“It seems to be a plague, something out of the middle ages. Did you ever see so many funerals, ever?”

– Catherine Ann Porter

A rousing history of one of the worst things to ever happen: the 1918 outbreak of H1N1 flu. Most of it focusses on the frantic research against it; I’d never heard of any of the scientists. They didn’t win, but they got us ready for next time.

Barry senses that the headline result - one-third of the entire world infected, with 25-100 million dead - is a numbing number. So, in modern terms:

It killed more people in twenty-four weeks than AIDS has killed in twenty-four years, more in a year than the Black Death killed in a century.

Or ten thousand 9/11s. It’s worth belabouring this, because we have a terrible habit of paying far more attention to human threats than natural ones, even when natural ones are far worse. (Witness our terrorism prevention budgets compared to our infectious disease control budgets, when the latter is a thousand times more lethal.)

So: The 1918 flu was worse than the entire First World War: 40+ million died of flu, compared with 17 million dead from war. 500 million people were permanently damaged by flu, vs 41 million by the war. 3% of all humans died of flu, including about 8% of young adults!.

But it’s hard to separate the War and the pandemic. The virus was spread everywhere by unprecedented numbers of troops, and by the massive supply convoys it induced, and by the War’s other human displacements. We don’t know how many of the pneumonia deaths only occurred because of the logistical degradation, poverty and pestilence of wartime. There are terrible nonlinearities involved in overcrowding and global movement of troops. But add millions at least to the overall death toll caused by WWI.

Therapeutic nihilism

The first third of the book is a prelude, describing how terrible medicine was up to the 20th Century. Medicine was “the withered arm of science”. Therapeutic nihilism (that is, “we can’t really do anything”) was the rational view, replacing millenia of Galenic woo.

Stengel reviewed dozens of ideas [for H1N1 treatments] advanced in medical journals. Gargles of various disinfectants. Drugs. Immune sera. Typhoid vaccine. Diphtheria antitoxin. But Stengel’s message was simple: This doesn’t work. That doesn’t work. Nothing worked... Nothing they were doing worked.

But this created a powerful vacuum: humans want to believe something can heal. The gap was filled with worse. Confabulations from this time still haunt us: homeopathy, chiropractic, naturopathy, Christian Science, and (though Barry doesn’t include them) the organic farming movement and psychoanalysis.

Few people come off well. Even among the scientists, we get a horrible example of perverse priors and premature updating: most scientific resources were devoted to fighting the wrong pathogen, due to a stubborn bad guess by an extremely eminent researcher.

Rockefeller Institute

Quite a lot of the entire world's research funding for H1N1 was concentrated in the Rockefeller Institute.

They'd make for a good case study in ultra-effective philanthropy, though of course in this case, the worst case, they were too late, started from too primitive a basis.

War: reportedly hazardous to public health

There is, therefore, but one response possible from us: Force! force to the utmost, force without stint or limit, the righteous and triumphant force which shall make right the law of the world and cast every selfish dominion down in the dust.
– Woodrow Wilson addressing one of his infective money-lending mobs.

Wilson tends to be viewed pretty positively, because he won. (“at last the world knows America as the savior of the world!”) But in the process he perverted an entire state and nation; ignored the terrible suffering of his own population for years; and refused a conditional peace with Austria in August, and again with the Kaiser’s new parliament in September. (This meant 70 extra days of war, which, if this period was as lethal as the rest of the war, means up to 800,000 completely unnecessary deaths, not counting the collateral damage from wasting even more medical resources, mixing the population even more, during the worst epidemic ever).

the military suctioned more and more nurses and physicians into cantonments, aboard ships, into France, until it had extracted nearly all the best young physicians. Medical care for civilians deteriorated rapidly. The doctors who remained in civilian life were largely either incompetent young ones or those over forty-five years of age, the vast majority of whom had been trained in the old ways of medicine.

He did great harm and should be viewed as we view Wilhelm II, whatever his unconsummated ideals. And this is before we consider blaming him, or the bloody virus, for the Treaty of Versailles, and so the rise of the Nazis.

But on April 3, 1919, Wilson fell ill with flu-like symptoms… Ever since, historians have wondered about this episode, both concerning Wilson’s prior health problems and his performance when he returned to the negotiating table a week later.

