Question: I don’t know much about the 1918 pandemic that I hear frequently mentioned these days. If it was such an epic tragedy, why isn’t it a bigger part of our collective knowledge? And now that folks are talking so much about it, is there anything we can learn from it that’s applicable to the COVID-19 pandemic?
Answer: I was wondering about this too! I didn’t know about the 1918 pandemic until I was in graduate school studying public health. I’ve always assumed that the brutal pandemic — with an estimated death toll of 50 million — was left out of our history books because it was so overshadowed by World War I. Earlier today, the New York Times published an article that tackles your first question so well. I highly recommend reading it! As it turns out, yes, the pandemic was overshadowed by the November 1918 Allies victory. But there’s more to it. Historian and author of “Pandemic 1918: Eyewitness Accounts” Catharine Arnold, describes that “Part of the problem was that dying from the flu was considered unmanly. To die in a firefight, that reflected well on your family. But to die in a hospital bed… that was difficult for loved ones to accept. There was a mass decision to forget.” Additionally, because leaders including then-President Wilson were eager to focus on and sustain the war effort, they rarely mentioned the virus. Even though Wilson nearly died from the flu during negotiations over the Treaty of Versailles, he never released any statement on the pandemic!
As to your second question, history repeats itself. There are many lessons to be learned from the 1918 pandemic. There was no sweeping national response to the 1918 pandemic. Rather, each US city took its own approach and the approaches varied dramatically. Researchers have used data from these different scenarios to study the impact of various interventions. In my relatively quick skim of relevant articles in pubmed, here are just a few lessons that stuck out:
- Social distancing measures work in the short-term if rapidly implemented: Cities that responded quickly with multiple non-pharmaceutical interventions (e.g. social distancing measures including closing schools, public events, etc.) had lower fatality rates. As study authors write, “rapid implementation of multiple non-pharmaceutical interventions can significantly reduce influenza transmission…”
- Cities will not implement social distancing measures indefinitely: Study authors also found that most cities stopped widespread social distancing measures within 6 weeks (range 2–8 weeks). As another researcher wrote in a fascinating paper on the lessons of the 1918 pandemic,”Perhaps the most important “lesson” taught by the pandemic was the realization that those measures that worked the best to control a highly infectious disease — bans on public gatherings, school closures, and strict quarantine and isolation — were precisely the ones most difficult to implement in a modern mass society. As an article in the July 5, 1919, Literary Digest summed it up, influenza’s spread “… was simple to understand, but difficult to control.”
- Getting people to be socially compliant with restrictions cannot last indefinitely: As one scientist wrote, “it was possible to get reasonable compliance with precautionary measures for a while, but not indefinitely, even in the more obedient social climate that prevailed in 1918. San Francisco had demonstrations in which citizens defiantly tore off their own masks.”
- Virus spread renews upon social distancing relaxation: Study findings also show that “viral spread was renewed upon relaxation of such measures…. … no city in our analysis experienced a second wave while its main battery of NPIs was in place. Second waves occurred only after the relaxation of interventions.”
- Cities less impacted during the first wave are more impacted during second wave: “Cities that had low peaks during the first wave were at greater risk of a large second wave. Cities that had lower peak mortality rates during the first wave also tended to experience their second waves after a shorter interval of time, ≈6–8 weeks after the first peak vs. 10–14 weeks for cities with higher peak mortality rates.”
- Cities that fair best implement both early and effective interventions and reintroduce these interventions when transmission again increases: A second set of researchers found that “ Cities that introduced measures early in their epidemics achieved moderate but significant reductions in overall mortality. Larger reductions in peak mortality were achieved by extending the epidemic for longer…. the cities that got closest to the theoretical maximum possible reduction in mortality were those that implemented both early and effective interventions throughout the first peak and then were able to reintroduce these when transmission again increased.”
- Political calculations and economic worries will stymie public health communication: As another set of researchers wrote, “Unfortunately, in 1918, demands of World War I influenced the timing and messaging of public health precautions in some cities. Many public health officials resisted and delayed community mitigation measures under pressure from civil authorities who believed morale, and subsequently wartime productivity, could suffer.”
- Telling the truth is paramount: As another scholar wrote in a far more in-depth review of the US 1918 pandemic communications, “The US response to the 1918 flu offers a case study of a communication strategy to avoid…The communication strategy of either reassurance or silence had its effect. Its effect was terror.” [Read this paper; it gave me chills.]
- Accurate case and death reporting will be challenging: As described in this paper, such challenges in 1918 were be both political and technical. One example — “In the January 1919 American Journal of Public Health issue, the editor wrote that data in many cases were incomplete and confused as “so great was the pressure for action, that very few were able to devote any time to observation for the sake of the future.”
- Those living or working in crowded conditions will be harder hit: This paper describes, “As is almost always the case with communicable diseases, poor, disadvantaged, and malnourished persons and those who lived in crowded conditions were at higher risk of death in 1918.”
1918 Public Health Service Poster from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862334/
