1918 and Lessons Not Learned

“I suspect that most of us get old without growing up, and that inside every adult (sometimes not very far inside) is a bratty kid who wants everything his own way.” -Bill Watterson

Imagine, it’s the middle of a pandemic. Not too hard. I came across this blurb.

“Newspapers… published instructions on how to make ‘flu masks.’ There were long lists of cancelled events, running the gamut of different religions and interests. But public resentment was building. One letter to the editor asked rhetorically if Dr. Starkloff was going to shut down all the bootleg entrepreneurs popping up in the wake of store closings.”1 (Yes, there are references tonight. I’m not doing APA format – I just want people to see that I’m not making things up. If English – sorry, ELA teachers don’t like this, as we say in the Kesselring household, “tough jelly beans.”)

If you haven’t heard of Dr. Max Starkloff before this, don’t worry. He doesn’t work for Dr. Anthony Fauci. He’s dead, actually, and has been so for over 78 years. He’s not coming on to testify in front of some panel in the House of Representatives. He was the Commissioner of Public Health for St. Louis City during the Spanish Flu Pandemic in 1918.

I only put that passage in there because I’ve got a lot of jumping back and forth to do in this post. And, to make a point. We’ve been here before – as different as the past 5+ months have felt, we’ve actually been through similar times. Sure, there are some differences – but we have a template. Insert comment about “those who do not learn from history are doomed to repeat it.”

Here’s what I’m going to do. I’m going to take a look at influenza data from the last 9 years. Why? The seasons run 6-ish months (October to April) in North America. We’re 5 months into this, so our numbers are close to lining up. Then, I’m going to explore how “we’ve been here before” – and it’s more recently than you think. The biggest piece – mindset – comes for the closer. We’ve got a lot of data to review. Fire up the coffee pot, this is going to be a LONG read.

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A lot of physicians don’t want to compare coronavirus and influenza – and from most standpoints, they are correct. I’m not arguing that point. However, yearly influenza data is the best data we HAVE to compare to. Further, it flares up – some years are worse than others. And, it gave us our last huge pandemic – at least, the one that is written about A LOT now (and there’s a good hometown contrast to use). For the record, and as I get further away from my medical career, there were influenza pandemics in 19572 and one in 19683. For the record, a lot of this data is readily available on the CDC’s website.

What I am showing is influenza data for each influenza season, starting for the 2010-2011 season, and running up to 2018-2019.4 I’ll deal with last winter separately. I’m not showing the entire table – just the year and number of deaths. I don’t feel like I can compare cases – because with coronavirus, we’re getting some positives in people that are largely asymptomatic, and the influenza data only shows symptomatic cases. And, to be clear, all of this is UNITED STATES DATA ONLY.

Season                        Number of deaths – estimate with (range)

2010-11                       37,000 (32,000 – 51,000)

2011-12                       12,000 (11,000 – 23,000)

2012-13                       43,000 (37,000 – 57,000)

2013-14                       38,000 (33,000 – 50,000)

2014-15                       51,000 (44,000 – 64,000)

2015-16                       23,000 (17,000 – 35,000)

2016-17                       38,000 (29,000 – 61,000)

The next two years are estimates

2017-18*                     61,000 (46,000 – 95,000)

2018-19*                     34,157 (26,339 – 52,664)

To other pieces of information. #1 – early returns on the 2019-2020 influenza season has a death toll between 24,000 and 62,000.5 #2 – 2009-2010 was the year of the “swine flu” pandemic. This is the H1N1 influenza. The season is counted to have run from April 2009 to April 2010 (at least as how I’m reading things). There were 12,469 deaths attributed to influenza in this season.6 Not to make light of it – but I refer to this as “piggy flu” – and I just gave a lecture to our two guinea pigs on proper hygiene. They learned nothing.

Using the Johns Hopkins Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html I’ve spent too much time here), as of 8:34 PM Central Time on August 2, 2020, we have 154,834 people that have died in the United States so far. To pinpoint an exact start date is a bit tricky. The WHO declared a pandemic on March 11, 2020.7 Did we have cases in the U.S. before then? Yes. (For the record, I don’t think that the Chinese government has been telling the truth – and it’s kind of moot. Just because they aren’t doesn’t mean we shouldn’t. Their lack of transparency does not influence how we should deal with the crisis. But the numbers from China have got to be B.S., and everyone should just assume that.) The New York Times has a timeline (https://www.nytimes.com/article/coronavirus-timeline.html). We don’t declare pandemics just when we get a few cases, but clearly things were circulating in the U.S. before March 11th. It’s going to be hard to pick ONE DAY, but using March 1st (for now) let’s look at 5 months of data – given that most influenza seasons run six months.

