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John M. Barry, author of the 2004 book The Great Influenza, an account of the 1918 pandemic, said the first phase of that pandemic, in early 1918, was mild. The disease didn't strike with full ferocity until the second wave about 6 months later, in September and October.

"The first wave was so mild that you could read in a scientific journal article that this disease looked like influenza and acted like influenza but it can't be influenza because it was, so far, absent the usual complications of influenza," Barry, told a luncheon audience on the first day of the "Business Planning for Pandemic Influenza" meeting at the Minneapolis Convention Center.

"At first it wasn't great at infecting people in large numbers," he said. "Over a period of about 6 months, it was becoming more and more and more efficient, and then suddenly seemed to erupt simultaneously all over the world on three continents."

On the basis of pandemic planning meetings he has attended, Barry said planners don't seem to be figuring on "the wave phenomenon." "I think it's important to take that into consideration, because you may well have 6 to 8 months after the first identified human [case], before the worst phase hits," he said. "There may be an opportunity there."

The 1918 pandemic had three waves, as Barry recounts in his book. The last wave, in the winter of 1918-19, was milder than the second, though still much worse than the first.

Barry said that in the pandemic of 1889, which also was severe, the third wave was the most lethal. If that happened in the next pandemic, "it would be good news for us, because by that time we would be fully protected by vaccine," he said. Once a pandemic flu virus emerges, it is expected to take at least 6 months to develop and begin producing a vaccine precisely matched to the virus.

US Army data make clear how fast the 1918 virus evolved in the course of the pandemic, according to Barry. At the first five major army camps affected, 20% of the troops who caught the flu suffered pneumonia, and 37% of the pneumonia patients died. At the last five camps hit by the virus, an average of just 3 weeks after the first five, only 7% of flu patients had pneumonia, and 17% of them died.

"You have to understand that this is going to be a constantly changing enemy," Barry said.

If Barry sounded faintly reassuring on the subject of pandemic phases, he was the opposite on other points.

He cited the prediction of other experts at the 2-day meeting that even if the next pandemic is severe, about 98% of people will survive. Though he didn't take issue with that overall, he said the toll could be much worse in certain places or among certain groups. In 1918, about a third of the populations of Alaska and Labrador perished, and in Western Samoa the toll was 22%. In Fiji, 16% of the people died in just 2 weeks. And among young adults in general—the hardest hit group—an estimated 4% to 8% succumbed.

In addition, today's population is "clinically more vulnerable" to flu than the population in 1918, Barry said. The reason is the many people with weakened immune systems, including the elderly, HIV/AIDS patients, and cancer patients.

To drive home the importance of preparedness, Barry talked about the widespread failure of public officials in 1918 to level with the public about the influenza threat. In an atmosphere of rigid wartime censorship, enforced by laws that "make the Patriot Act look like a resolution of the ACLU," any utterance that could have been construed as harmful to public morale was punishable, he explained.

Hence, public officials mostly downplayed or lied about the pandemic, saying things like, "This is ordinary influenza by another name," Barry said. Rather than allaying fear and panic, this approach increased them.

But there were a few places "that sort of did prepare and did tell the truth from the beginning," he said. "In San Francisco, the city from day 1 told the truth about the disease." As a result, "you didn't get the panic and social breakdown that you got elsewhere."
The lesson is that when people are told the truth about a danger, they can prepare and deal with it, he said. "So preparation does make a difference."
Barry, of Washington, DC, is a distinguished visiting scholar at Tulane University in New Orleans.