spain was not part of the war, so its press reported freely on the pandemic, which is the reason it got nicknamed the Spanish flu.  The US president at the time was Woodrow Wilson, who led the country into the war in 1917.  While Wilson is regarded by historians as having been one of the better presidents, Barry’s book is nothing short of harsh in its assessment of Wilson’s handling of the pandemic.  He denied it aggressively by considering it a military matter for too long, then by denying the public the proper resources.  Wilson died in 1921 after suffering a debilitating stroke, which Barry attributed to his struggles with the influenza.  After the virus took its heavy toll and the world began to pick up the pieces, society was more than ready for the booming twenties, which this book does not cover.  And it would be only 10 years later that it would face the great depression (also not covered).  And here we are today, in much better shape and with vastly greater technological resources to repeat the miracles that were made during prior times when the world was taken to its knees.

In conclusion, The Great Influenza is an interesting book that reveals how common pandemics have been in human history, as well as how resilient civilization has been in coping with them. It provides another vivid example of the axiom that crisis brings opportunity, since some of the greatest advancements in medicine came as a result of the foundations that were laid during this harsh crisis period, such as epidural anesthesia (1921), the first vaccine for diphotheria (1923), pertussis (1926), tuberculosis (1927), tetanus (1927), and penicillin (1928). Whether it was meant as such I don’t know, but for me this was an optimistic book.  A reason to be excited, instead of fearful, about what lies ahead.




Highlighted Passages:



“Another explanation for the failure of logic and observation alone to advance medicine is that unlike, say, physics, which uses a form of logic—mathematics—as its natural language, biology does not lend itself to logic. Leo Szilard, a prominent physicist, made this point when he complained that after switching from physics to biology he never had a peaceful bath again. As a physicist he would soak in the warmth of a bathtub and contemplate a problem, turn it in his mind, reason his way through it. But once he became a biologist, he constantly had to climb out of the bathtub to look up a fact. In fact, biology is chaos.”


“He [William Henry Welch] was also worried. His entire compensation would come from student fees, and the three- month course was not required. He confided to his sister, “I sometimes feel rather blue when I look ahead and see that I am not going to be able to realize my aspirations in life. . . . There is no opportunity in this country, and it seems unlikely there ever will be. . . . I can teach microscopy and pathology, perhaps get some practice and make a living after a while, but that is all patchwork and the drudgery of life and what hundreds do.” He was wrong. In fact he would catalyze the creation of an entire generation of scientists who would transform American medicine, scientists who would confront influenza in 1918, scientists whose findings from that epidemic still echo today.”


“For the rest of his life Welch would remain alone. More than just alone, he would never dig in, never entrench himself, never root. He never married. Despite working with others in ways that so often bind people together as comrades, with the single possible exception of the great and strange surgeon William Halsted— and that exception only a rumored possibility — he had no known intimate relationship, sexual or otherwise, with either man or woman. Although he would live in Baltimore for half a century, he would never own a home there nor even have his own apartment; despite accumulating considerable wealth, he would live as a boarder, taking two rooms in the home of the same landlady, then moving with his landlady when she moved, and allowing his landlady’s daughter to inherit him as a boarder. He would take nearly every dinner in one of his gentlemen’s clubs, retreating to a world of men, cigars, and the conversations of an evening for the rest of his life. And he would, observed a young colleague, “deliberately break off relationships which seemed to threaten too strong an attachment.” But if he lived on the surface of ordinary life, his life was not ordinary. He was free, not just alone but free, free of entanglements of people, free of encumbrances of property, utterly free. He was free to do extraordinary things.”

“Einstein reportedly once said that his own major scientific talent was his ability to look at an enormous number of experiments and journal articles, select the very few that were both correct and important, ignore the rest, and build a theory on the right ones. In that assessment of his own abilities, Einstein was very likely overly modest. But part of his genius was an instinct for what mattered and the ability to pursue it vertically and connect it horizontally.”

“First, he had not only knowledge but judgment. He had an extraordinary ability to hear someone describe his or her experiments, or read a paper, and immediately define the crucial points still obscure, the crucial series of experiments needed to clarify them. It was as if, although he could not himself conjure, he knew the techniques of conjuring and could teach others conjury. He had an equally extraordinary ability to judge people, to identify those with the promise to do what he had not done. He largely chose the medical school faculty, and he chose brilliantly. All were young when appointed. Welch was thirty-four; William Osler, a Canadian and arguably the most famous clinical physician of the modern era, forty; William Halsted, a surgeon who changed the way surgeons thought, thirty-seven; Howard Kelly, a gynecologist and pioneer in radiation therapy, thirty-one; J. J. Abel, a chemist and pharmacologist who would discover adrenaline and help revolutionize pharmacopoeia, thirty-six; W. H. Howell, a physiologist, thirty-three; and Mall, thirty-one. (Howell, Abel, and Mall had been graduate students at the Hopkins.) Second, Welch inspired. He inspired unconsciously, simply by being himself.”

“The total effect, said Simon Flexner, “made for an atmosphere of achievement . . . The desire to be like Welch, the desire to win his approval, these were the principal incentives of the eager young men who crowded his lab.” Finally, a certain mystery clung to Welch. Although this was not part of his genius it explained part of his impact. For all his cordiality he remained distant. The cordiality itself was a barrier others could not penetrate. He paid little, and decreasing, attention to students until they did something significant enough to get his attention. He seemed casual, even sloppy. He would get so animated in conversation that his cigar ash would routinely drop onto his coat, where it would lie unnoticed. He was never on time. His desk would be piled with months of unanswered correspondence. Younger colleagues gave him a nickname, a nickname that spread from the Hopkins to younger scientists everywhere. They called him, never to his face, “Popsy.” It was a comfortable, paternal, and warm nickname.”


“In the keynote speech at the next meeting of the Association of American Physicians, an association created to foster scientific medicine, Welch said, “The discovery of the healing serum is entirely the result of laboratory work. In no sense was the discovery an accidental one. Every step leading to it can be traced, and every step was taken with a definite purpose and to solve a definite problem. These studies and resulting discoveries mark an epoch in the history of medicine.” His comment was a declaration not of war but of victory. Scientific medicine had developed technologies that could both prevent and cure diseases that had previously killed in huge numbers, and killed gruesomely.”

“Welch took to him though they were opposites. Flexner was small and wiry, almost wizened, and no one ever called him charming. He had an edgy insecurity and said, “I have never been educated in any branch of learning. There are great gaps in my knowledge.” To fill the gaps, he read. “He read,” his brother Abraham said, “as he ate.” He devoured books, read everything, read omnivorously, from English literature to Huxley and Darwin. He felt he had to learn. His insecurities never fully left him. He talked of “sleepless nights and days of acute fear . . . a maddening nervousness which prevented me from having a quiet moment.” Yet others recognized in him extraordinary possibilities. Welch arranged a fellowship for him in Germany, and four years later he became professor of pathology at the Hopkins. Often he went into the field: to a mining town to study meningitis, to the Philippines to study dysentery, to Hong Kong to study plague. Nobel laureate Peyton Rous later called Flexner’s scientific papers “a museum in print, only they stir with life; for he experimented as well as described.” He never lost his street toughness but his sharp hard edges did become rounded. He married a woman who was herself extraordinary enough to captivate Bertrand Russell (sixty letters from him were in her papers) and whose sister was a founder of Bryn Mawr. The famed jurist Learned Hand became a close friend. And he left his mark on the Rockefeller Institute. Emerson said that an institution is the lengthened shadow of one man, and the institute did reflect Simon Flexner. Raymond Fosdick, later president of the Rockefeller Foundation, talked of the “steely precision of his reason. His mind was like a searchlight that could be turned at will on any question that came before him.” A Rockefeller researcher said he had “a logic far beyond that of most men, final as a knife.”


