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The last pandemic

This book taught me a lot about the Spanish Flu

John M. Barry’s 2004 book The Great Influenza has never been more relevant.


My dad’s mom, Lillian Gates, was lucky to have survived the 1918 influenza pandemic. Unlike COVID-19, which is hitting older people the hardest, the influenza pandemic caused the highest mortality among people in their twenties. The most vulnerable of all were pregnant women. In 1918, my grandmother was 27 and pregnant with my dad’s older sister. She was living in Bremerton, WA, which suffered big losses from influenza because it had a big Navy shipyard and sailors coming from all over the world.

Then as now people isolated themselves at home, streets were empty, and industry shut down. Doctors and nurses were incredibly heroic, putting their own lives at risk and working themselves to the bone. The best parts of human nature were frequently on display—but so were acts of ignorance, greed, and fear of the “other.”

To refresh my memory about the realities and lessons of that devastating pandemic, I recently reread The Great Influenza (2004), by John M. Barry. He does a great job of showing just how profoundly that pandemic affected not just millions of families like mine but also the entire flow of history.

Barry speculates that if not for the pandemic, World War II might never have erupted. In 1918, when President Woodrow Wilson was in the midst of negotiating with his British and French counterparts the treaty to end World War I, he got a violent case of the flu. He survived, but he was never the same again, physically or mentally. Previously, Wilson had insisted that the treaty must represent “peace without victory” and would not give in to the harsh terms French President Georges Clemenceau wanted to impose on the Germans. But after getting the flu, Wilson “yielded to Clemenceau everything of significance Clemenceau wanted,” Barry writes.

No one can know for sure what effect the flu really had on Wilson, or what the effect of a gentler Treaty of Versailles might have been. But Barry is sure that Wilson’s illness contributed to the rise of Hitler: “Historians with virtual unanimity agree that the harshness towardGermany of the Paris peace treaty helped create the economic hardship, nationalistic reaction, and political chaos that fostered the rise of Adolf Hitler.”

When The Great Influenza first came out, I got a copy from Bill Foege, a good friend and public-health hero who helped to eradicate smallpox. I’m glad I read it. It’s one of several books that made it clear to me that the world needed to do a better job of preparing for novel pathogens. Writing roughly 16 years ago, Barry was clear and persuasive that “another pandemic not only can happen…. It almost certainly will happen.”

I wasn’t the only one who took Barry’s admonition to heart. As ABC recently reported, “President George W. Bush was on vacation at his ranch in Crawford, Texas, when he began flipping through a … copy of a new book about the 1918 flu pandemic [given to him by Health Secretary Mike Leavitt]. He couldn’t put it down.” Bush and Leavitt then worked to pass a multi-billion-dollar pandemic-preparation bill.

So what are the big lessons from the 1918 influenza pandemic?

First and foremost, leadership matters. Scientific leaders like Army Surgeon General William Gorgas stepped up. And so did some, but by no means all, governors and mayors. In St. Louis, for example, the city mobilized quickly and staged effective responses that saved many lives. In Philadelphia, in contrast, the mayor ignored the advice of experts that he should cancel a massive parade in support of the war effort. A few days later, the bodies started piling up. “Undertakers, themselves sick, were overwhelmed. They had no place to put bodies…. Undertakers’ work areas were overflowing, they stacked caskets in halls, in their living quarters,” writes Barry.

“In 1918, America’s political leaders sugarcoated bad news to avoid panicking the public.”

Second, truth matters. In 1918, America’s political leaders—even health commissioners—sugarcoated bad news to avoid panicking the public. That greatly undermined their authority when citizens saw friends and neighbors dying in great numbers. Barry concludes 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.”

Third, philanthropy has an important role to play. In fact, things could have been much worse if not for the gifts of John D. Rockefeller, Johns Hopkins, and many other donors. These gifts fundamentally transformed American science and medicine in the late 19thth and early 20 centuries giving the country hundreds of thousands of well-trained professionals to treat those who fell ill from influenza and guide the public-health response.

Fourth, pandemics are humbling. Despite the brilliant work at the Rockefeller Institute, Johns Hopkins University, and other institutions, doctors never had the benefit of effective antiviral medications or a vaccine. In fact, it was not until 1933 that scientists confirmed that it was a virus, rather than a bacterium, that caused the influenza pandemic.

This time around, we have many more tools at our disposal for creating effective vaccines and therapeutics. But the science is still slower than any of us would like, and putting an end to this pandemic will require more than just great science. It will also take a lot of political will, especially encouraging social distancing and making sure that scientific miracles spread as far and wide as the virus itself.

When Melinda and I first started learning about childhood vaccines, we were appalled to learn that it often took decades for a new vaccine to be put to widespread use in the developing world. So even before we have all the tools we need to defeat COVID-19, my colleagues at the Gates Foundation, Gavi, and many other organizations are working to raise the money, organize the institutions, and develop a global plan of action for distributing them around the globe. In 1918, the world just didn’t have the systems to do that. Melinda and I are deeply committed to making sure we will this time around.