The Great Influenza - Book Summary

Unveiling the hidden horror of the 1918 flu pandemic

Imagine a malady so rapid and lethal that it overshadows the horrors of any plague humanity has known. That's precisely what unfurled in 1918 when a virulent influenza pandemic scythed through the populous, claiming lives with a ruthlessness that made medieval pandemics pale in comparison. In a mere year, it snuffed out more lives than the Black Death had in a century. Even more startling, its fatality count in just 24 weeks exceeded the number of deaths AIDS caused over 24 years.

But the story of this pandemic isn't merely about a deadly virus. It's also a tale of government oversight — and oversight — which took turns exacerbating the tragedy. As much as the influenza strain itself, bureaucratic blunders played a part in the staggering death toll.

As we step back in time to revisit this somber chapter, we'll unravel more than just grim statistics. We'll explore the essence of influenza, dissect why this particular strain was so fatal, and confront the grim reality that even the collaborative might of the world's scientific elite couldn't forestall the staggering loss of life.

Throughout this journey, you'll uncover surprising facts like:

- how, at one point in history, Harvard was considered a subpar institution for medical study,

- why a quiet farming area in Haskell, Kansas, remains etched in medical notoriety, and

- the chilling possibility that influenza may have inadvertently paved the path for Adolf Hitler's ascendancy in Germany.

American medicine's journey from obscurity to excellence

Let's take a step back to a time when "First, do no harm" — the core principle from the Hippocratic oath was first spoken. This ancient directive has echoed across centuries, but the practices it oversaw evolved at an astonishingly sluggish pace. Imagine a world where bloodletting and leeching, based on the antiquated belief of balancing bodily humors, were standard medical treatments well into the 1800s. Science, despite its strides, seemed to leave medicine in the proverbial dust.

And yet, the nineteenth century broke European medicine out of ancient rituals and saw it stride boldly into groundbreaking discoveries, such as Robert Koch's momentous demonstration in 1883 that diseases could be traced to germs. America, comparatively, trailed in these advancements — but not for long.

Here's the crux of the matter: As the world edged toward World War I, American medical science experienced a renaissance, inching ever closer to the vanguard of global medicine.

Enter the Johns Hopkins hospital and university in 1873, their establishment bankrolled by the late magnate Johns Hopkins' staggering bequest of three and a half million dollars. With a mission to become a lighthouse of medical excellence in America, where once the system lagged, incentivized more by profit than proficiency, the era ushered in by this institution marked a sea change.

Reflect, for a moment, on the state of Ivy League stalwarts like Harvard, where, as recently as 1870, academics were so lax that a student could clinch a medical degree despite failing a majority of their classes. Johns Hopkins raised the stakes — recruiting top-tier talent from German medical schools and fostering a culture of innovation and excellence. At the forefront was William Welch, an intellectually magnetic figure who led the charge of research at Hopkins.

The rise of Johns Hopkins did not go unnoticed. John D. Rockefeller, ever intent on cementing his own legacy, founded the Rockefeller Institute in 1901, which swiftly garnered prestige thanks to significant financial investment. 

The efforts of these institutions catapulted American medicine into an unprecedented epoch of quality, reaching parity — and in some aspects surpassing — European medical practice by the time the First World War loomed.

The capstone for Welch's illustrious career materialized in the shape of a public health school dedicated to preventing diseases, which he launched at Hopkins on the October 1, 1918. Ironically, on this day of inauguration, Welch was bedeviled by a worrisome cough and a pounding headache — symptoms of an ailment he'd recently encountered in the throes of an epidemic in the Northeast. His suspicion? A new and virulent strain of influenza was on the horizon.

The relentlessness of influenza in outsmarting human defenses

Picture the influenza virus — an entity far tinier than the eye can see, yet it possess a harrowing dexterity in breaching our body's defenses. It insinuates itself into our cells, hijacks the very machinery meant to sustain life, and turns it into a virus factory. All while William Welch sat unassuming, en route from Boston, the virus was an unseen stowaway, poised for proliferation.

Here lies the stark reality: Influenza is a master of disguise, continuously adapting to hoodwink our immune systems.

Once this viral invader inserts itself into human cells, it commandeers the genetic blueprint, commandeering the cells to churn out masses of new virus particles. These countless replicas are the orchestration of influenza's single, driving purpose — to replicate and colonize new hosts.

