The Great Influenza

Pandemic: From Kansas to the World

John M. Barry, in his excellent book The Great Influenza, notes that it cannot be proven that the 1918 “Spanish” influenza originated in Kansas, but there is circumstantial evidence, and it sure didn’t originate in Spain. Why then was this influenza, which would kill an estimated 25-50 million people globally christened this? Because the press was muzzled in the US, mostly due to the war, but also because President Wilson did not want fear of the flu to keep young men from enlisting and serving their country. More would die at home, of the flu, than on the battlefield: 675,000 versus 115,000. A staggering difference. Only Spain, which was neutral during the war, kept its press free and open, and it warned of this deadly disease. So, it was dubbed the “Spanish flu.”

From one known case the influenza virus traveled to Camp Funston in Kansas in early 1918. Within three weeks 1,100 troops at Funston were hospitalized. From there it traveled fast and far. US troops were shipped to Boston. It spread quickly there. Troops were then shipped off to Europe: nearly 40% of the two million American troops who arrived in France disembarked at Brest, France. By early April, the flu had arrived there; later that month, it hit Paris and Italy. The British army recorded their first cases mid-April, and then… a full scale, raging pandemic. Even German troops in the field reported the devastating effects. General Ludendorff actually blamed the loss of one military initiative on the flu!

On June 30, 1918, the British freighter City of Exeter docked in Philadelphia, carrying influenza. But Rupert Blue, the civilian surgeon general and head of the U.S. Public Health Service, issued no instructions to the maritime service to hold influenza-ridden ships! Dozens of ill crew members were taken immediately to Pennsylvania Hospital, seemingly with pneumonia. When they died, two physicians publicly stated to newspapers that they had not died of influenza. They were lying. Why would health officials lie?

Politics. “Those in control of the war’s propaganda machine wanted nothing printed that could hurt morale. The disease did not spread,” Barry writes. So the disease continued to decimate soldiers as no war could. Soldiers continued to be shipped out, and with them, the real enemy–influenza.

All that summer of 1918 England, Scotland, and Wales reported surges in cases, and deaths. Denmark, Norway, Holland and Sweden. After a military transport arrived in Bombay, India, the number of cases soared. The virus hitched a ride on the railroads of India, and soon it reached Shanghai. New Zealand and Australia in September; and Barry reports that 30% of the population of Sydney became ill. But the disease was rather mild still; in the French army, fewer than one hundred deaths resulted from 40,000 hospital admissions. The journal The Lancet (so named after the blood-letting device) published a report that perhaps this was not even influenza! The disease was fatal within 24-48 hours, which didn’t match what was known about influenza then. And it was noted that in Louisville, Kentucky, 40% of those who died were aged 25-35; usually the flu hits the most vulnerable: the very young, the very old and the sick. What was this disease?

True in 1918, as in today

Then, oddly, it was gone. On August 10, the British high command announced the end of the epidemic. Life started returning to normal. Churches opened, schools started. People stopped wearing face coverings, and avoiding one another.

But the virus was not gone. It had only retreated, quietly mutating, like a stealthy enemy revising its attack strategy. On the same day the British army declared the pandemic over, French sailors stationed at Brest were hospitalized with influenza and pneumonia in such vast numbers that they had to close the naval hospital. The influenza virus, like many other pandemics, was mutating. And it was mutating into a killer of unimaginable proportions.

Next week: The world at war, the treatments, the outcome.

1918: The Perfect Storm

The year 1918 became a perfect storm of war, disease, advanced medical science, leadership–and lack of leadership. A pandemic about to strike, with rich, fertile breeding grounds in army barracks as America geared up for war. A government that downplayed the pandemic; American medical experts at long last, after America had lagged so far behind in medical science compared to Europe. A nation afraid.

John M. Barry, in his book The Great Influenza, provides a thrilling look into the gathering storm. He writes that throughout the history of war, more soldiers would die of disease than in battle or of wounds. And war was already underway. World War I (called The Great War then) began in 1914. The US was famously isolationist, preferring to stay out of other countries’ problems. Even in 1915, when the Germans sank the Lusitania, President Woodrow Wilson wanted to remain neutral. Even in 1917, when Germany announced submarine warfare against neutral and merchant ships. But then came the Zimmerman note, where Germany proposed that Mexico join her in war against US. Wilson rose to leadership: he spoke of America as “born to exemplify the elements of righteousness derived from Holy Scripture.”

