with Paulina Firozi

For most of the seven years John M. Barry spent writing his book about the 1918 flu pandemic, he wanted to abandon the project. He’d originally wanted to write about the U.S. home front during World War I.

“Every day I wished I hadn’t signed the contract,” Barry told me over the phone.

Not anymore. Barry’s work “The Great Influenza” has become a must-read in the age of the novel coronavirus.

The 546-page book describes how a highly lethal virus killed around 50 million people worldwide between the spring of 1918 and early 1920 — more casualties than from any other pandemic, ever. This H1N1 virus – which historians believe originated in Kansas, likely passed from a pig to a human – struck near the end of the first World War, first among troops who then passed it to the civilian population.

The book inspired President George W. Bush to develop a comprehensive pandemic plan, for which the Centers for Disease Control and Prevention called on Barry as a subject-matter expert. In 2005, the National Academies of Sciences named it the year’s outstanding book on science or medicine.

These days, the book is a bestseller on Amazon and Barry has offered historical perspective surrounding covid-19, the disease caused by the novel coronavirus, in multiple op-eds. 

He’s optimistic the current pandemic won’t be nearly as lethal. The virus isn’t becoming more virulent, the government and media are taking it more seriously and a vaccine is in the works, he notes. The key to an effective pandemic response, he says, is for health officials to tell the truth about it. That didn’t happen in 1918 — far from it.

“There was no Tony Fauci back then,” Barry said, referring to the director of the Institute for Infectious Diseases at the National Institutes of Health, who has become a prominent leader in the response effort.

Your Health 202 author recently finished reading “The Great Influenza.” Here are the 12 things we found most interesting:

Doctors didn’t initially think the first wave was influenza because it was too mild.

Historians believe someone from Haskell County, Kan., initially carried a mild version of the virus to a huge Army base in March 1918, where it then swept through the world that spring, transmitted largely by troops packed in close quarters in barracks and on ships. But the symptoms were so mild that troops called it “three-day fever.” 

Even doctors questioned whether the disease was influenza. The symptoms were “of very short duration and so far absent of relapses or complications,” three British doctors wrote in the Lancet medical journal in an issue dated July 13,1918.

Doctors also doubted it was influenza in the second wave — but then because it was so deadly. 

When a more strident form of the virus started arriving in the United States in August after being transported to Europe and back again — largely via Navy ships — medical workers noticed dramatic and deadly complications. Victims who had developed pneumonia were so severely deprived of oxygen they turned blue, sometimes a very dark blue. 

Direly ill patients would also sometimes bleed from their mouth, nose or even ears. Between 5 and 15 percent of men hospitalized in Army camps bled from the nose, the result when blood flooded deeply diseased lungs.

Throughout fall 1918, this aggressive form of the virus swept through the U.S. and the world in a second wave, ultimately killing 0.65 percent of all Americans and double that percentage of young people. Italy lost 1 percent of its population to the virus, the worst death rate of any developed country. Less developed countries were especially vulnerable; historians estimate Mexico lost between 2.3 percent and 4 percent of its entire population.

At the time the virus struck, civilian medical care had deteriorated because of the war.

It was several years into World War I, and the U.S. military had employed many of the best doctors and nurses to care for 4 million enlisted Americans. The doctors who remained civilians tended to be either older — and therefore unaware of the latest medical advances — or incompetent younger ones. So when the outbreak spread from military bases, major U.S. cities were woefully ill-equipped to respond. 

Like today, ships were hot spots.

Troops returning to the United States from European countries brought back the newly aggressive virus starting in August. Many of them had been in Brest, France — a port town were death rates soared so high the naval hospital was overwhelmed.

The first of the U.S. cases was reported in a barracks operated by the Navy in Boston, where as many as 7,000 sailors in transit ate and slept. On Aug. 27, two sailors reported sick. The next day, it was eight sailors. The day after that, 58 men were admitted to the sick bay.

The first terrible outbreak was in Camp Devons, a military base 35 miles northwest of Boston. The base hospital, designed to hold just 1,200, was filled with more than 6,000 at one point, with men lying in hallways and on porches, where they died. Sailors also spread the virus to New Orleans, Philadelphia and New York.

Philadelphia was hit hardest of all U.S. cities.

The already overcrowded city was fertile ground for an epidemic. So many people died that undertakers were overwhelmed and would drive patrol wagons through the streets so that family members could load the bodies. Sometimes, bodies would lie on beds for days as others in the household were too sick to remove them.

