The Great Influenza: The Story of the Deadliest Pandemic in History Paperback – October 4, 2005

“Influenza killed more people in [1918] than the Black Death of the Middle Ages killed in a century; it killed more people in 24-weeks than AIDS has killed in 24-years.” Those are some pretty sobering statistics. John Barry takes an oddly forgotten moment in world history and makes it comes to life in this thorough, fast-paced and sharply written history of the great Spanish Influenza pandemic that struck the globe at the end of the First World War.Barry begins his narrative with a terrific overview of the history of medical science. The Warriors highlights the critical role played by Johns Hopkins University and Hospital in reforming and advancing the cause. The amazing thing is how stunted medical science remained for so long, essentially unaltered from the time of Hippocrates and Galens to the mid-nineteenth century. Indeed, medicine was “the withered arm of science.” This backwardness can be attributed to the failure to ask two basic questions: “What can I know? How can I know it?” For centuries – actually millennia – medicine was a basic exercise in observation, not probing experimentation. It was treated like Newton under the apple tree, unlocking the secrets of physics by observing the world around you. Only the world of biological science isn’t so neat and uniform; it’s chaotic. Thus, the use of bleeding (venestration), the most notorious practice of pre-modern medicine, was entirely logical from an observational perspective (e.g. “people with fevers are flushed; after bleeding they are pale.”). Logic and observation failed because neither tested hypotheses rigorously. As a result, medicine was long considered a “low science” and not much respected. When Hopkins was born in 1876 it was a deliberate break from the American university model of conveying the known, to a new, largely German model of methodically explaining the unknown.It wasn’t until 1891 that a major disease – diphtheria – was cured. Suddenly, there was a flood of research dollars into medicine. In 1890, there was $18M in national university endowments supporting American theological schools and just $500K supporting American medical schools. As late as 1904 most medical schools had no affiliation with either a university or a hospital, no admission criteria of any kind, and a staff that was paid purely from tuition receipts. A blistering study, the Flexner Report, on the state of American medical education in 1910 was a watershed moment, according to the author. Medical education was about to be reinvented, and re-built largely on the Hopkins example. Over the next decade 100 medical schools – about two-thirds of those then in existence – either went under or merged. In 1904, there were 28K American medical school students; by 1920 the number had been fully cut in half.The guiding light in this benevolent revolution was the first head of the Hopkins hospital, William Welch. Known for his judgment and inspiration, Welch “exuded confidence without arrogance, smugness, or pomposity.” He was “the glue that cemented together the entire American medical establishment.” A medical graduate of Yale, “a typical good American medical school, with no requirements for admission and no grades in any course,” he presided over the emergence of American medical science as a world leader in just over a generation.Part two, The Swarm, provides an introduction to virology and the astounding resiliency and adaptability of the influenza virus in particular. Barry describes the invasion and take over at the molecular level in arresting language. “An infection,” he writes, “is an act of violence; it is an invasion, a rape, and the body reacts violently.” Even today in the United States, about 36K people are killed by the flu every year, essentially the same that are killed by auto accidents or gun violence (including suicide).Part three, The Tinderbox, the author introduces a stridently hostile view of American mobilization leading up to World War I, skewering President Wilson and his extended administration at every turn. In short, the H1N1 flu virus of 1918 was unusually virulent, but what turned it into one of the greatest killers of all time was a potent mix of massive manpower mobilization combined with press censorship. Millions of young men, from both city and country, were shunted to over crowded barracks, and forced to share beds, utensils and air. “Never before in American history – and possibly never before in any country’s history – had so many men been brought together in such a way,” Barry claims. Meanwhile, the US government had virtual control over the flow of information and were aggressively on guard to squelch any news that smacked of defeatism or could damage morale, both military and civilian.Part four, It Begins, describes how the initial version of the flu that spread quickly out of the Kansas army camps and then across the Atlantic from February 1918 to April, reaching Australia by September 1918, was generally mild and not too disconcerting to public health officials. Owing to strict censorship the disease became known as the Spanish Influenza simply because neutral Spain had an open press and was the only country that freely reported on the illness. “Those in control of the war’s propaganda machine wanted nothing printed that could hurt morale,” the authors says again and again. Most health officials presumed the flu had come and gone. But instead, “It had gone underground, like a forest fire left burning in the roots, swarming and mutating, adapting, honing itself, watching and waiting, waiting to burst into flame.”Part five, Explosion, chronicles the rapid spread of the flu from Camp Devins, an