There is nothing new under the sun

OPINION

BY ALEX RODRIGUEZ

Viewing the 2020 COVID-19 Pandemic through the lens of “American Pandemic, The Lost Worlds of the 1918 Influenza Epidemic,” by Nancy K. Bristow

“What has been will be again, what has been done will be done again” – Ecclesiastes 1:9

American Pandemic is a history of the people that both lived through and died in the 1918 Influenza Pandemic. It is has a heavy focus on the rise of a formal public health establishment.  

While there are differences between the two pandemics, there are a striking number of similarities in regard to public health policy, with political and health offices attempting to mandate mitigation efforts using familiar tools such as masks, school closures, and the closing of public spaces and businesses. With fewer tools available to public health officials, implementation of the mandates was much less successful and widespread than today’s efforts.  

We start with the major differences between the 1918 Influenza Pandemic and the 2020 COVID-19 Pandemic.  

Three Striking Differences

Striking Difference 1 – Overall Fatalities

1918 [1]

  • 675,000 U.S. fatalities in 103 million population [2]
  • 6,553 deaths per million
  • 2.5% infection fatality rate (IFR) 

2020 – 

  • 201,000 U.S. fatalities [3] in 331 million population [4]
  • 619 deaths per million
  • IFR still to be determined – Range of 0.13% [5] – 0.37% [6] – to 0.65% [7]

The 1918 “Spanish Flu” Pandemic is currently 10.58 times more deadly than the 2020 COVID-19 Pandemic, when comparing deaths per million. 

Striking Difference 2 – Fatality Age Stratification

1918 

From the National Institutes of Health: “Overall, nearly half of the influenza-related deaths in the 1918 pandemic were in young adults 20–40 years of age, a phenomenon unique to that pandemic year. The 1918 pandemic is also unique among influenza pandemics in that absolute risk of influenza death was higher in those <65 years of age than in those >65; persons <65 years of age accounted for >99% of all excess influenza-related deaths in 1918–1919.” [8]

2020

By comparison, in 2020, 79% of all COVID-19 fatalities are >65 years of age. [9]

Excerpts from “American Pandemic”

The book is filled with accounts of school children and young adults passing away.  

From Camp Dodge in Iowa: “In the wards were more relatives beside the cots of a dead or dying boy, still and stunned by the suddenness of it, or grief stricken and inconsolable. In one ward I saw a mother on her knees beside her boy, holding his hands while he passed away. Another with her arms across her boy’s dead body, her head bowed upon his cot. Fathers would stand with bowed heads waiting for the end. Mothers fainted or became hysterical.” [10]

“Sick soldiers described similarly grim circumstances in their camps.  Gardner Jackson, though not sick with influenza, found himself in a combined flu and scarlet fever ward at Camp Hancock. (Camp Hancock, outside Augusta, Georgia, where 500 soldiers died during the Pandemic [11]).  I’ll never forget that first night there, with guys dying,” he recalled over forty years later. His experience there was “a rough one,” he explained, “because the morgue of the camp was right outside of the particular ward where we were, not more than twenty-five yards away.  The guys were dying of flu at such a terrific clip that they just couldn’t handle all the corpses.” [12]

Striking Difference 3 – Everything is Local in 1918

One of the most striking things I found in “American Pandemic” was that I do not recall seeing President Woodrow Wilson’s name or the name of any state governor mentioned throughout the entire book.  

(I could be wrong, I’d have to re-read the entire book to be 100% sure, but I was looking for this. Maybe I skimmed a page or two and the president’s name was mentioned). But I can confidently say there is virtually zero mention of Wilson or any governor, and there was certainly no any blame assigned to these leaders. The president appears to have delegated the national pandemic response to the Surgeon General.

The mitigation efforts described in this book were all local, and each community did the best they could. Virtually every story, if not all, described the disparate efforts in various communities across the U.S.

