The Great Influenza


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The Great Influenza: The Epic Story of the Deadliest Plague In History by John M. Barry

This is the hardcover edition. The paperback is not yet available

 
Book Description

No disease the world has ever known even remotely resembles the great influenza epidemic of 1918. Presumed to have begun when sick farm animals infected soldiers in Kansas, spreading and mutating into a lethal strain as troops carried it to Europe, it exploded across the world with unequaled ferocity and speed. It killed more people in twenty weeks than AIDS has killed in twenty years; it killed more people in a year than the plagues of the Middle Ages killed in a century. Victims bled from the ears and nose, turned blue from lack of oxygen, suffered aches that felt like bones being broken, and died. In the United States, where bodies were stacked without coffins on trucks, nearly seven times as many people died of influenza as in the First World War.

In his powerful new book, award-winning historian John M. Barry unfolds a tale that is magisterial in its breadth and in the depth of its research, and spellbinding as he weaves multiple narrative strands together. In this first great collision between science and epidemic disease, even as society approached collapse, a handful of heroic researchers stepped forward, risking their lives to confront this strange disease. Titans like William Welch at the newly formed Johns Hopkins Medical School and colleagues at Rockefeller University and others from around the country revolutionized American science and public health, and their work in this crisis led to crucial discoveries that we are still using and learning from today.

The Washington Post 's Jonathan Yardley said Barry's last book can "change the way we think." The Great Influenza may also change the way we see the world.

About the Author

John M. Barry is the author of four previous works of history, including the highly acclaimed Rising Tide: The Great Mississippi Flood of 1927 and How it Changed America. He is a Distinguished Visiting Scholar at the Center for Bioenvironmental Research of Tulane and Xavier universities.

 

Back Cover
Editorial Reviews

World War I

World History

From Publishers Weekly
In 1918, a plague swept across the world virtually without warning, killing healthy young adults as well as vulnerable infants and the elderly. Hospitals and morgues were quickly overwhelmed; in Philadelphia, 4,597 people died in one week alone and bodies piled up on the streets to be carted off to mass graves. But this was not the dreaded Black Death-it was "only influenza." In this sweeping history, Barry (Rising Tide) explores how the deadly confluence of biology (a swiftly mutating flu virus that can pass between animals and humans) and politics (President Wilson's all-out war effort in WWI) created conditions in which the virus thrived, killing more than 50 million worldwide and perhaps as many as 100 million in just a year. Overcrowded military camps and wide-ranging troop deployments allowed the highly contagious flu to spread quickly; transport ships became "floating caskets." Yet the U.S. government refused to shift priorities away from the war and, in effect, ignored the crisis. Shortages of doctors and nurses hurt military and civilian populations alike, and the ineptitude of public health officials exacerbated the death toll. In Philadelphia, the hardest-hit municipality in the U.S., "the entire city government had done nothing" to either contain the disease or assist afflicted families. Instead, official lies and misinformation, Barry argues, created a climate of "fear... [that] threatened to break the society apart." Barry captures the sense of panic and despair that overwhelmed stricken communities and hits hard at those who failed to use their power to protect the public good. He also describes the work of the dedicated researchers who rushed to find the cause of the disease and create vaccines. Flu shots are widely available today because of their heroic efforts, yet we remain vulnerable to a virus that can mutate to a deadly strain without warning. Society's ability to survive another devastating flu pandemic, Barry argues, is as much a political question as a medical one.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From The Washington Post's Book World/washingtonpost.com

At the time of the influenza pandemic of 1918, the stately, plump William Henry Welch was one of the most famous doctors in the world, even though he had not touched a patient since 1884. And while he was a renowned expert in microbiology and pathology and apprised of every cutting-edge medical advance of the early 20th century, he rarely ventured into the laboratory, let alone made any discoveries that might win him the coveted Nobel Prize.

