Journal of Legal Medicine

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The Great Influenza: The Epic Story of the

Deadliest Plague in History

Joseph B. Topinka, Daniel P. Molnar, Brandon I. Gardner & Rosemary E.

Wosky

To cite this article: Joseph B. Topinka, Daniel P. Molnar, Brandon I. Gardner & Rosemary E.
Wosky (2015) The Great Influenza: The Epic Story of the Deadliest Plague in History, Journal of
Legal Medicine, 36:3-4, 459-465, DOI: 10.1080/01947648.2015.1262197

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Journal of Legal Medicine, 36:459–465
Copyright © 2015 American College of Legal Medicine
0194-7648 print / 1521-057X online
DOI: 10.1080/01947648.2015.1262197

THE GREAT INFLUENZA: THE EPIC STORY OF

THE DEADLIEST PLAGUE IN HISTORY

Joseph B. Topinka, JD MBA MHA LLM, Daniel P. Molnar, JD, Brandon

I. Gardner, DO MPH, and Rosemary E. Wosky, RN MSN∗

OVERVIEW
In 2005, Mary Ann Gwinn of The Seattle Times wrote that John Barry’s The
Great Influenza, The Epic Story of the Deadliest Plague in History1 is “a lot to
absorb—perhaps too much.”2 She may be right; the book provides an intense
review of the 1918 influenza pandemic’s movement across the planet and the
efforts taken to confront it. The book is almost overwhelming in scope, but
it draws the reader into a remarkable, detailed account of the events leading
up to, during, and after the pandemic. The book remains as relevant today as
the day it was published 10 years ago. Although it is focused on the influenza
virus, much of what Barry writes applies to today’s newly emerging viruses,
such as Ebola and Zika.
At first, the book may confuse the reader because Barry does not begin
with the influenza pandemic; rather, he dedicates his early, and many of his
later chapters, to an account of how scientists and physicians like William

∗
Joseph Baar Topinka is an assistant professor in the Health Administration School at Texas State Uni-
versity where he teaches a course in employment law and a course in public health for administrators
and whose research focuses on public health and medical legal issues. Please address correspondence to
School of Health Administration, Texas State University, 601 University Drive, San Marcos, TX 78666-
4684, phone: 512-245-3556, Email: josephtopinka@txstate.edu. Daniel P. Molnar is a retired attorney
with the U.S. Army Judge Advocate General Corps where he specialized in medical malpractice and risk
management law. Major Brandon I. Gardner is the Chief of the Occupational Medicine Department at the
Army Medical Department Center and School and the U.S. Army Health Readiness Center of Excellence.
His expertise is in occupational medicine. Major Rosemary E. Wosky is the Chief of Army Public Health
Nursing at the Wiesbaden Army Health Clinic in the Republic of Germany. Her expertise is in military
public health and preventive medicine.
1
JOHN M. BARRY, THE GREAT INFLUENZA: THE EPIC STORY OF THE DEADLIEST PLAGUE IN HISTORY (2005).
Barry was given the Keck Award in 2005, as The Great Influenza was named the year’s outstand-
ing book on science or medicine by the National Academies of Science. See John M. Barry, http://
www.johnmbarry.com/.
2
Mary Ann Gwinn, Book Review, Chronicle of the Devastating Flu Epidemic of 1918 Is Frightening,
Readable, THE SEATTLE TIMES (Feb. 15, 2004), http://old.seattletimes.com/html/books/2001856452_
influenza15.html.

459
460 TOPINKA ET AL.

