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The Great Influenza

Book Notes

Rob Whiteley recommended this book to me, Ryan Holiday recommended this book to his reading list, and I strongly recommend this book to pretty much anyone who will listen. The Great Influenza was written over ten years ago and tells us ALL ABOUT the (no longer) upcoming pandemic. The parallels between the 1918 Spanish Flu and the 2019 CoVid19 pandemic are disheartening, making this book both a history book and a playbook on how NOT to handle a pandemic.

The Great Influenza tells us the history of The Spanish flu, which probably should have been called the Kansas Flu, which went from February 1918 to around April 1920, infecting about 500 million people (or about a third of the world's population). Somewhere between 20 million and 50 million died during that pandemic, even as people said "it's just the flu." Up to 60000 people die in the US from the flu even today, but hey, "it's just the flu" seems to be the dismissive way we ignored the warnings 100 years ago, and today.

The book is also an exploration of science, broad strokes on how we discover new ideas, hypothesize and test those ideas, and form theories of phenomena and solutions to problems. Discovery is rarely a straight line, yet we see only the end result, often ignoring all the hard work that goes into that end. There are many, many failures for every success, in science and pretty much everywhere. Barry explores some of these failures and shows how they lead to our successes.

Of note, we still don't have a cure for influenza, 100 years later. We have yearly vaccinations to prime our bodies to fight off the influenza viruses, but that's not the same as having rid the world of small pox.

I have to say, I had more than a little laugh at the Arizona "You can't tell me what to do" reaction during the 1918 Influenza. I mean, hello, viruses don't care. They didn't wear masks or isolate 100 years ago, and Arizona doesn't (didn't) wear masks or isolate these days (for the most part), because "you can't tell me what to do" says Arizona. How much stays the same. How much death happens because of ignorant beliefs. Frustrating and sad for the people in Arizona who are not idiots.

But here we are.

I strongly recommend this book, but maybe not 6 months into a pandemic. Might be too depressing if you have pandemic or isolation fatigue. That said, knowledge is power and knowing what NOT to do, which you can learn from this book, might be worth the chance.

If a society does set Goethe’s “Word . . . supremely high,” if it believes that it knows the truth and that it need not question its beliefs, then that society is more likely to enforce rigid decrees, and less likely to change. If it leaves room for doubt about the truth, it is more likely to be free and open. In the narrower context of science, the answer determines how individuals explore nature—how one does science. And the way one goes about answering a question, one’s methodology, matters as much as the question itself. For the method of inquiry underlies knowledge and often determines what one discovers: how one pursues a question often dictates, or at least limits, the answer.
Page 15

According to Kuhn, the prevailing paradigm tends to freeze progress, indirectly by creating a mental obstacle to creative ideas and directly by, for example, blocking research funds from going to truly new ideas, especially if they conflict with the paradigm. He argues that nonetheless researchers eventually find what he calls “anomalies” that do not fit the paradigm. Each one erodes the foundation of the paradigm, and when enough accrue to undermine it, the paradigm collapses. Scientists then cast about for a new paradigm that explains both the old and the new facts.
Page 15

A theory must make a prediction to be useful or scientific—ultimately it must say, If this, then that—and testing that prediction is the single most important element of modern methodology. Once that prediction is tested, it must advance another one for testing. It can never stand still.
Page 17

Those who wrote the Hippocratic texts, however, observed passively and reasoned actively.
Page 17

In fact, biology is chaos. Biological systems are the product not of logic but of evolution, an inelegant process. Life does not choose the logically best design to meet a new situation. It adapts what already exists. Much of the human genome includes genes which are “conserved”; i.e., which are essentially the same as those in much simpler species. Evolution has built upon what already exists.
Page 24

Welch confessed to his stepmother, “Such great things are expected of the faculty at the Johns Hopkins in the way of achievement and of reform of medical education in this country that I feel oppressed by the weight of responsibility. A reputation there will not be so cheaply earned as at Bellevue.” Yet precisely for that reason the Hopkins offered, he wrote, “undoubtedly the best opportunity in this country.” Declining would reveal him as a hypocrite and a coward.
Page 55