San Francisco acted most aggressively to stop the spread. 

In the current pandemic, San Francisco's mayor was the first to order a citywide lockdown. It was the same in 1918 — and it helped the city avoid widespread deaths initially. San Francisco's public health director quarantined all naval installations, organized a citywide effort to prepare and urged people to wear masks. 

But despite these efforts, the city was still struck by the pandemic's third wave, in winter 1919. The flu hit eastern cities far harder, but in the end San Francisco suffered the most deaths of any city on the West Coast.

Federal and state officials consistently played down the illness.

Wilmer Krusen, Philadelphia's public health director, only agreed to monitor the situation a full week after the virus first appeared in the city. Krusen insisted to reporters — who believed him — the influenza was only “old-fashioned influenza or grip.”

He allowed a major parade to be held on Sept. 28, where several hundred thousand people were jammed along the route. Within 72 hours, every bed in the city's 31 hospitals was filled. People were trying to bribe nurses $100 to let them in. On the third day after the parade, 117 people died in a single day. Krusen didn't ban public meetings until Oct. 3.

Some public officials even said fear made people more vulnerable to the disease. The Arizona Board of Health told people, “Don’t worry,” to avoid contracting the flu. Newspapers across the country perpetuated this myth.

The Public Health Service told people to do things such as “choose and chew” their food well.

The agency, which took the lead on public health before the Centers for Disease Control and Prevention was created in the 1940s, fell far short in its response. Its leader, Rupert Blue, made early missteps that allowed the virus to take hold and spread throughout the country. Nor did the service offer any treatment or vaccine for the flu.

The agency did distribute information to the public about how to fight the illness, although it was far too late to do any good. It sent ready-to-print plates to 10,000 newspapers, which said the following: “Remember the three Cs, clean mouth, clean skin, and clean clothes…Keep the bowels open…Food will win the war…Help by choosing and chewing your food well.”

President Woodrow Wilson never once publicly addressed the flu — even though he got it, too.

Wilson was confined to his bed for several days while in Paris in early 1919 to negotiate the end of the war. Some historians believe he was affected neurologically by a bad case of the flu, so much so that he yielded to demands by the French despite previously threatening to return home without a treaty.

“Influenza did weaken him physically, and — precisely at the most critical point of negotiations — influenza did at the least drain from him stamina and the ability to concentrate,” Barry writes. “That much is certain. And it is almost certain that influenza affected his mind in other, deeper ways.” 

Newspapers told people the disease was subsiding while it was actually exploding.

The Public Ledger in Philadelphia continually minimized the danger. It claimed Krusen's ban on public gatherings was not “a public health measure,” writing, “There is no cause for panic or alarm.” As daily deaths numbered in the 200s and 300s in the following days, the paper quoted public health officials as saying the peak of the epidemic had been reached.

This kind of propagandizing was common in media outlets throughout the country. Newspapers also ran all kinds of ads propagating false information about how to treat or prevent the virus, such as recommendations to keep one's feet dry or instructions on making a gas mask.

A third wave in early 1919 killed 11,000 people in New York City and Chicago.

In some areas, including Phoenix, San Francisco and parts of Michigan and Georgia, the third wave killed more people than the second wave. Officials in Savannah, Ga., who had reopened public gathering places, re-closed them on Jan. 15 with even stricter rules than before.

India was the hardest-hit of any country.

At peak, more people in Bombay died every day than during the 1900 bubonic plague. More than 10 percent of known cases resulted in death.

One doctor in Punjab, the region hit hardest, wrote that hospitals were so “choked that it was impossible to remove the dead quickly enough to make room for the dying…Nearly every household was lamenting a death and everywhere terror reigned.” 

Ahh, oof and ouch

AHH: Congress has spent a breathtaking amount of money on the coronavirus response. 

The $2.2 trillion legislation will boost the national debt to unprecedented levels, exceeding the size of the economy by the end of fiscal 2020 and soon surpassing the prior record after World War II, according to the Committee for a Responsible Federal Budget, The Washington Post’s Dan Balz writes.

Does that mean bigger government is here to stay? Conservative Republicans supported the massive spending bills, but the consensus on a more involved government is showing signs of fading. Yet advocates for bigger government may have the upper hand.

“Conservatives recognize the ground may be shifting in ways advantageous to those on the other side of the debate,” he writes. “More spending seems inevitable, particularly for public health and potentially for programs such as paid sick leave or family leave.”

Another round of spending is expected. And higher taxes could be necessary down the road to repay the debt Washington is incurring. 

