The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry (PDF)

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#1 New York Times bestseller“Barry will teach you almost everything you need to know about one of the deadliest outbreaks in human history.”—Bill Gates”Monumental… an authoritative and disturbing morality tale.”—Chicago Tribune The strongest weapon against pandemic is the truth. Read why in the definitive account of the 1918 Flu Epidemic. Magisterial in its breadth of perspective and depth of research, The Great Influenza provides us with a precise and sobering model as we confront the epidemics looming on our own horizon. As Barry concludes, “The final lesson of 1918, a simple one yet one most difficult to execute, is 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. A leader must make whatever horror exists concrete. Only then will people be able to break it apart.” At the height of World War I, history’s most lethal influenza virus erupted in an army camp in Kansas, moved east with American troops, then exploded, killing as many as 100 million people worldwide. It killed more people in twenty-four months than AIDS killed in twenty-four years, more in a year than the Black Death killed in a century. But this was not the Middle Ages, and 1918 marked the first collision of science and epidemic disease.

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⭐In the year 1800, the practice of medicine had changed little from that in antiquity. The rapid progress in other sciences in the 18th century had had little impact on medicine, which one historian called “the withered arm of science”. This began to change as the 19th century progressed. Researchers, mostly in Europe and especially in Germany, began to lay the foundations for a scientific approach to medicine and public health, understanding the causes of disease and searching for means of prevention and cure. The invention of new instruments for medical examination, anesthesia, and antiseptic procedures began to transform the practice of medicine and surgery.All of these advances were slow to arrive in the United States. As late as 1900 only one medical school in the U.S. required applicants to have a college degree, and only 20% of schools required a high school diploma. More than a hundred U.S. medical schools accepted any applicant who could pay, and many graduated doctors who had never seen a patient or done any laboratory work in science. In the 1870s, only 10% of the professors at Harvard’s medical school had a Ph.D.In 1873, Johns Hopkins died, leaving his estate of US$ 3.5 million to found a university and hospital. The trustees embarked on an ambitious plan to build a medical school to be the peer of those in Germany, and began to aggressively recruit European professors and Americans who had studied in Europe to build a world class institution. By the outbreak of World War I in Europe, American medical research and education, still concentrated in just a few centres of excellence, had reached the standard set by Germany. It was about to face its greatest challenge.With the entry of the United States into World War I in April of 1917, millions of young men conscripted for service were packed into overcrowded camps for training and preparation for transport to Europe. These camps, thrown together on short notice, often had only rudimentary sanitation and shelter, with many troops living in tent cities. Large number of doctors and especially nurses were recruited into the Army, and by the start of 1918 many were already serving in France. Doctors remaining in private practice in the U.S. were often older men, trained before the revolution in medical education and ignorant of modern knowledge of diseases and the means of treating them.In all American wars before World War I, more men died from disease than combat. In the Civil War, two men died from disease for every death on the battlefield. Army Surgeon General William Gorgas vowed that this would not be the case in the current conflict. He was acutely aware that the overcrowded camps, frequent transfers of soldiers among far-flung bases, crowded and unsanitary troop transport ships, and unspeakable conditions in the trenches were a tinderbox just waiting for the spark of an infectious disease to ignite it. But the demand for new troops for the front in France caused his cautions to be overruled, and still more men were packed into the camps.Early in 1918, a doctor in rural Haskell County, Kansas began to treat patients with a disease he diagnosed as influenza. But this was nothing like the seasonal influenza with which he was familiar. In typical outbreaks of influenza, the people at greatest risk are the very young (whose immune systems have not been previously exposed to the virus) and the very old, who lack the physical resilience to withstand the assault by the disease. Most deaths are among these