The Pale Horse

An Interview with John Barry

Octavian Report: Can you talk about how the epidemic influenza of 1918 begins and what it looks like as it ramps up?

John Barry: There was an animal virus that jumped to the human species. We're not sure when. It could have been as early as 1915. It could have been as late as January of 1918. We're not sure where. It could have been China, France, Vietnam, New York, or even rural Kansas. There was a very spotty first wave that was relatively mild and missed most of the world, although it got pretty widespread in western Europe, hit New York, hit Chicago, missed Los Angeles and much of the rest of the country.

Then the virus seemed to change, becoming much more lethal. The first outbreak of this lethal second wave was in Switzerland in July. This spread around the world and killed an estimated 50 to 100 million people. For much of the world, we don't have very good numbers. That's why the range is so enormous. If you adjust for the world's population, that would be equivalent to 220 million to 440 million people today. Fortunately, coronavirus doesn't look anything like that. It's far, far less lethal than the 1918 influenza virus.

However, there are a lot of similarities. For one thing, the way it transmits is essentially identical. Even the pathology seems quite similar. If anything, the coronavirus is significantly more transmissible then influenza was. In 1918, it infected about a third of the world's population. This virus would probably infect at least 60 percent, maybe 80 percent of the world's population if left unchecked, if there were no human interventions.

But, again, this is much less virulent, and another important difference is the timing. Influenza has an incubation period of one to four days, and most people get sick at two days. COVID-19 is two to 14 days. Most people get sick during the fifth or sixth days: roughly triple the incubation period.

The other thing is influenza can be spread before someone has any symptoms, but for a much shorter time before they develop symptoms than COVID-19, which can be spread for probably two days (and maybe longer than that) even before you have any symptoms and know you're sick yourself.

OR: Once the disease really begins to catch public attention, what is the public response?

Barry: The first wave, even in western Europe, was widespread but it wasn't particularly lethal. You can actually read medical articles suggesting that it wasn't influenza because it wasn't killing enough people. They already were familiar with the disease, of course, and even the pandemic. They had a pandemic that began in 1889 and also had seasonal influenza. Troops called it three-day fever in the spring.

It very quickly became apparent that the disease was quite different in the fall. In fact, one of the leading pathologists in the world, a guy named William Wells, who was the founding dean of the Hopkins Medical School — and was easily the most important person in the history of American medicine and arguably the most important person in the history of American science — performed autopsies at the first Army camp hit by the lethal second wave and initially thought it was a new disease, because he had never seen lungs like that. It was compared to poison gas as the only other thing that seemed to cause the lungs to look like that at autopsy (although he pretty quickly figured out it was actually influenza).

The context was important and affected the response dramatically. We were at war, and there was already an existing infrastructure of propaganda. There was already an existing effort to control the way people thought in the country. Songs like "I Wonder Who's Kissing Her Now" were banned from Army camps, for example. There was a law they could imprison you for 20 years. It prohibited you to "utter, write, print, or publish any disloyal, profane, or scurrilous or abusive language about the government of the United States." The law was enforced. The Supreme Court upheld that law. That's where the phrase "Can't shout fire in a crowded theater" came from, that Supreme Court decision.

So that's the context, and when the disease erupted, it fitted into that context. Because of concerns that saying something negative would hurt morale, you had national public health leaders saying things like, "This is ordinary influenza by another name.” Another national public health leader said, "You have nothing to fear if proper precautions are taken." That simply wasn't true, and everyone who experienced the disease or had neighbors who experienced the disease quickly recognized this was not an ordinary influenza. Most people did get an attack much like ordinary influenza, but a significant minority, large enough that everybody understood what was happening, had another experience.

Some of the symptoms were quite unusual for influenza, so it was misdiagnosed initially as typhoid, cholera, dengue. People could bleed not only from their nose, which was reasonably common, but also from their mouth and even their eyes and ears, which would be terrifying to a lay person (or even a professional). Clearly, this was not ordinary influenza, and the effort to calm people with false reassurances backfired. People knew they were being lied to, so the lies only spread more fear. There was no Anthony Fauci in 1918 at the national level. On very rare occasions, you had local public health leaders who were telling the truth from the beginning.

OR: What do the efforts of scientists to understand and fight the disease look like?

Barry: The scientific community obviously didn't have the tools we have. But make no mistake, they knew what they were doing. To give you a sense of how good they were, one person in my book, although he's a minor figure, won the Nobel Prize in 1966 for work he did in 1911. They only give the prize when they know you're right, and it took 55 years for the science to catch up to his 1911 discovery.