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John Barry on the deadliest pandemic in history

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 exactly 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 Tony 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.

They were energized, just as the scientific community today is energized and extremely focused, but they did not know what the pathogen was. They developed vaccines, but they were aimed at the wrong targets, although many people — probably most people who died — died of secondary bacterial pneumonia following influenza. Even today, that’s got a case fatality rate of eight percent when it follows influenza, because influenza does so many things to your immune system which make bacterial pneumonia more dangerous.

They did develop vaccines against several bacterial pneumonias. If you get a vaccination against pneumococcus today, that’s a straight-line descendant of what was developed in 1918. They tried convalescent serum, of course, which we’re trying today. But there wasn’t a lot they could do. Basically, all they could do was supportive care. Of course, they didn’t have the tools that a modern ICU unit has, so the supportive care was much less than can be given today. They could not even administer oxygen, at least not in the ways where we’re doing it today. Forget about ventilators.

In terms of the public health measures, eventually — but in most places, too late — cities issued closing orders and advised social distancing. By that time they didn’t really have to advise social distancing, because people were pretty terrified and kept away from each other.

OR: Woodrow Wilson himself suffered from it — how does the response to that fit in with the propagandistic approach of public officials you just described?

Barry: Wilson did not get sick until April in Paris during the peace negotiations. Wilson was so focused on the war, he never even issued a public statement about the pandemic. Not one, never. But he did get sick in Paris. I think it had consequential repercussions. Well noted at the time, every scientific assessment summary after the pandemic concluded that second only to pulmonary problems, the disease affected the mind. Wilson was disoriented. Everyone around him commented on his inability to focus, his lack of mental sharpness, that he was nothing like what he had been. Prior to his getting the disease, he had been adamant in the peace negotiations that the principles he had articulated as reasons why the U.S. was entering the war be incorporated into the peace treaty. He got sick, as I said, in the middle of the negotiations. Some of the negotiations actually occurred in his sick room with the British and French heads of state, and he caved in. Clemenceau, the French prime minister, was nicknamed “the Tiger.” Here is Wilson, mentally disoriented, unable to focus, physically weakened and tired out by the disease, trying to negotiate with the Tiger. The Tiger won and got the peace treaty the French wanted. The only thing Wilson got out of it was the League of Nations.

It’s conceivable that he would have caved in on everything to get the League of Nations, even if he had remained well. We don’t know for sure. But he did get sick. He was disoriented. His mind was affected. He was physically weaker, and he caved in, to the great distress of many people in the U.S. peace delegation. In fact, quite a group of his young aides, about ten or so, met in secret, including two people who subsequently became Secretary of State and others who became Assistant Secretaries of State. Walter Lippmann and Lincoln Steffens were also among this group of young aides. They all debated whether they were going to resign in protest, and a couple of them did resign. Others did not, but they were all enormously discouraged and disgusted by what Wilson had given away. John Maynard Keynes called Wilson “the greatest fraud on earth” afterwards.

OR: There are paradigmatic case studies coming out of Philadelphia and out of St. Louis that demonstrate the very different approaches of those cities. Can you talk a bit about those?

Barry: Philly was archetypal, in terms of lying to the public and not doing much. They had a Liberty Loan parade on September 28th. But by then, in Philadelphia, the disease was circulating. The medical community urged the health commissioner and the mayor to cancel the parade. They refused. This was patriotic. They had to help support the war effort. It’s a huge parade. Hundreds of thousands of people pressed close together. Like clockwork, 48 hours to 72 hours later, the disease just exploded in Philadelphia. It was not until after that in Philadelphia, quite a while after that, that they finally closed schools, banned public gatherings, and so forth. In fact, to illustrate just how there was fake news back then — because the news media was complicit with the government in trying to promote morale and not saying anything negative — after the city finally issued these closing orders, with people dying all over the city, one of the newspapers actually said the closing orders “are not a public health measure. You have no reason for panic or alarm.” Of course, everybody knew that was a lie.

