The Great Influenza

Book by John M. Barry

We are living in crazy times. Things are out of whack in the political sphere, to put it mildly. On top of that, the pandemic has upended everybody's lives and the economy. People are dying as doctors grapple with a new disease, while many others are losing their jobs and livelihoods. I've heard some describe the current times as unprecedented.

But are these times unprecedented?

Is this the first time that a pandemic hits every corner of the world? Is this the first time people have had to stay at home? Is this the first time that a massive number of businesses had to close? Is this the first time people need to wear masks to go outside?

The answer to all these questions is "no." These are unprecedented times for everyone alive, but none of these things are new; they have all happened before. Face masks, social distancing, and business shutdowns were all part of the reality of 1918.

Spanish Flu

The last real pandemic was the great influenza of 1918. It was horrifying, highly contagious, painful, and, yes, very deadly. It also struck at unimaginable speed and spread to every corner of the earth within a few months. It brought society very close to collapse and had profound and lasting consequences.

What scares me the most about the Spanish Flu is that science and civilization never triumphed over it, and it still hasn't. Science was never able to stop its spread, cure it, or prevent it with a vaccine. The virus went away by itself.

A lot of things have changed since then, but the human element remains the same. Our most primal emotions, needs, fears, and desires have not changed, even if many other things around the edges of our existence have.

Many people disregard the study of the Great Influenza as useless because "it's not comparable." But things don't have to be comparable to be useful or insightful. I also believe history is worth studying for its own sake. I suggest you read the book and draw your conclusions.

Not from Spain

The Spanish Flu did not originate in Spain but the US. It is popularly known as the Spanish flu because of some peculiarities of the time.

Much of the world was busy fighting World War I, so many counties had news censorships in place to ensure "the morale of the troops and civilian population." Spain, a neutral country, did not have such censorship. Its press was free to report on the pandemic as it struck through the country, even as it afflicted King Alfonso XIII. The unrestricted reporting in Spain, coupled with concealment in other counties, gave a false impression that Spain was the worst-hit country, hence the "Spanish" Flu.

Out of the Blue

Dr. Loring Miner first reported a novel strain of influenza in early January 1918. Haskell County, Kansas, where he practiced medicine, saw what appear to be the first cases. From there, the virus spread at a speed that few would think possible in a world that was not as globalized, integrated, and connected as today.

What made this strain of influenza spread so quickly, besides its extreme contagiousness, was WWI. In early 1918, Europe and much of the world was already three and a half years into the war, with the US only recently joining the allies. The US was on a full war footing, hoping to make its mark in the conflict, and mobilized every available resource towards the effort. Men were being recruited, trained, equipped, and shipped off to war as quickly as possible. The federal government imposed rationing on many goods and services, including food staples, rubber, fuel, coal, and other materials. The media was censored and was only allowed to publish a positive spin on the news to "protect and boost morale." People were encouraged to purchase Liberty Bonds as a patriotic act, and rallies were held to promote them. The government was, by that point, weaned into the very fiber of everyday life in America.

Young men from Haskell reported to Funston Army Camp. From there, they were transferred to other military facilities all around the country, many carrying the virus with them. Conditions in these camps were deplorable, with little to no ventilation and severe overcrowding, providing tinder for the virus.

The constant recruitment and concentration of young men spread the virus throughout the US within weeks. As these men were shipped to France for further training and, later on, join the fight in the front lines, the virus quickly spread to Europe. Soon, England, France, and Germany had thousands of infected soldiers on their hands. As soldiers rotated home on leave, they took the virus with them to Europe's civilian populations. Soon, the virus hit the rest of the world through shipping lines and coaling stations.

This first wave of the virus spread quickly and was extremely contagious. Still, it was generally mild for the majority of those infected. Most were bed-ridden for several days with chills, fever, and fatigue. Doctors were concerned about its virulence. Even though modern medicine was still in its infancy, they were keenly aware of the possibility of a mutation that would make the virus much deadlier.

An enemy like none other

Viruses are weird beings. They are not alive, under the typical test for what science considers life, yet they are not entirely inert, either. They are not made of cells and are generally incapable of achieving homeostasis, that is, the capacity to reach and maintain a steady-state on their own. They do not reproduce, at least not by the usual methods employed by other species. Viruses highjack a cell and then use it to produce more copies of itself, so they technically replicate. Viruses also don't grow in size or complexity as they consume nutrients or as time progresses. When they replicate, new copies are made fully-formed.

It does compare to other forms of life in its objectives, though: the survival of its genes.

To do that, they must strike a delicate balance between contagiousness and deadliness. A virus that is not very contagious cannot spread. A virus that kills its hosts too quickly runs the risk of not having enough time to infect new hosts or even of running out of hosts.

