The Great Influenza

by John M. Barry

  Colonel Gibson, commander of the Fifty-seventh Vermont, wrote of his regiment's experience on the Leviathan: 'The ship was packed' [C]onditions were such that the influenza could breed and multiply with extraordinary swiftness' . The number of sick increased rapidly, Washington was apprised of the situation, but the call for men for the Allied armies was so great that we must go on at any cost' . Doctors and nurses were stricken. Every available doctor and nurse was utilized to the limit of endurance. The conditions during the night cannot be visualized by anyone who had not actually seen them' [G]roans and cries of the terrified added to the confusion of the applicants clamoring for treatment and altogether a true inferno reigned supreme.'

  It was the same on other ships. Pools of blood from hemorrhaging patients lay on the floor and the healthy tracked the blood through the ship, making decks wet and slippery. Finally, with no room in sick bay, no room in the areas taken over for makeshift sick bays, corpsmen and nurses began laying men out on deck for days at a time. Robert Wallace aboard the Briton remembered lying on deck when a storm came, remembered the ship rolling, the ocean itself sweeping up the scuppers and over him and the others, drenching them, their clothes, their blankets, leaving them coughing and sputtering. And each morning orderlies carried away bodies.

  At first the deaths of men were separated by a few hours: the log of the Leviathan noted, '12:45 P.M. Thompson, Earl, Pvt 4252473, company unknown died on board' . 3:35 P.M. Pvt O Reeder died on board of lobar pneumonia' .' But a week after leaving New York, the officer of the day was no longer bothering to note in the log 'died on board,' no longer bothering to identify the military organization to which the dead belonged, no longer bothering to note a cause of death; he was writing only a name and a time, two names at 2:00 A.M., another at 2:02 A.M., two more at 2:15 A.M., like that all through the night, every notation in the log now a simple recitation of mortality, into the morning a death at 7:56 A.M., at 8:10 A.M., another at 8:10 A.M., at 8:25 A.M.

  The burials at sea began. They quickly became sanitary exercises more than burials, bodies lying next to one another on deck, a few words and a name spoken, then one at a time a corpse slipped overboard into the sea. One soldier aboard the Wilhelmina watched across the waves as bodies dropped into the sea from another ship in his convoy, the Grant: 'I confess I was near to tears, and that there was tightening around my throat. It was death, death in one of its worst forms, to be consigned nameless to the sea.'

  *

  The transports became floating caskets. Meanwhile, in France, by any standard except that of the cantonments at home, influenza was devastating troops. In the last half of October during the Meuse-Argonne offensive, America's largest of the war, more Third Division troops were evacuated from the front with influenza than with wounds. (Roughly the same number of troops were in the United States and Europe, but influenza deaths in Europe were only half those in America. The likely explanation is that soldiers at the front had been exposed to the earlier mild wave of influenza and developed some immunity to it.) One army surgeon wrote in his diary on October 17 that because of the epidemic, 'Some hospitals are not even working. Evacuation 114 had no medical officer but hundreds of pneumonias,' dying by the score.'

  Shipping more men who required medical care into this maelstrom made little sense. It is impossible to state how many soldiers the ocean voyages killed, especially when one tries to count those infected aboard ship who died later on shore. But for every death at least four or five men were ill enough to be incapacitated for weeks. These men were a burden rather than a help in Europe.

  Wilson had made no public statement about influenza. He would not shift his focus, not for an instant. Yet people he trusted spoke to him of the disease, spoke particularly of useless deaths on the transports. Chief among them was certainly Dr. Cary Grayson, a navy admiral and Wilson's personal physician, as he had been personal physician to Teddy Roosevelt and William Howard Taft when they were president. Highly competent and highly organized, Grayson had become a Wilson confidant who strayed into the role of adviser. (After Wilson's stroke in 1919, he would be accused of virtually running the country in concert with Wilson's wife.) He also had the confidence of and excellent relationships with Gorgas and Welch. It was likely that army medical staff had talked to Grayson, and Grayson had been urging army chief of staff General Peyton March to freeze the movement of troops to Europe. March had refused.

