00:20
MARCIA DAY CHILDRESS: Good afternoon.
00:21
I'd like to welcome you to today's Medical Center Hour.
00:25
I'm Marcia Day Childress, director of Humanities Programs
00:30
in the School of Medicine Center for Biomedical Ethics
00:33
and Humanities.
00:35
It's our center that produces the Medical Center Hour.
00:39
Today, we mark the start of a new Medical Center Hour
00:42
season, our 48th.
00:45
For nearly a half century, this hour
00:47
at midday in midweek through much of the school year
00:51
has hosted some of the University of Virginia's
00:54
richest conversations on current, sometimes contentious
00:59
matters of common concern to both medicine and society.
01:05
Medical Center Hour may be a medical school program,
01:07
but ever since its founding, it has welcomed everyone
01:10
at the university and the public as well.
01:14
So this is an inclusive forum, where professional pathways
01:18
intersect, where science and society meet, and work clinic
01:22
and community are represented and can relate to one another.
01:27
Importantly, Medical Center Hour is your forum.
01:31
Your voices and views are encouraged.
01:33
Indeed, we expect them in every program.
01:38
A quick reminder, we award nursing
01:40
as well as medical education credit, continuing education
01:44
credit hours.
01:46
The handout you received at the top of the auditorium
01:49
has instructions for physicians and nurses
01:52
who wish to request a continuing education credit.
01:56
And a quick word of grateful thanks.
01:58
The Medical Center Hour is funded in part
02:01
by the School of Medicine's John F Anderson Memorial
02:05
Lectureship, created in 1955 by medical alumnus Dr. John
02:10
Anderson.
02:11
His gift keeps on giving 63 years and counting.
02:17
This new season starts with a look back.
02:21
In partnership with the School of Nursing Bjorling
02:23
Center for Nursing Historical Inquiry and Historical
02:26
Collections in the Claude Moore Health Sciences Library,
02:30
Medical Center Hour is observing the centennial
02:33
of the 1918 influenza pandemic.
02:37
We're marking this grim anniversary
02:39
both to remember and to learn from this most deadly
02:43
of global disease pandemics.
02:46
Three Medical Center Hours this fall
02:48
highlight aspects of this world changing event,
02:52
pandemic preparedness or not, the science of the 1918
02:57
influenza, and the voices of those persons, families,
03:02
and communities, whose lives were lost or changed.
03:07
Please do join us for each program in Influenza 1918
03:11
to 2018, as we interrogate the past to better
03:15
know the present moment and to prepare for the future.
03:19
These program dates appear in your handout.
03:22
And all fall in conjunction with this,
03:24
we'll remind you to get your 2018 flu shot.
03:29
And now, I'm happy to welcome to the medical center
03:33
our Carol Byerly, who has taught at the University of Colorado
03:38
at Boulder.
03:39
She's a historian.
03:41
And the project of hers that we're featuring
03:44
is her 2005 book, Fever of War, The Influenza Epidemic
03:50
and the US Army during World War I.
03:53
It's interesting and odd coincidence today
03:57
that we are talking about catastrophic events
04:05
even as Virginia, North Carolina, and South Carolina
04:09
have declared states of emergency
04:13
in anticipation of Hurricane Florence.
04:18
Carol will be talking some about the kinds of preparedness
04:22
for natural disasters--
04:25
or for a biosocial disasters, in the same way
04:28
that a lot of the preparedness relates to the preparation
04:32
for natural disasters.
04:34
So with that in mind and also with questions about
04:40
are the kinds of preparations that we make in the military,
04:45
in society through public health programs,
04:50
the sorts of things that can help in the future?
04:53
What lessons do we derive from past experience, successes,
04:59
and failures?
05:00
And to set the stage, we're going back to 1918.
05:04
We may be going back a little further than that.
05:08
But to 1918, when the US was a new combatant nation in World
05:13
War I. There were a lot of American young men
05:18
in training camps and then shipping over
05:21
to Europe to fight in the war.
05:25
This set the stage for an outbreak of epidemic disease
05:31
that was then carried worldwide.
05:34
So I'll let Carol pick up the story from here.
05:37
Please welcome Carol Byerly.
05:39
[APPLAUSE]
05:45
CAROL BYERLY: OK, thank you very much for having me today.
05:51
I'm here to tell you a cautionary tale, here
05:57
to tell you a cautionary tale about pandemic disease, what
06:02
pandemic disease can do to a society
06:06
and what it can do to an army and what it can do to a war.
06:12
Pandemic disease is an issue of concern for Homeland Security.
06:18
And in fact, several years ago, I
06:20
was invited down to Fort Sam Houston
06:24
to talk to the North Army down there about the 1918 influenza.
06:32
And the commanding general had pandemic disease
06:37
on his portfolio.
06:39
And intellectually, he thought it
06:41
would be useful for me to tell them what happened in 1918.
06:47
So it was a very lively issue in the army, even today.
06:57
And so I'm going to tell you what I told them
07:00
about what happened in 1918.
07:02
And some of the best medical and scientific minds in the country
07:09
were in the Army Medical Department during World War I.
07:13
And they were defeated by this pandemic.
07:18
But they weren't surprised by it.
07:22
They were not surprised by it.
07:25
They knew that disease and war go hand in hand,
07:30
and that for millennia when nations or tribes or kingdoms
07:36
go to war, they also create these wonderful environments
07:40
for disease pathogens to exploit and make people sick.
07:45
So I am going to go back and begin
07:49
with our greatest, perhaps the greatest general
07:52
in human history, was Napoleon.
07:55
And how many of you are familiar with this image?
07:57
This is Charles Menard, was a French engineer.
08:01
And he offered this as a visual way
08:09
to show statistical information.
08:12
And Edward Tufte, who is a specialist in this,
08:14
had brought this up.
08:16
But this is a visual way to talk about Napoleon's campaign
08:19
into Russia in 1812.
08:22
Napoleon crossed the Neman River in June of 1812.
