Q&A: “Pandemics in Perspective: A Roundtable Discussion"

Select answers from Drs. Jane E. Boyd (JB), historical curator of Spit Spreads Death: The Influenza Pandemic of 1918–19 in Philadelphia at the Mütter Museum of The College of Physicians of Philadelphia, and Graham Mooney (GM), Associate Professor at Johns Hopkins University in the Department of the History of Medicine in the School of Medicine and the Department of Epidemiology in the Bloomberg School of Public Health

Question: Thanks for this great webinar. Working fine for me in Scotland. It seems that 'experts are back' in public discourse (at least in the UK) about COVID-19, they have regained authority. What was the status of past scientific and medical experts in past pandemics such as 1918? (Lawrence Dritsas)

JB: During the 1918–19 pandemic, state and local governments in the United States used the medical qualifications of health experts to reinforce public health messages. Newspapers also covered scientific research about the disease, quoting doctors and scientists as they raced to identify the source of infection and to develop vaccines and treatments. In Philadelphia, Dr. Wilmer Krusen, Director of the Department of Public Health and Charities, was quoted frequently in newspaper stories. He put his name on health posters printed in different languages and on signs posted on streetcars and around the city. One streetcar sign from October 1918 read:

LISTEN—MR. CITIZEN!

Dr. Krusen Says Spittle Becomes Dust and Blows About

Causes EPIDEMIC INFLUENZA Infection

4596 CITIZENS DIED HERE LAST WEEK!

IT’S SERIOUS STOP THE SPITTER

The title of our project, Spit Spreads Death, is taken from one of these signs. We know now that influenza does not spread in dust from dried spit, but focusing on public behavior like spitting or mask-wearing was a highly visible way for authorities to demonstrate that they were doing something to fight the disease. Dr. Krusen has often been blamed for the disastrous impact of the pandemic on Philadelphia, but a recent article places his actions during the flu in a wider context of urban public health and argues for his competence and quick action. 

GM: I'll refer to the section on "Medical systems and know-how" in this excellent History and Policy opinion piece by Michael Bresalier.

Question: What is the experience with confined populations during a pandemic—prisons? (David Maxey)

JB: Confining a group of people during a pandemic can be a double-edged sword. It can protect the group from becoming infected, or keep the disease from spreading outward to other groups, but it can also increase the infection rate within the group if the virus is already present, as we’ve seen on cruise ships. In the Philadelphia area in 1918–19, only a few institutions had strict influenza quarantines. Girard College, a full-scholarship boarding school for boys, had 903 influenza cases and nine deaths. Eastern State Penitentiary had just three deaths behind its high prison walls. Bryn Mawr College, a women’s college located in the suburbs west of Philadelphia, was also quarantined. Though 110 students (a quarter of the student body) fell ill, none died. Bryn Mawr was one of the “escape communities” with one or no pandemic flu deaths studied in a 2006 article on the effectiveness of non-pharmaceutical interventions (NPIs).

GM: This resource on Pandemics and Prison is embedded in a project about prison history.

Additional Reading:

“A Medical Historian on Why We Must Stay the Course in Fighting the Coronavirus,” The New Yorker, April 1, 2020.

Question: COVID-19 seems to present a unique challenge in that it is a very long-lasting and slow-moving illness—long incubation period (up to 14 days), followed by a week or more of milder symptoms and then a long hospitalization period for the seriously ill.  How does COVID-19 compare to the 1918 flu in that sense? (Diana Leonard)

JB: The 1918–19 influenza virus generally acted fast. Some people died within 24 hours of contracting the virus, though other cases lasted longer before death or recovery. The variety and complexity of secondary infections (mostly, but not exclusively, bacterial pneumonia) caused a range of illness lengths and symptoms. A 2007 article—co-authored by Dr. Anthony Fauci—details the origins and epidemiology of the 1918–19 influenza virus. This article compares the coronavirus to the most recent influenza pandemic, the swine flu pandemic of 2009. The CDC has a website about the 1918 virus and pandemic that includes information about the reconstruction of the virus’s genome. 

GM: Again, I refer to this.

Question: The predominant experience of the COVID pandemic in the USA is not being sick or witnessing disease, but rather experience of "being locked in one's home." How does it compare to people's experience during past pandemics, and how is it novel and unusual? (Jakub Kwiecinski)

GM: Obviously all epidemics are different. One great source for understanding how people have responded to social distancing is Giulia Calvi, Histories of a Plague Year: The Social and the Imaginary in Baroque Florence, translated by Dario Biocca and Bryant T. Ragan, Jr., Berkeley: University of California Press, 1989. (Calvi used used court records of what we might call transgressions against self-isolation regulations. For many epidemics, however, people were sent to hospitals. Here's a nice piece that reflects on what was a common experience for many until the mid-twentieth century.

Question: In previous epidemics how long does it take on average for society to “normalize.” With these current recommendations of social distancing how long before we see people feel comfortable with gathering again and interacting again? (Paul Spechler)

GM: Depends on what "normalize" means! Difficult to say. It may be, and it is my personal hope, that the post-pandemic "normal" looks very different to the pre-pandemic normal in some areas, particularly inequalities in access to health care.

