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The Great Influenza - book notes

When COVID-19 struck, I picked up a book on one of the most impactful pandemics in the world’s history to understand what we’re to face in the coming months. I was trying to work out the mechanics of a pandemic if you will. Apart from pure intellectual curiosity, my drive was to have a model for thinking about the news I read and my choices for the coming months.

It’s embarrassing to admit that I didn’t know much about natural viruses at the beginning of the year. I knew viruses are infectious, can cause major illnesses, and you should get vaccinated against them. And that’s about it. I didn’t even know what the virus actually is - a piece of genetic material. I knew a fair amount about computer viruses, so when I learned that a natural virus is a piece of DNA or RNA (life’s “software”), I was surprised how fitting the name “virus” was for the computer counterpart.

In any case, back in March, I thought I would get up to speed with pandemic mechanics, and I followed the recommendation of well-read circles I follow on Twitter to read The Great Influenza by John Berry. The book is entirely too long, but at the same time, I don’t regret reading it. The highlights are detailed research behind the book and a wide range of topics from the science behind infectious diseases (biology and medicine) to the impact on society and politics. The lowlights are too much of the US-confined focus, given the 1918 influenza outbreak was a pandemic (spread throughout the whole world) and sometimes too much dwelling on second-tier characters.

I was struck by how little the 1918 influenza pandemic occupies the public’s consciousness either in Europe or the US. I might have heard of “Spanish flu” during my history classes, but that’s about it. The death toll of that pandemic is comparable to the number of casualties of the First World War, but I don’t recall any mention of that pandemic when I was growing up.

How was it on the ground

The book is full of personal accounts of people struggling with the disease. This excerpt from a military physician stationed west of Boston writing to his friend made a particular impression on me with the vivid, personal writing:

These men start with what appears to be an attack of la grippe or influenza, and when brought to the hospital they very rapidly develop the most viscous type of pneumonia that has ever been seen. Two hours after admission they have the mahogany spots over the cheek bones, and a few hours later you can begin to see the cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves. There is no doubt in my mind that there is a new mixed infection here, but what I don’t know.

Previously healthy people were dying at an extremely rapid clip in 24-48 hours from the infection. And then, he continued:

It takes special trains to carry away the dead. For several days there were no coffins and the bodies piled up something fierce, we used to go down to the morgue (which is just back of my ward) and look at the boys laid out in long rows. It beats any sight they ever had in France after a battle. An extra long barracks has been vacated for the use of the morgue, and it would make any man sit up and take notice to walk down the long lines of dead soldiers all dressed up and laid out in double rows.

While COVID-19 is dangerous and needs to be taken seriously, we have it easy in 2020. Notice the physician wasn’t sure what this disease was in the first part of the quote. That was a theme in the book - across the US, people were confused by what kind of disease they saw for months on end. Rumors and guesses about cholera, typhoid, ganges, and black death circulated due to unusual symptoms. Even a basic question of whether this was a viral or bacterial disease took months to sort out due to lack of necessary technology and superficial understanding of the difference between the two (DNA’s connection to genetic information was discovered decades later). Compare it to today - the new coronavirus was recognized as a virus instantly and sequenced within a few weeks of first observed infections. The digital RNA signature traveled the world faster than the virus itself.

Mechanics of the epidemic

I’ve learned a few interesting bits about infectious diseases. They tend to come in waves. The underlying factors are diverse: for influenza, seasons (weather) plays a significant role in its spread. Influenza wanes in summer (as it does today’s version). Another factor is social behavior: as the disease spreads, the rumors and anxiety spread too, and that affects people’s behavior, which cuts down on people’s contacts and opportunities for the virus to jump from person to person. Influenza is also one of the fastest mutating viruses known to humankind, and it’s continuously producing new strains that might be more or less viral.