  Grayson convinced Wilson to summon March to the White House on October 7 to discuss the issue. Late that night Wilson and March met. Wilson said, 'General March, I have had representations sent to me by men whose ability and patriotism are unquestioned that I should stop the shipment of men to France until this epidemic of influenza is under control' . [Y]ou decline to stop these shipments.'

  March made no mention of any of the advice he had received from Gorgas's office. He insisted that every possible precaution was being taken. The troops were screened before embarking and the sick winnowed out. Some ships even put ashore in Halifax, Nova Scotia, those who fell seriously ill before the actual Atlantic crossing began. If American divisions stopped arriving in France, whatever the reason, German morale might soar. True, some men had died aboard ship, but, March said, 'Every such soldier who has died just as surely played his part as his comrade who died in France.'

  The war would end in a little over a month. The epidemic had made virtually all training in cantonments impossible. A parliament (not the kaiser) had already taken over the German government and sent out peace feelers, while Germany's allies had already collapsed, capitulated, or, in the case of Austria, asked for peace on any terms Wilson dictated. But March insisted, 'The shipment of troops should not be stopped for any cause.'

  March later wrote that Wilson turned in his chair, gazed out the window, his face very sad, then gave a faint sigh. In the end, only a single military activity would continue unaffected in the face of the epidemic. The army continued the voyages of troopships overseas.

  *

  If Wilson did nothing about influenza in the military but express concern about shipping troops to Europe, he did even less for civilians. He continued to say nothing publicly. There is no indication that he ever said anything privately, that he so much as inquired of anyone in the civilian arm of the government as to its efforts to fight the disease.

  Wilson had appointed strong men to his administration, powerful men, and they took decisive actions. They dominated the nation's thought, and they dominated the nation's economy. But none of those appointees had any real responsibility for health. Surgeon General Rupert Blue, head of the United States Public Health Service, did. And Blue was not a strong man.

  A square-faced man with a square thick athletic body, an amateur boxer, Blue was physically strong all right, even deep into middle age. But he was not strong in ways that mattered, in leadership. In a field that was largely new when he entered it, a field in which colleagues were cutting new paths into the wild in dozens of directions, he had broken no ground, demonstrated no professional courage, nor had he even showed real zeal. If he was by no means unintelligent, he lacked either real intellectual rigor or the creativity to ask important questions, and he had never manifested any truly special talents in or insights into public health.

  As far as scientific public health issues went, the real leaders of the medical profession considered him a lightweight. Welch and Vaughan had not even trusted him to name the Public Health Service's representative to the National Research Council, and so they themselves had picked a PHS scientist they respected. Cary Grayson thought so little of him that he began to build an alternative national public health organization. (He abandoned his effort when Tammany took over the New York City Department of Health.) Blue became surgeon general simply by carrying out assigned tasks well, proving himself an adept and diplomatic maneuverer, and seizing his main chance. That was all.

  After finishing his medical studies in 1892, Blue had immediately joined the Public Health Service and remained the
re his entire professional life. His assignments had moved him from port to port, to Baltimore, Galveston, New Orleans, Portland, New York, Norfolk, where he worked in hospitals and quarantine stations and on sanitation issues. His opportunity came with an outbreak of bubonic plague in San Francisco in 1903. Another PHS officer, a highly regarded scientist, had engaged in a running battle with local government and business leaders, who denied plague existed in the city. Blue did not prove that it did (Simon Flexner did that, demonstrating the plague bacillus in the laboratory, as part of a scientific team brought in to settle the question) but Blue did win grudging cooperation from local authorities in efforts to control the disease. This was no easy task, and he both oversaw the killing of rats and kept, according to one laudatory report, 'all interests in the State' harmonized.'

