Episode 90 - The Great Influenza with John M. Barry

Author John M. Barry joins the podcast today as we discuss his book The Great Influenza and how relevant it is to the time we are living through right now.

Full Transcript

Steve Meredith: Hi again everyone, and welcome to Solutions for Higher Education, a podcast featuring Scott L Wyatt, the president of Southern Utah University in Cedar City, Utah. I'm your host, Steve Meredith, and I'm joined in-studio today as I almost always am by President Wyatt. Scott, it's a beautiful summer day in Cedar City.

Scott Wyatt: Yeah, it's a nice day. It's the kind of day where you should sit outside and read a book.

Meredith: It's hard to do a podcast when you're doing that, but yes. [Both laugh] It is, it's that kind of day, you're right. And this is a great sitting under a tree book, the book we're going to talk about today, part of our summer book series. And I just have been fascinated with this book and really, my wife will verify that I have been wrapped up reading this late into the evenings and early mornings and just literally any time I can find time. I've really enjoyed reading this. Anyway, why don't you introduce the author of our book?

Wyatt: So, we are delighted to be joined today from Louisiana, John M. Barry, the author of The Great Influenza. John, welcome, and thank you for joining us today.

John Barry: Thank you, and it's a pretty nice day in New Orleans right now. It rained pretty hard earlier, so…

Wyatt: I was first introduced to your book by Dr. Blodgett, who is our Public Health Director for our region of the state, and we're friends and every once in a while he gives me a book and he brought your book by maybe two years ago and said, "If you liked that one, here, you'd really like this one." So, that's a…that was my introduction to your book, and what a fascinating book and what a relevant, interesting period of history for us to talk about today.

Barry: Unfortunately, too relevant.

Wyatt: Unfortunately, that's right. What brought you into this topic? How did you get into the topic to write this book? What motivated you?

Barry: Well, oddly enough, I never intended to. My earlier book, Rising Tide, there's a chapter in there largely about the Homefront, World War I, and events in 1919, one of the most interesting years in American history and I intended to write a book on that, and of course, the pandemic was a part of that. But I ended up getting diverted and spent seven years on this book. I have always been interested in science. When I was a kid, the only two things I ever wanted to do was write and do medical research. And I had written an earlier book which gave me a pretty good scientific grounding in immunology with Dr. Steven Rosenberg who pioneered in immunotherapy for cancer and also did the first human gene  therapy experiments. So, I had the background there and the pandemic had always interested me and so I'd say it became the entire book.

Wyatt: Yeah, The Great Influenza. You chose a title for the book that's probably better than "The Spanish Flu."

Barry: [Laughs] Well, I've never been good at titles. When I wrote for magazine and several other books, I never once…I don't want to say never but probably in the hundreds of magazine stories and a handful of books, I probably picked the title three times. [All laugh] That's counting The Great Influenza, but nobody could come up with a better one. So, it is…

Wyatt: Yeah, it's a good title. And Spanish Flu is what we call it, but of course it didn't originate in Spain.

Barry: No, no. It, as you know because you read the book, Spain was not at war, did not censor its press. All of the European countries, warring countries, did censor their press, didn't want to write anything negative. The U.S. did not formally censor its press but I did have a lot of self-censorship and some laws that were very tough. And Spain, when it hit Spain, and of course the king of Spain got sick so celebrity culture gets a lot of publicity, it picked up the name Spanish Flu. But not in Spain; in Spain they called it the Naples Flu. But we do know, as you said, it didn't start in Spain. It may have actually started in the United States. That's what I thought when I wrote the book, although it originally came out in 2004, there's been a lot of scientific research since then and I now think that it's probably most likely that it started in China, although it could still have started in the United States. I thought it was in a rural part of Kansas, Pasco County. There are other hypotheses, some very good virologists think it started in France.

Wyatt: Yeah.

Barry: A lot of people think Vietnam, another possibility is New York City. We'll probably never know…but not Spain. We do know it didn't start in Spain.

Wyatt: Didn't start in Spain. I have a brother that lives in Kansas and I said, "Do you know where the Spanish Flu started?" And he said, "Well, Kansas." [All laugh]

Barry: OK.

Wyatt: So, at least he was in the right…he was out of the wrong country at least.

