ON SEPTEMBER 29, 1919, Sir William Osler began coughing. One of the original “Four Doctors” in a famous portrait of the founding faculty of the Johns Hopkins Medical School, a portrait that symbolized the new primacy of science in American medicine, he was and still is regarded as one of the greatest clinicians in history. A man of wide interests, a friend of Walt Whitman, and author of the textbook that ultimately led to the founding of the Rockefeller Institute for Medical Research, Osler was then at Oxford.
Osler had already suffered one great loss with the death of his only child in the war. Now he suffered as well from a respiratory infection he diagnosed as influenza. In Oxford that fall, influenza was prevalent enough that the dons considered postponing the school term. To his sister-in-law, Osler wrote, “For two days I felt very ill & exhausted by the paroxysms” of coughing. He seemed to recover, but on October 13 his temperature rose to 102.5. He wrote a friend he had “one of those broncho-pneumonias so common after influenza.” He tried to work on a talk about Whitman and also wrote Welch and John D. Rockefeller Jr. about giving a grant to his alma mater, McGill University. But on November 7, he felt “a stab and then fireworks” on his right side. Twelve hours later he began coughing again: “A bout arrived which ripped all pleural attachments to smithereens, & with it the pain.”
After three weeks his physicans took him off morphine, gave him atropine, and said they were encouraged. On December 5 he received a local anesthetic and a needle was inserted into his lungs to drain fourteen ounces of pus. He gave up working on his Whitman talk and felt certain now of the end, joking, “I’ve been watching this case for two months and I’m sorry I shall not see the post mortem.”
His wife did not like the joke. His pessimism was crushing her: “[W]hatever he says always does come true—so how can I hope for anything but a fatal ending?” She tried to remain optimistic as the disease dragged on. But one day she found him reciting a Tennyson poem: “Of happy men that have the power to die, / And grassy barrows of the happier dead. / Release me, and restore me to the ground….”
He had turned seventy in July. A birthday tribute to him, a Festschrift—a collection of scientific articles in his honor—arrived on December 27, entitled, Contributions to Medical and Biological Research, Dedicated to Sir William Osler. Publication had been delayed because Welch was editing them. Welch never did anything on time.
His most recent biographer believes that had he been at the Johns Hopkins Hospital instead, he would have received better care. Physicians would have used x rays, electrocardiograms, earlier surgical intervention to drain an empyema, a pocket of pus from the lung. They might have saved him.
He died December 29, 1919, his last words being, “Hold up my head.”
He had always held his head high.
If finally it seemed past, yet it wasn’t past. In September 1919, as Osler was dying, Blue predicted that influenza would return: “Communities should make plans now for dealing with any recurrences. The most promising way to deal with a possible recurrence is, to sum it up in a single word, ‘preparedness.’ And now is the time to prepare.”
On September 20, 1919, many of the best scientists in the country met to try to reach a consensus on the cause of the disease or course of therapy. They could not, but the New York Times stated that the conference marked the beginning of a joint federal, state, and city effort to prevent a recurrence. Two days later the Red Cross distributed its own confidential battle plan internally: “Proposed Staff Organization for Possible Influenza Emergency / Confidential / Note: No publicity is to be given this bulletin until…the first indication of a recurrence of influenza in epidemic form, but until such time there should be no public statement by a Red Cross Chapter or Division office.”
By February 7, 1920, influenza had returned with enough ferocity that the Red Cross declared, “Owing to the rapid spread of influenza, the safety of the country demands, as a patriotic duty, that all available nurses or anyone with experience in nursing, communicate with the nearest Red Cross chapters or special local epidemic committees, offering their services.”
In eight weeks in early 1920, eleven thousand influenza-related deaths occurred in just New York City and Chicago, and in New York City more cases would be reported on a single day than on any one day in 1918. In Chicago, Health Commissioner John Dill Robertson, who had been so concerned about morale in 1918, organized three thousand of the most professional nurses into regional squads that could range over the entire city. Whenever an influenza case developed, that victim’s home was tagged.
The year 1920 would see either (sources differ) the second or third most deaths from influenza and pneumonia in the twentieth century. And it continued to strike cities sporadically. As late as January 1922, for example, Washington State’s health director, Dr. Paul Turner, while refusing to admit the return of influenza, declared, “The severe respiratory infection which is epidemic at this time throughout the state is to be dealt with the same as influenza…. Enforce absolute quarantine.”
Only in the next few years did it finally fade away in both the United States and the world. It did not disappear. It continued to attack, but with far less virulence, partly because the virus mutated further toward its mean, toward the behavior of most influenza viruses, partly because people’s immune systems adjusted. But it left a legacy.
