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Peter Attia MD#107 – John Barry: 1918 Spanish flu pandemic—historical account, parallels to today, and lessons
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CHAPTERS
- 0:11 – 5:16
Intro and Peter's Connection to John Barry's Work
Peter Attia introduces John Barry and the Spanish flu discussion, then talks about how Barry's earlier book with Steve Rosenberg, The Transformed Cell, shaped his career. Barry credits Rosenberg and describes his work in immunotherapy and gene therapy.
- •Preview of the episode's topics, including the three waves and Barry's changed views on the flu's origin
- •Attia describes The Transformed Cell as hugely influential on his thinking
- •Barry describes Steve Rosenberg's pioneering work at the National Cancer Institute
- •Barry notes Rosenberg and Tony Fauci are close friends
- 5:16 – 10:58
How Barry Came to Write The Great Influenza
Barry explains that he first wanted to write about the World War I home front, but chose the pandemic book because it seemed quicker to write and still pay the bills. It took over seven years instead of two, and he credits Oswald Avery's story with keeping him going.
- •Original plan was a much bigger book on the home front and 1919
- •The pandemic book was meant to take two years but took seven
- •The book got several updated acknowledgments over time
- •Oswald Avery's DNA discovery and struggles motivated him
- •Attia admits giving away his copy to a library
- 10:58 – 17:43
Origins of the 1918 Virus and the Three Waves
Barry gives an overview of the pandemic's scale and waves, and disputes calling it swine flu. He explains why he moved away from his Haskell County, Kansas origin hypothesis toward China as more likely, while noting the true origin may never be known.
- •Estimated 50 to 100 million dead; seven of eight gene segments avian
- •Evidence suggests people gave the virus to swine, not the reverse
- •Haskell County report and Fort Riley link underpinned his original hypothesis
- •China's mild experience suggests prior exposure and a possible origin there
- •Plague of the Middle Ages killed a far higher proportion of the population
- 17:43 – 21:03
Evidence the Spring and Fall Waves Were the Same Virus
Barry lays out why he is convinced the mild spring virus and the deadly fall virus were the same, including the identical age-death pattern, strong immune protection, and a sample from May. He adds that neither earlier wave protected against the third wave in 1919.
- •Same unusual W-shaped mortality curve in spring and fall, with peak death age 28
- •First wave gave 59% to 89% protection against second-wave illness
- •Taubenberger sequenced the virus and found a May sample of the same virus
- •Neither first nor second wave protected against the third wave
- 21:03 – 24:39
How the Pandemic Spread and the Role of the War
Barry and Attia discuss how a pandemic could spread in 1918 without modern transport. Barry says the war accelerated the spread by only a few weeks, and describes the surge in army camp pneumonia from late summer and the explosion at Camp Devens.
- •Pandemics do not need steam power; influenza crossed the Atlantic in the 1600s
- •Virus likely seeded itself globally before erupting
- •Army data showed rising pneumonia from late July and August
- •War sped up spread but did not cause it, given a reproductive number near two
- 24:39 – 29:25
Wartime Censorship, Propaganda, and Loss of Public Trust
Barry describes how wartime laws and the propaganda apparatus pushed officials and the press to minimize the pandemic. He argues that telling the public it was ordinary influenza while people died quickly eroded trust and frayed society.
- •Law punished disloyal or scurrilous speech about the government with up to 20 years in jail
- •Committee for Public Information aimed to keep morale up
- •Officials called it ordinary influenza and the press was complicit
- •Loss of trust led to people starving because no one would bring them food
- 29:25 – 35:59
Clinical Course, Pathology, and Immune Overreaction
Attia asks about the typical course of the disease. Barry describes how the virus could bind deep in the lung, attack many organs, and cause dramatic symptoms, and compares the immune-driven lung damage in young adults to what is seen with coronavirus today.