But influenza's true menace stems from its propensity for mutation. Unlike DNA, which carefully proofreads each replication to maintain genetic integrity, influenza's RNA genome is prone to errors during copying. Seemingly a flaw, these mutations are actually evolutions in disguise; even a single change can dramatically enhance the virus's infectious capabilities.

And so, influenza virus traverses the spectrum of its hosts, from the wild aquatic birds of its ancestral roots to the unsuspecting swine, and ultimately on to human beings.

Fortunately, we mammals are not utterly at the mercy of this microscopic usurper. Our immune system stands vigil with a phalanx of defenses, including the valiant dendritic white blood cells. These sentinels not only confront invaders but also serve as educators, instructing the immune fleet on which antigens to seek and subdue.

Yet, influenza wages a relentless campaign of molecular innovation, probing and testing against our immune defenses, seeking the formula that will allow it to leap across species barriers and infect with savage efficiency.

When a brand-new strain of influenza customizes itself to infect humans, the stakes are sky-high. Without previous encounters to prime our immune responses, a fresh influenza variant can sweep through populations unchecked — this is the drumbeat of pandemics. The 1918 outbreak loomed as a chilling testament, a scenario where humanity was unprepared to face an unfamiliar viral adversary with deadly results.

The unintentional breeding ground for a pandemic amid war efforts

In the twilight of a World War I ravaged year of 1918, the specter of death was no stranger. Rampant bloodshed had scarred Europe, and the human cost of trench warfare left an indelible mark of suffering. The United States, though slow to join the fray, embraced the war with a fervor once President Woodrow Wilson pledged his commitment to defeating Germany. Every societal sector was galvanized to serve this purpose, pulling men from the fabric of ordinary life to the frontlines via an extensive draft.

What transpired was a confluence of factors that unknowingly set the stage for viral dissemination:

By thrusting together millions of individuals from disparate corners of the nation into overcrowded military camps, America inadvertently created a melting pot of varying immune systems. This unprecedented gathering of humanity laid the foundations for a veritable viral feast.

Beyond the military, the magnet of lucrative war-time factory jobs drew countless rural dwellers to city life, cramping them into squalid living conditions ripe for disease transmission. The stage was inadvertently set for when the influenza virus struck with its full might.

Yet, amidst the chaos of war, there was an inadvertent boon for medical research. Injected with substantial funding, the Army looked towards science with hopes of staving off afflictions that could diminish their fighting force. The Rockefeller Institute, now the Army Auxiliary Laboratory Number One, was on the brink of pioneering a serum against pneumonia, which often proved fatal during influenza infections.

Keeping a watchful eye on troop concentrations, the surgeon general's concerns of a looming pandemic were assuaged by the belief that, with a pneumonia serum close at hand, the threat posed by influenza was less daunting.

But as events would soon reveal, the true impact of the influenza virus was vastly underestimated — a miscalculation that would lead to consequences more dire than any could foresee.

The deceptive calm before a lethal storm

Amid the biting winter of 1917-18, the people of Haskell County, Kansas, braced against the icy winds that were routine in their lives of toil and seclusion. Little did they know, their remote county was ground zero for a virus that would soon transcend its avian origins to carve a deadly path through humanity. By spring, the virus arrived at Camp Funston, finding fertile ground within the camp's 56,000 men before following American soldiers to Europe — thus igniting its transcontinental odyssey.

Initially, the virus cut a familiar profile, mimicking the seasonal flu in its spread. However, its second act would unleash a horror hitherto unseen:

The virus, benign at first, gained notoriety as the "Spanish Flu," a misnomer born out of Spain's neutral stance in the war, which allowed uncensored reporting on the outbreak. Following a brief intermission where infections waned, British officials prematurely declared the epidemic quelled. But the virus, ever mutable, was silently honing its virulence.

Mutations optimize a virus's reproducibility — and the 1918 strain had cultivated a lethality that began to unsparingly claim lives. When the second wave crashed ashore, the symptoms were no longer just typical of influenza; they were the stuff of nightmares. The afflicted suffered grisly symptoms, their skin transmuting into shades of blue and black, signaling an oxygen-starved body in distress.

Camp Devens, an Army base near Boston, became a gruesome tableau of the pandemic's ferocity. A facility meant for 1,200 patients swarmed with five times that number. Despite the dire situation, myopia plagued the command; troop movements persisted unperturbed, unwittingly escorting the deadly passenger to new territories.

