HOW I FOUND MY RHYTHM WHEN THE MUSIC STOPPED

At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on.  The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me.  After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.

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THE MAN IN A BLUE SARONG

I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.

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PATIENT “OWNERSHIP”

I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind).  One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.

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The time course of the 1918 pandemic was shorter, but also much more complicated. The unusual nature of the 1918 influenza infections was first reported in February 1918 to the U.S. Public Health Service (and included in only one issue of its weekly publication) by Dr. Loring Minor of rural Kansas. He recognized a cluster of perhaps 30-50 cases as an influenza of unusual severity and rapid spread, with deaths often occurring in young, healthy adults. By the end of March the local rural epidemic had run its course. However, a visiting soldier carried it to the nearby Camp Funston Army Base overflowing with 56,000 draftees/ enlistees. Their first case was diagnosed on March 4th and by the 25th, about one thousand cases were hospitalized and thousands more were sick in their barracks. Eventually 38 soldiers died in March. The physicians at the camp implored the Army command to isolate the camp, but ingress and deployments of soldiers continued. By mid-April most of the military in the U.S. as well as the European theater were seeing debilitating disease. About 40% of the soldiers were unable to leave their barracks. Front line Allies and European civilians had even more cases. Fortunately, the German army was also suffering from the disease and this may have saved a retreating Allied Army from a third German offensive that could have ended the war that spring. Deaths were more frequent than seen with the usual influenza epidemics, but still below 2% of cases. By the end of August 1918, the epidemic in the armed forces also had seemed to run its course.


Through the 1918 winter and summer the virus spread in U.S. civilian populations as scattered outbreaks occurred, largely in coastal or rail centers near military camps. Toward the fall, the virus spread inland to more isolated areas and increased rapidly. This pattern of spread is similar to what has been seen with COVID-19. The first waves hit crowded cities and trade centers like New York City, New Orleans, Detroit, Seattle and San Francisco while somewhat sparing smaller cities and rural populations until fall and winter 2020-21.


Prior to mid-September 1918 outbreaks resulted in only moderately more deaths than seasonal influenza of the period. However, occasionally highly fatal outbreaks were present. Louisville, KY saw an outbreak over the summer with 40% fatal infections. As had been observed by Dr. Loring, the deaths were largely in healthy adults instead of the usual victims, children and the elderly.


In October, a second wave of epidemic infections occurred around the world with increased mortality. Death rates from the new strain were often in the 40% range and occasionally even higher.


Are the viruses similar in lethality?

The answer to that question depends on which variant of the 1918 influenza virus you use for comparison. In 1918-20 about 675,000 influenza deaths occurred in a U.S. population of about 100 million. This would proportionally be about 2 million Americans dead in 2020-21. In the 1918 influenza two-thirds of all U.S. deaths occurred between October and December 31st, 1918. The U.S. lost about 100,000 soldiers to combat death in “The Great War” and 47,000 military influenza deaths. The German influenza deaths in October were probably a major factor in Germany’s unconditional surrender on November 11.


In this second phase symptoms came on within 24-72 hours of exposure and death was usually within 4-7 days, but occasionally within hours. Patients died with fulminant cutaneous cyanosis, hemoptysis, purpura, headache and high fever. Patients had an appearance similar to descriptions of the dreaded “Black Plague” that decimated Europe in the 1300’s. Recovered patients often suffered lasting cognitive issues. This may have included President Wilson, who was infected during the peace negotiations in the spring of 1919. The “new” influenza virus spreading in the fall of 1918 is perhaps the deadliest virus ever recorded, essentially equal to Ebola in death rates. Luckily, it burned itself out by the end of 1920. Similar serotype H1N1 influenza virus appearing in 2009 was much less dangerous.


The current contagion and mortality rates of COVID-19 are more comparable to the early 1918 virus seen in the winter through the summer of 1918. Current deaths run about 1-2% of infections in the U.S. Even the somewhat more aggressive COVID-19 variants do not reach the extreme mortality of the fall 1918 influenza, but is of an order well beyond the “usual” influenza strains in the world today (about 10-15-fold more deadly).


Do experts believe any public health practices could have lessoned the U.S, death rate in the 1918 pandemic?

The answer is a “probably” if the world hadn’t been at war. We had controlled polio, measles, small pox and diphtheria epidemics with quarantines. Unfortunately, throughout the pandemic the Wilson government and many newspapers down-played the domestic epidemic as well as the military disease. Troop deployments were not affected. The U.S. population was confused and fearful throughout the pandemic. Political authorities, both local and national, decried anyone writing about the disease as traitors to the war effort (government medical professionals were ignored and often relieved of their duties). Liberty Bond Rallies continued in most cities with the traditional parades, drinking and dancing in the beer halls. Spain (it was neutral) was about the only government to not distort news coverage of the disease and to Americans it became the “Spanish Flu”. Hispanic and Italian immigrants were harassed and occasionally attacked. Some residents were so afraid of the disease they refused to leave their homes and starved to death. Most citizens refused to help with the sick. Nurses and doctors were overwhelmed and many died. The Temperance Movement claimed the infected were cursed as punishment for their sinful lifestyles and this undoubtedly helped pave the way for later Prohibition legislation. Food and factory supply lines failed for lack of willing workers as much as workers lost to disease. Still, Wilson insisted on keeping factories of the war industry going. In 2020 our government’s response was hauntingly similar.


