John M. Barry

The story of the deadliest pandemic in history

The Great Influenza

Aamna

2.8 stars

The editor went seriously AWOL on this one. The writer couldn't decide what exactly to write about so wrote about everything & everyone. The narrative is part biography (of multiple people, mind you), part investigative journalism and part death registry. And that doesn't even include the parts when I was spaced out. 

Such wasted promise.

Gavin

Rousing history of one of the worst things that has ever happened: the 1918 outbreak of H1N1 flu. It focusses particularly on the great scientists who tried to fight it, none of whom I'd ever heard of. Also a meditation on epistemology, the modern mind, & the redemptive meaning of science for beasts like us.

Barry senses that the headline result - one-third of the entire world infected, with 
  25-100
 million dead - doesn't get enough of a rise from us. The numbers are numbing. So he couches it in modern shocking terms:

   It killed more people in twenty-four weeks than AIDS has killed in twenty-four years, more in a year than the Black Death killed in a century.

Or ten thousand 9/11s. It's worth belabouring this, because we have a weird habit of paying far more attention to human threats than natural ones, even when natural ones are far worse. (Witness our terrorism prevention budgets compared to our infectious disease control budgets, when the latter is a thousand times more lethal.)

So: The 1918 flu was worse than the entire First World War: 40+ million died of flu compared with 17 million dead from war; 500 million lives damaged by flu vs 41 million lives by war. 3% of everyone alive died of flu, including about 8% of young adults(!).

Except it's hard to separate the War and the pandemic. The virus was spread everywhere by unprecedented numbers of troops, and by the massive supply convoys it induced, and by the War's other human displacements. We don't know how many of the pneumonia deaths only occurred because of the logistical degradation, poverty and pestilence of wartime. There are terrible nonlinearities involved in overcrowding and global movement of troops. But add millions at least to the overall death toll caused by WWI.

The book is in the epic mode, all the way through. (That's not a straightforward compliment.) I liked it, but I understand if it's a bit American for you:

  
Man might be defined as “modern” largely to the extent that he attempts to control nature. In this relationship with nature, modern humanity has generally been the aggressor, and a daring one at that, altering the flow of rivers, building upon geological faults, and, today, even engineering the genes of existing species. Nature has generally been languid in its response, although contentious once aroused and occasionally displaying a flair for violence.

By 1918 humankind was fully modern, and fully scientific, but too busy fighting itself to aggress against nature. Nature, however, chooses its own moments. It chose this moment to aggress against man, and it did not do so prodding languidly. For the first time, modern humanity, a humanity practicing the modern scientific method, would confront nature in its fullest rage.


There's a long prelude describing how terrible medicine was up to the 20th Century. Medicine was "the withered arm of science". Therapeutic nihilism (that is, "we can't really do anything") was the only rational view, replacing millenia of Galenic woo.

  
Stengel reviewed dozens of ideas advanced in medical journals. Gargles of various disinfectants. Drugs. Immune sera. Typhoid vaccine. Diphtheria antitoxin. But Stengel’s message was simple: This doesn’t work. That doesn’t work. Nothing worked... Nothing they were doing worked.

Problem is, this rational scepticism created a powerful vacuum: humans need to believe something can heal, and the gap was filled with worse. Some confabulated gremlins from this time haunt us still: homeopathy, chiropractic, naturopathy, Christian Science, and (though Barry doesn't include them) the organic farming movement and psychoanalysis.

Few people come off well. Even among the scientists, we get a horrible example of perverse priors and premature updating: an enormous proportion of all scientific resources were devoted to fighting the wrong pathogen, due to a bad guess by an extremely eminent researcher.

Because so much of the state was occupied in war, in places there was wholesale social collapse:

  In Philadelphia meanwhile fear came and stayed. Death could come from anyone, anytime. 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. 

The impossibility of getting help compounded the isolation. 850 Philadelphia doctors and more nurses were away in the military. More than that number were sick. Philadelphia General Hospital had 126 nurses. Despite all precautions, despite wearing surgical masks and gowns, eight doctors and fifty-four nurses—43 percent of the staff—themselves required hospitalization. Ten nurses at this single hospital died. The Board of Health pleaded for help from retired nurses and doctors if they remembered “even a little” of their profession.

When a nurse or doctor or policeman did actually come, they wore their ghostly surgical masks, and people fled them. In every home where someone was ill, people wondered if the person would die. And someone was ill in every home...