Barry: Yeah.

Meredith: That's right.

Wyatt: Yeah, these things are…

Barry:  I actually wrote a scientific journal article about the site of origin. You know, I thought I had made a pretty good case and got a reasonable amount of traction in the science disciplinary for that hypothesis, although as I said a moment ago, I personally have now backed away from it, I think the evidence is better for somewhere else. But, it still may have been in Kansas.

Wyatt: You've mentioned the press and it might be fun for us…so, we're assuming that our listeners have read the book, so…in theory, but we know…

Barry: Never assume.

Meredith: Right.

Wyatt: But we know that some of them will be…will have not finished the book and this will hopefully motivate them to finish it or get it and read it, but let's…if it's OK, let's talk about some of the parallels and differences from 1918-1919 until now and you've raised one interested topic, and that is the press. So, in 1918, we were fighting World War I and the country that wasn't stifling public speech was Spain, and they got branded with this because of that. What parallels do you see, or differences, from 1918 and to 2020?

Barry: Well, in 1918 there was fake news without a doubt, but the reason it was fake was because they were repeating what the government wanted them to say, which was a lot of misleading information and in some cases, outright lies. That wasn't exactly for political interest or self-interest, that was because of the war. The government…you've got to remember, from Wilton's perspective, the largest demographic group in the country were Germans. He wasn't really confident that those of German descent would go to war against Germany enthusiastically. I know a very large demographic were Irish, and Ireland rebelled in 1916 against Britain, so you weren't sure that the Irish would fight on the side of Britain, and they created a propaganda arm called the Committee for Public Information. The architect for that committee said that, "There is nothing in experience that tells us truth is superior to falsehood. All that matters is the inspirational value." So, that kind of thinking informed this committee, which would issue not just press releases, they had a force of several hundred thousand people in a country of 108 million, 107 million, something like that, who would go to every public meeting, whether it was the Vaudeville show or a school board meeting and give a brief…they were called "Four Minute Men" and they would give a brief, inspirational piece of information every day and it always had to be positive, put the most positive spin on the news. Meanwhile…and that was sort of the carrot. There was also a stick. Congress passed a law that made it illegal—20 years in jail—to quote, write, utter…utter, write, print or publish any disloyal, profane, scurrilous or abusive language about the form of government of the United States (unquote). And even a congressman was sentenced to 10 years in jail under this law, so it was actually quite rigorously enforced and turned against newspapers when they criticized things, if they dared. Notice in there, it didn't say anything about truth being a defense. That law, strangely enough, was upheld by the Supreme Court. Not only was it upheld, but the person who wrote that opinion was Oliver Wendell Holmes who is well-known as a champion of free speech. But in his decision are two phrases that sort of lived on. One, he used the analogy of shouting "fire" in a crowded theater and the other was clear and present danger. So, here you have a propaganda arm going out and putting the best possible light and sometimes using outright lies about what's going on to keep the public trust up and then you threaten anybody that if they criticize anything that's going on, they might be subject to prosecution. The Justice Department, without any legal authority, gave out 100,000 badges to something called, "The American Protective League." And they, again, no legal authority, but they would spy on people, their neighbors and even their family sometimes. It was really quite a nasty, nasty situation. So, that was the context in which the pandemic arrived in sort of an infrastructure. And to prevent any negative interpretation of what was going on, you had national public health leaders saying things like, "This is ordinary influenza by another name." You know, Spanish Flu. But it wasn't ordinary influenza by another name, it was much, much more virulent, much more lethal than COVID-19. People could die in less than 24 hours, they could die with horrific symptoms, such as…in Army camps where the data is good, some camps, 15% of the soldiers had nose bleeds, but more frightening from that was that people could bleed from their eyes and ears, which would be pretty terrifying for a lay person and not exactly reassuring for a healthcare professional. So, people are dying in large numbers.

Wyatt: Quickly.

