Tweet
John Barry - US Senate Testimony on Pandemic Influenza and 1918
Here's the transcript of John Barry to our dear government leaders. At least he didn't pull too many punches.
John M. Barry
Distinguished Visiting Scholar
The Center for Bioenvironmental Research at Tulane and Xavier Universities
Contact info:
yen.cheong@uspenguingroup.com
212-366-2275
I thank you for the opportunity to testify, and to provide you with some background on a disease that, according to the Center for Disease Control and Prevention, kills 36,000 Americans in a normal year. By definition, an influenza pandemic would not be a normal year and kill far more Americans than that. And although I will tell you about what happened during the pandemic of 1918 and 1919, which killed more people than any other disease outbreak in history, a worst case scenario is not necessary to justify far more expenditures on influenza. The best case scenario is bad enough to get the attention of any American.
Another pandemic is virtually inevitable because of the nature of the influenza virus. It is one of a group of viruses that mutate so rapidly that virologists refer to them as "mutant swarms" or "quasi-species." All influenza viruses originate as bird viruses, but their mutation rate allows them to jump species, from birds to humans. It can jump directly, as happened in 1918, by mutation. It can also jump indirectly when an avian influenza virus infects the same cell as an influenza virus that earlier adapted to humans; the two viruses can swap genes and create a new hybrid virus capable of infecting people. This gene-swapping can occur not only in humans, but in other mammals.
Whenever a new avian influenza virus does transform itself into one that can pass easily from one person to another, human immune systems will not recognize it. This allows it to spread explosively through the world causing a worldwide epidemic-- a pandemic.
We have no idea when the next pandemic will occur. It may have started two weeks ago and we just don't know it yet, or it may not come for twenty years. But for at least the last five hundred years, pandemics have occurred three to five times a century, with the greatest duration between pandemics of 42 years. We are now at 37 years and counting.
Pandemics do not need air travel to spread. In the 1690s, when it took six to eight weeks to cross the Atlantic, influenza crossed from England to the colonies. In Virginia one report said "the people dyed... as in a plague." In Massachusetts Cotton Mather wrote, "All conditions of persons were attacked... The sickness extended to allmost all families. Few or none escaped, and many dyed especially in Boston, and some dyed in a strange or unusual manner, in some families all weer sick together, in some towns allmost all weer sick so that it was a time of disease."
We have substantial information only about the last four pandemics, which occurred in 1889, 1918, 1957, and 1968. Of these, by far the most lethal was the one in 1918, but there are some indications that similarly lethal influenza outbreaks occurred in the past as well. In 1580, according to one account, some Spanish cities reportedly were "nearly entirely depopulated by the disease."
No one knows with certainty how many people died in the 1918 pandemic, but according to Nobel laureate Frank MacFarlane Burnett, that pandemic killed at least 50 million people, and possibly 100 million. It did this in a world whose population was only 28% as large as today's. That is the equivalent of 175 to 350 million today. Yet even without adjusting for population and using Burnet's lower estimate, the 1918 influenza pandemic killed more people in 24 weeks than AIDS has killed in the 24 years that disease has been known. Well over half the deaths occurred in an incredibly short span of about 10 weeks, between late September and early December, 1918.
In the developed world, the overwhelming majority of victims suffered what we would today regard as a typical attack of the disease. For example, the case mortality rate in the U.S. was no more than 2%. But influenza attacks so many people that the U.S. death toll was an estimated 675,000, the equivalent of about 1.8 million today.
We were of course at war when the pandemic erupted, and some people have theorized that the war contributed to the lethality of the disease. This reminds me of what Thomas Huxley called the great tragedy of science, when a beautiful theory is slain by an ugly fact. This theory is entirely inconsistent with the actual course of the disease.
There are several other points worth making about 1918. Influenza normally behaves like a bully, killing people with the weakest immune systems, particularly the elderly and the very young. This is true not only with the endemic disease that occurs every year, but in the 1889, 1957, and 1968 pandemics.
This was not true in 1918. The people most likely to die in 1918 were healthy young adults, aged 20 to 35, people with the strongest immune systems.
Symptoms could be horrific. People turned so dark blue from lack of oxygen a physician reported he had difficulty distinguishing between black and white patients. Victims could bleed from their mouth, nose, ears, and eyes.
The impact on society was immense. Part of the problem came from false reassurances from all levels of government. The Surgeon General said, "There is no cause for alarm."
There was cause for alarm. Every city, town, and village an out of coffins. People could die less than 24 hours after their first symptoms. This enormous disconnect between what people saw for themselves and what they were being told destroyed all trust in authority. People became alienated. In city and country victims starved to death "not from lack of food but because the well are afraid to help the sick." Streets emptied. In Philadelphia in a city of almost two million people, one medical student who was in charge of an emergency hospital saw so few cars on his way home every night over a drive of 12 miles that he started counting them; one night he saw not a single other car on the road, and wrote, "The life of the city has almost stopped." Doctors and nurses were kidnapped. A confidential Red Cross report noted "a fear and panic akin to the terror of the Middle Ages of the plague." One sober scientist, not given to overstatement, wrote that if the epidemic had continued "for a few more weeks, civilization could disappear from the face of the earth."
