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FIRST RESPONDERS: The novel coronavirus moves more slowly than the virus behind the 1918 influenza pandemic, which spread quickly and lethally, says author John Barry ’69 (MA). Members of the St. Louis Red Cross Motor Corps (above) were at the ready to help. (Photograph: Alamy)

When the novel coronavirus went from epidemic to pandemic early this year, John Barry ’69 (MA) found himself in rather familiar territory. Barry is the author of The Great Influenza: The Epic Story of the Deadliest Plague in History (Viking). When the book was first published in 2004, the National Academy of Sciences named it the outstanding book of the year on science and medicine. In 2020, Barry’s book has returned to bestseller status.

In The Great Influenza, he considers what became known as the Spanish flu—so called because Spain, which stayed neutral in World War I, had not clamped down on press coverage of the virus in the name of morale—from a broad range of angles: scientists’ quest to understand a new pathogen, officials’ efforts or lack thereof to contain the spread of infection, communities’ and families’ horrifying experiences of a disease so contagious and lethal that it infected about a quarter of the US population and killed between 50 and 100 million people around the world, the equivalent of 220 to 440 million today.

Anchoring The Great Influenza is Barry’s consideration of leadership, science, and society. Trust, he argues, is crucial, because without trust in information people have no reliable knowledge of what is happening. In 1918, when leaders gave war-time morale priority over public health communication, terror overran society, so much so that some flu victims starved to death because others were too frightened to bring them food.

The fundamental lesson of the 1918 pandemic, Barry writes, is this: “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.”

Barry’s expertise drew him into public policy efforts. In the year The Great Influenza was published, he began to collaborate with federal government entities and the National Academies on influenza preparedness and response, and he was part of the original group that developed plans for public health measures in a pandemic before a vaccine is developed. He contributed to pandemic preparedness and response efforts during the administrations of Presidents George W. Bush and Barack Obama.

(This conversation has been edited and condensed.)

What are some of the important similarities between the 1918 flu virus and COVID-19?

They’re both animal viruses that jumped to humans. So, they’re novel for the given population. The mode of transmission is identical: primarily droplets, some airborne, maybe some fomite [transmission from contact with objects]—nobody knows how much.

Number three, they’re both primarily respiratory viruses. Number four is less well known, and that is that the 1918 virus infected practically every organ, much like COVID-19. There were notable neurological impacts and cardiovascular events—they were very common. It’s been noted that even the testes can be affected. That was true in 1918 as well.

That’s very unusual and certainly not the case for other influenza viruses.

What are the differences?

I guess the most important one is a different target demographic. In 1918, 95 percent, roughly, of the excess mortality was people younger than 65. Of course, that’s the opposite with COVID.

And number two is duration. This virus moves much more slowly than influenza, whether it’s the incubation period, how long you shed virus, how long you’re sick.

It has put vastly more stress on the economy because of the duration. We tried to interrupt transmission and save people’s lives, which was the right thing to do. But it certainly caused an increase in economic stress.

The most obvious difference is virulence—the rapidity of the virus’s spread and its severity. In 1918, it was many times more virulent.

You conclude the book, written in 2004, with the warning that in future pandemics, authorities must maintain the public’s trust. What do you think when you look at what’s happened in 2020?

A lot of countries did the right thing. They were extremely transparent. In those early meetings about nonpharmaceutical interventions [in the advisory groups that Barry joined in 2004], my message was to always tell the truth.

And I didn’t get a lot of pushback. Every now and then somebody would say, “Well, we don’t really want to scare people.” Yeah, you do, actually. You don’t want to use fear as a tool, but you want them to be able to judge the risk themselves, truthfully. And to understand the risk.

And be honest. And a lot of countries have done that because it’s pretty clearly the best thing to do. And as you know, the US is pretty close to dead last in the developed world in containing the virus. Unfortunately in Europe, which did have the virus pretty much contained—less than 200 cases a day in all of Italy, for example—they relaxed. The virus is teaching them they only won the battle, not the war.

What worries you most as you look ahead?

In April, I said I didn’t expect summer to provide relief. I said I expected something akin to ocean swells rather than waves, depending on how we came out of various lockdown phases. I also said that there is a danger of a storm surge. It’s relatively easy at this point to predict the behavior of the virus, but you cannot predict human behavior. The key is really behavior.

And what worried me most was the real possibility of that storm surge. Clearly that’s what we got. Now I’m worried that transmission will become so widespread as to be uncontrollable without massive interventions, which might not work anyway because there will be so much resistance. The frustrating thing is that it doesn’t have to be this way. Tens of thousands if not several hundred thousand people who will die could survive.

And there’s still so much we don’t know about the virus, such as its long-term impact. We know a significant percentage of those who get sick show some kind of heart damage. Is that permanent? Does it heal? Even people who have no symptoms whatsoever on X-ray show what’s referred to as “ground glass opacity” in the lungs. What is that damage? What does that mean long term?

The virus certainly affects blood vessels. What does that mean in terms of stroke and other cardiovascular problems years from now? In 1918, there were complications that didn’t surface at all until the 1920s. So, we just don’t know.