Henry Welch, Rufus Cole, George Sternberg, Franklin Mall, Loring Miner,
and others struggled to change the practice of medicine into a science-based
profession. Barry provides a historical framework for understanding the status
of the medical profession upon the eve of confronting this epidemiological
outbreak, the influenza pandemic of 1918. Barry’s description demonstrates
how ill-prepared the medical profession was in 1918. His account, however,
does show the development of research institutions like The Johns Hopkins
School of Hygiene and Public Health and their evolving practices, practices
that may be taken for granted today.
Barry foreshadows the coming influenza crisis, while weaving a com-
pelling description of the influenza viruses into his next few chapters. These
chapters provide the reader with a basic “Virus 101” class: how the viruses
attack cells in the body, how they mutate, and how they can recombine with
other strains to create newer, deadlier viruses.
Barry then addresses the various political issues of the time, including
the lack of support by the military for Army Surgeon General William Craw-
ford Gorgas, who, along with other physicians, had concerns about epidemic
disease and overcrowding of military cantonment facilities built to support
the growing American war machine of World War I. Later in the book, Barry
also addresses President Woodrow Wilson’s perspective on the influenza pan-
demic in the United States and its impact on the rest of the world, especially
those countries fighting with and against the United States in World War I.
In Chapter 14, Barry begins to describe the actual pandemic itself, argu-
ing that it originated in the military cantonments in Haskell County, Kansas,
in the late winter of 1918. From there, young soldiers carried the virus to other
locations such as Camp Grant in Illinois and Camp Devens in Massachusetts.
Boats, such as the Leviathan, loaded with troops deployed to Europe, and
trains, such as that going from Camp Grant, Illinois, to Camp Hancock, Geor-
gia, became moving coffins. Densely packed soldiers spread the virus to each
other and to different geographic locations, including New York, Chicago,
Seattle, Boston, and Philadelphia, with horrific results in terms of number of
fatalities. Before it ran its course, as many as 675,000 Americans died from
the disease and its complications. It did not spare America’s youth, killing one
in every 67 United States soldiers. Worldwide, the death toll was estimated to
be up to 100 million.3
Barry argues that the 1918 pandemic came in two waves: the first, in
the spring of 1918, was mild; the second, which began in August 1918, was
lethal. He submits three theories to explain this pattern. One theory is that

3
BARRY, supra note 1, at 238–39, 397. Estimates of the total vary. See, e.g., Jefferey K. Tauenberger &
David M. Morens, Perspective, 1918 Influenza: The Mother of All Pandemics, 12(1) EMERGING INFECTIOUS
DISEASES 15, 15 (Jan. 2006) (estimating worldwide deaths from the 1918–1919 influenza epidemic to be
50 million but arguably as high as 100 million).
THE GREAT INFLUENZA 461

the mild and the lethal influenza strains were two different diseases. Barry
dismisses this theory because many victims of the first wave were resistant
to the second. The second theory involves the first wave virus encountering
a second influenza virus in Europe and then “re-sorting” (mutating) genes.
Barry also dismisses this theory. Ultimately, Barry supports a third theory,
which involves the virus’s adaptation to man.

In 1918 each initial burst of lethality, isolated though it may have seemed, was much
like a first bubble rising to the surface in a pot coming to boil. The flame may have
ignited in Haskell and set off the first burst. The outbreak that killed 5 percent of all
French recruits at one small base was another. Louisville was still another, as were
the deaths on the City of Exeter and the outbreak in Switzerland. All these were bursts
of lethal disease, violent bubbles to the surface.4

MAJOR THEMES
According to Katherine A. Powers of The Boston Globe, “Barry has,
essentially, two separate stories going here. One is an account of the insti-
tutional and scientific development of modern medicine in the United States.
The other shows how government policy worsened—if not actually created—
a medical catastrophe.”5 These he intermixes with a level of horror over the
human suffering as they come together in their focus on the pandemic.
For example, Charles Richard, the Acting Army Surgeon General, rep-
resenting the modern institutional and scientific profession of medicine, urged
the United States Army’s Adjutant General and the United States Army’s
Chief of Staff to stop the transfer of personnel from one camp to another
in order to control the spread of the influenza. They refused and the Army
policies remained unchanged.
Another example involved Dr. Wilmer Krusen, the Director of the
Philadelphia Department of Public Health and Charities. He personally lacked
an adequate background in public health, and his policy lacked contingency
plans, stockpiled supplies, and lists of medical personnel that could be avail-
able in times of an emergency. He is best known for permitting a big Liberty
Loan parade to occur in Philadelphia in September 1918. Granted, the country
was at war and there was a need to raise money through the purchase of bonds,
but the event involved two miles of marchers, including “bands, flags, Boy
Scouts, women’s auxiliaries, marines, sailors, and soldiers.”6 Nearly 210,000
people “jammed the parade route.”7 Shortly thereafter, Krusen would issue a

4
BARRY,
supra note 1, at 180–81 (emphasis in original).
5
Katherine A. Powers, A Reading Life, As Disease Raged, Truth Was Another Casualty, THE BOSTON
GLOBE (Feb. 29, 2004), http://archive.boston.com/ae/books/articles/2004/02/29/as_disease_raged_
truth_was_another_casualty/?page=full.
6
BARRY, supra note 1, at 209.
7
Id.
462 TOPINKA ET AL.