Even before the epidemic ended, New York City Health Commissioner Royal Copeland estimated that twenty-one thousand children in the city had been made orphans by the epidemic. He had no estimate of children who lost only one parent. Berlin, New Hampshire, a tiny town, had twenty-four orphaned children not counting, said a Red Cross worker, “in one street sixteen motherless children.” Vinton County, Ohio, population thirteen thousand, reported one hundred children orphaned by the virus. Minersville, Pennsylvania, in the coal regions, had a population of six thousand; there the virus had orphaned two hundred children.
In March 1919 a senior Red Cross official advised district officers to help wherever possible on an emergency basis, because “the influenza epidemic not only caused the deaths of some six hundred thousand people, but it also left a trail of lowered vitality…nervous breakdown, and other sequella [sic] which now threaten thousands of people. It left widows and orphans and dependent old people. It has reduced many of these families to poverty and acute distress. This havoc is wide spread, reaching all parts of the United States and all classes of people.”
Months after “recovering” from his illness, the poet Robert Frost wondered, “What bones are they that rub together so unpleasantly in the middle of you in extreme emaciation…? I don’t know whether or not I’m strong enough to write a letter yet.”
Cincinnati Health Commissioner Dr. William H. Peters told the American Public Health Association meeting almost a year after the epidemic that “phrases like ‘I’m not feeling right,’ ‘I don’t have my usual pep,’ ‘I’m all in since I had the flu’ have become commonplace.” Cincinnati’s public health agencies had examined 7,058 influenza victims since the epidemic had ended and found that 5,264 needed some medical assistance; 643 of them had heart problems, and an extraordinary number of prominent citizens who had had influenza had died suddenly early in 1919. While it was hardly a scientific sample, Peters believed that few victims had escaped without some pathological changes.
Throughout the world similar phenomena were noted. In the next few years a disease known as “encephalitis lethargica” spread through much of the West. Although no pathogen was ever identified and the disease itself has since disappeared—indeed, there is no incontrovertible evidence that the disease, in a clearly definable scientific sense, ever existed—physicians at the time did believe in the disease, and a consensus considered it a result of influenza.
There were other aftershocks impossible to quantify. There was the angry emptiness of a parent or a husband or a wife. Secretary of War Newton Baker—who had been criticized for being a pacifist when Wilson appointed him—particularly took to heart charges that War Department policies had in effect murdered young men. In several cases troops from Devens were transferred to a post whose commander protested receiving them because of the epidemic. The protests were futile, the troops came, and so did influenza. The father of one boy who died at such a camp wrote Baker, “My belief is that the heads of the War Department are responsible.” Baker replied in a seven-page, single-spaced letter, a letter of his own agony.
The world was still sick, sick to the heart. The war itself…The senseless deaths at home, on top of all else…Wilson’s betrayal of ideals at Versailles, a betrayal that penetrated the soul…The utter failure of science, the greatest achievement of modern man, in the face of the disease…
In January 1923 John Dewey wrote in the New Republic, “It may be doubted if the consciousness of sickness was ever so widespread as it is today…. The interest in cures and salvations is evidence of how sick the world is.” He was speaking of a consciousness that went beyond physical disease, but physical disease was part of it. He was speaking of the world of which F. Scott Fitzgerald declared “all Gods dead, all wars fought, all faiths in man shaken.”
The disease has survived in memory more than in any literature. Nearly all those who were adults during the pandemic have died now. Now the memory lives in the minds of those who only heard stories, who heard how their mother lost her father, how an uncle became an orphan, or heard an aunt say, “It was the only time I ever saw my father cry.” Memory dies with people.
The writers of the 1920s had little to say about it.
Mary McCarthy got on a train in Seattle on October 30, 1918, with her three brothers and sisters, her aunt and uncle, and her parents. They arrived in Minneapolis three days later, all of them sick—her father had pulled out a gun when the conductor tried to put them off the train—met by her grandparents wearing masks. All the hospitals were full and so they went home. Her aunt and uncle recovered but her father, Roy, thirty-eight years old, died on November 6, and her mother, Tess, twenty-nine years old, died November 7. In Memories of a Catholic Girlhood she spoke of how deeply being an orphan affected her, made her desperate to distinguish herself, and she vividly remembered the train ride across two-thirds of the country, but she said almost nothing of the epidemic.
