The Great Influenza

by John M. Barry

  The study of epidemic disease is, of course, a prime focus of public health.

  Welch was sick the day of the scheduled opening, and getting sicker. He had recently returned from a trip to investigate a strange and deadly epidemic. His symptoms were identical to those of the victims of that epidemic, and he believed he too had the disease.

  The army Welch had created was designed to attack, to seek out particular targets, if only targets of opportunity, and kill them. On October 1, 1918, the abilities of that army were about to be tested by the deadliest epidemic in human history.

  Part II

  THE SWARM

  CHAPTER SIX

  HASKELL COUNTY, KANSAS, lies west of Dodge City, where cattle drives up from Texas reached a railhead, and belongs geographically to and, in 1918, not far in time from, the truly Wild West. The landscape was and is flat and treeless, and the county was, literally, of the earth. Sod houses built of earth were still common then, and even one of the county's few post offices was located in the dug-out sod home of the postmaster, who once a week collected the mail by riding his horse forty miles round-trip to the county seat in Santa Fe, a smattering of a few wooden buildings that was already well on its way to becoming the ghost town it would be in another ten years - today only its cemetery remains as a sign of its existence. But other towns nearby did have life. In Copeland, Stebbins Cash Store sold groceries, shoes, dry goods, dishes, hardware, implements, paints, and oils, while in Sublette, in the absence of a bank, S. E. Cave loaned money on real estate for 7.5 percent.

  Here land, crops, and livestock were everything, and the smell of manure meant civilization. Farmers lived in close proximity to hogs and fowl, with cattle, pigs, and poultry everywhere. There were plenty of dogs too, and owners made sure to teach their dogs not to chase someone else's cattle; that could get them shot.

  It was a land of extremes. It was dry enough that the bed of the Cimarron River often lay cracked and barren of water, dry enough that the front page of the local newspaper proclaimed in February 1918, 'A slow rain fell all day, measuring 27 one hundredths. It was well appreciated.' Yet torrential rains sometimes brought floods, such as the one in 1914 that drowned ranchers and wiped out the first and largest permanent business in the area, a ranch that ran thirty thousand head of cattle. In summer the sun bleached the prairie, parching it under a heat that made light itself quiver. In winter unearthly gales swept unopposed across the plains for hundreds of miles, driving the windchill past fifty degrees below zero; then the country seemed as frozen and empty as the Russian steppes. And storms, violent storms, from tornadoes to literally blinding blizzards, plagued the region. But all these extremes of nature came every season. Another extreme of nature came only once.

  Epidemiological evidence suggests that a new influenza virus originated in Haskell County, Kansas, early in 1918. Evidence further suggests that this virus traveled east across the state to a huge army base, and from there to Europe. Later it began its sweep through North America, through Europe, through South America, through Asia and Africa, through isolated islands in the Pacific, through all the wide world. In its wake followed a keening sound that rose from the throats of mourners like the wind. The evidence comes from Dr. Loring Miner.

  *

  Loring Miner was an unusual man. A graduate of the oldest university in the West, Ohio University in Athens, Ohio, a classicist enamored of ancient Greece, he had come in 1885 to this region. Despite a background so unlike those of his fellow frontiersmen, he had taken to the country and done well.

  Miner was a big man in many ways: physically large, with angular features and a handlebar mustache, gruff, someone who didn't suffer fools - especially when he drank, which was often. A certain rebelliousness was part of his bigness as well. He hadn't seen the inside of a church in years. Periodically he reread the classics in Greek but he ate peas with his knife. And in thirty years on that prairie he had built a small empire apart from medicine. In the Odd Fellows he was a past noble grand, he had chaired the county Democratic Party, had been county coroner, was county health officer. He owned a drugstore and grocery and expected his patients to buy from him, and he married into the family of the largest landowners in western Kansas. Even in Haskell there was a social order, and now, during the war, his wife used her social standing as head of the county Red Cross Woman's Work Committee. When she asked for something few said no to her, and most women in the county did Red Cross work - real work, hard work, almost as hard as farmwork.