army installation in Massachusetts, to the rest of the eastern seaboard and port cities in early autumn. The commanding officer at Camp Grant in Illinois committed suicide when the flu decimated his troops after he blocked the strict quarantine recommendations of camp physicians. Barry pays special attention to the city of Philadelphia where a massive Liberty Parade went ahead despite clear evidence that the deadly flu had arrived. “Within seventy-two hours after the parade," he writes, "every single bed in each of the city’s thirty-one hospitals was filled. And people began dying.” But still the government snuffed out true reporting on the extent and danger of the virus. “…Free speech trembled indeed,” Barry states emphatically.Part six, The Pestilence, describes the chilling effects of the Spanish Flu. Up to 20% of all flu cases developed a severe form of pneumonia; roughly 10% experienced bleeding from the ears, eyes and nose, just like Ebola; nearly 50% of all deaths in the U.S. during the pandemic were flu-related; the hardest hit demographic was young adults (suggesting that the flu was a strain of a more mild flu from decades before); the flu killed so viciously that it shaved a full ten years off of the national U.S. life expectancy. The hallmark of this flu was the virulence of the pneumonia it caused. The lungs were so destroyed that victims literally turned blue for lack of oxygen. “Intense cyanosis was a striking phenomenon," a contemporary witness reported. "The ears, lips, nose, cheeks, conjunctivae, fingers, and sometimes the entire body partook of a dusky, leaden hue."Part seven, The Race, explores the race to find the pathogen of the flu. “What caused this disease?” That was the question on the minds of America's leading researchers. From the very start the primary suspect was the so-called Pfeiffer bacillus, the pathogen from the 1890 pandemic isolated by German scientists. It was difficult to grow in the laboratory. The doctors battling the disease, especially Canadian-American Oswald Avery, the un-sung hero of the story according to Barry, proceeded carefully and deliberately to identify the pathogen despite the tremendous pressure to move faster.Part eight, The Tolling of the Bell, is a further indictment of the Wilson administration’s insistence on prosecuting war mobilization in the face of the flu pandemic right up until the German armistice. Tightly packed troop ships were sent to Europe despite the robust objections of public health officials and army doctors. Barry concedes that nothing could have stopped the spread of the flu, but argues that more intense efforts could have slowed down its merciless march. By the second week of October, Philadelphia was in complete crisis. On an average day the city witnessed 500 deaths from all causes (natural, accidents, homicides, suicides); now over 750 were dying from the flu alone. The week of October 16th nearly 5,000 perished. At least half-a-million were ill. The city ceased to function; no volunteers answered the call for assistance; social services ceased. All the while, reporting on the true nature of the disease was suppressed. Lack of reliable information, Barry writes, only made things worse. “Uncertainty follows distrust, fear follows uncertainty, and, under conditions such as these, terror follows fear.” “The war was over there. The epidemic is here. The war ended. The epidemic continued. Fear settled over the nation like a frozen blanket.”Part nine, Lingerer, covers the long tail of the disease. Just as quickly as the second wave struck, it ended. The flu tore through the potential population at an alarming rate. After this second wave finished the flu became more benign for two key reasons. First, even with antigen drift, those that survived the first or second wave of the flu developed immunity to the disease. Second, the virus itself continued to mutate, and as it mutated it became more average and thus less deadly. It is startling just how different various strains of the virus could be. For instance, at one army cantonment 35% of those with flu contracted pneumonia, and of those with pneumonia the death rate was 61%. A few weeks later another cantonment experienced only 7% pneumonia with a mortality rate of 18%. In other words, the cantonment with the virulent strain saw 21 men die for every 100 with the flu; a few weeks later it was less than 1 in a 100.In the end, the death toll was conservatively estimated at 21 million globally. The author suggests that 50-100 million is probably closer to the mark. In a 12-week period in the fall of 1918 approximately 5% of the world’s population died. That would be 350 million people at today’s global population numbers. In New York City alone the disease created 21K orphans.Part ten, Endgame, tells the sobering story of the results of medical inquiry on the disease. Despite tremendous gains in medical science and research, and tireless effort to identify the flu’s pathogen and to disrupt the spread of the disease, very little was known. Oswald Avery spent the rest of his life searching for the pathogen. The author describes it as an incredibly laborious and frustrating experience as the scientist eliminated, one-by-one, like Thomas Edison with the incandescent light bulb, every possible element. But in the process Avery made a startling discovery: DNA carried genetic information. His 1944 paper would launch other researchers, like James Watson, on his groundbreaking work. Barry claims that Avery’s research into the 1918 flu and its associated pneumonia led directly to the opening of an entirely new field: molecular biology.In closing, "The Great Influenza" is a terrific read on a fascinating, terrible, and reoccurring human experience.