At their core, viruses look to replicate, destroying host cells and wreaking havoc in the host's body in the process. And, it is perfectly designed to do just that. Nothing more, nothing less. Pure efficiency. No unneeded complexity. One of nature's masterpieces.

How do you kill a deadly enemy that's not alive in the first place? As opposed to bacteria, which can be killed by antibiotics, viruses are treated with antivirals designed to attack the replication process, not the virus itself. At most, antivirals slow the replication rate, allowing the immune system to mount its response without being overwhelmed. They are an imperfect solution, but they are all we have.

No antivirals were available in 1918.

Not your grandfather's medicine

It's more like your great-grandfather's medicine.

The early 20th Century was a transition period for medicine. When the Great Influenza hit, the development and practice of science-based medicine was still in its infancy and not yet generally used. In fact, there were places in the US where old methods, such as bloodletting, were still used.

But there were also many scientist doctors working to understand the disease, isolate the virus, and develop therapies, cures, or vaccines. These doctors, both civilian and military, led the charge, sometimes putting their lives on the line in their effort to control the pandemic and treat patients.

But really, all doctors could do was treat the symptoms and control a patient's fever as much as possible. Beyond that, the battle was fought inside the victim's body, mostly in the lungs. The only approach left to control the pandemic was prevention.

A nightmare scenario

In the fall of 1918, a new, deadlier strain of the virus hit. This one killed, and it did so within days of infection, and it killed in a gruesome manner.

The virus would lodge itself in the victim's lungs and begin wreaking havoc there. The virus played clever tricks on the immune system, inhibiting interferon release, usually the first line of defense against viral infections, triggering a disproportionate immune response. This battle destroyed the lungs and weakened the immune response against other stimuli, such as bacteria, which is why many developed bacterial pneumonia. The most severe cases lead to acute respiratory distress syndrome or ARDS.

Patients with ARDS that were treated in intensive care had mortality rates between 40% and 60%. Without intensive care, mortality rates reached 100%.

Symptoms included fever, painful headaches behind the eyes, swollen middle ear, renal failure, and loss of the sense of smell. As the disease progressed, cyanosis set in, where the patient's skin, lips, and tongue turned a deep tone of blue. Next, their nose, ears, and eyes began to bleed.

Doctors were pretty much hopeless. All they could do was watch, wait, and alleviate some of the symptoms with aspirin and morphine.

The new breed of scientific doctors all around the world worked frantically to develop a treatment or vaccine. Most believed, correctly, it was an airborne pathogen; that breathing it in could cause the disease. They did not know the exact details, like how long the virus could stay active in the air after it was exhaled. They did know that the lower the humidity, the longer the virus could survive in the air. They also knew it was a crowd disease that spread in large gatherings. They also believed, correctly again, that it could infect by hand-to-mouth contact.

However, this knowledge was of little use because only severe and rigorous isolation and quarantine could slow down the spread, and no scientist or public health official had the political power to take such action.

Throughout 1918, 47% of all deaths in the US were from influenza, hitting the young and healthy particularly hard. The virus depressed the average life expectancy in the US by more than ten years.

Ruthless actions, such as quarantines and shutdowns, could have slowed the spread. Doctors had noticed that the virus was getting weaker, so delaying its spread could save thousands of lives. There was precedent for such action. In 1916, several East Coast cities had dealt with a polio epidemic with strict measures. But the country was not at war, as it was in 1918.

WWI compounded the problems. The constant concentration and movement of hundreds of thousands of young soldiers across the country and then across the world was feeding fresh new hosts to the virus. Medical workers were getting sick at an alarming rate, which compounded the lack of trained medical staff, both doctors and nurses because many were off in Europe fighting the war. The military, which was conducting its own efforts to combat the pandemic, was instead hurting the civilian population by sucking up resources.

But what hurt the most was the lack of accurate information and strong leadership. President Woodrow Wilson never openly acknowledged or addressed the pandemic, which reduced trust and increased fear and uncertainty among the public. There was no coordinated response at the federal or state level. Instead, leadership came from local governments, and when even that was lacking, community leaders, such as wealthy businessmen.

Businesses shut down across the country and the world, not because of government mandates, but because so many people were getting sick, or were afraid of getting sick, that businesses did not have the manpower to operate.

By October, vaccines were appearing everywhere. Everyone claimed that their vaccine provided immunity and was safe, which was, of course, false, which only deepened mistrust among the public.

Hopelessness sets in

Everything doctors and community leaders did proved useless. The masks worn by millions were futile as designed. Vaccines didn't work, and all treatments and therapies also proved ineffective. Only preventing exposure to the virus could protect people. But the lockdowns were not severe enough. As author John Barry said, "in the end, the virus did its will around the world."

After the horrors of the second wave quieted down, complacency set in, and in the winter of 1918, a third wave hit. It was still deadly but not as terrible as the second wave.