  But Miner also personified Welch's comment that the results of medical education were better than the system. Although an isolated country doctor who began practicing before the establishment of the germ theory of disease, he had quickly accepted it, kept up with the astounding advances in his profession, built a laboratory in his office, learned how to use the new antitoxins for diphtheria and tetanus. By 1918 one of his sons had also become a doctor with a fully scientific education, and was already in the navy. He prided himself on his own scientific knowledge and puzzled over problems. His patients said they'd rather have him drunk than someone else sober.

  His practice ranged over hundreds of square miles. Perhaps that was what Miner liked about it, the great expanse, the extremes, the lonely wind that could turn as violent as a gunshot, the hours spent making his way to a patient, sometimes in a horse and buggy, sometimes by car, sometimes by train - conductors would hold the train for him, and in winter stationmasters would violate the rules and let him wait inside the office by the stove.

  But in late January and early February 1918, Miner had other concerns. One patient presented with what seemed common symptoms, although with unusual intensity - violent headache and body aches, high fever, nonproductive cough. Then another. And another. In Satanta, in Sublette, in Santa Fe, in Jean, in Copeland, on isolated farms.

  Miner had seen influenza often. He diagnosed the disease as influenza. But he had never seen influenza like this. This was violent, rapid in its progress through the body, and sometimes lethal. This influenza killed. Soon dozens of his patients (the strongest, the healthiest, the most robust people in the county) were being struck down as suddenly as if they had been shot.

  Miner turned all his energies to this disease. He drew blood, urine, and sputum samples, and used the laboratory skills his son had helped him improve. He searched all his medical texts and journals. He called his few colleagues in that part of the state. He contacted the U.S. Public Health Service, which offered him neither assistance nor advice. Meanwhile he likely did what little he could, trying diphtheria antitoxin with no effect, perhaps even trying tetanus antitoxin - anything that might stimulate the body's immune system against disease.

  The local paper, the Santa Fe Monitor, apparently worried about hurting morale in wartime, said little about deaths but on inside pages reported, 'Mrs. Eva Van Alstine is sick with pneumonia. Her little son Roy is now able to get up'. Ralph Lindeman is still quite sick'. Goldie Wolgehagen is working at the Beeman store during her sister Eva's sickness'. Homer Moody has been reported quite sick'. Mertin, the young son of Ernest Elliot, is sick with pneumonia'. We are pleased to report that Pete Hesser's children are recovering nicely'. Mrs J. S. Cox is some better but is very weak yet'. Ralph McConnell has been quite sick this week.'

  By now the disease overwhelmed Miner with patients. He pushed everything else aside, slept sometimes in his buggy while the horse made its own way home (one advantage over the automobile) through frozen nights. Perhaps he wondered if he was being confronted with the Plague of Athens, a mysterious disease that devastated the city during the Peloponnesian Wars, killing possibly one-third the population.

  Then the disease disappeared. By mid-March the schools reopened with healthy children. Men and women returned to work. And the war regained its hold on people's thoughts.

  The disease still, however, troubled Miner deeply. It also frightened him, not only for his own people but for the people beyond. Influenza was neither a 'reportable' disease (not a
disease that the law required physicians to report) nor a disease that any state or federal public health agency tracked.

  Yet Miner considered his experience so unusual, and this eruption of the disease so dangerous, that he formally warned national public health officials about it.

  Public Health Reports was a weekly journal published by the U.S. Public Health Service to alert health officials to outbreaks of all communicable diseases, not only in North America and Europe but anywhere in the world - in Saigon, Bombay, Madagascar, Quito. It tracked not just deadly diseases such as yellow fever and plague but far lesser threats; especially in the United States, it tracked mumps, chickenpox, and measles.

