The Great Influenza

by John M. Barry

  Finally, Blue began to organize the Public Health Service as well. Doctors and nurses were what was needed, doctors and nurses. But by then the virus had spanned the country, establishing itself on the perimeter, on the coasts, and it was working its way into the interior, to Denver, Omaha, Minneapolis, Boise. It was penetrating Alaska. It had crossed the Pacific to Hawaii. It had surfaced in Puerto Rico. It was about to explode across Western Europe, across India, across China, across Africa as well.

  Science, then as now a journal written by scientists for their colleagues, warned, 'The epidemics now occurring appear with electric suddenness, and, acting like powerful, uncontrolled currents, produce violent and eccentric effects. The disease never spreads slowly and insidiously. Wherever it occurs its presence is startling.'

  October, not April, would be the cruelest month.

  CHAPTER TWENTY-SEVEN

  NOTHING COULD HAVE STOPPED the sweep of influenza through either the United States or the rest of the world - but ruthless intervention and quarantines might have interrupted its progress and created occasional firebreaks.

  Action as ruthless as that taken in 2003 to contain the outbreak of a new disease called severe acute respiratory disorder, SARS, could well have had effect.* Influenza could not have been contained as SARS was - influenza is far more contagious. But any interruption in influenza's spread could have had significant impact. For the virus was growing weaker over time. Simply delaying its arrival in a community or slowing its spread once there (just such minor successes) would have saved many, many thousands of lives.

  There was precedent for ruthless action. Only two years earlier several East Coast cities had fought a polio outbreak with the most stringent measures. Public health authorities wherever polio threatened had been relentless. But that was before the United States entered the war. There would be no comparable effort for influenza. Blue would not even attempt to intrude upon war work.

  The Public Health Service and the Red Cross still had a single chance to accomplish something of consequence. By early October the first fall outbreaks and the memory of those in the spring had already suggested that the virus attacked in a cycle; it took roughly six weeks from the appearance of the first cases for the epidemic to peak and then abate in civilian areas, and from three to four weeks in a military camp with its highly concentrated population. After the epidemic abated, cases still occurred intermittently, but not in the huge numbers that overwhelmed all services. So Red Cross and Public Health Service planners expected the attack would be staggered just as the arrival of the virus was staggered, peaking in different parts of the country at different times. During the peak of the epidemic, individual communities would not be able to cope; no matter how well organized they were they would be utterly overwhelmed. But if the Red Cross and Public Health Service could concentrate doctors, nurses, and supplies in one community when most needed, they might be able to withdraw the aid as the disease ebbed and shift it to the next area in need, and the next.

  To manage this, Blue and Frank Persons, director of civilian relief and head of the new influenza committee of the Red Cross, divided the labor. The Public Health Service would find, pay, and assign all physicians. It would decide when and where to send nurses and supplies, to whom nurses would report, and it would deal with state and local public health authorities.

  The Red Cross would find and pay nurses, furnish emergency hospitals with medical supplies wherever local authorities could not, and take responsibility for virtually everything else that came up, including distributing information. The Red Cross did stipulate one limit on its responsibility: it would not meet requests from military camps. This stipulation was immediately forgotten; even the Red Cross soon gave the military precedence over civilians. Meanwhile, its War Council ordered each one of its 3,864 chapters to establish an influenza committee even (indeed, especially) where the disease had not yet hit. It gave instructions on the organization of those committees, and it stated 'each community should depend upon its own resources to the fullest extent.'

  Persons had one model: Massachusetts. There James Jackson, the Red Cross division director for New England, had done an amazing job, especially considering that the region was struck without warning by what was originally an unknown disease. While chapters made gauze masks (the masks that would soon be seen everywhere and would become a symbol of the epidemic) Jackson first tried to supply nurses and doctors himself. When he failed, he formed an ad hoc umbrella organization including the state Council of National Defense, the U.S. Public Health Service, state and local public health authorities, and the Red Cross. These groups pooled their resources and allocated to towns as needed.

  Jackson had brought in nurses from Providence, New Haven, New York, even from Halifax and Toronto. He had succeeded at least somewhat in alleviating the personnel shortage. But Massachusetts had been lucky. When the epidemic erupted there, no other locality needed help. In the fourth week of the epidemic, Jackson reported, 'We have not yet reached the point where any community has been able to transfer its nurses or supplies. In Camp Devens' forty nurses ill there with many cases of pneumonia.'

  He also advised Red Cross headquarters in Washington: 'The most important thing in this crisis is more workers to go into the homes quickly and aid the family. Consequently I have telegraphed to all my chapters twice regarding the mobilization of women who have had First Aid and Home Nursing training or any others who are willing to volunteer their services.'

  And he confided, 'The Federal public health service has been' unable to handle adequately the entire situation' . [They] have not been on the job.'

  It was October when he sent that wire. By then everyone needed nurses, or they were about to, and they knew it. By then everyone needed doctors, or they were about to, and they knew it. And they needed resources. The biggest task remained finding doctors, nurses, and resources. They needed all three.

