Isegoria

Governments aggravated the horrors of the 1918 flu:

For instance, the U.S. military took roughly half of all physicians under 45—and most of the best ones.

What proved even more deadly was the government policy toward the truth. When the United States entered the war, Woodrow Wilson demanded that “the spirit of ruthless brutality…enter into the very fibre of national life.” So he created the Committee on Public Information, which was inspired by an adviser who wrote, “Truth and falsehood are arbitrary terms….The force of an idea lies in its inspirational value. It matters very little if it is true or false.”

At Wilson’s urging, Congress passed the Sedition Act, making it punishable with 20 years in prison to “utter, print, write or publish any disloyal, profane, scurrilous, or abusive language about the form of government of the United State…or to urge, incite, or advocate any curtailment of production in this country of any thing or things…necessary or essential to the prosecution of the war.” Government posters and advertisements urged people to report to the Justice Department anyone “who spreads pessimistic stories…cries for peace, or belittles our effort to win the war.”

Against this background, while influenza bled into American life, public health officials, determined to keep morale up, began to lie.

Early in September, a Navy ship from Boston carried influenza to Philadelphia, where the disease erupted in the Navy Yard. The city’s public health director, Wilmer Krusen, declared that he would “confine this disease to its present limits, and in this we are sure to be successful. No fatalities have been recorded. No concern whatever is felt.”

The next day two sailors died of influenza. Krusen stated they died of “old-fashioned influenza or grip,” not Spanish flu. Another health official declared, “From now on the disease will decrease.”

The next day 14 sailors died—and the first civilian. Each day the disease accelerated. Each day newspapers assured readers that influenza posed no danger. Krusen assured the city he would “nip the epidemic in the bud.”

By September 26, influenza had spread across the country, and so many military training camps were beginning to look like Devens that the Army canceled its nationwide draft call.

Philadelphia had scheduled a big Liberty Loan parade for September 28. Doctors urged Krusen to cancel it, fearful that hundreds of thousands jamming the route, crushing against each other for a better view, would spread disease. They convinced reporters to write stories about the danger. But editors refused to run them, and refused to print letters from doctors. The largest parade in Philadelphia’s history proceeded on schedule.

The incubation period of influenza is two to three days. Two days after the parade, Krusen conceded that the epidemic “now present in the civilian population was…assuming the type found in” Army camps. Still, he cautioned not to be “panic stricken over exaggerated reports.”

He needn’t have worried about exaggeration; the newspapers were on his side. “Scientific Nursing Halting Epidemic,” an Inquirer headline blared. In truth, nurses had no impact because none were available: Out of 3,100 urgent requests for nurses submitted to one dispatcher, only 193 were provided. Krusen finally and belatedly ordered all schools closed and banned all public gatherings—yet a newspaper nonsensically said the order was not “a public health measure” and “there is no cause for panic or alarm.”

There was plenty of cause. At its worst, the epidemic in Philadelphia would kill 759 people…in one day. Priests drove horse-drawn carts down city streets, calling upon residents to bring out their dead; many were buried in mass graves. More than 12,000 Philadelphians died—nearly all of them in six weeks.

Across the country, public officials were lying. U.S. Surgeon General Rupert Blue said, “There is no cause for alarm if precautions are observed.” New York City’s public health director declared “other bronchial diseases and not the so-called Spanish influenza…[caused] the illness of the majority of persons who were reported ill with influenza.” The Los Angeles public health chief said, “If ordinary precautions are observed there is no cause for alarm.”

For an example of the press’s failure, consider Arkansas. Over a four-day period in October, the hospital at Camp Pike admitted 8,000 soldiers. Francis Blake, a member of the Army’s special pneumonia unit, described the scene: “Every corridor and there are miles of them with double rows of cots …with influenza patients…There is only death and destruction.” Yet seven miles away in Little Rock, a headline in the Gazette pretended yawns: “Spanish influenza is plain la grippe—same old fever and chills.”

People knew this was not the same old thing, though. They knew because the numbers were staggering—in San Antonio, 53 percent of the population got sick with influenza. They knew because victims could die within hours of the first symptoms—horrific symptoms, not just aches and cyanosis but also a foamy blood coughed up from the lungs, and bleeding from the nose, ears and even eyes. And people knew because towns and cities ran out of coffins.

People could believe nothing they were being told, so they feared everything, particularly the unknown. How long would it last? How many would it kill? Who would it kill? With the truth buried, morale collapsed. Society itself began to disintegrate.

In most disasters, people come together, help each other, as we saw recently with Hurricanes Harvey and Irma. But in 1918, without leadership, without the truth, trust evaporated. And people looked after only themselves.

In Philadelphia, the head of Emergency Aid pleaded, “All who are free from the care of the sick at home… report as early as possible…on emergency work.” But volunteers did not come. The Bureau of Child Hygiene begged people to take in—just temporarily—children whose parents were dying or dead; few replied. Emergency Aid again pleaded, “We simply must have more volunteer helpers….These people are almost all at the point of death. Won’t you…come to our help?” Still nothing. Finally, Emergency Aid’s director turned bitter and contemptuous: “Hundreds of women…had delightful dreams of themselves in the roles of angels of mercy…Nothing seems to rouse them now…There are families in which the children are actually starving because there is no one to give them food. The death rate is so high and they still hold back.”