Welch accepted the Hopkins offer. Dennis was furious. His friendship with Welch had been, at least on Dennis’s side, of great emotional depth and intensity. Now Dennis felt betrayed. Welch confided to his stepmother, “I grieve that a life-long friendship should thus come to an end, but . . . [i] t looks almost as if Dr. Dennis thought he had a lien upon my whole future life. When he appealed to what he had done for me I told him that was a subject which I would in no way discuss with him.”
Page 55

The greatest challenge of science, its art, lies in asking an important question and framing it in a way that allows it to be broken into manageable pieces, into experiments that can be conducted that ultimately lead to answers. To do this requires a certain kind of genius, one that probes vertically and sees horizontally. Horizontal vision allows someone to assimilate and weave together seemingly unconnected bits of information. It allows an investigator to see what others do not see, and to make leaps of connectivity and creativity. Probing vertically, going deeper and deeper into something, creates new information. Sometimes what one finds will shine brilliantly enough to illuminate the whole world. At least one question connects the vertical and the horizontal. That question is “So what?” Like a word on a Scrabble board, this question can connect with and prompt movement in many directions. It can eliminate a piece of information as unimportant or, at least to the investigator asking the question, irrelevant. It can push an investigator to probe more deeply to understand a piece of information. It can also force an investigator to step back and see how to fit a finding into a broader context. To see questions in these ways requires a wonder, a deep wonder focused by discipline, like a lens focusing the sun’s rays on a spot of paper until it bursts into flame. It requires a kind of conjury.
Page 60

Welch had a vital and wide curiosity, but he did not have this deeper wonder. The large aroused him. But he could not see the large in the small. No question ever aroused a great passion in him, no question ever became a compulsion, no question ever forced him to pursue it until it was either exhausted or led him to new questions. Instead he examined a problem, then moved on.
Page 61

Judge Learned Hand, one of Simon Flexner’s closest friends, later observed, “That community is already in the process of dissolution where each man begins to eye his neighbor as a possible enemy, where nonconformity with the accepted creed, political as well as religious, becomes a mark of disaffection; where denunciation, without specification or backing, takes the place of evidence; where orthodoxy chokes freedom of dissent.”
Page 125

Bullard had written from Europe about the war for Outlook, Century, and Harper’s Weekly. He pointed out that Britain was censoring the press and had misled the British people, undermining trust in the government and support for the war. He urged using facts only. But he had no particular affection for truth per se, only for effectiveness: “Truth and falsehood are arbitrary terms. . . . There is nothing in experience to tell us that one is always preferable to the other. . . . There are lifeless truths and vital lies. . . . The force of an idea lies in its inspirational value. It matters very little if it is true or false.”
Page 126

The research mattered, Avery was saying, not the life. And the life of research, like that of any art, lay within. As Einstein once said, “One of the strongest motives that lead persons to art or science is a flight from the everyday life. . . . With this negative motive goes a positive one. Man seeks to form for himself, in whatever manner is suitable for him, a simplified and lucid image of the world, and so to overcome the world of experience by striving to replace it to some extent by this image.
Page 158

Man might be defined as “modern” largely to the extent that he attempts to control, as opposed to adjust himself to, 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.
Page 166

At the Grove Park Inn, one of the most elegant settings in the city, they listened to a concert. Welch lit a cigar. A bellboy promptly told him smoking was not allowed. He and Cole withdrew to the veranda and began talking. Another bellboy asked them to please be quiet during the concert. Welch left in disgust.
Page 188

He had already achieved much, and he held the promise of much more. He also knew his own worth, not in the sense that it made him smug but in that it gave him responsibility, making his promise at least as much burden as ambition.
Page 200

Even if Lewis succeeded in making a vaccine, it would take weeks to produce in sufficient quantities. Thus, only drastic action could prevent the spread of influenza throughout the city. Banning public meetings, closing businesses and schools, imposing an absolute quarantine on the Navy Yard and on civilian cases—all these things made sense. A recent precedent existed. Only three years earlier Krusen’s predecessor—during the single term of the reform mayor—had imposed and enforced a strict quarantine when a polio epidemic had erupted, a disease Lewis knew more about than anyone in the world. Lewis certainly wanted a quarantine.
Page 203