statement noting that influenza was present in the civilian population at rates
similar to that seen in the military. In other words, the parade only encouraged
the further spread of the virus throughout the city’s population.
Physicians and scientists tried to warn of the influenza’s impact and
lethality. Yet, in the government’s effort to preserve wartime morale and hide
declining military readiness, it provided no guidance to the citizenry and no
official acknowledgment of the influenza’s danger. In fact, according to Barry,
the name “Spanish Flu” for the pandemic was a result of the effort to preserve
wartime morale around the world. Countries like France, Britain, and Ger-
many censored the press and avoided publishing any negative information
during the war. Spain was neutral during World War I and published many
reports about the influenza outbreak, especially when King Alphonse XIII
became ill. Only the Spanish newspapers published stories about the spread
of influenza and, thus, the pandemic became known as the Spanish Flu.
In sum, Barry provides many examples of where the two themes coin-
cide with resulting horrific, human repercussions: 2,000 of the 3,108 troops
transferred by train from Camp Grant to Camp Hancock had to be hospital-
ized, 43 died, and the virus was brought to Camp Hancock8 ; 117 people died
in a single day in Philadelphia after the Liberty Bond parade and that number
would “double, triple, quadruple, quintuple, sextuple.9 “[The] government’s
very efforts to preserve ‘morale’ fostered … fear.”10

SIGNIFICANCE FOR PUBLIC HEALTH

Michael Kenney writes that “[i]t would seem improbable to see the 1918
pandemic, as Barry does, as ‘a case study’ with lessons for the present.”11
We disagree. Barry’s description of the spreading of the influenza and the
reaction to it by the local and national governments all provide lessons from
which we can learn.12 Whether it was failing to control population density and
movement, such as in the various military camps, or actually encouraging
people to gather, as in Philadelphia, the book describes critical actions and
decisions or the lack thereof.
We can certainly learn from the struggles described in the book. Gov-
ernments can plan, stockpile, and be open and forthright about the true nature

8
Id. at 217.
9
Id. at 220.
10
Id. at 333.
11
Michael Kenney, Book Review, A Timely Account of the 1918 Flu Pandemic, THE BOSTON GLOBE (Feb. 11,
2004), http://archive.boston.com/ae/books/articles/2004/02/11/a_timely_account_of_the_1918_flu_
pandemic/.
12
Cf. Karen Brudney, Book Review, The Great Influenza: The Epic Story of the Deadliest Plague in History,
351 N. ENG. J. MED. 617, 618 (2004) (“Barry makes it all too easy to imagine a similarly devastating
epidemic with a similarly inadequate response.”).
THE GREAT INFLUENZA 463

of impending threats. People can take effective preventative measures, such

as social distancing, or using vaccines, a luxury not available in 1918. Most of
all, the book supports the need for public education. According to Barry, fear
filled the vacuum left when the government provided no guidance in 1918.
In the future, public health needs to be about providing necessary guidance
and education so that the proper decisions are made and actions are taken in
a given situation without fear. As Mary Ann Gwinn writes, the book demon-
strates the lesson of “the power of fear to paralyze a population.”13

RELEVANCE TO PUBLIC HEALTH LAW

Though Barry does not specifically address legal issues, there are a few
areas worth exploring. First, in times of crisis, such as what we have seen in
recent years with the Ebola pandemic,14 individual safety is critical. Barry
describes how in 1918 soldiers were packed into cantonment areas, trains,
and ships. Health concerns for individuals were minimized. For example, the
hospital was often the last building to be erected in cantonment areas. A sol-
dier’s status did not deprive him of his humanity, yet Barry’s description of
a soldier’s living conditions, especially once he began to become sick, puts
into question the military’s role in protecting the health, welfare, and safety
of its personnel at the time.
In the same vein, the government had the duty to provide for the safety
of its citizens. The example of the Liberty Bond parade in Philadelphia is
but one instance where the government failed to ensure citizen safety. Public
health law must ensure that there are some basic standards of safety that apply
to everyone. These standards should not put people at risk, and they should
not treat people insignificantly.
Second, people have a right to know about the risks that they face. The
Espionage Act of 1917, which prohibited giving aid to enemies of the United
States or interfering with the war effort, stifled free speech and was used to
justify withholding information concerning the extent of the influenza pan-
demic. The media has made such free speech limitations different today, but
the experiences of 1918 are still worth consideration in our era of a 24/7 news
cycle.
Throughout the book, Barry describes situations where people sim-
ply did not know about the danger presented by the influenza pandemic.
In Philadelphia, people were told they were safe when they were not. Dis-
information is as bad as no information and the consequences of both are

13
GWINN, supra note 2.
14
See Ebola (Ebola Virus Disease), CENTERS FOR DISEASE CONTROL, https://www.cdc.gov/vhf/ebola/ (last
visited July 25, 2016) (“Since March 2014, West Africa has experienced the largest outbreak of Ebola
in history.”).
464 TOPINKA ET AL.

