The following is an edited excerpt from and interview with John M. Barry, conducted in late 2005...

What are the similarities between 1918 and the current avian flu?

All influenza viruses start out as bird viruses. There are two ways they become human viruses. It can, as happened in 1918, simply mutate its way into a human virus. But there is another way called re-assortment when, if an existing human virus infects a cell, and that same cell infects an existing bird virus, the two viruses can exchange genes. What emerges will be a new virus, combining the different elements of those two viruses. It will be seen as a new virus, so the immune system won’t be able to respond to it and it will spread explosively around the world.

How does a virus attack a cell?

Imagine a pirate ship with grappling hooks. The virus will throw a bunch of grappling hooks at a cell and bind to its surface. Then it will attack the cell, by working its way through the cell membrane. Once it’s inside the cell, it’ll make its way to the nucleus.

The virus then orders the cell’s machinery (every cell essentially is like a little factory) to make new virus particles. A single cell will produce between 100,000 and a million influenza virus particles. (However, the virus mutates so rapidly that 99 per cent of those virus particles will not work. They won’t be able to replicate themselves.) That still leaves between 1000 and 10, 000 viruses from a single cell that can work, that can infect another cell and start the process all over again.

That’s one reason why influenza seems to strike suddenly rather than gradually. With a bacterial infection, you’ll get sick gradually. But a viral infection, it has this logarithmic jump in the number of cells that are affected over a period of a few hours. The onset of the disease can be extremely sudden. You can be feeling fine when you go out to work in the morning, and by the mid-day coffee break you are virtually collapsed.

In 1918 there are reports of people who went out to work in the morning and were dead before they came home that afternoon. I’m not sure I believe some of those reports, but there are clearly cases where people died within 24 hours of the symptoms that are well documented by scientific observation.

How do you describe a virus?

Viruses are on the edge of life. I think most scientists believe them to be living organisms, but some don’t. They don’t do anything but reproduce themselves. They don’t eat, they don’t excrete waste, they don’t breathe, and they don’t have a metabolism. They are simply an invasion of genes into living cells.

Since they are not fully alive, it’s hard to target them. We understand a lot about how they function, and we certainly understand a lot about the influenza virus, but we have yet to figure out a way to cure the disease.

Our only real weapon against it is vaccination. There are viruses that we have developed very effective vaccines against, polio for example. And yet there are some influenza, or the common cold, or HIV, which we have not been able yet to develop a vaccine against despite intensive work.

What’s the relationship between birds, pigs, people and the virus?

All influenza viruses start out as bird viruses. It mutates very rapidly. This allows them to jump species – not only to people, but also to other mammals. In terms of pigs, some virologists refer to them as a ‘mixing vessel,’ because a pig’s cells actually have receptors on them, which make it easy for an avian virus to invade a cell.

Human cells do not have receptors that are naturally conducive to binding with a bird virus directly, although obviously it can happen, and it did happen in 1918 with H5N1 and it’s happening now.

Why were you personally drawn to studying the 1918 pandemic?

I was interested in the home front during World War I, which to me is always seemed like a crucible where a lot of pressures in American society came together and then exploded in 1919, right after the war. It was like a pressure cooker on the home front. The lid was being kept on during the war, but as soon as the war ended than all those pressures were just released.

I was also always interested in the influenza pandemic. There was a figure in the book, Oswald Avery, whom I identified with a lot. Avery was one of the greatest scientists in the 20th century. As a direct result of his studies, beginning on influenza, he discovered that DNA carried the genetic code. It took him 25 years of work to come up with that. And during much of that time he wanted to throw everything he was working on out the window. I identified with him a lot during at least half of the seven years that I worked on the book.

I wanted to toss the whole thing. But the last year and a half, it started to come together. And obviously I am happy with the book, and I’m glad now that I did it. Although it’s one of those experiences that you look back on and don’t want to go through again.

It was very difficult finding material, and it was very difficult making sense of the material that I did find. When I started writing the book, I expected to be overwhelmed with information, but as I started looking for this information, much of it that I expected to find easily, didn’t exists. Most of the scientists didn’t make laboratory notes, they were too busy to do any of the things they would do routinely. Or they were too sick. As a historian, and as a writer, you would want those things that they usually keep track of, but under the crisis, they didn’t.

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How did a person die with influenza in 1918?

The overwhelming majority of Westerners who got influenza in 1918 had exactly the same disease that you are familiar with today. You have a terrible three days, and a week later you are fine. But a minority, and it wasn’t a tiny minority, had an entirely different experience. Their symptoms were extraordinarily varied, and severe.

People could turn so dark blue from the lack of oxygen that physicians had reported they had difficulty distinguishing black patients from white patients. Some of the more horrific symptoms included bleeding from your nose and mouth, and from your ears and even your eyes. In some cases, literally, the floor would be covered in blood. It was an incredibly gruesome situation.

