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

by John M. Barry

Influenza killed more people in a year than the Black Death of the Middle Ages killed in a century; it killed more people in twenty-four weeks than AIDS has killed in twenty-four years.

The two most important questions in science are “What can I know?” and “How can I know it?”

Science is at all times potentially revolutionary; any new answer to a seemingly mundane question about “how” something occurs may uncover chains of causation that throw all preceding order into disarray and that threaten religious beliefs as well.

The greatest challenge of science, its art, lies in asking an important question and framing it in a way that allows it to be broken into manageable pieces, into experiments that can be conducted that ultimately lead to answers. To do this requires a certain kind of genius, one that probes vertically and sees horizontally.

Horizontal vision allows someone to assimilate and weave together seemingly unconnected bits of information. It allows an investigator to see what others do not see, and to make leaps of connectivity and creativity. Probing vertically, going deeper and deeper into something, creates new information. Sometimes what one finds will shine brilliantly enough to illuminate the whole world.

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.

Miner had seen influenza often. He diagnosed the disease as influenza. But he had never seen influenza like this. This was violent, rapid in its progress through the body, and sometimes lethal. This influenza killed. Soon dozens of his patients—the strongest, the healthiest, the most robust people in the county—were being struck down as suddenly as if they had been shot.

NO ONE WILL EVER KNOW with absolute certainty whether the 1918–19 influenza pandemic actually did originate in Haskell County, Kansas. There are other theories of origin, including France, Vietnam, and China. But Frank Macfarlane Burnet, a Nobel laureate who lived through the pandemic and spent most of his scientific career studying influenza, later concluded that the evidence was “strongly suggestive” that the 1918 influenza pandemic began in the United States, and that its spread was “intimately related to war conditions and especially the arrival of American troops in France.”

Antigen drift can create epidemics. One study found nineteen discrete, identifiable epidemics in the United States in a thirty-three-year period—more than one every other year. 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.

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.

IN THE SPRING OF 1918 death was no stranger to the world. Indeed, by then the bodies of more than five million soldiers had already been fed into what was called “the sausage factory” by generals whose stupidity was matched only by their brutality.

Wilson’s hard line threatened dissenters with imprisonment. The federal government also took control over much of national life. The War Industries Board allocated raw materials to factories, guaranteed profits, and controlled production and prices of war materials, and, with the National War Labor Board, it set wages as well. The Railroad Administration virtually nationalized the American railroad industry. The Fuel Administration controlled fuel distribution (and to save fuel it also instituted daylight savings time). The Food Admininstration—under Herbert Hoover—oversaw agricultural production, pricing, and distribution. And the government inserted itself in the psyche of America by allowing only its own voice to be heard, by both threatening dissenters with prison and shouting down everyone else.

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.

In the meantime, in Spain the virus picked up its name. • • • Spain actually had few cases before May, but the country was neutral during the war. That meant the government did not censor the press, and unlike French, German, and British newspapers—which printed nothing negative, nothing that might hurt morale—Spanish papers were filled with reports of the disease, especially when King Alphonse XIII fell seriously ill. The disease soon became known as “Spanish influenza” or “Spanish flu,” very likely because only Spanish newspapers were publishing accounts of the spread of the disease that were picked up in other countries.

Royal Copeland, head of the New York City health department, and the port health officer jointly stated there was “not the slightest danger of an epidemic” because the disease seldom attacks “a well-nourished people.” (Even had he been right, a study by his own health department had just concluded that 20 percent of city schoolchildren were malnourished.) He took no action whatsoever to prevent the spread of infection.

One nurse at Great Lakes would later be haunted by nightmares. The wards had forty-two beds; boys lying on the floor on stretchers waited for the boy on the bed to die. Every morning the ambulances arrived and stretcher bearers carried sick sailors in and bodies out. She remembered that at the peak of the epidemic the nurses wrapped more than one living patient in winding sheets and put toe tags on the boys’ left big toe. It saved time, and the nurses were utterly exhausted. The toe tags were shipping tags, listing the sailor’s name, rank, and hometown. She remembered bodies “stacked in the morgue from floor to ceiling like cord wood.” In her nightmares she wondered “what it would feel like to be that boy who was at the bottom of the cord wood in the morgue.”

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.

Federal, municipal, and state courts closed. Giant placards everywhere warned the public to avoid crowds and use handkerchiefs when sneezing or coughing. Other placards read “Spitting equals death.” People who spat on the street were arrested—sixty in a single day. The newspapers reported the arrests—even while continuing to minimize the epidemic. Physicians were themselves dying, three one day, two another, four the next. The newspapers reported those deaths—on inside pages with other obituaries—even while continuing to minimize the epidemic. Health and city workers wore masks constantly.

In 1918 pathologists did see at autopsy the normal devastation of the lungs caused by the usual lobar and bronchopneumonias. But the lungs from those who died quickly during the pandemic, the lungs that so confused even Welch, those lungs were different. Said one pathologist, “Physical signs were confusing. Typical consolidation was seldom found.” And another: “The old classification by distribution of the lesions was inappropriate.” And another: “Essentially toxic damage to alveolar walls and exudation of blood and fluid. Very little evidence of bacterial action could be found in some of these cases.”

