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

by John M. Barry

“The foundation of morality is to have done, once and for all, with lying.”

But if he lived on the surface of ordinary life, his life was not ordinary. He was free, not just alone but free, free of entanglements of people, free of encumbrances of property, utterly free. He was free to do extraordinary things.

In the first six months of 1918, Miner’s warning of “influenza of severe type” was the only reference in that journal to influenza anywhere in the world. Other medical journals that spring carried articles on influenza outbreaks, but they all occurred after Haskell’s, and they were not issued as public health warnings. Haskell County remains the first outbreak in 1918 suggesting that a new influenza virus was adapting, violently, to man.

People suffering from influenza shed virus—expel viruses that can infect others—for usually no more than seven days after infection and often even

less. After that, although they may continue to cough and sneeze, they will not spread the disease.

There are three different types of influenza viruses: A, B, and C. Type C rarely causes disease in humans. Type B does cause disease, but not epidemics. Only influenza A viruses cause epidemics or pandemics, an epidemic being a local or national outbreak, a pandemic a worldwide one. Influenza viruses did not originate in humans. Their natural home is in wild aquatic birds, and many more variants of influenza viruses exist in birds than in humans. But the disease is considerably different in birds and humans. In birds, the virus infects the gastrointestinal tract. Bird droppings contain large amounts of virus, and infectious virus can contaminate cold lakes and other water supplies.

When a new influenza virus emerges, it is highly competitive, even cannibalistic. It usually drives older types into extinction. This happens because infection stimulates the body’s immune system to generate all its defenses against all influenza viruses to which the body has ever been exposed. When older viruses attempt to infect someone, they cannot gain a foothold. They cease replicating. They die out. So, unlike practically every other known virus, only one type—one swarm or quasi species—of influenza virus dominates at any given time. This itself helps prepare the way for a new pandemic, since the more time passes, the fewer people’s immune systems will recognize other antigens.

In the six months from September 1917 to March 1918, before the influenza epidemic struck, pneumonia struck down 30,784 soldiers on American soil. It killed 5,741 of them. Nearly all these pneumonia cases developed as complications of measles.

“passage.” This phenomenon reflects an organism’s ability to adapt to its environment. When an organism of weak pathogenicity passes from living animal to living animal, it reproduces more proficiently, growing and spreading more efficiently. This often increases virulence. In other words, it becomes a better and more efficient killer.

Yet men could appear healthy while incubating influenza themselves, and they could also infect others before symptoms appeared.

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.

But it did change, changed constantly, from mild cases of influenza from which victims recovered quickly to cases with strange symptoms never associated with influenza, from sudden violent viral pneumonias or ARDS to secondary invaders causing bacterial pneumonias.

Current vaccines target the hemagglutinin, the antigen most exposed to the immune system (see 103–104), which looks something like the head on broccoli. Unfortunately, the vaccines target the head portion, which mutates rapidly and is a part of the virus that can change without interfering with the functioning of the virus. That’s part of the reason influenza vaccines are not particularly good: between 2003 and 2017 their effectiveness ranged only from 10 percent to 61 percent. (Even at those levels, they prevent millions of cases and thousands of deaths and are well worth getting.) For the elderly, with their less robust immune systems, in some years the vaccine did not generate any protection at all.

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.

An unpublished 1918 study of army camps demonstrates this. 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.

So the problems presented by a pandemic are, obviously, immense. But the biggest problem lies in the relationship between governments and the truth.

Part of that relationship requires political leaders to understand the truth—and to be able to handle the truth.

There was terror afoot in 1918, real terror. The randomness of death brought that terror home. So did its speed. And so did the fact that the healthiest and strongest seemed the most vulnerable. 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.

In 1918 the lies of officials and of the press never allowed the terror to condense into the concrete. The public could trust nothing and so they knew nothing. Society is, ultimately, based on trust; as trust broke down, people became alienated not only from those in authority, but from each other.

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.