The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)
Part I. THE WARRIORS
THE MEN WHO CREATED the Rockefeller Institute always intended to have a small affiliated hospital built to investigate disease. No patient would pay for treatment and only those suffering from diseases being studied would be admitted. No other research institute in the world had such a facility. That much William Welch, Simon Flexner, Frederick Gates, and John D. Rockefeller Jr. did intend. But they did not plan to have what Rufus Cole, the hospital’s first director, all but forced upon them.
Tall, mustached, and elegant, with an ancestor who arrived at Plymouth, Massachusetts, in 1633, Cole did not appear to be a forceful man, did not seem someone capable of confronting Flexner. But he always remained true to those things that he had thought out, and his thinking was powerful. Then he yielded only to evidence, not to personality, and advanced his own ideas calmly and with tenacity. His longtime colleague Thomas Rivers called him “a modest man, a rather timid man,” who “would go out of his way to dodge” a confrontation. But, Rivers added, “He was considered the brightest man that ever graduated from Hopkins at the time he graduated…. If you get him mad, get him in a corner and kind of back him up,…[y]ou would find, generally to your sorrow, that the old boy wasn’t afraid to fight.”
Cole had wide interests and late in life wrote a two-volume, 1,294-page study of Oliver Cromwell, the Stuarts, and the English Civil War. But at the institute lunch table he focused. Heidelberger recalled, “He would sit there and listen to whatever was going on, and then he’d ask a question. Sometimes the question seemed almost naive for a person who was supposed to know as much as he did, but the result always was to bring out things that hadn’t been brought out before and to get much deeper down into the problem than one had before. Dr. Cole was really quite remarkable in that way.”
His father and two uncles were doctors, and at the Hopkins his professor Lewellys Barker had established laboratories next to patient wards to study disease, not just conduct diagnostic tests. There Cole had done pioneering research. He came away from that experience with ideas that would influence the conduct of “clinical” research—research using patients instead of test tubes or animals—to this day.
Flexner saw the hospital as a testing ground for ideas generated by laboratory scientists. The scientists would control experimental therapies. The doctors treating the patients would do little more than play the role of a technician caring for a lab animal.
Cole had other ideas. He would not allow the hospital and its doctors to serve, said Rivers, as a “handmaiden. He and his boys were not going to test Noguchi’s ideas, Meltzer’s ideas, or Levens’s ideas. Cole was adamant that people caring for patients do the research on them.”
In a letter to the directors Cole explained that the clinicians should be full-fledged scientists conducting serious research: “One thing that has most seriously delayed the advancement of medicine has been the physical and intellectual barrier between the laboratory and the wards of many of our hospitals. Clinical laboratories most often exist merely to aid diagnosis. I would therefore urge that the hospital laboratory be developed as a true research laboratory, and that moreover [the doctors] of the hospital be permitted and urged to undertake experimental work.”
This was no simple question of turf or bureaucratic power. Cole was setting an enormously important precedent. He was calling for—demanding—that physicians treating patients undertake rigorous research involving patients with disease. Precedents for this kind of work had been seen elsewhere, but not in the systematic way Cole envisioned.
Such studies not only threatened the power of the scientists doing purely laboratory research at the institute but, by implication, also changed the doctor-patient relationship. They were an admission that doctors did not know the answers and could not learn them without the patients’ help. Since any rigorous study required a “control,” this also meant that random chance, as opposed to the best judgment of the physician, might dictate what treatment a patient got.
Timid of nature or not, Cole would not yield. Flexner did. As a result, the Rockefeller Institute Hospital applied science directly to patient care, creating the model of clinical research—a model followed today by the greatest medical research facility in the world, the Clinical Center at the National Institutes of Health in Bethesda, Maryland. That model allowed investigators to learn. It also prepared them to act.
The Rockefeller Institute Hospital opened in 1910. By then the best of American medical science and education could compete with the best in the world. But an enormous gap existed in the United States between the best medical practice and the average, and an unbridgeable chasm separated the best from the worst.
In effect, there were outstanding generals, colonels, and majors, but they had no sergeants, corporals, or privates; they had no army to lead, at least not a reliable one. The gap between the best and the average had to be closed, and the worst had to be eliminated.
Physicians already practicing were unreachable. They had on their own either chosen to adopt scientific methods or not. Thousands had. Simon Flexner himself received his M.D. from a terrible medical school but had more than compensated, confirming Welch’s observation: “The results were better than the system.”
But the system of medical education still needed massive reform. Calls for reform had begun in the 1820s. Little had been accomplished outside a handful of elite schools.