  In the first six months of 1918, Miner's warning of 'influenza of severe type' was the only reference in that journal to influenza anywhere in the world. Other medical journals that spring carried articles on influenza outbreaks, but they all occurred after Haskell's, and they were not issued as public health warnings. Haskell County remains the first outbreak in 1918 suggesting that a new influenza virus was adapting, violently, to man.

  As it turned out, the death rate in Haskell as a percentage of the entire county's population was only a fraction of what the death rate for the United States would be later that year, when influenza struck in full force.

  People suffering from influenza shed virus (expel viruses that can infect others) for usually no more than seven days after infection and often even less. After that, although they may continue to cough and sneeze, they will not spread the disease. As sparsely populated and isolated as Haskell was, the virus infecting the county might well have died there, might well have failed to spread to the outside world. That would be so except for one thing: this was wartime.

  The same week that Homer Moody and a dozen others in Jean, Kansas, fell ill, a young soldier named Dean Nilson came home to Jean on leave from Camp Funston, located three hundred miles away within the vast Fort Riley military reservation. The Santa Fe Monitor noted, 'Dean looks like soldier life agrees with him.' After his leave, of course, he returned to the camp. Ernest Elliot left Sublette, in Haskell County, to visit his brother at Funston just as his child fell ill; by the time Elliot returned home, the child had pneumonia. Of nearby Copeland on February 21, the paper said, 'Most everybody over the country is having lagrippe or pneumonia.'€ On February 28 it reported that John Bottom just left Copeland for Funston: 'We predict John will make an ideal soldier.'€

  *

  Camp Funston, the second-largest cantonment in the country, held on average fifty-six thousand green young troops. The camp was built at the confluence of the Smoky Hill and Republican Rivers, where they form the Kansas River. Like all the other training camps in the country, Funston had been thrown together in literally a few weeks in 1917. There the army prepared young men for war.

  It was a typical camp, with typical tensions between army regulars and men who had until recently been civilians. When Major John Donnelly was stopped by military police for speeding, for example, he defended himself to the commanding general: 'I have, on a few occasions, corrected (enlisted) personnel along the road parallel to that camp for failure to salute; cases that I could not conscientiously overlook, there being no excuse whatever for their failure to do so. This, like my attempted correction of this guard, may not have been taken in the proper spirit, resulting in a feeling of insubordinate revenge and animosity towards me by members of this organization.'€

  There were also the usual clashes of egos, especially since Camp Funston and Fort Riley had different commanding officers. These clashes ended when Major General C. G. Ballou, who commanded the cantonment, sent a missive to Washington. He had developed what he described as a 'training ground for specialists'€ at Smoky Hill Flat. In fact, Smoky Hill Flat was the best of three polo fields on the base. The commanding officer of Fort Riley, only a colonel, established the post dump beside it. The general requested and received authority 'to exercise command over the entire reservation of Fort Riley,'€ and the colonel was relieved of his command.

  Funston was typical in another way. The winter of 1917-18 was one of record cold, and, as the army itself conceded, at Funston as elsewhere 'barracks and tents were overcrowded and inadequately heated, and it was impossible to supply the men with sufficient warm clothing.'€

  So army regulations (written for health reasons) detailing how much space each man should have were violated, and men were stacked in bunks with insufficient clothing and bedding and inadequate heating. That forced them to huddle ever more closely together around stoves.

  Men inducted into the army from Haskell County trained at Funston. There was a small but constant flow of traffic between the two places.

  On March 4 a private at Funston, a cook, reported ill with influenza at sick call. Within three weeks more than eleven hundred soldiers were sick enough to be admitted to the hospital, and thousands more (the precise number was not recorded) needed treatment at infirmaries scattered around the base. Pneumonia developed in 237 men, roughly 20 percent of those hospitalized, but only thirty-eight men died. While that was a higher death toll than one would normally expect from influenza, it was not so high as to draw attention, much less than the death rate in Haskell, and only a tiny fraction of the death rate to come.

