Until recently, the idea of a pandemic took most people’s imagination to Hollywood thrillers and the Black Plague that ravaged medieval Europe. But the most devastating plague to ever strike the human race took place a century ago, during the First World War. This story contains many lessons for how—and how not—to handle a pandemic. Barry’s tie-ins to our own day (most recent edition published in 2018) have an eerily prophetic ring to them in light of the corona virus that has recently swept the globe.

It was in the fall of 1918 that a group of sailors from the United States began presenting never-before seen symptoms that baffled clinicians. The presenting symptoms were bleeding in the nose and ears, pounding headaches, painful body aches, deep coughs (sometimes deep enough to tear abdominal musculature), and, finally, skin turning blue.

The medical professionals called in Paul Lewis, a lieutenant commander and a medical doctor who was more familiar with death in all its varieties than just about anyone alive at the time. He was also brilliant. More than a few colleagues—accomplished scientists in their own rights—called Lewis the most brilliant man they’d ever met.

Lewis was highly accomplished and still young. When polio had ravaged New York, he was part of the group that proved a virus was the culprit. And then he developed a vaccine that proved 100 percent effective in animal trials. He’d also founded a research institute in affiliation with University of Pennsylvania. Though Lewis was an accomplished man of science and familiar with death and all its friends, he was still baffled by the bodies of dying, blue-skinned sailors. He’d seen something similar among British soldiers weeks earlier, something influenza-like, but he wasn’t sure.

Whatever it was that the sailors who came through Boston to Philadelphia had brought with them that fall, it spread. Despite the best attempts of medical personnel to contain the unknown disease, it spread from the 19 soldiers to 87, and then to 600 within just a few days. Hospitals ran out of beds quickly and had to involve other medical facilities to care for the sick sailors and the civilians with whom they’d come in contact. Simultaneously, the same symptoms began showing up all over the world. This wasn’t a passing rash of influenza going around as doctors in the United States and Europe had thought. It was actually the second wave of a mild influenza that had appeared months earlier in America’s heartland. It was not nearly as devastating then, in symptoms or spread. The second, far more pernicious infection was spreading like wildfire in the fall of 1918, affecting not just sailors in New England, but also soldiers in the British Raj in India, and everywhere in between.

And so, as the Great War continued to rage, another war had begun. It wasn’t just a fight of nation against nation, but also of nation against some unknown disease. It began in a small town in the United States in the spring of 1918, but had laid dormant. But between the fall of 1918 and 1920, millions died. Of those who contracted influenza and succumbed, their deaths were swift and painful.

Earlier estimates put the death toll at 21 million, but this is now considered a low ball. More widely accepted estimates from epidemiologists are between 50 and 100 million. The majority of these deaths took place within a half-year window, during the fall and winter of 1918. The disease killed more people in a year than ever died in the medieval Black Plague or from AIDS.

What made this pandemic even more tragic was that it was the young (people in their 20s and 30s) who were especially vulnerable to the pathogen. If the higher estimates are accurate, that means the 1918 influenza took out about 10 percent of young adults on the planet.

The 1918 outbreak marked a milestone in human history. It was the first time that modern medicine and nature had challenged each other in such a robust way. The virus that led to the infamous Bubonic Plague 700 years earlier was a far milder strain, but it still decimated Europe because science and infrastructure couldn’t put up any real fight. This time, it was different, and it was the individuals who retained poise and calm in the midst of dire circumstances who stopped the bleeding and kept the catastrophe from being any more grim than it already was.

Around the time of the pandemic, there were a number of remarkable people who had helped bring medical practices and research to the cutting edge. There are some areas of study where, even a century later, medical practitioners remain indebted to these forebears’ expertise and the skills they developed in a time of influenza. Paul Lewis was one of those geniuses. Another was William Henry Welch, who founded the first academic program devoted to public health in 1916 at Johns Hopkins University in Baltimore.

Still, it took tremendous time and dedication to make medicine a modern, scientific pursuit. Until the late-1800s, the field of medicine had changed very little since the days of Hippocrates in ancient Greece. Even until 1900, only one medical school in five required a high school diploma in the United States, and only one medical school required a college degree for admission. Many applicants without any serious training in the physical sciences were admitted, simply by proving that they could pay tuition. Degrees were doled out to men (women were not admitted) simply for passing all the classes—even if they had never touched a body or seen a patient.

Eventually, medical practice began to improve and become more empirically verified, first in Europe and then in the United States. United States medical science was the worst in the developed world before it became the best.

