Mr. Barry, a professor at the Tulane University School of Public Health and Tropical Medicine, was nice enough to do an e-mail interview with me about the subject of his book and what we can learn from it.
What follows is that e-mail interview, lightly edited:
Tapper: John, thanks for doing this. I have a lot of questions about your great book! First one: What lessons can we learn from the influenza pandemic of 1918-19 that we should be applying today?
John Barry: There are several and I think they are all important.
No. 1, authorities need to tell the truth, even when it’s uncomfortable – especially when it’s uncomfortable. This is important for two reasons. First, it lessens fear. People are always more afraid of the unknown. When people don’t think they’re getting a straight message they feel uncertain. In a horror movie, it’s always scariest before the monster appears. Once the fear becomes concrete we can deal with it. We can deal with reality. Second, if you want people to comply with your recommendations – and compliance is crucial to success – they have to believe you and trust you. If they doubt you they will ignore you. In Singapore, the Prime Minister told blunt truths at the beginning, ended panic buying and, more importantly, it’s one reason Singapore has gotten way ahead of the virus.
In 1918 in Philadelphia, for example, people were lied to and the city all but fell apart. Volunteers were called for again and again and again, but no volunteers came forward. People were starving because no one had the courage to bring them food. In San Francisco, city leaders jointly signed a statement, full page in the paper, “WEAR A MASK AND SAVE YOUR LIFE.” They did not know masks did no good, but the point is that the city functioned well, even though people were afraid – with the result that, in another example, when schools closed teachers volunteered as anything from ambulance drivers to telephone operators.
Tapper: The President recently referred to the 1918-1919 influenza as being much deadlier than Covid-19, saying, “If you got it you had a 50/50 chance or very close of dying.” Is that accurate?
Barry: Not even close. The 1918 virus was deadlier than Covid-19, but in the West it had about a 2% case mortality rate. In the rest of the world it was much worse, not because western medical care was better but because in the West people had been exposed to other influenza viruses, which provided some natural cross-protection. In much of the undeveloped world people had seen few influenza viruses, and sometimes none so it was higher there, but nothing like 50%.
Tapper: Covid-19 started in Wuhan, China, and the Chinese government tried to keep it quiet and even silenced those sounding the alarms. While different from the World War I-era US culture of downplaying, if not suppressing bad news, and the WW1 French/British/German policy of outright censoring bad news. Do you think the lack of transparency cost lives today too? In other words: a lesson not learned by the Chinese?
Barry: Clearly the lack of transparency cost lives in China and will cost many more lives around the world. I’m no expert on China, but my guess is that was the typical bureaucratic response of underlings afraid to send bad news up the ladder so they tried to hide it. I doubt that it was a decision by top leadership, which I think did learn from SARS. If they had been truthful and had responded aggressively, we would be in a far better position. By contrast, the Chinese scientific community was open from the beginning, posting the genetic sequence of the virus as soon as they had it. That was hugely important and gave us a head start on drugs and a vaccine.
Tapper: One of the cruel ironies your book captures is how unfair it is for people to refer to the 1918-1919 influenza as the Spanish Flu. The Spanish didn’t have censorship so their newspapers were the first to acknowledge the pandemic – but it didn’t originate there. And other countries weaponized that press freedom against them.
Barry: That’s true that it did not start in Spain. We’re not sure where it did start – the leading hypotheses are China, the US, France and Vietnam, but it could have started somewhere else and definitely did not start in Spain. It did get its name because Spain was not at war and its press wrote freely about it, especially after the King got sick. But that occurred during the first spring wave, which was mild – so mild that some medical journal articles suggested it wasn’t influenza because not enough people were dying. So I don’t think it was a conscious effort to point the finger at some malignant outside force. Calling Covid-19 “the Chinese virus” by contrast seems to be a conscious political strategy.
Tapper: Your mention of the relatively mild first spring wave in 1918 reminds me that that pandemic had several waves. Dr. Anthony Fauci, the director of the National Insitute of Allergy and Infectious Diseases, says we should all prepare for such a thing in the current crisis. How did the waves work in 1918-1919 and what lessons can we glean?
Barry: In 1918, we had a generally mild spring wave, which was hit or miss. New York, Chicago and Louisville, among other places here and around the world, had pronounced but localized outbreaks yet Los Angeles did not record a single spring death from influenza. Although it was generally mild, there were plenty of hints that it could be very deadly. In one small Army post, for example, it killed 5% of the soldiers. In Louisville, it was pretty bad. Then came the lethal second wave that hit in September. Probably two-thirds of the deaths worldwide occurred between late September and late December. Then came a third wave in March and April 1919, lethal by any standard except the second wave.
There is absolutely no indication – zero, not the slightest hint anywhere in the world – that Covid-19 will become more virulent than it is now, so we can relax on that question. Don’t worry about it. However, I do expect it to come and go in several waves, and I expect it to become endemic – it will be here forever. But that is not necessarily scary. Right now no human’s immune system has ever seen it before. As our bodies become familiar with it, there’s a very good chance we will be able to deal with it much better naturally, even without a vaccine or drugs.
As far as lessons, this is a marathon. We can’t wait out the virus. But we also need to get ahead of it, get all sorts of things in place, before we restart the economy or we will be in big trouble
Tapper: President Trump on Thursday said he is “hearing it loud and clear from everybody” that people want to go back to work. He said, “We may take sections of the country, we may take large sections of our country that aren’t so seriously affected and do it that way, but we have to start the process pretty soon.” What do you think?