“Epidemiological evidence suggests that a new influenza virus originated in Haskell County, Kansas, early in 1918. Evidence further suggests that this virus traveled east across the state to a huge army base, and from there to Europe. Later it began its sweep through North America, through Europe, through South America, through Asia and Africa, through isolated islands in the Pacific, through all the wide world. In its wake followed a keening sound that rose from the throats of mourners like the wind. The evidence comes from Dr. Loring Miner.” … “His patients said they’d rather have him drunk than someone else sober.” … “By now the disease overwhelmed Miner with patients. He pushed everything else aside, slept sometimes in his buggy while the horse made its own way home—one advantage over the automobile—through frozen nights. Perhaps he wondered if he was being confronted with the Plague of Athens, a mysterious disease that devastated the city during the Peloponnesian Wars, killing possibly one-third the population. Then the disease disappeared. By mid-March the schools reopened with healthy children. Men and women returned to work. And the war regained its hold on people’s thoughts. The disease still, however, troubled Miner deeply. It also frightened him, not only for his own people but for the people beyond. Influenza was neither a “reportable” disease—not a disease that the law required physicians to report—nor a disease that any state or federal public health agency tracked.”


“More virologists think the opposite: that viruses began as more complex living cells and evolved—or, more accurately, devolved—into simpler organisms. This theory does seem to fit some organisms, such as the “rickettsia” family of pathogens. Rickettsia used to be considered viruses but are now thought of as halfway between bacteria and viruses; researchers believe they once possessed but lost activities necessary for independent life. The leprosy bacillus also seems to have moved from complexity—doing many things—toward simplicity—doing fewer. A third theory argues that viruses were once part of a cell, an organelle, but broke away and began to evolve independently. Whatever the origin, a virus has only one function: to replicate itself. But unlike other life forms (if a virus is considered a life form), a virus does not even do that itself. It invades cells that have energy and then, like some alien puppet master, it subverts them, takes them over, forces them to make thousands, and in some cases hundreds of thousands, of new viruses. The power to do this lies in their genes.”

“In most life forms, genes are stretched out along the length of a filament-like molecule of DNA, deoxyribonucleic acid. But many viruses—including influenza, HIV, and the coronavirus that causes SARS (severe acute respiratory syndrome)—encode their genes in RNA, ribonucleic acid, an even simpler but less stable molecule.” … “Genes resemble software; just as a sequence of bits in a computer code tells the computer what to do—whether to run a word processing program, a computer game, or an Internet search—genes tell the cell what to do. Computer code is a binary language: it has only two letters. The genetic code uses a language of four letters, each representing the chemicals adenine, guanine, cytosine, and thymine (in some cases uracil substitutes for thymine). DNA and RNA are strings of these chemicals. In effect they are very long sequences of letters. Sometimes these letters do not form words or sentences that make any known sense: 97 percent of human DNA contains no genes; called “nonsense” or “junk” DNA, its function is still unknown.”

“There are three different types of influenza viruses: A, B, and C. Type C rarely causes disease in humans. Type B does cause disease, but not epidemics. Only influenza A viruses cause epidemics or pandemics, an epidemic being a local or national outbreak, a pandemic a worldwide one.”

“Whenever a new variant of the influenza virus does adapt to humans, it will threaten to spread rapidly across the world. It will threaten a pandemic. Pandemics often come in waves, and the cumulative “morbidity” rate—the number of people who get sick in all the waves combined—often exceeds 50 percent. One virologist considers influenza so infectious that he calls it “a special instance” among infectious diseases, “transmitted so effectively that it exhausts the supply of susceptible hosts.” Influenza and other viruses—not bacteria—combine to cause approximately 90 percent of all respiratory infections, including sore throats.”

“Coronaviruses (the cause of the common cold as well as SARS), parainfluenza viruses, and many other viruses all cause symptoms akin to influenza, and all are often confused with it. As a result, sometimes people designate mild respiratory infections as “flu” and dismiss them. But influenza is not simply a bad cold. It is a quite specific disease, with a distinct set of symptoms and epidemiological behavior. In humans the virus directly attacks only the respiratory system, and it becomes increasingly dangerous as it penetrates deeper into the lungs. Indirectly it affects many parts of the body, and even a mild infection can cause pain in muscles and joints, intense headache, and prostration. It may also lead to far more grave complications.” … “The overwhelming majority of influenza victims usually recover fully within ten days. Partly because of this, and partly because the disease is confused with the common cold, influenza is rarely viewed with concern.”

“…the Centers for Disease Control estimates that influenza kills from 3,000 to 56,000 Americans a year, depending chiefly on the virulence of that year’s virus. It is, however, not only an endemic disease, a disease that is always around. It also arrives in epidemic and pandemic form. And pandemics can be more lethal—sometimes much, much more lethal—than endemic disease. Throughout known history there have been periodic pandemics of influenza, usually several a century. They erupt when a new influenza virus emerges. And the nature of the influenza virus makes it inevitable that new viruses emerge.


“Each one caused between ten thousand and forty thousand “excess deaths” in the United States alone—an excess over and above the death toll usually caused by the disease. As a result influenza kills more people in the United States than any other infectious disease, including AIDS. Public health experts monitor this drift and each year adjust the flu vaccine to try to keep pace. But they will never be able to match up perfectly, because even if they predict the direction of mutation, the fact that influenza viruses exist as mutating swarms means some will always be different enough to evade both the vaccine and the immune system. But as serious as antigen drift can be, as lethal an influenza as that phenomenon can create, it does not cause great pandemics. It does not create firestorms of influenza that spread worldwide such as those in 1889–92, in 1918–19, in 1957, and in 1968, and to a lesser extent in 2009.”

“Antigen shift, this radical departure from existing antigens, led to major pandemics long before modern transportation allowed rapid movement of people. There is mixed opinion as to whether several pandemics in the fifteenth and sixteenth centuries were influenza, although most medical historians believe that they were, largely because of the speed of their movement and the number of people who fell ill. In 1510 a pandemic of pulmonary disease came from Africa and “attacked at once and raged all over Europe not missing a family and scarce a person.” In 1580 another pandemic started in Asia, then spread to Africa, Europe, and America. It was so fierce “that in the space of six weeks it afflicted almost all the nations of Europe, of whom hardly the twentieth person was free of the disease,” and some Spanish cities were “nearly entirely depopulated by the disease.” There is no dispute, though, that other pandemics in the past were influenza. In 1688, the year of the Glorious Revolution, influenza struck England, Ireland, and Virginia. In these places “the people dyed . . . as in a plague.” Five years later, influenza spread again across Europe: “all conditions of persons were attacked. . . . [T]hose who were very strong and hardy were taken in the same manner as the weak and spoiled, . . . the youngest as well as the oldest.” In January 1699 in Massachusetts, Cotton Mather wrote, “The sickness extended to allmost all families. Few or none escaped, and many dyed especially in Boston, and some dyed in a strange or unusual manner, in some families all weer sick together, in some towns allmost all weer sick so that it was a time of disease.” At least three and possibly six pandemics struck Europe in the eighteenth century, and at least four struck in the nineteenth century. In 1847 and 1848 in London, more people died from influenza than died of cholera during the great cholera epidemic of 1832. And in 1889 and 1890, a great and violent worldwide pandemic—although nothing that even approached 1918 in violence—struck again. In the twentieth century, three pandemics struck. Each was caused by an antigen shift, by radical changes in either the hemagglutinin or the neuraminidase antigens, or both, or by changes in some other gene or genes. Influenza pandemics generally infect from 15 to 40 percent of a population; any influenza virus infecting that many people and killing a significant percentage would be beyond a nightmare. In recent years public health authorities have at least twice identified a new virus infecting humans but successfully prevented it from adapting to man. To prevent the 1997 Hong Kong virus, which killed six of eighteen people infected, from adapting to people, public health authorities had every single chicken then in Hong Kong, 1.2 million of them, slaughtered.”

