The Great Influenza: The Story of the Deadliest Pandemic in History

Thanks to the COVID-19 outbreak I became interested in learning about the 1918 pandemic. This was recommended by a friend. There really are two parts to this very detailed account- the history of the medical field around the turn of the century and then the story of the Spanish Flu (which likely didn’t originate in Spain at all). I enjoyed learning about Johns Hopkins and the state of the medical field in general. It was amazing to see how history repeats itself. I particularly appreciated this summary at the end:
“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.”

The book does three things:

First, it explains how scientific medicine emerged in America and how it affected and was affected by the pandemic of 1918. This is the main reason the book was written and its probably not why many people picked the book up. However, it's what the book does best. More below.

Second, it explains how other institutions affected and were affected by the pandemic of 1918. In these sections, the author patiently explains that nearly every institution in the country failed: the military, federal government, local governments, media, and social institutions.

Third, as an afterward to the book, the author explains the implications of this study to potential future epidemics and concludes succinctly we are unprepared and will likely face an epidemic in the future. He lays out a series of concrete steps that should be taken, but were not. This is why most folks are probably picking up the book. It’s devastating.

I try to evaluate books based on their intention and as a history of science and scientific institutions I think it’s a great book. Why are histories of science helpful? I’ll try to explain why this was helpful to me.

There's a picture in my head of how rational progress happens. Groups of like-minded people rationally debate a path forward and then take collective action. That's the standard that I use to judge the present.

The thing is, books like this remind me that just never happens. How did we establish modern medicine? Did it emerge naturally from the established institutions of the time? Did it emerge as a level-headed consensus of the best and brightest? Not at all.

A charismatic guy made a research institution in Baltimore, which barely even had a credible hospital, and recruited a bunch of great researchers to join him because of charisma and .

What about test vs-controlled experiments for medical trials? A hard headed guy convinced the head of the Rockefeller foundation to do them, even though no one there agreed with him. The Rockefeller foundation had a lot of money, which allowed them to fund a lot of studies. Leading universities played effectively no role in making these changes. They were so radical that you had to just go somewhere else and do it.

The author delights in these sorts of observations. In particular, he spends an inordinate amount of time observing how scientists behaved during the influenza itself – what compromises were they willing to make to get a fast result? How did they think when careful reflection seemed impossible?

His argument here felt muddled to me, but I believe his most salient point is that herd behavior dominated science during the pandemic. Countless scientists followed a central authority figure whose conclusions, though wrong, were stated firmly and early. People follow authority in times of fear and uncertainty. And scientists are, after all, people.

In contrast, the author lionizes a researcher, Avery, a hard headed, independent scientist, who refused to take the red herring and proceeds on his own. What follows is a thirty-year research project that results in the discovery of DNA.

And that feels like as close as we get to the author’s trying to tell us about science and its potential. ‘This – look here – is what science looks like. It does not arrive on time. It does not fight the epidemic. It does not happen when it’s needed and it is not popular or trendy. It’s dogged, hard work. Adherence to process. Unusual insight followed by unusual perseverance.’

If the book has a hero, surely it is Oswald Avery and his hero’s journey is the experience of not the Great Flu, but of the way the Great Flu contorted the scientific community, his community, into a high school cafeteria. And his ability to calmly walk through that cafeteria and let none of its rumblings perturb him.

And so that I feel is the gift this book has given us. A telling of how science behaves in a crisis. Like every other social institution, of course. And a real example of what the best of us can look like amidst that chaos. And realistic explanation of what the best of us can achieve and how they achieve it.


Here are my other observations / most meaningful takeaways from the book.


1. Small number of scientists created research medicine in the US. Prior to 1900 was a backward discipline relative to Europe. Leading institutions did not participate in reform, instead Johns Hopkins introduced a wholly new way of working to the continent. If Hopkins was the spark, then Rockefeller’s institute was the tinder that allowed scientific medicine to spread across the continent. The discipline grew in generations and degrees from an original founding class at Hopkins.

2. Influenzas spread rapidly and can increase in severity as spend more time passing thru hosts. Created the extremely deadly second wave.

All viruses reproduce really fast and mutate quite a bit. However, some viruses have consistent antigens (e.g., measles, small pox) and those viruses thus have consistent immunity because they are recognized by the body. Other viruses (e.g., flu) have antigens that mutate, likely because those antigens are not critical to the structure of the virus. As a result, the virus can mutate and retain efficacy while subverting immunity (memory t cells cannot recognize). This is what makes flu virus pandemics something that happen every now and again.

Pandemic itself:

3a. Army mobilization moved people around the globe in dense conditions. Spread the disease.

3b. Nationalism during war time meant media had to take a positive tone. Minimized the response.

3c. Corrupt large city governments had power in much of the populated northeast. Federal government had not yet assumed modern powers in the US. weakened the ability to control.

3d. Federal government organized its new and massive bureaucracy to win the world war. This oriented toward positive propaganda, made a response almost impossible. As every institution - schools, grocery stores, transportation shut down, military transport ships to Europe kept going.

I have tried to listen to this audiobook several times between February 2023 and now and I just can’t get through it. Maybe it’s just a difficult listening ‘read’. But whatever it is, the writer and editor need to stop saying / writing ‘the Hopkins’ when referring to Johns Hopkins - sorry I got hung up on that because I’m a resident of Maryland. After I heard that in one of the chapters around 8% way through the book I just couldn’t listen anymore. I got to 11% (2 hours and 12 minutes of my life to be precise) and stopped.

This book would have been great if it had had serious editing. The first 13 chapters are background on a number of scientists who fail to capture the imagination -- probably because he simply covers too many of them. In chapter 14, Barry finally starts to write about the pandemic, and by the time you're halfway through the book, the information is basically over. The rest is just a rehash of what you've read. However, the second quarter of the book was very interesting.