08:27
I told you we were going back.
08:28
He had 400,000 soldiers, a 20th century size
08:34
army, 400,000 soldiers.
08:36
And they traveled into Russia.
08:39
And this shows where different groups would peel off.
08:43
They go in, and the number is going down.
08:48
The number is going down.
08:50
And they travel across Russia through the fall.
08:54
And they get to Moscow.
08:56
And this shows the return army, the return army
09:00
coming back a different path, coming through
09:03
and returning to France defeated in December 1812
09:10
with 10,000 men.
09:14
Was this the brilliance of the Russian Army and the troops ?
09:19
No.
09:20
This is a story of typhus and dysentery.
09:24
And this is a very graphic depiction
09:27
of the power of disease to determine the fates of armies.
09:35
And so my medical officer-- and that's what I do.
09:37
I study medical officers-- they knew this.
09:39
We see this also in the Mexican War.
09:44
This is cholera and typhoid, dirty water generally.
09:49
And this is again typhoid, dysentery
09:53
are the big diseases that killed.
09:56
And we're getting better at killing people with power
09:58
more powerful weapons.
10:01
But still you have your outstripping
10:04
Spanish-American War was a scandal of eight times
10:09
as many men died of yellow fever and typhoid fever and malaria
10:16
as were defeated or killed in combat.
10:20
So my medical officers knew this was a problem.
10:26
And so the argument that I want to make today
10:29
is that in World War I, this is--
10:34
we've got modern medicine during World War I.
10:37
We've discovered germ theory.
10:40
We've know how to clean the water.
10:41
We're not going to have any typhoid.
10:43
We've got latrines.
10:45
We have a typhoid vaccine.
10:48
We know about mosquito mitigation.
10:50
We have vaccinations for smallpox.
10:53
And so it's modern medicine, X-rays, screening.
10:58
But medical officers knew they still couldn't do anything
11:01
about respiratory diseases.
11:04
And they were writing when we went to war, OK, we're good,
11:08
but what about respiratory diseases?
11:09
We're going to be in trouble.
11:12
And so my argument today is that war and influenza collaborated,
11:18
and that the war fostered disease
11:22
by creating conditions under which the influenza virus could
11:27
mutate and exploit war conditions to become
11:31
increasingly virulent and deadly--
11:36
that's redundant-- and then travel around the world.
11:42
And I want to argue that that's not just interesting,
11:46
but that the influenza shaped the war experience, especially
11:51
for the American war.
11:52
And the influenza pandemic, epidemic,
11:56
coincided completely with the two greatest battles
11:59
that the United States fought in World War I
12:02
and compromised the American ability
12:06
to execute their battle plans.
12:09
So that's the argument that I want to make today.
12:13
Well, I want to tell you how bad the flu was.
12:16
So the flu was-- this is modern medicine.
12:20
So we've already got germ theory.
12:23
We've got Pasteur.
12:24
We've got Reade.
12:25
We've got everybody.
12:26
And this is the mortality of influenza.
12:31
And it was sharp.
12:33
The drama behind the flu is not just
12:38
the high level of mortality--
12:40
we now believe it was about 50 million people died worldwide--
12:44
but that it happened in 18 months.
12:48
If you look at the Black Death, which was disastrous,
12:51
that happened over decades.
12:54
The encounter between the new and old world
12:56
was surely catastrophe, but that took decades.
13:01
This happened in 18 months.
13:04
50 million-- the original death toll was 21 million,
13:11
which was calculated in the 1920s.
13:13
And that held for about 70 years until people did research
13:17
in India.
13:19
And they started looking at the Indian records.
13:21
And they calculated about 17 million
13:23
died in India alone, which then threw the 21 million
13:27
figure into question.
13:30
A study in Japan just upgraded the number from 500,000
13:35
to 2 million.
13:36
And so the research is still coming in on the mortality
13:41
of this influenza.
13:47
And it's not a plague of the Middle Ages.
13:49
This is not the plague of the Middle Ages.
13:52
The flu came in three waves that you may be familiar with.
13:57
And this is the early wave in the spring and summer of 1918.
14:05
Men are getting sick, first in the camps in the United States.
14:10
And then we have reports of men, of influenza
14:14
moving through troops on both sides of the Western front.
14:18
Troublesome, it makes people sick, but doesn't kill them.
14:22
Then something happens-- and Jeffrey Taubenberger
14:24
can tell you more.
14:26
But he's pretty modest about what he can tell,
14:28
but he'll tell you more about what
14:29
happened-- and then in late August,
14:32
early September explosion.
14:35
And this is when we have the deadly second wave.
14:39
And this is when the United States is fighting
14:42
their big battles of the war.
14:44
And then it died down in December.
14:47
And then again recrudescence in early 1919,
14:52
it shows up in the South Pacific and interferes
14:55
with the Treaty of Versailles negotiations
14:58
and then disappears.
15:02
So one point I want to make, another point I want to make,
15:09
is that this is the mortality-- this is the three waves--
15:13
mortality was dramatic, 50 million.
15:17
But even more important point about influenza
15:21
and military populations and civilian as well is morbidity.
15:25
So the mortality rate was about 2% to 4%
15:32
in most American communities.
15:35
Morbidity rate was 25% to 40%.
15:40
Now, the population of the United States
15:43
in 1920 and during World War I was very conveniently
15:47
100 million.
15:49
So for a history major, how many people
15:52
were sick in the United States if you have 25% morbidity?
15:58
25 million people are sick in the country.
16:03
And that is the conservative rate.
16:06
And of the people that died, we have an estimate
16:10
of about 675,000 Americans died during the influenza epidemic.
16:19
And where did it emerge?
16:21
It did emerge in--
16:23
we believe it's controversial where, it's still being
16:26
debated where the flu emerged.
16:29
There are three theories.
16:31
But the most salient one and the one that makes most sense to me
16:33
is that it emerged in Camp Funston Kansas
16:40
is one of the first reports of influenza.
