The recent hullabaloo both in America and abroad about H1N1 (“swine flu”) last year brought influenza back into the zeitgeist in a way it has not been for many years—more years, likely, than the last couple of generations largely ignorant of just how serious influenza was and could potentially be in the future. About 14,000 deaths were caused by the swine flu worldwide to-date. Compare that figure to the estimates for mortality in the 1918 flu pandemic, which range from 20 million deaths on the low end to 120 million deaths on the high end.
The Great Influenza is what Richard Preston’s The Hot Zone should have been about instead of an Ebola threat that was, well, never actually a threat.
Oddly, the outbreak of influenza doesn’t occur until nearly halfway through Barry’s book; in some ways, the outbreak itself is treated as an afterthought, but Barry’s approach to the narrative makes a bit more sense when you read his epilogue. You see, The Great Influenza is peripherally about virology, yes: you will learn about viruses and bacteria and how they infect the body. But more than that, The Great Influenza is a cultural study of how people, governments, and scientists reacted to one of the most deadly events of the 20th century.
To understand how all of this unfolded, you must first understand the state of medical knowledge at the fin de siècle. The world was in the throes of a scientific revolution which was transforming how people lived—e.g. plumbing, electricity, and medicine—the old guard was still very much in force. Barry notes that shortly before 1900, most states required licensure for dentistry and pharmacy, but virtually anyone could be a physician, and so the state of scientific medical knowledge (materia medica) was dismal at best. The first hero whom Barry introduces will not, in fact, play any direct role during the pandemic aside from contracting the flu himself: William Henry Welch, though no extraordinary medical researcher himself, was more or less the godfather of the modern medical establishment, instrumental in the founding of the first “real” medical school (the Johns Hopkins) and the gradual systematization of medical knowledge and rejection of homeopathy, venisection (“bleeding”), and other quackeries like the miasma theory of disease.
By the time the outbreak hits in 1918, there has been significant progress made, but the number of competent doctors and nurses in the nation is still minimal, and of course the state of the art would seem primitive to us today. The galvanizing knowledge is that of the immune system: researchers had by that time just begun peeling the corners away from its mystery—enough to begin fighting such things as malaria and yellow fever with a forward-looking armament of medical weapons.
1918 was also, of course, the middle of the United States’ involvement in The Great War (or World War I), with president Woodrow Wilson at the helm. Though our popular notions of war propaganda tend to be the gung-ho slogans and posters of World War II, the culture of this war was chilling indeed, and it’s remarkable how much we’ve forgotten what an incredible bastard Woodrow Wilson was. Like John Adams, he managed to poke the nation in its eye with the Espionage Act of 1917 and the Sedition Act of 1918, two legislative examples of a general political, cultural, legal and martial malaise that effectively chilled the Bill of Rights. It also had the effect of suppressing not just outright dissent, but suppressing simple truth as well, and giving birth to a nation of idiots addled by patriotic stupor—the latter evidenced by, e.g., the story of a crowd lynching a man for refusing to by a war bond.
The former item, however, becomes more important from a public health standpoint. The 1918 strain of Influenza A (H1N1)1 went through several waves, the first of which was not very lethal, and therefore passed largely unnoticed. It was the second wave which caused so much destruction, and much of that destruction came from the generalized response by politicians, newspaper editors, army officials, and city burghers to the problem. Either due to sheer obstinacy, ignorance, callousness, or fear of being reported as subversive, the response of most of the men in charge (pick your city) was to tell everyone the following, in order:
- There’s no influenza outbreak.
- There’s an influenza outbreak, but it’s not dangerous.
- There’s a dangerous influenza outbreak, but it’s peaked, and on its way out.
- Okay, we’re screwed.
Though no one knows for sure where the 1918 influenza originated, Barry surmises that the most likely scenario is some sort of pig/poultry-to-human transfer happened in Haskell County, Kansas, was taken to Fort Riley in a wave of new draftees in the war, and from there was spread not just across the United States, but to France, the rest of Europe, and eventually the rest of the world. I bring this up not because it matters particularly that the viruses likely originated in the United States, but because in that scenario, it is likely the virus’ spread and ultimately its lethality was due almost entirely to the machinations of war. Further, the military officers in charge of logistics, even when warned that failure to quarantine military bases would likely kill hundreds of thousands of people, insisted that any failure to ship fresh troops to Germans might embolden the enemy and cost the Allies the war.
Though Barry expended a considerable number of pages explaining the (relative) improvement of scientific medicine by 1918, it would come to pass that the scientific establishment had no real answer or cure for the influenza outbreak. He certainly has an all-star cast (whom I won’t bother listing individually) working feverishly (no pun intended) on the problem all along, but ultimately the influenza pandemic describes a bell curve, and so after a ridiculous 6 weeks more closely resembling a scene of hell, the number of new contractions of the disease fall precipitously off. It would be difficult to overstate the apparent brutality of the vurus. Barry’s history centers on America, but I imagine the story is similar everyone. Whole villages struck down; families so sick and weak that they die on the floor where they fall; fear and paranoia paralyzing formerly-close communities. The only communities unaffected were those which enforced a strict quarantine2.
Strangely, Barry continues past the practical end of the infection and talks for some time about scientific researchers; one is relatively important—Oswald Avery, who ultimately discovered the role that DNA plays in genetics, topically the virus involved in the flu—and the other providing virtually no contribution to the field at all—Paul Lewis, a promising researcher who produced nothing of importance and died of Yellow Fever in Brazil. It’s an odd sort of denouement, and I’m not convinced it fits Barry’s narrative well.
There are a couple of important scientific points to take away from Barry’s book. The first is the general topic of virology, and I’ll take it for granted that you know generally how a virus differs from a bacterium. The second is that even the particularly deadly strain of influenza that ravaged the globe in 1918 often didn’t directly kill its victims: as often as the virus itself caused death via acute respiratory distress, it also left the weakened immune system vulnerable to secondary infection, usually in the form of bacterial pneumonia. Ironically, the best prescription for the flu, then as now, is bed rest and fluids. The third would be the terrible confluence of war and pandemic, and at least in this case they are largely one and the same. The fourth and final is the most humbling: as great as our medical science is, and as much as we may learn and prepare (even though we aren’t prepared) for a pandemic, humanity can and possibly will be brought to its knees again someday by an organism so small it requires an electronic microscope to view.
The Great Influenza is an expansive treatment of the topic; it’s doubtless an excellent treatment of the topic. But as I warned earlier, the book is less a medical thriller or morbid history than it is a cultural study, or a work of epidemiology. If the thought of waiting 200 pages for the outbreak to start annoys you, The Great Influenza may not be for you. On the other hand, those with sufficient patience will be pleasantly surprised by Barry’s work.