groups, leading to a “bathtub curve” of mortality. This outbreak was different: the young and elderly were largely spared, while those in the prime of life were struck down, with many dying quickly of symptoms which resembled pneumonia. Slowly the outbreak receded, and by mid-March things were returning to normal. (The location and mechanism where the disease originated remain controversial to this day and we may never know for sure. After weighing competing theories, the author believes the Kansas origin most likely, but other origins have their proponents.)That would have been the end of it, had not soldiers from Camp Funston, the second largest Army camp in the U.S., with 56,000 troops, visited their families in Haskell County while on leave. They returned to camp carrying the disease. The spark had landed in the tinderbox. The disease spread outward as troop trains travelled between camps. Often a train would leave carrying healthy troops (infected but not yet symptomatic) and arrive with up to half the company sick and highly infectious to those at the destination. Before long the disease arrived via troop ships at camps and at the front in France.This was just the first wave. The spring influenza was unusual in the age group it hit most severely, but was not particularly more deadly than typical annual outbreaks. Then in the fall a new form of the disease returned in a much more virulent form. It is theorised that under the chaotic conditions of wartime a mutant form of the virus had emerged and rapidly spread among the troops and then passed into the civilian population. The outbreak rapidly spread around the globe, and few regions escaped. It was particularly devastating to aboriginal populations in remote regions like the Arctic and Pacific islands who had not developed any immunity to influenza.The pathogen in the second wave could kill directly within a day by destroying the lining of the lung and effectively suffocating the patient. The disease was so virulent and aggressive that some medical researchers doubted it was influenza at all and suspected some new kind of plague. Even those who recovered from the disease had much of their immunity and defences against respiratory infection so impaired that some people who felt well enough to return to work would quickly come down with a secondary infection of bacterial pneumonia which could kill them.All of the resources of the new scientific medicine were thrown into the battle with the disease, with little or no impact upon its progression. The cause of influenza was not known at the time: some thought it was a bacterial disease while others suspected a virus. Further adding to the confusion is that influenza patients often had a secondary infection of bacterial pneumonia, and the organism which causes that disease was mis-identified as the pathogen responsible for influenza. Heroic efforts were made, but the state of medical science in 1918 was simply not up to the challenge posed by influenza.A century later, influenza continues to defeat every attempt to prevent or cure it, and another global pandemic remains a distinct possibility. Supportive treatment in the developed world and the availability of antibiotics to prevent secondary infection by pneumonia will reduce the death toll, but a mass outbreak of the virus on the scale of 1918 would quickly swamp all available medical facilities and bring society to the brink as it did then. Even regular influenza kills between a quarter and a half million people a year. The emergence of a killer strain like that of 1918 could increase this number by a factor of ten or twenty.Influenza is such a formidable opponent due to its structure. It is an RNA virus which, unusually for a virus, has not a single strand of genetic material but seven or eight separate strands of RNA. Some researchers argue that in an organism infected with two or more variants of the virus these strands can mix to form new mutants, allowing the virus to mutate much faster than other viruses with a single strand of genetic material (this is controversial). The virus particle is surrounded by proteins called hemagglutinin (HA) and neuraminidase (NA). HA allows the virus to break into a target cell, while NA allows viruses replicated within the cell to escape to infect others.What makes creating a vaccine for influenza so difficult is that these HA and NA proteins are what the body’s immune system uses to identify the virus as an invader and kill it. But HA and NA come in a number of variants, and a specific strain of influenza may contain one from column H and one from column N, creating a large number of possibilities. For example, H1N2 is endemic in birds, pigs, and humans. H5N1 caused the bird flu outbreak in 2004, and H1N1 was responsible for the 1918 pandemic. It gets worse. As a child, when you are first exposed to influenza, your immune system will produce