Starr went to Emergency Hospital #2 at Eighteenth and Cherry Streets. He did have help, if it could be called that, from an elderly physician who had not practiced in years and who brought Starr into touch with the worst of heroic medicine. Starr wouldn’t forget that, the ancient arts of purging, of venesection, the ancient art of opening a patient’s vein. But for the most part he and the other students elsewhere were on their own, with little help even from nurses, who were so desperately needed that in each of ten emergency hospitals supplied by the Red Cross only a single qualified nurse was available to oversee whatever women came as volunteers. And often the volunteers reported for their duty once and, from either fear or exhaustion, did not come again.

Nearly 1/4 of all the patients in his hospital died each day. Starr would go home, and when he returned the next day, he would find that between one-quarter and one-fifth of the patients in the hospital had died, replaced by new ones... Virtually all of them, along with their friends and relatives, were terrified that, no matter how mild the symptoms seemed at first, within them moved an alien force, a seething, spreading infection, a live thing with a will that was taking over their bodies — and could be killing them...
The city was frozen with fear, frozen into stillness. Starr lived 12 miles from the hospital. The streets were silent on his drive home, silent. They were so silent he took to counting the cars he saw. One night he saw no cars at all. He thought, “The life of the city had almost stopped.”


Everyone can read the collapse of official power in Philadelphia as supporting their politics. Anarchists can point to the benevolent spontaneous order that arose after the corrupt local government failed to act; libertarians can point out that this spontaneous order was all funded by the richest Philadelphians; statists can point out that, without actually-authoritative co-ordination, the effort eventually failed, because people defected against each other, in fear.

  The corpses had backed up at undertakers’, filling every area of these establishments and pressing up into living quarters; in hospital morgues overflowing into corridors; in the city morgue overflowing into the street. And they had backed up in homes. They lay on porches, in closets, in corners of the floor, on beds. Children would sneak away from adults to stare at them, to touch them; a wife would lie next to a dead husband, unwilling to move him or leave him. The corpses, reminders of death and bringers of terror or grief, lay under ice at Indian-summer temperatures. Their presence was constant, a horror demoralizing the city; a horror that could not be escaped. Finally the city tried to catch up to them.

The police wore their ghostly surgical masks, and people fled them, but the masks had no effect on the viruses and by mid-October thirty-three policemen had died, with many more to follow...
 More coffins came by rail, guarded by men with guns.


"There is, therefore, but one response possible from us: Force! force to the utmost, force without stint or limit, the righteous and triumphant force which shall make right the law of the world and cast every selfish dominion down in the dust. "- Woodrow Wilson addressing one of his money-lending mobs.


Wilson tends to be viewed pretty positively, just because he won. ("at last the world knows America as the savior of the world!") But he perverted an entire state and nation to do so, ignored the terrible suffering of his own damn population for years, and refused a conditional peace with Austria in August and with the Kaiser's new parliament in September. (This meant 30-70 extra days of war, which, if this period was as lethal as the rest of the war, means up to 800,000 completely unnecessary deaths, not to mention the continuing waste of resources during the worst epidemic ever). Wilson did great evil, was not much different from the Kaiser, the election aside.


   the military suctioned more and more nurses and physicians into cantonments, aboard ships, into France, until it had extracted nearly all the best young physicians. Medical care for civilians deteriorated rapidly. The doctors who remained in civilian life were largely either incompetent young ones or those over forty-five years of age, the vast majority of whom had been trained in the old ways of medicine. 


Barry's middle chapters are a frightening portrait of how rabidly un-American the US was in 1918. The laws were bad enough - for instance the ban on criticising the government. But then there's the unofficial "patriotic duties", punishable by beatings. State-sponsored atavism.


  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... 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...

Crowder bragged about doing “in a day what the Prussian autocracy had been spending nearly fifty years to perfect..."

In mid-August, as the lethal wave of the epidemic was gathering itself, Austria had already inquired about peace terms, an inquiry that Wilson rebuffed utterly. And as the epidemic was gathering full momentum, peace was only weeks away. Bulgaria had signed an armistice on September 29. On September 30, Kaiser Wilhelm had granted parliamentary government to the German nation; that same day Ludendorff had warned his government that Germany must extend peace feelers or disaster—immediate disaster—would follow. German diplomats sent out those feelers. Wilson ignored them. The Central Powers, Germany and her allies, were simultaneously breaking off one from one another and disintegrating internally as well. In the first week of October, Austria and Germany separately sent peace feelers to the Allies, and on October 7, Austria delivered a diplomatic note to Wilson formally seeking peace on any terms Wilson chose. Ten days later — days of battle and deaths — the Austrian note remained unanswered.