16:44
And there a number of forts and a number
16:47
of camps in the spring, as I said, that reported influenza.
16:51
It was enough that they would write it up and send it
16:53
into the Surgeon General.
16:55
But then that's part of the first wave.
16:57
And then it most likely traveled with the troops on troop ship
17:03
and then went to the Western Front
17:05
and mutated to explode later.
17:10
But these are wonderful environments for viruses,
17:13
because each of these camps had 25,000 to 55,000 young men
17:19
coming from all over the country sharing germs and living
17:24
in very close quarters and being stressed out
17:27
and eating new food and not having good sanitary habits.
17:33
And this is what military medical officers knew.
17:35
They worried about this all of the time.
17:43
As they went over across the ocean,
17:46
they're in very crowded conditions.
17:50
Wars are crowded affairs.
17:52
And so the United States was rushing
17:55
to get American troops over to support
17:58
the French and the British against the Germans
18:00
in 1917, 1918.
18:02
So they were refashioning ships to fit four in a row.
18:10
And then these would be hot bunks,
18:12
where you'd get your eight hours and then you go on duty
18:14
and somebody else would get your bed.
18:16
So these are crowded conditions that people
18:19
are going across the ocean.
18:21
And then they are being put in trains.
18:28
These trains were known to hold eight horses or 40 men
18:34
in France.
18:35
And so crowded conditions give way
18:39
to give wonderful environments for pathogens.
18:46
After my book was published, I was in the archives--
18:49
I still look for influenza stuff--
18:51
and I found a report by Captain Alan Chesney
18:56
who was at a hospital with the American Expeditionary
19:01
Forces in France.
19:03
And he was in charge of a hospital
19:05
that troops would move through on their way to the front.
19:10
He was later dean of the Johns Hopkins Medical School.
19:14
So he was no slouch.
19:17
And he documents, to my mind, the evolution
19:20
of the influenza virus.
19:24
I made this slide myself.
19:26
I'm very proud of this.
19:27
No.
19:28
So he finds the first unit that comes in from June to July,
19:34
it's the Fifth Artillery Brigade.
19:36
And they have 77 cases, mild, no deaths.
19:42
But he writes it up.
19:45
And they move out to see action.
19:48
And then the next unit is the 58th Artillery Brigade.
19:53
And they come in, and there are 200 cases.
19:56
And a brigade has about 1,600 men, which is helpful for you
20:00
to know.
20:02
And it was enough with 200 cases, they got worried
20:04
and they scrubbed down the entire barracks,
20:07
whitewashed it.
20:09
And then they brought in the last brigade
20:13
and that had 1,600 cases of influenza.
20:20
OK, so it's not 1,600 members in a brigade.
20:24
It's like 4,000.
20:27
And then 151 deaths.
20:30
And so he documented this.
20:33
And he said, "These successive outbreaks
20:36
tended to be progressively more severe,
20:40
both in character and extent, which
20:43
would speak for an increasing virulence
20:46
of the causative agent."
20:47
Now, they didn't have virology at this time.
20:50
They could see bacteria.
20:51
But they hadn't seen viruses, but they knew,
20:55
they watched it-- and that's one of the tragedies
20:57
for me is the medical officers knew what they were seeing
21:01
and they knew there was very little they
21:03
could do to stop it.
21:06
So the second deadly wave exploded
21:11
in the last week in August on the same day in Boston, Brest,
21:18
France, and Bombay, India.
21:21
And one of the convenient facts or aspects of influenza
21:26
is that it has an incubation period of only 24 to 48 hours.
21:31
So we can pinpoint when influenza comes to a community
21:36
to the day.
21:40
And again, they were able to observe this,
21:44
but they couldn't see the virus.
21:46
And they were speculating and theorizing about the virus.
21:53
Some people believed it was Pfeiffer's bacillus.
21:59
So when people would die of influenza,
22:01
they would do autopsies in the military medicine,
22:05
all soldiers can be autopsied without asking
22:08
for permission from a family.
22:11
And they were autopsying everybody
22:12
to see what was causing this.
22:14
And they would take some tissue, pieces of tissue, to examine,
22:19
and they saw secondary bacterial infections.
22:25
And so they thought it might be Pfeiffer's bacillus.
22:28
And people are now looking at this at these infections
22:31
and trying to identify the nature of these infections
22:36
and confirming that it was this secondary pneumonia that
22:41
was killing people.
22:43
Taubenberger will talk about this.
22:46
But he's the first one to use some of this tissue.
22:49
Roscoe Vaughan is a young private
22:53
who died at the age of 21 in Camp Jackson, South Carolina.
22:58
And again, these scientists, they don't know what to do.
23:01
But they're clipping tissue and sending it
23:03
to the Army Medical Museum.
23:05
And it was stored in wax.
23:08
And so this is what Jeffrey Taubenberger at the Army
23:14
Medical Institute of Pathology was
23:16
able to analyze in the 1990s and identify as H1N1,
23:24
the big one, the big one.
23:28
So I have a lot of I have a lot of charts.
23:32
So this influenza is going to move through the army in three
23:37
waves.
23:38
And it's going to kill more soldiers than the Germans did.
23:44
Again, more people are going to die
23:46
of disease in the 20th century in a modern army
23:50
than are killed in combat with industrial warfare.
23:57
This is the American Expeditionary Force in France.
24:00
Of course, more people died.
24:01
What is killing people in the United States?
24:04
Are the Germans coming over and shooting us with machine guns?
24:07
No.
24:07
This is disease.
24:10
This is at least 30,000 young men
24:12
are going to die of influenza and pneumonia
24:15
without even going to France, which causes great outrage.
24:19
And here, again, is this the death total,
24:23
a modest 115,000 compared to the millions totaled in the war.
24:29
But in the United States disease is what is killing people.
24:34
And what is that disease?
24:38
Pneumonia.
24:40
Pneumonia incident to influenza.
