The Great Influenza

Scientists do not all agree that the 1918–19 influenza pandemic actually started in Haskell, but that is the most commonly accepted theory. One of the problems with determining the exact truth is that viruses are “an enigma” (99). Scientists cannot even agree on the most basic origins of viruses as a whole. Some argue that viruses originated free of all other molecules and that, perhaps, other lifeforms have evolved from viruses. More commonly, virologists believe that viruses devolved into simpler organisms from more complicated ones, as though they broke off from one organelle and evolved on their own after that. Regardless, viruses are unique among cells. They are single-celled and perform just one task: replicating themselves. Virus cells do this by attaching themselves to RNA molecules and essentially taking control of a cell so that it produces more viral cells rather than performing its original function.

Barry describes three types of influenza viruses: A, B, and C. Of those, only A can infect humans and do so on a large enough scale to cause an epidemic. Influenza likely originated in birds, but it is extremely rare for viruses to spread directly from a bird to humans, as it would require the virus to adapt to humans before entering the human body. More commonly, the virus jumps between a bird and an intermediary mammal, commonly swine. Whenever an influenza does emerge to attack humans, it comes in waves, and those waves could lead to a pandemic, which is defined as a virus that has a more than 50% morbidity rate (“morbidity” refers to the number of people infected in all the waves combined”).

Even small amounts of influenza can be extremely deadly. Influenza attacks the respiratory system directly and differs from a cold or any type of coronavirus that gets erroneously referred to as the “flu.” The virus has a unique shape, resembling a dandelion (103). It latches onto a cell, eats away at its membrane, causes the cell to reproduce the virus, and then essentially explodes the cell, releasing a “a swarm of between 100,000 and 1 million new influenza viruses” (104). This swarm can further mutate in more deadly ways if the body does not fight it off.

The body uses the immune system to fight off infections. Some cells of the immune system attack anything that enters the body, but most of the immune system is made up of cells that target only specific antigens. Antibodies, for instance, only attack things they recognize as the virus they were developed to fight. Dendritic cells are especially key in this process, as they help label antigens and process them. After surrounding an unknown antigen, the dendritic cells will surround it, chop it up, and present it to white blood cells in the spleen and lymph nodes, which will then produce antibodies to fight the antigen. This causes the body to release enzymes that sometimes cause external symptoms like fever. The immune response as a whole is largely a race between the foreign antigen and the body to see which can produce more cells faster. If, however, the body does survive an infection, it retains some of the antibodies and creates memory T cells that will recognize the antigen next time it enters, expediting the process of creating antibodies. The whole point of vaccinations is to create antibodies to prevent infection in the future. Influenza, however, is especially adept at eluding the human body’s immune system.

For one thing, influenza mutates. Through an antigen drift, the virus can adapt to be less recognizable to the existing antibodies (though sometimes the changes are minor enough that the antibodies do recognize the virus). Antigen drifts are serious but they do not cause pandemics. Antigen shifts, however, do. In an antigen shift, the virus mutates enough to have a completely new gene coding for at least part of the virus, making it completely unrecognizable to the antibodies. These shifts also allow the virus to move from animal to human, and it is these shifts that have led to previous influenza pandemics like the 1688 pandemic in England, Ireland, and Virginia, and ones in London in 1847 and 1848. Worse, the influenza virus is extremely competitive with cells, even other influenza ones. They also eliminate existing antibodies, meaning that, in time, influenza exposure will make it likelier that a person can get seriously ill from another antigen, even one to which the body was supposedly immune. Thus, influenza remains extremely virulent, and indeed, the H1N1 virus of 1918, the influenza that originated in Kansas, created the most deadly pandemic of the 20th century.

