The Great Influenza

The virus caused several lingering symptoms. Anecdotal evidence suggested the virus caused mental problems including depression, hysteria, and paranoia. There was also a noted link between influenza and Parkinson’s disease a decade after the pandemic ended. Others noted an increase in suicides by those who recovered from the virus. Though the brain was not affected anywhere near as frequently as the lungs or other organs, the impact on the brain of one patient would have grave consequences for the rest of the world.

In January 1919 Wilson was in Paris, negotiating the peace treaty to end World War I with the other allied leaders. While many in his party had contracted influenza, Wilson seemed fine. He was forceful in negotiations with the French Premier Georges Clemenceau, who insisted on a treaty that punished Germany for the war and offered France land that had been lost in previous conflicts. Throughout the winter negotiations continued, with both Clemenceau and British Prime Minister Lloyd George getting minor cases of influenza too. Then, on April 3, after threatening to leave France without a treaty at all, Wilson suddenly came down with a severe case of influenza. After days spent in bed, he rejoined negotiations while bedridden, but it seemed his mind was no longer sharp, and he tired easily. He relented on all of Clemenceau’s demands, and the overly punitive Treaty of Versailles was created. It was the backlash against the effects of the treaty that enabled Adolf Hitler’s rise, and it seems the treaty went forth simply because Wilson suffered lingering mental effects from the virus.

Wilson had a stroke four months later that incapacitated him for the remainder of his presidency, but it is clear he did not have a stroke in Paris. Instead, influenza may have contributed to the stroke months later. Thus, the effects of influenza lingered in both Wilson and the world.

In the fall of 1919 many worried influenza would return for a fourth wave. Four months later, the virus rose again with enough severity that the Red Cross called for anyone with nursing experience to help out. The year 1920 saw huge numbers of fatalities from influenza (paling only to 1918 and possibly 1919), but the response to the virus was generally better, with physicians able to quarantine houses and with enough medical personnel to go around most cities. The virus finally faded away in the coming years, but it technically did not disappear. Rather, it mutated to a less virulent strain that infected fewer people due to immunities. Still, “it left a legacy” (391).

Beyond the orphans, widows, and widowers, the influenza pandemic also caused poverty and pain for millions. Physicians noted that few victims of influenza came away without some aspect of their bodies or minds affected too, as many reported trouble breathing, heart problems, or mental health issues.

Yet despite the pandemic’s effects on American life, there are few literary records of it. While World War I triggered some of the great literary movements of the 20th century, few writers addressed the influenza pandemic. Perhaps this is because the disease “was too universal” (395). Certainly, it was too universal to stir the type of racism or classism that other public health problems have caused. That said, the pandemic did erode public trust and stoke enough fear that several local governments collapsed. Communities that stayed together either had someone else pick up their leaders’ slack, as the wealthy did in Philadelphia, or they never lost faith in public officials, as was the case in San Francisco.

Finally, “it is impossible to state with any accuracy the death toll” (396). The original estimation was that more than 20 million people died worldwide, but every revision of the count since then has only increased the numbers. In the United States epidemiologists estimate that 675,000 people died out of 105 million citizens. Some estimates worldwide think that as many as 5% of the world’s population died in the combined waves, with the vast majority of those coming from the less developed world.

Aside from the deaths and the sense of betrayal and cynicism among survivors, some good legacies emerged from the pandemic. For one, world leaders made plans to cooperate on any future health needs. For another, several cities created better public health departments. But the main legacy of the influenza pandemic would be discovered in science laboratories.

While American medical expertise (and the numbers of skilled researchers, physicians, and scientists) grew exponentially after the founding of Hopkins, the influenza pandemic was a rude awakening to how much was still unknown. As Vaughan told a colleague in 1918, “Never again allow me to say that medical science is on the verge of conquering disease” (403). But researchers continued onward, comfortable that they knew less than they thought. To crack the code of influenza, research continued on two paths: tracing the epidemiology of the disease and following clues found in the laboratory.