William Welch, now titan of American public health, was summoned from the sanctuary of Johns Hopkins to spearhead an urgent scientific crusade against the advancing pathogen. Yet, faced with this virulent menace, Welch encountered the stark reality of the unknown; there was no immediate answer, no ready defense at hand. Ironically, in the throes of the Devens outbreak, Welch would find himself besieged by the very contagion he sought to thwart. Forced to step away from the fray by illness, he watched the medical establishment he had sculpted navigate the maelstrom without him.

Collapse and chaos: The devastating second wave of 1918's influenza

In early September 1918, Philadelphia unwittingly played host to a grim harbinger as 300 soldiers from Boston carried a lethal stowaway — a strain of flu poised to wreak havoc. Within a week, hundreds were hospitalized, and a clear uptick in illnesses was evident. The city, already heaving under the weight of overcrowded habitats and ceaseless war production, stood on the brink of an abyss.

The city's public health director, Wilmer Krusen, found himself at a crucial juncture, fully cognizant of the escalating crisis, not only in Philadelphia but across other military camps and cities as well. Yet, his response was one of alarming inaction:

Blinded by the perceived imperative of maintaining morale and contributing to the war effort, Krusen prioritized propaganda over public welfare. While the specter of influenza loomed large, the city's officials remained in a state of dangerous denial.

Planned as a beacon of patriotism, a large parade scheduled for September 28 was to march through Philadelphia's streets. Despite fervent protests from the medical community, the event went ahead, drawing an audience of more than 200,000 — all reassured by officialdom of their safety.

The flu's incubation period set a ticking clock, and within two to three days of the parade, the virus declared unequivocally that it was indeed within the city's walls. As hospitals buckled under a surge of patients and death claimed more and more citizens, the cityscape descended into one of desperation and dread. Corpses, some left in the beds where they drew their last plagued breath, bore witness to the unmanageable scale of the catastrophe.

Meanwhile, the Army's surgeon general's forewarnings after the Camp Devens outbreak echoed across military camps. Yet, the same fatal concoherence pervaded, with commanders like those at Camp Grant in Illinois dismissing the urgency, conducting business as usual until the cruel toll of the disease forced a disastrous reckoning.

In less than a week, the bedridden count at Camp Grant's hospital soared. Each day saw a fresh wave of sickness — in one instance, 1,800 troops succumbed in mere hours.

Confronted by the grim results of his oversight, the commanding officer at Camp Grant chose to take his own life — a tragic end that, nonetheless, could not halt the relentless march of the virus.

The lethal paradox of a young and robust immune response

In the cruelest twist of fate, the 1918 influenza spared many, yet it chose to unleash its full virulence on the most unexpected demographic. Departing from the predictable patterns of flu casualties, which typically counted the very young, the elderly, and the immunocompromised among its primary victims, this strain targeted the young, the vigorous, those in the zenith of their lives.

Here's the heart of the matter: The 1918 flu struck with speed and savagery, singling out the young and robust.

Pregnant women, too, were alarmingly vulnerable, finding themselves among the ranks of those blindsided by the ferocious attack. It was not so much the virus itself that sealed their fates but the ferocity of their bodies' defenses. The immune system, in its earnest effort to thwart the viral usurper, unwittingly filled the lungs with fluids and cellular debris, smothering the breath of life out of its host. Death, often, was startlingly swift — claiming lives within mere hours of the onset.

Harvey Cushing, a surgeon and future victim of the flu, poignantly dubbed these untimely dead as "doubly dead," their youth snatched away before its prime.

Victims endured a torment beyond mere sickness — the high fevers, the delirium, and for some, the chilling hallmarks of impending doom: the creeping onset of cyanosis, their skin a telltale blue, the grim harbinger of their last breath.

The toll was staggering; more U.S. military lives were claimed by influenza than the entirety of the Vietnam War. Yet, in a comparative sense, America's casualty count was modest. Its population had already weathered flu storms of previous seasons, girding them with some semblance of immunity, leading to pneumonia in only 10 to 20 percent of flu cases.

In stark contrast stood the remote corners of the world — untouched by prior flus, their virgin immune systems offered no resistance. Here the influenza spawned pneumonia in over 20 percent of cases, ravaging communities. Western Samoa grieved a grim statistic: 22 percent of its population perished in the pandemic's wake.

