At the domestic level, influenza had a sclerotic effect on governance within severely affected countries, overwhelming the capacity of the state (and often the society) to deal with the debilitation and mortality generated by the contagion. Crosby estimates that the influenza pandemic of 1918-19 generated at least 550,000 excess deaths in the United States (i.e., over and above those deaths that would typically result on an annual basis).75 As one would expect, one of the first sectors of US society to be overcome was the health sector. Hospitals did not possess the requisite surge capacity to deal with such a huge influx of ill patients. Specifically, hospitals did not possess the necessary beds and supplies, nor did they have adequate reserves of medical personnel (nurses and doctors) on hand to deal with the surge in infected civilians. Moreover, lacking adequate protection, many health providers themselves succumbed to the illness, and thereby became an additional burden on those who remained healthy. The contagion also undercut the timely and effective delivery of other public goods by the state to the people, including essential services such as communications. Crosby notes that "eight hundred and fifty employees of Bell Telephone Company of Pennsylvania stayed home from work on October 7, 1918" and that "on the next day Doctor Krusen of the Department of Health and Charities authorized the company to deny services to any persons making unessential calls, and it presently did so in a thousand cases."76 This sclerotic effect of the contagion also impacted the police and family services. The pandemic resulted in rampant absenteeism among police officers, firemen, garbage collectors, and social workers to care for children who had lost their parents.77 Further complicating the situation was the inability to bury the dead promptly and effectively:

The essential service which came closest to collapse in Philadelphia was (morticians). Unless morticians are able to fulfill their duty, two things happen. One, bodies accumulate, creating the possibility of secondary epidemics caused by the various organisms that batten on dead flesh. Two, and more immediately significant, the accumulation of corpses will, more than anything else, sap and even break the morale of a population. When that happens, superstitious horror thrusts common decency aside, all public services collapse, friends and even family members turn away from one another, and the death rate bounds upward.78

The discord associated with the pandemic was certainly not relegated to the environs of Philadelphia, but distributed throughout the United States. In the city of San Francisco there were acute shortages of medical personnel, police, communications personnel, educators, and even garbage collectors. "The Sanitary reduction works shut down when only 11 of its normal staff of 56 showed up for work."79

While the state's ability to respond was significantly curtailed by the contagion, successful adaptive response came in the form of the mobilization of civil society. It was this galvanic response of non-state organizations, religious, social, economic, and political, that enabled American society to overcome the ravages of the pandemic.80 Regarding this response by society, it seems reasonable to argue that the civil cohesion generated through the prolonged war effort (notably the Civil Defense Associations) empowered civil society to the extent that it was capable of dealing with the widespread death and disruption generated by the pathogen. It should be noted that different communities responded with varying degrees of effectiveness. San Francisco, for example, was plagued by particularly inept responses, by both civil society and the state. "Despite preliminary planning, organization never caught up with the flu until it had passed its peak. No local Council of National Defense arose to coordinate anti-pandemic forces; no central clearing house to process all calls for assistance . . . was ever created, and San Franciscans ran their doctors ragged checking on cases that needed no professional attention."81

The pandemic serves as a prime example of emergent properties, and the Oxford hypothesis supports this line of reasoning. The lethal pandemic influenza of 1918 likely derived its intensity from a combination of the conflict's constituent attributes (and their side effects). Such pernicious factors included the dense troop populations that moved rapidly and continuously around the world (functioning as highly efficient vectors of transmission), coupled with poor nutrition that undermined immune systems, the highly unsanitary conditions of the trenches and military camps, and a novel zoonosis (H1N1 avian influenza). Those permissive conditions, which resulted in rapid viral transmission from host to host, facilitated the evolution of traits of lethality in the virus, resulting in a highly contagious and lethal influenza pandemic. Individually, each one of these constitutive variables may have not generated any significant effect, but when combined in this fashion, led to one of the greatest global public health disasters in recorded history.

Ultimately, the balance of evidence from Germany, Austria, and the United States suggests that the 1918 influenza had various effects on state capacity in affected polities. One obvious effect was that the morbidity and mortality generated by the influenza pandemic generated profound institutional sclerosis. The strongest evidence for this emanates from the extensive problems that became manifest in both the Allied and German military forces during 1918. Other bureaucracies exhibited sclerosis in the United States, particularly those that provided public services such as health care, communication, law enforcement, sanitation, and so forth. Although the preliminary evidence presented here suggests that pandemic influenza did significantly impede the optimal function of state institutions in 1918, further cross-national historical research is required to validate this hypothesis.

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