Exploring the epidemiology of the disease involved tracing individual outbreaks of the virus and even individual patients. These studies helped transform a new field of medicine by showing that statistics are vital to research. Consequently, the Public Health Service began working with the Census Bureau on an influenza committee and eventually created a permanent office on statistics. Still, most of the work would be done in the laboratory, not the statistician’s office.

Nearly every lab, medical conference, and medical journal in the world was devoted to the influenza pandemic. Slowly, each researcher began to develop shared knowledge. First, scientists confirmed that the second wave of the virus was indeed a second wave and not a new virus. Statistics also proved what was already suspected: that the virus had killed a disproportionate number of people in their 20s and 30s. The most common explanation for why older populations were less susceptible to the virus was that an earlier version of influenza might have helped people create antibodies to combat the lethal strain of 1918. Finally, surveys and statistics confirmed that the disease easily spread in crowds, which explained why cities had larger outbreaks than rural areas, and why the poor died at higher rates than the rich. Still, so much was left unknown, including the identity of the pathogen.

Some information came much later. For example, samples taken by the army would be used 75 years later to help sequence the virus’s genome. But the rest of the work happened much earlier than that through Lewis and Avery, with one man’s life ending in tragedy, the other in scientific glory.

The simplest question was still the most important one: What caused the pandemic? The pursuit of the cause of the influenza pandemic is a textbook example of how science is conducted. During the pandemic, failure to find Pfeiffer’s bacillus seemed to suggest incompetent researchers rather than something other than the bacillus causing the virus. But as the pandemic raged on, researchers began to doubt not whether Pfeiffer’s bacillus could kill but what being able to find it actually confirmed.

Because so many researchers had had to compromise on the scientific method, some wondered if mistakes of technique had also impacted potential treatment. But by 1919, Park and Williams concluded that evidence suggested treatments failed because they attacked Pfeiffer’s rather than the actual cause of influenza, which seemed to be a virus. A decade later, Welch concluded that there was scant evidence Pfeiffer’s was the cause of the pandemic and that the pandemic must have been caused by a virus.

Meanwhile, Avery continued to obsess over the pneumococcus, specifically the hard candy-like shell that surrounded it. In 1923 he and a chemist, Michael Heidelberger, proved that capsules found in the blood and urine of pneumonia patients were carbohydrates that generated an immune response. This discovery, the result of painstaking years of methodical (though unorthodox) research, proved that substances other than protein could produce immune responses. The finding encouraged Avery, but five years later he grew discouraged when another researcher proved the candy-like shell did not seem to have any power, as pneumococci could exist with or without it. Avery shifted direction.

In the 1930s, after most of his assistants and collaborators moved on, Avery kept punching away at pneumonia. He stopped publishing papers or contributing much of anything, seemingly. Then, in 1943, he isolated DNA in the pneumococci and proved that the DNA was what transformed a pneumococcus from one without a shell to one with a shell. This was monumental, as no one knew what DNA did at that point in time. Avery “had demonstrated that DNA carried genetic information, that genes lay within DNA” (425). Avery inadvertently created the field of molecular biology when he was merely looking for a cure for pneumonia. Still, he would not win the Nobel Prize or be widely recognized for his monumental discovery, though his findings “were accepted as true by the scientists who mattered” (425).

For a few years after the pandemic, Lewis continued his research at the University of Pennsylvania. He thought he had developed a vaccine for pneumonia and became celebrated in scientific circles, but his vaccine was not that successful. Lewis grew frustrated. His lab was underfunded, and he found himself more often away from the lab and out at fundraisers. When offered a position at the University of Iowa, though, he demurred, taking instead a full-time lab position at Princeton. Lewis hired research assistants, but unlike Avery, who hired people with a specific task in mind, Lewis blindly threw researchers and resources at problems as they developed.