In fact, Welch's singularly greatest accomplishments were organizational. In 1889, he helped found the Johns Hopkins Hospital and, a few years later, its famed medical school. Under Welch's watch, "the Johns Hopkins" became the vanguard medical institution in the world. A rotund, balding, cigar-puffing, high-voiced man with a pointy Imperial beard, at one time or another he was president or director of just about every important national medical institution then in existence. "Popsy," as his students called him behind his back, was so powerful that he could make or break a budding young physician's career "almost by the flick of a wrist." So it was hardly surprising that President Woodrow Wilson asked him to orchestrate a medical response to an influenza epidemic spreading rapidly through army training camps, killing soldiers in droves before they ever had the chance to go overseas to fight in what we now call World War I.

When the newly commissioned Col. Welch and his medical team visited Camp Devins, just outside of Boston, in late September 1918, the sight was chilling. One colleague, the equally overweight dean of the University of Michigan Medical School, Victor Vaughan, reported that "dead bodies are stacked about the morgue like cord wood." In the autopsy suite, Welch turned pale at the sight of the cadavers' blue and swollen lungs. It was hardly the gruesome procedure of dissection that made Dr. Welch so queasy. In his long career, he had presided over tens of thousands of post-mortem examinations. Instead, he realized that he was witnessing evidence of a new and terrible plague. One long-time assistant later recalled that it was the only time he ever saw the imperturbable Welch really worried and disturbed.

Before the worldwide pandemic subsided, at least 40 million people died. And a miserable death it was: incendiary fevers followed by intense muscle aches, delirium, profuse bleeding and suffocating chest congestion. Roughly 10 percent of the dead were young adults. During the Renaissance, Italian physicians thought that a celestial "influence" caused influenza, hence its quaint name. In 1918, at the dawn of our scientific understanding of virology, scientists did not have a clue as to what made that year's strain so lethal. They still don't.

Although we have several other superb histories of the 1918 influenza pandemic, John M. Barry presents a fascinating look at how the epidemic spread and how physicians and researchers rallied to mobilize against a global health crisis. Barry also supplies useful profiles of the American microbe hunters who struggled to stem the tide -- and shows in turn how their work was shaped by the vast transformations in American medicine that began around 1900, most especially the increasing ability not only to treat dreaded diseases but to halt or prevent them entirely. By synthesizing the work of several accomplished historians of medicine, Barry produces a sharp account of the epidemic's sudden onset, as well as the no less dramatic (and sometimes panicked) responses that it inspired. Barry also underlines the dismaying speed with which many survivors forgot the great influenza outbreak almost as soon as it appeared to end.

At present, around the world, approximately 500,000 people die annually of influenza, most of them the elderly, infants or those with severe illnesses. Although this year's flu season seems to be winding down, many health officials stay awake at night worrying that eventually something will change in the virus's structure as it did in 1918 to create a devastating pandemic. As Barry describes, the influenza virus can rapidly disguise the very features that allow our bodies to fend it off -- and that, indeed, is why we all need a flu shot every season. It is also why virologists and vaccine manufacturers need to do a better job of predicting which strain of influenza will prevail each year and ensuring that there is enough vaccine to go around.

Paradoxically, the success we enjoyed during the 20th century in taming contagious diseases such as influenza often inspires a false confidence that we have conquered microbes. And this has prompted us to underfund public health programs designed to prevent new epidemics from occurring. But if we learn anything from the history of influenza, not to mention the lessons unfolding daily in an era of SARS, bird flu and other newly emerging infections, it should be that we never really conquer germs; we merely wrestle them to a draw. Reviewed by Howard Markel
Copyright 2004, The Washington Post Co. All Rights Reserved.

