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The Great Influenza (2004) by John M Barry

A rousing history of one of the worst things that has ever happened: the 1918 outbreak of H1N1 flu.* It focusses particularly on the great scientists who tried to fight it, none of whom I'd ever heard of, to my shame. It's also a meditation on epistemology, the modern mind, and the redemptive meaning of science for beasts like us.

Barry senses that the headline result - one-third of the entire world infected, with 25-100 million dead - doesn't produce the right reaction in us. The numbers are numbing. So he couches it in modern shocking terms:

It killed more people in twenty-four weeks than AIDS has killed in twenty-four years, more in a year than the Black Death killed in a century.

Or, ten thousand 9/11s. It's worth belabouring this, because we have a weird habit of paying far more attention to human threats than natural ones, even when natural ones are far worse. (Witness our terrorism prevention budgets compared to our infectious disease control budgets, when the latter is a thousand times more lethal.)

So: The 1918 flu was worse than the entire First World War: 40+ million died of flu compared with 17 million dead from war; 500 million lives damaged by flu vs 41 million lives by war. 3% of everyone alive died of flu, including about 8% of young adults(!).

Except, it's hard to separate the two things, the War and the pandemic. The virus was spread everywhere by unprecedented numbers of troops, and by the massive supply convoys it induced, and by the War's other human displacements. We don't know how many of the pneumonia deaths only occurred because of the logistical degradation, poverty and pestilence of wartime. There are terrible nonlinearities involved in overcrowding and global movement of troops. But add millions at least to the overall death toll caused by WWI.**

The book is written in the epic mode, all the way through. It is more readable than ordinary scholarship, but more careful than ordinary pop science. Ideal, for me, but I understand if it's a bit American for you:

Man might be defined as “modern” largely to the extent that he attempts to control, as opposed to adjust himself to, nature. In this relationship with nature, modern humanity has generally been the aggressor and a daring one at that, altering the flow of rivers, building upon geological faults, and, today, even engineering the genes of existing species. Nature has generally been languid in its response, although contentious once aroused and occasionally displaying a flair for violence.

By 1918 humankind was fully modern, and fully scientific, but too busy fighting itself to aggress against nature. Nature, however, chooses its own moments. It chose this moment to aggress against man, and it did not do so prodding languidly. For the first time, modern humanity, a humanity practicing the modern scientific method, would confront nature in its fullest rage.

There's a long prelude describing how terrible medicine was up to the 20th Century. Medicine was "the withered arm of science". Therapeutic nihilism (that is, "we can't really do anything") was the only rational view, replacing millenia of Galenic woo.

Stengel reviewed dozens of ideas that had been advanced in medical journals. Gargles of various disinfectants. Drugs. Immune sera. Typhoid vaccine. Diphtheria antitoxin. But Stengel’s message was simple: This doesn’t work. That doesn’t work. Nothing worked... Stengel was correct. Nothing they were yet doing worked.

Problem is, this rational scepticism created a powerful vacuum: humans need to believe something can heal, and the gap was filled with worse. Some confabulated gremlins from this time haunt us still: homeopathy, chiropractic, naturopathy, Christian Science, and (though Barry doesn't include them) the organic farming movement and psychoanalysis.

Few people come off well. Even among the scientists, we get a horrible example of perverse priors and premature updating: an enormous proportion of all scientific resources were devoted to fighting the wrong pathogen, due to a bad guess by an extremely eminent researcher.

Because so much of the state was occupied in war, in places there was wholesale social collapse:
In Philadelphia meanwhile fear came and stayed. Death could come from anyone, anytime. People moved away from others on the sidewalk, avoided conversation; if they did speak, they turned their faces away to avoid the other person’s breathing. People became isolated, increasing the fear.

The impossibility of getting help compounded the isolation. Eight hundred fifty Philadelphia doctors and more nurses were away in the military. More than that number were sick. Philadelphia General Hospital had 126 nurses. Despite all precautions, despite wearing surgical masks and gowns, eight doctors and fifty-four nurses—43 percent of the staff—themselves required hospitalization. Ten nurses at this single hospital died. The Board of Health pleaded for help from retired nurses and doctors if they remembered “even a little” of their profession.

When a nurse or doctor or policeman did actually come, they wore their ghostly surgical masks, and people fled them. In every home where someone was ill, people wondered if the person would die. And someone was ill in every home...