The scientific community's race against an elusive enemy

When the 1918 flu pandemic unfurled its dark wings across America, the nation's top scientists were neither dismissive nor dilatory; they understood the gravity of the crisis at hand. With alacrity, they embarked on a quest to untangle the mysteries shrouding the virus, their dedication to the pursuit of answers a stark contrast to the political landscape of the time.

Faced with an enigmatic pathogen, they could claim only scarce common ground:

They recognized that the flu traversed the air, latching onto susceptible hosts in congested spaces. They were aware, too, that its transmission wasn't limited to breathing alone; an innocent touch to the face could invite infection just as easily. But even armed with these insights, they hit a wall of apathy. Their warnings fell on deaf ears, frequently disregarded by officials more concerned with other matters, even the surgeon general.

With a crisis advancing at full tilt, the foremost challenge confronting America's scientific community was to ascertain the virus's origin:

Pioneering this endeavor were some of the brightest minds of the time — Oswald Avery from the Rockefeller Institute, William Park and Anna Williams from the New York City Department of Public Health, and Paul Lewis of the University of Pennsylvania.

Charting the way forward, they leaned on the hypothesis by renowned microbiologist Richard Pfeiffer, who once linked influenza to the bacterium Bacillus influenzae during an earlier pandemic. Park and Williams, too, staked their bets on this bacterium, their experiments seemingly corroborating its culpability. As death's shadow fell just beyond Lewis's laboratory in Philadelphia, the trio urgently piecemealed together a vaccine.

Yet Avery, a scientist of meticulous method, harbored deep-seated doubts. His probing at Camp Devens couldn't reliably trace the illness back to B. influenzae. To reach a definitive conclusion, he needed more evidence, more time – luxuries the pandemic did not afford.

As they pressed onward in their scientific crusade, the toll of the pandemic mounted relentlessly.

Tragic consequences of governmental neglect during a global crisis

The 1918 influenza pandemic was ruthlessly efficient, a viral tempest that knew no boundaries and spared no quarter once it had made its transition from birds to humans. Unhindered, it spread across the globe, leaving devastation in its relentless wake.

There were junctures, critical moments where strategic action by the U.S. government could have mitigated the relentless onslaught of the virus — moments that were tragically missed:

Slowing the virus's march could have unclogged the overwhelmed hospitals, potentially offering better care to those afflicted and reducing transmission to caretakers and loved ones. President Woodrow Wilson, however, remained conspicuously silent on the pandemic, his attention riveted on World War I to the detriment of a domestic crisis that demanded urgent leadership.

The lapse in leadership ran deep: In late September 1918, Army Surgeon General William Gorgas sounded the alarm, imploring the halting of troop movements to curb the spread of influenza. These entreaties fell on deaf ears; the war effort trumped all concerns as fresh troops continued their transatlantic passage to Europe, unwittingly transforming their ships into floating tombs.

Wilson's inattention to his troops' plight was mirrored in his inaction toward American civilians. Surgeon General Rupert Blue rebuffed pleas for research funding that could have advanced the fight against pneumonia, a frequent and fatal complication of the flu, because it was not seen as "immediately necessary."

The toll of this neglect wrought havoc. The medical field was gutted, with civilian hospitals understaffed or closed, their medical professionals succumbing to the illness alongside — or even in excess of — the general populace.

Philadelphia became emblematic of the pandemic's ruthless efficiency. The city, already grappling with the demands of war, was besieged by the virus. At the peak of the pandemic, death seized close to 800 lives in a single day, with the weekly fatality count skyrocketing from an average of 400 to 4,500.

As the City of Brotherly Love battled this unseen enemy, haunting cries echoed through its streets — calls for residents to lay their deceased out, a grim reminder of the lethal cost of the government's paralysis in the face of a clear and present danger.

The waning of a pandemic and the immeasurable aftermath

The ferocious grasp of the 1918 influenza seemed invincible, yet it receded as mysteriously as it had arrived. In Philadelphia, where the outbreak had reached its harrowing apex, life began to resume its rhythm by the end of October, with the reopening of public spaces signaling a return to normalcy.

Two pivotal processes intertwined to quell the pandemic:

First, the wave of immunity began to crest. As the virus swept through communities, survivors were left with the remnants of resistance, a tempered shield against the virus that had traversed the globe. Within six to eight weeks of the initial onslaught, new cases started to drop precipitously.

