The Great Influenza
By John M. Barry
The 1918 influenza pandemic which
began in Kansas
and killed an estimated 100 million people world-wide in a 24 day period is
examined in great detail in The Great Influenza by John M. Barry. Although this is an extensively researched
book with a tremendous amount of medical and scientific information it is never
boring. This is a story which could have
been as sleep-inducing as an M-1 Histology lecture but has the pace of a
Grisham novel and the suspense of any best-selling mystery. In the Prologue Mr. Barry describes his book
as “a story of science, of discovery, of how one thinks, and of how one changes
the way one thinks.” The lessons learned
in the early 1900s are very appropriate to be reviewed a century later.
The story is divided into ten
sections. The first “The Warriors” is an
overview of American medicine as it existed in the late 1800s and how it was
revolutionized mainly by William Henry Welch and the Johns Hopkins
Medical School
and research laboratories. Dr. Welch
almost single handedly changed American medicine from a field not far removed
from the practices of Hippocrates to a rigorous, science based investigative
discipline. Welch, along with William Halsted
at Hopkins and Simon Flexner of the Rockefeller Institute brought American
medicine into the modern age and enabled the medical response to the 1918
Influenza epidemic.
The following sections “set the
stage”. Section two (“The Swarm”) is a
very succinct course on virology, directed to the layman and appreciated by
this reviewer who is very deficient in his knowledge of infectious disease. “The Tinderbox” explains the social and
geopolitical factors which contributed to the situation which became the
perfect storm for a pandemic. The U.S
entrance into the Great War precipitated a number of amazing
circumstances. For those appalled by the the George W. Bush administration's Patriot Act and its potential for restriction of personal freedoms,
Woodrow Wilson’s Sedition Act looks like downright fascism. The Sedition Act was responsible for the
imprisonment of anyone who spoke or published words questioning the federal
government. This Act was eventually
upheld as constitutional by none other than Chief Justice Oliver Wendell
Holmes. This law essentially put a lid
on any accurate reporting of the flu epidemic.
The facts were thought to be detrimental to public morale and the war
effort. The conscription of most men between 18 and 45
years of age created crowded conditions in training camps, again creating a
situation ripe for rapid dissemination of infectious disease. Physicians were secretly “graded” by local
medical societies and the best physicians and almost all nurses were rapidly conscripted
into the army and sent over seas, leaving the medical care of the citizenry to
older physicians, trained prior to the era of scientific method and regarded as
“inferior”. The Rockefeller Institute
was transformed into “Army Auxiliary Laboratory Number One” and entire medical
school faculties were sent as units to Europe.
The ensuing sections of the book
documents the incredible spread of the disease and the terrible ferocity with
which it struck, especially in younger patients. At one point at Camp Pike in Arkansas, for instance,
13,000 out of 60,000 soldiers were simultaneously sick with influenza. The death rate among young adults approached
40% and often people woke up feeling fine, had an acute onset of symptoms and
were dead within twelve hours.
The modern laboratories established
by Welch at Hopkins, Victor Vaughan at Michigan, Charles Eliot at Harvard and
William Pepper at Penn as well as Oswald Avery at the Rockefeller Institute,
William Park and Anna Williams (virus experts) at the New York City Department
of Public Health and Paul Lewis in Philadelphia were all in a race to identify
the pathogen responsible for this pandemic and, if possible, develop a vaccine
to treat and prevent the disease. The
desperation caused by the presence of death all around them, including within
the ranks of their own laboratory workers produced a frenetic research
response. The work produced in 1918 is
still evident today. Pfeiffer discovered
the “Influenza Bacillus” (what we call H. Influenza today) which was the
bacteria responsible for the rapid demise of the younger patient
population. Avery developed the
“chocolate agar” growth medium to expedite growth and identification of H. Influenza,
which clarified the role of this pathogen in the pandemic. Many of the deaths were in fact due to secondary
overwhelming bacterial pneumonias and what we recognize today as acute
respiratory distress syndrome.
The concluding sections of the book
deal with the aftermath of the pandemic.
The repercussions were felt in every segment of society and in every geographic
location. An interesting historical
footnote is that Woodrow Wilson succumbed to influenza during the negotiations at
the end of World War I. After two week
convalescence, Wilson
backed off of all of his previous demands, conceded to the French and stripped Germany of
territory, its army, and crippled its economy.
The author hypothesizes that Wilson
was suffering from post-influenza psychosis or mental disturbance and quotes
Lloyd George as saying “Wilson
suffered a nervous and spiritual breakdown in the middle of the Conference (the
Paris Peace Commission).” Barry
concludes: “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.”
The flurry of research activity
during and following the pandemic led to the discovery by Avery that the
substance that transformed a pneumococcus from one without a capsule to a more
virulent one with a capsule was DNA. A
report from Avery, MacLeod and McCarty titled “Studies on the Chemical Nature
of the Substance Inducing Transformation of Pnuemococcal Types. Induction of Transformation by a
Desoxyribonucleic Acid Fraction Isolated from Pneumococcus Type III” was
published in the February 1944 Journal of Experimental Medicine. This report demonstrated that DNA carried
genetic information, that genes lay within DNA.
This report was the direct result of Avery’s years of research into the
cause of the 1918 influenza pandemic.
This information inspired many scientists, including James Watson and
Francis Crick to determine the structure of DNA. Watson wrote in The Double Helix: "Avery
gave us the first text of a new language; or rather he showed us where to look
for it. I resolved to search for this
text.” Barry observes: “In fact, what
Avery accomplished was a classic of basic science. He started his search looking for a cure for
pneumonia and ended up opening the field of Molecular Biology.”
The author concludes by warning
that although medical science has made incredible strides, the stage could be
set for another pandemic. Overcrowding
in urban areas, poor hygiene and sanitary conditions in third world countries (as
well as American inner cities) and the “shrinking of the planet” by
international travel all contribute to a situation where a virulent new virus,
should it occur, could spread rapidly.
The severity of a pandemic similar to “The Great Influenza” would easily
and quickly overwhelm the world’s medical system. The World Health Organization has guidelines
in place to accurately assess risk of new diseases and promptly respond to that
risk. These lessons learned from the
1918 experience are largely responsible for the quick identification and
limitation of SARS (Severe Acute Respiratory Syndrome, a disease which spread
from animals to man in the spring of 2003).
Barry warns, however, that “Every expert on influenza agrees that the
ability of the influenza virus to re-assort genes means that another pandemic
not only can happen, it almost certainly
will happen.”
The Great Influenza by John M.
Barry is an excellent book and a tremendous compilation of data and information
on this timely subject.
