COVID-19, like previous outbreaks of infectious disease at the turn of the twenty-first century, has reawakened interest in the 1918–1919 Spanish influenza pandemic. As we wrestle with the unknowns and strive to contain the spread of the coronavirus that causes COVID-19, the 1918–1919 influenza pandemic operates as a poignant benchmark; how do morbidity, mortality, and case fatality rates of COVID-19 and Spanish flu compare? What can the public health response to the flu—or lack thereof—teach us about social distancing measures in the present? Does the Spanish flu’s seasonal waves foretell similar, cyclical resurgences of COVID-19? When will it be safe to lift social distancing measures without seeing a resurgence like that observed in flu cases in 1918–1919?

With pandemic, past and present, on everyone’s minds, it seems Elizabeth Outka’s Viral Modernism: The Influenza Pandemic and Interwar Literature, published by Columbia University Press earlier this year, couldn’t have been released at a more morbidly opportune moment. Irrespective of its timeliness, however, Viral Modernism offers significant contributions to the literary-historical study of the 1918–1919 influenza pandemic, as well as to the study of transatlantic modernist literature. Original readings of canonical modernist texts, including Virginia Woolf’s To the Lighthouse and Mrs. Dalloway and Katherine Anne Porter’s oft-cited Pale Horse, Pale Rider—essentially the urtext of 1918–1919 influenza pandemic—excavate the lasting aesthetic impacts of the Spanish flu, which left at least fifty million dead worldwide and proved unprecedentedly lethal for otherwise healthy young adults (Tautenberger and Morens 2006).

Since Alfred W. Crosby republished the second edition of his 1976 monograph Epidemic and Peace as America’s Forgotten Pandemic in 1989, scholars have pondered Spanish flu’s marked absence in early twentieth-century literature, even—especially—in the oeuvres of authors who had intimate, first-hand experience of the pandemic, such as Gertrude Stein, Ernest Hemingway, William Faulkner, D. H. Lawrence, T. S. Eliot, and William Butler Yeats, among others. As scholarly interest in the representation of contagion in literature and culture burgeoned in the wake of SARS (2002), H5N1 (avian influenza, 2007), and H1N1 (swine flu, 2009) outbreaks and amid heightened fears of infectious disease, a cluster of articles published in the early 2000s explore this absence. Their analyses frequently turn to Porter’s Pale Horse, Pale Rider as one of the few twentieth-century novels to directly thematize the 1918–1919 pandemic—indeed, because Porter’s short novel remembers what the literary and historical record had (he asserts) otherwise forgotten, Crosby dedicated America’s Forgotten Pandemic to her—seeking in her fictionalized, though semi-autobiographical, account of the flu an explanation for its widespread absence in cultural memory. Catherine Belling (2009) pairs Pale Horse, Pale Rider with historical fiction to plumb the limits of language and narrative, and David A. Davis employs trauma theory to explore Porter’s novel “as a crucial work of memory that bridges the personal and the collective” (2011, 59). Laurel Bollinger challenges earlier critics’ focus on Pale Horse, Pale Rider’s autobiographical dimensions, noting that “Porter was notoriously unreliable in narrating her life,” and encourages close attention to the eschatological allusions through which “Porter creates a particularly modernist response to trauma” (2013, 366). Similarly, Jewel Spears Brooker (whom Bollinger cites) dissects Porter’s use of myth, apocalyptic imagery, and experimental narrative techniques in order to elevate the text as “one of the triumphs of literary modernism” (2009, 232). While Caroline Hovanec likewise argues that the flu serves as a particularly apt “trope for the dehumanizing, denaturalizing, and disjunctive forces of modernity,” she curates a wider corpus of pandemic literature; placing Pale Horse, Pale Rider into conversation with two contemporaneous texts, William Maxwell’s They Came Like Swallows and John O’Hara’s “The Doctor’s Son,” she illustrates the flu virus’s effects on the individual body (via Pale Horse, Pale Rider), the family (via They Came Like Swallows), and the community (via “The Doctor’s Son”) (2011, 178). Among them, Joshua Doležal (2009) is unique in eschewing reference to Pale Horse, Pale Rider all together, grounding his analysis of modernism and pandemic flu in Willa Cather’s One of Ours. Nevertheless, he, too, takes the conspicuous absence of influenza in modernist literature as his provocation.