John Dos Passos was in his early twenties and seriously ill with influenza, yet barely mentioned the disease in his fiction. Hemingway, Faulkner, Fitzgerald said next to nothing of it. William Maxwell, a New Yorker writer and novelist, lost his mother to the disease. Her death sent his father, brother, and him inward. He recalled, “I had to guess what my older brother was thinking. It was not something he cared to share with me. If I hadn’t known, I would have thought that he’d had his feelings hurt by something he was too proud to talk about….” For himself, “[T]he ideas that kept recurring to me, perhaps because of that pacing the floor with my father, was that I had inadvertently walked through a door that I shouldn’t have gone through and couldn’t get back to the place I hadn’t meant to leave.” Of his father he said, “His sadness was of the kind that is patient and without hope.” For himself, “the death of my mother…was a motivating force in four books.”
Katherine Anne Porter was ill enough that her obituary was set in type. She recovered. Her fiancé did not. Years later her haunting novella of the disease and the time, Pale Horse, Pale Rider, is one of the best—and one of the few—sources for what life was like during the disease. And she lived through it in Denver, a city that, compared to those in the east, was struck only a glancing blow.
But the relative lack of impact it left on literature may not be unusual at all. It may not be that much unlike what happened centuries ago. One scholar of medieval literature says, “While there are a few vivid and terrifying accounts, it’s actually striking how little was written on the bubonic plague. Outside of these few very well-known accounts, there is almost nothing in literature about it afterwards.”
People write about war. They write about the Holocaust. They write about horrors that people inflict on people. Apparently they forget the horrors that nature inflicts on people, the horrors that make humans least significant. And yet the pandemic resonated. When the Nazis took control of Germany in 1933, Christopher Isherwood wrote of Berlin: “The whole city lay under an epidemic of discreet, infectious fear. I could feel it, like influenza, in my bones.”
Those historians who have examined epidemics and analyzed how societies have responded to them have generally argued that those with power blamed the poor for their own suffering, and sometimes tried to stigmatize and isolate them. (The case of “Typhoid Mary” Mallon, an Irish immigrant in effect imprisoned for twenty-five years, is a classic instance of this attitude; if she had been of another class, the treatment of her might well have been different.) Those in power, historians have observed, often sought security in imposing order, which gave them some feeling of control, some feeling that the world still made sense.
In 1918 what might be considered a “power elite” did sometimes behave according to such a pattern. Denver Health Commissioner William Sharpley, for example, blamed the city’s difficulties with influenza on “foreign settlements of the city,” chiefly Italians. The Durango Evening Herald blamed the high death toll among Utes on a reservation on their “negligence and disobedience to the advice of their superintendent and nurses and physicians.” One Red Cross worker in the mining regions of Kentucky took offense at uncleanliness: “When we reached the miserable shack it seemed deserted…. I went on in and there laying with her legs out of the bed and her head thrown way back on a filthy pillow was the woman, stone dead, her eyes staring, her mouth yawning, a most gruesome sight…. The mother of the woman’s husband came in, an old woman living in an indescribable shack some 300 feet away…. I can still smell the terrible odor and will never forget the nauseating sight. The penalty for filth is death.”
Yet, despite such occasional harshness, the 1918 influenza pandemic did not in general demonstrate a pattern of race or class antagonism. In epidemiological terms there was a correlation between population density and hence class and deaths, but the disease still struck down everyone. And the deaths of soldiers of such promise and youth struck home with everyone. The disease was too universal, too obviously not tied to race or class. In Philadelphia, white and black certainly got comparable treatment. In mining areas around the country, whether out of self-interest or not, mine owners tried to find doctors for their workers. In Alaska, racism notwithstanding, authorities launched a massive rescue effort, if too late, to save Eskimos. Even the very Red Cross worker so nauseated by filth continued to risk his own life day after day in one of the hardest-hit areas of the country.
During the second wave, many local governments collapsed, and those who held the real power in a community—from Philadelphia’s bluebloods to Phoenix’s citizens’ committee—took over. But generally they exercised power to protect the entire community rather than to split it, to distribute resources widely rather than to guarantee resources for themselves.
Despite that effort, whoever held power, whether a city government or some private gathering of the locals, they generally failed to keep the community together. They failed because they lost trust. They lost trust because they lied. (San Francisco was a rare exception; its leaders told the truth, and the city responded heroically.) And they lied for the war effort, for the propaganda machine that Wilson had created.
It is impossible to quantify how many deaths the lies caused. It is impossible to quantify how many young men died because the army refused to follow the advice of its own surgeon general. But while those in authority were reassuring people that this was influenza, only influenza, nothing different from ordinary “la grippe,” at least some people must have believed them, at least some people must have exposed themselves to the virus in ways they would not have otherwise, and at least some of these people must have died who would otherwise have lived. And fear really did kill people. It killed them because those who feared would not care for many of those who needed but could not find care, those who needed only hydration, food, and rest to survive.