antibodies which identify and target the variant to which you were first exposed. If you were infected with and recovered from, say, H3N2, you’ll be pretty well protected against it. But if, subsequently, you encounter H1N1, your immune system will recognise it sufficiently to crank out antibodies, but they will be coded to attack H3N2, not the H1N1 you’re battling, against which they’re useless. Influenza is thus a chameleon, constantly changing its colours to hide from the immune system.Strains of influenza tend to come in waves, with one HxNy variant dominating for some number of years, then shifting to another. Developers of vaccines must play a guessing game about which you’re likely to encounter in a given year. This explains why the 1918 pandemic particularly hit healthy adults. Over the decades preceding the 1918 outbreak, the primary variant had shifted from H1N1, then decades of another variant, and then after 1900 H1N1 came back to the fore. Consequently, when the deadly strain of H1N1 appeared in the fall of 1918, the immune systems of both young and elderly people were ready for it and protected them, but those in between had immune systems which, when confronted with H1N1, produced antibodies for the other variant, leaving them vulnerable.With no medical defence against or cure for influenza even today, the only effective response in the case of an outbreak of a killer strain is public health measures such as isolation and quarantine. Influenza is airborne and highly infectious: the gauze face masks you see in pictures from 1918 were almost completely ineffective. The government response to the outbreak in 1918 could hardly have been worse. After creating military camps which were nothing less than a culture medium containing those in the most vulnerable age range packed in close proximity, once the disease broke out and reports began to arrive that this was something new and extremely lethal, the troop trains and ships continued to run due to orders from the top that more and more men had to be fed into the meat grinder that was the Western Front. This inoculated camp after camp. Then, when the disease jumped into the civilian population and began to devastate cities adjacent to military facilities such as Boston and Philadelphia, the press censors of Wilson’s war machine decided that honest reporting of the extent and severity of the disease or measures aimed at slowing its spread would impact “morale” and war production, so newspapers were ordered to either ignore it or print useless happy talk which only accelerated the epidemic. The result was that in the hardest-hit cities, residents confronted with the reality before their eyes giving to lie to the propaganda they were hearing from authorities retreated into fear and withdrawal, allowing neighbours to starve rather than risk infection by bringing them food.As was known in antiquity, the only defence against an infectious disease with no known medical intervention is quarantine. In Western Samoa, the disease arrived in September 1918 on a German steamer. By the time the disease ran its course, 22% of the population of the islands was dead. Just a few kilometres across the ocean in American Samoa, authorities imposed a rigid quarantine and not a single person died of influenza.We will never know the worldwide extent of the 1918 pandemic. Many of the hardest-hit areas, such as China and India, did not have the infrastructure to collect epidemiological data and what they had collapsed under the impact of the crisis. Estimates are that on the order of 500 million people worldwide were infected and that between 50 and 100 million died: three to five percent of the world’s population.Researchers do not know why the 1918 second wave pathogen was so lethal. The genome has been sequenced and nothing jumps out from it as an obvious cause. Understanding its virulence may require recreating the monster and experimenting with it in animal models. Obviously, this is not something which should be undertaken without serious deliberation beforehand and extreme precautions, but it may be the only way to gain the knowledge needed to treat those infected should a similar wild strain emerge in the future. (It is possible this work may have been done but not published because it could provide a roadmap for malefactors bent on creating a synthetic plague. If this be the case, we’ll probably never know about it.)Although medicine has made enormous strides in the last century, influenza, which defeated the world’s best minds in 1918, remains a risk, and in a world with global air travel moving millions between dense population centres, an outbreak today would be even harder to contain. Let us hope that in that dire circumstance authorities will have the wisdom and courage to take the kind of dramatic action which can make the difference between a regional tragedy and a global cataclysm.