Outka first publishes on influenza and modernism amid this pandemic turn in literary studies. Viral Modernism extends the argumentative thread that she introduces in “‘Wood for the Coffins Ran Out’: Modernism and the Shadowed Afterlife of the Influenza Pandemic,” an article appearing in Modernism/Modernity in 2014, at the tail end of the early-2000s flu boom. Like earlier analyses of the pandemic’s place in—or rather, absence from—early twentieth-century literature, “Wood for the Coffins Ran Out” interrogates how and why the 1918–1919 influenza pandemic is missing from modernist texts, specifically. In it, Outka asks:

Why did the flu, which produced so much death and suffering, largely disappear from American and British history and much of its literature? And given its historic position in 1918–1919, why is it not investigated as a central trauma within modernist studies? (2014, 943)

This “modernist mystery” likewise motivates Viral Modernism, and the article serves as a blueprint or overture of the later monograph (2020, 1). Both works open with a brief history of the flu pandemic and a visceral accounting of its ravages, detailing the death toll and symptomology in visceral, grisly detail. Outka describes this as “a sensory and affective history of the pandemic” in Viral Modernism, asserting that these details—the unsettling blueish traces of cyanosis and sudden, profuse bleeding from facial orifices observed in flu patients, the distinctly foul odor of sickness and antiseptic, the sight of corpses stacked like firewood, the sound of church bells tolling ceaselessly for the dead—illuminate “the pandemic’s fragmented traces in the literature and the larger culture” (7). In both her article and subsequent monograph, Outka first identifies these “fragmented traces” of the pandemic in texts that directly thematize the flu (Porter’s Pale Horse, Pale Rider, for example), then unearths them in quintessential modernist texts that do not (like Woolf’s Mrs. Dalloway).

Maintaining this same basic structure in Viral Modernism is crucial to the text’s critical intervention. Indeed, while some variation on the question of influenza’s absence motivates the majority of literary-historical studies of the influenza pandemic in early twentieth-century literature, Outka’s work posits an original answer to this query: the pandemic is not truly absent from anglophone interwar literature at all. On the contrary, she insists that the pandemic is an absent presence that irrevocably shapes a modernist literary aesthetic. Once attuned to reading for the traces of pandemic influenza in modernist literature, Outka contends, we come to recognize how profoundly this spectral, second trauma shaped the culture of the interwar era, as well as the plots, tropes, and conventions of literary modernism.

Literary modernism is often characterized by fragmentation and experimentation: disconcerting, stream-of-consciousness narratives imbued with myth and mourning and cynicism. It is typically understood as a response to the untold violence of World War I and rapid technological advances at the turn of the century—innovations which, in turn, enabled a ruthlessly efficient model of industrial and scientific warfare. In short, WWI is conventionally understood as the central trauma of the modernist era. But the tremendous loss of life and lingering aftereffects of the pandemic must have been formatively traumatic for the “Lost Generation” of artists and authors, as well, Outka insists. This is a deceptively simple assertion because, as Viral Modernism demonstrates, WWI is all-encompassing. Locating the flu in modernism requires more than merely adjusting our focus or switching our lens—it requires a new microscope.

