1918 – 2020

“Investigators today believe that in the United States the 1918–19 epidemic caused an excess death toll of about 675,000 people”

The Great Influenza: The Story of the Deadliest Pandemic in History was published in 2004, a full 15 years before COVID-19 would race around the planet beginning in 2019.

My greatest takeaway from this book might well be a sense of disappointment: in our inability to learn, in our government’s inability to lead, and in our inability to understand and trust science.

In other words, not a lot has changed in 100 years. And that’s sad.

“History Doesn’t Repeat Itself, but It Often Rhymes” – Mark Twain

I’d not paid much attention to the history of the country at the begining of the 20th century. Oh, of course, there was “The War to End All Wars”, the Great Depression, a stock market crash. And there was something about a flu pandemic.

But all of that was history. Each of which had been eclipsed in many ways by subsequent events. Another world war, a booming economy thereafter, and incredible advances in medicine.

1918 was ancient history that didn’t really apply to modern life, or so I thought.

I was wrong.

Institutions

Democrat Samuel Tilden would win the popular vote by a comfortable margin. But he would never take office as president. Instead the Republican secretary of war would threaten to “force a reversal” of the vote, federal troops with fixed bayonets would patrol Washington, and southerners would talk of reigniting the Civil War. That crisis would ultimately be resolved through an extra-constitutional special committee and a political understanding: Republicans would discard the voting returns of three states—Louisiana, Florida, South Carolina—and seize a single disputed electoral vote in Oregon to keep the presidency in the person of Rutherford B. Hayes.

I had no idea. As I write this we’re days before what is, effectively, the same effort: an attempt to overturn a presidential election by declaring some of the votes invalid. What will happen remains to be seen.

This effort in 1876 sets the stage for the politics to follow. In the same year English scientist Thomas Huxley would deliver a speech at the opening of the Johns Hopkins University. Both he and the school would go on to play important roles in the events of the coming decades.

The outcome would help define one element of the character of the nation: the extent to which the nation would accept or reject modern science and, to a lesser degree, how secular it would become, how godly it would remain.

If I have one fault with this book, is that it focuses perhaps too much on the individuals — scientists, doctors, politicians, and the like — and not enough on society as a whole. It’s a story telling device, and an important one, but I came in more interested in the much larger societal picture, rather than individual biographies. The people are critical, no question, but it’s the impact of everything on the day to day that — while addressed some — left me wanting more.

And, indeed, much of what I took away from the book has more to do with institutional parallels to todays events, than the admittedly heroic efforts of the individuals involved.

The War to End All Wars

World War I plays an important role in the 1918 pandemic.

The war shaped the politics of the day. News was controlled so as to maintain morale at home. This meant that honest news about the pandemic was typically too little, and almost always too late.

The news would also be manipulated in ways that sound very familiar today.

Still others fomented terror, believing that blaming the enemy—Germany—could help the war effort, or perhaps actually believing that Germany was responsible. Doane himself charged that “German agents . . . from submarines” brought influenza to the United States. “The Germans have started epidemics in Europe, and there is no reason why they should be particularly gentle to America.”

Not only did the war effort promote the spread of the virus, it also impeded the efforts to contain it. The obvious, of course, was the movement of troops — often against medical advice — that allow the pandemic to spread as it did. Once the United States entered the war, President Wilson would go “all in”, making it the top priority not only for the government, but the entire country. Troops were being drafted, trained, and transported by the thousands, typically in conditions ideal for the virus to spread.

And spread it did. The Great Influenza describes, in often graphic detail, the conditions at the assorted training camps and military encampments. It’s a wonder more did not die.

There’s an interesting side note that the author only alludes to, but that struck me as soon as I read it.

… the harshness toward Germany of the Paris peace treaty helped create the economic hardship, nationalistic reaction, and political chaos that fostered the rise of Adolf Hitler.

In the months prior to his death, Woodrow Wilson championed dealing with Germany justly. In fact, it was a sticking point in much of the treaty negotiation process. Wilson is generally considered to have died of complications resulting from a stroke, but there’s a strong argument that the stroke itself was a side effect of having contracted, and recovered from, influenza in the weeks prior. During those weeks, however, his demeanor changed, and he made massive concessions before the treaty was signed; concessions which impacted Germany quite negatively.

That influenza might have lasting impacts on an individual’s thought processes and mentation is now considered a very strong possibility.

It’s very possible that a domino labeled “influenza” was somewhere near the start of a row toppled leading to World War II.

Differences

Before I focus on more of the similarities, there are a few important differences between 1918 and today.

One could argue that we don’t have a World War underway, and that massive troop movements aren’t responsible for mass transmission. On the other hand, the general public is significantly more mobile today, on both a national and international scale, taking up the mantle of disease vector quite efficiently.