Wilson wasn’t the same man. He tired easily and quickly lost focus and patience. He seemed paranoid, worried about being spied upon by housemaids. He achieved some of his specific goals but was unable or unwilling to articulate a broader vision for a better world. In other words, he acted like a man with residual neurological problems stemming from a recent bout of Spanish flu.

Over the next crucial weeks, Wilson lost his best chance to win the peace by agreeing in principle to draconian terms favoured by France. The final settlement punished Germany with a formal admission of guilt, enormous reparations and the loss of about 10 per cent of its territory.

This is too neat, too terrible. It reads like greentext, though all of the steps make sense (H1N1 cases in his entourage; severe cognitive deficits from recovered patients). Wikipedia doesn’t even mention it, so I suppose it’s fringe. Barry is aware of the temptation to tie everything into one knot, and hedges.

You already believe, probably, that World War I was a terrible senseless waste of life. Well, now magnify that belief by a factor of 5 or 6.

Crimes, abetting the virus

  • In every belligerent nation, months of censorship of the press for "morale", preventing social distancing.
  • In every belligerent nation, diverting more than half of the medical staff, even after decimation of the domestic population.
  • In every belligerent nation, massive troop movements to many corners of the planet, massive unprecedented spreading.
  • In America, war bond parades and marches, millions and millions of community mixing contacts.
  • Rejecting peace terms twice, prolonging the war and continuing to divert half the world's medical resources.

Woodrow Un-American

Barry's middle chapters are a frightening portrait of how rabidly un-American the US was in 1918. The laws were bad enough - for instance the ban on criticising the government. But then there's the unofficial "patriotic duties", punishable by beatings. State-sponsored atavism.

By the summer of 1918, however, Wilson had injected the government into every facet of national life and had created great bureaucratic engines to focus all the nation’s attention and intent on the war.

He had created a Food Administration to control and distribute food, a Fuel Administration to ration coal and gasoline, a War Industries Board to oversee the entire economy. He had taken all but physical control over the railroads and had created a federally sponsored river barge line that brought commerce back to life on the Mississippi River, a commerce that had been killed by competition from those railroads. He had built many dozens of military installations, each of which held at least tens of thousands of soldiers or sailors. He had created industries that made America’s shipyards teem with hundreds of thousands of laborers launching hundreds of ships, dug new coal mines to produce coal for the factories that weaned America’s military from British and French weapons and munitions—for, unlike in World War II, America was no arsenal of democracy.

He had created a vast propaganda machine, an internal spy network, a bond-selling apparatus... He had even succeeded in stifling speech, in the summer of 1918 arresting and imprisoning — some for prison terms longer than ten years —not just radical labor leaders and editors of German-language newspapers but powerful men, even a congressman.

He had injected the government into American life in ways unlike any other in the nation’s history. And the final extension of federal power had come only in the spring of 1918, after the first wave of influenza had begun jumping from camp to camp, when the government expanded the draft from males between the ages of twenty-one and thirty to those between the ages of eighteen and forty-five. Only on May 23, 1918, had Provost Marshal Enoch Crowder, who oversaw the draft, issued his “work or fight” order, stating that anyone not employed in an essential industry would be drafted...

Crowder bragged about doing “in a day what the Prussian autocracy had been spending nearly fifty years to perfect..."

In mid-August, as the lethal wave of the epidemic was gathering itself, Austria had already inquired about peace terms, an inquiry that Wilson rebuffed utterly. And as the epidemic was gathering full momentum, peace was only weeks away. Bulgaria had signed an armistice on September 29. On September 30, Kaiser Wilhelm had granted parliamentary government to the German nation; that same day Ludendorff had warned his government that Germany must extend peace feelers or disaster—immediate disaster—would follow. German diplomats sent out those feelers. Wilson ignored them. The Central Powers, Germany and her allies, were simultaneously breaking off one from one another and disintegrating internally as well. In the first week of October, Austria and Germany separately sent peace feelers to the Allies, and on October 7, Austria delivered a diplomatic note to Wilson formally seeking peace on any terms Wilson chose. Ten days later — days of battle and deaths — the Austrian note remained unanswered.

Earlier Wilson had spoken of a “peace without victory,” believing only such a peace could last. But now he gave no indication that the war would soon be over. Although a rumor that the war had ended sent thrills through the nation, Wilson quickly renounced it. Nor would he relent. He was not now fighting to the death; he was fighting only to kill...