In Viral Modernism, Outka “flip[s] the era’s central metaphor, as it were, and read[s] the pandemic and illness as providing an enabling vehicle through which the war may be compared and in which the war imagery resides,” and the result is captivatingly original readings of familiar texts (245). The coda, for example, rereads the “Time Passes” section of Woolf’s To the Lighthouse for the spectral, miasmic traces of the influenza pandemic, noting how the text’s “indifferent yet relentless” threats are “structured like a pathogenic threat” (246). The air, wind, water, and darkness that wreak havoc on the Ramsay’s home mimic viral contagion by “evok[ing] the chaos and amorality of an intangible, nonhuman destruction” (249). Reading “Time Passes” for traces of pandemic attends to domestic disruption and the death of women, specifically, in ways that the focus on war cannot. More fully registering “the unexpectedness and horror with which death so often strikes” in the aftermath of war and flu, attending to evidence of the pandemic in Woolf’s novel in this way thereby prompts a deeper appreciation for “the gendered way war registers as a recognized tragedy while illness becomes swallowed within the larger atmosphere of loss” (249, 205). Moreover, reading for the pandemic illustrates “the ways literature may register a vast hidden trauma like the influenza pandemic” by “mak[ing] linguistically tangible the ineffable quality of a viral threat, shaping it into darkness, air, wind, mist, and water” (253). This reading demonstrates the promise of Outka’s project and the potential for future work—what insights will we gain by reading other early twentieth-century texts for pandemic? How might our perception of interwar grief and mourning shift when we acknowledge the flu dead alongside the war dead?

To find the flu in modernist literature, as Outka does in “Time Passes,” we must first understand how and why the pandemic has been silenced, she argues. Although the war and the flu coexisted temporally and spatially, as crowded army camps, troop ships, and trenches provided ideal conditions for the disease to spread, Outka contends that WWI has obscured the influenza pandemic in cultural memory, modernist literature, and literary criticism in three ways: by blocking, overshadowing, and incorporating it. War overshadowed flu for a number of reasons, Outka, contends, including its relatively short timeline compared to the four long years of WWI and commonly held convictions that to focus on the flu rather than the war was unpatriotic. As the name “Spanish flu” itself demonstrates—because neutral Spain was not prohibited from reporting on the pandemic by wartime censorship, early reports of the outbreak came out of Spain—the war quite literally blocked official recognition of the flu; even what little (and late) coverage of the pandemic had been published at the time was frequently drowned out by war reports, she explains. Moreover, because the two tragedies were so deeply entangled, and because infectious disease has always been a leading cause of death among armed forces, the war and pandemic collapsed into a single tragedy; the flu dead were counted among the war dead, the shock and grief occasioned by the pandemic incorporated into post-war mourning.

In part one of Viral Modernism, “Pandemic Realism,” Outka traces how the pandemic has been incorporated, overshadowed, and blocked by the war, as well as the challenges to narrating illness, whether on an individual or global scale. Illness is characterless and plotless, Outka asserts. It defies clear, causal narratives and is both “difficult to describe and difficult to turn into tangible characters,” and it is for these reasons, as well, that the influenza pandemic appears to be absent from interwar literature (26). Outka grounds this section of Viral Modernism in close readings of four American novels: Porter’s Pale Horse, Pale Rider, Cather’s One of Ours, Maxwell’s They Came Like Swallows, and Thomas Wolfe’s Look Homeward, Angel. These texts are unique, Outka notes, for narrating the flu directly, and she posits that they can do so because they are both geographically (written by Americans and set in the United States) and temporally (these novels are the latest to be written and published among the corpus Outka analyzes) from the front lines of WWI. In the process of disentangling war and flu in these texts, she assembles an almanac of flu themes: the plots, metaphors, and narrative conventions that shape how these stories of sickness and death are recounted. Flu appears in these novels in references to viral resurrection, survivor’s guilt, and the ominous, miasmic threat of contagion as Cather, Porter, Maxwell, and Wolfe confront the representational challenges posed by pandemic. These beautifully crafted chapters both expand our repertoire of flu literature by bringing little studied texts into a conversation that has largely focused on Porter’s Pale Horse, Pale Rider and provide an essential framework for unearthing miasmic traces of the pandemic lurking in early twentieth-century anglophone literature.