In St. Louis, by contrast, the public health commissioner had some power and exercised it, or at least convinced the mayor to go along. They did close down. In the phrase we use today, they did succeed in flattening the curve. The healthcare system in St. Louis was not overwhelmed. So you compare the curve in Philadelphia — a very steep peak and a more gradual drop off — with the curve in St. Louis — there’s a much, much flatter peak, and it lasts a lot longer. This is what we’re trying to accomplish with our public health measures today.

OR: What were the economic ramifications of the pandemic, and why do you think it is such an underdiscussed subject in mainstream history given its massive death toll?

Barry: For clarity here: the death numbers now are generally considered 50 to 100 million, although there are some people who think it was less than that. In terms of why it hadn’t been written about, I think historians, until maybe 30 years or so ago, tended to only write about what people did to people and ignored what nature did to people, as a general rule. There were some exceptions. In fact, I would recommend one of my favorite books. It’s by a Nobel Laureate, Macfarlane Burnet — the first person to come up with the 50 to 100 million estimate. He wrote The Natural History of Infectious Disease. It’s a great book. Probably out of print. There’s also a very good book called America’s Forgotten Pandemic by Alfred Crosby, who’s a terrific historian. So the bigger question is: how come there’s so little in literature about it? That, I don’t understand. John Dos Passos is one of my favorite writers. He got influenza himself on a troop ship, which was like a floating coffin, on his way to Europe, and he barely mentioned influenza in his entire body of work. I don’t have an explanation for that.

On the economics: as I said at the beginning, one of the big differences between influenza and COVID-19 is duration. Influenza moves much more quickly, and influenza would hit a community and pass through it in six to ten weeks. Then it was essentially gone. There, in many cases, would be another wave, but that would come months later. In between, the disease was there, but with very little activity of infection.

Plus, the closing orders were not as extreme as what we’re doing now. Pretty much everything was considered a war industry. So if it didn’t directly relate to an optional public gathering, like a church service or a theater, businesses weren’t closed. There was tremendous absenteeism out of fear, so the economy was affected. There was a brief, reasonably intense recession linked to the pandemic, but we came out of it, and things got back to normal pretty quickly economically. We have a much bigger problem today. We’ve taken much more extreme measures to control the virus. To do that also requires a lot more time, so the economic impact is much greater than it was in 1918.

OR: George W. Bush read your book and was inspired by it. Could you talk about what it’s like to see a work of history — and your own, into the bargain — penetrating the minds of policymaking at the highest level?

Barry: To give you a complete history of that, Tommy Thompson, the former governor of Wisconsin and Bush’s first Secretary of HHS, was interested in pandemic influenza. Indeed, on September 11th, 2001, he was in a meeting on it and left very reluctantly. My book didn’t come out for three years after that. He had left, but an assistant secretary named Stewart Simonson, who is today Assistant Director General of the WHO, had been alerted to the pandemic and made sensitive to it by Thompson. He read my book and brought it to Mike Levitt, then HHS Secretary, and Levitt brought it to Bush’s attention.

Bush did make it a very high priority for his entire administration. Levitt sat down with every member of the cabinet except one, I believe, to get their buy-in. Simonson led the effort on the Hill, and they passed a $7.1 billion piece of legislation, which created the national stockpile, laid out a huge investment in vaccine manufacturing technology and capacity and basic research, and built up a planning process of what to do should a pandemic strike. I did participate in the early conceptual meetings on what to do. The so-called nonpharmaceutical interventions, i.e., what do you do when you don’t have drugs? What recommendations to make there?

I was gratified. Any writer is gratified when anybody reads his or her book. That’s what you write for. When I wrote the book, I certainly didn’t have any purpose in mind, in the sense of affecting policy. I wasn’t trying to get anybody’s attention to the issue. I actually wrote the book almost by accident. I had intended to write a book on the home front in World War I, culminating in the events of 1919, which I consider one of the most interesting years in American history. That was my initial plan. The book strictly on the pandemic grew out of that, but it was almost an accident. Of course, at the time, I wasn’t a great fan of President Bush. In retrospect, I certainly think much more highly of him. But that had nothing to do with partisanship. Preparing for a pandemic is a nonpartisan issue.