A few things strike me from the data immediately. 2 influenza seasons stayed well below 20,000 deaths (2011-2012, and ironically, if I’m looking at the data right, 2009-2010, the H1N1 pandemic). 2017-18 was horrible. 2014-15 and 2012-13 weren’t great either. Almost every other influenza season has had an estimated death toll in the mid-30,000 range (and last year’s data is still “in process”). Adding up those 9 seasons (I won’t use the 2009-2010 pandemic, hang on), that’s an average death toll of 37,462 people per influenza season. (Using the data from 2009-2010 would bring that average DOWN 34,963 deaths per influenza season).

I know mathematical “averages” aren’t the only way to look at this, but let’s keep it simple. If we take the current death toll from coronavirus (154,834) and divide it by the average yearly death toll of influenza (37,462), then we have 4.13 times more people that have died from coronavirus than a typical influenza season. And, we’re one month short in length of a typical influenza season. And we won’t be done with coronavirus on September 1st. To give you an idea of how many people that is, take a look at this list of cities (https://en.wikipedia.org/wiki/List_of_United_States_cities_by_population). Goodbye, Springfield, MA. Adios to Macon, GA and Kansas City, KS. Salinas, CA – it’s close. For people in my state, Springfield, MO is almost gone.

I don’t think we’re winning.

Again, even in bad influenza seasons, things aren’t THIS bad. Why? #1 – even if people don’t get influenza vaccines, many people have had it before. Even as the influenza mutates from year to year, some people have some level of residual protection from prior infections. It might not be great, but there’s something. Coronavirus, at least this form, is entirely new. That means there’s no “immune system memory” to mount a faster immune response (which is why we vaccinate against a whole slew of things in the first place. Further, we have a yearly influenza vaccine (Lord knows, not perfect, but it significantly helps). For the record, a majority of Americans DON’T get a flu shot.8 (Really, Nevada, all those people in casinos, and only 33% of you got your flu shot in 2018-19? I think I won’t be gambling for a while…) Your body does a lot better on the 2nd go-around, if it survives the first). Furthermore, early data suggests that coronavirus is more contagious than influenza and one more person can spread coronavirus to more people than one person with influenza can.9 It’s pretty easy to see: No primary immunity + no vaccination + more contagious = more deaths.

Aside from raw numbers, I haven’t said anything to this point that couldn’t (or wasn’t) predicted months ago. But seeing numbers helps. Numbers don’t lie, people do. I think it’s easy to see why so many in healthcare are worried. Our medical system gets full in a typical influenza season. And it’s not just influenza – it’s all the stuff influenza makes worse. Most people know about influenza complications like pneumonia or worsening someone’s asthma, but how about a 6x increase in heart attacks?10

Are people denied care? No. Are hospitals closer to capacity in a typical flu season. Yes. Can the flu season take a while to run its course? Yes. Have our hospitals and healthcare systems wobbled in certain areas due to coronavirus? Yes. What’s going to happen when the two seasons overlap if we don’t get coronavirus under control? Well, I just showed you the numbers, you tell me. It’s not too much of a stretch to wonder if: 1) coronavirus will do the same thing (bring out a bunch of other health problems) and 2) what happens when influenza and coronavirus party together?

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We tend to think that this is all brand new, but it’s not. I know it’s been referenced before, but it helps to take a very close look.

You can see here (https://www.nationalgeographic.com/history/2020/03/how-cities-flattened-curve-1918-spanish-flu-pandemic-coronavirus/#close) how different cities responded to the 1918 pandemic.11 Let’s bang on Philadelphia for a minute. After all, they have booed and thrown batteries at Santa Claus, so 10 seconds of a historical smack talk is OK. Philadelphia responded to the pandemic with a yawn and held a parade. That didn’t work out so well. St. Louis granted extra control to the mean, and obviously dictatorial Dr. Starkloff. Things turned out better here – you’ll notice on the graph that we had a decrease in cases about 11-12 weeks into the pandemic. Officials took their foot off the gas, and eased up on restrictions. Notice the 2nd bump? Hmmm…. It’s not like that’s happening now.