Barry: To do that now would be disastrous. The virus will get everywhere, and I mean everywhere. There are ways to get parts and even all of America back to work eventually, but they are complex.
Right now, as far as regions where so far there is little transmission, Singapore and South Korea have created models for what to do, but right now we don’t have the resources to follow their lead even in places that so far have little community transmission. First, we need capability for all sorts of surveillance starting with tests, which are still not available in anywhere near quantities needed. In fact right now people are running out reagents that make the tests work. Once we do solve the testing problem, if there are still regions without much community transmission, we can use tests and contact tracing and isolation and quarantine as those countries did to keep them operating, but all that has to be enforced rigidly. Rigidly. Any leakage will likely launch an explosive outbreak.
Tapper: Soldiers and other service members were at real risk then and now because of travel and close quarters. How did the militaries of the world deal with the 1918-1919 influenza?
Barry: The 1918 virus killed the young, not the elderly. Well over 90% of the excess mortality was in people UNDER 65, roughly two-thirds of the deaths were age 18-50, and the peak age for death was 28. Soldiers were, of course, in the age group that was the prime target. The US military training camps obviously had high mortality. There’s an important lesson from them. There were 120 camps. Ninety-nine of them imposed some form of isolation and quarantine. Twenty-one did not. There was no difference in morbidity and mortality … that sounds discouraging but if you look deeper you see two very important lessons in that data.
First, they had to sustain these measures over time and most camps got sloppy after a few weeks, so the initial benefits were lost. That’s one lesson. You have to keep doing it to have impact.
Second, only a very few camps rigidly enforced all measures. Those few camps did succeed in flattening the curve substantially, but there were so few their results were submerged in the larger purely statistical study. Lesson is: you have to do it right, six feet apart, wash your hands etc, all the time, every time.
Now in an Army barracks, of course, it is much harder to achieve social distancing than the way most people live. So, in one sense civilians have an easier time in getting results – if they do what they should do and they keep doing it.
Tapper: Leaders during times such as these have to strike a balance between acknowledging ugly facts and projecting hope, admitting struggles and failures, and confidently leading the public out of the darkness. How did US leaders do it then versus now?
Barry: Woodrow Wilson never made a public statement about the pandemic. Never. And because of the war he had created a propaganda machine whose architect wrote, “The force of an idea lies in its inspirational value. It matters very little if it is true or false.” So to keep morale up during the war, the government lied. National public health leaders said things like, “This is ordinary influenza by another name.” They tried to minimize it. As a result, more people died than would have otherwise. Also, since people very quickly learned this was not ordinary influenza – people could die in 24 hours, symptoms could be as terrifying as bleeding from the nose, mouth, eyes and ears – and because they could not trust what they were being told, real terror gripped some people, so much so that society itself began to fray and it became everyone for himself. That’s different from most disasters, when people come together to help each other. In a very few places, like San Francisco, leaders were blunt about the threat. Those cities functioned much better. The community did come together.
Barry: In San Francisco, which functioned better than other cities I know of, there was plenty of fear but also a tremendous, well-organized volunteer effort. Every block was taken care of to make sure people got food and, if sick, were taken to emergency hospitals. After the outbreak, the San Francisco Chronicle crowed that when the city’s history was written “one of the most thrilling episodes will be the story of how gallantly the city of Saint Francis behaved when the black wings of war-bred pestilence hovered over the city.” Very few places could say that, but even in Philadelphia – which all but disintegrated into chaos, where desperate calls for citizen volunteers went unanswered – when the city asked police for four volunteers to remove bodies from homes, more than 100 police officers volunteered.
Tapper: It’s cliché to quote Santayana but it’s just true: those who forget the past are condemned to repeat it. Did people all too readily forget the 1918-19 influenza?
Barry: Whenever someone quotes Santayana, I quote Hegel: what we learn from history is that we learn nothing from history. The George W. Bush administration was determined to prove Hegel wrong and to learn the lessons of 1918. Led by an assistant secretary of Health and Human Services named Stewart Simonson, and backed up by the President himself, they created an infrastructure to prepare for a pandemic. President Barack Obama continued it and did in fact respond well both to H1N1 and Ebola. Trump spent January, February, and part of March forgetting every lesson. Hopefully his change of tone, now 11 days old, continues – although his desire to start everything up again in a few weeks suggests otherwise.
Tapper: Last question – and thank you so much for your time! How did the world get through the Influenza of 1918-1919? What did they do that we need to be doing more of?
Barry: Basically, in 1918 they just survived it. Most cities did impose social distancing but too late – the virus was already disseminated by the time the measures were imposed, so they had little effect. In a few exceptions, like St. Louis, they did succeed in flattening the curve. The result was 675,000 dead Americans, adjusted for population growth that’s equivalent to about 2 million today. That influenza virus was more lethal than Covid-19 but Covid-19 is likely to infect more people, so even with a lower case fatality rate you could see a huge death toll – unless we act.
Eventually people’s immune systems did become accustomed to the virus and became capable of dealing with it more effectively. In addition the virus itself seemed to change. Eventually it morphed into seasonal flu.
I agree with Tony Fauci. This virus is likely to be around from now on. It’s not going away. My hope is natural immunity along with drugs and vaccines will significantly diminish the threat of Covid-19.
CORRECTION: This story has been updated to accurately convey Barry’s reference to social distancing of six feet apart.