Even among elite schools change came slowly. Not until 1901 did Harvard, followed soon by Penn and Columbia, join the Hopkins in requiring medical students to have a college degree. But even the best schools failed to follow the Hopkins’s lead in recruiting quality faculty, instead choosing professors in clinical medicine from among local physicians. The official history of Penn’s medical school conceded, “Inbreeding of a faculty could hardly go farther.” Harvard’s clinical professors were actually selected by a group of doctors who had no status at Harvard and met at the Tavern Club to make their decisions, which were usually based on seniority. Not until 1912 would Harvard select a clinical professor from outside this group.
Pressure did come from within the profession to improve. Not only those at the Hopkins, Michigan, Pennsylvania, Harvard, and other leading medical schools devoted themselves to reform. So did a large number of individual physicians and surgeons. In 1904 the American Medical Association finally formed a Council on Medical Education to organize the reform movement. The council began inspecting all 162 medical schools—more than half of all the medical schools in the world—in the United States and Canada.
Three years later the AMA council issued a blistering—but confidential—report. It concluded that at the better schools improvement was occurring, although, despite enormous effort by many reformers, not at a rapid enough pace. But the worst schools had barely changed at all. Faculty still owned most of them, most still had no connection to a university or hospital and no standards for admission, and tuition still funded faculty salaries. One school had graduated 105 “doctors” in 1905, none of whom had completed any laboratory work whatsoever; they had not dissected a single cadaver, nor had they seen a single patient. They would wait for a patient to enter their office for that experience.
The report had some effect. Within a year, fifty-seven medical schools were requiring at least one year of college of their applicants. But that still left two-thirds of the schools with lower or no requirements, and it did not address the content of the education itself.
Unable to confront its own membership again—in 1900 the AMA had only eight thousand members out of one hundred ten thousand doctors and feared antagonizing the profession—the AMA gave its report to the Carnegie Foundation, insisted that it remain confidential, and asked for help. In turn, the Carnegie Foundation commissioned Simon Flexner’s brother Abraham to survey medical education. Although not a doctor, Flexner had been an undergraduate at the Hopkins—he said that even among undergraduates “research was the air we breathed”—and had already demonstrated both a ruthless, unforgiving judgment and a commitment to advancing model educational institutions. In his first job after college, he had taught in a Louisville high school—where he failed his entire class of fifteen students—and had experimented with new ways of teaching. Later he would create the Institute for Advanced Study at Princeton, and personally recruit Albert Einstein to it.
Abraham Flexner began his study by talking at length to Welch and Franklin Mall. Their views influenced him, to say the least. He stated, “The rest of my study of medical education was little more than an amplification of what I had learned during my initial visit to Baltimore.”
In 1910, the same year the Rockefeller Institute Hospital opened, his report Medical Education in the United States and Canada appeared. It soon came to be known simply as “The Flexner Report.”
According to it, few—very, very few—schools met his standards, or any reasonable standard. He dismissed many schools as “without redeeming features of any kind…general squalor…clinical poverty…. [O]ne encounters surgery taught without patient, instrument, model, or drawing; recitations in obstetrics without a manikin in sight—often without one in the building.” At Temple, at Halifax University, at the Philadelphia College of Osteopathy, the dissecting rooms “defy description. The smell is intolerable, the cadavers now putrid.” At North Carolina Medical College Flexner quoted a faculty member saying, “‘It is idle to talk of real laboratory work for students so ignorant and clumsy. Many of them, gotten through advertising, would make better farmers.’”
Flexner concluded that more than 120 of the 150-plus medical schools in operation should be closed.
It was the Progressive Era. Life was becoming organized, rationalized, specialized. In every field “professionals” were emerging, routing the ideas of the Jacksonian period, when state legislatures deemed that licensing even physicians was antidemocratic. Frederick Taylor was creating the field of “scientific management” to increase efficiencies in factories, and Harvard Business School opened in 1908 to teach it. This rationalization of life included national advertising, which was now appearing, and retail chains, which were stretching across the continent; United Drug Stores the largest, had 6,843 locations.
But the Flexner report did not merely reflect the Progressive Era. Nor did it reflect the context in which one Marxist historian tried to place scientific medicine, calling it “a tool developed by members of the medical profession and the corporate class to…legitimize” capitalism and shift attention from social causes of disease. Noncapitalist societies, including Japan, Russia, and China, were adopting scientific medicine as well. The report reflected less the Progressive Era than science. Not surprisingly, progressives failed in a similar effort to standardize training of lawyers. Anyone could read a statute; only a trained specialist could isolate a pathogen from someone sick.
The Progressive Era was, however, also the muckraking era. Flexner’s report raked muck and created a sensation. Fifteen thousand copies were printed. Newspapers headlined it and investigated local medical schools. Flexner received at least one death threat.