It is also impossible to state with any accuracy the death toll. The statistics are estimates only, and one can only say that the totals are numbing.
The few places in the world that then kept reliable vital statistics under normal circumstances could not keep pace with the disease. In the United States, only large cities and twenty-four states kept accurate enough statistics for the U.S. Public Health Service to include them in their database, the so-called registration area. Even in them everyone from physicians to city clerks was trying to survive or help others survive. Record keeping had low priority, and even in the aftermath little effort was made to compile accurate numbers. Many who died never saw a doctor or nurse. Outside the developed world, the situation was far worse, and in the rural regions of India, the Soviet Union—which was engaged in a brutal civil war—China, Africa, and South America, where the disease was often most virulent, good records were all but nonexistent.
The first significant attempt to quantify the death toll came in 1927. An American Medical Association–sponsored study estimated that 21 million died. When today’s media refers to a death toll of “more than 20 million” in stories on the 1918 pandemic, the source is this study.
But every revision of the deaths since 1927 has been upward. The U.S. death toll was originally put at 550,000. Now epidemiologists have settled on 675,000 out of a population of 105 million. In the year 2004, the U.S. population exceeds 291 million.
Worldwide, both the estimated toll and the population have gone up by a far greater percentage.
In the 1940s Macfarlane Burnet, the Nobel laureate who spent most of his scientific life studying influenza, estimated the death toll at 50 to 100 million.
Since then various studies, with better data and statistical methods, have gradually moved the estimates closer and closer to his. First several studies concluded that the death toll on the Indian subcontinent alone may have reached 20 million. Other new estimates were presented at a 1998 international conference on the pandemic. And in 2002 an epidemiological study reviewed the data and concluded that the death toll was “in the order of 50 million,…[but] even this vast figure may be substantially lower than the real toll.” In fact, like Burnet, it suggested that as many as 100 million died.
Given the world’s population in 1918 of approximately 1.8 billion, the upper estimate would mean that in two years—and with most of the deaths coming in a horrendous twelve weeks in the fall of 1918—in excess of 5 percent of the people in the world died.
Today’s world population is 6.3 billion. To give a sense of the impact in today’s world of the 1918 pandemic, one has to adjust for population. If one uses the lowest estimate of deaths—the 21 million figure—that means a comparable figure today would be 73 million dead. The higher estimates translate into between 175 and 350 million dead. Those numbers are not meant to terrify—although they do. Medicine has advanced since 1918 and would have considerable impact on the mortality rate (see Afterword). Those numbers are meant simply to communicate what living through the pandemic was like.
Yet even those numbers understate the horror of the disease. The age distribution of the deaths brings that horror home.
In a normal influenza epidemic, 10 percent or fewer of the deaths fall among those aged between sixteen and forty. In 1918 that age group, the men and women with most vitality, most to live for, most of a future, accounted for more than half the death toll, and within that group the worst mortality figures fell upon those aged twenty-one to thirty.
The Western world suffered the least, not because its medicine was so advanced but because urbanization had exposed its population to influenza viruses, so immune systems were not naked to it. In the United States, roughly 0.65 percent of the total population died, with roughly double that percentage of young adults killed. Of developed countries, Italy suffered the worst, losing approximately 1 percent of its total population. The Soviet Union may have suffered more, but few numbers are available for it.
The virus simply ravaged the less developed world. In Mexico the most conservative estimate of the death toll was 2.3 percent of the entire population, and other reasonable estimates put the death toll over 4 percent. That means somewhere between 5 and 9 percent of all young adults died.
And in the entire world, although no one will ever know with certainty, it seems more than just possible that 5 percent—and in the less developed countries approaching 10 percent—of the world’s young adults were killed by the virus.
In addition to the dead, in addition to any lingering complications among survivors, in addition to any contribution the virus made to the sense of bewilderment and betrayal and loss and nihilism of the 1920s, the 1918 pandemic left other legacies.
Some were good ones. Around the world, authorities made plans for international cooperation on health, and the experience led to restructuring public health efforts throughout the United States. The New Mexico Department of Public Health was created; Philadelphia rewrote its city charter to reorganize its public health department; from Manchester, Connecticut, to Memphis, Tennessee, and beyond, emergency hospitals were transformed into permanent ones. And the pandemic motivated Louisiana Senator Joe Ransdell to begin pushing for the establishment of the National Institutes of Health, although he did not win his fight until a far milder influenza epidemic in 1928 reminded Congress of the events of a decade earlier.
All those things are part of the legacy left by the virus. But the disease left its chief legacy in the laboratory.