Earlier Wilson had spoken of a “peace without victory,” believing only such a peace could last. But now he gave no indication that the war would soon be over. Although a rumor that the war had ended sent thrills through the nation, Wilson quickly renounced it. Nor would he relent. He was not now fighting to the death; he was fighting only to kill...

If Wilson and his government would not be turned from his end even by the prospect of peace, they would hardly be turned by a virus. And the reluctance, inability, or outright refusal of the American government to shift targets would contribute to the killing. Wilson took no public note of the disease, and the thrust of the government was not diverted. The relief effort for influenza victims would find no assistance in the Food Administration or the Fuel Administration or the Railroad Administration. From neither the White House nor any other senior administration post would there come any leadership, any attempt to set priorities, any attempt to coordinate activities, any attempt to deliver resources.

...the military would give no help to civilians. Instead it would draw further upon civilian resources. The same day that Welch had stepped out of the autopsy room at Devens and called Gorgas’s office, his warning had been relayed to the army chief of staff, urging that all transfers be frozen unless absolutely necessary and that under no circumstances transfers from infected camps be made... Gorgas’s superiors ignored the warning. There was no interruption of movement between camps whatsoever; not until weeks later, with the camps paralyzed and, literally, tens of thousands of soldiers dead or dying, did the army make any adjustments.


Because the disease was everywhere, ravaging the entire species (and beyond), the book can't cover everything. Very little is said about non-Americans, i.e about 98% of the death and chaos. This is partly because there just isn't a lot of evidence about them, despite their influenza immunity and medical care being even worse. (This is why the top estimates reach 100m deaths, three times the median estimate.) Here is a passage about just a tiny number of them, in the north:

  In Alaska, whites protected themselves. Sentries guarded all trails, and every person entering the city was quarantined for five days. Eskimos had no such luck. A senior Red Cross official warned that without “immediate medical assistance the race” could become “extinct.”...

The navy provided the collier USS Brutus to carry a relief expedition... They found terrible things. One doctor visited ten tiny villages and found “three wiped out entirely; others average 85% deaths… Survivors generally children… probably 25% frozen to death before help arrived.”

The virus probably did not kill all of them directly. But it struck so suddenly it left no one well enough to care for any others, no one to get food, no one to get water. And those who could have survived, surrounded by bodies, bodies of people they loved, might well have preferred to go where their family had gone, might well have wanted to no longer be alone... Two hundred sixty-six people had lived in Okak, and many dogs, dogs nearly wild. When the virus came, it struck so hard so fast people could not care for themselves or feed the dogs. The dogs grew hungry, crazed with hunger, devoured each other, then wildly smashed through windows and doors, and fed... In all of Labrador, at least one-third the total population died. 


---
Barry commits at least one big error: he's horrified by the medical schools of the time having "no standards for admission":

   In research and education especially, American medicine lagged far behind [European medicine]... At least one hundred US medical schools would accept any man willing to pay tuition... and only a single medical school required its student to have a college degree... the Johns Hopkins itself, not student fees, paid [its] faculty salaries, and it required medical students to have not only a college degree but fluency in French and German and a background of science courses. 


But his enthusiasm for Johns Hopkins introducing the college degree requirement is misplaced. Contemporary US doctors (who all have 3 years of pre-med, or even more college, before they start medical training) are probably no better clinicians than undergraduate doctors in other countries, and are far further in debt. This requirement is probably one reason the American system is so fucked.

I suppose Barry is just confusing the open admissions situation with the schools' appallingly low graduation standards, which is certainly one reason eC20th medicine sucked. (Many doctors had never looked down a microscope, never used a stethoscope on a patient, never seen a dissection.)
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PS: Mostly unimportant corrections by a virologist here. Reply to these from Barry here.

Arun Khanna

I wanted to like this book a lot more than I did. The 1918 Influenza Pandemic seems like a pretty big deal -- it killed many more Americans than the entire combat experience in WWI (and just look at how many books there are about that). 

This book does have some good parts, I found the middle part to be pretty interesting when the author described the actual disease itself. However, the author focuses far too much attention on the lives of some scientists who are only tangentially related to the subject at hand. I generally disdain personality-driven non-fiction books and this just takes it to another level. I wish he spent more time on the CDC's response and how other foreign governments reacted.

The Great Influenza The story of the deadliest pandemic in history

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