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

by John M. Barry

It was the first great collision between a natural force and a society that included individuals who refused either to submit to that force or to simply call upon divine intervention to save themselves from it, individuals who instead were determined to confront this force directly, with a developing technology and with their minds.

In every war in American history so far, disease had killed more soldiers than combat. In many wars throughout history, war had spread disease.

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

Science and religion in fact part ways over the first question, what each can know. Religion, and to some extent philosophy, believes it can know, or at least address, the question “Why?”

This answer involves not simply academic pursuits; it affects how a society governs itself, its structure, how its citizens live. If a society does set Goethe’s “Word . . . supremely high,” if it believes that it knows the truth and that it need not question its beliefs, then that society is more likely to enforce rigid decrees, and less likely to change. If it leaves room for doubt about the truth, it is more likely to be free and open.

Proving and elaborating upon the germ theory would ultimately open the way to confronting all infectious disease. It would also create the conceptual framework and technical tools that Welch and others later used to fight influenza.

Simply put, the germ theory said that minute living organisms invaded the body, multiplied, and caused disease, and that a specific germ caused a specific disease.

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.

At least one question connects the vertical and the horizontal. That question is “So what?” Like a word on a Scrabble board, this question can connect with and prompt movement in many directions. It can eliminate a piece of information as unimportant or, at least to the investigator asking the question, irrelevant. It...

First, he had not only knowledge but judgment.

Second, Welch inspired. He inspired unconsciously, simply by being himself. In the early days of the school, Welch was heavy but not yet fat, short, with bright blue eyes that flashed above a dark beard called an “imperial”—a mustache and pointed goatee.

Everything about him was positive. His intelligence and the depth and breadth of his knowledge stimulated his teaching as well.

AMERICAN MEDICAL EDUCATION needed a revolution. When the Hopkins medical school did at last open in 1893, most American medical schools had still not established any affiliation with either a teaching hospital or a university, most faculty salaries were still paid by student fees, and students still often graduated without ever touching a patient.

In 1884, German scientist Friedrich Loeffler isolated the diphtheria bacillus from throats of patients, grew it on a special medium (laboratories today still use “Loeffler’s serum slope” to grow the bacteria from suspected cases), and began careful experiments in animals that took several years.

Each Friday especially mattered; investigators routinely presented their most recent work in a casual setting, and colleagues made comments, suggested experiments, added different contexts.

Science is not democratic. Votes do not matter. Yet this vote marked the coming of age of American medicine. It was by no means due solely to the Hopkins.

Timid of nature or not, Cole would not yield. Flexner did. As a result, the Rockefeller Institute Hospital applied science directly to patient care, creating the model of clinical research—a model followed today by the greatest medical research facility in the world, the Clinical Center at the National Institutes of Health in Bethesda, Maryland. That model allowed investigators to learn. It also prepared them to act.

In effect, there were outstanding generals, colonels, and majors, but they had no sergeants, corporals, or privates; they had no army to lead, at least not a reliable one. The gap between the best and the average had to be closed, and the worst had to be eliminated.

Even among elite schools change came slowly. Not until 1901 did Harvard, followed soon by Penn and Columbia, join the Hopkins in requiring medical students to have a college degree.

One school had graduated 105 “doctors” in 1905, none of whom had completed any laboratory work whatsoever; they had not dissected a single cadaver, nor had they seen a single patient. They would wait for a patient to enter their office for that experience.

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. • • •

All influenza viruses mutate constantly. The timing of the Funston explosion strongly suggests that the influenza outbreak there came from Haskell; if Haskell was the source, whoever carried it to Funston brought a mild version of the virus, but it was a version capable of mutating back to lethality.

Numerous other scientists agree with him. And the evidence does strongly suggest that Camp Funston experienced the first major outbreak of influenza in America; if so, the movement of men from an influenza-infested Haskell to Funston also strongly suggests Haskell as the site of origin.

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.

Pandemics often come in waves, and the cumulative “morbidity” rate—the number of people who get sick in all the waves combined—often exceeds 50 percent. One virologist considers influenza so infectious that he calls it “a special instance” among infectious diseases, “transmitted so effectively that it exhausts the supply of susceptible hosts.”

By entering the cell, as opposed to fusing with the cell on the cell membrane—which many other viruses do—the influenza virus hides from the immune system. The body’s defenses cannot find it and kill it.

AN INFECTION is an act of violence; it is an invasion, a rape, and the body reacts violently. John Hunter, the great physiologist of the eighteenth century, defined life as the ability to resist putrefaction, resist infection. Even if one disagrees with that definition, resisting putrefaction certainly does define the ability to live.

In the days before antibiotics, an infection launched a race to the death between the pathogen and the immune system.

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.

Wilson declared, “It isn’t an army we must shape and train for war, it is a nation.”

Technology has always mattered in war, but this was the first truly scientific war, the first war that matched engineers and their abilities to build not just artillery but submarines and airplanes and tanks, the first war that matched laboratories of chemists and physiologists devising or trying to counteract the most lethal poison gas. Technology, like nature, always exhibits the ice of neutrality however heated its effect. Some even saw the war itself as a magnificent laboratory in which to test and improve not just the hard sciences but theories of crowd behavior, of scientific management of the means of production, of what was thought of as the new science of public relations.

From the beginning of their planning, these men focused on the biggest killer in war—not combat, but epidemic disease. Throughout the wars in history more soldiers had often died of disease than in battle or of their wounds. And epidemic disease had routinely spread from armies to civilian populations.

So 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.

The shortage of nur...

prove even more serious. Indeed, it would prove deadly, especial...

The U.S. Army had exploded from a few tens of thousands of soldiers before the war to millions in a few months. Huge cantonments, each holding roughly fifty thousand men, were thrown together in a matter of weeks. Hundreds of thousands of men occupied them before the camps were completed. They were jammed into those barracks that were finished, barracks designed for far less than their number, while tens of thousands of young soldiers lived through the first winter in tents.

Hospitals were the last buildings to be constructed.

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.

THE 1918 INFLUENZA PANDEMIC, like many other influenza pandemics, came in waves.

The increase in killing efficiency does not continue indefinitely. If a pathogen kills too efficiently, it will run out of hosts and destroy itself. Eventually its virulence stabilizes and even recedes.

As the virus moved, two parallel struggles emerged. One encompassed all of the nation. Within each city, within each factory, within each family, into each store, onto each farm, along the length of the track of the railroads, along the rivers and roads, deep into the bowels of mines and high along the ridges of the mountains, the virus would find its way. In the next weeks, the virus would test society as a whole and each element within it. Society would have to gather itself to meet this test, or collapse.

Two, three, and four entire families would cram themselves into a single two- or three-room apartment, with children and teenagers sharing a bed.

In all of South Philadelphia, home to hundreds of thousands of Italians and Jews, there would be no high school until 1934.

Ironically, the very lack of city services strengthened the machine since it provided what the city did not: food baskets to the poor, help with jobs and favors, and help with the police—the commissioner and many magistrates were in Vare’s pocket. People paid for the favors with votes which, like a medieval alchemist, he transmuted into money.

These were unusual times. The Great War made them so. One cannot look at the influenza pandemic without understanding the context. Wilson had realized his aims. The United States was waging total war.

Total war requires sacrifice and good morale makes sacrifices acceptable, and therefore possible. The sacrifices included inconveniences in daily life.

The preservation of morale itself became an aim. For if morale faltered, all else might as well. So free speech trembled.