  *

  Even in the face of this pandemic, doctors could help. They could save lives. If they were good enough, if they had the right resources, if they had the right help, if they had time.

  True, no drug or therapy could alleviate the viral infection. Anyone who died directly from a violent infection of the influenza virus itself, from viral pneumonia progressing to ARDS, would have died anyway. In 1918, ARDS had virtually a 100 percent mortality rate.

  But there were other causes of death. By far the most common was from pneumonia caused by secondary bacterial infections.

  Ten days, two weeks, sometimes even longer than two weeks after the initial attack by the virus, after victims had felt better, after recovery had seemed to begin, victims were suddenly getting seriously ill again. And they were dying. The virus was stripping their lungs all but naked of their immune system; recent research suggests that the virus made it easier for some kinds of bacteria to lodge in lung tissue as well. Bacteria were taking advantage, invading the lungs, and killing. People were learning, and doctors were advising, and newspapers were warning, that even when a patient seemed to recover, seemed to feel fine, normal, well enough to go back to work, still that patient should continue to rest, continue to stay in bed. Or else that patient was risking his or her life.

  Half a dozen years earlier medicine had been helpless here, so helpless that Osler in his most recent edition of his classic text on the practice of medicine had still called for bleeding of patients with pneumonia. But now, for some of those who developed a secondary bacterial infection, something could be done. The most advanced medical practice, the best doctors, could help - if they had the resources and the time.

  Avery, Cole, and others at the Rockefeller Institute had developed the vaccine that had showed such promising result in the test at Camp Upton in the spring, and the Army Medical School was producing this vaccine in mass quantities. Avery and Cole had also developed the serum that slashed the mortality for pneumonias caused by Types I and II pneumococcus, which accounted for two-thirds or more of lobar pneumonias in normal cir
cumstances. These were not normal circumstances; bacteria that almost never caused pneumonia were now making their way unopposed into the lungs, growing there, and thriving there. But Types I and II pneumococci were still causing many of the pneumonias, and in those cases this serum could help.

  Other investigators had developed other vaccines and sera as well. Some, like the one developed by E. C. Rosenow at the Mayo Clinic and used in Chicago, were useless. But others may have done some good.

  Physicians also had other assets to call upon. Surgeons developed new techniques during the epidemic that are still in use to drain empyemas, pockets of pus and infection that formed in the lung and poisoned the body. And doctors had drugs that alleviated some symptoms or stimulated the heart; major hospitals had x rays that could aid in diagnosis and triage; and some hospitals had begun administering oxygen to help victims breathe - a practice neither widespread nor administered nearly as effectively as it would be, but worth something.

  Yet for a doctor to use these resources, any of them, that doctor had to have them - and also had to have time. The physical resources were hard to come by, but time was harder. There was no time. For that Rockefeller serum needed to be administered with precision and in numerous doses. There was no time. Not with patients overflowing wards, filling cots in hallways and on porches, not with doctors themselves falling ill and filling those cots. Even if they had resources, they had no time.

  And the doctors found by the Public Health Service had neither resources nor time. Nor was it simple to find the doctors themselves. The military had already taken at least one-fourth (in some areas one-third) of all the physicians and nurses. And the army, itself under violent attack from the virus, would lend none of its doctors to civilian communities no matter how desperate the circumstances.

  That left approximately one hundred thousand doctors in a labor pool to draw from - but it was a pool limited in quality. The Council of National Defense had had local medical committees secretly grade colleagues; those committees had judged roughly seventy thousand unfit for military service. Most of that number were unfit because they were judged incompetent.

  The government had had a plan to identify the best of those remaining. As part of the mobilization of the entire nation, in January 1918 the Council of National Defense had created the 'Volunteer Medical Service.' This service tried to enlist every doctor in the United States, but it particularly wanted to track the younger physicians who were women or had a physical disability - in other words, those mostly likely to be good doctors who were not subject to and rejected by the draft.

  The mass targeting succeeded. Within eight months, 72,219 physicians had joined this service. They had joined, however, only to prove their patriotism, not as a commitment to do anything real - for membership required of them nothing concrete, and they received an attractive piece of paper suitable for framing and office display.

  But the plan to identify and have access to good doctors within this group collapsed. The virus was penetrating everywhere, doctors were needed everywhere, and no responsible doctor would abandon his (or, in a few instances, her) own patients in need, in desperate need. In addition, the federal government was paying only $50 a week - no princely sum even in 1918. Out of one hundred thousand civilian doctors, seventy-two thousand of whom had joined the Volunteer Medical Service, only 1,045 physicians answered the pleas of the Public Health Service. While a few were good young doctors who had not yet developed a practice and were waiting to be drafted, many of this group were the least competent or poorest trained doctors in the country. Indeed, so few doctors worked for the PHS that Blue would later return $115,000 to the Treasury from the the $1 million appropriation he had considered so insufficient.