- •Western case mortality about 2%, far worse in immunologically naive populations
- •Virus bound to both upper airway and deep lung cells, causing viral pneumonia
- •Symptoms included cyanosis, nosebleeds, and bleeding from mucosal membranes
- •Strong immune responses and cytokines damaged the lungs, as in ARDS today
- •Barry guesses a third to 40% of deaths were directly viral; bacterial pneumonia mortality was 35% then versus 8% now
- 35:59 – 44:47
Philadelphia's Parade and the Case for Telling the Truth
Barry recounts the September 1918 Liberty Loan parade in Philadelphia despite medical warnings, and the deaths that followed. He argues that honesty is essential because imagination is scarier than facts and credibility cannot be regained once lost, citing pandemic planning groups.
- •Parade went ahead as doctors urged cancellation and editors killed stories
- •Influenza exploded within 48 to 72 hours; about 14,500 died in Philadelphia
- •Press even said closures were not a public health measure
- •Barry says step one in non-pharmaceutical planning is to tell the truth
- •Saying we don't know is fine if you say when you will know
- 44:47 – 52:09
St. Louis, New York, and San Francisco: Social Distancing and Community Trust
Barry contrasts cities' responses: St. Louis acted early on distancing, while New York did little but likely benefited from its spring wave. San Francisco was honest with a 'wear a mask' campaign, and although masks probably did little, community trust held and people volunteered.
- •Early distancing before wide spread can be effective; late measures much less so
- •New York and Chicago did little but had benign experiences, likely from spring exposure
- •San Francisco leaders issued a joint 'wear a mask and save your life' message
- •Despite high mortality, San Francisco functioned cohesively
- •Barry sees honesty as promoting cooperation and cites neighbors helping in New Orleans today
- 52:09 – 59:26
Third Wave, India, and Global Death Toll
Barry says the third wave resulted from viral drift rather than seasonality, and discusses the huge death tolls in India and other immunologically naive populations. He gives figures on deaths among young adults and specific worker groups.
- •Third wave attributed to antigen drift, not seasonality
- •Early estimate of 21.7 million deaths was extrapolated from Western case mortality
- •Western Samoa lost 22% of its population
- •Indian troops had over 20% case mortality versus 9% for British troops in the same camp
- •Two-thirds of the dead were aged 18 to 45; some worker groups lost 3% to 6%
- 59:26 – 1:04:32
Economic and Cultural Aftermath, and the 2009 H1N1 Pandemic
Barry explains the brief postwar recession and speculates on the pandemic's cultural impact in the 1920s. The conversation then turns to the 2009 H1N1 pandemic, which Barry describes as two diseases: mild for most but 1918-like for the seriously ill.
- •Short, deep recession followed the war as soldiers returned to the workforce
- •Pandemic may have contributed to ennui in the 1920s, though little was written about it
- •2009 virus could bind deep in the lung
- •Deaths in 2009 skewed young, like 1918, though most had comorbidities
- 1:04:32 – 1:16:13
Coronavirus Compared to 1918, and Assessing the Current Response
Barry compares coronavirus to 1918, noting both bind deep in the lung but coronavirus has a much longer incubation period that complicates management. He criticizes the federal response and testing failures, praises states and countries that acted well, and discusses Sweden and the difference between infection and case fatality rates.
- •Incubation of two to 14 days versus about two days for influenza lengthens the outbreak
- •Barry criticizes federal leadership, the testing debacle, and the lack of contact-tracing infrastructure
- •Germany and several Asian countries handled it better
- •Case fatality and infection fatality rates are not interchangeable; serologic IFRs are needed to compare
- •Barry says Fauci should be the spokesperson and expectations should be controlled
- 1:16:13 – 1:22:02
Looking Ahead: Preparedness and Closing
Asked if he is optimistic, Barry says people now remember 2020 and expects significant investment in monitoring emerging diseases. He notes past underfunding of influenza research and the benefit of knowledge from SARS and MERS, then the conversation wraps up with thanks and Attia's membership outro.
- •West Nile got more research money than influenza despite lower threat
- •H5N1 prompted a $7 billion US preparedness bill
- •A universal flu vaccine might exist with sustained investment
- •Future threats most likely viruses as development encroaches on the wild