From Booklist
Late in this history of the 1918 influenza pandemic, Barry observes that the event "has survived in memory more than in any literature." Apparently, people would rather not record horrors that make them feel insignificant. Fortunately, there are deep-digging historians. Barry presents the pandemic as the first great challenge to the modern American medical establishment, whose response, although it was overwhelmed, demonstrated what medical science applied to public health practice might do, and as a test of national, state, and municipal political responsiveness to domestic crisis. Medicine, though far too lightly equipped, rose to the occasion, but politicians, from President Wilson on down, refused to acknowledge any crisis except the war in Europe and thwarted medicine's best preventive efforts. To portray the forces that met the crisis, Barry first tells the story of scientific medicine in America, begun by the shaping of Johns Hopkins Hospital and University under William Welch into the model for all other U.S. physicians' training and medical research institutions. The researchers who directly engaged the great flu were Welch proteges, and though they failed at the time, the continued research of one culminated in discovering the significance of DNA. Meanwhile, the death and panic, national and worldwide--the flu most probably started in Kansas, and troop movements that the army continued against its surgeon general's advice spread it cross-country and to Europe--were appalling. For readers, however, they are the somber underscoring of an enthralling symphony of a book, whose every page compels attention. Ray Olson
Copyright © American Library Association. All rights reserved

Los Angeles Times
[a] well-researched, well-written account

The New York Times Book Review
Praise for Rising Tide : "Extraordinary . . . an accomplished and important social history."

Booklist, Starred review
an enthralling symphony of a book, whose every page compels attention.

Kirkus, Starred review
Majestic, spellbinding treatment of a mass killer.

Boston Globe
a sobering account of the 1918 flu epidemic, compelling and timely.

San Diego Union-Tribune
...spellbinding... The Great Influenza is a compelling and scary read.

Chapter One

'The Great Influenza'
By JOHN M. BARRY

Published: March 14, 2004

In September 12, 1876, the crowd overflowing the auditorium of Baltimore's Academy of Music was in a mood of hopeful excitement, but excitement without frivolity. Indeed, despite an unusual number of women in attendance, many of them from the uppermost reaches of local society, a reporter noted, "There was no display of dress or fashion." For this occasion had serious purpose. It was to mark the launching of the Johns Hopkins University, an institution whose leaders intended not simply to found a new university but to change all of American education; indeed, they sought considerably more than that. They planned to change the way in which Americans tried to understand and grapple with nature. The keynote speaker, the English scientist Thomas H. Huxley, personified their goals.

The import was not lost on the nation. Many newspapers, including the New York Times, had reporters covering this event. After it, they would print Huxley's address in full.

For the nation was then, as it so often has been, at war with itself; in fact it was engaged in different wars simultaneously, each being waged on several fronts, wars that ran along the fault lines of modern America.

One involved expansion and race. In the Dakotas, George Armstrong Custer had just led the Seventh Cavalry to its destruction at the hands of primitive savages resisting encroachment of the white man. The day Huxley spoke, the front page of the Washington Star reported that "the hostile Sioux, well fed and well armed" had just carried out "a massacre of miners."

In the South a far more important but equally savage war was being waged as white Democrats sought "redemption" from Reconstruction in anticipation of the presidential election. Throughout the South "rifle clubs," "saber clubs," and "rifle teams" of former Confederates were being organized into infantry and cavalry units. Already accounts of intimidation, beatings, whippings, and murder directed against Republicans and blacks had surfaced. After the murder of three hundred black men in a single Mississippi county, one man, convinced that words from the Democrats' own mouths would convince the world of their design, pleaded with the New York Times, "For God's sake publish the testimony of the Democrats before the Grand Jury."

Voting returns had already begun to come in (there was no single national election day) and two months later Democrat Samuel Tilden would win the popular vote by a comfortable margin. But he would never take office as president. Instead the Republican secretary of war would threaten to "force a reversal" of the vote, federal troops with fixed bayonets would patrol Washington, and southerners would talk of reigniting the Civil War. That crisis would ultimately be resolved through an extraconstitutional special committee and a political understanding: Republicans would discard the voting returns of three states (Louisiana, Florida, South Carolina) and seize a single disputed electoral vote in Oregon to keep the presidency in the person of Rutherford B. Hayes. But they also would withdraw all federal troops from the South and cease intervening in southern affairs, leaving the Negroes there to fend for themselves.

To act upon the world himself, he became a proselytizer for faith in human reason. By 1876 he had become the world's foremost advocate of the theory of evolution and of science itself. Indeed, H. L. Mencken said that "it was he, more than any other man, who worked that great change in human thought which marked the Nineteenth Century." Now President Gilman gave a brief and simple introduction. Then Professor Huxley began to speak.