But as I said before, a 1918-like scenario is not needed to justify the full attention of the government to influenza. A best case scenario serves well enough.
This is because in recent years, despite antibiotics would cut deaths from complicating secondary bacterial infections, we have become more vulnerable to influenza, not less vulnerable, both in its economic impact and in the death toll.
Ironically, medical science has increased our vulnerability by its enormous advances that have increased the number of people living with impaired immune systems. These include not only many more elderly, but cancer survivors who have undergone chemotherapy or radiation therapy-- which weakens the immune system-- transplant recipients, people infected with HIV, and others.
As a result, a mild virus would kill more Americans than in the past, not less. The 1968 influenza pandemic was the mildest that we know of, with approximately 34,000 deaths in the U.S., equivalent to about 55,000 in today's population. By comparison, the CDC projects that a pandemic caused by even such a mild virus would today most likely kill between 89,000 and 207,000 in the United States alone.
Deaths are, however, only one measure of the impact of a pandemic. A pandemic will also cause massive economic losses and social disruption. Increased efficiencies and just-in-time inventory management in business and health care have both cut into the surge capacity to make needed goods and exposed much of the economy to supply disruptions.
There is however one bright spot. Although in past decades, the nation has paid too little attention to influenza, and therefore we have made little progress on improving our ability to make vaccines, or in finding real solutions that can only come from basic research, such as developing a vaccine that works against conserved portions of the virus, or in finding effective anti-viral drugs. But if we pay attention to influenza now, even in the relatively short term of the next few years, it may be possible to improve our vaccine production capacity enough to make a real difference.
Influenza pandemics seem to come in waves. Certainly that was the case in 1889, 1918, 1957, and 1968. The first wave, which in 1918 probably lasted six to eight months, was mild. In 1957 the first isolate was identified in February, and the pandemic did not really erupt until September. In 1968 there seems to have been a year between identification of the first isolate as a new virus and serious pandemic disease. And in the 1889-1890 pandemic, the third wave was the most deadly.
So a window of opportunity does exist. If surveillance and vaccine production capacity improve enough, we do have a chance to intervene successfully and cut the death toll significantly.
How much our ability to fight this disease improves is largely up to the appropriations committee.
Thank you.
John M. Barry
Distinguished Visiting Scholar
The Center for Bioenvironmental Research at Tulane and Xavier Universities
Contact info:
yen.cheong@uspenguingroup.com
212-366-2275
I thank you for the opportunity to testify, and to provide you with some background on a disease that, according to the Center for Disease Control and Prevention, kills 36,000 Americans in a normal year. By definition, an influenza pandemic would not be a normal year and kill far more Americans than that. And although I will tell you about what happened during the pandemic of 1918 and 1919, which killed more people than any other disease outbreak in history, a worst case scenario is not necessary to justify far more expenditures on influenza. The best case scenario is bad enough to get the attention of any American.
Another pandemic is virtually inevitable because of the nature of the influenza virus. It is one of a group of viruses that mutate so rapidly that virologists refer to them as "mutant swarms" or "quasi-species." All influenza viruses originate as bird viruses, but their mutation rate allows them to jump species, from birds to humans. It can jump directly, as happened in 1918, by mutation. It can also jump indirectly when an avian influenza virus infects the same cell as an influenza virus that earlier adapted to humans; the two viruses can swap genes and create a new hybrid virus capable of infecting people. This gene-swapping can occur not only in humans, but in other mammals.
Whenever a new avian influenza virus does transform itself into one that can pass easily from one person to another, human immune systems will not recognize it. This allows it to spread explosively through the world causing a worldwide epidemic-- a pandemic.
We have no idea when the next pandemic will occur. It may have started two weeks ago and we just don't know it yet, or it may not come for twenty years. But for at least the last five hundred years, pandemics have occurred three to five times a century, with the greatest duration between pandemics of 42 years. We are now at 37 years and counting.
Pandemics do not need air travel to spread. In the 1690s, when it took six to eight weeks to cross the Atlantic, influenza crossed from England to the colonies. In Virginia one report said "the people dyed... as in a plague." In Massachusetts Cotton Mather wrote, "All conditions of persons were attacked... The sickness extended to allmost all families. Few or none escaped, and many dyed especially in Boston, and some dyed in a strange or unusual manner, in some families all weer sick together, in some towns allmost all weer sick so that it was a time of disease."
We have substantial information only about the last four pandemics, which occurred in 1889, 1918, 1957, and 1968. Of these, by far the most lethal was the one in 1918, but there are some indications that similarly lethal influenza outbreaks occurred in the past as well. In 1580, according to one account, some Spanish cities reportedly were "nearly entirely depopulated by the disease."