Starr went to Emergency Hospital #2 at Eighteenth and Cherry Streets. He did have help, if it could be called that, from an elderly physician who had not practiced in years and who brought Starr into touch with the worst of heroic medicine. Starr wouldn’t forget that, the ancient arts of purging, of venesection, the ancient art of opening a patient’s vein. But for the most part he and the other students elsewhere were on their own, with little help even from nurses, who were so desperately needed that in each of ten emergency hospitals supplied by the Red Cross only a single qualified nurse was available to oversee whatever women came as volunteers. And often the volunteers reported for their duty once and, from either fear or exhaustion, did not come again.

Nearly one-quarter of all the patients in his hospital died each day. Starr would go home, and when he returned the next day, he would find that between one-quarter and one-fifth of the patients in the hospital had died, replaced by new ones... Virtually all of them, along with their friends and relatives, were terrified that, no matter how mild the symptoms seemed at first, within them moved an alien force, a seething, spreading infection, a live thing with a will that was taking over their bodies — and could be killing them...

The city was frozen with fear, frozen into stillness. Starr lived twelve miles from the hospital. The streets were silent on his drive home, silent. They were so silent he took to counting the cars he saw. One night he saw no cars at all. He thought, “The life of the city had almost stopped.”

Everyone can read the collapse of official power in Philadelphia as supporting their politics. Anarchists can point to the benevolent spontaneous order that arose after the corrupt local government failed to act; libertarians can point out that this spontaneous order was all funded by the richest Philadelphians; statists can point out that, without actually-authoritative co-ordination, the effort eventually failed, because people defected against each other, in fear.

The corpses had backed up at undertakers’, filling every area of these establishments and pressing up into living quarters; in hospital morgues overflowing into corridors; in the city morgue overflowing into the street. And they had backed up in homes. They lay on porches, in closets, in corners of the floor, on beds. Children would sneak away from adults to stare at them, to touch them; a wife would lie next to a dead husband, unwilling to move him or leave him. The corpses, reminders of death and bringers of terror or grief, lay under ice at Indian-summer temperatures. Their presence was constant, a horror demoralizing the city; a horror that could not be escaped. Finally the city tried to catch up to them.

Krusen sent police to clear homes of bodies that had remained there for more than a day, piling them in patrol wagons, but they could not keep up with the dying and fell further behind. The police wore their ghostly surgical masks, and people fled them, but the masks had no effect on the viruses and by mid-October thirty-three policemen had died, with many more to follow...
More coffins came by rail, guarded by men with guns.

There is, therefore, but one response possible from us: Force! force to the utmost, force without stint or limit, the righteous and triumphant force which shall make right the law of the world and cast every selfish dominion down in the dust.
- Woodrow Wilson addressing one of his money-lending mobs

Wilson tends to be viewed pretty positively, just because he won. ("at last the world knows America as the savior of the world!") But he perverted an entire state and nation to do so, ignored the terrible suffering of his own damn population for years, and refused a conditional peace with Austria in August and with the Kaiser's new parliament in September. (This meant 30-70 extra days of war, which, if this period was as lethal as the rest of the war, means up to 800,000 completely unnecessary deaths, not to mention the continuing waste of resources during the worst epidemic ever). Wilson did great evil, was not much different from the Kaiser, the election aside.

the military suctioned more and more nurses and physicians into cantonments, aboard ships, into France, until it had extracted nearly all the best young physicians. Medical care for civilians deteriorated rapidly. The doctors who remained in civilian life were largely either incompetent young ones or those over forty-five years of age, the vast majority of whom had been trained in the old ways of medicine. The shortage of nurses would prove even more serious. Indeed, it would prove deadly, especially in civil society.

Barry's middle chapters are a frightening portrait of how rabidly un-American the US was in 1918. The laws were bad enough - for instance the ban on criticising the government. But then there's the unofficial "patriotic duties", punishable by beatings. State-sponsored atavism.

By the summer of 1918, however, Wilson had injected the government into every facet of national life and had created great bureaucratic engines to focus all the nation’s attention and intent on the war.

He had created a Food Administration to control and distribute food, a Fuel Administration to ration coal and gasoline, a War Industries Board to oversee the entire economy. He had taken all but physical control over the railroads and had created a federally sponsored river barge line that brought commerce back to life on the Mississippi River, a commerce that had been killed by competition from those railroads. He had built many dozens of military installations, each of which held at least tens of thousands of soldiers or sailors. He had created industries that made America’s shipyards teem with hundreds of thousands of laborers launching hundreds of ships, dug new coal mines to produce coal for the factories that weaned America’s military from British and French weapons and munitions—for, unlike in World War II, America was no arsenal of democracy.

He had created a vast propaganda machine, an internal spy network, a bond-selling apparatus extending to the level of residential city blocks. He had even succeeded in stifling speech, in the summer of 1918 arresting and imprisoning — some for prison terms longer than ten years —not just radical labor leaders and editors of German-language newspapers but powerful men, even a congressman.