“One more thing makes influenza unusual. When a new influenza virus emerges, it is highly competitive, even cannibalistic. It usually drives older types into extinction. This happens because infection stimulates the body’s immune system to generate all its defenses against all influenza viruses to which the body has ever been exposed. When older viruses attempt to infect someone, they cannot gain a foothold. They cease replicating. They die out. So, unlike practically every other known virus, only one type—one swarm or quasi species—of influenza virus dominates at any given time. This itself helps prepare the way for a new pandemic, since the more time passes, the fewer people’s immune systems will recognize other antigens.”


“All of Europe was weary of the war. Only in the United States Anglophiles and Francophiles, most of them concentrated on the East Coast and many of them holding positions of power or influence, were not weary. Only in the United States Anglophiles and Francophiles still regarded war as glorious. And they put intense pressure on President Woodrow Wilson to enter the war. The war had begun in 1914. Wilson had withstood this pressure. A German submarine had sunk the Lusitania in 1915 and he had not gone to war despite outrage in the press, instead winning a German commitment to limit submarine warfare. He had resisted other justifications for war. He could fairly campaign for reelection in 1916 on the slogan “He Kept Us Out of War.” And he warned, “If you elect my opponent, you elect a war.” On election night he went to bed believing he had lost, but woke up reelected by one of the narrowest margins in history.”

“America had never been and would never be so informed by the will of its chief executive, not during the Civil War with the suspension of habeas corpus, not during Korea and the McCarthy period, not even during World War II. He would turn the nation into a weapon, an explosive device. As an unintended consequence, the nation became a tinderbox for epidemic disease as well. ••• Wilson declared, “It isn’t an army we must shape and train for war, it is a nation.” To train the nation, Wilson used an iron fist minus any velvet glove. He did have some legitimate reasons for concern, reasons to justify a hard line. For reasons entirely unrelated to the war, America was a rumbling chaos of change and movement, its very nature and identity shifting. In 1870 the United States numbered only forty million souls, 72 percent of whom lived in small towns or on farms. By the time America entered the war, the population had increased to roughly 105 million. Between 1900 and 1915 alone, fifteen million immigrants flooded the United States; most came from Eastern and Southern Europe, with new languages and religions, along with darker complexions. And the first census after the war would also be the first one to find more people living in urban areas than rural.”

The bill gave Postmaster General Albert Sidney Burleson the right to refuse to deliver any periodical he deemed unpatriotic or critical of the administration. And, before television and radio, most of the political discourse in the country went through the mails. A southerner, a narrow man and a hater, nominally a populist but closer to the Pitchfork Ben Tillman wing of the party than to that of William Jennings Bryan, Burleson soon had the post office stop delivery of virtually all publications and any foreign-language publication that hinted at less-than-enthusiastic support of the war.

There are lifeless truths and vital lies. . . . The force of an idea lies in its inspirational value. It matters very little if it is true or false.”


From the beginning of their planning, these men focused on the biggest killer in war—not combat, but epidemic disease. Throughout the wars in history more soldiers had often died of disease than in battle or of their wounds. And epidemic disease had routinely spread from armies to civilian populations.

This was true not just in ancient times or in the American Civil War, in which two men died from disease for every battle-related death (counting both sides, one hundred eighty-five thousand troops died in combat or of their wounds, while three hundred seventy-three thousand died of disease). More soldiers had died of disease than combat even in the wars fought since scientists had adopted the germ theory and modern public health measures. In the Boer War that raged from 1899 to 1902 between Britain and the white settlers of South Africa, ten British troops died of disease for each combat-related death. (The British also put nearly a quarter of the Boer population in concentration camps, where 26,370 women and children died.) In the Spanish-American War in 1898, six American soldiers died of disease—nearly all of them from typhoid—for every one killed in battle or who died of his wounds.

The medical corps told enlisted men to masturbate instead of using prostitutes. It produced posters with such slogans as “A Soldier who gets a dose is a traitor.” It examined enlisted men twice a month for venereal disease, required any men infected to identify the person with whom or the building in which they had had sex, docked the pay of soldiers or sailors sick with venereal disease, and also made them subject to court-martial. With support from the most senior political leadership, the military by law prohibited prostitution and the sale of alcohol within five miles of any base — and the military had seventy bases.


“Another sought an explanation for the far higher morbidity rates of pneumonia among blacks over whites.”

“Then, suddenly, noted an army report, “Stated briefly, the influenza . . . occurred as an explosion.” It exploded indeed. In a single day, 1,543 Camp Devens soldiers reported ill with influenza. On September 22, 19.6 percent of the entire camp was on sick report, and almost 75 percent of those on sick report had been hospitalized. By then the pneumonias, and the deaths, had begun.” … “Yet on September 26 the medical staff was so overwhelmed, with doctors and nurses not only ill but dying, they decided to admit no more patients to the hospital, no matter how ill.” … “Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white.” … “Blood was everywhere, on linens, clothes, pouring out of some men’s nostrils and even ears while others coughed it up. Many of the soldiers, boys in their teens, men in their twenties—healthy, normally ruddy men—were turning blue. Their color would prove a deadly indicator.”

“There are few diseases as infectious as influenza. . . . It is probable that patients become foci of infection before the active symptoms. . . . No disease which the army surgeon is likely to see in this war will tax more severely his judgement and initiative.”

Keegan was incorrect only in that he limited his estimate to “the entire country.” He should have said “the entire world.”


“…what happened in Philadelphia from that point would prove—too often—to be a model for what would happen elsewhere.”  … “and Philadelphia had the largest African American population of any northern city, including New York or Chicago.” … “In all of South Philadelphia, home to hundreds of thousands of Italians and Jews, there would be no high school until 1934.”

“And he was by nature someone who thought most problems disappeared on their own. Krusen publicly denied that influenza posed any threat to the city.”

“Meanwhile the Evening Bulletin assured its readers that influenza posed no danger, was as old as history, and was usually accompanied by a great miasma, foul air, and plagues of insects, none of which were occurring in Philadelphia. Plummer assured reporters that he and Krusen would “confine this disease to its present limits, and in this we are sure to be successful. No fatalities have been recorded among Navy men. No concern whatever is felt by either the military and naval physicians or by the civil authorities.”