Barry: They're dying with…some of them quickly, but most didn't…that was unusual, but it certainly happened, the less than 24 hours. Many of them with very, very strange symptoms. Everybody knew this was not ordinary influenza by another name, so they knew they were being lied to. And that led to a fraying of society. I think society is based on trust, trust disintegrated, it became every person, every family for themselves in the worst situation. That didn't happen everywhere, but that was the worst case, unfortunately, or close to the worst case was common enough that in the book I quoted Victor Vaughan who was a sober, serious scientist who had been the dean of the University of Michigan Medical School before the war and was a colonel, Head of Communicable Diseases for the Army during the war and right at the pandemic's peak, he wrote, "If this continues its current rate of acceleration for a few more weeks, civilization could easily disappear from the face of the earth." That's how bad it looked like it could get in the worst case. Just about the time that he was writing that, things improved, so we didn't go down that road. But it was a horrific experience. You didn't have anybody calling it a hoax in 1918, you didn't have anybody doubting how serious it was in 1918. Today of course, unfortunately, you have sort of a split in administration. A split government. You've got the public health professionals who are trying to take this seriously from the very beginning and you've got a political operation that sees the pandemic almost as a personal attack on the President. The virus doesn't care who is in charge, and it is serious and it is real and the response out of Washington has been, quite frankly, incomprehensible and other countries, practically every other developed country has handled it much better than the United States has, when we had more resources than anybody else.

Wyatt: When in 1918…so, in 1918, the communication from government started out with, "This is just the flu, don't worry about it, life is fine." And, as you mentioned, inspiration was one of the keys and if somebody disagrees with them, they get punished. At what point did that change? Because the inspirational value goes away as soon as you realize you're not being told the truth.

Barry: Yeah. Probably early October…

Wyatt: Second wave.

Barry: The surgeon generals…well, the first wave, there was a first wave, but the first wave was…I think the virus wasn't very good in adapting to people and it was very spotty. For example, Los Angeles didn't have a single death from influenza in the spring of 1918, not one. I think most of the country did not experience a first wave and most of the world didn't either, although it was pretty widespread in western Europe. So, that wave was really spotty. It's quite different from COVID-19 where it spread rapidly around the world. Obviously we have airplanes now, it can spread in hours, didn't have that back then. But I think the virus probably did mutate and become better at infecting people and that second wave was widespread, largely simultaneous around the world. And beginning…well, the pandemic you could say some people think two years, some people three years, but probably close to 2/3 of the deaths occurred in a period of about 13 to 14 weeks in the fall of 1918. So, even though technically it was spread out, there was really this incredibly compressed timeframe when most of the people died and most of the action was. And that was the second wave. There was a third wave which is very unusual. The third wave began in late winter of 1918-1919, so like maybe early March 1919. So, you had two influenza waves in the same winter. That is extraordinarily unusual. And what happened was, the virus mutated again so that it became different enough that you didn't have any natural immune protection. The first and second waves, even though I've just said it mutated and became better at infecting people, it was close enough in those two waves that if you were infected in the first wave, you were protected in the second wave. In fact, your level of protection, and I did write a peer-reviewed scientific journal article on this along with some co-authors from the  national institutes of health, you actually had better protection than any vaccine we've ever developed for influenza. So, those two viruses were…I mean, they were the same virus. But it changed enough for the third wave that neither first nor second wave exposure protected you against the third wave. And then again, there was more in the 1919-1920 influenza season, partly because peoples' immune systems had seen the virus and they were better able to deal with it and partly because the virus continued to mutate, seems to have gotten more mild, it became seasonal influenza. And that virus actually continued to circulate and was the seasonal influenza virus, or descendants of it, again, it mutates regularly very rapidly, so it would have changed significantly, but until 1957.

Meredith: Hmm.

Barry: COVID-19 is a different situation. From the very beginning, it's been very, very good at infecting people. I'm' sure your listeners by now will all have heard of a reproductive number of a little over two.

Wyatt: Right.

Barry: Well, that compares to seasonal influenza is about 1.2, the 1918 virus was about 1.8, and this is 2.2. And that may not sound like…or 2.3, somewhere in that neighborhood for COVID-19, that may not sound like a big difference, but it's a huge difference. It's much more contagious than influenza is. Even at a reproductive number of 1.1/1.2, that's enough for seasonal influenza to infect 10% of the population, 15% of the population any given year. So, you double that and you're talking about the epidemiologist and [inaudible] early on, and this seems to have been borne out, if left to its own devices, if there had been no interventions, no lockdowns, the virus would infect 68% of the world's population. That's a lot of people.