In 1918 especially, this question of balance played a crucial role in the war between virus and immune system, and between life and death. The virus was often so efficient at invading the lungs that the immune system had to mount a massive response to it. What was killing young adults a few days after the first symptom was not the virus. The killer was the massive immune response itself.

ARDS by no means accounts for all the influenza deaths in 1918 and 1919, or even for a majority of them. It explains only those who died in a few days, and it explains why so many young healthy people died. Although influenza almost certainly killed some people in ways that had little to do with the lungs—for example, someone whose already weak heart could not stand the additional strain of fighting the disease—the overwhelming majority of non-ARDS deaths came from bacterial pneumonias. The destruction of the epithelial cells eliminated the sweeping action that clears so much of the respiratory tract of bacteria, and the virus damaged or exhausted other parts of the immune system as well. That gave the normal bacterial flora of the mouth unimpeded entry into the lungs. Recent research also suggests that the neuraminidase on the influenza virus makes it easier for some bacteria to attach to lung tissue, creating a lethal synergy between the virus and these bacteria. And in the lungs, the bacteria began to grow.

All real scientists exist on the frontier. Even the least ambitious among them deal with the unknown, if only one step beyond the known. The best among them move deep into a wilderness region where they know almost nothing, where the very tools and techniques needed to clear the wilderness, to bring order to it, do not exist. There they probe in a disciplined way. There a single step can take them through the looking glass into a world that seems entirely different, and if they are at least partly correct their probing acts like a crystal to precipitate an order out of chaos, to create form, structure, and direction. A single step can also take one off a cliff.

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.

NOTHING COULD HAVE STOPPED the sweep of influenza through either the United States or the rest of the world—but ruthless intervention and quarantines might have interrupted its progress and created occasional firebreaks.

Newspapers reported on the disease with the same mixture of truth and half-truth, truth and distortion, truth and lies with which they reported everything else. And no national official ever publicly acknowledged the danger of influenza.

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.

But as Camus knew, evil and crises do not make all men rise above themselves. Crises only make them discover themselves. And some discover a less inspiring humanity.

Monument and Ignacio, Colorado, went further than banning all public gatherings. They banned customers from stores; the stores remained open, but customers shouted orders through doors, then waited outside for packages.

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.

Australia had escaped. It had escaped because of a stringent quarantine of incoming ships. Some ships arrived there with attack rates as high as 43 percent and fatality rates among all passengers as high as 7 percent. But the quarantine kept the virus out, kept the continent safe, until late December 1918 when, with influenza having receded around the world, a troopship carrying ninety ill soldiers arrived. Although they too were quarantined, the disease penetrated—apparently through medical personnel treating troops. By then the strain had lost much of its lethality. In Australia the death rates from influenza were far less than in any other Westernized nation on earth, barely one-third that of the United States, not even one-quarter that of Italy. But it was lethal enough.

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. Historians with virtual unanimity agree that the harshness toward Germany of the Paris peace treaty helped create the economic hardship, nationalistic reaction, and political chaos that fostered the rise of Adolf Hitler. It

The disease has survived in memory more than in any literature. Nearly all those who were adults during the pandemic have died now. Now the memory lives in the minds of those who only heard stories, who heard how their mother lost her father, how an uncle became an orphan, or heard an aunt say, “It was the only time I ever saw my father cry.” Memory dies with people. The writers of the 1920s had little to say about it.

They knew so little. So little. They knew only that isolation worked. The New York State Training School for Girls had quarantined itself, even requiring people delivering supplies to leave them outside. It had had no cases. The Trudeau Sanatorium in upstate New York had similar rules. It had no cases. Across the continent, a naval facility in San Francisco on an island that enforced rigid quarantine. It had no cases. All that proved was that the miasma theory, which none of them believed in anyway, could not account for the disease.

Statistics also confirmed what every physician, indeed every person, already knew. In the civilian population as well, young adults had died at extraordinary, and frightening, rates. The elderly, normally the group most susceptible to influenza, not only survived attacks of the disease but were attacked far less often. 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.

Finally, a door-to-door survey in several cities also confirmed the obvious: people living in the most crowded conditions suffered more than those with the most space. It also seemed—although this was not scientifically established—that those who went to bed the earliest, stayed there the longest, and had the best care also survived at the highest rates. Those findings meant of course that the poor died in larger numbers than the rich. (Questions about race and the epidemic yielded contradictory information.)

Nothing in science is as damning as the inability of an outside experimenter to reproduce results.

Avery was attacking the most fundamental questions of immunology and, ultimately, genetics. From each failed experiment he learned, perhaps not much but something. And what he was learning went beyond how to fine-tune an experiment. What he was learning from his failures had large ramifications that applied to entire fields of knowledge. One could argue that none of Avery’s experiments failed.

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 communication implies managing the truth. You don’t manage the truth. You tell the truth.