Author John M. Barry, who wrote a best-selling history of the 1918 influenza, painted a grim picture of a pandemic-stricken nation in this week’s UCSF Medical Grand Rounds.

“It is only a matter of a few hours then until death comes. It is horrible. One can stand it to see one, two or 20 men die, but to see these poor devils dropping like flies. We’ve been averaging about 100 hundred deaths per day,” Barry read from his book The Great Influenza: The Story of the Deadliest Pandemic in History. Currently the number one nonfiction paperback on the New York Times bestseller list, his book tells the haunting story of the 1918 influenza pandemic that killed between 50 and 100 million people in some estimates, and simultaneously explores how U.S. medical education evolved in the decades surrounding the pandemic. 

Barry joined UCSF’s Dr. Bob Wachter this week in a one-on-one interview, a first for Grand Rounds during this pandemic. 

Ordinary influenza by another name?

Barry kicked off the interview by situating listeners in 1918: a world in which the United States and most of Europe were at war while a highly deadly pandemic roared across the globe. Information about the pandemic was largely censored by governments intent on keeping morale high. The name “Spanish flu” evolved not because the disease originated there, but because Spain was one of the only countries openly reporting on the flu — because it was not involved in World War I. 

“There was no Tony Fauci in 1918. That was consistent with the [U.S. President Woodrow] Wilson administration’s effort to focus on the war. They were concerned that any negative news about anything would detract from the war effort,” Barry said. “But it was immediately apparent to people that this was not ordinary influenza by another name.”

With reports of sick individuals bleeding from the nose, eyes, ears and mouth citizens were alarmed. These horrifying symptoms, alongside the fact that people between the ages of 18 and 45 comprised almost two-thirds of deaths, instilled the public with skepticism towards public health departments and newspapers that insisted this was just the normal flu. 

“People realized they couldn’t believe anything they were being told,” Barry said. “And this only created more fear and, in some cases, panic.” Of course, 1918 was not the only time when individuals were suspicious of their governments during a pandemic. 

Masks and non-pharmaceutical interventions: 1918 and now

One of the biggest rifts in combating COVID-19 today is between those who believe in the necessity of wearing masks and those who flaunt guidelines on political principle or lack of trust in agencies like the Centers for Disease Control and Prevention. It turns out, the mask debate isn’t new. What is new, however, is how it has been politicized.

There was, Barry said, “very widespread usage” of masks during the 1918 pandemic, alongside many other now-familiar non-pharmaceutical interventions such as hand-washing, staying away from crowds and temporarily closing businesses.

“The first time around, people accepted it, obviously they could see how lethal the disease was. There was no partisanship,” Barry said. 

Resistance became a factor when cities that had previously closed and reopened were asked to close once more because the influenza wave had returned. This resistance often came from the business community, which was able to exert pressure on corruption-ridden local governments to change policies. 

Barry did highlight one city whose government strongly encouraged mask use and was able to maintain public trust throughout the pandemic: San Francisco. 

The San Francisco exception

In his book, Barry writes that “San Francisco was a rare exception; its leaders told the truth, and the city responded heroically.” He told Wachter how the mayor, business community, labor leaders and medical leaders all signed a joint statement that ran in huge type in the newspaper: “Wear a mask and save your life.” 

Though Barry believes masks weren’t effective in stopping the influenza pandemic that tore through San Francisco, this messaging didn’t pretend that there was no public health threat. “Trust in San Francisco did not disintegrate in the community function,” Barry said. When volunteers were needed, teachers in closed schools heeded the call to action and became ambulance drivers, telephone operators and more. “The difference was that it met the challenge as a community trying to come together,” Barry concluded. 

So what was the biggest lesson of 1918? “To tell the truth,” Barry said, noting that state and federal pandemic preparedness plans in recent years have incorporated the idea of transparency. “The problem is, you have to have someone who will execute the plan. And this time around, unfortunately, we did not have anyone who would execute the plan.”

Wachter asked: Are some of the problems of the COVID-19 pandemic (debates about masks, a desire to protect people from the ugly truth) specific to this presidency, or part of a general truth about the way people in power handle these types of situations? Earlier in the interview, he pointed out that Wilson uttered alternative facts about the pandemic during his presidency too, and Ronald Reagan failed to mention AIDS publicly until several years — and tens of thousands of lost lives — into the epidemic. 

“I tend to quote Hegel,” Barry said, referencing German philosopher Georg Wilhelm Friedrich Hegel. “What we learn from history is that we learned nothing from history.”

There will not be a Department of Medicine Grand Rounds next week, July 2. Grand rounds will resume on Thursday, July 9.