Wyatt: That's a lot of people.

Barry: The 1918 virus infected about 1/3 of the world's population, some places more, some places less. And we also…but we did intervene. So, we haven't really…we stopped the first wave by interrupting transmission with the lockdowns in many places around the world, most places, and therefore we still have a huge percentage of the population, well over 90% in the United States, probably about 95% who are susceptible to the virus. Which is why, if we're not careful as we come out of lockdown, it's still out there and it will continue to infect people, and could potentially explode. The great irony of this is that we have figured out how to keep it in its box, not stop it entirely, not eradicate it, but keep it clamped down, it's up to us to do it, we can succeed in this without locking down the economy, but we all have to play our part. And the most important thing by far is social distancing, and then comes masks and hand washing and staying home if you have the slightest symptoms. Those four things, if we had pretty much everybody doing it, we would have…we would definitely take the top off this thing and people could function pretty normally and the economy could come back without much of a problem. If we don't do it, we can…you know, I'm sitting here in New Orleans, I don't think about waves, I think about hurricane storm surges. A big one.

Wyatt: One of the…when you're talking about the economy and social distancing and masks and everything, one of the interesting comparisons or points of comparison between 1918 and 2020 is the sense to which people are complaining about their civil liberties. We have a variety of people in the country saying things like, "You're going to take away our civil liberties here in 2020, and we'll probably never get them back." But when we look at the history of 1918, interestingly enough, Cedar City where our university is, small, relatively small community, it wasn't the federal government or the state that was imposing the restrictions, it was the city, and it was against the law with criminal penalties to go out on the streets for four weeks in October/November, that range, without a mask on. And…anyway, it's interesting to compare the extent to which people were complaining about the economic issues and the civil liberties issues.

Barry: That is interesting. A lot of people or places did that. I'm not familiar with what happened where you are, not every city by any stretch passed…made it mandatory. A lot of them did, particularly as you moved further toward the west coast.

Wyatt: Right.

Barry: You know, and social distancing. I was just this morning I was listening to a press conference from the governor of Louisiana and he was making the point that instead of worrying about what your rights are and thinking you have a right not to wear a mask, you should be thinking about doing the right thing. And I think that's a good way of putting it. Asymptomatic people and people who are about to get sick but haven't shown symptoms yet, which would be technically pre-symptomatic people, they do spread the disease. So, you can feel completely well and shed virus and infect other people and spread the disease to your coworkers, to your friends, to your family. A so-called co-morbidity, something that increases risk, is just obesity, not to mention things like high blood pressure. It's not clear yet, but it's quite possible that pregnancy becomes a high-risk situation. It certainly was in 1918. I mean, these are different viruses, but pregnancy puts an additional burden on the body and in 1918, that was probably the highest risk group. The range of studies of pregnancy found that case mortality ranged from 21% to 71% of pregnant women. Now, we don't know that that's anything like the case with COVID-19, but pregnancy could be a high risk. So, if you're going around risking exposing coworkers, friends and family by not wearing a mask…and the mask does protect you as well to a much more limited extent. The reason it protects other people more than it protects you is because it catches the larger…you now, if you not just cough but even speak, then droplets escape from your mouth and the mask will catch them. And that's the primary mode of spread. The mask will protect you from droplets. It won't really protect you from really tiny, airborne viruses that float in the air, but it will protect you against droplets as well.

Meredith: John, another interesting comparative point between then and now is that the 1918 version of this flu virus seemed to kill people across a wide range of ages…

Barry: Right.

Meredith: And seemed maybe especially acute among the young who seemed that they could be immune because they just were in the very prime of their lives and at their greatest physical strength, and yet, as you say, even the very healthiest specimens could be dead in a very, very short time and that that was shocking to many people. In fact, I think out of your book there's a quote about that it was almost like watching…because so many young people died, it was like watching them die twice. They lost their lives but they also lost their youth. It wasn't the end of their lives.