“Plummer declared, “The disease has about reached its crest. We believe the situation is well in hand. From now on the disease will decrease.”

“Krusen’s public face remained nothing but reassuring. He now conceded that there were “a few cases in the civilian population” and said that health inspectors were looking for cases among civilians “to nip the epidemic in the bud.” But he did not say how.”

“These were unusual times. The Great War made them so. One cannot look at the influenza pandemic without understanding the context. Wilson had realized his aims. The United States was waging total war.” … “A man who can’t lend his govt $1.25 a week at the rate of 4{e8995b072a3d7400d607924a5f38be16c4e0aa6d4b23e82c0e389504a2781b12} interest is not entitled to be an American citizen.”


Then he demonstrated for them an innovation he had experimented with: the wearing of gauze masks by patients with respiratory disease. Welch called the mask “a great thing . . . an important contribution in prevention of spray infections.” He encouraged Capps to write an article for the Journal of the American Medical Association and advised Pearce to conduct studies of the masks’ effectiveness. Cole agreed: “This is a very important matter in connection with the prevention of pneumonia.” … “The gauze masks Capps was so proud of, the masks Welch had praised, were no longer being made; Capps ran out of material and personnel to make them.”

He also made the more general point that “one of the most vital measures in checking contagion” is eliminating crowding. “Increasing the space between beds in barracks, placing the head of one soldier opposite the feet of his neighbor, stretching tent flags between beds, and suspending a curtain down the center of the mess table, are all of proved value.”

“Seven days into the epidemic soldiers still capable of work converted nine more barracks into hospitals. There were shortages of aspirin, atropine, digitalis, glacial acetic acid (a disinfectant), paper bags, sputum cups, and thermometers—and thermometers that were available were being broken by men in delirium.”

“It seemed to work. Two hundred and thirty-four men suffering from pneumonia received the serum; only 16.7 percent died, while more than half of those who did not receive it died. But it was in short supply.”

“…175 patients have been released after winning their fight.”


“Medical care was making little difference anyway. Mary Tullidge, daughter of Dr. George Tullidge, died twenty-four hours after her first symptoms. Alice Wolowitz, a student nurse at Mount Sinai Hospital, began her shift in the morning, felt sick, and was dead twelve hours later.”

“On October 3, only five days after Krusen had let the parade proceed, he banned all public meetings in the city—including, finally, further Liberty Loan gatherings—and closed all churches, schools, theaters. Even public funerals were prohibited. Only one public gathering place was allowed to remain open: the saloon, the key constituency of the Vare machine. The next day the state health commissioner closed them.”

“In ten days—ten days!—the epidemic had exploded from a few hundred civilian cases and one or two deaths a day to hundreds of thousands ill and hundreds of deaths each day.”

“The peak of the influenza epidemic has been reached.” When 289 Philadelphians died the next day, the papers said, “Believing that the peak of the epidemic has passed, health officials are confident.”

“In each of the next two days more than three hundred people died, and again Krusen announced, “These deaths mark the high water mark in the fatalities, and it is fair to assume that from this time until the epidemic is crushed the death rate will constantly be lowered.”

“Don’t get frightened or panic stricken over exaggerated reports.”

“The city morgue had room for thirty-six bodies. Two hundred were stacked there. The stench was terrible; doors and windows were thrown open. No more bodies could fit. Bodies lay in homes where they died, as they died, often with bloody liquid seeping from the nostrils or mouths. Families covered the bodies in ice; even so, the bodies began to putrefy and stink.”

“The plague. In the streets people had been whispering the word. The word slipped, somehow, once, by accident, into that newspaper. The “morale” issue, the self-censorship, the intent by editors to put every piece of news in the most positive possible context, all meant that no newspaper used that word again. Yet people did not need newspapers to speak of the Black Death. Some bodies were turning almost black.”

“The virus had spanned the country, establishing itself on the Atlantic, in the Gulf, on the Pacific, on the Great Lakes. It had not immediately erupted in epidemic form, but it had seeded itself. Then the seeds began to sprout into flowers of flame.”

“On September 28, when the Liberty Loan paraders marched through Philadelphia streets, there were as yet only seven cases reported in Los Angeles, two in San Francisco. But the virus would get there soon enough.”

“People moved away from others on the sidewalk, avoided conversation; if they did speak, they turned their faces away to avoid the other person’s breathing. People became isolated, increasing the fear.”


“But this was influenza, only influenza. The overwhelming majority of victims got well. They endured, sometimes a mild attack and sometimes a severe one, and they recovered.”

“There was no such grace about influenza in 1918. It killed the young and strong. Studies worldwide all found the same thing. Young adults, the healthiest and strongest part of the population, were the most likely to die. Those with the most to live for—the robust, the fit, the hearty, the ones raising young sons and daughters—those were the ones who died.”

“In South African cities, those between the ages of twenty and forty accounted for 60 percent of the deaths. In Chicago the deaths among those aged twenty to forty almost quintupled deaths of those aged forty-one to sixty. A Swiss physician “saw no severe case in anyone over 50.” In the “registration area” of the United States—those states and cities that kept reliable statistics—breaking the population into five-year increments, the single greatest number of deaths occurred in men and women aged twenty-five to twenty-nine, the second greatest number in those aged thirty to thirty-four, the third greatest in those aged twenty to twenty-four. And more people died in each of those five-year groups than the total deaths among all those over age sixty.”

“Seventy years after the pandemic, Edwin Kilbourne, a highly respected scientist who has spent much of his life studying influenza, confirmed this observation, stating that the condition of the lungs was “unusual in other viral respiratory infections and is reminiscent of lesions seen following inhalation of poison gas.”


“We have had a number of cases where people were perfectly healthy and died within twelve hours.” The Journal of the American Medical Association carried reports of death within hours: “One robust person showed the first symptom at 4:00 P.M. and died by 10:00 A.M.”

“In Rio de Janeiro, a man asked medical student Ciro Viera Da Cunha, who was waiting for a streetcar, for information in a perfectly normal voice, then fell down, dead.”

“The influenza outbreak in 1997 in Hong Kong, when a new virus jumped from chickens to humans, killed only six people and it did not adapt to man. More than a million chickens were slaughtered to prevent that from happening, and the outbreak has been much studied. In autopsies pathologists noticed extremely high cytokine levels, discovered even that the bone marrow, lymphoid tissue, spleen—all involved in the immune response—and other organs were themselves under attack from an immune system turned renegade. They believed that this “syndrome [was] not previously described with influenza.” In fact, investigators in 1918 had seen the same thing.”

“One pulmonary expert describes ARDS as “a burn inside the lungs.” It is a virtual scorching of lung tissue. When viral pneumonia causes the condition, the immune system toxins designed to destroy invaders are what, in effect, flame in the lung, scorching the tissue”

“In 2003 a new coronavirus that causes SARS, “severe acute respiratory syndrome,” appeared in China and quickly spread around the world. Coronaviruses cause an estimated 15 to 30 percent of all colds and, like the influenza virus, infect epithelial cells. When the coronavirus that causes SARS does kill, it often kills through ARDS, although since the virus replicates much more slowly than influenza, death from ARDS can come several weeks after the first symptoms.