⭐“Influenza killed more people in [1918] than the Black Death of the Middle Ages killed in a century; it killed more people in 24-weeks than AIDS has killed in 24-years.” Those are some pretty sobering statistics. John Barry takes an oddly forgotten moment in world history and makes it comes to life in this thorough, fast-paced and sharply written history of the great Spanish Influenza pandemic that struck the globe at the end of the First World War.Barry begins his narrative with a terrific overview of the history of medical science. The Warriors highlights the critical role played by Johns Hopkins University and Hospital in reforming and advancing the cause. The amazing thing is how stunted medical science remained for so long, essentially unaltered from the time of Hippocrates and Galens to the mid-nineteenth century. Indeed, medicine was “the withered arm of science.” This backwardness can be attributed to the failure to ask two basic questions: “What can I know? How can I know it?” For centuries – actually millennia – medicine was a basic exercise in observation, not probing experimentation. It was treated like Newton under the apple tree, unlocking the secrets of physics by observing the world around you. Only the world of biological science isn’t so neat and uniform; it’s chaotic. Thus, the use of bleeding (venestration), the most notorious practice of pre-modern medicine, was entirely logical from an observational perspective (e.g. “people with fevers are flushed; after bleeding they are pale.”). Logic and observation failed because neither tested hypotheses rigorously. As a result, medicine was long considered a “low science” and not much respected. When Hopkins was born in 1876 it was a deliberate break from the American university model of conveying the known, to a new, largely German model of methodically explaining the unknown.It wasn’t until 1891 that a major disease – diphtheria – was cured. Suddenly, there was a flood of research dollars into medicine. In 1890, there was $18M in national university endowments supporting American theological schools and just $500K supporting American medical schools. As late as 1904 most medical schools had no affiliation with either a university or a hospital, no admission criteria of any kind, and a staff that was paid purely from tuition receipts. A blistering study, the Flexner Report, on the state of American medical education in 1910 was a watershed moment, according to the author. Medical education was about to be reinvented, and re-built largely on the Hopkins example. Over the next decade 100 medical schools – about two-thirds of those then in existence – either went under or merged. In 1904, there were 28K American medical school students; by 1920 the number had been fully cut in half.The guiding light in this benevolent revolution was the first head of the Hopkins hospital, William Welch. Known for his judgment and inspiration, Welch “exuded confidence without arrogance, smugness, or pomposity.” He was “the glue that cemented together the entire American medical establishment.” A medical graduate of Yale, “a typical good American medical school, with no requirements for admission and no grades in any course,” he presided over the emergence of American medical science as a world leader in just over a generation.Part two, The Swarm, provides an introduction to virology and the astounding resiliency and adaptability of the influenza virus in particular. Barry describes the invasion and take over at the molecular level in arresting language. “An infection,” he writes, “is an act of violence; it is an invasion, a rape, and the body reacts violently.” Even today in the United States, about 36K people are killed by the flu every year, essentially the same that are killed by auto accidents or gun violence (including suicide).Part three, The Tinderbox, the author introduces a stridently hostile view of American mobilization leading up to World War I, skewering President Wilson and his extended administration at every turn. In short, the H1N1 flu virus of 1918 was unusually virulent, but what turned it into one of the greatest killers of all time was a potent mix of massive manpower mobilization combined with press censorship. Millions of young men, from both city and country, were shunted to over crowded barracks, and forced to share beds, utensils and air. “Never before in American history – and possibly never before in any country’s history – had so many men been brought together in such a way,” Barry claims. Meanwhile, the US government had virtual control over the flow of information and were aggressively on guard to squelch any news that smacked of defeatism or could damage morale, both military and civilian.Part four, It Begins, describes how the initial version of the flu that spread quickly out of the Kansas army camps and then across the Atlantic from February 1918 to April, reaching Australia by September 1918, was generally mild and not too disconcerting to public health officials. Owing to strict censorship the disease became known as the Spanish Influenza simply because neutral Spain had an open press and was the only country that freely reported on the illness. “Those in control of the war’s propaganda machine wanted nothing printed that could hurt morale,” the authors says again and again. Most health officials presumed the flu had come and gone. But instead, “It had gone underground, like a forest fire left burning in the roots, swarming and mutating, adapting, honing itself, watching and waiting, waiting to burst into flame.”Part five, Explosion, chronicles the rapid spread of the flu from Camp Devins, an army installation in Massachusetts, to the