No one knows with certainty how many people died in the 1918 pandemic, but according to Nobel laureate Frank MacFarlane Burnett, that pandemic killed at least 50 million people, and possibly 100 million. It did this in a world whose population was only 28% as large as today's. That is the equivalent of 175 to 350 million today. Yet even without adjusting for population and using Burnet's lower estimate, the 1918 influenza pandemic killed more people in 24 weeks than AIDS has killed in the 24 years that disease has been known. Well over half the deaths occurred in an incredibly short span of about 10 weeks, between late September and early December, 1918.
In the developed world, the overwhelming majority of victims suffered what we would today regard as a typical attack of the disease. For example, the case mortality rate in the U.S. was no more than 2%. But influenza attacks so many people that the U.S. death toll was an estimated 675,000, the equivalent of about 1.8 million today.
We were of course at war when the pandemic erupted, and some people have theorized that the war contributed to the lethality of the disease. This reminds me of what Thomas Huxley called the great tragedy of science, when a beautiful theory is slain by an ugly fact. This theory is entirely inconsistent with the actual course of the disease.
There are several other points worth making about 1918. Influenza normally behaves like a bully, killing people with the weakest immune systems, particularly the elderly and the very young. This is true not only with the endemic disease that occurs every year, but in the 1889, 1957, and 1968 pandemics.
This was not true in 1918. The people most likely to die in 1918 were healthy young adults, aged 20 to 35, people with the strongest immune systems.
Symptoms could be horrific. People turned so dark blue from lack of oxygen a physician reported he had difficulty distinguishing between black and white patients. Victims could bleed from their mouth, nose, ears, and eyes.
The impact on society was immense. Part of the problem came from false reassurances from all levels of government. The Surgeon General said, "There is no cause for alarm."
There was cause for alarm. Every city, town, and village an out of coffins. People could die less than 24 hours after their first symptoms. This enormous disconnect between what people saw for themselves and what they were being told destroyed all trust in authority. People became alienated. In city and country victims starved to death "not from lack of food but because the well are afraid to help the sick." Streets emptied. In Philadelphia in a city of almost two million people, one medical student who was in charge of an emergency hospital saw so few cars on his way home every night over a drive of 12 miles that he started counting them; one night he saw not a single other car on the road, and wrote, "The life of the city has almost stopped." Doctors and nurses were kidnapped. A confidential Red Cross report noted "a fear and panic akin to the terror of the Middle Ages of the plague." One sober scientist, not given to overstatement, wrote that if the epidemic had continued "for a few more weeks, civilization could disappear from the face of the earth."
But as I said before, a 1918-like scenario is not needed to justify the full attention of the government to influenza. A best case scenario serves well enough.
This is because in recent years, despite antibiotics would cut deaths from complicating secondary bacterial infections, we have become more vulnerable to influenza, not less vulnerable, both in its economic impact and in the death toll.
Ironically, medical science has increased our vulnerability by its enormous advances that have increased the number of people living with impaired immune systems. These include not only many more elderly, but cancer survivors who have undergone chemotherapy or radiation therapy-- which weakens the immune system-- transplant recipients, people infected with HIV, and others.
As a result, a mild virus would kill more Americans than in the past, not less. The 1968 influenza pandemic was the mildest that we know of, with approximately 34,000 deaths in the U.S., equivalent to about 55,000 in today's population. By comparison, the CDC projects that a pandemic caused by even such a mild virus would today most likely kill between 89,000 and 207,000 in the United States alone.
Deaths are, however, only one measure of the impact of a pandemic. A pandemic will also cause massive economic losses and social disruption. Increased efficiencies and just-in-time inventory management in business and health care have both cut into the surge capacity to make needed goods and exposed much of the economy to supply disruptions.
There is however one bright spot. Although in past decades, the nation has paid too little attention to influenza, and therefore we have made little progress on improving our ability to make vaccines, or in finding real solutions that can only come from basic research, such as developing a vaccine that works against conserved portions of the virus, or in finding effective anti-viral drugs. But if we pay attention to influenza now, even in the relatively short term of the next few years, it may be possible to improve our vaccine production capacity enough to make a real difference.
Influenza pandemics seem to come in waves. Certainly that was the case in 1889, 1918, 1957, and 1968. The first wave, which in 1918 probably lasted six to eight months, was mild. In 1957 the first isolate was identified in February, and the pandemic did not really erupt until September. In 1968 there seems to have been a year between identification of the first isolate as a new virus and serious pandemic disease. And in the 1889-1890 pandemic, the third wave was the most deadly.
So a window of opportunity does exist. If surveillance and vaccine production capacity improve enough, we do have a chance to intervene successfully and cut the death toll significantly.
How much our ability to fight this disease improves is largely up to the appropriations committee.
Thank you.