Excerpts from “American Pandemic”

“As with patients, there was no single public health experience of the pandemic, and each community suffered and survived in its own way.” [13]

There was some support in the form of medical personnel at the national level, through the U.S. Public Health Service. Meanwhile the Red Cross shouldered supplying nurses, field hospitals, supplies, and aid.  

“…the USPHS shouldered responsibility for organizing medical and nursing personnel for the country as a whole during the pandemic. As influenza erupted in the Boston area, the Surgeon General recognized that the need for health care professionals would far exceed those immediately available, particularly given the depletion of their ranks due to the war. While the USPHS quickly deployed both its regular officers and additional nurses to communities hit by the epidemic, it also asked for aid from the American Medical Association, the Volunteer Medical Service Corps, and the Red Cross…

“Though additional physicians were soon employed by the USPHS, the problem of the nursing shortage struck the agency as a more difficult one.  The Red Cross would lead the efforts to mitigate this crisis, while also playing several other important roles. Over the course of the epidemic, the Red Cross organized nursing resources and supplied nurses to those communities in the greatest need of emergency assistance. They also took on responsibility for establishing and supplying emergency hospitals and kitchens; providing transportation for patients, medical professionals, and supplies; offering aid to families stricken by the scourge; and participating in the broad-based educational efforts necessary to mobilize the public.  To help coordinate the local work, a Red Cross representative was appointed for each state.  

“Even as the Red Cross played a leadership role, the USPHS retained substantial control over its work.  The Health Service appointed a field director for every state, often the state’s health officer.”  [14]

There is Nothing New Under the Sun – Public Health Policy

There is Nothing New Under the Sun – Progressivism and public health mitigation efforts

** 1918 – Progressive public health authorities attempt to coerce the public into various mitigation efforts. Those efforts are met with early public cooperation but ever-increasing resistance as the pandemic wore on.  

** 2020 – For millions, the COVID-19 pandemic will be a story of ever-increasing scope and coercion by many of our state and public health officials. A simple goal of “Two weeks to stop the spread” morphed into the impossible goal of eliminating all traces of COVID-19 in just a few short months. This same effort occurred in the 1918 Pandemic on a smaller scale by progressive public health authorities who had fewer tools at their disposal to modify behavior.  

Excerpts from “American Pandemic”

“…local health officials initially found the public supportive. From providing emergency budgets to organizing their communities, Americans cooperated with many of their requests, looking to experts to guide them through the epidemic and working together to help their communities. And yet this early cooperation was not always enough to halt the epidemic, which too often returned to communities in a renewed wave. As the crisis persisted, the public sometimes became restive. Resisting the continued impositions in their lives, individuals began to defy the authorities… As public health authorities attempted to shape American behaviors, they adopted the strategies of Progressivism, seeking to use government power to control the epidemic while educating and mobilizing the public to support these actions. Similarly, citizens’ reactions–their initial support for and eventual weariness with the actions of officials–reflected the broader ascendance and collapse of Progressivism. In this sense the epidemic ended just in time, preventing what might have been a much broader rebellion against the authority of the state in the realm of public health.” [15]

As large numbers of the populace began to disregard emergency measures altogether, this “posed a dilemma for public health officials–how to preserve the public’s health (My note: As if these government officials are humanly capable of “preserving the public health”) even as the public grew tired of restrictions and more suspicious of health officials’ authority and power.”  [16]

Public health officials “… did not anticipate the resistance that emerged late in the epidemic. Implicit in the public health plan for the epidemic was a willingness to coerce the public in ways necessary to ensure behavior that comported with the vision of public health authorities. Progressivism always held the potential to employ coercive measures to accomplish its goals… Public health authorities assumed that their authority should include the power to control Americans’ behaviors, both public and private, when such behaviors threatened the “welfare of the community”… even when that authority included repressive measures. During the epidemic and in its most immediate aftermath, some argued that this was precisely what was occurring. Yet the reality of the public resistance, particularly as the epidemic wore on, suggests that the relationship was not so simple.  While early in the epidemic citizens rallied to the public health cause, relying on experts for guidance and entrusting their health to the authorities, such a reaction did not outlast the epidemic.” [17] 

There is Nothing New Under the Sun – Debate and Conflict over School Closures

** 1918 – Progressive public health authorities recommend the closure of schools. This recommendation made more sense during a pandemic that was killing children and young people by the hundreds of thousands. But many communities argued that open schools, in many cases, were a safer, more controlled, healthier environment than the alternative, and they kept schools open. In 1918, there were fewer tools available to the progressives to mandate their recommendations.