He had injected the government into American life in ways unlike any other in the nation’s history. And the final extension of federal power had come only in the spring of 1918, after the first wave of influenza had begun jumping from camp to camp, when the government expanded the draft from males between the ages of twenty-one and thirty to those between the ages of eighteen and forty-five. Only on May 23, 1918, had Provost Marshal Enoch Crowder, who oversaw the draft, issued his “work or fight” order, stating that anyone not employed in an essential industry would be drafted...

Crowder bragged about doing “in a day what the Prussian autocracy had been spending nearly fifty years to perfect..."

In mid-August, as the lethal wave of the epidemic was gathering itself, Austria had already inquired about peace terms, an inquiry that Wilson rebuffed utterly. And as the epidemic was gathering full momentum, peace was only weeks away. Bulgaria had signed an armistice on September 29. On September 30, Kaiser Wilhelm had granted parliamentary government to the German nation; that same day Ludendorff had warned his government that Germany must extend peace feelers or disaster—immediate disaster—would follow. German diplomats sent out those feelers. Wilson ignored them. The Central Powers, Germany and her allies, were simultaneously breaking off one from one another and disintegrating internally as well. In the first week of October, Austria and Germany separately sent peace feelers to the Allies, and on October 7, Austria delivered a diplomatic note to Wilson formally seeking peace on any terms Wilson chose. Ten days later — days of battle and deaths — the Austrian note remained unanswered.

Earlier Wilson had spoken of a “peace without victory,” believing only such a peace could last. But now he gave no indication that the war would soon be over. Although a rumor that the war had ended sent thrills through the nation, Wilson quickly renounced it. Nor would he relent. He was not now fighting to the death; he was fighting only to kill... If Wilson and his government would not be turned from his end even by the prospect of peace, they would hardly be turned by a virus. And the reluctance, inability, or outright refusal of the American government to shift targets would contribute to the killing. Wilson took no public note of the disease, and the thrust of the government was not diverted. The relief effort for influenza victims would find no assistance in the Food Administration or the Fuel Administration or the Railroad Administration. From neither the White House nor any other senior administration post would there come any leadership, any attempt to set priorities, any attempt to coordinate activities, any attempt to deliver resources.

...the military would give no help to civilians. Instead it would draw further upon civilian resources. The same day that Welch had stepped out of the autopsy room at Devens and called Gorgas’s office, his warning had been relayed to the army chief of staff, urging that all transfers be frozen unless absolutely necessary and that under no circumstances transfers from infected camps be made... Gorgas’s superiors ignored the warning. There was no interruption of movement between camps whatsoever; not until weeks later, with the camps paralyzed and, literally, tens of thousands of soldiers dead or dying, did the army make any adjustments.

Because the disease was everywhere, ravaging the entire species (and beyond), the book can't cover everything. Very little is said about non-Americans, i.e about 98% of the death and chaos. This is partly because there just isn't a lot of evidence about them, despite their influenza immunity and medical care being even worse. (This is why the top estimates reach 100m deaths, three times the median estimate.)

Here is a passage about just a tiny number of them, in the north:
In Alaska, whites protected themselves. Sentries guarded all trails, and every person entering the city was quarantined for five days. Eskimos had no such luck. A senior Red Cross official warned that without “immediate medical assistance the race” could become “extinct.”...

The navy provided the collier USS Brutus to carry a relief expedition. At Juneau the party divided and went in smaller boats to visit villages.

They found terrible things. One doctor visited ten tiny villages and found “three wiped out entirely; others average 85% deaths… Survivors generally children… probably 25% frozen to death before help arrived.”

A later relief expedition followed, funded by the Red Cross, dividing itself in the Aleutian Islands into six groups of two doctors and two nurses each, then boarding other ships and dispersing... The group crossed the Naknek River to a village with a seafood cannery. Twenty-four adult Eskimos had lived there before the epidemic. Twenty-two had died...

Entire family groups, a dozen people or more, lived in this one room. “On entering these barabaras, Dr. McGillicuddy’s party found heaps of dead bodies on the shelves and floors, men, women, and children and the majority of the cases too far decomposed to be handled.”

The virus probably did not kill all of them directly. But it struck so suddenly it left no one well enough to care for any others, no one to get food, no one to get water. And those who could have survived, surrounded by bodies, bodies of people they loved, might well have preferred to go where their family had gone, might well have wanted to no longer be alone. And then the dogs would have come.

... he met a Hudson’s Bay Company man who told him “sickness… has struck the place like a cyclone, two days after the Mail boat left”...