If Wilson and his government would not be turned from his end even by the prospect of peace, they would hardly be turned by a virus. And the reluctance, inability, or outright refusal of the American government to shift targets would contribute to the killing. Wilson took no public note of the disease, and the thrust of the government was not diverted. The relief effort for influenza victims would find no assistance in the Food Administration or the Fuel Administration or the Railroad Administration. From neither the White House nor any other senior administration post would there come any leadership, any attempt to set priorities, any attempt to coordinate activities, any attempt to deliver resources.

...the military would give no help to civilians. Instead it would draw further upon civilian resources. The same day that Welch had stepped out of the autopsy room at Devens and called Gorgas’s office, his warning had been relayed to the army chief of staff, urging that all transfers be frozen unless absolutely necessary and that under no circumstances transfers from infected camps be made... Gorgas’s superiors ignored the warning. There was no interruption of movement between camps whatsoever; not until weeks later, with the camps paralyzed and, literally, tens of thousands of soldiers dead or dying, did the army make any adjustments.

The undocumented apocalypse

Because the disease was everywhere, ravaging the species (and beyond), the book can’t cover everything. Very little is said about non-Americans, i.e about 98% of the death and chaos. This is partly because there just isn’t a lot of evidence about them, despite their influenza immunity and medical care being even worse. (This is why the top estimates reach 100m deaths, three times the median estimate.)

Here is a passage about just a tiny number of them, in the north:

In Alaska, whites protected themselves. Sentries guarded all trails, and every person entering the city was quarantined for five days. Eskimos had no such luck. A senior Red Cross official warned that without “immediate medical assistance the race” could become “extinct.”...

The navy provided the collier USS Brutus to carry a relief expedition... They found terrible things. One doctor visited ten tiny villages and found “three wiped out entirely; others average 85% deaths… Survivors generally children… probably 25% frozen to death before help arrived.”

The virus probably did not kill all of them directly. But it struck so suddenly it left no one well enough to care for any others, no one to get food, no one to get water. And those who could have survived, surrounded by bodies, bodies of people they loved, might well have preferred to go where their family had gone, might well have wanted to no longer be alone...

Two hundred sixty-six people had lived in Okak, and many dogs, dogs nearly wild. When the virus came, it struck so hard so fast people could not care for themselves or feed the dogs. The dogs grew hungry, crazed with hunger, devoured each other, then wildly smashed through windows and doors, and fed...

In all of Labrador, at least one-third the total population died.

The fall of Philadelphia

Because so much of the state was occupied in war, in places there was wholesale social collapse:

In Philadelphia meanwhile fear came and stayed. Death could come from anyone, anytime. People moved away from others on the sidewalk, avoided conversation; if they did speak, they turned their faces away to avoid the other person’s breathing.

The impossibility of getting help compounded the isolation. 850 Philadelphia doctors and more nurses were away in the military. More than that number were sick. Philadelphia General Hospital had 126 nurses. Despite all precautions, despite wearing surgical masks and gowns, eight doctors and fifty-four nurses — 43 percent of the staff—themselves required hospitalization. Ten nurses at this single hospital died. The Board of Health pleaded for help from retired nurses and doctors if they remembered “even a little” of their profession.

When a nurse or doctor or policeman did actually come, they wore their ghostly surgical masks, and people fled them. In every home where someone was ill, people wondered if the person would die. And someone was ill in every home...

Starr went to Emergency Hospital #2 at Eighteenth and Cherry Streets. He did have help, if it could be called that, from an elderly physician who had not practiced in years and who brought Starr into touch with the worst of heroic medicine. Starr wouldn’t forget that, the ancient arts of purging, of venesection, the ancient art of opening a patient’s vein. But for the most part he and the other students elsewhere were on their own, with little help even from nurses, who were so desperately needed that in each of ten emergency hospitals supplied by the Red Cross only a single qualified nurse was available to oversee whatever women came as volunteers. And often the volunteers reported for their duty once and, from either fear or exhaustion, did not come again.

Nearly 1/4 of all the patients in his hospital died each day. Starr would go home, and when he returned the next day, he would find that between one-quarter and one-fifth of the patients in the hospital had died, replaced by new ones... Virtually all of them, along with their friends and relatives, were terrified that, no matter how mild the symptoms seemed at first, within them moved an alien force, a seething, spreading infection, a live thing with a will that was taking over their bodies — and could be killing them...