Question: How do we a avoid over preparing for every possible situation and even with having stockpiles of outdated technology? (Bill Mancuso)

GM: Not sure if "outdated technology" is referring to anything specific here. I'm not a big fan of the particular flavor of hindsight in this article, but Mark Lipsitch does make a good point when he says that, "the dilemma of public health is the more it does its job, the more it seems like it's overreacted."

Question: What kind of “spin” happened during the 1918 pandemic? (Nils van Ammers)

JB: News coverage of the 1918–19 pandemic in the United States was hampered by wartime laws that restricted free speech and freedom of the press and punished criticism of the government. Remarkably, President Woodrow Wilson made no public statements about the pandemic. In Philadelphia, as in most cities, war news dominated the papers. Even at the height of the pandemic in October 1918, influenza stories only sometimes made the front pages. To keep up morale, headlines of flu stories—like “Death Rates Mount But Cases Decline”—tried to put a positive spin on bad news. Despite these limitations, newspapers are a major source for researching the pandemic. In addition to case and death statistics, they printed health advice from the city; reported on the work of doctors, nurses, and volunteers; and recorded the deaths of people from all walks of life, from society matrons to policemen.

Question: What were the economic effects of the 1918-19 Flu Pandemic? Is our situation unique? (Matt Monteverde)

JB: Unlike now with coronavirus, there weren’t widespread, long-term business shutdowns in 1918. Public gathering places like schools, theaters, and saloons were closed in many cities, but most stores and other businesses remained open. Factories continued to operate to meet wartime production demands, though with reduced productivity. Because the flu came and went so quickly, any closures or slowdowns only lasted for a few weeks at most. As soon as death rates declined, cities and states lifted restrictions. A just-published article examines the highly disruptive effect of the 1918–19 pandemic on the U.S. economy. The authors conclude: “Timely measures that can mitigate the severity of the pandemic can reduce the severity of the persistent economic downturn.” 

GM: I haven't looked at this article in great depth, but this preprint paper is available. It may also address in part the question raised above by Paul Spechler.

Question: Was there a correspondent “gain” for organized labor after the 1918-19 flu pandemic? We’re currently seeing a valorization of grocery clerks and delivery drivers, was there ever something similar after the Spanish Flu? (Matt Monteverde)

JB: That’s a fascinating question, but it’s not something we studied specifically for our project—you’d need a labor historian to answer it properly. One study of the labor market from 1914 to 1919 found increased manufacturing wages in cities with high pandemic mortality, most likely because of the grim fact that employers were competing for a smaller pool of workers.

Question: How can we label the lack of coverage in media during the 1918 influenza pandemic as irresponsible—or even the holding of a liberty loan parade in Philadelphia as such—when they occurred during a World War? Do we not owe something to our soldiers? Isn’t this type of censorship and morale building also a core necessity of public health and wellness? (Nicholas Bonneau)

JB: Morale-building is important, but censorship that suppresses life-saving information can be dangerous. In Philadelphia, a few doctors tried to warn the city and the public of the risks of holding large public gatherings during a disease outbreak, but the pressure on the city to meet fundraising goals was too great and the Liberty Loan parade went ahead. The parade was not the only factor in the pandemic virus’s rapid spread in Philadelphia, but it almost certainly played a role. Once the pandemic took hold in the city, however, volunteers who were already mobilized for the war effort quickly pivoted to face the crisis. Clubs, businesses, organizations, and individuals set up an emergency telephone switchboard, drove victims to hospitals, helped to care for the sick in hospitals and homes, and much more. So we can say that patriotism and the war also had a positive effect on Philadelphia’s response to the disease. 

GM: I think the question points to governments navigating the fine line between transparency and keeping hold of the narrative. I think World War II also bears thinking about for comparisons. I read this with interest, particularly the implication that social solidarity can't be manufactured by messaging alone. "You cannot kill a virus by being cheerful" should give governments pause for thought.

Additional Reading:

Kevin Siena, “Epidemics and ‘essential work’ in early modern Europe,” History & Policy (March 25, 2020).

Question: Did the shadow of World War One and the great tragedies it wrought minimize the public’s view and reporting of the 1918 Flu Pandemic? (Ryan Berley)

JB: World War I certainly overshadowed the pandemic, though the exact relationships of the two events still need to be examined thoroughly. War stories were all over the newspapers, pushing pandemic stories to the inside pages, and censorship laws restricted reporting. Once the war was over, communities built memorials to the military personnel who had died in combat, but there were almost no public memorials for the victims of the pandemic. Instead, families mourned their lost loved ones quietly and privately. 

Question: What correlations can be made to the arts during 1918 and now? What was helpful then and what can be now? (Rheytchul Kimmel)

JB: One of the notable things about the 1918–19 pandemic is how small a cultural footprint it left behind, especially compared to the literature, visual arts, and music directly inspired by World War I. Pale Horse, Pale Rider, a short novel by Katherine Anne Porter published in 1939, is one of the few exceptions. The story is based on the author’s own experiences of being severely ill during the pandemic. But even though the pandemic is neglected in the cultural and artistic sphere, we discovered that many families have passed down memories of the event through the generations. Storytelling, no matter what form it takes, has always helped people to make meaning out of chaos and trauma.