What followed next set the stage for enormous failings in America for the pandemic that would soon strike. A lockdown on freedom of the press: Wilson controlled freedom of speech; Attorney General Thomas Gregory instructed the Library of Congress to monitor what books people read. A New Sedition Act made it punishable by 20 years in prison to speak or write anything “disloyal, profane, abusive towards the US government.” States outlawed teaching German; sauerkraut was even renamed “Liberty cabbage.” Postmaster General Albert Sidney Burleson refused to deliver any periodical he thought unpatriotic or critical.

People were encouraged to turn each other in for being unpatriotic. Wilson virtually nationalized the railroad industry; forced factories to produce war materials. Wilson created a Committee on Public Information, which demanded 100% patriotism. Any song that hurt patriotism was banned. And the press was carefully monitored and allowed to print only carefully selected facts. Barry writes, “Fear was ‘an important element to be bred in the civilian population. It is difficult to unite a people by talking only on the highest ethical plane. To fight for an ideal, perhaps, must be coupled with thoughts of self-preservation.’” This would have a huge impact later, when the pandemic struck.

Meanwhile, the government also mobilized nurses and doctors into the army, leaving the civilian public health system weakened. Recall from last week that American medicine had only just finally become modernized, thanks to the establishment of the Johns Hopkins Institute. In 1914, there were only 140,000 physicians in US; and of them, only 776 served in military. Now, even the military medical system wasn’t very equipped. Congress did not give “a penny” to the army medical department. Barry cites one camp of 60,000 soldiers had no microscope.

Wilson did make a wise decision by asking the amazing Dr. William Welch and Johns Hopkins University to help with war-related research. Welch is often called the “Dean of American Medicine,” and had helped it become science based. He had been first dean of the Johns Hopkins School of Medicine and was also the founder of the Johns Hopkins School of Hygiene and Public Health, the first in the country–this would play a huge role in combatting a pandemic. Now at 67 years old, he was needed more than he could know. It seemed all his life was preparing for this moment. But on opening day of the school he founded, October 1, 1918, he felt ill and could not attend. He had just returned from examining a strange, devastating epidemic.

Dr. William Welch

And the war machine revved up: a shortage of nurses for civilian hospitals; the press muzzled; an army expanding from a few tens of thousands of soldiers to millions in a few months. And where to put them all? In huge camps, in tents, each holding 50,000 men. Ready to be shipped to Boston, and then to the world.

And with them was an uninvited volunteer that would kill more than the war itself, ready to take advantage of wartime, of the bitter cold winter, of lack of freedom of the press, the reduced civilian nurses and doctors… influenza. A pandemic during a perfect storm.

Next week: The pandemic.

The Great Influenza 2: American medicine finally catches up

These are notes taken from John Barry’s excellent book The Great Influenza. It’s a fascinating study in what is still the worst pandemic in history to strike humans. There are so many comparisons one can make to what is happening now—although I see so many on social media drawing the wrong conclusions about pandemics and how to protect against their spread. The amazing thing about the Spanish flu of 1918 is how its arrival happened at a great confluence of science, medicine and personalities.

Barry writes that the revolution of modern science and medical science began as science focused on what to how. In other words, methodology, research, empirical evidence. For most of history investigators into science relied too much on reason, on their own minds. They could know something if their logic followed a sound premise. Their premises were based primarily on observation. For example, I recall reading in another book on medical history how infusing an irrational, out-of-control man with calf’s blood should make him calm, because a calf was gentle by nature. (Probably it calmed him, right to his death)

This belief in reason alone actually blinded us. For 2,500 years medicine made almost no progress. The Hippocratic texts relied on passive observation and active reasoning, not scientific testing method. Doctors believed that natural processes should not be interfered with.