  The Public Health Service sent these 1,045 doctors to places where there were no doctors at all, to places so completely devastated by the disease that any help, any help at all, was embraced. But they sent them with almost no resources, certainly without Rockefeller vaccines and serum or the training to make or administer them, certainly without x rays, certainly without oxygen and the means to administer it. The huge caseloads overwhelmed them, weighed them down, kept them moving.

  They diagnosed. They treated with all manner of materia medica. Yet in reality they could do nothing but advise. The best advice was this: stay in bed. And then the doctors moved on to the next cot or the next village.

  What could help, more than doctors, were nurses. Nursing could ease the strains on a patient, keep a patient hydrated, resting, calm, provide the best nutrition, cool the intense fevers. Nursing could give a victim of the disease the best possible chance to survive. Nursing could save lives.

  But nurses were harder to find than doctors. There were one-quarter fewer to begin with. The earlier refusal of the women who controlled the nursing profession to allow the training of large numbers either of nursing aides or of what came to be called practical nurses prevented the creation of what might have been a large reserve force. The plan had been to produce thousands of such aides; instead the Army School of Nursing had been established. So far it had produced only 221 student nurses and not a single graduate nurse.

  Then, just before the epidemic struck, combat had intensified in France and with it so had the army's need for nurses. The need had in fact become so desperate that on August 1, Gorgas, just to meet existing requirements, transferred one thousand nurses from cantonments in the United States to hospitals in France and simultaneously issued a call for 'one thousand nurses a week' for eight weeks.

  The Red Cross was the route of supply for nurses to the military, especially the army. It had already been recruiting nurses for the military with vigor. After Gorgas's call, it launched an even more impassioned recruiting campaign. Each division, each chapter within a division, was given a quota. Red Cross professionals knew that their careers were at risk if they did not meet it. Already recruiters had a list of all nurses in the country, their jobs and locations. Those recruiters now pressured nurses to quit jobs and join the military, pressured doctors to let office nurses go, made wealthy patients who retained private nurses feel unpatriotic, pushed private hospitals to release nurses.

  The drive was succeeding; it was removing from civilian life a huge proportion of those nurses mobile enough, unencumbered by family or other responsibilities, to leave their jobs. The drive was succeeding so well that it all but stripped hospitals of their workforce, leaving many private hospitals around the country so short-staffed that they closed, and remained closed until the war ended. One Red Cross recruiter wrote, 'The work at National Headquarters has never been so difficult and is now overwhelming us' .[We are searching] from one end of the United States to the other to rout out every possible nurse from her hiding place' . There will be no nurses left in civil life if we keep on at this rate.'

  The recruiter wrote that on September 5, three days before the virus exploded at Camp Devens.

  CHAPTER TWENTY-EIGHT

  PHILADELPHIA STAGGERED under the influenza attack, isolated and alone. In Philadelphia no sign surfaced of any national Red Cross and Public Health Service effort to help. No doctors recruited by the Public Health Service were sent there. No nurses recruited by the Red Cross were sent there. Those institutions gave no help here.

  Each day people discovered that friends and neighbors who had been perfectly healthy a week (or a day) earlier were dead. What should I do? People were panicked, desperate. How long will it go on?

  The mayor, arrested in the early days of the epidemic and then himself ill, had done absolutely nothing. A review of five daily newspapers, the Press, Inquirer, Bulletin, Public Ledger, and North American, did not find even a single statement about the crisis from the mayor. The entire city government had done nothing. Wilmer Krusen, head of the city health department, no longer had the confidence of anyone. Someone had to do something.

  Paul Lewis felt the pressures, felt the death all about him. He had felt at least some pressure since the sailors from the City of Exeter
had been dying what seemed so long ago. In early September, with the virus killing 5 percent of all Philadelphia navy personnel who showed any symptoms of influenza at all, that pressure had intensified. Since then he and everyone under him had hardly left their laboratories to go home. Finding B. influenzae had begun his real work, not concluded it.

  Never had he been so consumed with the laboratory. He had started his experiments with the pneumococcus. He had begun to explore the possibility that a filterable virus caused influenza. He had continued to look at the influenza bacillus. He and others had developed a vaccine. He was trying to make a serum. All of these he did simultaneously. For the one thing he did not have was time. No one had time.

  If Lewis had a scientific weakness, it was that he too willingly accepted guidance from those he respected. Once when he asked for more direction from Flexner, Flexner had rebuffed him, saying, 'I much prefer that you arrange plans' . I have not planned specifically for your time, but much prefer to leave the direction of it to you.' Lewis respected Flexner. He respected Richard Pfeiffer as well.

  In the overwhelming majority of cases he was now finding Pfeiffer's B. influenzae in swabs from living patients, in autopsied lungs. He was not finding it alone, necessarily, or always. It was not certain proof, but more and more he was coming to believe that this bacterium did in fact cause disease. And, under the pressure of time, he abandoned his investigation into the possibility that a filterable virus caused influenza.