The Great Influenza (69 page)

Questions about who will have the authority to make and enforce such decisions, and under what circumstances, must be settled in advance. Neither an epidemic nor an attack will leave time for debate.

Some of the issues are almost purely ethical ones. If, say, containment of a pathogen is possible, but doing so requires isolating a building entirely, possibly saving many lives but at the cost of those in that building - what then? Medical ethics require physicians to do their best for each individual patient, but a military commander may ethically sacrifice a patrol, a platoon, a company to save a larger group. What ethic applies?

Another ethical question involves the free flow of scientific information. An investigator will probably at some point discover what made the 1918 virus so lethal. The influenza virus can be created to design in the laboratory, so publishing the information would give it to terrorists. A weaponized influenza virus could be the equivalent of a worldwide nuclear holocaust. But publishing would also give the information to researchers who could find a way to block whatever mechanism made the virus deadly, conceivably both countering any made-to-order killer virus and preventing any future natural outbreak on that scale. Should the information be published?

Scientific journals have already developed voluntary guidelines on what to publish, but these are not simple questions. Some go to the heart of medical or societal ethics, others to limits on freedom.

And some of these issues, such as stockpiling vaccines or training workers, simply cost enormous sums of money. So does paying nurses enough to escape the current nursing shortage, which may soon approach that of 1918.

What to do depends upon the assessment of the risk. Just as there was disagreement over the threat from the Soviet Union during the Cold War and how large the defense budget had to be to handle that threat, there will be disagreement over how real and how severe the threat from biological weapons is and how much must be spent (in money and in the erosion of values) to defend against it.

But there is another lesson from 1918 that is clear. It is also less tangible. It involves fear and the media and the way authorities deal with the public.

* 

There was terror afoot in 1918, real terror. The randomness of death brought that terror home. So did its speed. And so did the fact that the healthiest and strongest seemed the most vulnerable.

The media and public officials helped create that terror - not by exaggerating the disease but by minimizing it, by trying to reassure.

Terror rises in the dark of the mind, in the unknown beast tracking us in the jungle. The fear of the dark is an almost physical manifestation of that. Horror movies build upon the fear of the unknown, the uncertain threat that we cannot see and do not know and can find no safe haven from. But in every horror movie, once the monster appears, terror condenses into the concrete and diminishes. Fear remains. But the edge of panic created by the unknown dissipates. The power of the imagination dissipates.

In 1918 the lies of officials and of the press never allowed the terror to condense into the concrete. The public could trust nothing and so they knew nothing. So a terror seeped into the society that prevented one woman from caring for her sister, that prevented volunteers from bringing food to families too ill to feed themselves and who starved to death because of it, that prevented trained nurses from responding to the most urgent calls for their services. The fear, not the disease, threatened to break the society apart. As Victor Vaughan (a careful man, a measured man, a man who did not overstate to make a point) warned, 'Civilization could have disappeared within a few more weeks.'

So the final lesson, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that.

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. Lincoln said that first, and best.

Leadership must make whatever horror exists concrete. Only then will people be able to break it apart.

Acknowledgments

T
HIS BOOK
was initially supposed to be a straightforward story of the deadliest epidemic in human history, told from the perspectives of both scientists who tried to fight it and political leaders who tried to respond to it. I thought it would take me two and a half years to write, three at the most.

That plan didn't work. Instead this book took seven years to write. It has evolved (and, I hope, grown) into something rather different than originally conceived.

It took so long 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 research. They changed the very nature of medicine in the United States.

And, finding useful material on the epidemic proved remarkably difficult. It was easy enough to find stories of death, but my own interests have always focused on people who try to exercise some kind of control over events. Anyone doing so was far too busy, far too overwhelmed, to pay any attention to keeping records.

In the course of these seven years, many people helped me. Some shared with me their own research or helped me find material, others helped me understand the influenza virus and the disease it causes, and some offered advice on the manuscript. None of them, of course, is responsible for any errors of commission or omission, whether factual or of judgment, in the book. (Wouldn't it be entertaining to once read an acknowledgment in which the author blames others for any mistakes?)

Two friends, Steven Rosenberg and Nicholas Restifo at the National Cancer Institute, helped me understand how a scientist approaches a problem and also read parts of the manuscript and offered comments. So did Peter Palese at Mount Sinai Medical Center in New York, one of the world's leading experts on the influenza virus, who gave very generously of his time and expertise. Robert Webster, at St. Jude Medical Center, like Palese a world leader in influenza research, offered his insights and criticisms as well. Ronald French checked the manuscript for accuracy on the clinical course of the disease. Vincent Morelli introduced me to Warren Summers, who along with the entire pulmonary section of the Louisiana State University Health Sciences Center in New Orleans helped me understand much of what happens in the lung during an influenza attack; Warren was extremely patient and repeatedly helpful. Mitchell Freidman at the Tulane Medical School also explained events in the lung to me.

Jeffrey Taubenberger at the Armed Forces Institute of Pathology kept me abreast of his latest findings. John Yewdell at the National Institutes of Health also explained much about the virus. Robert Martensen at Tulane made valuable suggestions on the history of medicine. Alan Kraut at American University also read and commented on part of the manuscript.