In summary, what can we learn from study of the 1918 Influenza Pandemic?

First of all, the most important difference between the two pandemics lies in the fact that we have yet to see a truly game-changing mutation in the COVID-19 virus strains. The current vaccines, although less effective in some strains, have significantly slowed virus spread. Still, there is danger from the emergence of a strain that the vaccines do not recognize. Even more, experts fear a mutation that produces more fatal disease such as was seen in the fall 1918 influenza, particularly if it occurs as a second mutation in a vaccine resistant strain. If so, COVID-19 death rates could exceed even the worst seen in the 1918 pandemic. As global infections surge in countries with little vaccine availability, the conditions are ripe for these mutations to develop. For this reason, it is critical that U.S. vaccine participation is high and global vaccine distribution occurs as rapidly as possible. Current estimates are 2 years or more to achieve global vaccination levels of greater than 70%. Additionally, even if moderate U.S. death rates can be tolerated as a trade- off to avoid severe economic damage, a persistent endemic level of infection will also increase the odds of a more deadly phase of the pandemic may occur.


Secondly, governmental withholding of accurate information from the public can amplify the morbidity and mortality of the disease. In 1918 a few isolated cities and islands were able to avoid the second influenza phase by almost complete closure to outside persons and trade as well as enforcing bans on group activities. St. Louis is often touted as an example of policies that resulted in “control”, even though they saw an eventual rate of 358 influenza deaths per 100,000 population (about 1/2 the national rate in 1918-20 and about double the COVID-19 U.S. mortality rate to date). St. Louis was fortunate in that they had no influenza cases until October of 1918. Still, it shows that early planning and enforced control measures had some chance of mitigating death rates. They instituted many of the policies promoted by the 2020 CDC, but didn’t completely shut down the city and were flexible according to the infection rates as time went by. Independent community leadership worked closely with business and the medical community.


Boston and Philadelphia on the other hand saw large outbreaks in the summer and early fall; and were major ports of military deployments to Europe. Local political authorities in those cities did very little to control the spread, yet their few mitigation efforts are often compared to St. Louis.


Most of the information in this article was obtained from the book by historian John M. Barry entitled The Great Influenza. The original publication came out in 2005. A more recent digital version includes an Afterword put out about 1918, a couple of years before the COVID-19 disease outbreak. It includes this warning: “The final lesson of 1918, a simple one yet one most difficult to execute, is that those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate nothing, to try to manipulate no one. Lincoln said that first and best. ‘A leader must make whatever horror exists concrete. Only then will people be able to break it apart.’ “


There are many additional facets of the 1918 Influenza Pandemic that deserve discussion but are beyond this article. These include economic effects of the disease, the direct and indirect influence on the war, post-1918 political movements, immigration, and subsequent medical advancements.           

The COVID-19 pandemic erupted in early 2020. The cause, the SARS-CoV-2 virus, was a new, highly infectious virus. It had an early lethality in the range of 2 to 8%. There were no drugs or vaccine to combat it. Until these could be developed, quarantine and other mitigation practices were our only weapons against spread. Many experts have analyzed the deadly 1918 Influenza Pandemic in hopes of identifying previously successful practices. I hope to answer some of the important questions in this article.


Can we really compare the  two pandemics?

Historians strongly disagree about many details of the pandemic, with global cases estimated anywhere from 20-100 million. This makes almost all comparisons of mitigation practices speculative. In 1918 no national influenza health statistics were systematically compiled. Infection control practices were widely variable from city to city and were instituted at dramatically different phases of the pandemic. Deaths eventually became so frequent that the names of the dead were not even entered in some records, just the body count. For instance, much has been made of reports that “masks” were of no use in controlling infection in 1918. Gauze, 4 layers thick, was used as respiratory masks. They had been important in control of tuberculosis within medical wards, but did not prevent influenza spread. There can be no comparison to the two-layer, snug, tightly knit cloth masks recommended for public use by CDC today. Similarly, mitigation efforts for COVID-19 have been no more organized or enforced on a national scale than those in 1918.  

BY TERRY CLARK, MD, FCAP

How similar is the biology of  the viruses?

Both are variants that arose from viruses that are endemic in other species and through mutation achieved the ability to spread among humans. Influenza pandemics have been frequent but rarely as lethal as 1918. The exact origin for the COVID-19 virus is under intense scrutiny, but Its origin is of no current importance in relation to U.S. mitigation and won’t be discussed here.


Are the time frames of the two pandemics comparable?

the COVID-19 pandemic. While we are somewhere between at least 18 months to perhaps 24 months since the origination of human transmission by the virus, we have really seen only one “phase” in virus biology. Different areas of the world have seen surges of infection at different times. In the U.S. surges generally followed holidays that stimulated travel, family gatherings, and loosening of various mitigation restrictions by some states. The worst was the Thanksgiving-New Year period which began from a high baseline and occurred during the optimal winter respiratory illness season. That surge has only abated as vaccine distribution progressed and the spring weather came.