“To be a scientist requires not only intelligence and curiosity, but passion, patience, creativity, self-sufficiency, and courage. It is not the courage to venture into the unknown. It is the courage to accept—indeed, embrace—uncertainty. For as Claude Bernard, the great French physiologist of the nineteenth century, said, “Science teaches us to doubt.” … “A scientist must accept the fact that all his or her work, even beliefs, may break apart upon the sharp edge of a single laboratory finding. And just as Einstein refused to accept his own theory until his predictions were tested, one must seek out such findings.” … “Not all scientific investigators can deal comfortably with uncertainty, and those who can may not be creative enough to understand and design the experiments that will illuminate a subject—to know both where and how to look. Others may lack the confidence to persist. Experiments do not simply work. Regardless of design and preparation, experiments—especially at the beginning, when one proceeds by intelligent guess-work—rarely yield the results desired. An investigator must make them work. The less known, the more one has to manipulate and even force experiments to yield an answer.”

“No one interested in any truth will torture the data itself, ever. But a scientist can—and should—torture an experiment to get data, to get a result, especially when investigating a new area. A scientist can—and should—seek any way to answer a question: if using mice and guinea pigs and rabbits does not provide a satisfactory answer, then trying dogs, pigs, cats, monkeys. And if one experiment shows a hint of a result, the slightest bump on a flat line of information, then a scientist designs the next experiment to focus on that bump, to create conditions more likely to get more bumps until they either become consistent and meaningful or demonstrate that the initial bump was mere random variation without meaning. There are limits to such manipulation. Even under torture, nature will not lie, will not yield a consistent, reproducible result, unless it is true. But if tortured enough, nature will mislead; it will confess to something that is true only under special conditions—the conditions the investigator created in the laboratory. Its truth is then artificial, an experimental artifact.”

“The most damning condemnation is to dismiss a finding as “not reproducible.” That can call into question not only ability but on occasion ethics.”


“As influenza stretched its fingers across the country and began to crush out lives in its grip, virtually every serious medical scientist—and many simple physicians who considered themselves of scientific bent—began looking for a cure. They were determined to prove that science could indeed perform miracles.”


“In 1918 the institution of the federal government had more force than it had ever had—and in some ways more force than it has had since. But it was aiming all that force, all its vital energy, in another direction. ••• The United States had entered the war with little preparation in April 1917, and mobilizing the country took time. By the summer of 1918, however, Wilson had injected the government into every facet of national life and had created great bureaucratic engines to focus all the nation’s attention and intent on the war. He had created a Food Administration to control and distribute food, a Fuel Administration to ration coal and gasoline, a War Industries Board to oversee the entire economy. He had taken all but physical control over the railroads and had created a federally sponsored river barge line that brought commerce back to life on the Mississippi River, a commerce that had been killed by competition from those railroads. He had built many dozens of military installations, each of which held at least tens of thousands of soldiers or sailors. He had created industries that made America’s shipyards teem with hundreds of thousands of laborers launching hundreds of ships, dug new coal mines to produce coal for the factories that weaned America’s military from British and French weapons and munitions—for, unlike in World War II, America was no arsenal of democracy. He had created a vast propaganda machine, an internal spy network, a bond-selling apparatus extending to the level of residential city blocks. He had even succeeded in stifling speech, in the summer of 1918 arresting and imprisoning—some for prison terms longer than ten years—not just radical labor leaders and editors of German-language newspapers but powerful men, even a congressman. He had injected the government into American life in ways unlike any other in the nation’s history. And the final extension of federal power had come only in the spring of 1918, after the first wave of influenza had begun jumping from camp to camp, when the government expanded the draft from males between the ages of twenty-one and thirty to those between the ages of eighteen and forty-five. Only on May 23, 1918, had Provost Marshal Enoch Crowder, who oversaw the draft, issued his “work or fight” order, stating that anyone not employed in an essential industry would be drafted—an order that caused major league baseball to shorten its season and sent many ballplayers scurrying for jobs that were “essential”—and promising that “all men within the enlarged age would be called within a year.” All men, the government had said, with orders for an estimated thirteen million to register September 12. Crowder bragged about doing “in a day what the Prussian autocracy had been spending nearly fifty years to perfect.” All this enormous and focused momentum would not be turned easily.”


“And even as the epidemic rooted itself in Bronxville, the paper condemned “alarmism” and warned, “Fear kills more than the disease and the weak and timid often succumb first.” Fear, that was the enemy. Yes, fear. And the more officials tried to control it with half-truths and outright lies, the more the terror spread.”

“The Los Angeles public health director said, “If ordinary precautions are observed there is no cause for alarm.” Forty-eight hours later he closed all places of public gatherings, including schools, churches, and theaters.”

“Chicago Public Health Commissioner John Dill Robertson violently rejected that suggestion as unwarranted and very damaging to morale. In his official report on the epidemic, he bragged, “Nothing was done to interfere with the morale of the community.” Later he explained to other public health professionals, “It is our duty to keep the people from fear. Worry kills more people than the epidemic.”

“Dr. Woodward said the increase in cases today was not alarming.” At Camp Dix “the camp medical authorities asserted they have the epidemic under control.” And the paper noted the first influenza deaths in New Orleans two days before the New Orleans daily newspaper the Item mentioned any death in the city.”

“In 2003 SARS killed over eight hundred people around the world, froze Asian economies, and frightened millions of people in Hong Kong, Singapore, and elsewhere into wearing masks on the streets.”

Albert Camus wrote, “What’s true of all the evils in the world is true of plague as well. It helps men to rise above themselves.”

“Doane himself charged that “German agents . . . from submarines” brought influenza to the United States. “The Germans have started epidemics in Europe, and there is no reason why they should be particularly gentle to America.”


“Physicians injected people with typhoid vaccine, thinking—or simply hoping—it might somehow boost the immune system in general even though the specificity of the immune response was well understood. Some claimed the treatment worked. Others poured every known vaccine into patients on the same theory. Quinine worked on one disease: malaria. Many physicians gave it for influenza with no better reasoning than desperation.”

“Vaccines continued to be produced in great numbers—eighteen different kinds in Illinois alone. No one had any real idea whether any would work. They had only hope.”

“Places that isolated themselves—such as Gunnison, Colorado, and a few military installations on islands—escaped. But the closing orders that most cities issued could not prevent exposure; they were not extreme enough.”

“In Brazil—where the virus was relatively mild, at least compared with Mexico or for that matter Chile—Rio de Janeiro suffered an attack rate of 33 percent.”

“As elsewhere, India had suffered a spring wave. As elsewhere, this spring wave was relatively benign. In September influenza returned to Bombay. As elsewhere, it was no longer benign.” … “Yet India was not like elsewhere. There influenza would take on truly killing dimensions. A serious epidemic of bubonic plague had struck there in 1900, and it had struck Bombay especially hard. In 1918 the peak daily influenza mortality in Bombay almost doubled that of the 1900 bubonic plague, and the case mortality rate for influenza reached 10.3 percent.”

“Victor Vaughan, Welch’s old ally, sitting in the office of the surgeon general of the army and head of the army’s Division of Communicable Diseases, watched the virus move across the earth. “If the epidemic continues its mathematical rate of acceleration, civilization could easily,” he wrote in hand, “disappear . . . from the face of the earth within a matter of a few more weeks.”


“The influenza virus is different. Since birds provide a natural home for it, influenza does not depend upon civilization. In terms of its own survival, it did not matter if humans existed or not.”