William Henry Welch was a forerunner who helped bring the massive and much-needed changes to the United States’ medical education. Welch was a capable scientist, physician, and professor, but his strength lay in his ability to inspire. He was a charming and charismatic individual. The students he taught at Johns Hopkins adored him and would become the most coveted in the United States. These Welch protégés formed an army of elites who would become more desperately needed than they knew in 1918. Welch was a man who convinced people that improvements in the American medical field were horribly overdue, and he provided a road map for how to get there, as well as a prestigious group of medical professionals to navigate it.

Welch’s influence revolutionized medicine in the United States, but another thing that  made Welch singular was that he saw what most everyone else had missed: humanity’s vulnerability to epidemics. He had noticed the trend that every time the United States went to war, disease killed far more combatants than the opposing armies. Moreover, war had a way of spreading illness. These facts led Welch to predict that, with the Great War on, it was just a matter of time before some kind of epidemic broke out.

Welch had pushed Johns Hopkins for a public health program since the 1880s, and he finally got his wish in 1916 when the Johns Hopkins School of Hygiene and Public Health was founded. This was just two years before the influenza began to emerge. He saw that robust public health (of which epidemiology, or the study of disease, is a central feature) was the best way to save lives. He was right, and his intuition holds true to this day.

The influenza outbreak of 1918 most likely began in Haskell County, Kansas. There are other theories that it began in China or Vietnam or France, but the United States is the most probable starting point, and there’s no earlier record than from Haskell County. The virus drifted from Haskell to a nearby military base, when it was still tame in comparison to what was to come. Not much more was said about the outbreak than a forgettable health notice about “influenza of severe type” the Midwest. From there, the virus worked its way through the ranks of soldiers and was then exported to other U.S. bases and the various war theaters across Afro-Eurasia. It came roaring back to America in the fall of 1918, in the previously mentioned New England cities.

What makes influenza dangerous is that it’s caused by viruses—not bacteria (a discovery that one of William Henry Welch’s many protégés made). It’s not quite an organism, but it’s not as lifeless as a chemical compound either. Its mission is to replicate, but it cannot do so apart from a host. It needs an organism’s cells in order to make thousands or even hundreds of thousands of self-copies.

What makes influenza viruses unique is that they are extremely infectious and competitive. Influenza viruses set off all the body’s warning bells, and the immune system sets up defenses based on what the body has already encountered. But a new variation of the virus is unknown to the body, and attacks a compromised and blind immune system. The body beats down any other viruses that might be present, and then, once all other familiar viruses have been eliminated, the new influenza virus begins its work. 

The United States was unprepared for the pandemic for a variety of reasons. One was Woodrow Wilson’s monitoring and manipulation of the press during World War I in order to make sure that the American people remained loyal to the war effort. George Creel—essentially Wilson’s minister of propaganda—kept a tight leash on information, created a spy network, and jailed dissenters who questioned the Wilson administration. There was a yawning chasm between the public and full, reliable information, even before the new influenza came on the scene.

Not only was there a propaganda machine running full tilt, there was a dearth of doctors and nurses in the United States. Thousands of nurses and doctors—among them the best and the brightest—were sent to Europe to support the war effort. Wilson said he wanted “the spirit of ruthless brutality to enter into every fibre of American life.” Even for civilians at home, life became austere. Excellent medical help was not readily available stateside. There were not nearly enough nurses to help civilians when the pandemic came crashing through North America.

What happened to the group of infected U.S. sailors that came back from war and were moved from Boston to Philadelphia became a tragically common occurrence throughout the country. The infected went to understaffed, crowded hospitals run by incompetent medical personnel. Within a matter of days, half of Philadelphia was infected, and some people were offering $100 bribes for nurses to admit them. But all the beds of all 31 hospitals in the Philadelphia area were full, so bribes fell on deaf and overworked ears.

The war engulfing the world contributed to these other realities to create the perfect storm that made the 1918 pandemic the deadliest in human history. The initial spring 1918 wave had been mild, but the fall outbreak in cities as far apart as Boston, Bombay, and Beijing constituted a vicious resurgence of the virus. It was as if the virus had gone dormant for a time, adapting, mutating, reassessing its moment to strike. When it did strike, it struck the world all at once. The attack was forceful enough to infect hundreds of millions of people around the globe. More than half the population of some cities were infected. A third of Japan was infected. Seven percent of Iran’s and Russia’s populations were wiped out. Some Pacific islands saw more than a fifth of their populations obliterated. In India alone, almost 20 million perished from the second wave of influenza. They couldn’t pull the corpses out of hospitals fast enough to make room for new patients.

