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

by John M. Barry

The immune system changes with age. Young adults have the strongest immune system in the population, most capable of mounting a massive immune response. Normally that makes them the healthiest element of the population. Under certain conditions, however, that very strength becomes a weakness. In 1918 the immune systems of young adults mounted massive responses to the virus. That immune response filled the lungs with fluid and debris, making it impossible for the exchange of oxygen to take place. The immune response killed.

(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.)

One key to science is that work be reproducible. Someone in another laboratory doing the same experiment will get the same result. The result then is reliable enough that someone else can build upon it. The most damning condemnation is to dismiss a finding as “not reproducible.”

There were dozens of ways to grow bacteria but often only one way to grow a particular kind. Some grow only without oxygen, others only with it in plentiful supply. Some require alkaline media, others acid. Some are extremely delicate, others stable. Every step, every attempt to grow the pathogen, meant effort, and effort meant time. Every hour incubating a culture meant time. They did not have time.

He believed Avery uncomfortable in and possibly incapable of handling the chaos of social interaction. But he believed Avery comfortable with and capable of confronting the chaos of nature. Avery could do so because of his “uncanny sense of what was truly important” and “imaginative vision of reality. . . . He had the creative impulse to compose those facts into meaningful and elegant structures. . . . His scientific compositions had, indeed, much in common with artistic creations which do not imitate actuality but transcend it and illuminate reality.” Years

He advised, “Whenever you fall, pick up something.” And he often said, “Disappointment is my daily bread. I thrive on it.”

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. Action as ruthless as that taken in 2003 to contain the outbreak of a new disease called severe acute respiratory syndrome, SARS, could well have had effect.* Influenza could not have been contained as SARS was—influenza is far more contagious. But any interruption in influenza’s spread could have had significant impact. For the virus was growing weaker over time. Simply delaying its arrival in a community or slowing its spread once there—just such minor successes—would have saved many, many thousands of lives. There was precedent for ruthless action.

Krusen, Emergency Aid, and the Catholic Church teamed up to do one more thing, the most important thing. They began to clear the bodies.

But by now the city had heard enough pleas, and had withdrawn into itself. There was no trust, no trust, and without trust all human relations were breaking down.

One physician who recommended a return to “heroic medicine” explained that the more the doctor did, the more the body was stimulated to respond. In disease as in war, he said, the fighter must seize initiative.

The Army now has available for all officers, enlisted men, and civilian employees of the Army, a lipo vaccine containing pneumococcus Types I, II, and III.” The army distributed two million doses of this vaccine in the next weeks. This marked an enormous production triumph. Earlier a prominent British scientist had pronounced it impossible for the British government to produce even forty thousand doses on short notice. But the vaccine still protected only against pneumonias caused by Types I and II pneumococci, and it came too late; by then the disease had already passed through nearly all cantonments.

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.

They found terrible things. Terrible things. In Nome, 176 of 300 Inuits had died. But it would get worse. One doctor visited ten tiny villages and found “three wiped out entirely; others average 85% deaths. . . . Survivors generally children . . . probably 25% this number frozen to death before help arrived.”

In the Indian subcontinent alone, it is likely that close to twenty million died, and quite possibly the death toll exceeded that number.

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.

The virus itself, more than any treatment provided, determined who lived and who died.

An army physician at Walter Reed Hospital investigating serious mental disturbances and even psychoses that seemed to follow an attack of influenza specifically noted, “Delirium occurring at the height of the disease and clearing with the cessation of fever is not considered in this report.”

A 1996 virology textbook said, “A wide spectrum of central nervous system involvement has been observed during influenza A virus infections in humans, ranging from irritability, drowsiness, boisterousness, and confusion to the more serious manifestations of psychosis, delirium, and coma.”

The 1918 virus did seem to reach the brain. The war fought on that battlefield could destroy brain cells and make it difficult to concentrate, or alter behavior, or interfere with thinking, or even cause temporary psychosis. If this occurred in only a minority of cases, the virus’s impact on the mind was nonetheless real.

Hoover believed Wilson’s mind had lost “resiliency.”

Colonel Starling of the Secret Service noticed that Wilson “lacked his old quickness of grasp, and tired easily.” He became obsessed with such details as who was using the official automobiles. When Ray Stannard Baker was first allowed to see Wilson again, he trembled at Wilson’s sunken eyes, at his weariness, at his pale and haggard look, like that of a man whose flesh has shrunk away from his face, showing his skull.

Only one historian, Alfred Crosby, seems to have paid any attention to Wilson’s actual symptoms—including high fever, severe coughing, and total prostration, all symptoms that perfectly fit influenza and have no association whatsoever with stroke—and the on-site diagnosis of Grayson, an excellent physician highly respected by such men as Welch, Gorgas, Flexner, and Vaughan.

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.

Only in the next few years did it finally fade away in both the United States and the world. It did not disappear. It continued to attack, but with far less virulence, partly because the virus mutated further toward its mean, toward the behavior of most influenza viruses, partly because people’s immune systems adjusted. But it left a legacy.

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. I could feel it, like influenza, in my bones.”

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.

Despite that effort, whoever held power, whether a city government or some private gathering of the locals, they generally failed to keep the community together. They failed because they lost trust. They lost trust because they lied. (San Francisco was a rare exception; its leaders told the truth, and the city responded heroically.) And they lied for the war effort, for the propaganda machine that Wilson had created. 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. And fear really did kill people. It killed them because those who feared would not care for many of those who needed but could not find care, those who needed only hydration, food, and rest to survive.

Well this sounds familiar. terrible

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. 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. The virus simply ravaged the less developed world. In Mexico the most conservative estimate of the death toll was 2.3 percent of the entire population, and other reasonable estimates put the death toll over 4 percent. That means somewhere between 5 and 9 percent of all young adults died.

But for all their frenzy of activity, they had still always avoided chaos, they had always proceeded from well-grounded hypotheses. They had not, as Avery said with contempt, poured material from one test tube into another. 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. Others had done these things and more, but they had not.

They also recognized their failures. They had lost their illusions. They had entered the first decades of the twentieth century confident that science, even if its victories remained limited, would triumph. Now Victor Vaughan told a colleague, “Never again allow me to say that medical science is on the verge of conquering disease.” With the contempt one reserves for one’s own failings, he also said, “Doctors know no more about this flu than fourteenth-century Florentine doctors had known about the Black Death.” But they had not quit. Now this scientific brotherhood was beginning its hunt. It would take longer than they knew. •

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 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.

But in the midst of that dry spell, Avery told a young researcher there were two types of investigators: most “go around picking up surface nuggets, and whenever they can spot a surface nugget of gold they pick it up and add it to their collection. . . . [The other type] is not really interested in the surface nugget. He is much more interested in digging a deep hole in one place, hoping to hit a vein. And of course if he strikes a vein of gold he makes a tremendous advance.”

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.