24:46
And this is all Ayers--
24:48
Ayers was a statistician at Yale and one of the most preeminent
24:53
statisticians in the country.
24:55
And so all these best people came into the military
24:58
during the war, and he produced this statistical summary
25:01
of what happened in World War I.
25:06
The army lost a staggering 8,743,100 man-days
25:16
to influence among enlisted men.
25:19
They counted this stuff.
25:22
The Navy recorded-- or estimated they had
25:27
a morbidity rate of 40%, 40%.
25:37
So more charts.
25:41
This is what we mean by explosive.
25:44
So this is a chart that shows the deaths in the US army
25:50
do to influenza.
25:54
And when we say explosive, are we being hyperbolic?
25:57
No.
25:58
This is a very traumatic--
26:01
and it's the death rate per soldiers.
26:05
And you see late September, early October.
26:13
So this influenza was unique in its lethality and then
26:17
its explosive nature.
26:20
But it was also unique in another very upsetting way.
26:24
And that was what I call the terrible w--
26:29
I mean, I'm not the only one who calls it that--
26:31
but the terrible w curve of mortality.
26:36
And this curve usually influenza and pneumonia, as you know,
26:42
only kills the very young and the very old
26:46
who have weak immune systems.
26:51
But this influenza, the mortality curve
26:55
specialized in the age divisions of between 20 and 40,
27:04
the age of the army, young adults.
27:09
And so the irony and the horror for many people
27:13
was that you have the best and the healthiest people
27:16
in your society and they're dying in days.
27:25
We have again with this short incubation period,
27:28
we can pinpoint to the day when the flu
27:31
arrived in the United States.
27:33
It arrived according to Surgeon General Braisted
27:36
of the Navy on August 27, 1918.
27:41
And there were three cases of influenza
27:44
that came into the pier in Boston
27:46
off a ship, committed to the sick list.
27:49
The next day, there were eight cases.
27:51
The next day, were there were 58 cases.
27:55
And the next day, three of the medical officers
28:00
who saw these people fell sick and had to be hospitalized.
28:04
And so the next week, influenza had reached Boston and Camp
28:12
Devons, an army camp close by.
28:14
And the camp was soon overwhelmed with thousands
28:18
of hospital admissions.
28:20
It had 40,000 trainees and 10,000 hospital admissions
28:27
within days, overwhelming the community.
28:33
And this is happening to the civilian population as well.
28:40
What are the symptoms?
28:43
Quick onset, high fever of 104, exhaustion, torpor, sinuses.
28:52
People with pneumonia would turn this terrifying blue color
28:57
because they weren't getting oxygen to their blood.
29:00
George Soper explained it this way in Science magazine.
29:04
"The onset is sudden.
29:07
The patient can often tell the exact moment of his attack.
29:12
In the typical case, he is very sick, wholly incapacitated
29:16
for exertion.
29:17
He lies curled up and can hardly be aroused for food."
29:23
How do you fight a war with people curled up
29:29
with influenza?
29:32
Most patients survived.
29:33
Most patients survived.
29:36
But if they developed this deadly pneumonia,
29:38
they could die within a couple of days.
29:44
If you didn't die, you would maybe
29:46
be bedridden for two weeks.
29:51
And it would take you weeks to recover from this disease.
29:56
There, of course, were no vaccines.
29:57
They were developing vaccines.
29:59
They were taking sera out of all kinds of patients.
30:03
They were sacrificing rabbits and hamsters, rats and mice.
30:08
A lot of experimentation went on.
30:10
And there were no vaccines that worked.
30:12
They were spraying all kinds of horrible things
30:14
in people's noses and mouths.
30:16
And they were using masks, really trying hard to--
30:22
So here, this is one thing is you
30:26
put people foot to head, foot to head,
30:28
so they can't infect one another.
30:31
They knew it was airborne disease.
30:35
But this would be terrifying.
30:37
Another thing is to try to put sheeting between the beds.
30:42
The Surgeon General recommended 100 square feet per patient.
30:45
But this is not possible during war
30:48
when you have 10,000 patients in your hospital.
30:54
So without respirators, without anti-virals,
30:58
the only thing you could really do
31:00
is to keep people warm and safe and nourished.
31:05
And that was good nursing care.
31:11
And the good nursing care, as I told the nurses group
31:14
yesterday, good nursing care is what
31:17
made the difference between life and death.
31:19
If you could prevent people from developing pneumonia,
31:23
you saved their lives.
31:24
And the nurses had this-- the irony
31:27
is that where the medical officers are feeling
31:29
like failures because they are letting these 20-year-olds die
31:32
under their care and they're supposed
31:34
to be modern physicians, nurses had a sense of exhilaration
31:39
in a way of getting to serve their country
31:41
and taking care of these young men
31:42
and being appreciated for it.
31:46
So influenza was debilitating to the individual.
31:52
And it was also debilitating to the military
31:59
in consuming resources.
32:04
When I teach World War I, when I taught World War I,
32:07
I would say that it wasn't the American military that
32:12
won the war or changed the balance in World War I,
32:15
it was the American economy and the American's ability
32:19
to provide food and armament to the Allies against the Germans.
32:26
But the real thing that they were able to do
32:28
is provide healthy soldiers who weren't exhausted
32:32
from four years, who were healthy,
32:34
farm boys who were well-fed.
32:37
And they're showing up well-fed, well equipped, naive as can be,
32:43
but willing to fight.
32:45
And this is what is going to demoralize
32:47
and help get to the armistice, discourage Ludendorff.
32:54
But here we have the American men who are falling sick--
33:00
who are arriving, but they're going to soon fall sick.
33:05
One of my problems when I was doing my research in the 1990s
33:10
was that most histories of World War I
33:13
don't talk about the influenza.
33:16
And I used to go and look at the index of books on World War
33:20
I and check the index and see if they had influenza.
33:23
And they wouldn't have anything about influenza.
