Book Review: The Great Influenza

I recently finished John Barry’s seminal work on the pandemic that spanned 1918-20, The Great Influenza.  Beginning in the spring of 1918, a new influenza began sweeping the globe, ultimately resulting in 35-100 million deaths globally and over 600,000 in the U.S.  The disease mistakenly came to be known as the Spanish Flu, but historians are relatively sure that it began on hog farms in Kansas.  By extracting tissue samples from frozen Eskimo corpse, we now know that the virus was the H1N1 virus, the same virus that re-emerged in a different strain as the Swine Flu in a pandemic in 2009.

Barry’s book is as much a tribute to a handful of doctors and scientists that dragged the practice of medicine in the United States into the 20^th century, sometimes kicking and screaming.  The men he commemorates, like William Henry Welch (who founded the Johns Hopkins School of Medicine), were truly remarkable individuals who made enormous contributions to the advancement of medicine, but ironically found themselves mostly powerless to stem the tide of the pandemic.

Barry narrates the course of the pandemic in excruciating, and frequently gruesome, detail.  It is not a read for the faint of heart or those with a weak stomach.

During the COVID-19 outbreak, there have been many comparisons of it to the 1918 influenza pandemic.  My take-away from the book is that while there are certainly many lessons to be learned from the previous pandemic, there also many important distinctions.

Here are some of the highlights:

• Many of the fatalities in 1918 were caused by secondary bacterial infections that invaded victims’ lungs after their immune system had been exhausted by the virus.  The estimates are that from 50-80% of the fatalities were caused by a secondary infection.  Of course, this was before the widespread use of antibiotics, so that outcome is unlikely to be repeated in this or any future viral epidemic. 
• Barry paints a very vivid picture of health facilities being overrun with patients – and the attendant horrific consequences.  In 1918, however, there was little healthcare workers could do for influenza patients except to attempt to keep them hydrated and nourished.  So, it is unclear whether the 1918 healthcare system being overwhelmed made much difference in the ultimate number of fatalities.  But today, with many therapeutic options (e.g., ventilators), the healthcare system being overwhelmed would significantly and unnecessarily increase the number of fatalities. 
• World War I and the actions of the U.S. Army, in particular, greatly accelerated the spread of the virus.  The early cases occurred in ridiculously overcrowded training cantonments.  The Army ignored the advice of its own doctors and moved troops from infected camps to other locations and ultimately to Europe.  Ships carrying troops then became vehicles to spread the virus across the globe, including neutral countries not involved in the war. 
• I found Barry’s views on various suppression measures, what he called non-pharmacological interventions (NPIs), to be somewhat conflicting.  In the book he chronicles the NPIs attempted in 1918, many nearly identical to the measures being implemented today.   But he mostly minimizes their effectiveness.  “So, NPIs, whether imposed by governments or taken by individuals, will have limited usefulness . . . , nonetheless, these NPIs are the only tools available.”  (p.455-6) He also opined that “surgical masks are next to useless except in very limited circumstances” [p.457] and that “closing borders would be of no benefit.” [p.456]  However, in a recent New York Times op-eds here and here and in a YouTube podcast, he seems to have greater faith in their effectiveness.  His somewhat different view appears to be based to some extent on that it appears COVID has a longer incubation period, which should make suppression strategies somewhat more effective.
• Another major difference between the epidemics was that the one in 1918 killed far more young adults. Part of the virus’ virulence, at least in the early going, was its tendency to set off a cytokine storm, in which the body’s immune system would over-react to the virus with such fury that it killed the tissue it was supposed to be protecting.  So far, over 80% of COVID-19 victims are elderly.  Epidemiologists have a concept of “years of life lost” compared to “lives lost.”  “Years of life lost” looks at the age of the victim compared to life expectancy.  By this measure, the 1918 pandemic had a far more tragic impact than the toll COVID-19 is extracting. 
• One of Barry’s themes that he very forcefully makes on several occasions in the book is the importance of candor from public officials about the epidemic.  In 1918, details of the epidemic were minimized by public officials and a compliant press because they felt it would hurt public morale in the middle of a war.  He has made the same point in his comments about COVID-19.  Barry’s criticism of those in 1918 seems a bit harsh to me, as it is made retrospectively with what we know now about what happened.  And while I do not purport to defend or criticize what any particular official has said about the COVID-19 outbreak, I think that we do not fully appreciate the “fog of war’ surrounding the outbreak now.

It is, of course, axiomatic that those who ignore history are doomed to repeat it, as Winston Churchill famously said.  But Samuel Clemmons’ quote may be more apropos in this case: “History doesn’t repeat itself, but it often rhymes.”  In other words, there are lessons to be learned from the 1918 pandemic, but every pandemic is unique.  The COVID-19 pandemic will not be a repeat of 1918.

Note: For the true historian, Barry spends a great deal of time discussing Woodrow Wilson and his reaction, or rather lack thereof, to the pandemic.  Barry believes that Wilson suffered an influenza infection during the Paris peace talks in 1919 and that the infection affected his behavior and the course of the negotiations.  [pp. 382-388]