The influenza itself has at least one significant difference.

Despite aberrations, then, in general in youth the virus was violent and lethal; in maturity it mellowed. The later the epidemic struck a locality, and the later within that local epidemic someone got sick, the less lethal the influenza.

The 1918 crisis affected primarily the strong and able-bodied. Older populations, those that today we consider “high risk”, were proportionately safer in 1918. (There are theories, one candidate being that an earlier, less aggressive pandemic, was a variant, and caused its survivors to develop partial immunity.)

Similarly the virus was weakening over time. The later communities were exposed to the disease, the lower the rate of sickness and death.

At this writing a new, more contagious version of our current enemy became evident just a couple of weeks ago.

Similarities

What struck me were the similarities. The “rhyme”, if you will, of Twain’s history.

Public health measures lack the drama of pulling someone back from the edge of death, but they save lives by the millions.

Wearing a mask, today, is still controversial. It has less drama than the heroic efforts happening in the hospitals across the country.

surgical needles (these too were all imported, so they set up a U.S. factory to produce them)

The supply chain, and specifically reliance on overseas sources for critical items, was already a weakness 100 years ago.

Krusen publicly denied that influenza posed any threat to the city.

Politicians and city officials routinely denied that the epidemic was a problem, well past the point of it being patently obvious.

Doctors and nurses were what was needed. Doctors and nurses. And especially nurses.

Nursing could give a victim of the disease the best possible chance to survive. Nursing could save lives.

Shortages of doctors were perhaps worse in 1918 (especially of qualified doctors), but it was nurses who made the real difference to those suffering, and who were perhaps in even shorter supply. In both cases their rate of infection and death was depressingly high.

The federal government was giving no guidance that a reasoning person could credit. Few local governments did better. They left a vacuum. Fear filled it.

Do I even have to say it? Our government’s lack of leadership (and, to be fair, that of several other countries) has only served to make our crisis that much worse. The same was true in 1918.

Vision

The book ends with an afterword — again, published in 2004 — that spells out what preparedness might mean, and what the future might hold.

You can guess where this is going.

And a severe influenza pandemic would hit like a tsunami, inundating intensive-care units even as doctors and nurses fall ill themselves and generally pushing the health care system to the point of collapse and possibly beyond it.

We are there today.

Indeed, during a routine influenza season, usage of respirators rises to nearly 100 percent; in a pandemic, most people who needed a mechanical respirator probably would not get one.

This happened exactly as predicted.

… similar problems—such as if a particular secondary bacterial invader is resistant to antibiotics, or shortages of such seemingly trivial items as hypodermic needles or bags to hold IV fluids (a severe shortage of these bags is a major problem as I write this)—could easily moot many medical advances since 1918.

… much of the U.S. vaccine supply is manufactured outside the country; in a lethal pandemic, there is a question whether another government would allow its export before its own population was protected.

A “shortage of trivial items” — one might not consider PPE “trivial”, but the shortages continue. And yes, where vaccine is produced, and the massive nature of the logistics getting the vaccine distributed, are just now becoming crystal clear.

Disease impact would also ripple through the economy to disastrous effect. With everyone from air traffic controllers to truck drivers out sick, just-in-time inventory systems would crash, supply chains would collapse, for lack of some part production lines would shut down, while schools and day-care facilities might close for weeks, and an overburdened “last mile” would limit the ability of people to work from home.

The economic impacts have been massive. While the “last mile” problem has certainly improved since the book’s publication, it remains a significant issue for many, as do the basic economics of being able to afford equipment and connectivity.

… SARS was infinitely easier to control than influenza would be. As it was, the world was put at risk by China, which initially lied and hid the disease. China’s candor has improved significantly, but China is still not fully transparent.

Indeed, while I concur with the author’s statement that China’s better but not as open as it should be, there are many who believe whole-heartedly that China is simply to blame. (See the quote above regarding Germany if this sounds at all familiar.)

… modelers have concluded that “layering” several interventions—most of them different kinds of “social distancing”—would at least stretch out the length of an influenza outbreak in a local community, easing the strain on the health care system.

Honestly, I thought “social distancing” was a new term. It’s need was predicted long ago, as was the concept, if not the term, “flattening the curve”.

Finally, if any NPIs are to have any effect, the public has to comply with the recommendations and sustain that compliance. That will be difficult.

NPI: non-pharmaceutical interventions. You know, like wearing a mask? “That will be difficult” is, at best, an understatement.

So the problems presented by a pandemic are, obviously, immense. But the biggest problem lies in the relationship between governments and the truth.

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 no one.

Honestly, this is perhaps the most depressing comparison of the entire book. “Manipulation” is the name of the game today, regardless of which side of whatever political fence you happen to be on.

One can only hope that, maybe, just maybe, we might learn something from our experience this time around.

One can hope.