disastrous. The excuse that community morale or wartime morale would

otherwise suffer is hardly an argument in support of such action. Public health
law needs to ensure that information about threats is foremost above such
practices; affirmatives steps must be taken to get information out to the pub-
lic and government officials. The law must require some effort to educate the
public and governmental leaders, so that ignorance is replaced with knowl-
edge and fear is replaced with empowerment.
Third, public health officials must have the political power to implement
isolation and quarantine. According to Barry, no national figure at the time of
the pandemic in 1918 had the political power to implement such measures. For
example, Army Surgeon General Gorga’s calls to end the transfer of troops
were ignored, and he did not have the political power to stop the transfers
himself. Today, things have changed, and people take for granted that such
public health powers are vested in public health officials around the country.
Federal, state, and even local public health law reflects that reality. But does
the public truly understand these critical powers and how they could be used
in times of crisis? The various public responses to the Ebola and Zika viruses
have not demonstrated such a clear comprehension.
Fourth, Barry addresses the many scientists and physicians whose lab-
oratory research ultimately revealed the structure of DNA and whose efforts
identified the source of the influenza pandemic as a virus. Public health law
must support a legal framework for research that defines what can and cannot
be done and to whom. In one part of the book, Barry describes how individuals
were subjected to various untested procedures that clinicians hoped could cure
those infected. Such efforts were the last resort in many instances, but there
were no laws governing such research in 1918. Today, the law provides pa-
rameters for clinical investigations and, within these parameters, public health
law needs to encourage the constant development of new vaccines to prevent
infectious diseases and medicine to treat those already infected.
Fifth, public policy must recognize the need to share scarce resources
during wartime. Between one quarter and one third of all United States
physicians were in military service during World War I. This left many
communities in an underserved status during the 1918 influenza pandemic.
Furthermore, many of the nation’s laboratories were focused on the de-
velopment of weapons, so there were fewer resources available for in-
fluenza research. Exacerbating the situation was the military’s refusal to pro-
vide medical assistance to civilians. This led to many unnecessary civilian
deaths.
Finally, disparate treatment based on race or class has no place when
responding to such a crisis as seen in 1918. Barry notes that the influenza
pandemic was universal and not tied to race or class. Both black and white
populations received comparable treatment. If there was any lack of treat-
ment, it was based on geography, such as mining towns or secluded villages
THE GREAT INFLUENZA 465

in Alaska where resources were simply not available. Public health law must
always ensure that adequate resources are made available and that race or class
is not a prerequisite for the receipt of such resources and medical treatment.15

CONCLUSION
The Great Influenza, The Epic Story of the Deadliest Plague in History
is a well-written, thoroughly researched, and comprehensive book. Barry’s
2005 edition of the book contains an exhaustive bibliography, as well as an
additional afterword discussing our preparedness for modern pandemics. The
afterword could actually be read before reading the book itself, because it
applies the past to our current reality.
Barry’s forecast is cynical, but he recommends several realistic steps
society should take in order to be ready for the next influenza pandemic.
These recommendations have not diminished over the passage of time since
the book was first published. First, he believes that surveillance is critical.
Through surveillance, we can identify new viruses and track them to provide
a better chance of developing and distributing an appropriate vaccine. Sec-
ond, Barry advocates the need for governments to be truthful and open in
their communications with other countries. He refers to China’s lack of dis-
closure for months about SARS (severe acute respiratory syndrome). Such a
practice would make it impossible to contain another highly infectious agent.
Third, Barry recommends that countries with a scientific infrastructure, like
the United States, investigate influenza immediately so that rational decisions
on resources can be made in advance. Fourth, vaccine manufacture and surge
capacity must be developed, along with stockpiling available antivirals. Fi-
nally, Barry emphasizes that, as a society, we must learn from the influenza
pandemic of 1918 that panic is not a solution for crisis and that public trust
is crucial. Barry’s concluding thoughts are most illustrative and will certainly
be relevant for many years to come:

[T]hose who occupy positions of authority must lessen the panic that can alienate
the members of society. A society that takes as its motto, “every man for himself” is
no longer a civilized society.
Those in authority must retain the public’s trust. The way to do that is to distort
nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said
that first, and best.
A leader must make whatever horror exists concrete. Only then will people be able
to break it apart.16

15
See Georges C. Benjamin, Pandemic Influenza: Preparing for the Worst, 58 ADMIN. L. REV. 663, 666
(arguing that significant involvement by the legal profession is required when addressing a pandemic).
16
BARRY, supra note 2, at 462.