33:25
But then I would go back to charts
33:26
like this I'd go to the Ayer's statistic
33:29
that showed me 39,000 people dying
33:31
in the United States of flu.
33:34
And then I would go to this statistic.
33:35
This is from a hospital, a camp hospital in France.
33:41
And this is the admission sheet for 163rd Depot,
33:49
one unit, admission sheet.
33:52
They're privates.
33:53
They're all privates.
33:54
They're all young men.
33:55
And this says pneumonia following influenza.
34:00
And these are ditto marks, ditto marks.
34:06
And we are trying to get our troops to the front lines
34:11
to fight the Germans.
34:14
Our army was 4 million by the time the flu hit.
34:21
And 2 million were in France.
34:23
So how many people would be sick at the most conservative
34:27
estimate?
34:27
How many would be sick in France?
34:30
500,000.
34:34
500,000.
34:34
And they weren't just sick.
34:36
It wasn't just they were sick.
34:38
Their people had to take care of them.
34:41
And it took two to four men to carry a stretcher.
34:45
And then they of course are going
34:46
to consume resources, medical resources.
34:52
And so one writer wrote, "Rarely before in the history of war
34:57
has infection exhibited a more explosive character
35:01
or has so large a proportion of troops
35:05
been infected in camps under conditions of abundant shelter
35:09
and food and freedom from the strains
35:12
and anxiety of conflict."
35:14
This is in Science magazine--
35:16
rarely in the history.
35:21
So the challenge for me as historian
35:24
is, OK, so a lot of people got sick.
35:26
So what?
35:28
Who cares?
35:30
How am I going to get this story into the military histories
35:34
of World War I?
35:38
And you can see the challenge.
35:44
On the home front, the Surgeon General of the Army
35:48
is going nuts.
35:49
He is saying you've got to cancel the draft.
35:52
You can't bring new, fresh men into these camps
35:55
that have disease.
35:56
You've got to stop shipping men overseas.
35:59
You can't be cramming them on to ships
36:02
and then sending them to France, because you're just
36:05
fostering disease.
36:07
But what are people saying in the War Department?
36:09
No, we've got to get troops to France.
36:11
The Germans are coming.
36:13
We've got to get troops to France.
36:14
So this was a very contentious issue.
36:18
And it went up to Woodrow Wilson.
36:22
And he decided that troops would continue to go on troop ships,
36:27
but they would reduce the crowding by 15%.
36:31
So that was the public policy that came out.
36:35
They continued to draft until the end of October.
36:38
And then they had to suspend the draft.
36:40
But they continued to do parades.
36:43
And people say, well, why are some cities worse than others?
36:46
One of the things is they still had their liberty bond parades
36:50
where everybody could trade their germs in the streets.
36:53
So that is one kind of technical public policy way
36:57
that the flu interfered.
37:01
And General Pershing knew he didn't need more troops.
37:04
He said send me nurses.
37:06
That's what I need.
37:08
I need nurse.
37:09
I've got telegrams to that effect.
37:13
So if we have 25% morbidity, 500,000, then
37:20
the conduct of the war, the American Battle
37:25
of Meuse-Argonne, the most famous,
37:28
began on September 26, which was at the height of the influenza
37:34
epidemic.
37:35
And it broke down a few days afterwards.
37:40
And there are even reports of Pershing breaking down.
37:44
And what caused it?
37:45
What are the reasons for the breakdown in the Meuse-Argonne?
37:49
Traffic jams.
37:54
And there's reports of traffic on the roads bringing patients
38:00
back from the front and then taking replacements up
38:04
to the front, because the idea was
38:06
you don't want sick people clogging the mobile hospitals
38:12
behind the troops.
38:13
You don't want sick people.
38:14
You want to clear those beds for the really injured.
38:18
But then it turned out if you did that, they
38:20
were going to get pneumonia.
38:21
So you had to keep them in the front.
38:22
And so all of this moving back and forth.
38:26
The Meuse-Argonne Battle was stopped
38:30
also because of this humiliating phenomenon of stragglers.
38:35
And there are estimates of 100,000 American stragglers.
38:40
And a straggler is someone who has
38:43
been detached from his unit.
38:45
He's not with his unit.
38:47
He's not under anybody's control.
38:49
He's virtually AWOL.
38:51
100,000.
38:52
And so historians and military people
38:55
have said, what kind of soldiers are Americans?
38:57
You know, they don't know to do this?
38:59
And I'm saying maybe they had a temperature.
39:03
Maybe they were curled up next to an ambulance.
39:12
This is Red Cross.
39:13
You've got four people carrying a stretcher at the Red Cross.
39:18
So I don't know how you fight a war if 40% of your troops
39:23
have a temperature of 103.
39:27
In '18 October, the Surgeon General of the AEF
39:31
said, "Influenza and pneumonia continue
39:35
to prevail in all parts of the AEF."
39:40
Continue to prevail.
39:42
And in one tally during the war, there
39:45
were 227,000 men hospitalized for battle wounds, 227,000.
39:53
There were 340,000 hospitalized for influenza.
40:00
And this is people that were bad enough to be hospitalized.
40:02
This is not people who just stayed in their tents
40:05
or wandered off and stayed in some peasant's barn
40:08
for a few days and went back.
40:10
And we have all kinds of anecdotal evidence of that.
40:15
And this is a hospital in France.
40:18
Just all these guys are totally out of it.
40:22
And students always want to hear about patients.
40:25
You always want to hear about patients.
40:27
And very few of them wrote.
40:30
But one was a young lawyer, Frank Holden
40:32
with the 82nd division.
40:34
He came back and served in the Georgia state legislature.
40:38
But he tells about when he got the flu.
40:42
And when everybody was going to leave the tent to go fight,
40:47
he couldn't get out of bed.
40:49
He said, "I had such a pain in my head and my chest
40:52
and was suffering so that I was unable to get up.
40:56
My chest felt as though needles were sticking
40:58
in it when I tried to cough."
