How This Might End: Lessons From the Spanish Flu

Welcome, everyone. You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. I've been talking about COVID-19 since March, and everybody wants to know, when will this end? Can we learn anything from the Spanish flu? Many people have been talking about the pandemic that occurred over 100 years ago.

So to help provide some insights in how this pandemic may end, I've asked Dr. Howard Markel. He's the director for the History of Medicine at the University of Michigan. Dr. Markel, Thanks for joining me.

Hi, John.

Well take us back 100 years, in terms of, a lot of people are mentioning the Spanish flu. But everyone doesn't really now what was going on. So you can you give us a quick history lesson of the pandemic of 1918?

Well, probably in the summer, but not necessarily, there was a short, mild wave of influenza. Since we don't have viral samples, we can't really prove that. But we do know that in the fall of 1918, influenza, which we have since discovered was the H1N1 strain of influenza, ripped through the world, basically, and particularly the United States. And then there was a second wave or surge in the January to April part of 1919, which was pretty darn bad, but not as bad as the fall one. And then there was another surge, by the way, that nobody talks about, in the winter of 1920.

Well, by the time it was over, probably 40 million people around the world died. In the United States alone, anywhere from 550 to 750,000 people died, and at least 10 million Americans got very, very sick with influenza, which as you know is not a common cold, not a mild infection. It makes you quite ill indeed. There was very little medical care as we understand it. A hospital was basically a bed and maybe somebody feeding you hot liquids. There was no IVs, no antibiotics. And a lot of people who got the flu got a secondary bacterial pneumonia. And that's what killed them, because there was no medication for that.

So it was quite virulent. No one had experience with it. And it particularly affected, unlike most seasonal flus, which tends to affect and kill very little babies and very old people, it was a W shaped curve of mortality that in the middle V, where people from the age from 20 to 45. And they were dying like flies, and that was very odd for influenza.

Were people wearing masks? Was there social distance? Was there handwashing? People say there were issues with sanitation back then.

There were, of course, issues with sanitation. Not everyone had running water. 1918 is around the time in the United States where there were finally more people living in a city than living up in the country. There were soldiers, because there was World War I gearing up. And they were in army camps, where they dug latrines, and washed their hands from perhaps a well. So that was an issue.

Face masks were really in its infancy. And when they were worn in a few places, such as San Francisco, and Seattle, and Los Angeles, they were made out of four or five layers of gauze. You know how porous a layer of gauze is. So it's not exactly the most definitive way to prevent contracting influenza. But there were social distancing measures. That, in essence, was public health back then, quarantine and isolation. So you isolate the I'll, and you quarantine those you suspect of having contact with the ill. Public gathering bans, you know the closure of bars, of amusements, of theatrical events, of bars, and so on, and school closures. And in fact, we at the Center for the History of Medicine at the University of Michigan work with the CDC to do a rather comprehensive study of this. It was published in the Journal of the AMA in August of 2007.

But we found that those cities that did those social distancing measures and acted early, did more than one or layered them, and did them for a long period of time, did far better in terms of morbidity and mortality than those that did not. And in fact, that is the essence-- that is where flattening the curve came from. It was hard work that was the first historical evidence base of that concept.

Is that the lesson that we've learned from the pandemic? Because people will say, well, you know what? It's so different back then. Can we really make the same comparisons? You just referenced, there were issues with running water. So is it is it fair to make the comparisons? Because everyone keeps talking about 100 years ago.

Well, as a historian, I'm well aware of the differences between now and then. That's what I do for a living. And of course, the nation was smaller. The federal government had very little involvement at all in health issues back then, so very different medical context. And everything was different.

But what was the same was that you had big, populated cities that use these measures against an easily transmitted respiratory virus. And what's incredible is that it's not just the historical example of flattening the curve that seemed to bear out. It was also other modeling studies that were developed later. And then in the 2009 influenza pandemic, in the early weeks in Mexico, where they did not yet know it was not terribly lethal-- they thought it was highly lethal, as you may recall, in those first few weeks-- they too did a social distancing program. And their epi curves, their epidemic curves, were identical, if you will, to the ones that we found.

And of course, we have the best experiment of all, sadly. We have been doing social distancing measures all around the world. Nature Magazine called it the one measure that saved more lives in a shorter period of time than anything ever concocted by humans. And I think that's actually true. I mean, if you look at the lives that were saved, and the infections that were prevented when it was being done, it was working.

But you have to remember, social distancing is really a form of hiding from the virus. It doesn't prevent the virus. It doesn't treat the virus. It doesn't make you immune from the virus. And it's not an issue of waves, as much as that the virus is circulating, and circulating widely. So when you go out there, whether you're wearing a mask or not, but you interact with more people, for longer periods of time, you are increasing your risk of contracting COVID-19. It's as simple as that.

And the virus, we have to remember-- humans are the host. So it goes to your point about, if you're hiding, and you can't find a host, is it just going to fizzle out and die? And I wanted to ask you about how the pandemic up 1918 resolved. You mentioned that it came back in 1920. So was it herd immunity that everyone's talking about, recognizing it killed tens of millions of people? We didn't have a vaccine. We didn't have treatment.

