The Great Influenza: The Story of the Deadliest Pandemic in History

By John M. Barry

What you’ll learn

Until recently, the idea of a pandemic took most people’s imagination to Hollywood thrillers and the Black Plague that ravaged medieval Europe. But the most devastating plague to ever strike the human race took place a century ago, during the First World War. This story contains many lessons for how—and how not—to handle a pandemic. Barry’s tie-ins to our own day (most recent edition published in 2018) have an eerily prophetic ring to them in light of the corona virus that has recently swept the globe.

Read on for key insights from The Great Influenza: The Story of the Deadliest Pandemic in History.

1. The 1918 influenza virus targeted young adults, and killed far more than the Black Plague or AIDS.

It was in the fall of 1918 that a group of sailors from the United States began presenting never-before seen symptoms that baffled clinicians. The presenting symptoms were bleeding in the nose and ears, pounding headaches, painful body aches, deep coughs (sometimes deep enough to tear abdominal musculature), and, finally, skin turning blue.

The medical professionals called in Paul Lewis, a lieutenant commander and a medical doctor who was more familiar with death in all its varieties than just about anyone alive at the time. He was also brilliant. More than a few colleagues—accomplished scientists in their own rights—called Lewis the most brilliant man they’d ever met.

Lewis was highly accomplished and still young. When polio had ravaged New York, he was part of the group that proved a virus was the culprit. And then he developed a vaccine that proved 100 percent effective in animal trials. He’d also founded a research institute in affiliation with University of Pennsylvania. Though Lewis was an accomplished man of science and familiar with death and all its friends, he was still baffled by the bodies of dying, blue-skinned sailors. He’d seen something similar among British soldiers weeks earlier, something influenza-like, but he wasn’t sure.

Whatever it was that the sailors who came through Boston to Philadelphia had brought with them that fall, it spread. Despite the best attempts of medical personnel to contain the unknown disease, it spread from the 19 soldiers to 87, and then to 600 within just a few days. Hospitals ran out of beds quickly and had to involve other medical facilities to care for the sick sailors and the civilians with whom they’d come in contact. Simultaneously, the same symptoms began showing up all over the world. This wasn’t a passing rash of influenza going around as doctors in the United States and Europe had thought. It was actually the second wave of a mild influenza that had appeared months earlier in America’s heartland. It was not nearly as devastating then, in symptoms or spread. The second, far more pernicious infection was spreading like wildfire in the fall of 1918, affecting not just sailors in New England, but also soldiers in the British Raj in India, and everywhere in between.

And so, as the Great War continued to rage, another war had begun. It wasn’t just a fight of nation against nation, but also of nation against some unknown disease. It began in a small town in the United States in the spring of 1918, but had laid dormant. But between the fall of 1918 and 1920, millions died. Of those who contracted influenza and succumbed, their deaths were swift and painful.

Earlier estimates put the death toll at 21 million, but this is now considered a low ball. More widely accepted estimates from epidemiologists are between 50 and 100 million. The majority of these deaths took place within a half-year window, during the fall and winter of 1918. The disease killed more people in a year than ever died in the medieval Black Plague or from AIDS.

What made this pandemic even more tragic was that it was the young (people in their 20s and 30s) who were especially vulnerable to the pathogen. If the higher estimates are accurate, that means the 1918 influenza took out about 10 percent of young adults on the planet.

The 1918 outbreak marked a milestone in human history. It was the first time that modern medicine and nature had challenged each other in such a robust way. The virus that led to the infamous Bubonic Plague 700 years earlier was a far milder strain, but it still decimated Europe because science and infrastructure couldn’t put up any real fight. This time, it was different, and it was the individuals who retained poise and calm in the midst of dire circumstances who stopped the bleeding and kept the catastrophe from being any more grim than it already was.

2. Only a few scientists saw the world’s vulnerability to epidemics and began planning accordingly.

Around the time of the pandemic, there were a number of remarkable people who had helped bring medical practices and research to the cutting edge. There are some areas of study where, even a century later, medical practitioners remain indebted to these forebears’ expertise and the skills they developed in a time of influenza. Paul Lewis was one of those geniuses. Another was William Henry Welch, who founded the first academic program devoted to public health in 1916 at Johns Hopkins University in Baltimore.

Still, it took tremendous time and dedication to make medicine a modern, scientific pursuit. Until the late-1800s, the field of medicine had changed very little since the days of Hippocrates in ancient Greece. Even until 1900, only one medical school in five required a high school diploma in the United States, and only one medical school required a college degree for admission. Many applicants without any serious training in the physical sciences were admitted, simply by proving that they could pay tuition. Degrees were doled out to men (women were not admitted) simply for passing all the classes—even if they had never touched a body or seen a patient.

Eventually, medical practice began to improve and become more empirically verified, first in Europe and then in the United States. United States medical science was the worst in the developed world before it became the best.

William Henry Welch was a forerunner who helped bring the massive and much-needed changes to the United States’ medical education. Welch was a capable scientist, physician, and professor, but his strength lay in his ability to inspire. He was a charming and charismatic individual. The students he taught at Johns Hopkins adored him and would become the most coveted in the United States. These Welch protégés formed an army of elites who would become more desperately needed than they knew in 1918. Welch was a man who convinced people that improvements in the American medical field were horribly overdue, and he provided a road map for how to get there, as well as a prestigious group of medical professionals to navigate it.

Welch’s influence revolutionized medicine in the United States, but another thing that  made Welch singular was that he saw what most everyone else had missed: humanity’s vulnerability to epidemics. He had noticed the trend that every time the United States went to war, disease killed far more combatants than the opposing armies. Moreover, war had a way of spreading illness. These facts led Welch to predict that, with the Great War on, it was just a matter of time before some kind of epidemic broke out.

Welch had pushed Johns Hopkins for a public health program since the 1880s, and he finally got his wish in 1916 when the Johns Hopkins School of Hygiene and Public Health was founded. This was just two years before the influenza began to emerge. He saw that robust public health (of which epidemiology, or the study of disease, is a central feature) was the best way to save lives. He was right, and his intuition holds true to this day.

3. The 1918 influenza began in Kansas, but it was quickly exported to the rest of the world, infecting hundreds of millions.

The influenza outbreak of 1918 most likely began in Haskell County, Kansas. There are other theories that it began in China or Vietnam or France, but the United States is the most probable starting point, and there’s no earlier record than from Haskell County. The virus drifted from Haskell to a nearby military base, when it was still tame in comparison to what was to come. Not much more was said about the outbreak than a forgettable health notice about “influenza of severe type” the Midwest. From there, the virus worked its way through the ranks of soldiers and was then exported to other U.S. bases and the various war theaters across Afro-Eurasia. It came roaring back to America in the fall of 1918, in the previously mentioned New England cities.

What makes influenza dangerous is that it’s caused by viruses—not bacteria (a discovery that one of William Henry Welch’s many protégés made). It’s not quite an organism, but it’s not as lifeless as a chemical compound either. Its mission is to replicate, but it cannot do so apart from a host. It needs an organism’s cells in order to make thousands or even hundreds of thousands of self-copies.

What makes influenza viruses unique is that they are extremely infectious and competitive. Influenza viruses set off all the body’s warning bells, and the immune system sets up defenses based on what the body has already encountered. But a new variation of the virus is unknown to the body, and attacks a compromised and blind immune system. The body beats down any other viruses that might be present, and then, once all other familiar viruses have been eliminated, the new influenza virus begins its work.

The United States was unprepared for the pandemic for a variety of reasons.

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