By spring of 1917, World War I had been raging for years, and more than 5 million soldiers had already died in what generals on the frontlines called “the sausage factory” (119). US President Woodrow Wilson had resisted the urge to join in the war, even winning reelection in 1916 as the candidate who “Kept Us Out of the War,” as his own slogan put it (120). But after the Germans resumed unrestricted submarine warfare, and after the discovery of the Zimmermann note (intercepted German documents encouraging Mexico to join Germany in war against the United States to seize territories lost in the Mexican–American War), Wilson reluctantly got a declaration of war from Congress. With war declared, he sought to “turn the nation into a weapon,” but doing so would also turn the nation into a “tinderbox” for epidemic disease (121).

As part of the war effort, Wilson discouraged dissent, silencing freedom of speech, censoring the press, and arresting union leaders, German speakers, and anyone who seemed at odds with the war effort. To this end, Wilson created the Committee on Public Information (the CPI) and put George Creel in charge. Creel put propaganda into newspapers and censored popular songs in an effort to recruit soldiers and war volunteers and raise money for the war effort. This propaganda and censoring force would have the unintended consequence of worsening the influenza attack (128).

As part of his total war effort, Wilson also put the American Red Cross under the purview of his War Council. Wilson used the Red Cross to enter every community in the nation. Among other things, the agency supplied nurses to the military, organized base hospitals overseas, and even equipped railroad cars throughout the country to be used as mobile laboratories in the event of a disease outbreak.

As the military draft expanded, more soldiers became more tightly packed in army barracks across the country. And because “the government controlled the flow of information” (132), Americans would not even be aware of what that packing of barracks would lead to: a pandemic.

World War I was “the first truly scientific war,” and it made use of weapons created by engineers and chemists (especially in the form of poison gases). Welch, watching this from afar, wrote to Wilson in 1916 to suggest the National Academy of Sciences (of which Welch was then the president) help plan for any war effort. Wilson invited Welch and other scientists to the White House, where they created the National Research Council. By this point, there was an unofficial hierarchy in the American sciences. Welch was at the top with Flexner and other founders of various institutions, with the army’s Surgeon General William Gorgas right below. All of them would end up on the National Research Council (as well as the Council of National Defense), as would the University of Michigan’s Victor Vaughan. The only prestigious person left off the councils was Rupert Blue, the US surgeon general and head of the US Public Health Service, because he was not seen as a scientist as much as a politician.

The council knew that throughout history, more soldiers had died of disease than from combat, and they prepared a plan for confronting disease. Of the men on the council, Gorgas had the most responsibility for military medicine. He had helped treat malaria outbreaks early in his career, and as surgeon general of the army, he had spearheaded an effort to fight venereal diseases in the ranks. However, while most would listen to him on subjects of venereal disease and sanitation, “the army paid him little heed on anything else” (139). He could not even get funding for field testing on a gangrene antitoxin. Gorgas, Welch, and company would have to act independent of the army to make the changes they wanted to see. But a pandemic, of course, cannot be fought unilaterally.

Their first project was to recruit physicians and nurses for the military. They did so but had more trouble getting nurses, as there was already a dearth of trained nurses in the United States but especially in the military at large. Nursing, like medicine as a whole, had become more scientific over the past decades, and physicians suggested that two types of nurses ought to be trained: “practical nurses,” who would not be educated or trained, and “graduate nurses,” who would (142). Because nursing was one of the few professions in which women had any power, the women who ran nursing programs rejected the proposal. The nursing profession triumphed over the male-dominated physicians and military; however, they were helped by Creel’s Committee on Public Information, which prevented the public “from learning just how profound the need for nurses was” (143). Regardless, most of the well-trained physicians and nurses ended up in Europe with the troops, leaving a dearth of good physicians and (especially) nurses in the United States. Medical care for civilians decreased in quality, adding “kindling to the tinderbox” the war was creating (143).