Let's be clear about this term of herd immunity. And I'm telling you this is an old pediatrician. Herd immunity was never developed as a population kind of a measure when a virus spreads through a particular community. It was based on active immunity, giving people immunizations, giving lots of children immunizations, for example, for measles, mumps. And when you immunized actively, 90 or more of percent of a community, then when that infection came into that community, subsequently, it would not spread.

The notion of letting it rip and letting a lot of people get it-- first of all, you would never get levels of 60% to 90%, which is what people are estimating you would need. 20% simply wouldn't do it. And what is the point of living in the 21st century, if we're relying on 13th century methodologies of letting it spread throughout a community to protect us? Not to mention the incredible expense of taking care of people and the terrible tragedy of those who would die.

So it wasn't-- I mean, there were some people who were immune, to be sure. But of course, as you know, with flu, just like probably with coronavirus, you're not immune for that long of a period of time, maybe four or five months. But that's why we give flu vaccines every year. Some of it's because it's a different strain. But also, some of it is that your immunity has worn down.

How long do strains last? Because there was talk that ultimately, the pandemic of 1918 really morphed into something else. Do we have a sense of how long?

No, because these are issues of mutation, and where is the virus coming from. Influenza-- and by the way, you said 1918 is very different from 2020. Well, of course it is. But what nobody is saying is that the main historical actor in these two pandemics are quite different. Influenza is a very different virus than coronavirus 19, with the exception that their bones respiratory transmitted viruses. Influenza tends to burn itself out when the cold weather gets warmer. We know that. We were hoping that was the case with coronavirus, because we saw that with SARS, for example in 2003.

But this virus does quite well in warm weather, as we're finding out. But it probably will rage better in cold weather, especially as we're all indoors and crowded, and we use artificial forms of heat, which can cause little breaks in your mucosa, your nose and your mouth and so on. But it probably burn itself out because the weather changed. There were people who were immune. And the virus might have just attenuate and gotten more mild. But influenza every year changes, because it depends on the NMO host and the human host and the level of mutations. And are those mutations more than just typographical errors in the genome?

I mean, the real story-- I call this the mutation that was heard around the world-- was when coronavirus 19 mutated from whatever animal it was a host in, to the point that human beings could not only contract it, but easily transmit it to other humans by breathing on them. That was the killer mutation.

Well, you've studied the past, but I'm going to ask you about the future. How do you think this all ends?

Oh my. You know, historians like me are uncomfortable with the whole concept of the future. That's why you look in the past.

I know. But I can push you anyway.

As a doctor, I make prognoses all the time, however. There's a wonderful poem by TS Eliot, this is the way the world ends, with a whimper, not a bang. And it was written in 1925, but I'm blanking on the title of the poem. But will it just go away? Will it just vanish, like a miracle? Well, hopefully. I think, what the magic bullet that will protect us, and then end this nightmare, will be a safe, potent, and effective vaccine.

Once we do achieve herd immunity the old fashioned way, based on vaccines, I think then we have a fighting chance of ending this chapter in human history. But-- there's a huge but-- not just for industry or doctors or scientists or medicine to come up with the safe vaccine. But it's all of our responsibility, say here in the United States, or in Germany, or England, or other countries around the world, to roll up our sleeves and take that vaccination. And we already have an amazing amount of politicization with this pandemic, more than any I've ever seen or studied. That's a lot of epidemics over a lot of time. And we have anti-vaccinationists, and we have libertarians, we have this and that.

And so it will be essential to have leadership from the government, and in science, and in medicine, who demonstrates that the vaccine is safe and effective, and that we as a community all get vaccinated. Because it's a socially mediated disease. I can get you sick. And I won't get you sick, and you won't get be sick if we're both vaccinated.

In the history of pandemics, where does COVID-19, in your mind, rank, not just in terms of human fatalities, but also on the impact on life during that time?

That's a great dual measure, I think. The Black Death of the 13th and 14th century, of course, if you don't believe in it, go to Italy and look at all the frescoes in various churches and so on. I would count the Black Death of the 13th and 14th century. It's really high on my list maybe, number one. 1918-1919, number two, but certainly the greatest in terms of death and cases. And I would put COVID as a close third-- maybe not number one or two, but it's certainly up there in the top five. And a lot depends on how long this goes on.

Sure, and certainly not a ranking we want. Like other pandemics that you've studied, in general, you think it'll last a period of two years? Three years? A year? What's the historical reference?

Well, we don't have a historical reference. Because when you're using a very old pandemic, for example, like the Black Death, there was no medicine. And then the doctors who did exist had a completely different idea of what caused infectious diseases. And of course, even with 1918, you had, still, you had germ theory. But it was still a theory. And you had no medications to end it, and certainly no vaccines.

I wrote a piece for the New Yorker magazine this August about just that. And I said we would be measuring this not in weeks or in months but in years. Could it be only a year? I hope. Could it be more than that? It may. And as I said, it really depends on whether we get this vaccine.

Dr. Markel, I want to thank you for providing your insights, to giving us a history lesson, so we can learn from the past and not repeat, as you know, the line about we don't want to repeat the mistakes of the past.

Those who ignore the past are destined to repeat it. That keeps people like me gainfully employed.

Well, I thank you for sharing your insights.

Thank you.

And thank you for watching Coronavirus in Context.