One man Lewis hired, Richard Shope, worked with Lewis on identifying and tracing swine influenza, but it was the only real success Lewis had. Lewis even confessed to Flexner, his mentor, that he felt he was not productive for most of the 1920s. His own research was going nowhere, and Flexner kept encouraging him to leave Princeton and take the Iowa job. While Lewis had some of the gifts Welch did, he seemed to lack “the creativity and organizational vision to actually run a major laboratory investigation” (439). But Lewis refused to accept that. Rather than go to Iowa, in 1928 he went to Brazil to study the deadly strain of yellow fever that had developed there. He somehow infected himself in a laboratory accident (intentionally or unintentionally) after five months there and died.

Shope, in the years after Lewis’s death, definitively proved that the influenza of 1918 was caused by a virus, the same virus Shope and Lewis had isolated in swine. He put Lewis’s name on the papers he coauthored, as was tradition in the sciences. This means that, had Lewis lived, he would have been a coauthor on some of the most important virology studies ever conducted, and he probably could have contributed to them more fully, given his breadth of knowledge in the field.

Park, Avery, and Lewis each represented a different strain of researcher. Park saw research as a tool that could help end people’s suffering and pain, but this belief limited the types of findings he could make. Avery was focused and determined. With persistence, he made monumental discoveries. And Lewis “was a romantic, and a lover” (447). He always wanted to see more, even though he saw more when he was shown something by someone else than he could ever find on his own. The laboratory did not return Lewis’s love, and in a sense, he may have been the last person to die due to the influenza pandemic of 1918.

Since the book was originally published, other viruses have struck, and scientists have learned more about the origins of the influenza of 1918. They have, for instance, figured out that seven of the eight segments of the original virus “are of avian origin” and that the virus probably “jumped species to humans probably after a reassortment with another virus” (450). Additionally, scientists now know that most viral pandemics come in waves and that the 1918 influenza virus may have existed in humans for several years before it became as virulent and transmissible as it was.

More important, there are new pandemics to worry about. If a serious strain of influenza were to spread, it could devastate the planet. As a point of comparison, if something as severe as the 1918 pandemic impacted the world today, there would be between 150 million and 425 million deaths, given how much larger the world’s population is today. While this number of deaths is unlikely given advancements in antibiotics and treatment, there would still be tens of millions of fatalities and devastating effects on the global economy. Indeed, Barry was part of a committee created by the Obama administration to identify exactly what needs would result from a pandemic, and the team adjusted their needs as it witnessed the effects of the 2009 H1N1 pandemic. So what can pandemics like those in 1918 and 2009 teach us about how to prepare for a future pandemic?

For one, the best-case scenario would be to create a universal vaccine for all influenza viruses. This is tough to create, since influenza mutates so rapidly, but developing it should be of the highest priority. Short of that, there are other tools that can help stop the spread of a virus. A good surveillance system of world diseases (which the World Health Organization has) helps, as do pharmaceuticals and vaccine-manufacturing technologies (to a point—pharmaceuticals only do so much in confronting a virus, and manufacturing technologies do not help if a vaccine is not developed). Quarantines could be successful but are unlikely to be so, given that humans do not tend to do well with being quarantined. If, for instance, army bases in 1918 could not show enough rigid discipline to sustain a lockdown, what hope is there for a city in the present day? Border closings would be similarly useless, as they would only delay the spread of the disease, not prevent it.

That leaves mundane tasks like washing hands and keeping things clean. Keeping sick children and adults at home is only common sense. Covering mouths when coughing or sneezing is important. All these measures require the public to buy in to the measures, meaning citizens must trust their governments to tell the truth. Political leadership has too often been the weak link in any effort to prevent the spread of disease, whether influenza, swine flu, or Ebola.

“Real terror” existed in 1918 and led to increased harm for all citizens of the world (460). The final task for any leader is to not contribute to that terror and to not encourage an “every man for himself” attitude or approach (461). A leader must tell the truth so the people can make sense of it themselves.