41:00
Doctor said he had a temperature of 103.
41:05
But Holden begged him not to send
41:07
to the rear, which is to take him off the battlefield.
41:10
He was humiliated, because he said I'm not injured.
41:13
I haven't fought.
41:14
I'm just feeling bad.
41:17
But when he got on the ambulance,
41:19
he wished he had been injured in his hand or something,
41:21
because he said, those guys were joking,
41:23
and he was thinking he was dying.
41:27
He was thinking about his mother.
41:29
And he said, you know, what you think
41:30
about when you think you're dying,
41:32
you think about your mother.
41:35
So it took them two days to get to the base hospital.
41:38
And this is part of the traffic jam.
41:40
This is very hard to be moving people
41:42
around medical transport.
41:44
And this one guy, took him two days.
41:48
And so he wanted to get back for active duty
41:52
after a couple of weeks.
41:53
And he got out of bed and he fell down.
41:57
And so many of the boys when he got back to his old battalion
42:01
told me it looked horrible.
42:03
So that's one guy, consumption of hospital resource,
42:07
consumption of medical transport and regular transport,
42:12
keeping people busy-- this is wearing masks--
42:16
diverting the psychological attention of people, really,
42:21
really difficult.
42:25
Another man that I have testimony from
42:28
is a law student-- these lawyers write.
42:31
So anyway, got to have some.
42:33
So a law student, Harry Presley, he
42:36
was with the military police.
42:37
He did not see combat.
42:39
He was with the military police in Brest.
42:41
And he got sick and was hospitalized for 10 days
42:45
and he tried to get out of bed before he could.
42:49
And he said, "I think I'm feeling better," he wrote home.
42:52
"I got to spitting up blood yesterday.
42:55
And so today called on the doctor,
42:57
and he examined me with a stethoscope.
42:59
And he couldn't find anything wrong."
43:01
I was just spitting up blood.
43:03
So this is kind of a low bar.
43:06
And he said he recovered slowly, but he lost 30 pounds.
43:11
He went from 142 to 110.
43:15
So this is morbidity.
43:17
This is my morbidity argument is that what disease can
43:22
do military efforts.
43:26
So the United States recovered, went on
43:29
to fight the Meuse-Argonne, and take us to the armistice,
43:35
and so all was well.
43:38
But after the war, there was question
43:41
about the American performance.
43:43
And the United States had one of the highest casualty
43:47
rates in armies.
43:49
And some people said that was because they weren't battle
43:52
tested, but it was also because they totally
43:55
overlapped influenza.
43:58
And I think we need to throw that into our analysis.
44:02
So I want to close with two points.
44:06
And one is we're probably going to go to more wars.
44:09
We're at war now.
44:10
And we shouldn't be surprised when there are diseases.
44:15
History doesn't just stop.
44:17
So we should expect diseases.
44:20
And we should remember that it's not just the death toll,
44:24
it's the sickness rate.
44:26
And when I was down at Fort Sam Houston,
44:29
the commanding officer got up after my presentation.
44:34
And he said, you know, people, when we are called upon
44:38
to help our Americans, we go to earthquake, we go to a fire,
44:46
we go to a flood, we go to a hurricane,
44:49
and then we come home and we're safe.
44:52
But when there's a pandemic, we will be sick too.
44:56
And we have to think of how to prepare for that.
45:01
So get your flu shot.
45:06
So thank you.
45:07
[APPLAUSE]
45:12
CAROL BYERLY: And I'm happy to take questions.
45:14
MARCIA DAY CHILDRESS: Yes.
45:15
And so we do have generous amount
45:17
of time for questions and discussion with Carol.
45:21
She's raised a lot of good points.
45:23
She's given us a very good sketch
45:27
of what was going on historically 100 years ago.
45:32
And from that, she's also raised some questions
45:35
about the kinds of things that we should be thinking about.
45:39
Actually some of this is what's being talked about,
45:42
as I mentioned earlier, as part of the public health
45:46
preparedness for the hurricane.
45:50
But some of this is, yes, we are at war now,
45:53
so these are also real conditions.
45:57
We're also hosting this program inside a medical center.
46:02
And I do recall in earlier years some discussions
46:07
about avian influenza possibilities
46:09
and things like this.
46:10
And a lot of the questions came down, again,
46:12
to one of your last points.
46:14
How do you do this when not only is your patient population
46:19
sick, but the people who are taking care of them
46:22
are sick or at risk of becoming sick?
46:25
And how do we make these decisions
46:29
about how we organize our forces,
46:32
how manage our resources, how we organize our society
46:39
at a time like this?
46:41
So when we bring a mic to you, if you
46:43
have a question or comment, please identify yourself.
46:48
And we'll see where the discussion goes.
46:51
Also, UVA bookstore is here with Carol's book
46:55
outside the upstairs door.
46:58
It's a fascinating read.
47:00
And also, again, as you read it, you're
47:03
reminded of correspondences with today.
47:08
And you're also mindful of the fact
47:10
that flu shots will be offered soon.
47:14
Yes.
47:18
CAROL BYERLY: I could probably hear you.
47:20
MARCIA DAY CHILDRESS: Well, we want this for the recording.
47:21
CAROL BYERLY: OK, oh, that's right.
47:23
That's right.
47:23
I forget.
47:24
AUDIENCE: So, hi.
47:24
Thanks a lot.
47:25
This is Carrie Douglass.
47:26
And I'm in anthropology.
47:30
So I have a couple of data issues
47:32
that I wanted you to ferret out for me a little bit.
47:34
So in the United States, you said 600 and some thousand
47:38
died.
47:40
How many of those were military?
47:42
CAROL BYERLY: Statistically, none of them,
47:45
because that's going to be civilian counts
47:47
AUDIENCE: So that was civilian count.
47:49
CAROL BYERLY: Yeah, public health service.
47:52
AUDIENCE: So the whole epidemic that came in,
47:56
and when you were showing the spiking,
47:58
was that for the whole United States,
48:01
or the world, or just the military?