rest of the eastern seaboard and port cities in early autumn. The commanding officer at Camp Grant in Illinois committed suicide when the flu decimated his troops after he blocked the strict quarantine recommendations of camp physicians. Barry pays special attention to the city of Philadelphia where a massive Liberty Parade went ahead despite clear evidence that the deadly flu had arrived. “Within seventy-two hours after the parade,” he writes, “every single bed in each of the city’s thirty-one hospitals was filled. And people began dying.” But still the government snuffed out true reporting on the extent and danger of the virus. “…Free speech trembled indeed,” Barry states emphatically.Part six, The Pestilence, describes the chilling effects of the Spanish Flu. Up to 20% of all flu cases developed a severe form of pneumonia; roughly 10% experienced bleeding from the ears, eyes and nose, just like Ebola; nearly 50% of all deaths in the U.S. during the pandemic were flu-related; the hardest hit demographic was young adults (suggesting that the flu was a strain of a more mild flu from decades before); the flu killed so viciously that it shaved a full ten years off of the national U.S. life expectancy. The hallmark of this flu was the virulence of the pneumonia it caused. The lungs were so destroyed that victims literally turned blue for lack of oxygen. “Intense cyanosis was a striking phenomenon,” a contemporary witness reported. “The ears, lips, nose, cheeks, conjunctivae, fingers, and sometimes the entire body partook of a dusky, leaden hue.”Part seven, The Race, explores the race to find the pathogen of the flu. “What caused this disease?” That was the question on the minds of America’s leading researchers. From the very start the primary suspect was the so-called Pfeiffer bacillus, the pathogen from the 1890 pandemic isolated by German scientists. It was difficult to grow in the laboratory. The doctors battling the disease, especially Canadian-American Oswald Avery, the un-sung hero of the story according to Barry, proceeded carefully and deliberately to identify the pathogen despite the tremendous pressure to move faster.Part eight, The Tolling of the Bell, is a further indictment of the Wilson administration’s insistence on prosecuting war mobilization in the face of the flu pandemic right up until the German armistice. Tightly packed troop ships were sent to Europe despite the robust objections of public health officials and army doctors. Barry concedes that nothing could have stopped the spread of the flu, but argues that more intense efforts could have slowed down its merciless march. By the second week of October, Philadelphia was in complete crisis. On an average day the city witnessed 500 deaths from all causes (natural, accidents, homicides, suicides); now over 750 were dying from the flu alone. The week of October 16th nearly 5,000 perished. At least half-a-million were ill. The city ceased to function; no volunteers answered the call for assistance; social services ceased. All the while, reporting on the true nature of the disease was suppressed. Lack of reliable information, Barry writes, only made things worse. “Uncertainty follows distrust, fear follows uncertainty, and, under conditions such as these, terror follows fear.” “The war was over there. The epidemic is here. The war ended. The epidemic continued. Fear settled over the nation like a frozen blanket.”Part nine, Lingerer, covers the long tail of the disease. Just as quickly as the second wave struck, it ended. The flu tore through the potential population at an alarming rate. After this second wave finished the flu became more benign for two key reasons. First, even with antigen drift, those that survived the first or second wave of the flu developed immunity to the disease. Second, the virus itself continued to mutate, and as it mutated it became more average and thus less deadly. It is startling just how different various strains of the virus could be. For instance, at one army cantonment 35% of those with flu contracted pneumonia, and of those with pneumonia the death rate was 61%. A few weeks later another cantonment experienced only 7% pneumonia with a mortality rate of 18%. In other words, the cantonment with the virulent strain saw 21 men die for every 100 with the flu; a few weeks later it was less than 1 in a 100.In the end, the death toll was conservatively estimated at 21 million globally. The author suggests that 50-100 million is probably closer to the mark. In a 12-week period in the fall of 1918 approximately 5% of the world’s population died. That would be 350 million people at today’s global population numbers. In New York City alone the disease created 21K orphans.Part ten, Endgame, tells the sobering story of the results of medical inquiry on the disease. Despite tremendous gains in medical science and research, and tireless effort to identify the flu’s pathogen and to disrupt the spread of the disease, very little was known. Oswald Avery spent the rest of his life searching for the pathogen. The author describes it as an incredibly laborious and frustrating experience as the scientist eliminated, one-by-one, like Thomas Edison with the incandescent light bulb, every possible element. But in the process Avery made a startling discovery: DNA carried genetic information. His 1944 paper would launch other researchers, like James Watson, on his groundbreaking work. Barry claims that Avery’s research into the 1918 flu and its associated pneumonia led directly to the opening of an entirely new field: molecular biology.In closing, “The Great Influenza” is a terrific read on a fascinating, terrible, and reoccurring human experience.