And if you think that business restrictions, restrictions on religious gatherings, or school closings are new, think again. In mid-October 1918, cases were rising in St. Louis, and Dr. Starkloff pushed for more restrictions. It did not make people happy.12 A passage from reference 12:

The business community immediately vocalized its opposition to the restricted business hours. Only two days later, Starkloff bowed to the pressure, and rescinded the business hour restriction, citing the hardship he felt it caused for small business owners. Mayor Kiel, however, under pressure from not only the business community but religious leaders as well, advocated lifting the gathering bans entirely, starting with a two-day trial. Starkloff broached this idea to his advisory committee on October 24, but the physicians on the panel did not agree; they argued against lifting the ban until cases dropped below 150 a day. Kiel, understanding that the medical advice took precedent over financial concerns, gave way. Displeased clergy and business owners – theater owners especially – continued pressing for a change.

It’s the same conversation that we’ve had over the last 5 months, played out 102 years ago. “We need to open.” “When will we open?” “Why aren’t we open now?” “When will this be over?” (More on these questions in the last section) Just like a Hollywood remake, nothing’s new here. Sure, we have social media to carp about it, so everyone knows how WE feel. And the businesses have changed – no eBay, no Google, and certainly no “telecommuting” – but the concerns are the same.

And the solution – “Stay at home.” “Wear a mask.” “It’s over when numbers are low and stay low.” It’s all the same.

One portion has changed. The ability to vaccinate. Remember, there are antivirals, but they aren’t the greatest. Tamiflu (oseltamivir is the generic) for influenza; remdesivir for coronavirus. No, we aren’t talking about hydroxychloroquine, don’t be stupid.

As quoted earlier, about 45% of Americans roll up their sleeves and get their influenza vaccine (sometimes we get north of 50%, but not often). And if you look at news articles and follow the comments on Facebook (I *have* to stop doing that), whether or not to get the coronavirus vaccine – if / when it is available – is pretty polarizing. A common refrain is: we’ve never done this in short order before.

And, that’s not true. Times two – at least.

Back to “Piggy Flu” – if you remember the timeline, the pandemic started in April 2009. By then, manufacturers have to be close to making influenza vaccines for the upcoming season. “Piggy Flu” was H1N1 (quick aside, influenza A can be H3N2 or H1N1, and then there’s influenza B – all four are in your syringe!)13 Problem with “Piggy Flu” is that it changed / mutated a bunch, and the H1N1 in the vaccine was not going to be a match for the virus that was circulating. A vaccine was made to match this virus, and was placed in the influenza vaccine for the upcoming fall. If you recall looking at the data – that entire 12 months influenza season had one of the 2 lowest death totals. This was done in short order, and was safe.

This happened during the West Africa Ebola Epidemic in 2014. This link (https://www.statnews.com/2020/01/07/inside-story-scientists-produced-world-first-ebola-vaccine/) is a fascinating read.15 Basically, during the epidemic, the scientific community went from an experimental, safe in animals vaccine to a vaccine going through Phase 3 trials and helping halt the pandemic. I will suggest to you that Ebola is significantly more deadly than coronavirus, and yet in 2014-15, the scientific community pulled this off – safely.

I’m not an economist – I can’t tell a story or cite historical references on how to help people successfully navigate the business / economic portions of our current predicament. But – we have been here before. We have a blueprint; we *hopefully* will have the ability to safely vaccinate in 6-9 months (I’m not worried about safety; I’m worried about effectiveness). So, what’s the &#!* holdup?

Blood
Instead of whining about what you can’t do, lend a hand. I donated a “triple” on August 1. Please consider doing the same.

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Did you read my opening quote?

Bill Watterson said it best.

I’ll put it another way. The problem isn’t science. It’s much simpler than that.

The problem is us. It’s selfishness. And it’s why I’m not optimistic. I think we’ll wind up doing much worse than we should do. It’s why we’ve done so poorly already. It’s hard not to think that we’re completely hosed because of it.

I’m going to make an analogy – and it might drive some people batty at first. I’m not equating our current situation to the heroism required for the past crisis, but it does make the connection between mandates vs. “let people decide on their own to do the right thing.”

Let’s talk about rations in the U.S. during World War II.

Remember, during WWII, there were supplies needed by the military for the on-going war that civilians still needed.15 What were the supplies? Tires, gasoline, sugar, canned meats, cheese, etc… the list went on. I was surprised (when reading up for this piece) that only certain professionals were allowed to replace their tires – doctors, firefighters, delivery drivers made the list. If you didn’t, you got patches and the treads “replaced” (how do you even do that?) This went on from 1942 past the end of the war. If items were to be rationed (it was announced) – they got snapped up. And black markets developed for “high demand” items.