  All influenza viruses mutate constantly. The timing of the Funston explosion strongly suggests that the influenza outbreak there came from Haskell; if Haskell was the source, whoever carried it to Funston brought a mild version of the virus, but it was a version capable of mutating back to lethality.

  Meanwhile Funston fed a constant stream of men to other American bases and to Europe, men whose business was killing. They would be more proficient at it than they could imagine.

  CHAPTER SEVEN

  NO ONE WILL EVER KNOW with absolute certainty whether the 1918-19 influenza pandemic actually did originate in Haskell County, Kansas. There are other theories of origin. (For a fuller discussion of them see Afterword.) But Frank Macfarlane Burnet, a Nobel laureate who lived through the pandemic and spent most of his scientific career studying influenza, later concluded that the evidence was 'strongly suggestive' that the 1918 influenza pandemic began in the United States, and that its spread was 'intimately related to war conditions and especially the arrival of American troops in France.' Numerous other scientists agree with him. And the evidence does strongly suggest that Camp Funston experienced the first major outbreak of influenza in America; if so, the movement of men from an influenza-infested Haskell to Funston also strongly suggests Haskell as the site of origin.

  Regardless of where it began, to understand what happened next one must first understand viruses and the concept of the mutant swarm.

  Viruses are themselves an enigma that exist on the edges of life. They are not simply small bacteria. Bacteria consist of only one cell, but they are fully alive. Each has a metabolism, requires food, produces waste, and reproduces by division.

  Viruses do not eat or burn oxygen for energy. They do not engage in any process that could be considered metabolic. They do not produce waste. They do not have sex. They make no side products, by accident or design. They do not even reproduce independently. They are less than a fully living organism but more than an inert collection of chemicals.

  Several theories of their origin exist, and these theories are not mutually exclusive. Evidence exists to support all of them, and different viruses may have developed in different ways.

  A minority view suggests that viruses originated independently as the most primitive molecules capable of replicating themselves. If this is so, more advanced life forms could have evolved from them.

  More virologists think the opposite: that viruses began as more complex living cells and evolved (or, more accurately, devolved) into simpler organisms. This theory does seem to fit some organisms, such as the 'rickettsia' family of pathogens. Rickettsia used to be considered viruses but are now thought of as halfway between bacteria and viruses; researchers believe they once p
ossessed but lost activities necessary for independent life. The leprosy bacillus also seems to have moved from complexity (doing many things) toward simplicity (doing fewer). A third theory argues that viruses were once part of a cell, an organelle, but broke away and began to evolve independently.

  Whatever the origin, a virus has only one function: to replicate itself. But unlike other life forms (if a virus is considered a life form), a virus does not even do that itself. It invades cells that have energy and then, like some alien puppet master, it subverts them, takes them over, forces them to make thousands, and in some cases hundreds of thousands, of new viruses. The power to do this lies in their genes.

  *

  In most life forms, genes are stretched out along the length of a filament-like molecule of DNA, deoxyribonucleic acid. But many viruses - including influenza, HIV, and the coronavirus that causes SARS (Severe Acute Respiratory Syndrome) - encode their genes in RNA, ribonucleic acid, an even simpler but less stable molecule.

  Genes resemble software; just as a sequence of bits in a computer code tells the computer what to do (whether to run a word processing program, a computer game, or an Internet search, genes tell the cell what to do.

  Computer code is a binary language: it has only two letters. The genetic code uses a language of four letters, each representing the chemicals adenine, guanine, cytosine, and thymine (in some cases uracil substitutes for thymine).

  DNA and RNA are strings of these chemicals. In effect they are very long sequences of letters. Sometimes these letters do not form words or sentences that make any known sense: in fact, 97 percent of human DNA does not contain genes and is referred to as 'nonsense' or 'junk' DNA.

  But when the letters spell out words and sentences that do make sense, then that sequence is by definition a gene.