Carol R. Byerly. Fever of War: The Influenza Epidemic in the U.S. Army during World War I. New York: New York University Press, 2005. xv + 251 pp. $21.00 (paper), ISBN 978-0-8147-9924-6; $65.00 (cloth), ISBN 978-0-8147-9923-9.
Reviewed by Sanders Marble (Office of Medical History, U.S. Army)
Published on H-War (October, 2005)
The History of an Aberration
This revision of Carol Byerly's dissertation examines the impact of the 1918-1919 influenza epidemic on the U.S. Army, particularly looking at how army doctors and other government officials responded. (Byerly does not look at the epidemic outside the U.S. Army.) In only 190 pages of main text, Byerly sets out to cover four themes: the impact of the disease on U.S. conduct of the war; the nature of military medicine; governmental responsibility for the health and welfare of its soldiers; and how cultural values and politics shaped medical policy and the historical memory of the epidemic.
Chapter 1 gives a good background on Army doctors, their prestige and mindset. In the late nineteenth and early twentieth centuries, doctors had made great headway against endemic and epidemic diseases through public health measures such as improved sanitation and pasteurization. The Army's Medical Corps benefited from the public esteem of doctors in general, and had its own triumphs against malaria and yellow fever. However, the Army's doctors were as much a part of their times as anyone; for example, they were opposed to blacks or women joining their ranks, and many also believed in eugenics. Byerly is certainly accurate pointing to these biases, but it is not clear how admitting more black or female doctors would have made any difference to the Army's handling of the flu epidemic.
Chapter 2 is a well-nuanced record of relations between the Army Medical Department and the Army hierarchy, specifically the General Staff and the Secretary of War. The doctors asked for more living space for trainees and soldiers, quarantine facilities, and gradual integration of draftees, all steps intended to reduce epidemics among new soldiers. The General Staff, focused on organizing an army as quickly as possible in order to end the war sooner, disallowed most medical requests. Doctors resented being subordinate to their educational (and perceived social) inferiors, and also felt great responsibility for soldiers as individuals. Doctors, who took the blame for small disease outbreaks, leaked reports to show that the line officers had denied medical requests. Byerly quietly takes the side of doctors who wanted authority to issue orders on medical grounds that would have had substantial policy implications. For instance, a slower mobilization and training program would have delayed the deployment of American forces to Europe.
Chapters 3 and 4 are the story of the flu epidemic, first in training camps in the United States and then in France. It is a fluid and vivid description, citing personnel high and low. Byerly contends that the war fostered the flu by creating conditions in trenches that allowed viral mutations (pp. 72, 93). However, the initial outbreak was in the American Midwest, nowhere near the trenches, and crowded city slums probably offered as good a mutating ground. Additionally, the flu caused tens of thousands of civilian deaths among people who were not crowded into tents or trenches. The tight focus on the Army does not allow much consideration of outside factors. Byerly forcefully makes the point that sick rates (not just death rates) can have a strong impact in an attritional war. 50 percent more AEF soldiers were hospitalized for flu than for war wounds (including gas casualties), creating a large need for replacements and a heavy burden on the hospital system. Flu in the AEF was also probably underreported, because only hospitalized cases were counted. Moreover, many of the "stragglers" that bedeviled the AEF operationally, probably had the flu. The large numbers of flu patients could swamp the medical system, affecting the ability to care for battle casualties.
Chapter 5 is a social history of how deaths from disease fit into the public's ideal of a heroic war. Byerly spends some time showing that combat service was considered more valorous and worthy than non-combatant service, and that the same held true for deaths; disease deaths were less dramatic and less valuable than combat deaths. Further, while the public was concerned about its citizen soldiers (especially whether the government was taking adequate care of "our boys"), the end of the war largely ended public and Congressional interest. Doctors showed a similar interest pattern, writing many articles in 1919-20, with interest fading rapidly thereafter.
Chapter 6 looks deeper into the historiography of the flu, almost entirely through the Army's own history, The Medical Department of the U.S. Army in the World War (Washington, DC: Government Printing Office, 15 Vol., 1921-1929). Byerly shows that the Army did a fairly poor job of analyzing several factors, for instance age, race, and length of service. She contends Army doctors framed the epidemic as an aberration, outside the modern medical experience, and points out that that presentation allowed both doctors and the public to retain faith in scientific medicine.
Byerly concludes that doctors (both inside and outside the Army) largely ignored the flu epidemic in their histories, statistically setting the epidemic to one side. Once that was done, the Army data showed improved mortality rates and medical progress. She hints that massaging the data had implications for later public policy, but does not particularly develop what those consequences were (p. 185). Her example of the U.S. Army's WWII problems with malaria blurs the line between an infectious disease (influenza) and a communicable one (malaria) with very different control measures.
Overall, Byerly does a good job of describing the position of doctors in the Army, a relationship with professional tensions on both sides laid atop bureaucratic or organizational tensions. Her description of the flu epidemic is clear and thoughtful, with insights on how it affected the military in particular. She leans towards sympathy for doctors and individual patients, and impatience with the Army as a war-fighting organization. The Army command accepted the risk (and then the certainty) of higher sick rates (and higher death rates) by continuing to crowd men into training camps and troopships. Doing so certainly caused more disease deaths, but it may have saved even more lives by readying and deploying a large AEF in 1918 instead of 1919, and thus defeating Germany sooner. Writing from a medical history perspective, Byerly spends little time discussing this. She also makes a great deal of the postwar data interpretation that set the flu aside as an aberration. Yet the flu was an aberration; there has not been a pandemic since 1919. Taking the statistical spike as a possibility (which it is), Byerly says it would be good public policy to provide for a worst-case scenario, and have spare medical personnel and facilities waiting for the next pandemic. However, given the costs of having a second medical system waiting, essentially as an insurance policy, it might not be a good public policy option.
This is a well-written, well-researched book that generally stays tightly on topic. It is a good history of the flu epidemic in the Army, although some of the recommendations made are questionable.
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Sanders Marble. Review of Byerly, Carol R., Fever of War: The Influenza Epidemic in the U.S. Army during World War I.
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