** 2020 – School closures across the country in the Spring and continued closures in the Fall in many cities and states will have long-lasting repercussions, especially in light of the fact that COVID-19 has had little viral impact on children and young adults. Long-term school closures in 2020 have already proven to increase drop-out rates, gaps, and delays in learning and have affected the ability for millions of parents to work. The impact is especially difficult on minorities and the poor, who typically do not have the ability to work from home, have poor technology options, and do not have the means to transfer to private or pod schools or hire tutors.     

Excerpts from American Pandemic

“It was the closing of schools, though, that generated the greatest conflict among public health forces. The USPHS recommended the closure of schools. At the same time, the Health Service also acknowledged that all closures and prohibitions were local matters to be handled ‘after consideration of circumstances.’ …Others agreed that local conditions were relevant and suggested that, with careful sanitary controls, keeping the schools open could prove safer than closing them. When New York City’s Commission of Health, Royal S. Copeland, asked Victor Vaughan, a recent President of the American Medical Association, to assess the city’s response to the epidemic, Vaughan reassured him that keeping the schools open seemed a reasonable response… ‘At present I believe that under the proper sanitary supervision the majority of children are better off in the schools than they would be in their homes or on the streets.’ As Vaughan’s comment illustrated, many public health experts worried that school closures placed a heavy responsibility on an unready public… In Chicago, Health Commissioner Robertson offered a similar line of reasoning, suggesting that closing the schools ‘would send the children into the streets and alleys without supervision,’ while in school they would be ‘under the scrutiny of a doctor and a nurse and the corps of teachers.’ [18]

“Even while deferring to local handling of the epidemic, the Surgeon General continued to maintain the importance of school closures…[believing] that closures slowed the pace of the epidemic and bought communities time to prepare for influenza’s full onslaught.” [18]

“…communities sometimes saw in their schools a site for waging the fight against the epidemic. In Illinois, for instance, the Influenza Commission allowed schools to continue to operate if they offered appropriate medical inspections of their students… In other cases community leaders agreed to close their schools and follow the restrictions, but they did so under vocal protest.” [19]

“Other communities attempted to minimize the closing of their schools, either shutting the doors slowly or seeking to reopen them as quickly as possible.” [20]

There is Nothing New Under the Sun – Debate and Conflict over Masks 

** 1918 – Progressive public health authorities generally recommended the masking of the public. Those efforts were met with early public cooperation but quickly met resistance. Public health officials were caught going maskless and ignoring their own rules, as well as debate over the efficacy of masks, meant a quick end to universal mask-wearing in communities that attempted to mandate it.  

** 2020 – Masks have become a sign of virtue, despite dubious efficacy and despite public health officials being caught maskless and ignoring their own rules. Outdoor mask-wearing is widespread despite mountains of evidence that outdoor transmission is virtually impossible with social distancing.  People who eschew masks are shamed by the press and social media for catching a respiratory virus. The progressives have more tools at their disposal to mandate their recommendations.  

Excerpts from American Pandemic

“It was the wearing of masks that produced the most broad-based and visible challenges to the emergency measures. In the early days of the crisis most citizens followed the health authorities’ rules, including orders to don masks. As the epidemic retreated, however, resistance rose. Even the renewed strength of influenza… did little to restore authorities’ earlier control over the population. With massive noncompliance, local public health leaders were ultimately unsuccessful in exerting full control.