Normally he lectured on evolution, but today he was speaking on a subject of even greater magnitude. He was speaking about the process of intellectual inquiry. The Hopkins was to be unlike any other university in America. Aiming almost exclusively at the education of graduate students and the furtherance of science, it was intended by its trustees to rival not Harvard or Yale (neither of them considered worthy of emulation) but the greatest institutions of Europe, and particularly Germany. Perhaps only in the United States, a nation ever in the act of creating itself, could such an institution come into existence both so fully formed in concept and already so renowned, even before the foundation of a single building had been laid.

"His voice was low, clear and distinct," reported one listener. "The audience paid the closest attention to every word which fell from the lecturer's lips, occasionally manifesting their approval by applause." Said another, "Professor Huxley's method is slow, precise, and clear, and he guards the positions which he takes with astuteness and ability. He does not utter anything in the reckless fashion which conviction sometimes countenances and excuses, but rather with the deliberation that research and close inquiry foster."

Huxley commended the bold goals of the Hopkins, expounded upon his own theories of education (theories that soon informed those of William James and John Dewey) and extolled the fact that the existence of the Hopkins meant "finally, that neither political nor ecclesiastical sectarianism" would interfere with the pursuit of the truth.

In truth, Huxley's speech, read a century and a quarter later, seems remarkably tame. Yet Huxley and the entire ceremony left an impression in the country deep enough that Gilman would spend years trying to edge away from it, even while simultaneously trying to fulfill the goals Huxley applauded.

For the ceremony's most significant word was one not spoken: not a single participant uttered the word "God" or made any reference to the Almighty. This spectacular omission scandalized those who worried about or rejected a mechanistic and necessarily godless view of the universe. And it came in an era in which American universities had nearly two hundred endowed chairs of theology and fewer than five in medicine, an era in which the president of Drew University had said that, after much study and experience, he had concluded that only ministers of the Gospel should be college professors.

The omission also served as a declaration: the Hopkins would pursue the truth, no matter to what abyss it led.

In no area did the truth threaten so much as in the study of life. In no area did the United States lag behind the rest of the world so much as in its study of the life sciences and medicine. And in that area in particular the influence of the Hopkins would be immense.

By 1918, as America marched into war, the nation had come not only to rely upon the changes wrought largely, though certainly not entirely, by men associated with the Hopkins; the United States Army had mobilized these men into a special force, focused and disciplined, ready to hurl themselves at an enemy.

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?"

For most religions the answer to this question ultimately comes down to the way God ordered it. Religion is inherently conservative; even one proposing a new God only creates a new order.

The question "why" is too deep for science. Science instead believes it can only learn "how" something occurs.

The revolution of modern science and especially medical science began as science not only focused on this answer to "What can I know?" but more importantly, changed its method of inquiry, changed its answer to "How can I know it?"

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.

In the narrower context of science, the answer determines how individuals explore nature (how one does science). And the way one goes about answering a question, one's methodology, matters as much as the question itself. For the method of inquiry underlies knowledge and often determines what one discovers: how one pursues a question often dictates, or at least limits, the answer.

Indeed, methodology matters more than anything else. Methodology subsumes, for example, Thomas Kuhn's well-known theory of how science advances. Kuhn gave the word "paradigm" wide usage by arguing that at any given point in time, a particular paradigm, a kind of perceived truth, dominates the thinking in any science. Others have applied his concept to nonscientific fields as well.

According to Kuhn, the prevailing paradigm tends to freeze progress, indirectly by creating a mental obstacle to creative ideas and directly by, for example, blocking research funds from going to truly new ideas, especially if they conflict with the paradigm. He argues that nonetheless researchers eventually find what he calls "anomalies" that do not fit the paradigm. Each one erodes the foundation of the paradigm, and when enough accrue to undermine it, the paradigm collapses. Scientists then cast about for a new paradigm that explains both the old and new facts.