Former Federal Reserve chair Janet L. Yellen said the experience “could be paradigm shifting.” 

William Galston of the Brookings Institution said the moment could end a cycle that began with the past decade’s Great Recession and the tea party revolt in 2009 that triggered forces that helped elect President Trump. “So the movement that began in opposition to a bailout is ending in an administration that finds itself forced to sponsor — and in many respects urge on — the largest expansion of government financial activity in our history,” Galston said.

What happens next? 

“The pandemic has exposed crippling weaknesses in the federal government and troubling vulnerabilities in society that will be more difficult to ignore when the crisis begins to ease. For the first time, many Americans are looking to government for their very economic survival. In time, that could make them look at government differently,” Balz writes. 

OOF: Dozens of antibody tests on the market weren’t vetted by federal health regulators. 

The Food and Drug Administration has allowed more than 90 antibody tests on the market without prior review, our Post colleague Laurie McGinley reports

That includes some antibody tests — meant to identify those who overcame covid-19 and developed an immune response — that are of uncertain quality and have been marketed fraudulently. 

There’s concern that unvetted tests could spark confusion.

If the tests are inaccurate, for one, they could say that individuals have immunity when they don’t. 

 “The emergence of dozens of tests never reviewed by the FDA — many of which are being aggressively marketed — could confuse doctors, hospitals, employers and consumers clamoring for the products, according to critics who say the agency’s oversight of the tests has been lax,” Laurie writes. “The questions are taking on special importance as federal and state officials debate strategies, including using serological testing, to help determine when they can end state and local lockdowns.” 

Now, the Food and Drug Administration has stepped up warnings about such tests. FDA Commissioner Stephen Hahn said during a Washington Post Live interview that “people should be very cautious” about tests that haven’t received emergency use authorization from the agency.

OUCH: The death toll in Wuhan is markedly higher than Chinese officials had previously announced.

The government "raised the official toll in Wuhan by 50% to 3,869 deaths,” the Associated Press’s Ken Moritsugu reports. “While China has yet to update its national totals, the revised numbers push up China’s total to 4,632 deaths from a previously reported 3,342.” 

But the jump in numbers is not necessarily a surprise. "It is virtually impossible to get an accurate count when health systems are overwhelmed at the height of a crisis — and they confirm suspicions that many more people died than the official figures had showed," Ken writes.

There have been long-running questions about the accuracy of China’s official case count, leading to “accusations that Chinese officials were seeking to minimize the impact of the outbreak and could have brought it under control sooner.” 

According to Wuhan’s coronavirus response headquarters gave a few reasons for the undercount, saying it was part a result of mistaken reporting by medical staff, deaths at institutions that weren’t linked to the epidemic information network, and deaths that occurred outside hospitals.

The administration's coronavirus response

U.S. experts working at the World Health Organization sent the Trump administration real-time information as the coronavirus emerged.

More than a dozen researchers, physicians and public health experts, many from the Centers for Disease Control and Prevention, were at the U.N. agency’s Geneva headquarters as the coronavirus emerged late last year. They sent information about its emergence and spread to administration officials, The Post's Karen DeYoung, Lena H. Sun and Emily Rauhala report. 

A spokeswoman for the Department of Health and Human Services, Caitlin B. Oakley, confirmed to The Post that HHS had 17 staff members, including 16 from the CDC, at the WHO “working on a variety of programs, including covid-19 and Ebola.” 

President Trump, which is withholding WHO funds, says the agency failed to communicate the extent of the virus’s threat and that such a failure is to blame for the rapid spread in the United States. He has also criticized Chinese leadership for withholding information. 

Oakley said the presence of CDC staffers didn't mean the agency's leaders were being forthright. “[J]ust because you have Americans embedded in WHO providing technical assistance does not change the information you are getting from WHO leadership.” 

Some state leaders are chiding Trump for encouraging anti-shutdown protests. 

Maryland Gov. Larry Hogan (R) said Trump’s comments defending protesters were unhelpful and nonsensical. Virginia Gov. Ralph Northam (D) suggested Trump is focused on protests because he has not been able to provide more critical tests, our colleagues Luz Lazo, Erin Cox and Hannah Natanson report. 

In an interview on CNN, Hogan said he understood the desire to restart the economy, but said doing so soon would be reckless. 

“I understand the frustration among the people that want to get things open right away. I’m frustrated, too. I wish I had someone to protest to,” Hogan said. He added: “I don’t think it’s helpful to encourage demonstrations and encourage people to go against the president’s own policy…It just doesn’t make any sense.” 

