Although his story opens with the establishment of the Johns Hopkins Hospital in 1876, Barry immediately takes a detour into the history of medicine dating back to Hippocrates, and traces the history of medical/scientific thought from Ancient Greece to the end of the 19^th century. He then introduces a series of physicians, scientists, and medical researchers who will play their parts in the story of the pandemic (this first section is called “The Warriors”) and outlines their training, research, and interactions.  

It isn’t until page 91 that he takes us to the rural Kansas county in which the story of the pandemic begins. For although it was called the “Spanish Flu,” that was actually an eponym of convenience; in fact, the first cases of pandemic flu seem to have arisen on the American prairie. However, newspaper reporting on the new pandemic was felt by the Allies and Central Powers alike to be contrary to the public interest (the war was still raging), so it was left to neutral Spain, whose king had come down with the disease, to publish the early reports. In this section, “The Swarm”, Barry also briefly reviews the basic (not to worry, very basic) microbiology of viruses and the history of some prior pandemics. He follows this with the section called “The Tinderbox,” in which he traces the events leading up to the entry of the United States into World War I, and the importance of that war and the political and social conditions surrounding it in the history of the pandemic. From here on in the influenza itself takes center stage; in sections called “It Begins,” “Explosion,” “Pestilence,” “The Race,” and “The Tolling of the Bell,” the rapid and lethal course of the pandemic is described in gripping (no pun intended) detail. The last two sections discuss the scientific advances (and some false starts) brought about by the cadre of researchers working day and night to tame the outbreak, and then Barry finally turns to the retreat of the virus and ultimate end of the pandemic. The book ends as it began, returning to the stories of the individual men and women of science who engaged in the battle to beat the disease of which it had initially been said by many that “[t]his was, after all, only influenza.”  

For anyone seeking to understand the 1918 influenza pandemic not only from a scientific and medical historical standpoint, but also with an appreciation of the political and sociocultural milieu in which it took place, you can’t do much better than Barry’s work. It is not short—it clocks in at 461 pages, with another nearly 40 pages of endnotes and a 20 page bibliography—but it is well-paced and reads smoothly; the narrative carries you along, a testament to the author’s writing style. Barry succeeds in putting a human face on the pandemic and creates a mental image of the horror of pandemic disease which can stand up alongside those we have of the Black Death of the mid-fourteenth century, with which it is often compared. For those of us who know the flu as a seasonal visitor, (for most of us a major annoyance, but nonetheless a disease that kills tens of thousands each year), the images of massive and rapid death—villages abandoned except for piles of corpses, trains that “left one station with the living…[and]…arrived with the dead and dying”—seem surreal. Barry paces the book in such a way that one can almost hear the stopwatch ticking in the background; The Great Influenza is scientific and historical reporting done with great attention to detail and to getting the medical facts right, but it is reporting done with a novelist’s flair.  

Even as the pandemic begins to recede, leaving in its wake not only the dead but those living with its sequelae, such as post-encephalitic syndromes (the Woodrow Wilson/Treaty of Versailles anecdote is particularly striking), the helplessness of medical science is reaffirmed; the pandemic recedes of its own accord, because the virus mutates to less virulent forms, and the very large number of those who have survived helps to create herd immunity.   

In the book’s Afterword, added in 2018, the author discusses and compares influenza pandemics which followed the 1918 experience, talks about some of the antiviral drugs introduced over the years and how they work, and speculates about what the next great influenza pandemic might look like and how it might be prepared for. His concern was prescient, although it would be a coronavirus, rather than influenza, that would cause widespread death and societal disruption. In fact, one of the most jarring aspects of this story is the fact that, if one changes the dates and the names, the tale bears an uncanny resemblance to the COVID-19 story, right down to the attempts at minimization by the government and even the isolation and victimization of an ethnic group (in 1918 the Germans, who were the enemy in the world war, rather than Asian-Americans, as it would be during COVID).  

The Great Influenza is a detailed, highly readable, and sobering account of an episode which demonstrated once again that despite what we may think, we are not the masters of the world in which we live, and that a microbe could rapidly kill on a devastating scale and upend society—again—and there was initially little that could be done to stop it.  

THE GREAT INFLUENZA: A Story of the Deadliest Pandemic in History
John Barry 
Penguin Books, New York, 2004 (reissued with new afterword, 2018)
461 pages 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image by Medhum.org

The modern world is full of inexplicable conflicts. As one who has spent my life developing vaccines against infectious diseases it is puzzling to see the growing opposition to vaccination, which in the United States and other developed countries have eliminated or limited diseases that once decimated populations. I am old enough to remember as a child the deaths of other children, and indeed as a child I suffered three serious infectious diseases, one of which caused temporary paralysis of my face. 

Later in life, I graduated medical school and became an intern at a large metropolitan hospital in Cleveland. One of the common infections I saw in children was due to a bacterium called Hemophilus influenzae type B, which causes meningitis and epiglottitis (swelling of the structure at the top of the trachea that leads to the lungs). I treated those infections with antibiotics, but that succeeded best if the illnesses were in early stages. I remember one night on duty when a 3-year-old gasping for air was brought in to the Emergency Room by his father. The child had been put to bed that evening appearing to be healthy, but became ill hours later. I rushed into the room ready to help but in seconds, before I could do anything, the child died before my eyes. I will not forget the anguish of his father, or the anguish of other parents I saw whose children were ill with infections. Owing to the later development and employment of a vaccine against H. influenzae type B, the disease has disappeared from the United States. 

In part, the current opposition to vaccines can be attributed to the absence of these diseases they cause, which makes people feel invincible, and in part to a society in which communication of lies and fabrications is easy and rife. Modern communication allows dissemination of arguments based on fabrications to masquerade as facts, and to allow some to profit from those fabrications. Another example of a foolish approach to the issue of vaccination is the attempt by the current administration to break up the measles-mumps-rubella vaccine into three separate injections, despite years and years of safe use of the MMR vaccine that has dramatically controlled those diseases. The effects on public health will be awful. 

Although there is no easy way to deal with this situation, I have long thought that including education in statistics for all school children would be one useful step, so that they understand the relations between risk and benefit when they become adults. The fact of the matter is there is no choice in life that is without risk. The question is what is the ratio of risk to benefits in making that choice? All statistical analyses show that vaccination has little risk and great benefit, so why should we let lies about vaccination prevail? 

All licensed vaccines go through a process involving 5 Phases: Phase 1 involves testing a vaccine in a small number of people. Phase 2 involves increasing the number to several hundred. Phase 3 involves thousands of vaccinees, compared to a group of placebo recipients, checking for safety and efficacy of the vaccine. Phase 4 is after licensure, when observations are accumulated in millions of vaccinees. Phase 5 involves collection and analysis by CDC and potentially other organizations of reports by physicians about safety and efficacy of the vaccine. 

Obviously, if a reaction to a vaccine is frequent, that will be detected in the first three phases. If a reaction is uncommon but significant, it will be detected in phase 4. (Actually, a vaccine against rotavirus, an important cause of infantile diarrhea, dehydration, and death, was taken off the market because of phase 4 findings, to be replaced by a safer vaccine developed in my lab.) The problem is that when millions are being vaccinated, bad things are certain to happen by chance. The question then is are they caused by the vaccine? The answer to that question can only be ascertained by careful study, not by jumping to conclusions. 

Web image from Wikicommons.