The Great Influenza (14 page)

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.

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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.

Part II

THE SWARM

CHAPTER SIX

H
ASKELL
C
OUNTY,
K
ANSAS,
lies west of Dodge City, where cattle drives up from Texas reached a railhead, and belongs geographically to and, in 1918, not far in time from, the truly Wild West. The landscape was and is flat and treeless, and the county was, literally, of the earth. Sod houses built of earth were still common then, and even one of the county's few post offices was located in the dug-out sod home of the postmaster, who once a week collected the mail by riding his horse forty miles round-trip to the county seat in Santa Fe, a smattering of a few wooden buildings that was already well on its way to becoming the ghost town it would be in another ten years - today only its cemetery remains as a sign of its existence. But other towns nearby did have life. In Copeland, Stebbins Cash Store sold groceries, shoes, dry goods, dishes, hardware, implements, paints, and oils, while in Sublette, in the absence of a bank, S. E. Cave loaned money on real estate for 7.5 percent.

Here land, crops, and livestock were everything, and the smell of manure meant civilization. Farmers lived in close proximity to hogs and fowl, with cattle, pigs, and poultry everywhere. There were plenty of dogs too, and owners made sure to teach their dogs not to chase someone else's cattle; that could get them shot.

It was a land of extremes. It was dry enough that the bed of the Cimarron River often lay cracked and barren of water, dry enough that the front page of the local newspaper proclaimed in February 1918, 'A slow rain fell all day, measuring 27 one hundredths. It was well appreciated.' Yet torrential rains sometimes brought floods, such as the one in 1914 that drowned ranchers and wiped out the first and largest permanent business in the area, a ranch that ran thirty thousand head of cattle. In summer the sun bleached the prairie, parching it under a heat that made light itself quiver. In winter unearthly gales swept unopposed across the plains for hundreds of miles, driving the windchill past fifty degrees below zero; then the country seemed as frozen and empty as the Russian steppes. And storms, violent storms, from tornadoes to literally blinding blizzards, plagued the region. But all these extremes of nature came every season. Another extreme of nature came only once.

Epidemiological evidence suggests that a new influenza virus originated in Haskell County, Kansas, early in 1918. Evidence further suggests that this virus traveled east across the state to a huge army base, and from there to Europe. Later it began its sweep through North America, through Europe, through South America, through Asia and Africa, through isolated islands in the Pacific, through all the wide world. In its wake followed a keening sound that rose from the throats of mourners like the wind. The evidence comes from Dr. Loring Miner.

* 

Loring Miner was an unusual man. A graduate of the oldest university in the West, Ohio University in Athens, Ohio, a classicist enamored of ancient Greece, he had come in 1885 to this region. Despite a background so unlike those of his fellow frontiersmen, he had taken to the country and done well.

Miner was a big man in many ways: physically large, with angular features and a handlebar mustache, gruff, someone who didn't suffer fools - especially when he drank, which was often. A certain rebelliousness was part of his bigness as well. He hadn't seen the inside of a church in years. Periodically he reread the classics in Greek but he ate peas with his knife. And in thirty years on that prairie he had built a small empire apart from medicine. In the Odd Fellows he was a past noble grand, he had chaired the county Democratic Party, had been county coroner, was county health officer. He owned a drugstore and grocery and expected his patients to buy from him, and he married into the family of the largest landowners in western Kansas. Even in Haskell there was a social order, and now, during the war, his wife used her social standing as head of the county Red Cross Woman's Work Committee. When she asked for something few said no to her, and most women in the county did Red Cross work - real work, hard work, almost as hard as farmwork.

But Miner also personified Welch's comment that the results of medical education were better than the system. Although an isolated country doctor who began practicing before the establishment of the germ theory of disease, he had quickly accepted it, kept up with the astounding advances in his profession, built a laboratory in his office, learned how to use the new antitoxins for diphtheria and tetanus. By 1918 one of his sons had also become a doctor with a fully scientific education, and was already in the navy. He prided himself on his own scientific knowledge and puzzled over problems. His patients said they'd rather have him drunk than someone else sober.

His practice ranged over hundreds of square miles. Perhaps that was what Miner liked about it, the great expanse, the extremes, the lonely wind that could turn as violent as a gunshot, the hours spent making his way to a patient, sometimes in a horse and buggy, sometimes by car, sometimes by train - conductors would hold the train for him, and in winter stationmasters would violate the rules and let him wait inside the office by the stove.