In the case of 1918 influenza, the first wave came in spring and was mild. People barely noticed an uptick in deaths in the US or Europe. Summer was calm from the public health point of view. The second wave came in the fall of 1918 and was fierce. In the US, over 300 thousand deaths were reported in about eight weeks (scaling relative to today’s population the toll would be over 900 thousand people). In India, the fall took the death toll of over 20 million people.

The virus kept waning and coming back until 1920 - the disease persisted for two long years. An interesting and less talked about is the impact on people who survived. Many of them had severe health complications. One of them is an autoimmune response when the body loses track of who is the invader and starts to attack its healthy cells. Another is a multi-organ failure from the virus itself. Reverberations of the 1918 influenza were felt for over a decade with people struggling with mental health issues from brain infections.

My point here is not to list all these issues but to highlight that focusing solely on fatalities is not enough to describe society’s true cost and people’s well-being. When thinking of risks of the current coronavirus pandemic, the death rate does not tell the whole story.

The state of biology and medicine

The Great Influenza starts off with a hundred-pages-plus introduction to the state of biology and medical science on the cusp twentieth century. I was surprised to learn how little we knew at the time. As I alluded above, our understanding of the difference between viruses and bacteria was very shallow. When humanity launched into the air with the first airplane experiments, we couldn’t figure out what kind of disease was killing humanity en masse.

Random controlled trials were described as “unethical” because they relied on statistics instead of reasoning. Completely aside: this reminds me of the big debate in the AI community between the old-school reasoning-oriented oriented approaches and now-hot deep learning relying on statistics.

Medical science more often resembled shamanism with the idea of bloodletting wide-spread as an all-around cure. I’m stunned that we had the theory of general relativity before the 1918 pandemic, but we didn’t understand what DNA is.

Microscope - a magnificent new tool

The discussion of the state of biology and medicine included the device invented over 80 years before the 1918 pandemic - the microscope. The use of a microscope to probe the nature practiced in Europe but lagging behind in America is attributed to the Old Continent’s edge in medicine. European biologists acquired the new capability of testing theories of disease spread in a lab setting. A quote from Louis Pasteur captures the excitement at the time:

I’m on the edge of mysteries, and the veil is getting thinner and thinner.

A microscope was pivotal to the development of the germ theory of the disease. Further probing of the theory would lead to the creation a conceptual framework for confronting infectious diseases, including influenza. Public health, as a rigorous discipline, was born.

It is interesting to me how a relatively simple instrument had such an outsized impact when you consider 2-hop consequences. Another quote from the book sums it up nicely:

Nature answer only when she is questioned - Jacob Henle

Public health runs on trust

I found The Great Influenza dwelling on minor details too much. However, I really enjoyed the specifics of the political climate during World War I in the US.

Political administration was covering up the early indications of the epidemic to keep the public calm. The goal was to avoid disrupting the support for America’s participation in the war. All events and missteps described in the book reveal pandemic response’s basic truism: you can either do too little or too much. Never just right.

However, doing too much requires the public’s cooperation, which hinges on thorough, honest communication. The US administration did just the opposite. It went as far as creating a misinformation campaign - fabricating a rosy picture within the country. When facts on the ground disagreed with the campaign, plain censorship would kick in. The virus spreads people are dying but (censored) media and political leaders are whitewashing the reality and lies are increasingly clear. And then next step that everyone loses trust, panics, and society disintegrates. People stop caring for each other out of fear of the unknown. Lincon said it the best:

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

Public health runs on public trust. It’s simple to understand yet exceedingly difficult to implement in practice.

Practical take-away

While the disease’s nitty-gritty details were interesting to me personally, I think the most practical take-aways congregate on the upper layer of understanding how society and politics work in an epidemic.

The key to successful epidemic response is doing so much of science-based policy that it feels like an overreaction. However, there’s always a reason not to act: an upcoming election, a war to win, or stock market worship.

The US in 2020 has 4% of the world population, but around 20% of deaths from COVID-19 when I write this note. Sadly, it’s a metric of a state that went astray. I don’t see that changing in the coming few months. Given what I learned about an epidemic’s mechanics from the book, I dread for the coming winter.