I also particularly thank John MacLachlan of the Tulane-Xavier Center for Bioenvironmental Research, who very much helped make this book possible. William Steinmann, head of the Center for Clinical Effectiveness and Life Support at the Tulane Medical Center, gave generously of his office space, knowledge of disease, and friendship.

All of the above have M.D.s or Ph.D.s or both. Without their assistance I would have been lost trying to understand my own cytokine storm.

People who write books are always thanking librarians and archivists. They have good reason to. Virtually everyone at the Rudolph Matas Medical Library at Tulane University was extraordinarily helpful to me, but Patsy Copeland deserves truly special mention. So do Kathleen Puglia, Sue Dorsey, and Cindy Goldstein.

I also want to thank Mark Samels of WGBH's
American Experience,
who made available all the material collected for its program on the pandemic; Janice Goldblum at the National Academy of Sciences, who did more than just her job; Gretchen Worden at the Mutter Museum in Philadelphia; Jeffrey Anderson, then a graduate student at Rutgers, and Gery Gernhart, then a graduate student at American University, both of whom generously offered me their own research; and Charles Hardy of West Chester University, who gave me oral histories he had collected; and Mitch Yockelson at the National Archives, who gave me the benefit of his knowledge. Eliot Kaplan, then the editor of
Philadelphia Magazine
, also supported the project. I also want to thank Pauline Miner and Catherine Hart in Kansas. For help with photos I want to especially thank Susan Robbins Watson at the American Red Cross, Lisa Pendergraff at the Dudley Township Library in Kansas, Andre Sobocinski and Jan Herman at the Bureau of Navy Medicine, Darwin Stapleton at the Rockefeller University archives, and Nancy McCall at the Alan Mason Chesney archives at Johns Hopkins. I also want to thank Pat Ward Friedman for her information about her grandfather.

Now we come to my editor, Wendy Wolf. Although this is only my fifth book, counting magazine articles I've worked with literally dozens of editors. Wendy Wolf very much stands out. She edits the old-fashioned way; she works at it. On this manuscript she worked particularly hard, and working with her has been a pleasure. It is a true statement to say that, for better or worse (and I hope better), this book wouldn't exist without her. I'd also like to thank Hilary Redmon for her diligence, reliability, and just general assistance.

Thanks also to my agent Raphael Sagalyn, as good a professional as there is. I've had many editors but only one agent, a fact that speaks for itself.

Finally I thank my brilliant wife, Margaret Anne Hudgins, who helped me in too many ways to enumerate, including both in concept and in the particular (but chiefly by being herself. And then there are the cousins.

Notes

Abbreviations

PROLOGUE

the smartest man:
Personal communication with Dr. David Aronson, Jan. 31, 2002, and Dr. Robert Shope, Sept. 9, 2002.

fifty million deaths:
Niall Johnson and Juergen Mueller, 'Updating the Accounts: Global Mortality of the 1918/1920 'Spanish' Influenza Pandemic,'
Bulletin of the History of Medicine
(2002), 105/15.

'doubly dead':
Sherwin Nuland,
How We Die
(1993), 202.

college degree:
Kenneth M. Ludmerer,
Learning to Heal: The Development of American Medical Education
(1985), 113.

'vibrate and shake':
William James, 'Great Men, Great Thoughts, and Environment' (1880); quoted in Sylvia Nasar,
A Beautiful Mind
(1998), 55.

''Tis writ, 'In the beginning'':
Johann Wolfgang Goethe,
Faust, Part One
(1949), 71.

Part I: The Warriors

CHAPTER ONE

'the hostile Sioux': Washington Star,
Sept. 12, 1876.

'For God's sake': New York Times,
Sept. 12, 1876.

'great change in human thought':
H. L. Mencken, 'Thomas Henry Huxley 1825/1925,'
Baltimore Evening Sun
(1925).

'voice was low, clear and distinct':
For accounts of this speech, see
New York Times, Washington Post, Baltimore Sun,
Sept. 13, 1876.

endowed chairs of theology:
Simon Flexner and James Thomas Flexner,
William Henry Welch and the Heroic Age of American Medicine
(1941), 237.

theories that attributed epilepsy:
Roy Porter,
The Greatest Benefit to Mankind
(1997), 56.

'a theory is a composite memory':
Quoted in Charles-Edward Amory Winslow,
The Conquest of Epidemic Disease: A Chapter in the History of Ideas
(1943), 63.

four kinds of bodily fluids:
For a discussion of the theory, see Porter,
The Greatest Benefit to Mankind,
42/66, passim.

'the true path of medicine':
Ibid., 77.

'recognizable only by logic':
Vivian Nutton, 'Humoralism,' in
Companion Encyclopedia to the History of Medicine
(1993).

'our own observation of nature':
Quoted in Winslow,
Conquest of Epidemic Disease,
126.

'unequalled' between Hippocrates and Pasteur':
Ibid., 142.

'Don't think. Try.':
Ibid., 59.

'I placed it upon a rock':
Quoted in Milton Rosenau's 1934 presidential address to the Society of American Bacteriologists, Rosenau papers, UNC.

'more simple and consistent system':
For an excellent review of this see Richard Shryock,
The Development of Modern Medicine,
2nd ed. (1947), 30/31.