The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)
Part III. THE TINDERBOX
WHILE AMERICA still remained neutral William Welch, then president of the National Academy of Sciences, and his colleagues watched as their European counterparts tried to perfect killing devices.
Technology has always mattered in war, but this was the first truly scientific war, the first war that matched engineers and their abilities to build not just artillery but submarines and airplanes and tanks, the first war that matched laboratories of chemists and physiologists devising or trying to counteract the most lethal poison gas. Technology, like nature, always exhibits the ice of neutrality however heated its effect. Some even saw the war itself as a magnificent laboratory in which to test and improve not just the hard sciences but theories of crowd behavior, of scientific management of the means of production, of what was thought of as the new science of public relations.
The National Academy had itself been created during the Civil War to advise the government on science, but it did not direct or coordinate scientific research on war technologies. No American institution did. In 1915 astronomer George Hale began urging Welch and others in the NAS to take the lead in creating such an institution. He convinced them, and in April 1916 Welch wrote Wilson, “The Academy now considers it to be its plain duty, in case of war or preparation for war, to volunteer its assistance and secure the enlistment of its members for any services we can offer.”
Wilson had been a graduate student at the Hopkins when Welch had first arrived there and immediately invited him, Hale, and a few others to the White House. There they proposed to establish a National Research Council to direct all war-related scientific work. But they needed the president to formally request its creation. Wilson immediately agreed although he insisted the move remain confidential.
He wanted confidentiality because any preparation for war set off debate, and Wilson was about to use all the political capital he cared to in order to create the Council of National Defense, which was to lay plans for what would become, after the country entered the war, the virtual government takeover of the production and distribution of economic resources. The council’s membership was comprised of six cabinet secretaries, including the secretaries of war and the navy, and seven men outside the government. (Ironically, considering Wilson’s intense Christianity, three of the seven were Jews: Samuel Gompers, head of the American Federation of Labor; Bernard Baruch, the financier; and Julius Rosenwald, head of Sears. Almost simultaneously, Wilson appointed Brandeis to the Supreme Court. All this marked the first significant representation of Jews in government.)
But Wilson’s silent approval was enough. Welch, Hale, and the others formed their new organization, bringing in respected scientists in several fields, scientists who asked other colleagues to conduct specific pieces of research, research that fitted in with other pieces, research that together had potential applications. And medicine, too, had become a weapon of war.
By then a kind of organizational chart had developed in American scientific medicine. This chart of course did not exist in any formal sense, but it was real.
At the top sat Welch, fully the impresario, capable of changing the lives of those upon whom his glance lingered, capable as well of directing great sums of money to an institution with a nod. Only he held such power in American science, and no one else has held such power since.
On the rung below him were a handful of contemporaries, men who had fought beside him to change medicine in the United States and who had well-deserved reputations. Perhaps Victor Vaughan ranked second to him as a builder of institutions; he had created a solid one at Michigan and been the single most important voice outside the Hopkins demanding reform of medical education. In surgery the brothers Charles and William Mayo were giants and immensely important allies in forcing change. In the laboratory Theobald Smith inspired. In public health Hermann Biggs had made the New York City Department of Health probably the best municipal health department in the world, and he had just taken over the state health department, while in Providence, Rhode Island, Charles Chapin had applied the most rigorous science to public health questions and reached conclusions that were revolutionizing public health practices. And in the U.S. Army, Surgeon General William Gorgas also had developed an international reputation, continuing and expanding upon George Sternberg’s tradition.
Both the National Research Council and the Council of National Defense had medical committees that were controlled by Welch himself, Gorgas, Vaughan, and the Mayo brothers, all five of whom had already served as president of the American Medical Association. But conspicuous by his absence was Rupert Blue, then the civilian surgeon general and head of the U.S. Public Health Service (USPHS). Welch and his colleagues so doubted his abilities and judgment that they not only blocked him from serving on the committees but would not allow him even to name his own representative to them. Instead they picked a USPHS scientist they trusted. It was not a good sign that the head of the public health service was so little regarded.
From the beginning of their planning, these men focused on the biggest killer in war—not combat, but epidemic disease. Throughout the wars in history more soldiers had often died of disease than in battle or of their wounds. And epidemic disease had routinely spread from armies to civilian populations.
This was true not just in ancient times or in the American Civil War, in which two men died from disease for every battle-related death (counting both sides, one hundred eighty-five thousand troops died in combat or of their wounds, while three hundred seventy-three thousand died of disease). More soldiers had died of disease than combat even in the wars fought since scientists had adopted the germ theory and modern public health measures. In the Boer War that raged from 1899 to 1902 between Britain and the white settlers of South Africa, ten British troops died of disease for each combat-related death. (The British also put nearly a quarter of the Boer population in concentration camps, where 26,370 women and children died.) In the Spanish-American War in 1898, six American soldiers died of disease—nearly all of them from typhoid—for every one killed in battle or who died of his wounds.