Barry: Yeah, that was a very prominent physician scientist said that they were doubly dead in that they died so young. That was very unusual for influenza. Fortunately, not the case with COVID-19. Normally, influenza kills the very old and the very young, and it certainly killed the very young in 1918. In fact, it killed children under the age of five at a rate that if you compared it to today, it would equal all-cause mortality for a period of 23 years. So, imagine the number of kids under age five who died from every cause—drowning, car accidents, cancer—over a 23 year period compressed into a few weeks dying in 1918. Think of the impact on parents. But most of the deaths, probably 2/3 of the total, were people aged 18-45, and the peak age of death was about 28. And, again, very unusual and obviously not the case with COVID-19.

Wyatt: I was visiting the cemeteries, it's one of those things that some of us do for Memorial Day, and it had never occurred to me, but in looking at the gravestones of my wife and I, our ancestors, we each have a great uncle or aunt that died in October of 1918. And they were both in that age group that you've described, in their 20s.

Barry: Mhmm.

Wyatt: Just…it just causes, "Oh my goodness, that's really interesting that we have two members of our family that died then." One was in the infantry but never left the country, the other one wasn't.

Barry: Well, yeah…it was not a great time.

Meredith: One of the things I love about this book is how painstakingly researched it is and how you're able to weave a just multiple thread narrative that kind of wanders through the beginning of modern American medicine and John Hopkins University and the beginning of epidemiology and bacteriology and through the politics of Woodrow Wilson and it was just…it's been a fascinating read. As I look at some of the names that come through here, you know, you talk about Rockefeller and William Welch and a number of other characters that kind of help drive the narrative of this book. Who do you think are going to be the…when whoever it is that's the John Barry that 100 years from now writes a book about the 2019-2020 flu, who do you think will be the personalities? Obviously Donald Trump will be one for good or for ill…do you think…who do you think we'll remember out of this time?

Barry: Well, it's a little bit too early. In the book, I did focus on the scientists who tried to confront and made incredible progress and then were great scientists. To give you a sense of how good they were, the Nobel Prize, you don't get that unless the committee knows that you're correct. They won't give it to someone with a controversial finding. There was one character in the book who won the Nobel Prize in 1966 for work he actually did in 1911. He was 55 years ahead of the curve. 

Wyatt: This is what's interesting about it, and in reading your book and seeing what's going on today, it's…one of the most fascinating parts of this whole thing is comparing then to now and then projecting forward and thinking, "How will we respond for the next one of these?" I…until your book, John, I had assumed that this was really a World War I veteran circulation thing. But, it's interesting to learn that all the places where this 1918 flu, influenza, started without the influence of anybody from World War I, these Inuit villages and small places in Africa and even maybe New York City or other places, talk to us about that?

Barry: Well, I mean the virus hits everywhere. Just as COVID-19 is very likely to get where you are, even though you're not a big city. And there are…were villages in Alaska as well as in the middle of the jungle in Africa where there was 100% mortality. Now, that probably wasn't because of the virus per se, but if everybody gets sick at the same time, no one can even give somebody else water or food. So, plus the psychological impact of everybody around you dying, I mean, it's insidious and did get everywhere except for a few very isolated places that shut themselves off. Gunnison, Colorado managed to do that. You couldn't get off a train in Gunnison and they barricaded the roads. There was an island in the Pacific that did that and a few places like that, but the virus…it may have taken a little bit longer to get there, but people think in 1918, the world was much more primitive than it is today, and of course it was, but as the death toll indicates, it was also much more connected than we probably would otherwise think. Because that virus did go everywhere. The death toll is estimated at between 15 and 100 million people in a much smaller population. If you adjust for population, that would be equal to 220 to 440 million people today. And obviously we didn't have good statistics back then, which is why that death toll is given in a range, a pretty big range. But, you know, it got everywhere as this virus will.

Wyatt: The range you're talking about is the size of the United States.

Barry: Right, that's where it lies of course.

Wyatt: Right.

Barry: Inside the U.S. we have decent statistics for about 2/3 of the country. About 1/3 of the country did not have good statistics, but probably about 675,000 Americans who died, which would be equivalent to roughly two million today, which is actually a pretty good outcome in terms of…if you compare that to the rest of the world.

Wyatt: What do you think is going to be our biggest takeaway from this pandemic?