Second, the virus itself was undergoing transformation. Each subsequent mutation wrestled with the impossibility of eclipsing the original strain's lethality, leading invariably to less virulent iterations. As a result, cities that encountered the flu later faced a less formidable foe.

At the heart of the matter is this sobering truth: The pandemic subsided, yet comprehending the full breadth of its impact remains a daunting task.

For the afflicted who journeyed to recovery, their ordeal was not always the end. Lingering effects could ravage the brain and nervous system, driving lifelong mental affliction. This shadow fell across all strata of society, manifesting even within the upper echelons of global leadership:

Consider President Woodrow Wilson, who, in April 1919, became yet another statistic in the pandemic's reach. His illness precipitated a drastic shift, impairing his mental acuity and stability. Ill-fated paranoia gripped him, sowing delusions of espionage within his own walls. This mental unraveling shifted the trajectory of the peace talks that sought to conclude the First World War.

Compelled by weakness, Wilson capitulated to French demands, aiding in the imposition of punitive economic measures upon Germany — a catalyst for the turmoil and destitution that would eventually fuel Adolf Hitler's ascendancy.

The repercussions of the flu did not discriminate, its scythe cutting through the fabric of families, condemning thousands of New York City children to orphanhood. Initial studies postulated a global death toll of 20 million — a count that has since soared in estimations, with modern figures positing a staggering 100 million, representing over five percent of the global population at the time. The 1918 pandemic's legacy, it seems, is etched not just in history books, but in the very genome of our collective human experience.

The enduring scientific challenge in the shadow of the pandemic

Following the devastation caused by the 1918 influenza, scientists around the world were left grappling with the enormity of their failure. The pandemic eventually receded, burning itself out without any scientific intervention — a stark reminder of the limits of human knowledge and the enigmatic nature of viral diseases. The sentiments of the time were aptly summarized by a physician who equated their understanding of the flu with that of medieval doctors' knowledge of the Black Death.

However, for many in the scientific community, the end of the pandemic didn't spell the end of their quest. The search for a cure became a haunting obsession:

Haunted by the suffering they had witnessed, a cadre of scientists continued to dedicate their lives to unraveling the mysteries of the flu. The central puzzle was simple yet elusive: What was the real causative agent behind the influenza?

Park and Williams, once firm in their belief that the bacterium Bacillus influenzae lay at the root of the pandemic, eventually recanted their assertion. But as quickly as their change of heart occurred, their funding evaporated, and their fervent search for answers had to be abandoned.

Meanwhile, Lewis and Avery carried on. Avery poured decades into the research, and while he did not resolve the riddle of the influenza's origin, his labors eventually bore remarkable fruit. Upon his retirement in 1943, Avery presented a groundbreaking discovery — that DNA is the fundamental medium for the transfer of genetic traits. His work would become a cornerstone of molecular biology.

On the other hand, Lewis, steadfast in his conviction of the involvement of B. influenzae , was gradually blinded by his own dogmatism. His career, once marked by ingenuity, began to flounder as his later scientific endeavors fell short of his earlier acclaim. Desperate to reclaim his reputation, Lewis embarked on a venture to Brazil to study an outbreak of yellow fever — a mission that would claim his life in 1929.

Ironically, mere years after his demise, Lewis's lab culminated their efforts, demonstrating that antibodies from human survivors of the 1918 influenza could guard pigs against swine flu. This breakthrough ushered in a monumental achievement in 1933: the isolation of the virus responsible for human influenza. It was a discovery that, though posthumous, was rooted in the methodologies Lewis helped establish. The legacy of the pandemic and those who endeavored to decipher it, thus, endured far beyond the realm of their lifetimes.

Reflecting on the monumental struggle against the 1918 flu pandemic

The 1918 influenza pandemic was a testament to our vulnerability in the face of nature's most microscopic threats. Despite the concerted efforts of the era's brightest scientific minds, the pandemic ravaged populations globally, sowing destruction and despair on an unfathomable scale. Hindered by limited understanding and compounded by government inaction, the medical community found itself outpaced by the virus' relentless proliferation.

Today, the legacy of that pandemic underscores the critical importance of preparedness and innovation in medical science. While we have made strides with the widespread implementation of flu vaccines and more sophisticated virological research, the shadows cast by the events of 1918 serve as a sobering reminder of the potential for new pandemics to emerge — and the enduring need for vigilance, rapid response, and global cooperation to prevent history from repeating itself.