  This success won him powerful friends. (He was not successful enough, however, to prevent plague spreading from rats to wild rodent populations; today plague exists in squirrels, prairie dogs, and other animals in much of the Pacific Coast and inland to Arizona, New Mexico, and Colorado.) When plague resurfaced in San Francisco in 1907 he was called back. Another success won him more powerful friends. In 1912 he rose to surgeon general. That same year Congress expanded the Public Health Service's power. From that position he pushed for national medical insurance, which the medical profession then advocated, and in 1916 he became president of the American Medical Association. In his presidential address he declared, 'There are unmistakable signs that health insurance will constitute the next great step in social legislation.'

  Wilson did not bother to choose a new surgeon general, but when the war began he did make the Public Health Service part of the military. It had consisted chiefly of several quarantine stations that inspected incoming ships, the Marine Hospital Service, which cared for merchant seamen and some federal workers, and the Hygienic Laboratory. Now it became responsible for protecting the nation's health, if only so the nation could produce more war matériel. Blue did not grow with the job.

  In advance of the epidemic, Gorgas had used all means possible to protect the millions of soldiers from disease. His counterpart Navy Surgeon General William Braisted had done little to match Gorgas, but he was supporting work by such men as Rosenau in Boston and Lewis in Philadelphia.

  Blue by contrast did, literally, less than nothing; he blocked relevant research. On July 28, 1918, Blue rejected a request from George McCoy, director of the Hygienic Laboratory, for $10,000 for pneumonia research designed to complement the efforts of the Rockefeller Institute. Although Congress in 1912 had given the agency authority to study 'diseases of man and conditions affecting the propagation thereof,' Blue determined that McCoy's 'investigation is not immediately necessary to the enforcement of the law.'

  Blue knew of the possibility of influenza in the United States. On August 1, the Memphis Medical Monthly published comments by him warning of it. Yet he made no preparations whatsoever to try to contain it. Even after it began to show evidence of lethality, even after Rufus Cole prodded his office to collect data, neither he nor his office attempted to gather information about the disease anywhere in the world. And he made no effort whatsoever to prepare the Public Health Service for a crisis.

  Many of those under him were no better. The Commonwealth Pier outbreak began late in August, and by September 9 newspapers were reporting that influenza victims filled 'all the hospital beds at the forts at Boston harbor,' Camp Devens had thirty-five hundred influenza cases, and Massachusetts hospitals were filling with civilians. Yet the local Public Health Service officer later insisted, 'The first knowledge of the existence of the disease reached this officer September 10th.'

  The virus had reached New Orleans on September 4; the Great Lakes Naval Training Station on September 7; New London, Connecticut, on September 12.

  Not until September 13 did the Public Health Service make any public comment, when it said, 'Owing to disordered conditions in European countries, the bureau has no authoritative information as to the nature of the disease or its prevalence.' That same day Blue did issue a circular telling all quarantine stations to inspect arriving ships for influenza. But even that order only advised delaying infected vessels until 'the local health authorities have been notified.'

  Later Blue defended himself for not taking more aggressive action. This was influenza, only influenza, he seemed to be saying, 'It would be manifestly unwarranted to enforce strict quarantine against' influenza.'

  No quarantine of shipping could have succeeded anyway. The virus was already here. But Blue's circular indicated how little Blue had done (in fact he had done nothing) to prepare the Public Health Service, much less the country, for any onslaught.

  The virus reached Puget Sound on September 17.

  Not until September 18 did Blue even seek to learn which regions of the United States the disease had penetrated.

  On Saturday, September 21, the first influenza death occurred in Washington, D.C. The dead man was John Ciore, a railroad brakeman who had been exposed to the disease in New York four days earlier. That same day Camp Lee outside Petersburg, Virginia, had six deaths, while Camp Dix in New Jersey saw thirteen soldiers and one nurse die.

  Still Blue did little. On Sunday, September 22, the Washington newspapers reported that Camp Humphreys (now Fort Belvoir), just outside the city, had sixty-five cases.

  Now, finally, in a box immediately adjacent to those reports, the local papers finally published the government's first warning of the disease:

  Surgeon General's Advice to Avoid Influenza

  Avoid needless crowding.

  Smother your coughs and sneezes.

  Your nose not your mouth was made to breathe thru.

  Remember the 3 Cs - clean mouth, clean skin, and clean clothes.