But the process (and progress) of science is more fluid than Kuhn's concept suggests. It moves more like an amoeba, with soft and ill-defined edges. More importantly, method matters. Kuhn's own theory recognizes that the propelling force behind the movement from one explanation to another comes from the methodology, from what we call the scientific method. But he takes as an axiom that those who ask questions constantly test existing hypotheses. In fact, with a methodology that probes and tests hypotheses (regardless of any paradigm)progress is inevitable. Without such a methodology, progress becomes merely coincendental.

Yet the scientific method has not always been used by those who inquire into nature. Through most of known history, investigators trying to penetrate the natural world, penetrate what we call science, relied upon the mind alone, reason alone. These investigators believed that they could know a thing if their knowledge followed logically from what they considered a sound premise. In turn they based their premises chiefly on observation.

This commitment to logic coupled with man's ambition to see the entire world in a comprehensive and cohesive way actually imposed blinders on science in general and on medicine in particular. The chief enemy of progress, ironically, became pure reason. And for the bulk of two and a half millennia (twenty-five hundred years) the actual treatment of patients by physicians made almost no progress at all.

One cannot blame religion or superstition for this lack of progress. In the West, beginning at least five hundred years before the birth of Christ, medicine was largely secular. While Hippocratic healers (the various Hippocratic texts were written by different people) did run temples and accept pluralistic explanations for disease, they pushed for material explanations.

Hippocrates himself was born in approximately 460 b.c. On the Sacred Disease, one of the more famous Hippocratic texts and one often attributed to him directly, even mocked theories that attributed epilepsy to the intervention of gods. He and his followers advocated precise observation, then theorizing. As the texts stated, "For a theory is a composite memory of things apprehended with sense perception." "But conclusions which are merely verbal cannot bear fruit." "I approve of theorizing also if it lays its foundation in incident, and deduces its conclusion in accordance with phenomena."

But if such an approach sounds like that of a modern investigator, a modern scientist, it lacked two singularly important elements.

First, Hippocrates and his associates merely observed nature. They did not probe it.

This failure to probe nature was to some extent understandable. To dissect a human body then was inconceivable. But the authors of the Hippocratic texts did not test their conclusions and theories. A theory must make a prediction to be useful or scientific (ultimately it must say, If this, then that) and testing that prediction is the single most important element of modern methodology. Once that prediction is tested, it must advance another one for testing. It can never stand still.

Those who wrote the Hippocratic texts, however, observed passively and reasoned actively. Their careful observations noted mucus discharges, menstrual bleeding, watery evacuations in dysentery, and they very likely observed blood left to stand, which over time separates into several layers, one nearly clear, one of somewhat yellowy serum, one of darker blood. Based on these observations, they hypothesized that there were four kinds of bodily fluids, or "humours": blood, phlegm, bile, and black bile. (This terminology survives today in the phrase "humoral immunity," which refers to elements of the immune system, such as antibodies, that circulate in the blood.)

This hypothesis made sense, comported with observations, and could explain many symptoms. It explained, for example, that coughs were caused by the flow of phlegm to the chest. Observations of people coughing up phlegm certainly supported this conclusion.

The war involving the Hopkins was more muted but no less profound. The outcome would help define one element of the character of the nation: the extent to which the nation would accept or reject modern science and, to a lesser degree, how secular it would become, how godly it would remain.

Precisely at 11:00 a.m., a procession of people advanced upon the stage. First came Daniel Coit Gilman, president of the Hopkins, and on his arm was Huxley. Following in single file came the governor, the mayor, and other notables. As they took their seats the conversations in the audience quickly died away, replaced by expectancy of a kind of declaration of war.

Of medium height and middle age (though he already had iron-gray hair and nearly white whiskers) and possessed of what was described as "a pleasant face," Huxley did not look the warrior. But he had a warrior's ruthlessness. His dicta included the pronouncement: "The foundation of morality is to have done, once and for all, with lying." A brilliant scientist, later president of the Royal Society, he advised investigators, "Sit down before a fact as a little child, be prepared to give up every preconceived notion. Follow humbly wherever and to whatever abysses nature leads, or you shall learn nothing." He also believed that learning had purpose, stating, "The great end of life is not knowledge but action."

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