This seemed like the book to read since I got a break and wanted to get smart on virology and try to make sense of what’s happening in our world. Professionally, I’ve been deep in the world of cyber security and defence technologies but I’ve always looked over the fence what’s happening in the Pharmaceutical industry and this book was intended to be a bridge that I’ve needed to cross for sometime. In total, this book is a sweeping scientific and social history as a cautionary and instructive tale. How governments fail in the face of inexplicable nature is one of his most potent themes. Readers interested in science, social science, the social fabric and especially those compelled by dealing with the 2020 coronavirus pandemic, may be up for the challenge.

For me, this book was a long slog to get through at 555 pages that combined history, science, and some biographies of the folks that made modern medicine possible. This book gave me far more than I ever wanted to know about the Great Influenza Epidemic of 1918-19. It begins in September of 1876 with the founding of the Johns Hopkins University, with its emphasis on medical research against the backdrop of a terribly poor state of medical science in the US. It continues with the difficulty in getting doctors and educators to believe that there was a place for research in medicine at all. I kept waiting for the plague to begin and, sure enough, chapter 14 begins with the news that in February of 1918 someone from Haskell County Kansas most likely carried the disease to Camp Funston, a U.S. Army training camp located on Fort Riley, southwest of Manhattan, Kansas. It goes on to tell in great detail the difficulty of convincing the army, or most anyone in power, that it was killing people, even as it was doing exactly that.

The Great Influenza was written by John Barry, a distinguished scholar, historian and adjunct faculty member at Tulane University. Among his other well-known works are Rising Ride, about a devastating 1927 Mississippi flood. His book, Roger Williams and The Creation of the American Soul, concerns one’s American lasting influence, especially in the United States’ unprecedented insistence on the separation of church and state. This may of explained why he so eagerly (and annoyingly) constrasted science against faith in the first several chapters of the book.

He clearly is fascinated with how events shape the US national fabric, as seen also in his Power Plays: Politics, Football, and Other Blood Sports and The Ambition and the Power: The Fall of Jim Wright: A True Story of Washington. For Barry – who wrote this book well before the 2020 coronavirus pandemic – the 1918 influenza outbreak has a recurring theme: the consistent lying, obfuscation and incompetence of American officials, notably how they refused to alert the citizenry they were pledged to protect about the dangers they faced. Overall, he presses three major themes: (1) be honest with the public, (2) honor the heros on the front lines of research and (3) people in power should be held to account.

The 1918-1919 influenza pandemic swept the world. From its early start in the midwest US, through its subsequent spread through troop movements during World War I, the influenza virus killed approximately 50 to 100 million people (compared with the 2M deaths I forecast for the novel coronavirus). The sheer destruction of 1918-1919 influenza pandemic is difficult to grasp: it killed an estimated 5% of the world’s population – 50 million to 100 million people, about 675,000 people in the United States. Government officials, in stark parallel to 2020’s coronavirus pandemic, dismissed the outbreak or lied about it.

One of the most shocking parts of this world is how unprepared we were to understand disease then. No treatment then available could stop the rapidly mutating virus. While we have mRNA vaccines at crazy speeds (thanks DARPA), there are still uncanny parallels to today and harkens to deadly lessons apparently still unlearned.

Barry traces the flu to its source. The pandemic started in 1918 when men from Haskell County, Kansas trained at a US Army base, Camp Funston, where a cook reported ill with influenza on March 4, 1918. More than 1,100 soldiers entered hospitals and 38 died. Then the Army transferred soldiers from Funston to US bases and to Europe. Barry lays out the virus’s path. It traveled with the soldiers, moving through North America, Europe, South America, Africa, Asia and scattered Pacific islands. I was ashamed by the feeling that this was the "American Influenza" in the same sense the Trump admistration wanted to blame the Novel Coronovirus on China.

Viruses Only Replicate

One area of Barry’s science reporting is particularly compelling: his primer on influenza viruses. He explains that they originated in “wild aquatic birds.” Exposure to an avian virus can infect people, but, he underscores, people can’t infect people unless the virus mutates to adapt to person-to-person transmission. Which it has; the US Centers for Disease Control says influenza now kills 3,000 to 56,000 Americans a year.

Influenza is a viral disease. When it kills, it usually does so in one of two ways: either quickly and directly with a violent viral pneumonia so damaging it has been compared to burning the lungs; or more slowly and indirectly by stripping the body of defenses…

Barry offers a lot of food for thought in one simple idea: replication is a virus’s only function. The influenza virus hides from the immune system by “entering” a cell, but not “fusing” with it, as other viruses do. About 10 hours after an influenza virus attaches to a cell, the cell releases a “swarm” of 100,000 to one million influenza viruses. Barry successfully conveys the horror of this invasion.

Many viruses, fungi and bacteria infect the lungs. The most ubiquitous is the pneumococcus, which can initiate or aggravate lung infections. Barry explores medical history prior to 1918 flu outbreak as a context for medicine’s utter helplessness. Scientists failed to develop a serum against pneumococcus in 1892, despite medical advances against tetanus, meningitis, diphtheria and typhoid. Barry tells how desperate doctors tried fighting the flu with the vaccine for typhoid and with quinine, a malaria treatment.

Barry’s depiction of experts’ inability to understand the influenza virus provides a stark reminder of the mystery of the 2020 coronavirus pandemic. He makes the danger of the 1918 plague plain when he writes that face masks were no protection against it. People’s only hope was to avoid exposure, but no one, he explains, understood quite how to do that.