When the third wave waned, the virus continued to kill millions of people around the world during 1919, with local outbreaks hitting here and there. Yet, even these comparatively less deadly outbreaks were destructive. It still killed, and it did so at a rate that would have categorized it as the most lethal influenza virus ever known.

In the Western world, the heaviest blows fell upon the young and those densely packed together, such as minors in schools and industrial workers and soldiers. Among these, the death rate reached to 6.21%.

In Guam, the virus killed almost 5% of the entire population in just a few weeks. In the Mexican state of Chiapas, 10% of the population died from the virus. It killed 7% of the entire people in much of Russia and Iran. In the Fiji Islands, 14% of the population died from the virus within a 16-day window between November 25 and December 10. India suffered massively, with a mortality rate of 9.61%. In the Indian subcontinent alone, estimates place the number of dead at close to 20 million, possibly more.

If the epidemic continues its mathematical rate of acceleration, civilization could easily disappear from the face of the earth within a few more weeks.

-- Victor Vaughan, head of the army's Division of Communicable Diseases writing in late 1918

Nature steps in

As mentioned, individual viruses highjack a cell and use it to make thousands of replicas, which then highjack more cells. Crucially, these replicas are not all exactly the same. Each one has tiny variations. The replicas whose variations made them less able to highjack cells and replicate don't survive. The ones whose variations made them more efficient are successful and make more replicas very similar to themselves. It's like a Darwinian contest at lightning speed.

This same process mutated the virus from a relatively mild strand when it made the jump from animal (most likely birds) to human, into the deadly killer of the second wave. But once that happened, once the virus made itself an efficient killer, the next mutations were, statistically, more likely to make it less deadly. If a virus is too efficient and kills its human host too quickly, it gets little chance to infect new humans. In other words, it does not help a virus's odds of survival to kill too efficiently.

And that's precisely what happened. The virus slowly mutated into a milder and milder form until, a few years later, it disappeared from the global stage.

Immunity also played a role in easing the pandemic. As the virus worked its way through the population, the vast majority of survivors developed some immunity to it. Local cycles of contagion usually lasted six to eight weeks, from the first case to the end of the regional pandemic. It left as suddenly and as violently as it arrived.

In the end, the total death toll from the pandemic is estimated to be between 21 to 100 million people, the actual figure most likely closer to 50 million. Considering the global population was 1.8 billion, the Great Influenza took 5% of the global population.

A similar death rate today would imply over 390 million deaths.

The Wake

The pandemic left lasting effects. Besides the human loss and suffering, on top of the millions of children left orphaned and the pain inflicted, the Great Influenza showed humanity how frail it is. At the same time, it proved how resilient it can be.

No. The Coronavirus pandemic is not the first time humanity faces such a challenge. It is not the first time we have taken measures that seem odd and carry a high cost. And no, this is not the worst we've had it as a race, which should give us some solace and strength at the same time. This, too, shall pass.

But I cannot close this note without stating what is now evident: The COVID-19 pandemic is not the last pandemic we will face. It is not even the worst pandemic we will face. The big one, the one that is comparable to the Great Influenza in its deadliness, is likely to be influenza again. Our old enemy, which last time arrived suddenly, bested us and left on its own terms, will be back. Its spread will be much, much worse, and its effects more far-reaching. And if it strikes when we lack leaders on the global and local stages, the results will be worse still.

Like any predator that goes after the weakest target and strikes when least expected, so too will influenza hit again. It will strike when we are least prepared, like in the middle of a global crisis, and it will do so without mercy.

But unlike most of nature's predators, which kill their prey without disturbing the equilibrium of its ecosystem, the influenza virus would not care to wipe humanity off the face of the earth. You see, for a virus to kill its host is really an unintended consequence of its success. If a virus kills its host too quickly, it hurts its chances of infecting other hosts, limiting its odds of survival.

Not so for influenza.

From the book: “Some diseases, such as measles, depend on civilization for their own existence. Since a single exposure to measles usually gives lifetime immunity, the measles virus cannot find enough susceptible individuals in small towns to survive. Without a new human generation to infect, the virus dies out. Epidemiologists have estimated that missiles require an unvaccinated population of at least half a million people, living in close contact, to continue to exist. The influenza virus is different. Since birds provide a natural home for it, influenza does not depend upon civilization. In terms of its own survival, it does not matter if humans exist or not.”

I had hoped to end this post on a positive note, but the truth is that, as painful as this pandemic has been, we should see it as a practice run for when the real test begins. The big one is still out there, and it will test us. It will test our medical and scientific knowledge. It will test our modern communications and supply networks. It will test our political and civilian leadership. But most of all, it will test our humanity. For the next pandemic, we will need to come together and fight it. No political squabbling, no conspiracy theories, no animosity between countries and factions. Because influenza won't care and will provide no quarter, and neither should we.

Here's to hoping we learn the right lessons.