The Great Influenza (John M. Barry)

 

The 1918 influenza pandemic rocked the world in the waning years of World War I, killing between 35-100 million people. The Great Influenza is the story of both the disease and the scientists working to fight it. 

The author wanted to include the political angle- what the leaders did to fight it from a social/political perspective- but "finding useful material on the epidemic proved remarkably difficult . . . [the political leaders were] far too busy, far too overwhelmed, to pay attention to keeping records." So instead the focus on the state of medical science- "partly because it didn't seem possible to write about the scientists without exploring the nature of American medicine at this time, for the scientists in this book did far more than laboratory reasearch. They changed the very nature of medicine in the United States." So this book was about how American medicine was modernizing in addition to explaining the potential origins, spread, horrors, and impact of the illness itself.

The book was good; informative and well-written. I was mildly disappointed, as I wished for more insight into effective public pandemic policy (or, at least, lessons learned from failed attempts). It's an occasional mention throughout, and then covered at the end, but that isn't the focus. 

Rating: A-

Post-script:

This book excited me because it was written before COVID and, as a result, unaffected by current political influences and "heat of the moment" emotion that can cloud judgment. Due to his research, the author was included on committees in the early 2000s looking at pandemic preparation, as many used this 1918 pandemic as a model. He talks about some suggestions at the very end- the last 10 pages- and that part is intriguing, if unsatisfying. I'd have like to read much more on the topic- and the back cover implies the books covers it, saying "this [1918] crisis provides us with a precise and sobering model as we confront the epidemics looming on our own horizon." If this crisis did, the book didn't cover it. But it sounds more accurate to say the 1918 flu did not provide us with a great model, but more a cautionary tale in several aspects. 

In the final ten pages, here are the comments, observations, and lessons based on the "commonalities of the few pandemics we have information about: 1889, 1918, 1957, 1968, and 2009:"* 

• Pandemics come in waves. We've seen this with COVID, with the first wave (in Europe) in early 2020, then smoldering, then roaring back in the autumn.
• Every wave of a pandemic is at least a little different, due to rapid mutation.
• The one answer is a universal vaccine. Obvious, and nearly impossible to create, test, manufacture, distribute, and administer quickly enough. Mutations can render it less effective or useless- and it may be impossible to develop an effective one in the first place.

Vaccines aside, what can we do or what must we remember? Barry's points, either at the end or collected from principles throughout the book:

• Develop and maintain a good surveillance system. This requires cooperative governments and capable medical personnel to identify new diseases (and mutations of it) and distribute knowledge quickly. Doing so is a critical 'early alert' mechanism that accelerates vaccine development and other countermeasures.
• Prepare. There are known items to either stockpile or ensure manufacturing capacity is present to produce: medicines, ventilators, oxygen tanks, masks, and so on. Supply chain is relevant here, too- identifying and addressing in advance the basic materials necessary should a pandemic erupt.
• Plan. The government must identify plans (in advance of a pandemic). Plans of paths to take based on certain triggers- and sticking to them even when emotion might tempt to do otherwise.
• Public officials and the media must tell the truth. Not minimize, not exaggerate- deliver the unvarnished truth. In 1918, "the fear, not the disease, threatened to break society apart." And the fear was generated, in part, by officials downplaying the pandemic. This countered what people saw with their eyes- healthy people dying with alarming rapidity, bodies literally piling up in the streets- and the result was chaos. "Those in authority must retain the public's trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one."
• Remember the need for concerted action. "Society cannot function if it is every man for himself." And this action must be within and between communities, towns, states, and countries. Action taken in one without appropriate steps in another will be effectively pointless. The public must comply for public health measures to have any hope of success.
• Remember the realities of science. The scientific method is such that initial hypotheses may be proved wrong. In the heat of the moment, the demand for action- to do something, anything, NOW- can lead scientists and medical personnel alike to give advice based on initial and limited observations. Advice that could be proven wrong as more information comes to light. This could mean that later recommendations contradict earlier ones. We abhor a vacuum of knowledge, so we want to act, even when (frankly) nobody knows what to do. This can lead doctors and scientists (not to mention government/media) to take educated guesses and make proclamations just to do something. (My addition: remember that, and treat each other with grace as we stumble in darkness together.)
• Identify public health measures. There are several:
• The only way to completely avoid a disease transmitted from human to human is simple: avoid humans. Some towns or institutions did isolate- implement a complete 'external' lockdown (nobody in or out) in 1918 and were completely spared. Duration must be 6-10 weeks (depending on virus/etc.) A lockdown of this severity is almost impossible. 
• Mundane but known hygienic tasks like washing hands must be done rigorously. "Success depends on rigor, emphasis, and discipline."
• Masks can protect, but must be worn properly (and most people- even doctors- do not do so). Interestingly, the author argues that "for a few individuals and situations N95 masks may make sense, but for the general public over a period of weeks they do not."
• Observe obvious matters like keeping sick people home and appropriate coughing etiquette.
• "In a truly lethal pandemic, state and local authorities could take much more aggressive steps, such as closing theaters, bars, and even banning sporting events . . . " 
• Interestingly, studies of past pandemics argue against children being super-spreaders, finding that the spread was overwhelmingly adult to adult (at first), and then adult to child (later). As such, the author argues that closing schools "might well make sense in a lethal pandemic, but it will not in a mild one." 

Our current pandemic proves that, regardless of scientific advances in the past century, there are unstoppable forces in nature. Forces that require truth, cooperation, planning, preparedness, hard work, and sacrifices to confront and endure. There are no easy answers and even hindsight may not shed light on what should have been done. Thus, it's important (as always) to treat each other with truth and grace, looking not only to ourselves, but thinking on how we can love each other in such difficult days.

*remember those were all influenza epidemics, which is different than COVID. Nevertheless, I believe some of the principles hold true.