The Spanish-American War deaths especially were entirely unnecessary. The army had expanded in a matter of months from twenty-eight thousand to two hundred seventy-five thousand, and Congress had appropriated $50 million for the military, but not a penny went to the army medical department; as a result, a camp of sixty thousand soldiers at Chickamauga had not a single microscope. Nor was army surgeon general Sternberg given any authority. Military engineers and line officers directly rejected his angry protests about a dangerously unsanitary camp design and water supply. Their stubbornness killed roughly five thousand American young men.
Other diseases could be equally dangerous. When even normally mild diseases such as whooping cough, chickenpox, and mumps invade a “virgin” human population, a population not previously exposed to them, they often kill in large numbers—and young adults are especially vulnerable. In the Franco-Prussian War in 1871, for example, measles killed 40 percent of those who fell ill during the siege of Paris, and a measles epidemic erupted in the U.S. Army in 1911, killing 5 percent of all the men who caught the disease.
Those facts were of deep concern to Welch, Vaughan, Gorgas, and the others. They committed themselves to ensuring that the best medical science be available to the military. Welch, sixty-seven years old, short, obese, and out of breath, put a uniform on, devoted much time to army business, and took a desk in Gorgas’s personal office that he used whenever in Washington. Vaughan, sixty-five years old and equally obese at 275 pounds, put a uniform on and became head of the army’s Division of Communicable Disease. Flexner at age fifty-four put a uniform on. Gorgas had them all commissioned majors, the highest rank then allowed (regulations were changed and they all later became colonels).
They thought not only about caring for soldiers wounded in combat. They thought not only about finding a source for digitalis, which was imported from Germany (Boy Scouts gathered foxglove in Oregon and tests found it produced a suitable drug), or surgical needles (these too were all imported, so they set up a U.S. factory to produce them), or discovering the most efficient way to disinfect huge amounts of laundry (they asked Chapin to look into this).
They thought about epidemic disease.
The single man who had the chief responsibility for the performance of military medicine was Surgeon General of the Army William Crawford Gorgas. The army gave him little authority with which to work—not much more than Sternberg had had. But he was a man able to accomplish much in the face of not only benign neglect but outright opposition from those above him.
Naturally optimistic and cheerful, devout, son of a Confederate officer who became president of the University of Alabama, Gorgas took up medicine ironically in pursuit of another aim: a military career. After he failed to get an appointment to West Point, it seemed his only way into the army, and he took it despite his father’s bitter opposition. He soon became entirely comfortable in medicine and preferred to be addressed as “Doctor” rather than by rank, even as he rose to “General.” He loved learning and set aside a fixed amount of minutes each day for reading, rotating his attention among fiction, science, and classical literature.
Gorgas had a distinct softness around his eyes that made him appear gentle, and he treated virtually everyone with whom he came into contact with dignity. His appearance and manner belied, however, his intensity, determination, focus, and occasional ferocity. In the midst of crisis or obstacles his public equanimity made him a center of calm, the kind that calmed and gave confidence to others. But in private, after encountering obtuseness if not outright stupidity in his superiors, he slammed drawers, hurled inkwells, and stormed out of his office muttering threats to quit.
Like Sternberg, he spent much of his early career at frontier posts in the West, although he also took Welch’s course at Bellevue. Unlike Sternberg, he did not personally do any significant laboratory research. But he was every bit as tenacious, every bit as disciplined.
Two experiences epitomized both his abilities and his determination to do his job. The first came in Havana after the Spanish-American War. He did not belong to Walter Reed’s team investigating yellow fever. Their work in fact did not convince him that the mosquito carried the disease. Nonetheless he was given the task of killing mosquitoes in Havana. He succeeded in this task—despite doubting its usefulness—so well that in 1902 yellow fever deaths there fell to zero. Zero. And malaria deaths fell by 75 percent. (The results convinced him that the mosquito hypothesis was correct.) An even more significant triumph came when he later took charge of clearing yellow fever from the construction sites along the Panama Canal. In this case his superiors rejected the mosquito hypothesis, gave him the barest minimum of resources, and tried to undermine his authority, his effort, and him personally, at one point demanding that he be replaced. He persisted—and succeeded—partly through his intelligence and insight into the problems disease presented, partly through his ability to maneuver bureaucratically. In the process he also earned a reputation as an international expert on public health and sanitation.
He became surgeon general of the army in 1914 and immediately began massaging congressmen and senators for money and authority to prepare in case the country went to war. He wanted no repeat of Sternberg’s Spanish-American experience. Believing his work done, in 1917 he submitted his resignation to join a Rockefeller-sponsored international health project. When the United States entered the war, he withdrew his resignation.