But Plummer was Lewis’s commanding officer. He and Krusen wanted to wait. Both feared that taking any such steps might cause panic and interfere with the war effort. Keeping the public calm was their goal. Those polio restrictions had been imposed when the country wasn’t fighting a war.
Page 203

Advertising was about to emerge as an industry; J. Walter Thompson—his advertising agency was already national, and his deputy became a senior Creel aide—was theorizing that it could engineer behavior; after the war the industry would claim the ability to “sway the ideas of whole populations,” while Herbert Hoover said, “The world lives by phrases” and called public relations “an exact science.”
Page 205

Total war requires sacrifice and good morale makes sacrifices acceptable, and therefore possible. The sacrifices included inconveniences in daily life. To contribute to the war effort, citizens across the country
Page 205

endured the “meatless days” during the week, the one “wheatless meal” every day. All these sacrifices were of course voluntary, completely voluntary—although Hoover’s Food Administration could effectively close businesses that did not “voluntarily” cooperate. And if someone chose to go for a drive in the country on a “gasless Sunday,” when people were “voluntarily” refraining from driving, that someone was pulled over by hostile police.
Page 205

But Hagadorn believed that disease could be controlled.
Page 213

And this was only influenza.
Page 213

Those pockets of air leaking through ruptured lungs made patients crackle when they were rolled onto their sides. One navy nurse later compared the sound to a bowl of Rice Krispies, and the memory of that sound was so vivid to her that for the rest of her life she could not tolerate being around anyone who was eating Rice Krispies.
Page 235

Extreme earaches were common.
Page 235

The headaches throbbed deep in the skull, victims feeling as if their heads would literally split open, as if a sledgehammer were driving a wedge not into the head but from inside the head out. The pain seemed to locate particularly behind the eye orbit and could be nearly unbearable when patients moved their eyes.
Page 236

The ability to smell was affected, sometimes for weeks.
Page 236

This was influenza, only influenza. Yet to a layperson at home, to a wife caring for a husband, to a father caring for a child, to a brother caring for a sister, symptoms unlike anything they had seen terrified. And
Page 236

The immune system begins its defense far in advance of the lungs, with enzymes in saliva that destroy some pathogens
Page 246

Then it raises physical obstacles, such as nasal hairs that filter out large particles and sharp turns in the throat that force inhaled air to collide with the sides of breathing passageways.
Page 246

Mucus lines these passageways and traps organisms and irritants. Underneath the layer of mucus lies a blanket of “epithelial cells,” and from their surfaces extend “cilia,” akin to tiny hairs which, like tiny oars, sweep upward continuously at from 1,000 to 1,500 beats a minute. This sweeping motion moves foreign organisms away from places they can lodge and launch an infection, and up to the larynx. If something does gain a foothold in the upper respiratory tract, the body first tries to flush
Page 246

it out with more fluid—hence the typical runny nose—and then expel it with coughs and sneezes.
Page 246

And if one experiment shows a hint of a result, the slightest bump on a flat line of information, then a scientist designs the next experiment to focus on that bump, to create conditions more likely to get more bumps until they either become consistent and meaningful or demonstrate that the initial bump was mere random variation without meaning. There are limits to such manipulation. Even under torture, nature will not lie, will not yield a consistent, reproducible result, unless it is true. But if tortured enough, nature will mislead; it will confess to something that is true only under special conditions—the conditions the investigator created in the laboratory. Its truth is then artificial, an experimental artifact. One key to science is that work be reproducible. Someone in another laboratory doing the same experiment will get the same result. The result
Page 263

then is reliable enough that someone else can build upon it. The most damning condemnation is to dismiss a finding as “not reproducible.” That can call into question not only ability but on occasion ethics. If a reproducible finding comes from torturing nature, however, it is not useful. To be useful, a result must be not only reproducible but . . . perhaps one should call it expandable. One must be able to enlarge it, explore it, learn more from it, use it as a foundation to build structures upon. These things become easy to discern in hindsight. But how does one know when to persist, when to continue to try to make an experiment work, when to make adjustments—and when finally to abandon a line of thought as mistaken or incapable of solution with present techniques? How does one know when to do either? The question is one of judgment. For the distinguishing element in science is not intelligence but judgment. Or perhaps it is simply luck.
Page 263