In 1918, fear devastated society every bit as much as the disease itself. The government and the media attempted to mitigate fears by withholding the truth—which had just the opposite effect. Fears amplified in the absence of information.

Anyone who’s seen a horror movie knows that it is the unknown that creates fear. It’s the mystery that haunts us. We wonder what that thing is lurking in the shadows, and what it might do to us. As soon as the villain or the monster comes into the light, and we see it for what it is, it’s not nearly as horrifying. It might be a force to be taken seriously, but fear is localized in the thing itself. We know what it is and what it isn’t, what it is and isn’t capable of doing to us. Citizens can act and prepare accordingly.

A common term in public relations is “risk communication.” Risk communication operates on the premise that pandemonium will break out if the truth isn’t unveiled delicately, partially and then more gradually. The assumption is that the public can’t handle it. Businesses do this; so does the government. But truth isn’t a thing to be managed—it’s something to be told. Telling the truth and telling it fully doesn’t amplify hysteria—it mitigates it.

There have been a handful of major pandemics since 1918: in 1957, 1968, and 2009. Like the 1918 pandemic, these infections came in waves. Moreover, each wave was different. Influenza viruses mutate rapidly to infect as many hosts as possible.

Are we prepared for an influenza outbreak like the 1918 pandemic? A former Center for Disease Control director says that an influenza pandemic is still, hands down, the worst case scenario for public health. Medicine and infrastructure have improved throughout the world over the past century, which would probably save the majority of those infected, but if we encountered a virus as vicious as the 1918 strain, it would likely still take out tens of millions of people globally.

We now know a great deal about influenza, but all our knowledge doesn’t help us much. A universal vaccine is the best hope for a pandemic-resistant humanity, but that cure is still a ways off.

Okay, but here’s what we have going for us: For one, global health surveillance is much better, and there are organizations that track and update health situations by country in real time. Time is of the essence in quashing or responding well to a pandemic, so global surveillance is a helpful tool for the world. The problem is that it’s still incomplete, and there are some countries whose governments are not forthcoming about what’s happening in their nations. In 2003, this global health surveillance system got wind of SARS (severe acute respiratory syndrome caused by the coronavirus) that was spreading in China. The spread was easier to quell than an influenza outbreak would have been, but it showed China’s opacity as the nation declined to share accurate, critical information. While China has become more forthright on matters of health over the years, its government still routinely withholds health information. And, unfortunately, China is not the only country to hamper our best attempts at vigilance. 

In addition to a global surveillance system, investment into influenza research is increasing. West Nile at its worst killed fewer than 300 people in one year. But there was a time when more funds were allocated to West Nile research than influenza research—even though influenza was killing over 50,000 a year around that same time. Priorities are changing for the better, and there are promising leads that scientists are pursuing—a universal vaccine among them.

Pharmaceuticals are not a panacea, however. It takes considerable time and expense to create vaccines. And even if the United States develops a vaccine, production will likely take place in another country. In the event of a pandemic, there is a slim chance that the government of the producing nation would ever release those vaccines to the United States. Naturally, that government would want it for their own people.

NPIs (non-pharmaceutical interventions) have become a new area of research that focuses on prevention and public health response to minimize a pandemic’s impact. But NPIs carry their own challenges, one being that the influenza virus is airborne, and inhalation is the most common path to infection. At the same time, these viruses can stay on a doorknob or a glass for hours, or even days. A complete and strict self–quarantine might be the only foolproof way to avoid contracting the virus. But this means no going out, no picking up packages or mail piling up at your door, no contact with anyone for six to 10 weeks as the virus works its way through a locale.

Government-imposed quarantines will have limited effectiveness, as well. It’s hard to keep everyone indoors for that long, and to insist on it would be deleterious for the economy. It would ruin supply chains, and, while it might prevent further contamination via imports, it would also stop the flow of vital medical supplies, like gowns, masks, IV-bags and tubes, and medicine.

A total quarantine is the only way to curb a pandemic’s spread, but this is next to impossible for a government to pull off. Moreover, some case studies suggest that, with anything less than a total quarantine and closed borders, disease spreads at about the same rate through society. Between the high social and economic costs to a society, and the extreme difficulties in effecting a successful total quarantine, it’s not our best option.