Then sixty-three years old, white-haired, with a handlebar mustache, and thin—as a boy he had been almost fragile, and he remained thin despite an appetite for food that rivaled Welch’s—he took as his first task surrounding himself with the best possible people, while simultaenously trying to inject his and their influence into army planning. His War Department seniors did not consult his department on the sites for its several dozen new cantonments, but army engineers did pay close attention to the medical department in the actual design of the training camps. They too wanted no repeat of the mistakes that had killed thousands of soldiers in 1898.
But only in one other area did the army medical department receive even a hearing from War Department leadership. That was its massive campaign against venereal disease, a campaign supported strongly by a political union of progressives, many of whom believed in perfecting secular society, and from Christian moralists. (The same political odd couple would soon unite to enact Prohibition.) Gorgas’s office recognized “to what extremes the sexual moralist can go. How unpractical, how intolerant, how extravagant, even how unreasoning, if not scientifically dishonest, he can be.” But it also knew that one-third of all workdays lost to illness in the army were caused by venereal disease. That loss the military would not tolerate.
The medical corps told enlisted men to masturbate instead of using prostitutes. It produced posters with such slogans as, “A Soldier who gets a dose is a traitor.” It examined enlisted men twice a month for venereal disease, required any men infected to identify the person with whom or the building in which they had had sex, docked the pay of soldiers or sailors sick with venereal disease, and also made them subject to court-martial. With support from the most senior political leadership, the military by law prohibited prostitution and the sale of alcohol within five miles of any base—and the military had seventy bases with ten thousand or more soldiers or sailors scattered around the country. The health boards of twenty-seven states passed regulations allowing detention of people suffering venereal infection “until they are no longer a danger to the community.” Eighty red-light districts were shut down. Even New Orleans had to close down its legendary Storyville, where prostitution was legal, where Buddy Bolden, Jelly Roll Morton, Louis Armstrong, and others had invented jazz in the whore-houses. And New Orleans mayor Martin Behrman was no reformer; he headed a political machine so tight it was called simply “the Ring.”
But if Gorgas had the power to act decisively on venereal disease, if engineers listened to his sanitary experts in designing water supplies, the army paid him little heed on anything else. On no subject where he had only science behind him, science without political weight, could he get even a hearing from army superiors. Even when an American researcher developed an antitoxin for gangrene, Gorgas could not convince them to fund testing at the front. So Welch arranged for the Rockefeller Institute to pay the expenses of a team of investigators to go to Europe, and for the British army to test the antitoxin in British hospitals. (It worked, although not perfectly.)
In many ways, then, Gorgas, Welch, Vaughan, and their colleagues operated as a team independent of the army. But they could not operate independently in regard to epidemic disease, and they could not operate either independently or alone as camps filled with hundreds of thousands—in fact, millions—of young men.
When the war began there were one hundred forty thousand physicians in the United States. Only 776 of them were serving in the army or navy. The military needed tens of thousands of physicians, and it needed them immediately. It would make no exceptions for scientists. Most would volunteer anyway. Most wanted to participate in this great crusade.
Welch and Vaughan joined the military, despite their being one hundred pounds overweight and past the regular army’s mandatory retirement age, and they were not alone. Flexner joined at age fifty-four. Flexner’s protégé Paul Lewis at Penn, Milton Rosenau at Harvard, and Eugene Opie at Washington University joined. All around the country laboratory scientists were joining.
And to avoid losing scientists piecemeal either as volunteers or to the draft, Flexner suggested to Welch that the entire Rockefeller Institute be incorporated into the army. Welch carried the idea to Gorgas, and Gorgas’s deputy wired Flexner, “[U]nit will be arranged as you desire.” And so the Rockefeller Institute became Army Auxiliary Laboratory Number One. There would be no auxiliary laboratory number two. Men in uniforms marched down laboratory and hospital corridors. An army adjutant commanded the technicians and janitors, maintained army discipline among them, and drilled them on parade on York Avenue. Lunch became “mess.” A mobile hospital unit on wheels with buildings, wards, labs, laundry, and kitchen was rolled into the front yard of the institute from Sixty-fourth to Sixty-sixth Streets to treat soldiers with intractable wounds. Sergeants saluted scientists who—except for two Canadians who became privates—received officer rank.
This was no mere cosmetic change to allow life to go on as usual.* At Rockefeller the fiber of the work was rewoven. Nearly all research shifted to something war-related, or to instruction. Alexis Carrel, a Nobel laureate in 1912 who pioneered the surgical reattachment of limbs and organ transplantation as well as tissue culture—he kept part of a chicken heart alive for thirty-two years—taught surgical techniques to hundreds of newly militarized physicians. Others taught bacteriology. A biochemist studied poison gas. Another chemist explored ways to get more acetone from starch, which could be used both in making explosives and to stiffen the fabric that covered airplane wings. Peyton Rous, who had already done the work that would later—decades later—win him a Nobel Prize, redirected his work to preserving blood; he developed a method still in use that led to the first blood banks being established at the front in 1917.