However, Barry reserves his harshest criticism for leaders in the media or government whose ill fated decisions were a disaster for the public. Barry reports that the 1918 virus struck in waves. The spring wave killed relatively few; the second wave was more destructive. And the deliberate dishonesty of officials was deadly indeed.

The pandemic ravaged Philadelphia. Barry regards its municipal public health director, Wilmer Krusen, with well-deserved contempt. When locals planned a Liberty Loan parade to promote war bonds, he advised the public to “avoid crowds,” but allowed the parade to go on. Barry states his belief, here as in his other works, that officials must take responsibility for the people under their charge. He regards failure to do as a high moral crime.

On October 1, 1918 the virus killed 117 people in Philadelphia; the 31 local hospitals were full. Daily influenza deaths soared from 254 on October 5 to 428 on October 8. Death overwhelmed funeral homes and the morgue. Barry paints a vivid picture of dead bodies in homes, on porches and in yards.

Barry cites Royal Copeland – municipal health commissioner of New York City when influenza killed its first victim there on September 15 – as another failed official. As patients poured into hospitals, Copeland dismissed the illnesses as just one among “other bronchial diseases.” The virus killed 33,000 New Yorkers. The plague ravaged New York, and then New Orleans, Louisville, Pittsburgh and Baltimore. It hit Portugal and Greece and, by summer, death tolls rose in England, Scotland and Wales.

The Red Cross recruited nurses to work in American cities but prioritized providing the military with nurses. Soldiers died on transport ships in such numbers that the vessels became "floating caskets".

President Wilson’s Flu

Most flu victims were in their 20s. Barry reveals that their immune response to the virus filled their lungs with “fluid and debris.” The elderly demonstrated immunity worldwide, probably because they’d been exposed to an earlier, milder pandemic. Linking, as ever, the past to the present, Barry notes that the 1918 pandemic caused a disintegration of the lungs that health experts now call acute respiratory distress syndrome (ARDS).

Barry is stark (and maybe wrong) about how the influenza outbreak changed history. The disease damaged the nervous system and brain and mentally destabilized victims. Barry depicts President Woodrow Wilson’s trip to Paris in 1919, when he developed a cough, diarrhea, a 103-degree fever – influenza symptoms. Wilson negotiated during his illness, but Barry finds that the president made multiple shocking concessions he had resisted days earlier. Barry presents Wilson as much weakened and disoriented from the flu. Wilson suffered a stroke four months after signing the Paris peace treaty, which treated Germany harshly and set the stage for Adolf Hitler’s rise to power. Barry links this stroke to Wilson’s earlier viral illness.

People who survived exposure to the 1918 influenza developed greater immunity as the virus mutated to a less-lethal form. Barry found that the further along in the epidemic the outbreak hit a US city, the lower its mortality rate. The 1918 virus faded away in the early 1920s.

Heros

The author cites scientists with links to Johns Hopkins, the Rockefeller Institute, Harvard and the University of Pennsylvania as foremost in battling the virus. He treats their efforts as a tale of suspense, but that isn’t always as convincing as his depiction of the disease and its effects.

The accepted cause of influenza in 1918 was a bacillus known as B. influenzae. While thought to be the source of infection at the time, it is now known to be a cause of secondary infections, not the influenza itself (which is viral). The combination of an elusive pathogen and a bunch of secondary invaders masquerading as the culprit stymied researchers at the time and kept them busy for decades afterwards.

Barry’s focus is almost entirely on the United States and largely on American researchers. Here, in his efforts to carve individual human dramas from the great mass of the pandemic, he often loses the thread. In order to explain the nature of medical research in America, he centers on the post-Civil-War experiences of William Welch, the driving force behind the creation of the Johns Hopkins medical research labs. We expect Welch to become a leading figure in the battle against the influenza, but all Welch did in 1918 was get sick and then get better, sidelining him for the duration of the epidemic, whereupon he disappears from Barry’s story.

Ultimately, Barry has two heroes: Oswald Avery and Paul Lewis. Both became nearly obsessed with research on the influenza pathogen. Neither solved many of its mysteries. Avery digressed into a completely different line of work that led to his discovery that DNA plays the key role in genetics. Lewis became disheartened, and his research career dwindled after a brilliant start; he ended up sacrificing his own life in an attempt many years later to fight a yellow-fever outbreak in Brazil.

Highest praise is reserved for the luminaries of the medical research field — William Welch, Oswald Avery, Simon Flexner and others — who toiled tirelessly to combat the disease. Amid Barry’s thorough biographical snapshots of these men — a veritable Who’s Who of the history of modern medicine — one man stands apart as the story’s fallen hero: Paul Lewis.

In the early 1900s, Lewis, then a scientist at the Rockefeller Institute, not only proved that a virus caused polio but also developed a vaccine that protected monkeys from the disease. Turning his focus to the flu epidemic, Lewis successfully identified the disease as influenza and committed himself to developing a vaccine. But as Barry acknowledges, the greatest challenge for Lewis and his colleagues was not the research they undertook during the epidemic, but rather the accounting that came afterward, when they were left to "sift through the detritus of their failures for clues to success." Describing that process, Barry speculates that medicine’s psychic burdens may ultimately have been more than Lewis could bear, and that his death from yellow fever, contracted in a laboratory accident, was actually a suicide.