“Events in San Francisco offer a classic example of the waxing and waning of popular support of public masking… Though the city relied on the range of preventive techniques encouraged by public health authorities nationwide, it was the masking of the public that many locals credited with slowing the epidemic… [Effective November 1] the Board of Supervisors passed an ordinance unanimously that required all citizens to wear masks when on public streets, in any place where more than two people assembled, and even in their own homes… San Franciscans responded enthusiastically, exhausting the supply of masks as quickly as they were offered…

“[The Board of Health] had hoped to continue to control the disease by keeping the city in masks until the epidemic had fully passed… such a strategy proved impossible. Gradually, San Franciscans abandoned the masks. At first the police responded with arrests, including 400 during one raid on hotel lobbies. Soon, though, authorities from the mayor to the chief of the Bureau of Health were discovered maskless. On November 21 citizens were finally allowed to shed their masks. By this point, though, the masks had become not only unpopular, but an object of humor, and even ridicule.”  [21]

“…public health experts generally advised the use of masks by doctors and nurses and others who would be in close contact with the ill… some public health leaders, including the Surgeon General, recognized that they were not based on any definitive information.  Since the masks were only useful if they were ‘properly made,’ officials debated their use by the general public… others feared such rules would backfire if the public used masks improperly and gained a false sense of security as a result. As Herman Spalding of Chicago declared of the mask, ‘As it is worn by most people, it is worse than useless.'” [22]

There is Nothing New Under the Sun – Debate over Closing of “Non-essential” gatherings

** 1918 – Progressive public health authorities recommended the closing of public spaces and the banning of public gatherings, including churches, dance halls and bars, and other businesses. Community acceptance of those recommendations varied, but there were no general lockdowns of entire cities/states, as we’ve seen in 2020. These closures were typically done under heavy protest and lasted a matter of weeks. With limited enforcement mechanisms and lack of entertainment options inside the home, citizens were not long for closures, despite the scope of the pandemic.  

** 2020 – Public health authorities recommended to federal and state leadership to fully close down all non-essential businesses and gatherings in their states, including churches. Most states complied for at least 6 weeks. Re-openings have varied from state to state, with many states still in some form of lockdown 6 months later, despite the easing of the pandemic weeks and months before. The closures have become heavily politicized, and enforcement methods are much more effective in 2020, allowing heavy-handed mayors and governors to continue to use the hammer of lockdowns on their citizens when more focused mitigation efforts would have made more sense.  

Excerpts from American Pandemic

“The general logic behind bans and closures was simple and broadly accepted. As the USPHS maintained, because influenza was an infectious disease spread from person to person through droplet infection, keeping individuals away from one another, and especially away from crowded situations, was the key to slowing infection rates. The APHA agreed and called for a blanket prohibition on all ‘non-essential gatherings.’ At the same time, it recognized that while closures might be effective in smaller communities… it might be impractical in certain contexts, given the impossibility of halting all public business during the epidemic. Most public health leaders, though, continued to argue that at least limited bans and closures were necessary.  

“For some, religious services were a necessity during such a difficult time.  Dr. John Dill Robertson, the Commissioner of Health in Chicago, argued that closing churches would eliminate opportunities for health education in addition to robbing citizens of the ‘spiritual uplift which they should have at such a time.’ Alternatively, the APHA imagined that churches might sometimes remain open but only with restrictions designed to limit services and minimize contact. Others continued to argue that church services, like most public gatherings, were simply too dangerous during the worst of the epidemic. [23]  In Washington D.C., the local African American newspaper chastised local preachers for their resistance to closures, suggesting, ‘These preachers ought to be ashamed of themselves. Their attitude suggests superstition or medievalism or pure selfishness; certainly not a regard for the public good.'”  [20]

In regard to public entertainments and other businesses, once they were closed, “the public began clamoring almost immediately for their reopening.” The quarantine was “more irksome every day.” Local businessmen complained bitterly about the loss of profits they faced, saying their businesses had been “hit hard” and business was “rotten.”  [20]