Judgment is so difficult because a negative result does not mean that a hypothesis is wrong. Nor do ten negative results, nor do one hundred negative results. Ehrlich
Page 264

How does one know when one knows? When one is on the edge, one cannot know. One can only test.
Page 264

LABORATORIES EVERYWHERE had turned to influenza. Pasteur’s protégé Émile Roux, one of those who had raced German competitors for a diphtheria antitoxin, directed the work at the Pasteur Institute. In Britain virtually everyone in Almroth Wright’s laboratory worked on it, including Alexander Fleming, whose later discovery of penicillin he first applied to research on Pfeiffer’s so-called influenza bacillus. In Germany, in Italy, even in revolution-torn Russia, desperate investigators searched for an answer.
Page 266

Institutions are a strange mix of the mass and the individual. They abstract. They behave according to a set of rules that substitute both for individual judgments and for the emotional responses that occur whenever individuals interact. The act of creating an institution dehumanizes it, creates an arbitrary barrier between individuals. Yet institutions are human as well. They reflect the cumulative personalities of those within them, especially their leadership. They tend, unfortunately, to mirror less admirable human traits, developing and protecting self-interest and even ambition. Institutions almost never sacrifice. Since they live by rules, they lack spontaneity. They try to order chaos not in the way an artist or scientist does, through a defining vision that creates structure and discipline, but by closing off and isolating themselves from that which does not fit. They become bureaucratic.
Page 299

the coroner—Vare’s man—blamed the increasing death toll on the ban by the state public health commissioner on liquor sales, claiming alcohol was the best treatment for influenza.
Page 328

In virtually every home, someone was ill. People were already avoiding each other, turning their heads away if they had to talk, isolating themselves. The telephone company increased the isolation: with eighteen hundred telephone company employees out, the phone company allowed only emergency calls; operators listened to calls randomly and cut off phone service of those who made routine calls. And the isolation increased the fear. Clifford Adams recalled, “They stopped people from communicating, from going to churches, closed the schools, . . . closed all the saloons. . . . Everything was quiet.”
Page 328

The attrition rate even where volunteers did not come into contact with the sick—in the kitchens, for example—was little better. Finally Mrs. Martin turned bitter and contemptuous: “Hundreds of women who are content to sit back . . . had delightful dreams of themselves in the roles of angels of mercy, had the unfathomable vanity to imagine that they were capable of great spirit of sacrifice. Nothing seems to rouse them now.
Page 331

They have been told that there are families in which every member is ill, in which the children are actually starving because there is no one to give them food. The death rate is so high and they still hold back.”
Page 331

In 1918 fear moved ahead of the virus like the bow wave before a ship. Fear drove the people, and the government and the press could not control it. They could not control it because every true report had been diluted with lies. And the more the officials and newspapers reassured, the more they said, There is no cause for alarm if proper precautions are taken, or Influenza is nothing more or less than old-fashioned grippe, the more people believed themselves cast adrift, adrift with no one to trust, adrift on an ocean of death.
Page 340

But as Camus knew, evil and crises do not make all men rise above themselves. Crises only make them discover themselves. And some discover a less inspiring humanity.
Page 343

Monument and Ignacio, Colorado, went further than banning all public gatherings. They banned customers from stores; the stores remained open, but customers shouted orders through doors, then waited outside for packages.
Page 348

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.
Page 396

Paul Lewis was a romantic, and a lover. He wanted. He wanted more and loved more passionately than Park or Avery. But as is true of many romantics, it was the idea of the thing as much or more than the thing itself that he loved. He loved science, and he loved the laboratory. But it did not yield to him. The deepest secrets of the laboratory showed themselves to Lewis when he was guided by others, when others opened a crack for him. But when he came alone to the laboratory, that crack closed. He could not find the right loose thread to tug at, the way to ask the question. To him the laboratory presented a stone face, unyielding to his pleadings.
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