Fever of War Byerly, Carolyn. Fever of War. New York University Press, 2005. A book review by LTC Stephen Ford February 2006

The influenza pandemic of 1918 – 1919 killed 20 to 40 million people and raged as the American Expeditionary Force (AEF) mobilized to fight alongside its allies in World War I. The “Spanish Flu” (as it was later misnamed) killed more people in one year than the Great War claimed in the previous four. In Fever of War, Carolyn Byerly provides a well-researched historical account and analysis of the Army Medical Department’s own experience in war, not only in support of the AEF against Germany and the Austro-Hungarian Empire, but its more formidable enemy: influenza.

            Unfortunately, while this book delivers on its historical account, it generally fails in its analysis. Dr. Byerly’s thesis is that “the pandemic was caused by the Great War which exploited conditions by producing an ecologic environment in the trenches in which the virus could thrive and mutate to unprecedented virulence.” 

In actuality, the pandemic virus probably had its origins in Kansas, nowhere near the trenches of the Western Front. Science would suggest the pandemic virus probably originated in waterfowl and infected humans, but did not initially cause serious disease.  Over time, and as a result of selective host immune pressure, the virus dramatically changed (known as antigenic shift) and developed the ability to not only cause severe illness but spread from person-to-person as well. These changes (or mutations) resulted in a new virus for which there was no pre-existing immunity, leaving all people vulnerable--Soldier and civilian alike. Available Census Bureau statistics would indicate people living in crowded urban slums had disease and death rates equal to or exceeding those of Soldiers on the Western Front.

            A second contention made by Dr. Byerly is that senior medical officer hubris and overconfidence in fighting infectious disease contributed to an explosion of influenza in military training camps, aboard troop transports, and in the trenches. While it is true that medical officers rightly took great pride in their success in controlling yellow fever and malaria in Cuba , both were vector-borne diseases with an identifiable source: the mosquito. The implementation of sanitation measures and control of mosquito populations greatly reduced illness and deaths and remains a heralded medical discovery even today.  The influenza virus, on the other hand, was not identified as a cause of disease until 1933; does not involve an insect vector; and continues to kill 36,000 people in the U.S. each year, despite an effective vaccine, antiviral medications, and antibiotics to treat secondary bacterial pneumonias. In addition, these influenza deaths occur in a primed population, which means people have some pre-existing immunity to the circulating influenza virus.

So would these modern deaths then be the result of arrogance and overconfidence on the part of modern-day physicians? Interestingly enough, recommended initial interventions during a present-day pandemic include the same social-distancing measures recommended by medical officers during World War I for barracks and berthing spaces.

Lastly, Dr. Byerly contends that medical officers compiling and writing The Medical Department of the United States Army in the World War paid little attention to the impact of disease “to hide their inability to slow or stop disease spread and its resultant sick rates and mortality.”  To the contrary, this historical record devotes an entire volume to Communicable and other Diseases which includes a chapter entitled “Inflammatory Diseases of the Respiratory Tract (Bronchitis, Influenza, Bronchopneumonia, Lobar Pneumonia).”  This chapter details at length the impact of influenza and pneumonia on Soldiers both in the U.S. and Europe. It is actually quite remarkable that the Army Medical Department was able to compile this data and recognize that pneumonia (probably primary influenza pneumonias) and rapid progression to organ failure caused most deaths in a previously young and healthy population.  The Medical Department in the World War  is comprehensive; evaluated available science and hospitalization records; and represents the only thorough epidemiologic record of its kind from this era. To apply a current standard of epidemiologic investigation and analysis to historical efforts diminishes the great leap forward this document represents.

My suggestion, read Fever of War for its well-researched medical history, then read The Medical Department of the United States Army in the World War, and do your own analysis.

Reviewed by LTC Stephen Ford, Deputy Director, MILVAX Agency, February 2006