While the closure of public spaces and the prohibition on public gatherings brought some vehement resistance, such protest was always limited to a small number of individuals willing to challenge the authorities. Many citizens also worked within the established legal system to challenge the restrictions and accepted the authority of the courts to determine the outcome. [24]   

There is Nothing New Under the Sun – Class and the Impact of Poverty

** 1918 – “For patients and families alike, the suffering and confusion produced by the epidemic could be made substantially worse by poverty.” [25] The poor were sometimes judged by their living conditions or health to make a determination of their “worthiness” for aid. Minorities and foreigners were targeted for special criticism.  

** 2020 – These same pandemic class and poverty issues are exasperated by long-term business and school closures, causing significant unemployment and learning deficiencies. The group least able to withstand long term lockdown policies is the group being impacted the most.  

Excerpts from American Pandemic

“Shortage of medical and nursing care particularly afflicted the poor. With the well-to-do able to pay for the services of local doctors and nurses, those with limited financial means were often forced to look to local government and charity for assistance… For the poorest and most marginalized of Americans, hunger, inadequate sanitation, and preexisting bad health worsened the pandemic’s impact… For families living with material deprivation before the epidemic hit, the disruption of wage-earning… even for a short time, might mean hunger, cold, and even homelessness.”  [25]

“[Health and aid workers] brought their own middle-class assumptions to [interactions with the poor], which conditioned their responses. Especially common in these judgements were distinctions between the “deserving” and “undeserving” poor, between those who were worthy of aid and those who were not.”  [26]    

“[The] preoccupation with a family’s intentions toward work reflected an underlying tendency among aid workers to suspect the poor of dishonesty and laziness, and of attempting to take advantage of others’ generosity.”  [27]

“Certain groups of poor citizens were targeted for special criticism.  In urban areas, aid workers sometimes reported on the particular shortcomings of the foreign poor, whom they depicted as especially ignorant of modern medical care. Such a response was shaped, at least in part, by the unprecedented immigration of the decades preceding the pandemic. Individual immigrants… confronted wariness and criticism as they suffered through influenza in late 1918, reactions fostered by nativism and cultural difference.” [28]

“Already living on the edge of desperation, families of lesser means often could not weather the epidemic without aid, but they sometimes discovered this aid came with a high price.” [29]

There is Nothing New Under the Sun – Consideration of Public Fear 

** 1918 – Minimization of “public fear was a central feature of public health work during the epidemic… Health leaders balanced the need to alert citizens with a determination to avoid frightening them.” [30] Remember, this was during a pandemic that killed 1 in 152 Americans, with young people more than half of the deaths.

** 2020 – Maximization of public fear drives revenue to Big Pharma, drives revenue to media outlets, and is a means to a political end. Even months after the epidemic is over in various communities, public fear is a central feature and goal of many in public health, despite a pandemic that is 10 times less lethal overall, and 50 times less lethal to the young, than the 1918 Spanish Flu.  

Excerpts from American Pandemic

“The Surgeon General did not exploit what might seem the most obvious message for motivating the public–the direct expression of the danger posed by influenza and the seriousness of the burgeoning epidemic.  Nowhere did he describe the horrible scenes witnessed as the epidemic struck or depict in detail the appalling symptoms that had frightened even the most experienced physicians. Instead, he kept his references vague and his language muted.  

“This approach was common throughout public health leaders’ communications with the American public. Certainly some worried early in the epidemic that the public did not understand the seriousness of the situation… Yet direct expressions of the degree of danger the epidemic posed were unusual in public health communications. Instead these officials attempted to mobilize the public without reliance on the rhetoric of alarm.  