Barry: Well, it remains to be seen. Either something utterly bungled or something where the citizens of the United States rally to the cause and took charge of the illness by acting responsibly. I don't know which it will be. It's too early. We intervened and stopped the first wave, so there really wasn't a first wave, but that does leave, as I said earlier, probably about 95% of the population susceptible to the virus. We will see, you know, if we do everything right, we're going to see…we came out of lockdown, it's not possible to prevent upticks, you're going to get upticks, but they can be controllable. Even without drugs and of course we still have no drugs that can…well, we have one but it's in short supply [inaudible]. Hopefully there will be a lot more drugs coming soon and that's a fair help, but it's not a magic potion. But even without drugs, we have learned a lot about how to care for people. For example, there were…if you have a certain level of oxygenation of the blood, the standard of care is you put someone on a ventilator when their blood isn't carrying a lot of oxygen. But, we've learned that that's not the right thing to do in many cases. We're learning about all sorts of other ways to treat people that gives them a better chance of surviving even without the drugs. So, we're improving, almost on a daily basis we're learning more about critical care. So, if we can keep the hospitals and the intensive care beds from being overrun, we can lower the case fatality rate. The most important number coming out of China in my view was that the case fatality rate in Wuhan was 5.8% and in the rest of China, it was 0.7%. And the difference was that the healthcare system in China was overwhelmed and in the rest of China it wasn't. So, they had intensive care unit beds in the rest of China and they didn't have any in Wuhan. And similarly, in Italy, they ran out of intensive care beds and they were completely overwhelmed. We didn't have that situation anywhere in the United States, although we came very, very close to it in New York...

Wyatt: Mhmm.

Barry: And for that matter, in Louisiana where I am. Right on the edge of that, but we managed to stay on the right side of the edge.

Wyatt: Yeah, we…

Barry: But, you know…

Wyatt: We kept the beds so free in our neck of the woods that they laid off a lot of nurses and healthcare workers.

Barry: Huh.

Wyatt: Which is kind of an interesting side to it. And I asked you what will be the takeaways, what will we remember from the 2020 pandemic, and it's never fair to ask a historian to…

Meredith: Predict the future. [All laugh]

Wyatt: Predict the future. It's always easier to predict the past.

Barry: Yeah.

Wyatt: What a very fascinating period of time.

Meredith: Then and now.

Barry: True.

Wyatt: Yeah. What have we not asked you that you think is particularly relevant? This book of yours, this topic, what a fascinating topic. Others have written books about the great influenza, but I think that yours is regarded still as the very best book, and we recommend it to our listeners.

Barry: Thank you, you're very wise. [All laugh]

Wyatt: Well, thanks for joining us today.

Barry: OK.

Wyatt: It would be fun to talk again in a year or two years after we know more about the period hat we're in.

Barry: Yeah.

Meredith: It would be fun to follow up with you, yeah.

Barry: Yeah. And good luck this fall opening your university and…when are you opening, incidentally?

Wyatt: So, our first day of classes are right after Labor Day.

Barry: OK...

Wyatt: So, the first of September.

Barry: Because I know some schools have actually decided to change their schedules a little bit. Open in August and take off earlier when it gets colder, but…

Wyatt: We're…like some other states, Utah is exploring the possibility of starting at the same time but then not bringing students back after Thanksgiving and just moving to remote for the last week or so.

Barry: Uh-huh.

Wyatt: So, that would…

Barry: We'll see whether we need to have that.

Wyatt: Yeah.

Barry: Yeah. Well, we'll know a lot more in a few more months.

Wyatt: Yeah. One of our challenges is that we have a pretty good summer school, and so it's hard to…if we didn't have summer school, it would be much easier to move the start of fall.

Barry: Mhmm.

Wyatt: Anyway…well, thank you so much, John.

Barry: You're welcome, it's been fun. Take care.

Meredith: You've been listening to Solutions for Higher Education, a podcast featuring Scott Wyatt, the president of Southern Utah University in Cedar City, Utah. We've had as our guest today John M. Barry and we've discussed his book, The Great Influenza. John is a New York Times bestselling author; we highly recommend this book. It's fascinating, it's painstakingly researched, and really an interesting read. If you haven't had a chance to read it, please do. John joined us by phone from his home in the French quarter, beautiful New Orleans, Louisiana, and we thank him for joining us and we thank you, our listeners, for joining us. We'll be back again soon, bye bye.