Note that during a major effort, the government had two options. 1) Create a mandate that ensured the vast majority of people “did the right thing” so supplies got where they needed to go or 2) leave it to a public “honor system” – suggest that people ration and trust that people will do what is the “suggested approach.” If you aren’t laughing at #2, you should be.

Yet, when we need people to do the same thing here with this crisis, there is a considerable cry to “leave it to the individual.” Hmmm….

And before you completely recoil at my comparison to WWII – the death toll sits at a little over 407,000 (and 671,000 wounded).16 That 407,000 number is in play for coronavirus deaths in the United States if we don’t get our act together (considering we are sitting at 154,834 and counting). Again, I’m not talking about how things happened – but if we look at cost, hospitalizations, what it takes to recover – the analogy is there.

So why the resistance to do the right thing – mask up, keep your distance, and I hope to God that handwashing isn’t an issue (but it probably is).

-This has become political. An issue that is about survival and health has become a battle between ideology somehow. That’s long, complex, and a post of its own (not from me). Measures that should be taken to get as many Americans through this crisis with their health intact has become “Democrat vs. Republican” and not “this is what public health dictates.” This is sad.

-A corollary to this is that people don’t want to give up and admit they were / are wrong. We locked down once and cases dropped. Some (many, most) states opened back up early (Hi, Texas!) Numbers went back through the roof, stressing out the healthcare system in some areas. State leaders are putting mud in their eyes and fingers in the ears. “NO SECOND LOCKDOWN!” This strikes me as childish and illustrates what makes a bad leader.

-We don’t do well when ideals / rights come into direct conflict with each other. “It’s my right” vs “this is what everyone needs.” It’s not easy. Sometimes our ideals clash – and it cannot be resolved nicely. How do you prioritize one ideal over the other? And for how long can you do this? I’m going to be clear, but from where I sit – during this pandemic, this cannot be avoided. Which leads to the last point.

-Unlike other threats, we can’t see this enemy. This isn’t a traditional war. This isn’t a hurricane that devastated a coastal area, or recovery from an earthquake. For some people, seeing / experiencing is believing. And when it comes to infectious diseases, that’s a very dangerous play.

-We’re too damn selfish. We always have been, and now it’s being exposed. As a country, we have this idealized, romanticized version of ourselves. Right now, our practices don’t match our behavior. There’s a lot of “I want” and “I need”, and very little examination of how each one of us fits in the bigger picture. Aligning with the quote in the Calvin and Hobbes collection, we’re a nation of spoilt brats, and it shows. This could be an entire anthology of books. There is a clear collective resistance to taking care of as many people as possible. I was following another FB thread (I’m really bad at scrolling along), and someone was upset that their church wasn’t opened (not unique – this is common right now). Full disclosure – I’m a practicing Presbyterian. I wanted to comment, but didn’t. Every one of these threads is the same – “churches should be allowed to open” and “this is overreach.” As though a virus knows not to attack based upon location.  Conveniently, these institutions forget to answer the question: Am I my brother’s keeper? Yes – and we need this now more than ever. Being your brother’s keeper includes so much more than opening your church building.

This is insanely complicated. I fully comprehend that we have an economic aspect to this. If it were just a healthcare decision, it would be simple: ride this out at home for as long as possible. Should our national leaders (President) be doing much better? Yes. Will they do better? Doubtful. These attitudes make addressing this pandemic infinitely more complicated. All I can say is this: if you truly want to minimize mandates, take a good, hard look in the mirror. If our goal is to get through this with as few lives lost as possible (and something resembling an economy) – we have to cooperate. This isn’t about proving ideology, this isn’t about being “right”, and this isn’t about winning an argument. It’s about taking care of each other. And unless you want a ration book like you’ve never seen, it’s way past time to set ego aside and cooperate.

NOTE: I didn’t put this number out here earlier (I’m not reworking the order of my references, sorry, not sorry), but deaths due to the “Spanish Flu” in the United States was estimated to be 675,000.17 A little over 53,000 U.S. soldiers died of combat deaths in WWI; but about 45,000 soldiers died of “Spanish Flu” while in Europe in 1918.18 I am unsure if that 45,000 is included in the 675,000 or stands separately.

