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

by John M. Barry

in New York State coughing or sneezing without covering the face was now punishable by a year in jail and a $500 fine .

His father had a store. Four of eight salesgirls died. “Farmers stopped farming and the merchants stopped selling merchandise and the country really more or less just shut down holding their breath. Everyone was holding their breath.”

Prescott, Arizona, made it illegal to shake hands.

But at dozens of shipyards in New England, the absentee records were striking. At the L. H. Shattuck Company, 45.9 percent of the workers stayed home. At the George A. Gilchrist yard, 54.3 percent stayed home. At Freeport Shipbuilding, 57 percent stayed home. At Groton Iron Works, 58.3 percent stayed home.

The influenza citizens’ committee took similar initiatives. It deputized a special police force and also called upon all “patriotic citizens” to enforce anti-influenza ordinances, including requiring every person in public to wear a mask, arresting anyone who spit or coughed without covering his mouth, dictating that businesses (those that remained open) give twelve hundred cubic feet of air space to each customer, and halting all traffic into the city and allowing only those with “actual business here” to enter.

Quinine worked on one disease: malaria. Many physicians gave it for influenza with no better reasoning than desperation.

No medicine and none of the vaccines developed then could prevent influenza. The masks worn by millions were useless as designed and could not prevent influenza. Only preventing exposure to the virus could. Nothing today can cure influenza, although vaccines can provide significant—but nowhere near complete—protection, and several antiviral drugs can mitigate its severity. 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. Closing saloons and theaters and churches meant nothing if significant numbers of people continued to climb onto streetcars, continued to go to work, continued to go to the grocer. Even where fear closed down businesses, where both store owners and customers refused to stand face-to-face and left orders on sidewalks, there was still too much interaction to break the chain of infection. The virus was too efficient, too explosive, too good at what it did. In the end the virus did its will around the world.

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Epidemiologists have computed that measles requires an unvaccinated population of at least half a million people living in fairly close contact to continue to exist. 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.

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.

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.

Coming from the President, whom we all knew so well, these were very funny things, and we could but surmise that something queer was happening in his mind. One thing was certain: he was never the same after this little spell of sickness.”

Blue predicted that influenza would return: “Communities should make plans now for dealing with any recurrences. The most promising way to deal with a possible recurrence is, to sum it up in a single word, ‘preparedness.’ And now is the time to prepare.”

The first significant attempt to quantify the death toll came in 1927. An American Medical Association–sponsored study estimated that 21 million died. When today’s media refers to a death toll of “more than 20 million” in stories on the 1918 pandemic, the source is this study. But every revision of the deaths since 1927 has been upward. The U.S. death toll was originally put at 550,000. Now epidemiologists have settled on 675,000 out of a population of 105 million. In the year 2004, the U.S. population exceeds 291 million.

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 a normal influenza epidemic, 10 percent or fewer of the deaths fall among those aged between sixteen and forty. In 1918 that age group, the men and women with most vitality, most to live for, most of a future, accounted for more than half the death toll, and within that group the worst mortality figures fell upon those aged twenty-one to thirty.

The Western world suffered the least, not because its medicine was so advanced but because urbanization had exposed its population to influenza viruses, so immune systems were not naked to it.

They had not done the wild things that had no basis in their understanding of the workings of the body. They had not given quinine or typhoid vaccine to influenza victims in the wild hope that because it worked against malaria or typhoid it might work against influenza.

Hmmmmmmm.......

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.

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.

Fleming found that penicillin killed staphylococcus, hemolytic streptococcus, pneumococcus, gonococcus, diphtheria bacilli, and other bacteria, but it did no harm to the influenza bacillus. He did not try to develop penicillin into a medicine. To him the influenza bacillus was important enough that he used penicillin to help grow it by killing any contaminating bacteria in the culture. He used penicillin as he said, “for the isolation of influenza bacilli.”

In Faust, Goethe wrote, “Too old am I to be content with play, / Too young to live untroubled by desire.”

Ugh

T. S. Eliot said any new work of art alters slightly the existing order. Avery accomplished that all right, and far more.

Between 1959 and 1997, only two people suffered documented infections by avian viruses; neither victim died. But in 1997, an H5N1 avian influenza virus, the so-called bird flu, killed six of eighteen people in Hong Kong. Millions of fowl were slaughtered in an unsuccessful effort to wipe it out, and it reemerged with a vengeance in 2003. Since then, H5N1 and more recently an H7N9 avian virus have been infecting humans at previously unknown rates. Between 2003 and 2017—the latest numbers as I write this—these viruses have infected 2,342 people and killed 1,053 of them—a case fatality rate of 44.9 percent. The case fatality rate is high because both viruses bind only to cells deep in the lung, so the starting point for the disease is, in effect, viral pneumonia.

In 1918, the world population was 1.8 billion, and the pandemic probably killed 50 to 100 million people, with the lowest credible modern estimate at 35 million. Today the world population is 7.6 billion. A comparable death toll today would range from roughly 150 to 425 million.

Chiefly because antibiotics would slash the toll from secondary bacterial infections, if a virus caused a 1918-like pandemic today, modern medicine could likely prevent significantly more than half of those deaths—assuming adequate supplies of antibiotics, which is quite an assumption—but tens of millions would still die.

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.

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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.

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.

For one, the World Health Organization and governments have developed a good surveillance system. The problem is that it is incomplete—too many countries still do not participate—and dependent on governments to cooperate. 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. And China is not the only reluctant partner.

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 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.

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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.

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In a truly lethal pandemic, state and local authorities could take much more aggressive steps, such as closing theaters, bars, and even banning sports events—in 1919 even the Stanley Cup finals were canceled—and church services.

For if there is a single dominant lesson from 1918, it’s that governments need to tell the truth in a crisis.

So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that. Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best.

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