The war also consumed the supply of practicing physicians. Gorgas, Welch, and Vaughan had already laid plans for this. In December 1916 they had, through the Council of National Defense, asked state medical associations to secretly grade physicians. Roughly half of all practicing physicians were judged incompetent to serve. So when America did enter the war, the military first examined every male graduate of medical school in 1914, 1915, and 1916, seeking, as Vaughan said, the “best from these classes.” This would supply approximately ten thousand doctors. Many of the best medical schools also sent much of their faculty to France, where the schools functioned as intact units, staffing and unofficially lending their names to entire military hospitals.
Yet these moves could not begin to satisfy the need. By the time the Armistice was signed thirty-eight thousand physicians would be serving in the military, at least half of all those under age forty-five considered fit for service.
The military, and especially the army, did not stop there. In April 1917 the army had fifty-eight dentists; in November 1918 it had 5,654. And the military needed nurses.
There were too few nurses. Nursing had, like medicine, changed radically in the late nineteenth century. It too had become scientific. But changes in nursing involved factors that went beyond the purely scientific; they involved status, power, and the role of women.
Nursing was one of the few fields that gave women opportunity and status, and that they controlled. While Welch and his colleagues were revolutionizing American medicine, Jane Delano, Lavinia Dock—both of whom were students in Bellevue’s nursing program while Welch was exposing medical students there to new realities—and others were doing the same to nursing. But they fought not with an entrenched Old Guard in their own profession so much as with physicians. (Sometimes physicians, threatened by intelligent and educated nurses, waged a virtual guerrilla war; in some hospitals physicians replaced labels on drug bottles with numbers so nurses could not question a prescription.)
In 1912, before becoming surgeon general, Gorgas had anticipated that if war ever came, the army would need vast numbers of nurses, many more than would likely be available. He believed, however, that not all of them would have to be fully trained. He wanted to create a corps of “practical nurses,” who lacked the education and training of “graduate nurses.”
Others were also advancing this idea, but they were all men. The women who ran nursing would have none of it. Jane Delano had taught nursing and had headed the Army Nurse Corps. Proud and intelligent as well as tough, driven, and authoritarian, she had then just left the army to establish the Red Cross nursing program, and the Red Cross had all responsibility for supplying nurses to the army, evaluating, recruiting, and often assigning them.
She rejected Gorgas’s plan, telling her colleagues it “seriously threatened” the status of professional nursing and warning, “Our Nursing Service would be of no avail with these groups of women unrelated to us, organized by physicians, taught by physicians, serving under their guidance.” She told the Red Cross bluntly that “if this plan were put through I should at once sever my connection with the Red Cross…[and] every member of the State and Local Committee would go out with me.”*
The Red Cross and the army surrendered to her. No training of nursing aides commenced. When the United States entered the war it had 98,162 “graduate nurses,” women whose training probably exceeded that of many—if not most—doctors trained before 1910. The war sucked up nurses as it sucked up everything else. In May 1918 roughly sixteen thousand nurses were serving in the military. Gorgas believed that the army alone needed fifty thousand.
After Gorgas again pleaded with the Red Cross “to carry out the plans already formulated,” after learning confidential information about the desperation in combat hospitals, Delano reversed herself, supported Gorgas, and tried to convince her colleagues of the need for “practical” nurses.
Her professional colleagues rebuffed them both. They refused to participate in organizing any large training program of such aides, and agreed only to establish an Army Nursing School. By October 1918 this new nursing school had produced not a single fully trained nurse.
The triumph of the nursing profession at large over the Red Cross and the United States Army, an army at war, was extraordinary. That the victors were women made it more extraordinary. Ironically, this triumph reflected as well a triumph of George Creel’s Committee on Public Information over the truth, for Creel’s propaganda machine had prevented the public from learning just how profound the need for nurses was.
In the meantime the military’s appetite for doctors and nurses only grew. Four million American men were under arms with more coming, and Gorgas was planning for three hundred thousand hospital beds. The number of trained medical staff he had simply could not handle that load. So the military suctioned more and more nurses and physicians into cantonments, aboard ships, into France, until it had extracted nearly all the best young physicians. Medical care for civilians deteriorated rapidly. The doctors who remained in civilian life were largely either incompetent young ones or those over forty-five years of age, the vast majority of whom had been trained in the old ways of medicine. The shortage of nurses would prove even more serious. Indeed, it would prove deadly, especially in civil society.
All this added kindling to the tinderbox. Still more kindling would come.