“A public health worker attempting to control influenza at the Groton Iron Works urged supervisors to be careful how they approached the subject of the flu with employees. Beginning by explaining the certainty of influenza’s arrival, he went on to outline the symptoms and the important role supervisors could play. ‘Ask you to help by watching men under you and sending any men with symptoms to yard hospital immediately,’ he pleaded.  Even as he urged them to be on alert, though, he also cautioned the foreman to avoid causing undue anxiety among the workers. ‘Work quietly,’ the message concluded, and ‘do not alarm [the] men.’

“Others in the world of public health went still further, overstating their ability to prevent the disease and control the epidemic…”  [31]  But even with these extreme cases of efforts to reassure the public, “this commitment to keeping the public calm was widespread.

“Having rejected fear tactics as a mobilizing mechanism, public health advocates were forced to rely on other rhetorical choices to encourage the citizenry’s cooperation. Given the wartime context, it was not surprising that leadership would turn to appeals to duty, patriotism, and the war effort to convince Americans to join the fight against Influenza.” [32] 

In conclusion, if there was ever evidence of Ecclesiastes Chapter 1, it is in viewing the 2020 COVID-19 Pandemic through the lens of the 1918 Spanish Flu Pandemic. Public health policy in 1918 bears a striking resemblance to 2020, with the biggest exception, sadly, being the mindset around public fear. Let us hope that we remember the lessons of both 1918 and 2020 when the next pandemic invariably hits, hopefully many decades from now.  

Citations

  1. American Pandemic – Nancy K Bristow – Paperback edition page 3
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740912/#:~:text=The%20estimated%20population%20of%20the,generally%20put%20at%2020%20million.
  3. https://covidtracking.com/data/national
  4. https://www.worldometers.info/world-population/us-population/
  5. https://www.irishtimes.com/news/ireland/irish-news/covid-19-world-in-for-a-hell-of-a-ride-in-coming-months-dr-mike-ryan-says-1.4370626?mode=amp 
  6. https://twitter.com/EthicalSkeptic/status/1312269752786706432/photo/1
  7. https://reason.com/2020/09/29/the-latest-cdc-estimates-of-covid-19s-infection-fatality-rate-vary-dramatically-with-age/
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291398/ 
  9. https://twitter.com/tlowdon/status/1311680333272674304?s=20 
  10. American Pandemic – Nancy K Bristow – Paperback edition page 49-50
  11. https://www.augustachronicle.com/news/2017-08-13/way-we-were-great-war-brought-camp-hancock-augusta
  12. American Pandemic – Nancy K Bristow – Paperback edition page 51
  13. American Pandemic – Nancy K Bristow – Paperback edition page 86
  14. American Pandemic – Nancy K Bristow – Paperback edition page 89
  15. American Pandemic – Nancy K Bristow – Paperback edition page 86
  16. American Pandemic – Nancy K Bristow – Paperback edition page 118
  17. American Pandemic – Nancy K Bristow – Paperback edition pages 120-121
  18. American Pandemic – Nancy K Bristow – Paperback edition pages 96-97
  19. American Pandemic – Nancy K Bristow – Paperback edition page 112
  20. American Pandemic – Nancy K Bristow – Paperback edition page 113
  21. American Pandemic – Nancy K Bristow – Paperback edition page 115-117
  22. American Pandemic – Nancy K Bristow – Paperback edition page 93-94
  23. American Pandemic – Nancy K Bristow – Paperback edition page 94-95
  24. American Pandemic – Nancy K Bristow – Paperback edition page 114
  25. American Pandemic – Nancy K Bristow – Paperback edition page 61
  26. American Pandemic – Nancy K Bristow – Paperback edition page 64
  27. American Pandemic – Nancy K Bristow – Paperback edition page 65
  28. American Pandemic – Nancy K Bristow – Paperback edition page 67
  29. American Pandemic – Nancy K Bristow – Paperback edition page 69
  30. American Pandemic – Nancy K Bristow – Paperback edition page 99
  31. American Pandemic – Nancy K Bristow – Paperback edition page 100
  32. American Pandemic – Nancy K Bristow – Paperback edition page 102