⭐I heard the author speak on the WHY IS THIS HAPPENING podcast. He was so knowledgable and informative about what we are going through now and what happened in 1918 that I felt I had to get the book to better understand how we will get through the next 2 years.Barry writes a page turner from the prologue onward one cannot put the book down.A must read while in ‘locked down’

⭐The influenza pandemic of1918-20 killed up to 100 million people – morethan died in the 2 world wars.The author considers the ddisease started in oct 1918 at a military base in Kansas and spread to Europe via troop movements and then to the whole world. In some communties the death rate was 100.This massive tome of 550 pages gives the history ofd the disease,people involved,personal portraits and cultural responses.Very well wrtitten with some good pict8urres.Highlpy rrecommended.

⭐Very disappointed. I rarely want to throw a book away but after 130 pages of tedius filler (and just starting to get on to the pandemic) I really do feel if life’s worth wasting on this. I get some may be interested in the minute details of the American health system and the construction of the Universities . But I bought a book on a pandemic and I’ve read other books on the Black Death that were straight into the story and explaining the situation as the book progress. The book does not know what it wants to be .. one minute its waxing lyrical about William Welch learning .. then onto how a virus works, straight in! I mean he starts off using complex medical terms for chemicals with no explanation as to what they are. Then its other small niggles . Describing a dam hitting a town like a ‘hammer’ does not smack to me of someone writing a non fiction discourse with a scholarly historical narritive. The main issue is that little is discussed outside America. The cover should say The story of the Deadliest Pandemic from an American perspective. Needless to say I’m really disappointed with this book. If I could award it negative stars I’d certainly do it. I’m just sad to have wasted time reading this when I could have been reading something really enjoyable.

⭐I bought this book for my husband’s birthday. It seemed relevant at this time of covid-19 being around. He is finding it absorbing and keeps quoting from some of the pages, comparing what went on in the early 20th century to what’s happening right now. The writing is detailed and interesting; I have a feeling the book will be shared around many friends due to its topicality. A highly recommended read.

⭐When writing a book about an event you of course want back story and a summary of events leading up to the main topic. However for a book about the 1918-19 Influenza pandemic to spend about 80 pages in the 19th century to me seems an unnecessary distraction. Ok so germ theory was still in its infancy in 1918 and America in one generation had gone from a medical backwater to being at the forefront of science just in time to witness one of the greatest pandemics in history but really is 5 chapters and a virtual blow-by-blow account of the founding of John Hopkins really warranted?Like other reviews I agree that it is also a very American centric view of a disease that affected millions globally. It may have started in the US and a lot of the scientific work may have happened there but with Britain being the most powerful country in the world at that time and with all the globe’s attention on war torn France and with Asia and it’s crowded populations also ravaged by influenza it seems an odd choice to be so myopic in telling a global story.Saying that the writing is fluid and the science and politics are well explained as is the building sense of a race against an unseen enemy but really this book needs either re-editing or a more honest (and by that I mean global) assessment of one of the forgotten tragedies of the 20th century.If you liked this there’s more historical debate and fun at @HistoryGems on Facebook and Twitter

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