“Twenty years before the great influenza pandemic, H. G. Wells published War of the Worlds, a novel in which Martians invaded the earth. They loosed upon the world their death ships, and they were indomitable. They began to feed upon humans, sucking the life force from them down to the marrow of the bone. Man, for all his triumphs of the nineteenth century, a century in which his achievements had reordered the world, had become suddenly impotent. No force known to mankind, no technology or strategy or effort or heroism that any nation or person on earth had developed, could stand against the invaders. Wells wrote, “I felt the first inkling of a thing that presently grew quite clear in my mind, that oppressed me for many days, a sense of dethronement, a persuasion that I was no longer a master, but an animal among the animals. . . . The fear and empire of man had passed away.” But just as the destruction of the human race seemed inevitable, nature intervened. The invaders were themselves invaded; the earth’s infectious pathogens killed them. Natural processes had done what science could not. With the influenza virus, natural processes began to work as well. At first those processes had made the virus more lethal. Whether it first jumped from an animal host to man in Kansas or in some other place, as it passed from person to person it adapted to its new host, became increasingly efficient in its ability to infect, and changed from the virus that caused a generally mild first wave of disease in the spring of 1918 to the lethal and explosive killer of the second wave in the fall. But once this happened, once it achieved near-maximum efficiency, two other natural processes came into play. One process involved immunity. Once the virus passed through a population, that population developed at least some immunity to it. Victims were not likely to be reinfected by the same virus, not until it had undergone antigen drift. In a city or town, the cycle from first case to the end of a local epidemic in 1918 generally ran six to eight weeks. In the army camps, with the men packed so densely, the cycle took usually three to four weeks.”

“Individual cases continued to occur after that, but the explosion of disease ended, and it ended abruptly. A graph of cases would look like a bell curve—but one chopped off almost like a cliff just after the peak, with new cases suddenly dropping to next to nothing. In Philadelphia, for example, in the week ending October 16 the disease killed 4,597 people. It was ripping the city apart, emptying the streets, sparking rumors of the Black Death. But new cases dropped so precipitously that only ten days later, on October 26, the order closing public places was lifted. By the armistice on November 11, influenza had almost entirely disappeared from that city. The virus burned through available fuel. Then it quickly faded away.”

“But the 1918 virus, like all influenza viruses, like all viruses that form mutant swarms, mutated rapidly. There is a mathematical concept called “reversion to the mean”; this states simply that an extreme event is likely to be followed by a less extreme event. This is not a law, only a probability. The 1918 virus stood at an extreme; any mutations were more likely to make it less lethal than more lethal. In general, that is what happened. So just as it seemed that the virus would bring civilization to its knees, would do what the plagues of the Middle Ages had done, would remake the world, the virus mutated toward its mean, toward the behavior of most influenza viruses. As time went on, it became less lethal.

“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. In Seattle, in Portland, in Los Angeles, in San Diego, the dead did not pile up as in the East. In St. Louis, in Chicago, in Indianapolis, the dead did not pile up as in the West. But if the dead did not pile up there as they had in Philadelphia and New Orleans, they still did pile up.”

“But the virus, even as it lost some of its virulence, was not yet finished. Only weeks after the disease seemed to have dissipated, when town after town had congratulated itself on surviving it—and in some places where people had had the hubris to believe they had defeated it—after health boards and emergency councils had canceled orders to close theaters, schools, and churches and to wear masks, a third wave broke over the earth. The virus had mutated again. It had not become radically different. People who had gotten sick in the second wave had a fair amount of immunity to another attack, just as people sickened in the first wave had fared better than others in the second wave. But it mutated enough, its antigens drifted enough, to rekindle the epidemic. Some places were not touched by the third wave at all. But many—in fact most—were.”

“And far from the usual assurances that the disease was ordinary “la grippe,” on October 22 the mayor, Hassler, the Red Cross, the Chamber of Commerce, and the Labor Council jointly declared in a full-page newspaper ad, “Wear a mask and save your life!” claiming that it was “99{e8995b072a3d7400d607924a5f38be16c4e0aa6d4b23e82c0e389504a2781b12} proof against influenza.” By October 26, the Red Cross had distributed one hundred thousand masks. Simultaneously, while local facilities geared up to produce vaccine, thousands of doses of a vaccine made by a Tufts scientist were raced across the continent on the country’s fastest train.

“The virus was still not finished. All through the spring of 1919 a kind of rolling thunder moved above the earth, intermittent, unleashing sometimes a sudden localized storm, sometimes even a lightning bolt, and sometimes passing over with only a rumble of threatened violence in the distant and dark sky. It remained violent enough to do one more thing.” [i.e. affected Wilson’s brain]


In 2002 Robert Webster, one of the world’s leading experts on the virus at St. Jude Children’s Hospital in Memphis, observed, “These viruses do from time to time get across to central nervous systems and play hell.” He recalled a child in Memphis who was an excellent student, got influenza, and became “a vegetable. I’ve seen enough examples in my lifetime to believe . . . influenza can get into the brain. It’s tenuous but real. Put the virus into chickens, it can go up the olfactory nerve and the chicken’s dead.”

“House had first gotten influenza during the first wave in March 1918, was confined to his home for two weeks, went to Washington and relapsed, and then spent three weeks in bed at the White House. Although a spring attack often conferred immunity to the virus, after the Armistice he was struck down a second time. He was in Europe then, and on November 30 he got up for the first time in ten days and met with French premier Georges Clemenceau for fifteen minutes. Afterward he noted, “Today is the first day I have taken up my official work in person for over a week. I have had influenza 10 days and have been exceeding miserable. . . . So many have died since this epidemic has scourged the world. Many of my staff have died and poor Willard Straight among them.” Now, in January 1919, he was attacked still a third time. He was sick enough that some papers reported him dead. House wryly called the obituaries “all too generous.” But the blow was heavy: more than a month after his supposed recovery he wrote in his diary, “When I fell sick in January I lost the thread of affairs and I am not sure that I have ever gotten fully back.”

“In February 1919, deaths in Paris from influenza and pneumonia climbed back up to 2,676, more than half the peak death toll. Wilson’s daughter Margaret had influenza in February; she was kept in bed in Brussels at the American legation. In March another 1,517 Parisians died, and the Journal of the American Medical Association reported that in Paris “the epidemic of influenza which had declined has broken out anew in a most disquieting manner. . . . The epidemic has assumed grave proportions, not only in Paris but in several of the departments.”

“Four months later Wilson suffered a major and debilitating stroke. For months his wife and Grayson would control all access to him and become arguably the de facto most important policy makers in the country.”

No one can know what would have happened. One can only know what did happen. Influenza did visit the peace conference. Influenza did strike Wilson. Influenza did weaken him physically, and—precisely at the most crucial point of negotiations—influenza did at the least drain from him stamina and the ability to concentrate. That much is certain. And it is almost certain that influenza affected his mind in other, deeper ways.

John Maynard Keynes quit Paris calling Wilson “the greatest fraud on earth.”


“The year 1920 would see either (sources differ) the second or third most deaths from influenza and pneumonia in the twentieth century. And it continued to strike cities sporadically. As late as January 1922, for example, Washington State’s health director, Dr. Paul Turner, while refusing to admit the return of influenza, declared, “The severe respiratory infection which is epidemic at this time throughout the state is to be dealt with the same as influenza. . . . Enforce absolute quarantine.”