  Food will win the war. [H]elp by choosing and chewing your food well.

  Wash your hands before eating.

  Don't let the waste products of digestion accumulate.

  Avoid tight clothes, tight shoes, tight gloves - seek to make nature your ally not your prisoner.

  When the air is pure breathe all of it you can - breathe deeply.

  Such generalizations hardly reassured a public that knew that the disease was marching from army camp to army camp, killing soldiers in large numbers. Three days later a second influenza death occurred in Washington; John Janes, like the first Washington victim, had contracted the disease in New York City. Also that day senior medical personnel of the army, navy, and Red Cross met in Washington to try to figure out how they could aid individual states. Neither Blue nor a representative of the Public Health Service attended the meeting. Twenty-six states were then reporting influenza cases.

  Blue had still not laid plans for an organization to fight the disease. He had taken only two actions: publishing his advice on how to avoid the disease and asking the National Academy of Sciences to identify the pathogen, writing, 'In view of the importance which outbreaks of influenza will have on war production, the Bureau desires to leave nothing undone' . The Bureau would deem it a valuable service if the Research Council arrange for suitable laboratory studies' as to the nature of the infecting organism.'

  Crowder canceled the draft. Blue still did not organize a response to the emergency. Instead, the senior Public Health Service officer in charge of the city of Washington reiterated to the press that there was no cause for alarm.

  Perhaps Blue considered any further action outside the authority of the Public Health Service. Under him the service was a thoroughly bureaucratic institution, and bureaucratic in none of the good ways. Only a decade earlier he had been stationed in New Orleans, when the last yellow-fever epidemic to strike the United States had hit there, and the Public Health Service had required the city to pay $250,000 (in advance) to cover the federal government's expenses in helping to fight that epidemic. Only a few weeks earlier, he had rejected the request from the service's own chief scientist for money to research pneumonia in concert with Cole and Avery at the Rocke
feller Institute.

  But governors and mayors were demanding help, beseeching everyone in Washington for help. Massachusetts officials in particular were begging for help from outside the state, for doctors from outside, for nurses from outside, for laboratory assistance from outside. The death toll there had climbed into the thousands. Governor Samuel McCall had wired governors for any assistance they could offer, and on September 26 he formally requested help from the federal government.

  Doctors and nurses were what was needed. Doctors and nurses. And especially nurses. As the disease spread, as warnings from Welch, Vaughan, Gorgas, dozens of private physicians, and, finally, at last, Blue poured in, Congress acted. Without the delay of hearings or debate, it appropriated $1 million for the Public Health Service. The money was enough for Blue to hire five thousand doctors for emergency duty for a month (if he could somehow find five thousand doctors worth hiring.

  Each day (indeed, each hour) was showing the increasingly explosive spread of the virus and its lethality. Blue, as if suddenly frightened, now considered the money too little. He had not complained to Congress about the amount; no record exists of his having asked for more. But the same day Congress passed the appropriation, he privately appealed to the War Council of the Red Cross both for more money and for its help.

  The Red Cross did not get government funds or direction, although it was working in close concert with the government. Nor was its charge to care for the public health. Yet even before Blue asked, it had already allocated money to fight the epidemic and had begun organizing its own effort to do so - and do so on a massive scale. Its nursing department had already begun mobilizing 'Home Defense Nurses,' fully professional nurses, all of them women, who could not serve in the military because of age, disability, or marriage. The Red Cross had divided the country into thirteen divisions, and the nursing committee chief of each one had already been told to find all people with any nursing training, not only professionals or those who had dropped out of nursing schools (for the Red Cross checked with all nursing schools) but down to and including anyone who had ever taken a Red Cross course in caring for the sick at home. It had already instructed each division to form at least one mobile strike force of nurses to be ready to go to areas most in need. And before anyone within the government sought aid, the War Council of the Red Cross had designated a 'contingent fund for the purpose of meeting the present needs in coping with the epidemic of Spanish influenza.' Now the council agreed instantly to authorize expenditure of far more money than was in the contingency fund.