48:04
CAROL BYERLY: The really dramatic spike
48:05
was the death rate in the US military.
48:08
AUDIENCE: OK.
48:09
And at that point in the camps.
48:11
They weren't over in Europe yet, is that right?
48:14
CAROL BYERLY: No, that was in both.
48:16
AUDIENCE: OK, so that was some Americans
48:19
that already got into Europe.
48:21
But not in the continental United States.
48:22
CAROL BYERLY: The whole army.
48:24
AUDIENCE: So is the first appearance-- sorry,
48:27
I have a series of data questions--
48:28
is the first appearance that 27th of July up in Boston
48:34
off the ship, was that for the whole United States or just
48:38
for the military?
48:40
CAROL BYERLY: Well, that was the second appearance.
48:43
And that was 27th of August.
48:46
And that went both to civilian and military populations
48:50
within days.
48:51
OK
48:52
AUDIENCE: , How did it-- so this is my last question.
48:54
So outside of the Army--
48:57
I've always studied and taught that this was particularly bad
49:01
in the army because of the barracks and then the effect
49:03
it had on--
49:04
CAROL BYERLY: But then the colleges,
49:06
I mean, universities were shut down.
49:07
AUDIENCE: So, yeah, how did he get to other places.
49:09
CAROL BYERLY: It was very similar
49:11
in civilian populations.
49:13
And so we have a number of studies
49:16
done in different cities.
49:18
I just reviewed a book that compares
49:21
the influence in four different cities in Pennsylvania.
49:25
And so we have a lot of information on that.
49:29
Colleges were closed for like six weeks, sometimes.
49:33
AUDIENCE: Was that a preventive or was
49:34
that because it exploded within colleges?
49:37
CAROL BYERLY: Both.
49:38
It did explode.
49:39
It was rife within the society.
49:43
And the statistics are amazingly similar.
49:48
In the University of Colorado, there
49:50
was a student training corps of 300 people and 100 got sick,
49:56
which is a 33% morbidity rate.
49:58
AUDIENCE: So there were parallels as far as the--
50:01
that it exploded amongst clusters.
50:03
CAROL BYERLY: It's porous.
50:04
I mean, the civilian and the military populations
50:09
are porous.
50:10
They're interacting.
50:11
But what they aren't porous is the data,
50:14
because I study military medical records.
50:20
And the Army has a 15 volume histories of what went on.
50:27
And they were tracking across the army in France
50:30
and in the United.
50:31
AUDIENCE: So just again, that 650,000 deaths--
50:35
CAROL BYERLY: That's America--
50:36
AUDIENCE: American deaths.
50:37
CAROL BYERLY: Yes.
50:38
AUDIENCE: Again, how many of that--
50:39
that was all military or not?
50:42
That was all Americans.
50:44
CAROL BYERLY: That was civilians.
50:45
AUDIENCE: Civilian--
50:45
CAROL BYERLY: Yes.
50:46
AUDIENCE: And not military.
50:47
The military was a separate.
50:48
CAROL BYERLY: Right.
50:54
AUDIENCE: Hi, Susanna Williams, I'm from the nursing school.
50:58
So I was just wondering, it almost sounds to me,
51:01
you said 86% of the deaths were from pneumonia.
51:04
CAROL BYERLY: Right.
51:05
AUDIENCE: So it almost sounds like that the influenza was
51:07
kind of like the barn doors opening
51:10
and what actually came in as the killer was
51:12
the strain of pneumonia.
51:13
CAROL BYERLY: Right.
51:14
That's the thought.
51:15
AUDIENCE: Yeah.
51:16
So is that like kind of the generic thing of what
51:19
happens with influenza, it's the door opener?
51:22
Or was that just the H2N1?
51:23
CAROL BYERLY: Well, in the first chapter
51:26
of my book, when the training camps first opened in the fall,
51:32
there were epidemics of measles and mumps, which are also
51:37
airborne viral diseases.
51:40
And the complication was pneumonia.
51:42
And that is what killed people.
51:45
And it's different kinds of pneumonia.
51:47
They were able to see different kinds of bacteria.
51:52
People were saying, well, maybe it was viral pneumonia.
51:55
But basically there's a recent study
51:57
that looks at some of this tissue
51:59
and said, no, it was secondary--
52:01
what are they called-- opportunistic infections.
52:05
And now they're trying to look at where
52:07
the virus attacks in the lungs.
52:09
And it's all this stuff that is beyond my ken,
52:12
as far as historian is concerned.
52:14
But trying to understand more about this particular virus
52:18
and why it was so deadly and what was it about.
52:21
AUDIENCE: Right, and so it was primarily the respiratory.
52:24
Thanks.
52:25
CAROL BYERLY: Yes.
52:32
AUDIENCE: Hello, Rebecca [INAUDIBLE],, public health
52:34
and bioethics.
52:35
So do you think the way military tactics have changed
52:39
over the past century will be more
52:43
protective against something like this happening
52:45
in the future with future communicable diseases?
52:49
CAROL BYERLY: I don't know.
52:50
I mean, first of all, we do training differently.
52:53
So we don't put 50 young men together in a room
52:58
and let them share germs.
53:00
And we have a lot of vaccines.
53:03
They're all very intense about vaccines.
53:05
But wars change environments.
53:09
And wars change environments, and we have these new--
53:14
and I look at each war as having its own signature disease.
53:21
And I would say the most recent war,
53:24
the signature disease has been traumatic brain injury.
53:29
And that is an environmental thing.
53:31
But we're surprised.
53:32
We don't know what to do about it.
53:34
And so I would advocate-- and I present this as a cautionary
53:37
tale--
53:38
looking ahead and anticipating these things,
53:41
so that we have capacity, and we have an open mind.
53:45
There were some weird infections from the Iraq
53:48
war because of dust storms and fires around chemical dumps.
53:54
And people were surprised.