The city was frozen with fear, frozen into stillness. Starr lived 12 miles from the hospital. The streets were silent on his drive home, silent. They were so silent he took to counting the cars he saw. One night he saw no cars at all. He thought, “The life of the city had almost stopped.”

Everyone can read the collapse of official power in Philadelphia as supporting their politics. Anarchists can point to the benevolent spontaneous order that arose after the corrupt local government failed to act; libertarians can note that this was entirely funded by the richest Philadelphians; statists can point out that, without authoritative co-ordination, the effort eventually failed, because people defected against each other in fear.
The corpses had backed up at undertakers’, filling every area of these establishments and pressing up into living quarters; in hospital morgues overflowing into corridors; in the city morgue overflowing into the street. And they had backed up in homes. They lay on porches, in closets, in corners of the floor, on beds. Children would sneak away from adults to stare at them, to touch them; a wife would lie next to a dead husband, unwilling to move him or leave him. The corpses, reminders of death and bringers of terror or grief, lay under ice at Indian-summer temperatures. Their presence was constant, a horror demoralizing the city; a horror that could not be escaped. Finally the city tried to catch up to them.

The police wore their ghostly surgical masks, and people fled them, but the masks had no effect on the viruses and by mid-October thirty-three policemen had died, with many more to follow...
More coffins came by rail, guarded by men with guns.

Errata / debate

We're in luck: around the swine flu pandemic, a virologist gave many corrections to Barry's descriptions of the virus. They range from nitpicking to raising a real controversy Barry doesn't cover (adaptive virulence shifts). Spirited and somewhat convincing reply from Barry here.

Why did medicine suck?

Barry makes at least one big error: he's horrified by the medical schools of the time having "no standards for admission":

In research and education especially, American medicine lagged far behind [European medicine]... At least one hundred US medical schools would accept any man willing to pay tuition... and only a single medical school required its student to have a college degree...

the Johns Hopkins itself, not student fees, paid [its] faculty salaries, and it required medical students to have not only a college degree but fluency in French and German and a background of science courses.

But Barry's enthusiasm for Johns Hopkins' degree requirement is misplaced. Contemporary US doctors (who all have 3 years of pre-med, or even more, before they start medical training) are probably no better clinicians than undergraduate doctors in other countries, and are far further in debt. And the requirement is probably one reason the American system is so expensive: we require unbelievably expensive credentials of doctors, and they respond by demanding higher salaries.

Perhaps Barry is confusing the schools' open admissions with their appallingly low graduation standards, which were certainly one reason eC20th medicine sucked. (Many doctors had never looked down a microscope; never used a stethoscope on a patient; never seen a dissection.)


The book is in the epic mode throughout. (That's not only a compliment.)

Man might be defined as “modern” largely to the extent that he attempts to control nature. In this relationship with nature, modern humanity has generally been the aggressor, and a daring one at that, altering the flow of rivers, building upon geological faults, and, today, even engineering the genes of existing species. Nature has generally been languid in its response, although contentious once aroused and occasionally displaying a flair for violence.

By 1918 humankind was fully modern, and fully scientific, but too busy fighting itself to aggress against nature. Nature, however, chooses its own moments. It chose this moment to aggress against man, and it did not do so prodding languidly. For the first time, modern humanity, a humanity practicing the modern scientific method, would confront nature in its fullest rage.

He goes for meditations on epistemology, the modern mind, the redemptive meaning of science for beasts like us. I liked it, but it dismays other readers.

Why listen to me on this topic?

Nonfiction book reviews by nonspecialists are hazardous. It is just not easy to detect pseudo-empirical bullshit without

  1. immersion in the field and/or good priors for what makes for an extraordinary claim in it;

  2. incredible amounts of fact-checking gruntwork, at least 5x the time it takes to just read something; or

  3. incredible amounts of argument-checking, which doesn't need domain knowledge, but often involves a lot of interpretive work.
I always try to do (3) but surely often fail.

In this case, no good reason to trust me. Barry is just a science-adjacent historian, not a scientist, and in his struggle to make a narrative, he fills in quite a lot of emotional colour which is at best vaguely inferred from letters.

I was glad to see a virologist weigh in, above: his corrections are worrying, since they're pretty fundamental, but limited in scope to a few pages.

Cross-posted from Goodreads.


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Tags: review, xrisk, epistemology, biorisk


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