But in late January and early February 1918, Miner had other concerns. One patient presented with what seemed common symptoms, although with unusual intensity - violent headache and body aches, high fever, nonproductive cough. Then another. And another. In Satanta, in Sublette, in Santa Fe, in Jean, in Copeland, on isolated farms.

Miner had seen influenza often. He diagnosed the disease as influenza. But he had never seen influenza like this. This was violent, rapid in its progress through the body, and sometimes lethal. This influenza killed. Soon dozens of his patients (the strongest, the healthiest, the most robust people in the county) were being struck down as suddenly as if they had been shot.

Miner turned all his energies to this disease. He drew blood, urine, and sputum samples, and used the laboratory skills his son had helped him improve. He searched all his medical texts and journals. He called his few colleagues in that part of the state. He contacted the U.S. Public Health Service, which offered him neither assistance nor advice. Meanwhile he likely did what little he could, trying diphtheria antitoxin with no effect, perhaps even trying tetanus antitoxin - anything that might stimulate the body's immune system against disease.

The local paper, the
Santa Fe Monitor,
apparently worried about hurting morale in wartime, said little about deaths but on inside pages reported, 'Mrs. Eva Van Alstine is sick with pneumonia. Her little son Roy is now able to get up'. Ralph Lindeman is still quite sick'. Goldie Wolgehagen is working at the Beeman store during her sister Eva's sickness'. Homer Moody has been reported quite sick'. Mertin, the young son of Ernest Elliot, is sick with pneumonia'. We are pleased to report that Pete Hesser's children are recovering nicely'. Mrs J. S. Cox is some better but is very weak yet'. Ralph McConnell has been quite sick this week.'

By now the disease overwhelmed Miner with patients. He pushed everything else aside, slept sometimes in his buggy while the horse made its own way home (one advantage over the automobile) through frozen nights. Perhaps he wondered if he was being confronted with the Plague of Athens, a mysterious disease that devastated the city during the Peloponnesian Wars, killing possibly one-third the population.

Then the disease disappeared. By mid-March the schools reopened with healthy children. Men and women returned to work. And the war regained its hold on people's thoughts.

The disease still, however, troubled Miner deeply. It also frightened him, not only for his own people but for the people beyond. Influenza was neither a 'reportable' disease (not a disease that the law required physicians to report) nor a disease that any state or federal public health agency tracked.

Yet Miner considered his experience so unusual, and this eruption of the disease so dangerous, that he formally warned national public health officials about it.

Public Health Reports
was a weekly journal published by the U.S. Public Health Service to alert health officials to outbreaks of all communicable diseases, not only in North America and Europe but anywhere in the world - in Saigon, Bombay, Madagascar, Quito. It tracked not just deadly diseases such as yellow fever and plague but far lesser threats; especially in the United States, it tracked mumps, chickenpox, and measles.

In the first six months of 1918, Miner's warning of 'influenza of severe type' was the only reference in that journal to influenza anywhere in the world. Other medical journals that spring carried articles on influenza outbreaks, but they all occurred after Haskell's, and they were not issued as public health warnings. Haskell County remains the first outbreak in 1918 suggesting that a new influenza virus was adapting, violently, to man.

As it turned out, the death rate in Haskell as a percentage of the entire county's population was only a fraction of what the death rate for the United States would be later that year, when influenza struck in full force.

People suffering from influenza shed virus (expel viruses that can infect others) for usually no more than seven days after infection and often even less. After that, although they may continue to cough and sneeze, they will not spread the disease. As sparsely populated and isolated as Haskell was, the virus infecting the county might well have died there, might well have failed to spread to the outside world. That would be so except for one thing: this was wartime.

The same week that Homer Moody and a dozen others in Jean, Kansas, fell ill, a young soldier named Dean Nilson came home to Jean on leave from Camp Funston, located three hundred miles away within the vast Fort Riley military reservation. The
Santa Fe Monitor
noted, 'Dean looks like soldier life agrees with him.' After his leave, of course, he returned to the camp. Ernest Elliot left Sublette, in Haskell County, to visit his brother at Funston just as his child fell ill; by the time Elliot returned home, the child had pneumonia. Of nearby Copeland on February 21, the paper said, 'Most everybody over the country is having lagrippe or pneumonia.'€ On February 28 it reported that John Bottom just left Copeland for Funston: 'We predict John will make an ideal soldier.'€