While the military and the nation as a whole became devoted to Wilson’s total war effort, Gorgas was obsessing over a hypothetical epidemic that might sweep military camps where young men from different regions of the country would be put in close contact with each other for the first time. Gorgas made sure to stockpile the vaccines, antitoxins, and sera that did exist by 1917, and created a “special unit for ‘the prevention of infectious disease’” (147). Heeding the advice of Rufus Cole and Oswald Avery (both members of the Rockefeller Institute), Gorgas alerted army brass that pneumonia should be the primary fear. This advice was ignored.

The winter of 1917–18 was especially cold, and army camps were both overcrowded and bitterly frigid. Measles spread among the soldiers all across the country, and measles often led to pneumonia, which led to deaths in the camps. In fact, pneumonia was the “leading cause of death around the world” (151), so Gorgas and others were right to be concerned. Welch told Gorgas to get a recipe for a pneumonia medicine created by Oswald Avery, a Canadian then working for the Rockefeller Institute. Avery was the “leading investigator of pneumonia” in the world and would, years later, “create a scientific revolution that would change the direction of all genetic research” (151). For now, though, his concern centered on influenza which, like measles, often kills patients through pneumonia.

Pneumonia is an inflammation of the lungs that is typically caused by some kind of infection. As a result of both pneumonia itself and the body’s immune response, the lungs become hardened. Death occurs when the pneumonia hardens to such an extent that the lungs cannot transfer enough oxygen into the bloodstream or when the pneumonia pathogen itself enters the bloodstream. Influenza causes pneumonia regularly, either through a viral attack on the lungs or, as is more typical, by weakening the body and allowing “so-called secondary invaders, bacteria, to infest the lungs virtually unopposed” (153). The most common cause of pneumonia is pneumococcus, a bacteria that can function as either a primary or secondary invader. Scientists had tried to cure pneumonia for decades but had only figured out that there were different types of pneumonia. Even as late as 1916, medical textbooks still listed pneumonia as incurable.

Rufus Cole at the Rockefeller Institute focused most of his and his team’s research on changing that. Cole had devised a serum that helped develop some immunity to one type of pneumonia and wanted to round out a team that could build on that. He hired Oswald Avery based on one paper on tuberculosis Cole had read. Avery was the opposite of Welch: He was obsessed only with research and had few other interests, and he could probe into something with depth. He devoted himself to the pneumonia research, which dragged on. He and his team, which included his roommate Alphonse Dochez, were able to cure mice with Cole’s serum but had little luck with humans. But he persisted, growing new strains of the pneumococcus bacteria (some lethal, some not) and learning everything he could about it.

Eventually, he identified three prevalent strains of pneumococci. He learned that the serum only bound to one type, and he perfected new sera to try with the other types. One of the sera was especially helpful at combating pneumonia in lab animals, and Avery wanted to test it on humans. Mostly, though, Avery became focused on the fact that some pneumococci were surrounded by a hard capsule of sugar, like the “hard shell of sugar surrounding the soft insides of M&M candy” (161). Avery would dwell on that shell for decades and would eventually “yield a momentous discovery” (161). But first came the influenza epidemic.

Cole, Avery, and Dochez tested their serum on human patients and found that administering a large dose of it did cut death rates by more than 50% but that it was not a cure. Still, it was progress, and Gorgas sent army doctors to the Rockefeller Institute to learn how to prepare the serum. At the same time, Cole, Avery, and Dochez developed vaccines for the other types of pneumonia. They worked fairly well, but there were not enough tests conducted on them to prove conclusive. These vaccines came too late to fight the measles outbreak in the camps, but they were successful enough for Gorgas and Welch to create a special board on pneumonia, chaired by Cole, with lab research run by Avery. The board listened to input from camp hospitals and laboratories while also offering its own assessment. The board as a whole became increasingly worried about preventing another measles outbreak. Welch and the board requested the military quarantine all new recruits for 10 to 14 days to prevent the chance of spreading disease. As of May 1918, the board was relieved to know that overall crowding in army hospitals was down, though crowding in the barracks remained high. The board mentioned influenza as a concern but was not particularly worried about it.