Way, way back in 2005, President George W. Bush read John Barry’s book, a copy of which was given to him by HHS Secretary Leavitt. Came to work a few days later and asked his staff what plans America had for combating the next pandemic. Nada. Bush might not have learned anything from the Vietnam War he strove to miss, when he decided to charge into Iraq, but he SURE seems to have learned something from history, thanks to Barry, and insisted the United States be prepared for the next pandemic. Wags in the West Wing started calling Barry’s book by the subject line, since that is how much the overall plan would cost. Dr. Fauci, just last Sunday, said on “Face the Nation” that he would be “astounded” if there was not an “autopsy” on America’s appalling response to the COVID Pandemic. Certainly, a good starting point would be what happened to the seven-billion-dollar plan.This is such an impressive book and is the one essential book that we all should read, now almost two years into the latest pandemic. The thesaurus of superlatives is quickly exhausted in describing this book. Barry says that it took him seven years to write this. There are 60 pages of references at the end. Few authors have that unique ability to meld the science and the human drama. His style is crisp and lucid.It is one thing to write a biography; Barry did the research for seven to ten. He then distilled that knowledge into concise and lively portraits, with the quirks, rivalries, and warts of the leading medical people who would confront the pandemic. I had heard of none of these individuals, apparently due to my wandering in the wilderness too long. There is William Henry Welsh, the one man who largely transformed how medicine was practiced in America, trying to get the practitioners educated and the snake oil off the shelves. Oswald T. Avery, a private in the Army during WWI, would do brilliant work at the Rockefeller Institute. William Park, Anna Wessel Williams and Rufus Cole made substantial contributions. There is the brilliant and troubled Paul Lewis, whose story may have helped inspire portions of Sinclair Lewis’ (no relation) “Arrowsmith.” Paul Lewis would die in Brazil, in 1929. Barry posits: “And whether his death was a suicide or a true accident, his failure to win what he loved killed him. One could consider Lewis, in a way meaningful to him, the last victim of the 1918 pandemic.”Philadelphia was particularly hard hit by the influenza outbreak. Barry provides an excellent account of all the relevant factors and the role of the Edwin Vare’s political machine, and how, when the “terror” of the flu took hold, the ol’ Blue Bloods, the Wartons, Biddles had to take charge. Wilson was hell-bent on getting the Doughboys over There, to Europe, with devastating effects on military bases in the USA, due in particular to overcrowding. Barry relates what happened at Camp Devin in MA., in detail.With pitch-perfect tone, Barry uses the ironic refrain throughout the book: “It’s just the flu.”As Barry relates, it was not until the late 20’s, that Lewis’ protégé, Richard Shope proved that it was a virus, and not a bacterium that had killed something like 50 million people.The book was originally issued in 2004; Barry did an Afterword in 2018, just before all hell broke loose on what we did NOT learn. In the Afterword, hauntingly, in light of what has transpired, he said:“So, the problems presented by a pandemic are, obviously, immense. But the biggest problem lies in the relationship between governments and the truth…But as horrific as the disease itself was, public officials and the media helped create that terror- not by exaggerating the disease but by minimizing it, by trying to reassure. A specialty among public relations consultants has evolved in recent decades called ‘risk communication’. I don’t much care for the term. For if there is a single dominant lesson from 1918, it’s that governments need to tell the truth in a crisis. Risk communications implies managing the truth. You don’t manage the truth. You tell the truth.” Amen, from that eponymous corner.I live in New Mexico, which, thanks to our Governor, has imposed some of the more restrictive measures to control the spread of the disease and I am all in favor of that. Nonetheless, several of our major hospitals have imposed “crisis standards of care,” a fancy phrase for that dreadful French word: triage. It is required to wear masks indoors, and I do, though I think it only improves my changes of not contracting COVID by 10-20% as compared to no mask. Therefore, I found Barry’s quite dismissive rejection of the efficacy of masks in preventing COVID supportive of my own beliefs. In fact, looks like Barry would consider 10-20% far too generous:“Surgical masks are next to useless except in very limited circumstances, chiefly in the home” (P. 477). “The masks worn by millions were useless as designed and could not prevent influenza. Only preventing exposure to the virus could” (P. 358-59).In my idiosyncratic rating system, for books or movies I really like, I provide a 6-star rating, sometimes adding a “plus” for the truly great ones. For the 7-billion-dollar book that took 7 years to write, and is written so well, on such a complex subject and is so relevant for our lives today, I am providing it my very first 7-star rating.