What did people in the communities do to protect themselves?

People isolated themselves. I think a lot of that was because we had two things going on. First, you had the government line. The Surgeon General of the United States said: “There is no cause for alarm.” There was cause for alarm, but his reassurances were repeated over and over by local officials practically everywhere. Meanwhile, people see their spouses die horribly, in less than 24 hours, and undertakers are not available, cemeteries are full.

People rapidly lost all faith in authority, and didn’t trust anything that they were told. This created a sense of alienation, and made it every person for himself, or herself. It spread terror and isolation.

The Red Cross reported that people were starving to death – not from lack of food, but because people were too frightened to go near the sick to bring them food. In most cases, you know, the communities began to fall apart.

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What seemed to work that we could look at now?

Nothing really worked in 1918, nor would it really work today. Cities passed ordinances against shaking hands, against spitting. Washing your hands constantly could work. Limiting your contact with people could obviously limit your chance of infection.

The streets in many cities around the world virtually emptied in 1918. It just froze society once it got going. Absentee rates were 40, 50, 60 per cent in some of the war industries.

In the army camps, scientists reported that in the camps that used quarantine rigidly, they did seem to have some effect on the course of the virus. But if the quarantine was not rigidly enforced, if there were any exceptions made at all, it didn’t seem to have any effect whatsoever.

Who was at most risk to die in 1918?

If you were a healthy young adult, and you interacted with people, you were at the highest risk of dying. The one demographic subgroup was probably pregnant women – they are young adults already, and they have the additional burden and stresses of pregnancy on their body already. Pregnant women had the highest rates of mortality - sometimes extraordinary - mortality rates.

In 1918, how did they deal with the people dying so quickly in such a short period of time?

The ‘death system,’ the mortuaries, the cemeteries, and so forth, they were just overwhelmed. Bodies lay in homes for days at a time, sometimes more than a week. In Philadelphia, you literally had priests driving horse-drawn carts driving down city streets calling upon people to bring out their dead.

They were buried in mass graves, dug by steam shovels. It was a horrific circumstance. In some cases, where they had funerals, there were no coffins. They were, for each funeral, renting coffins. They would have a service with somebody in the coffin, and then the body would go to the cemetery without a coffin, and then that same coffin would be reused for another service 15 or 20 minutes later.

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What were the biggest mistakes in 1918 that made things worse?

Not taking influenza seriously. The second biggest mistake was that governments did not tell the truth to the public.

I don’t think that would occur now. Since 2003, and even more recently, influenza has gotten an enormous amount of attention and governments are taking it seriously now. At least Western governments are.

The second problem, not telling the truth to the public, I’m not so confident that that would not repeat itself. It’s already been demonstrated that governments in Asia haven’t entirely told the truth.

In the end, what can 1918 teach us? So much has changed scientifically, the general health of people, is it really useful looking at something from that long ago?

1918 teaches us how lethal influenza could be. It teaches us certain things about the importance of telling the truth when there is a major event of any kind. Even when the population was totally panicked, people who were trained did their jobs. Not just nurses and doctors, who behaved with unbelievable heroism and went into the worst areas and died in large numbers, but the police and volunteers who removed the bodies from homes. The lesson is that these people, if they have a sense of what they are supposed to do, they will do their jobs. If people are actually trained and know what to expect, they will continue to function.

But if there is no leadership and no preparation, you run the risk of a disintegration of services. It’s very important not just to have plan but also to practice that plan, and to prepare people.

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What would you personally do if H5N1 developed into a pandemic?

I think it’s important to recognize that any pandemic is a serious event. We are most worried right now about H5N1 because it’s been killing half of the people it infects. But, we don’t know that the next pandemic – and there will be another pandemic, the nature of the virus virtually guarantees it – we don’t know if it’ll come tomorrow, or if it’ll come in 20 years.

Our society has changed so much even since the last pandemic in 1968, which was so mild that most people who lived through it aren’t even aware that a pandemic occurred. Yet that mild virus, if it struck today, would today kill between 89,000 - 200,000 Americans. That’s a pretty severe blow.

And the impact on the economy would be even greater than it was in 1968, because our habits have changed. Businesses have become so much more efficient because there is no slack. You have just in time inventory, you more people more frequently eating out at restaurants, you have no excess hospital beds, you have all sort of things that mean even a mild pandemic would be more severe today than it was in 1968.

In terms of what I personally would do, frankly I would cut down on my contacts with people. I would sit at home as much as possible with my family. I certainly wouldn’t shake hands, and I would have a large store of canned goods and bottled water and hunker down.

Do you have your own personal supply of Tamiflu?

No. Tamiflu is not an answer. The virus is one of the fastest mutating viruses in existence. I don’t have any faith that this virus, once it got into the human population, wouldn’t develop resistance to Tamiflu, or any other individual antiviral. The real answer will be a vaccine that will work against all influenza viruses.

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