“Memory dies with people.”

“John Dos Passos was in his early twenties and seriously ill with influenza, yet barely mentioned the disease in his fiction. Hemingway, Faulkner, Fitzgerald said next to nothing of it. William Maxwell, a New Yorker writer and novelist, lost his mother to the disease. Her death sent his father, brother, and him inward. He recalled, “I had to guess what my older brother was thinking. It was not something he cared to share with me. If I hadn’t known, I would have thought that he’d had his feelings hurt by something he was too proud to talk about. . . .”

People write about war. They write about the Holocaust. They write about horrors that people inflict on people. Apparently they forget the horrors that nature inflicts on people, the horrors that make humans least significant. And yet the pandemic resonated. When the Nazis took control of Germany in 1933, Christopher Isherwood wrote of Berlin: “The whole city lay under an epidemic of discreet, infectious fear.

During the second wave, many local governments collapsed, and those who held the real power in a community—from Philadelphia’s bluebloods to Phoenix’s citizens’ committee—took over. But generally they exercised power to protect the entire community rather than to split it, to distribute resources widely rather than to guarantee resources for themselves.

“It is impossible to quantify how many deaths the lies caused. It is impossible to quantify how many young men died because the army refused to follow the advice of its own surgeon general. But while those in authority were reassuring people that this was influenza, only influenza, nothing different from ordinary “la grippe,” at least some people must have believed them, at least some people must have exposed themselves to the virus in ways they would not have otherwise, and at least some of these people must have died who would otherwise have lived.”

“Given the world’s population in 1918 of approximately 1.8 billion, the upper estimate would mean that in two years—and with most of the deaths coming in a horrendous twelve weeks in the fall of 1918—in excess of 5 percent of the people in the world died.”

“Today’s world population is 6.3 billion. To give a sense of the impact in today’s world of the 1918 pandemic, one has to adjust for population. If one uses the lowest estimate of deaths—the 21 million figure—that means a comparable figure today would be 73 million dead. The higher estimates translate into between 175 and 350 million dead. Those numbers are not meant to terrify—although they do. Medicine has advanced since 1918 and would have considerable impact on the mortality rate (see pages 450–451). Those numbers are meant simply to communicate what living through the pandemic was like.”

“In the United States, roughly 0.65 percent of the total population died, with roughly double that percentage of young adults killed. Of developed countries, Italy suffered the worst, losing approximately 1 percent of its total population. The Soviet Union may have suffered more, but few numbers are available for it.”


“Pennsylvania, the University of Michigan, or Columbia. The group was so small that it still included the first generation of revolutionaries, with Welch and Vaughan and Theobald Smith and a few others still active. Then came their first students, men only a few years younger: Gorgas, who had reached mandatory retirement age from the army days before the war ended—the army could have allowed him to remain, but he had no friends among army superiors—and who then shifted to international public health issues for a Rockefeller-funded foundation; Flexner and Park and Cole in New York; Milton Rosenau in Boston; Frederick Novy at Michigan; and Ludwig Hektoen in Chicago. Then came the next half generation of protégés: Lewis in Philadelphia; Avery, Dochez, Thomas Rivers, and others at Rockefeller; George Whipple in Rochester, New York; Eugene Opie at Washington University in St. Louis; and a few dozen more. It was only in the next generation, and the next, that the numbers of true researchers began to multiply enormously and spread throughout the country.”

“Now two million men were returning from Europe. After other wars, even in the late nineteenth century, returning troops had carried diseases home. British, French, and Russian troops had spread cholera after the Crimean War; Americans troops had spread typhoid, dysentery, and smallpox after the Civil War; Prussians had brought smallpox home from the Franco-Prussian War; and Americans had returned from the Spanish-American War carrying typhoid.”

“This resistance of the elderly was a worldwide phenomenon. The most likely explanation is that an earlier pandemic (later analysis of antibodies proved it was not the 1889–90 one), so mild as to not attract attention, resembled the 1918 virus closely enough that it provided protection.”

“In the laboratory, however, the fog remained dense. The pathogen remained unknown. Enormous resources were being poured into this research everywhere. In Australia, Macfarlane Burnet lived through the epidemic as a teenager, and it burned itself into his consciousness. As he said soon after receiving the Nobel Prize, “For me as for many others interested in bacteriology and infectious disease, the outstanding objective in medicine for years was . . . influenza.” Yet all this work had not penetrated the fog.”

“After two years of extraordinary—and continuing—efforts by many of the world’s best investigators, in 1920 Welch made a frustrating prediction: “I think that this epidemic is likely to pass away and we are no more familiar with the control of the disease than we were in the epidemic of 1889. It is humiliating, but true.”


“Fleming never did see penicillin as an antibiotic. A decade later Howard Florey and Ernst Chain, funded by the Rockefeller Foundation, did, and they developed Fleming’s observation into the first wonder drug. It was so scarce and so powerful that in World War II, U.S. Army teams recovered it from the urine of men who had been treated with it, so it could be reused. In 1945, Florey, Chain, and Fleming shared the Nobel Prize.”

“In 1931, Pfeiffer himself still argued that, of all organisms yet described, the pathogen he had called Bacillus influenzae and that informally bore his name had “the best claim to serious consideration as the primary etiologic agent, and its only competition is an unidentified filterable virus.”

“Avery loved an Arab saying: “The dogs bark, the caravan moves on.” He had nothing to publish because his work was being done chiefly by subtraction. But it was moving on. He had isolated whatever transformed the pneumococcus. Now he was analyzing that substance by eliminating one possibility after another.”


Instead of Ghana, however, he would go to Brazil. A particularly virulent strain of yellow fever had surfaced there.

Then, on June 29, Russell sent a note hand-delivered by messenger to Flexner: “The following message from Rio de Janeiro, regarding Dr. Paul Lewis, was sent to me today, with the request that it be delivered to you. ‘Lewis’s illness began on June 25th. Doctors state it to be yellow fever. Condition of June 28th, temperature 103.8, pulse 80. . . .’ The Foundation is sending the message to Dr. Theobald Smith and also to Mrs. Lewis at Milwaukee.”


Chiefly, I wanted to see how American society reacted to an immense challenge, a war nature had launched against humanity imposed on a war humans had launched against one another. I wanted to explore how individuals who had at least some power to deal with this challenge reacted, whether they be politicians or scientists, and what effects their decisions had on society. And I wanted to see what lessons we might take from such an investigation.

Almost all victims have been infected through direct contact with birds (a very few occurred within families), but every time the virus infects a person, it has another opportunity to develop the capacity to bind to human cells in the upper respiratory tract, as do seasonal influenza viruses. This would allow it to pass easily from person to person. If that happens, the case fatality rate would drop—most victims would start with ordinary influenza, not a viral pneumonia—but another pandemic would occur.

In 1918 such a virus did infect humans. Since the original publication of this book, scientists have found evidence (the question is not settled) that seven of the eight segments of the 1918 virus are of avian origin, and the virus jumped species to humans probably after a reassortment (see 112) with another virus in which it acquired a human hemagglutinin gene—the gene which allows the virus to bind to and thus infect cells. And even that eighth segment had recent avian roots. This reassortment would have occurred when the avian virus infected a mammal—human, horse, pig, whatever—that was simultaneously infected by another influenza virus carrying that gene.