But in 1798, experimentation and methodology started to take root. The English doctor Edward Jenner, after overhearing a milkmaid say that she couldn’t get smallpox because she had had the cowpox, experimented with cows, and found that exposure to cowpox immunized one. Though this had been known in China and India for years, what made this a stand-out was his methodology and rigorous testing.

But this was late to come to the US. Dr. Benjamin Rush in Philadelphia, one of our premier physicians, still applied the observation method. He was advocate of venesection! (Read: “bleeding”) Meanwhile Pierre Louis (of the French School 1800-1850) created for first time a database by comparing cases. Disease began to be seen as something that entered the body, and not as something wrong with the blood. We so take this for granted now, but then, this actually was not realized till the mid-1800s.

Paris was the medical Mecca then. In 1853 Dr. John Snow applied mathematics as an epidemiologist, observing the cholera outbreak in London, and gathering data by going door to door, and interviewing the families of the dead—and basically gave birth to public health. (He also used anesthesia on Queen Victoria, when she gave birth to her ninth and last child! And we know she is the carrier of the “Royal Disease” –aka hemophilia) Only in 1830, did physicians began using a microscope in Europe. The Germans used it the most. In fact, Dr. Jacob Henle was the first to formulate the modern germ theory.

Johns Hopkins

Medicine was evolving and not soon enough. And not fast enough in America. We lagged behind Europe in all things medical. But that soon changed.

In 1873 Johns Hopkins, American entrepreneur died, and left a trust of a staggering $3.5 million to found a university and a hospital. He and his trustees were Quakers, and they decided to model the new institution after German universities. It opened in 1876 and by 1914 the American medical science caught up to Europe.

And it was just in time. A viral juggernaut was about to strike the US, and then, the rest of the world.

Next week: the Spanish flu starts in Kansas.

The Great Influenza

I always believe we can learn so much from history, and that’s one reason I enjoy reading about history so much, especially medical history. This is incredibly relevant now, as the pandemic dominates the news, and our lives.

A few years ago, I read a great book called “The Great Influenza,” by John M. Barry (Penguin Books, 2004). I decided to reread it, since so many people on social media are making comparisons to coronavirus and the Spanish influenza pandemic of 1918, particularly in how our government is handling it.

Tonight, I just want to set the stage for the pandemic. It’s incredible to see how far we have come medically since the early 1900s.

First, know that the Spanish flu to this day remains the worst disease in history. Nothing can compare, not HIV, not COVID-19. From just 1918 to 1920 from 21-50 million would die from it. It’s estimated that 8-10% of all young adults then living may have been killed by it.  

What I love about this book is that it’s also the story of science, and how our thinking changes in response to a medical crisis. We’re watching that in action even now, as politicians, physicians, the nightly news and even our own friends now social media battle it out for what are the right approaches to take.

First—and this is incredible–medicine was not held in high esteem in the US. Barry reports that as late as 1900 only 20% of medical schools required a high school diploma! Almost anyone could call themselves doctor. Most medical students attended lectures, took one test, and never even saw a patient until they started practicing.

Barry notes that when Union Surgeon William Hammond stopped the use of violent purgatives (to rid the patient of “bad humors” like bile), he was court martialed and condemned by American Medical Association! No institution supported any medical research, and at Harvard, one professor of surgery admitted most medical students could barely write! Harvard president Charles Eliot realized the entire medical system had to be updated and improved.

And so began a movement to improve the American medical system. To whom did we look? Europe. The best medical institutions in the world were in Germany and France.

And so on September 12.1876, Johns Hopkins University was founded to change the way medicine was researched, delivered, and taught in America. If you watch CNN, you’ll note in the right hand margin that its daily statistics on COVID-19, including number of cases and number of deaths, is from Johns Hopkins University.

Thomas Henry Huxley

During the opening celebration, keynote speaker and English scientist Thomas H. Huxley, said, “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.”

It’s unfortunately not what many people are doing these days: accusations of misleading the public for political gain are tossed around from the CDC to the White House to news outlets, leaving us confused and anxious. Huxley would rather we listen and learn with open minds. And we can learn from the Spanish flu pandemic. To be continued next Sunday…

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