The impact was immediate. Armed now with the outcry Flexner had generated, the AMA’s Council on Medical Education began rating schools as “Class A” and fully satisfactory; “Class B,” which were “redeemable” or “Class C,” which were “needing complete reorganization.” Schools owned and operated by faculty were automatically rated C.
Less than four years after Flexner’s report was issued, thirty-one states denied licensing recognition to new graduates of Class C institutions, effectively killing the schools outright. Class B schools had to improve or merge. Medical schools at such universities as Nebraska, Colorado, Tufts, George Washington, and Georgetown kept a tenuous hold on AMA approval but survived. In Baltimore three Class B schools consolidated into the present University of Maryland medical school. In Atlanta, Emory absorbed two other schools. Medical schools at such institutions as Southern Methodist, Drake, Bowdoin, and Fordham simply collapsed.
By the late 1920s, before the economic pressure of the Depression, nearly one hundred medical schools had closed or merged. The number of medical students, despite a dramatic increase in the country’s population, declined from twenty-eight thousand in 1904 to fewer than fourteen thousand in 1920; in 1930, despite a further increase in the country’s population, the number of medical students was still 25 percent less than in 1904.
Later, Arthur Dean Bevan, leader of the AMA reform effort, insisted, “The AMA deserved practically all the credit for the reorganization of medical education in this country…. 80% of the Flexner report was taken from the work of the Council on Medical Education.” Bevan was wrong. The AMA wanted to avoid publicity, but only the leverage of the publicity—indeed, the scandal—Flexner generated could force change. Without the report, reform would have taken years, perhaps decades. And Flexner influenced the direction of change as well. He defined a model.
The model for the schools that survived was, of course, the Johns Hopkins.
Flexner’s report had indirect impact as well. It greatly accelerated the flow, already begun, of philanthropic funds into medical schools. Between 1902 and 1934, nine major foundations poured $154 million into medicine, nearly half the total funds given away to all causes. And this understates the money generated, because the gifts often required the school to raise matching funds. This money saved some schools. Yale, for example, was rated a weak Class B school but it launched a fund-raising drive and increased its endowment from $300,000 to almost $3 million; its operating budget leaped from $43,000 to $225,000. The states also began pouring money into schools of state universities.
The largest single donor remained the Rockefeller Foundation. John D. Rockefeller himself continued to see a homeopathic physician.
Welch had turned the Hopkins model into a force. He and colleagues at Michigan, at Penn, at Harvard, and at a handful of other schools had in effect first formed an elite group of senior officers of an army; then, in an amazingly brief time, they had revolutionized American medicine, created and expanded the officer corps, and begun training their army, an army of scientists and scientifically grounded physicians.
On the eve of America’s entry into World War I, Welch had one more goal. In 1884, when the Hopkins first offered Welch his position, he had urged the establishment of a separate school to study public health in a scientific manner. Public health was and is where the largest numbers of lives are saved, usually by understanding the epidemiology of a disease—its patterns, where and how it emerges and spreads—and attacking it at its weak points. This usually means prevention. Science had first contained smallpox, then cholera, then typhoid, then plague, then yellow fever, all through large-scale public health measures, everything from filtering water to testing and killing rats to vaccination. Public health measures lack the drama of pulling someone back from the edge of death, but they save lives by the millions.
Welch had put that goal aside while he focused on transforming American medicine, on making it science-based. Now he began to pursue that goal again, suggesting to the Rockefeller Foundation that it fund a school of public health.
There was competition to get this institution, and others tried to convince the foundation that though creating a school of public health made good sense, putting it in Baltimore did not. In 1916, Harvard president Charles Eliot wrote bluntly to the foundation—and simultaneously paid Welch a supreme compliment—when he dismissed the entire Hopkins medical school as “one man’s work in a new and small university…. The more I consider the project of placing the Institute of Hygiene at Baltimore, the less suitable expedient I find it…. In comparison with either Boston or New York, it conspicuously lacks public spirit and beneficent community action. The personality and career of Dr. Welch are the sole argument for putting it in Baltimore—and he is almost 66 years old and will have no similar successor.”
Nonetheless, that “sole argument” sufficed. The Johns Hopkins School of Hygiene and Public Health was scheduled to open October 1, 1918. Welch had resigned as a professor at the medical school to be its first dean.
The study of epidemic disease is, of course, a prime focus of public health.
Welch was sick the day of the scheduled opening, and getting sicker. He had recently returned from a trip to investigate a strange and deadly epidemic. His symptoms were identical to those of the victims of that epidemic, and he believed he too had the disease.
The army Welch had created was designed to attack, to seek out particular targets, if only targets of opportunity, and kill them. On October 1, 1918, the abilities of that army were about to be tested by the deadliest epidemic in human history.