Of 220 people at Hebron, 150 died. The dead lay in their beds, sweat having frozen their bedclothes to them. Gordon... wrote, “A feeling of intense resentment at the callousness of the authorities, who sent us the disease by mail-boat, and then left us to sink or swim, filled one’s heart almost to the exclusion of all else...”

Two hundred sixty-six people had lived in Okak, and many dogs, dogs nearly wild. When the virus came, it struck so hard so fast people could not care for themselves or feed the dogs. The dogs grew hungry, crazed with hunger, devoured each other, then wildly smashed through windows and doors, and fed... In all of Labrador, at least one-third the total population died.

The book is a little repetitive; after the high horror of the Philadelphia, Eskimo, and war fever chapters, the other chapters, on regional suffering and scientific misadventure, are more of the same. A great deal of financial and institutional machinations are given, which is good if you weren't aware just how much of modern medicine were created by private foundations, but dull even then.

Here is one deep passage on them though:
Institutions are a strange mix of the mass and the individual. They abstract. They behave according to a set of rules that substitute both for individual judgments and for the emotional responses that occur whenever individuals interact. The act of creating an institution dehumanizes it, creates an arbitrary barrier between individuals.

Yet institutions are human as well. They reflect the cumulative personalities of those within them, especially their leadership. They tend, unfortunately, to mirror less admirable human traits, developing and protecting self-interest and even ambition. Institutions almost never sacrifice. Since they live by rules, they lack spontaneity. They try to order chaos not in the way an artist or scientist does, through a defining vision that creates structure and discipline, but by closing off and isolating themselves from that which does not fit. They become bureaucratic.

The best institutions avoid the worst aspects of bureaucracy in two ways. Some are not really institutions at all. They are simply a loose confederation of individuals, each of whom remains largely a free agent whose achievements are independent of the institution but who also shares and benefits from association with others. In these cases the institution simply provides an infrastructure that supports the individual, allowing him or her to flourish so that the whole often exceeds the sum of the parts. (The Rockefeller Institute was such an institution.) Other institutions avoid the worst elements of bureaucracy by concentrating on a clearly defined purpose. Their rules have little to do with such procedural issues as a chain of command; instead rules focus on how to achieve a particular result, in effect offering guidance based on experience. This kind of institution even at its best can still stultify creativity, but such institutions can execute, can do a routine thing efficiently...

In 1918 the institution of the federal government had more force than it had ever had — and in some ways more force than it has had since. But it was aiming all that force, all its vital energy, in another direction.

Barry commits at least one big error: he's horrified by the medical schools of the time having "no standards for admission":

In research and education especially, American medicine lagged far behind [European medicine]... At least one hundred US medical schools would accept any man willing to pay tuition... and only a single medical school required its student to have a college degree... the Johns Hopkins itself, not student fees, paid [its] faculty salaries, and it required medical students to have not only a college degree but fluency in French and German and a background of science courses.

But his enthusiasm for Johns Hopkins introducing the college degree requirement is misplaced. Contemporary American doctors (who have all completed 3 years of pre-med, or even more college, before they start medical training) are probably no better clinicians than undergraduate doctors in other countries, and are far further in debt.

And this requirement is probably one reason the American health system is so fucked: there is a chronically straitened supply of healthcare professionals everywhere, but a needless $100,000+ barrier to entry can't help. Some suggestive facts:

I actually can't find much data on cross-country quality of care, and none on cross-country doctor quality, which is appalling. So have some anecdata from Scott Alexander, instead:
I’ve done medicine in both America and Ireland. The doctors in both countries are about equally good. When Irish doctors take the American standardized tests, they usually do pretty well. Ireland is one of the approximately 100% of First World countries that gets better health outcomes than the United States. There’s no evidence whatsoever that American doctors gain anything from those three extra years of undergrad. And why would they? Why is having a philosophy degree under my belt supposed to make me any better at medicine?
(Though Alexander also thinks that the worst US supply bottleneck is not enough residencies for foreign med students, not med school admissions. This one at least seems to be slowly improving.)
I suppose Barry is just confusing the open admissions situation with the schools' appallingly low graduation standards, which is certainly one reason eC20th medicine sucked. (Many newly licenced doctors had never looked down a microscope, never used a stethoscope on a patient, never even seen a dissection.)

(Why does extra education, even in science, have little effect on clinical standards? A hint: Doctors forget most of the basic science they learn within about 2 years of graduating.)