And a severe influenza pandemic would hit like a tsunami, inundating intensive-care units even as doctors and nurses fall ill themselves and generally pushing the health care system to the point of collapse and possibly beyond it. Hospitals, like every other industry, have gotten more efficient by cutting costs, which means virtually no excess capacity—on a per capita basis the United States has far fewer hospital beds than a few decades ago. Indeed, during a routine influenza season, usage of respirators rises to nearly 100 percent; in a pandemic, most people who needed a mechanical respirator probably would not get one.

Disease impact would also ripple through the economy to disastrous effect. With everyone from air traffic controllers to truck drivers out sick, just-in-time inventory systems would crash, supply chains would collapse, for lack of some part production lines would shut down, while schools and day-care facilities might close for weeks, and an overburdened “last mile” would limit the ability of people to work from home.

Planners prepared for a Category 5 hurricane. The 2009 H1N1 swine flu pandemic, not even a tropical storm, threw them off-balance. This pandemic, the mildest ever known, taught new lessons, including some that required rethinking NPI policy. The 2009 pandemic killed “only” an estimated 150,000 to 575,000 worldwide, with probably about 12,000 U.S. deaths. (However, if one looks at the 2009 pandemic in terms of total years of life lost, not just deaths, it was much more severe: the average age of victims was only forty, and 80 percent of victims were younger than sixty-five. In seasonal influenza, only 10 percent of deaths occur in those under sixty-five.) By comparison, ordinary seasonal influenza kills up to 650,000 people worldwide annually, and in the United States the disease kills between 3,000 and 56,000 a year, depending mainly on the virulence of the virus and to a lesser extent on the efficacy of that year’s vaccine.

“The biggest concern is always for an influenza pandemic . . . [It] really is the worst-case scenario.”

First, all five came in waves. (A few scientists argue that the difference in lethality between 1918’s first and second waves mean that these were caused by different viruses, but evidence showing otherwise seems overwhelming. For one thing, exposure to the first wave provided as high as 94 percent protection against the second wave, far better protection than the best modern vaccine affords, and that’s just one piece of the evidence that the same virus caused both waves.)

Incidentally, the 1968 pandemic gave us the H3N2 virus, which has continued to cause the most severe disease of several circulating influenza viruses ever since.

Of course, if developing a universal vaccine were easy it would have been done, but for decades few resources went to such research. Consider for a moment that prior to the emergence of H5N1, the U.S. government was spending more money on the West Nile virus than on influenza. While influenza was killing as many as 56,000 Americans a year, West Nile in its deadliest year killed 284. And West Nile will never be a major threat; it is not a disease that will ever explode through the human population. Yet it was receiving more research dollars than influenza.

The question of vaccines aside—where are we? How prepared are we for a new pandemic? ••• Here is what has gone right: For one, the World Health Organization and governments have developed a good surveillance system.

In 2003, the system even picked up SARS, which was originally thought to be a new influenza virus, and contained it, but SARS was infinitely easier to control than influenza would be. As it was, the world was put at risk by China, which initially lied and hid the disease. China’s candor has improved significantly, but China is still not fully transparent.

Obviously, surveillance matters because it provides the earliest possible alert of potential pandemic viruses, which in turn accelerates the production of a vaccine—and with all its flaws, a vaccine remains the best defense against a pandemic.

…even under a best case scenario, even with the new technologies, it will still take months to deliver large quantities of vaccine. In addition, much of the U.S. vaccine supply is manufactured outside the country; in a lethal pandemic, there is a question whether another government would allow its export before its own population was protected.

So current pharmaceuticals would fall far short of solving the problem of a pandemic. What else can be done? In the past several years numerous governments have looked at NPIs—i.e., ways to mitigate a pandemic’s impact using public health measures. No easy answers exist. The virus is airborne, so it can be inhaled, which seems to be the primary manner of transmission, but it can also survive on a surface—a doorknob, say, or a can of beer—at least for hours or, depending on temperature and humidity, possibly for days. So it can also be transmitted if someone opens a door, then covers a yawn. The only way to avoid it is to completely isolate oneself from society for the six to ten weeks it takes an outbreak to burn through a community, including not accepting deliveries, not going out, and so forth.

So NPIs, whether imposed by governments or taken by individuals, will have limited usefulness. And even to the limited extent an intervention might be successful, it must be sustained. Based on studies of what U.S. cities did in 1918, modelers have concluded that “layering” several interventions—most of them different kinds of “social distancing”—would at least stretch out the length of an influenza outbreak in a local community, easing the strain on the health care system. The historical data used in some of these models was flawed, and in assessing such 1918 actions as closing schools, none of the models considered that the cities that experienced the spring wave likely had a population with some immunity, which may have affected the model’s results.

Nonetheless, these NPIs are the only tools available. One tool of no use is widespread quarantine. For some diseases quarantine makes good sense, and in theory in some circumstances it could help even for influenza—but only in theory. An unpublished 1918 study of army camps demonstrates this. The army had data on 120 training camps—99 imposed quarantine and 21 did not. But there was no difference in mortality or morbidity between camps implementing quarantine and those that didn’t; there was not even any difference in how long it took influenza to pass through the camp. The story, however, isn’t quite that simple: the epidemiologist who performed the study looked not just at numbers but at actual practice, and found that out of the 99 camps that imposed quarantine, only a half dozen or so rigidly enforced it. Those few did benefit. But if the overwhelming majority of army bases in wartime could not enforce a quarantine rigidly enough to benefit, a civilian community in peacetime certainly could not.

Closing borders would be of no benefit either. It would be impossible to shut down trade, prevent citizens from returning to the country, etc. That would shut down the entire economy and enormously magnify supply chain problems by ending imports—including all health-related imports like drugs, syringes, gowns, everything. Even at that, models show that a 90 percent effective border closing would delay the disease by only a few days, at most a week, and a 99 percent effective shutting of borders would delay it at most a month.

Telecommuting is another obvious action, although the so-called last mile cannot support a significant surge in Internet usage.

The argument for school closing: Because adults have much more cross-protection from exposure to other influenza viruses than children do, children usually suffer higher attack rates. They are also less careful about, for example, disposing of tissue when they sneeze, washing their hands, and so forth, so they routinely spread influenza and other infectious diseases—not only to each other, but to adults. (Inoculating children with a pneumococcal vaccine caused from a 38 percent to 94 percent decline in pneumonia in the elderly—their grandparents.) Without a doubt schools played a significant role in spreading the 1957, 1968, and 2009 pandemics, and continually do so in spreading seasonal influenza.

Part of that relationship requires political leaders to understand the truth—and to be able to handle the truth. If there’s a lesson from the 2009 pandemic, it’s that too many governments were incapable of doing so. Every Western government and many non-Western ones had prepared plans for a pandemic, as did the World Health Organization. They were reasonable plans that included good recommendations. Many of the plans attempted to limit the role of personality by laying out explicit steps to take—or not take—based on certain triggers. But planning does not equal preparation, and too many political leaders ignored the plans.

Brazil was slow to release information and its southern regions had the world’s highest fatality rates.

For if there is a single dominant lesson from 1918, it’s that governments need to tell the truth in a crisis. Risk communication implies managing the truth. You don’t manage the truth. You tell the truth.

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