53:56
And so I would suggest not being surprised all the time
54:00
and having an open mind and anticipating
54:04
that diseases will exploit--
54:07
malaria just about stopped World War II,
54:11
because the commanders did not want
54:14
to bother with anti-malarial steps in the Pacific theater.
54:19
And so you had 100% morbidity among some units in the Pacific
54:25
theater.
54:26
And so MacArthur, Douglas MacArthur stopped the war
54:30
and said, if you do not take your quinine,
54:33
you will be court martialed.
54:36
And so it became a court martial offense
54:39
to not take your quinine.
54:40
And everybody could tell, because Atabrine--
54:42
they used Atabrine because the Japanese had
54:44
occupied Indonesia, and so it turned your skin yellow.
54:47
So if your skin wasn't yellow, you weren't taking--
54:53
but it took them a year to figure that out.
54:57
And then they started developing malarialists.
55:00
And they would land on an island before the troops
55:05
and make sure that it was free of malarial mosquitoes
55:09
or there was prevention set up.
55:11
And then they could fight the war.
55:15
But having the medical people run after the soldiers
55:20
and to clean up the messes, and this is kind of what we do.
55:23
Another argument, during the Iraq war,
55:27
Walter Reed was overwhelmed with patients.
55:31
And that was a big scandal.
55:32
But why were people surprised?
55:36
Because people don't want to think about it.
55:38
They don't want to think about this aspect of war
55:42
is that it's more about injuries.
55:44
It's about combat.
55:45
It's not about public health.
55:49
And so that's my message is that public health,
55:52
these are big populations.
55:53
We need to keep the healthy.
55:58
MARCIA DAY CHILDRESS: Other questions?
56:01
Comments?
56:04
What has this prompted you to think about here and now?
56:07
Getting flu shots.
56:11
You know in one of your early slides that
56:14
showed outbreaks, sort of intensive centers of flu,
56:19
one of the ones that seemed remote
56:21
from a lot of the military training camps
56:24
and things was a sort of oval that
56:28
seemed to be in sort of central Appalachia.
56:32
What do you know about that?
56:34
And was that mainly civilian?
56:36
CAROL BYERLY: Well, the flu traveled
56:39
with the speed of trains.
56:42
And so it would be, if it were troops-- so there
56:45
could be troops that went home.
56:47
And it would travel.
56:49
And so you could see San Francisco was
56:53
sick before the central areas.
56:56
And so that was just easier.
56:58
It had more commerce and there were trains.
57:00
And there is a book, Mark Humphreys
57:02
has written a book that follows influenza
57:05
across the trains in Canada.
57:09
MARCIA DAY CHILDRESS: Well, certainly the railroads
57:11
went through Appalachia for the coal and other things,
57:16
but established transportation and connection--
57:18
CAROL BYERLY: And there were troops.
57:19
There were camps in Kentucky.
57:21
And there were a number of camps.
57:23
The camps are where the people are.
57:26
But this work has been done--
57:32
troop ships get fueling in Latin America.
57:36
So you I've read some stories about Latin American influenza
57:41
is identified and pegged to the arrival of a troop ship,
57:46
because we're in a world war.
57:49
And now, just recently a flight from Dubai
57:53
was quarantined because of influenza.
57:55
And my sister who is a nurse said,
57:57
that's what's going to happen.
57:58
When it happens, it's going to be on an airplane.
58:02
MARCIA DAY CHILDRESS: Yeah, that coming just a few days
58:05
before this program, I thought, oh, please,
58:07
we don't need that kind of coincidence.
58:11
CAROL BYERLY: But actually my point
58:12
would be it wasn't necessarily the flu itself
58:16
that stopped that plane.
58:18
It was the fear of flu.
58:21
And as I tell my students, I've had one mosquito shut down
58:25
an entire dinner party outside.
58:28
And that is during West Nile fever.
58:31
And somebody saw a mosquito and they said, we're out of here.
58:33
And we all went inside.
58:35
So disease has this power to whip us around.
58:39
If it's real or not, that's the way we understand it.
58:44
MARCIA DAY CHILDRESS: Well, you know also from Carol's talk,
58:48
she alluded to the fact that Jeffrey Taubenberger,
58:52
the virologist, who's now at NIH,
58:54
will be giving the second of our influenza
58:57
related presentations.
58:59
That will happen on October 31, on Halloween.
59:04
And then in mid-November, the 14th of November,
59:08
we're going to be listening to the voices of loss
59:15
from a community in Virginia, perhaps
59:19
in that area of Appalachia, from a small town,
59:24
poems from the poet Ellen Bryant Voigt,
59:28
who is a native of Chatham, Virginia, a community that
59:31
was hard hit by influenza.
59:34
And we're right at 100 years, on sort
59:37
of at the edge of living memory of this sort of event
59:41
and all of its complicated implications.
59:45
And so we hope that you're being here and thinking
59:49
about this helps us to think and look forward
59:53
to how we might be approaching everything
59:56
from the stricken plane and its passengers,
60:03
to how we think about how we wage war,
60:07
and what all of those consequences are for all of us.
60:12
So thank you all for being here.
60:13
Thank you too to Carol Byerly for kicking off our series
60:17
and kicking off our Medical Center Hour season.
60:19
Please join us next week.
60:21
We have family physician Martina Shoultens here
60:25
from the University of British Columbia.
60:28
She spent 10 years working in a clinic for immigrants
60:32
and refugees in Vancouver.
60:37
Her talk is titled, "Your Heart is
60:39
the Size of Your Fist, a Doctor Reflects on 10
60:42
Years in a Refugee Clinic."
60:44
She has a book by the same title.
60:48
I urge all of you to come back.
60:50
We'll be doing this in collaboration
60:53
with the Generalist Scholars Program and Primary Care Week
60:57
here in the medical school.
60:59
So again, thank you all for being here today,
61:01
and we'll see you next week.
61:02
Thank you, Carol.
61:03
[APPLAUSE]

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