Outka turns to three iconic modernist texts in part two of Viral Modernism, titled “Pandemic Modernism,” uncovering evidence of the flu in Woolf’s Mrs. Dalloway, T. S. Eliot’s “The Waste Land,” and W. B. Yeats’ “The Second Coming” by identifying in these texts the “pandemic literary paradigm” developed in part one (99). Reading these texts for the flu reveals the pandemic’s presence in interwar literature, once we know how to locate it, but also the ways in which “modernist literary techniques emerge as aesthetic tools suited both to representing a hard-to-depict viral threat and to obscuring it” (100). That is, literary modernism contributes to the flu’s erasure at the same time that the pandemic is central to modernist style, Outka concludes. These chapters offer fresh takes on familiar texts, as well as a stunning account of the pandemic’s scale and legacy. Biographical details—Yeats’ pregnant wife nearly died from the flu just weeks before he wrote “The Second Coming,” for example—newly contextualize the canonical works Outka approaches in part two of Viral Modernism, and her reading of the gendered dynamics of war and pandemic in Mrs. Dalloway in the chapter “On Seeing Illness” is especially enlightening.

The third and final part of the manuscript, a section titled “Pandemic Cultures,” is comprised of one final chapter (“Spiritualism, Zombies, and the Return of the Dead”) and a brief coda. While the genealogy of the zombie Outka traces here is interesting, I found the chapter less compelling than those included in parts one and two of Viral Modernism. And where these first two sections of the monograph are argumentatively cohesive, I find that “Spiritualism, Zombies, and the Return of the Dead” feels somewhat out of place. This is an intriguing piece of scholarship nonetheless, and of particular interest to scholars of zombie and/or horror film.

By way of conclusion, I find it illuminating to reproduce the monograph’s hauntingly prescient final paragraph in its entirety:

As scientists and researchers continually remind us, we are not ready for the next severe global pandemic, which—as they also remind us—is most assuredly coming. On the one hand, the last one hundred years have seen dramatic advances in disease treatments, and efforts are made every day to monitor and prevent outbreaks and to develop new vaccines. On the other hand, as I write this coda, dramatic cuts are proposed in the United States to some of the very programs that might prevent or respond to future global pandemics. Public support for such programs tends to peak during outbreaks, like the swine flu in 2009 and Ebola in 2014, but then wanes in their aftermath. And in the United States, as budgets for health care programs are reduced, funds for military spending has increased. The willingness to tolerate this discrepancy echoes the difference I have traced throughout this study between the attention the war received and the attention the pandemic received. For all the reasons I have analyzed, military threats, political conflict, and human-based violence are typically treated, represented, and seen far more clearly than threats posed by disease; the pandemic killed more people, but it’s the war we remember. It would be more than possible to build and augment effective global response systems that would greatly reduce the impact of a deadly pandemic—but first far more people have to see the threat and be willing to act. The works I investigate remind us that even a modern catastrophic pandemic that has already happened can be hidden, unless we learn to read for its presence. (254; emphasis in original)

As I drafted this review of Viral Modernism, I watched the death toll from COVID-19 steadily rise, surpassing 100,000 in the U.S. on May 27, 2020 (Welna). We are witnessing in real time the dire consequences of cuts to pandemic preparedness programs. How will we hold this loss in our cultural memory? What traces of it will be found in our literary record ten or even one hundred years from now? What can we, as medical humanists, do to honor the dead and to prevent this pandemic from being forgotten? Viral Modernism illustrates the lasting trauma of pandemic influenza as evinced in modernist literary aesthetics: the cynicism and grief and disillusionment. And yet the casualties of COVID-19 deserve more than an indirect memorial, more than fragmented traces long overshadowed by war or politics.

Remembering—and learning to read for—the 1918–1919 influenza pandemic is one way to start. In this regard, Viral Modernism is indispensable. It offers to medical humanists—to scholars of contagion as a cultural phenomenon and the sociopolitical dimensions of infectious disease, practitioners of narrative medicine, historians of medicine and public health—an expanded understanding of the pandemic’s literary legacy. To those who study transatlantic modernist literature, it presents new insight on canonical texts especially relevant in the current moment. And to anyone who teaches courses in literature and medicine or early twentieth century literature and culture, it provides a meaningful template for thinking through the stakes of pandemics past, present, and future.