2nd NOTE: I also didn’t add a direct comment on the debate about whether or not schools should be open. Again, from a purely “healthcare” standpoint, the decision is clear. Our leaders have sold out our school systems. Now, each superintendent and school board has to figure this out on their own. The only absolutely horrible decision is to send students and teachers back with little to no safety precautions OR schools that are fully open while cases are rising – which some places are doing. Had we (collectively) done our job back in May, cases would be lower NOW and the first quarter of the school year should have been less eventful. I have my strong beliefs on how things should be done based upon my previous medical knowledge, but it is hard for school leaders. What’s the number of cases in your zip code? Surrounding zip codes? Tech situation? Income disparity? Who’s feeding the students? Who’s watching them if they aren’t in school? How about cleaning supplies? Spacing inside your building? Can you expand? What’s your weather like? It goes on… So, I’m not going to fire at schools and school boards. We’ve put them in a canoe on the Niagara River, with no paddles, and they are 50 yards from the falls. Good luck! Yeah, it’s going to be a mess that didn’t need to happen.

References

  1. https://www.stlmag.com/history/history-of-the-1918-spanish-flu-pandemic-in-st-louis/
  2. https://www.cdc.gov/flu/pandemic-resources/1957-1958-pandemic.html
  3. https://www.cdc.gov/flu/pandemic-resources/1968-pandemic.html
  4. https://www.cdc.gov/flu/about/burden/index.html#:~:text=While%20the%20impact%20of%20flu,61%2C000%20deaths%20annually%20since%202010.
  5. https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm
  6. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html
  7. https://www.statnews.com/2020/03/11/who-declares-the-coronavirus-outbreak-a-pandemic/
  8. https://www.cdc.gov/flu/fluvaxview/coverage-1819estimates.htm
  9. https://www.npr.org/sections/goatsandsoda/2020/03/20/815408287/how-the-novel-coronavirus-and-the-flu-are-alike-and-different
  10. https://health.clevelandclinic.org/can-the-flu-trigger-a-heart-attack/
  11. https://www.nationalgeographic.com/history/2020/03/how-cities-flattened-curve-1918-spanish-flu-pandemic-coronavirus/#close
  12. https://www.influenzaarchive.org/cities/city-stlouis.html#
  13. https://www.cdc.gov/flu/prevent/keyfacts.htm#:~:text=Most%20flu%20vaccines%20in%20the,and%20two%20influenza%20B%20viruses.
  14. https://www.nejm.org/doi/full/10.1056/NEJMp2005630
  15. https://www.nationalww2museum.org/war/articles/rationing
  16. https://www.nationalww2museum.org/students-teachers/student-resources/research-starters/research-starters-us-military-numbers
  17. https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html#:~:text=It%20is%20estimated%20that%20about,occurring%20in%20the%20United%20States.
  18. https://www.army.mil/article/210420/worldwide_flu_outbreak_killed_45000_american_soldiers_during_world_war_i#:~:text=The%20flu%20struck%20an%20estimated,died%20of%20influenza%20in%201918.

Author: Jason Kesselring

I am a 42 year old high school chemistry teacher (and former pediatrician), happily married, and a father of two wonderful children. I'm occasionally active on Twitter; you can find me: @STLLenny and on Facebook (@trialofmilesjk)

One thought on “1918 and Lessons Not Learned”

  1. At the outset of WWII, the US created the Office of Defense Transportation to “assure maximum utilisation of the domestic transportation facilities…for the successful prosecution of the war.” The ODT, among other things, put restrictions on travel and limits on gatherings of individuals coming from across state lines. The Congressional Record 1942-1945 is full of angry letters from church leaders (arguing “over reach”) and diatribes from congressmen (arguing that the restrictions amounted to a breach of the church/state divide) and dire economic warnings that the limiting leisure travel would see us backslide into the Depression. In the end, most put aside these concerns in the interest of patriotic duty and the common good. As you said, we’ve been here before. But can we also go back to some of our WWII-era unity? Puh-lease? References: Flamm BJ. Putting the Brakes on ‘non-essential’ Travel: 1940s Wartime Mobility, Prosperity, and the US Office of Defense. J Transport Hist 2006;27(1):71-92. DOI: 10.7227/TJTH.27.1.6.3. Hall EA. Extending of Remarks: ODT Travel Order Restricting Religious Gatherings. Congressional Record 1945;9(11): A2902.4. United States. Office of Defense Transportation. Civilian War Transport: A Record of the Control of Domestic Traffic Operations, 1941-1946. GPO, 1948: 83.Kirsten Hebert, Contributing Editorkhebert@aoa.orgThe 48th Annual AOA Congress Banquet, June 26, 1945 at the Hotel Gibson. Notice the arrangement of the tables in a “V” formation to recall the “V for Victory Campaign.” The striped tablecloths and photographer’s perspective technique accentuated effect. This image (2016.IMG.1048) is curated by The Archives & Museum of Optometry., St. Louis, MOdoi: 10.14434/hindsight.v51i2.30276

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