There was terror afoot in 1918, real terror. The randomness of death brought that terror home. So did its speed. And so did the fact that the healthiest and strongest seemed the most vulnerable. The media and public officials helped create that terror — not by exaggerating the disease but by minimizing it, by trying to reassure. every horror movie, once the monster appears, terror condenses into the concrete and diminishes. Fear remains. But the edge of panic created by the unknown dissipates. The power of the imagination dissipates.

In 1918 the lies of officials and of the press never allowed the terror to condense into the concrete. The public could trust nothing and so they knew nothing. So a terror seeped into the society that prevented one woman from caring for her sister, that prevented volunteers from bringing food to families too ill to feed themselves and who starved to death because of it, that prevented trained nurses from responding to the most urgent calls for their services. The fear, not the disease, threatened to break the society apart. As Victor Vaughan—a careful man, a measured man, a man who did not overstate to make a point—warned, “Civilization could have disappeared within a few more weeks.”

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. Leadership must make whatever horror exists concrete. Only then will people be able to break it apart.

* The 1918 strain was called 'Spanish flu' at the time, and is called this in lazy recent books, just because the Spanish government didn't ban media coverage of it. But it was probably of American or Chinese origin.

** "Ah", you say, scholarly, "but the end of the First World War set up the conditions for the Second. So we should add some of the deaths of the Second to the First".
Barry has you on this: he speculates that Woodrow Wilson's bizarre behaviour at the treaty negotiation - where he contracts the flu and then suddenly changes his entire platform, giving in to Clemenceau's sadism - is the result of influenza's mental degradation:
...the virus sometimes caused one final complication, one final sequela. The influenza virus affected the brain and nervous system... The connection between influenza and various mental instabilities seemed clear... Menninger spoke of the “almost unequalled neurotoxicity of influenza” and noted that two-thirds of those diagnosed with schizophrenia after an attack of influenza had completely recovered five years later. Recovery from schizophrenia is extremely rare, suggesting that some reparable process had caused the initial symptoms.

A 1996 virology textbook said, “A wide spectrum of central nervous system involvement has been observed during influenza A virus infections in humans, ranging from irritability, drowsiness, boisterousness, and confusion to the more serious manifestations of psychosis, delirium, and coma.”...

The 1918 virus did seem to reach the brain. The war fought on that battlefield could destroy brain cells and make it difficult to concentrate, or alter behavior, or interfere with thinking, or even cause temporary psychosis. If this occurred in only a minority of cases, the virus’s impact on the mind was nonetheless real. But that impact would, by terrible coincidence, have a profound effect indeed...

...[Wilson's physician] wrote a confidential letter to be hand-delivered: “The President was taken violently sick last Thursday. He had a fever of over 103 and profuse diarrhoea... [It was] the beginning of an attack of influenza. That night was one of the worst through which I have ever passed. I was able to control the spasms of coughing but his condition looked very serious.”...

Then, abruptly, still on his sickbed, only a few days after he had threatened to leave the conference unless Clemenceau yielded to his demands, without warning to or discussion with any other Americans, Wilson suddenly abandoned principles he had previously insisted upon. He yielded to Clemenceau everything of significance Clemenceau wanted, virtually all of which Wilson had earlier opposed.

Now, in bed, he approved a formula Clemenceau had written demanding German reparations and that Germany accept all responsibility for starting the war. The Rhineland would be demilitarized; Germany would not be allowed to have troops within thirty miles of the east bank of the Rhine. The rich coal fields of the Saar region would be mined by France and the region would be administered by the new League of Nations for fifteen years, and then a plebiscite would determine whether the region would belong to France or Germany. The provinces of Alsace and Lorraine, which Germany had seized after the Franco-Prussian War, were moved from Germany back to France. West Prussia and Posen were given to Poland—creating the “Polish corridor” that separated two parts of Germany. The German air force was eliminated, its army limited to one hundred thousand men, its colonies stripped away—but not freed, simply redistributed to other powers.

Even Lloyd George commented on Wilson’s “nervous and spiritual breakdown in the middle of the Conference.”

Four months later Wilson suffered a major and debilitating stroke. For months his wife and Grayson would control all access to him and become arguably the de facto most important policy makers in the country.

Influenza did visit the peace conference. Influenza did strike Wilson. Influenza did weaken him physically, and — precisely at the most crucial point of negotiations — influenza did at the least drain from him stamina and the ability to concentrate. That much is certain. And it is almost certain that influenza affected his mind in other, deeper ways.

Historians with virtual unanimity agree that the harshness toward Germany of the Paris peace treaty helped create the economic hardship, nationalistic reaction, and political chaos that fostered the rise of Adolf Hitler.

PS: Mostly unimportant corrections by a virologist here. Reply to these from Barry here.