Some of the anti-quarantine protests are stemming from pro-gun activists on Facebook. 

There are far-right, pro-gun activists pushing for anti-quarantine demonstrations across the United States. It’s the “latest illustration that some seemingly organic demonstrations are being engineered by a network of conservative activists,” our Post colleagues Isaac Stanley-Becker and Tony Romm report. 

The social media groups have continued to expand after Trump endorsed such protests in a series of tweets on Friday, suggesting citizens should “liberate” states. 

“The Facebook groups target Wisconsin, Ohio, Pennsylvania and New York, and they appear to be the work of Ben Dorr, the political director of a group called ‘Minnesota Gun Rights,’ and his siblings, Christopher and Aaron,” they write. “…The online activity helps cement the impression that opposition to the restrictions is more widespread than polling suggests. Nearly 70 percent of Republicans said they supported a national stay-at-home order, according to a recent Quinnipiac poll. Ninety-five percent of Democrats backed such a measure in the survey.” 

Congress on coronavirus

Congressional leaders are close to a deal with the administration on more coronavirus relief. 

The $400 billion-plus deal would bolster funding for a small-business loan program that dried up because of high demand, our Post colleagues Erica Werner and Jeff Stein report. It would also include about $100 billion in additional funding for hospitals and coronavirus testing. 

At his daily coronavirus task force briefing last night, Trump said they are “getting close to a deal.” “We have some very good negotiations going on right now, and I think you could have a nice answer tomorrow,” he said. 

“The deal would add about $300 billion to the Paycheck Protection Program for small businesses that was swamped by demand in the three weeks since Congress created it as part of a $2 trillion coronavirus rescue bill,” Erica and Jeff report. 

“It also would add $60 billion to a separate emergency loan program for small businesses that also is out of money, Senate Minority Leader Charles E. Schumer (D-N.Y.) said on CNN. The agreement would include $75 billion for hospitals and $25 billion for testing, which have been major Democratic demands. Some of the money in the small-business program would be directed specifically to rural and minority businesses, said people familiar with the plan who spoke on the condition of anonymity to describe it.” 

Coronavirus latest

Here are other headlines and developments to catch up on this morning.

What does a return to normal look like? 
  • Before the economy can truly recover, people must feel confident in returning to their pre-pandemic lives, our Post colleague Ashley Parker reports. No such confidence currently exists. A Pew Research Center poll released Thursday found three-fourths of U.S. adults believe the worst is yet to come, and two-thirds worry about easing restrictions too soon.
  • A new Wall Street Journal-NBC News poll also found nearly six in 10 say they’re concerned lifting stay-at-home orders too quickly will fuel the pandemic and lead to more lives lost, the Wall Street Journal’s Catherine Lucey reports.
  • Before the nation can reopen, researchers at Harvard University say coronavirus testing needs to triple, the New York Times’s Keith Collins reports.
  • Researchers are racing to understand what level of immunity those who have recovered from covid-19 have, and how long immunity will last, the Wall Street Journal’s Robert Lee Hotz reports.
In the states: 
  • Trump said the government will ramp up efforts to acquire critical testing supplies after numerous Democratic and Republican governors said the administration hasn’t done enough, our Post colleagues Shane Harris, Felicia Sonmez and Mike DeBonis report.
  • California and Florida have released the names of nursing homes in their states that have had coronavirus cases, The Post’s Meryl Kornfield reports.
The hardest hit: 
  • We don't know how many American have lost their health insurance during the pandemic. But our colleague Amy Goldstein writes there are some clues, such as the 22 million workers who have filed unemployment claims since mid-March. “The latest census data show that job-based coverage accounted for 55 percent of Americans’ health insurance, though the kinds of work disappearing the most — restaurant jobs and others in the service industry — have always been less likely to offer health benefits,” she adds.
On the front lines: 
  • Doctors across the country as well as in Spain, the United Kingdom and China are wondering where all the heart attack, stroke, appendicitis or bowel obstruction patients have gone. The concern is there’s a “sub-epidemic of people who need care at hospitals but dare not come in,” The Post’s Lenny Bernstein and Frances Stead Sellers report.
  • One in three jobs held by women has been designated essential amid the pandemic, the New York Times’s Campbell Robertson and Robert Gebeloff report, citing an analysis of census data and federal essential worker guidelines. They add that nonwhite women are more likely to be doing such essential work than anyone else.

Sugar rush