Just the flu

It was only the flu. That refrain recurs throughout John M. Barry’s exhaustive history of the 1918 influenza epidemic. While true, it’s also a horrific understatement, given the millions who died. Influenza killed more Americans in 24 weeks in the autumn of 1918 than have died from AIDS in 24 years. And it killed, in addition to the usual very young and very old sufferers, a disproportionate number of Americans between the ages of 18 and 30: the young, the strong, the people needed to run the country and the war.

Barry tells the story of the so-called Spanish flu (misnamed because of a publicized outbreak in Spain—he makes a reasonable case that it actually started in Kansas), but he goes beyond simple narrative to set the epidemic in cultural and political contexts. The development of modern scientific medical practices, which came relatively late to the United States, provides the lens through which he focuses on the epidemic.

But in Barry’s attention to the doctors and researchers who worked on influenza, he does not slight the stories of “regular people.” He details the horrors of the military encampments, with the sick, dying and dead young men piling up unattended; as well as tragedies in hard-hit cities, such as Philadelphia, where the corpses of flu victims were left in front of houses to be picked up by horse-drawn carts in an eerie flashback to medieval plague tales.

Barry also provides the best explanation of the physiology of influenza for the general reader that I’ve ever come across. The twin specters of antigen drift and antigen shift, combined with the ability to re-assort genes into new strains of the disease, are what make influenza so deadly that it continues to kill tens of thousands of Americans annually. Barry uses the metaphor of a football player changing uniforms (too lengthy to explain here fully, but it works) to clarify the way the disease works, and he details the unhappy consequences for humans unlucky enough to get a “hard” case of the flu.

But the medical and scientific contexts aren’t enough to explain why the pandemic of 1918 was so deadly, and it is in providing political and cultural contexts that Barry’s book is most timely. In 1918, America was led by a president with a single-minded—almost religious—dedication to victory in the Great War. At the time, dissent was punished far more severely than ever before or since; among those imprisoned for daring to speak out against the war was a U.S. congressman. Newspapers, the major source of information, voluntarily censored themselves, sacrificing the public’s right to know on the altar of “morale” and the war effort.

The result was that, in a populace provided with minimal—or deliberately false—information about the epidemic, fear became a major factor in the breakdown of stricken communities. Children were left to starve after their parents died, because neighbors were too frightened to take them in. Services broke down in city after city. Nurses refused to work. Soldiers died because their commanders refused to follow the quarantine recommendations of the surgeon general.

Barry even suggests that it was President Woodrow Wilson’s bout with the flu during treaty talks that led to his capitulation to Georges Clemenceau’s desire to adopt the punitive and disastrous Treaty of Versailles.

Did influenza ultimately bring about the rise of Hitler and World War II? It’s worth considering. And, in light of the current politicization of medicine in a variety of ways, from flu-vaccine shortages to stem-cell research, this book certainly raises some timely points. In a normal year, influenza kills more than 30,000 Americans. But it’s only the flu.