Philadelphia’s misery was not unique. In Luce County, Michigan, a couple and three children were all sick together, but, a Red Cross worker reported, “Not one of the neighbors would come in and help. I …telephoned the woman’s sister. She came and tapped on the window, but refused to talk to me until she had gotten a safe distance away.” In New Haven, Connecticut, John Delano recalled, “Normally when someone was sick in those days [people] would bring food over to other families but…Nobody was coming in, nobody would bring food in, nobody came to visit.” In Perry County, Kentucky, the Red Cross chapter chairman begged for help, pleaded that there were “hundreds of cases…[of] people starving to death not from lack of food but because the well were panic stricken and would not go near the sick.”

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Prompted by the re-emergence of avian influenza, governments, NGOs and major businesses around the world have poured resources into preparing for a pandemic. Because of my history of the 1918 pandemic, The Great Influenza, I was asked to participate in some of those efforts.

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Then there are the less glamorous measures, known as nonpharmaceutical interventions: hand-washing, telecommuting, covering coughs, staying home when sick instead of going to work and, if the pandemic is severe enough, widespread school closings and possibly more extreme controls. The hope is that “layering” such actions one atop another will reduce the impact of an outbreak on public health and on resources in today’s just-in-time economy. But the effectiveness of such interventions will depend on public compliance, and the public will have to trust what it is being told.

That is why, in my view, the most important lesson from 1918 is to tell the truth. Though that idea is incorporated into every preparedness plan I know of, its actual implementation will depend on the character and leadership of the people in charge when a crisis erupts.

I recall participating in a pandemic “war game” in Los Angeles involving area public health officials. Before the exercise began, I gave a talk about what happened in 1918, how society broke down, and emphasized that to retain the public’s trust, authorities had to be candid. “You don’t manage the truth,” I said. “You tell the truth.” Everyone shook their heads in agreement.

Next, the people running the game revealed the day’s challenge to the participants: A severe pandemic influenza virus was spreading around the world. It had not officially reached California, but a suspected case—the severity of the symptoms made it seem so—had just surfaced in Los Angeles. The news media had learned of it and were demanding a press conference.

The participant with the first move was a top-ranking public health official. What did he do? He declined to hold a press conference, and instead just released a statement: More tests are required. The patient might not have pandemic influenza. There is no reason for concern.

I was stunned. This official had not actually told a lie, but he had deliberately minimized the danger; whether or not this particular patient had the disease, a pandemic was coming. The official’s unwillingness to answer questions from the press or even acknowledge the pandemic’s inevitability meant that citizens would look elsewhere for answers, and probably find a lot of bad ones. Instead of taking the lead in providing credible information he instantly fell behind the pace of events. He would find it almost impossible to get ahead of them again. He had, in short, shirked his duty to the public, risking countless lives.

And that was only a game.

In many ways, Hong Kong’s success containing the virus is against the odds:

Hong Kong has the fourth highest population density in the world and 90% of the population uses public transportation.

Hong Kong was affected early, with the first confirmed case on January 22. By end-January, there were already 13 confirmed cases.

There were multiple daily direct flights from Wuhan and tens of thousands of daily Mainland Chinese visitors in January and thousands of European visitors in February.

Hong Kong is among the world’s most elderly countries, with a median age of 44.4.

Despite this, as of April 8, Hong Kong has only had 4 deaths due to COVID-19 and fewer than 1000 confirmed positive cases.

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Hong Kong began shutting down public facilities when there were fewer than 10 confirmed cases. The government acted with urgency as soon as the first cases began to appear. Hong Kong shut down all schools, parks, and public museums on January 29th when there were just 9 confirmed cases and zero deaths. The Hong Kong Marathon was canceled on February 8, when the city had only 36 confirmed cases. This stands in stark contrast with governments elsewhere who were quick to administer travel bans but slow to encourage, much less mandate, social distancing. Examples include President Trump suggesting the threat from COVID-19 was exaggerated and Bill DiBlasio recommending New Yorkers go out on the town in early March. Other examples include the mayor of Los Angeles allowing a 27,000-person LA marathon when there were hundreds of cases in California and Madrid holding the International Women’s March in early March. According to Professor Yanzhong Huang at Seton Hall University, “Hong Kong chose in the very beginning to move toward maximizing protection, while [other countries] seemed focused on minimizing disruption to the economy and society.”

Hong Kong isolates ALL positive cases and quarantines close contacts in government facilities. Every person who tests positive, even if symptom-free, is put into the public hospital system. Patients are then required to remain at hospitals until they produce two consecutive negative tests. Should hospitals run out of beds, the government will isolate patients in other facilities. Details about every case are made public through government websites. All known contacts of the positive cases must spend 14 days in government quarantine. The importance of isolating positives cannot be understated. A study of one China province showed that 80% of cluster infections originated from people who tested positive and were told to rest at home. Wuhan began quarantining all mild cases in makeshift hospitals converted from offices, stadiums, and gymnasiums in early February, a move that helped dramatically slow the spread of the virus. Doctor Aaron E. Carroll wrote in the New York Times that a robust system of contact tracing and isolation is necessary to prevent further outbreak and lockdown.

Hong Kong’s population has broad virus awareness, largely a result of SARS. The memories and lessons of SARS linger in Hong Kong. Since well before COVID-19, masks have been commonly used by individuals who harbor a common cold. Buttons on elevators are frequently sterilized once if not more times each day. It is customary not to wear shoes within the home and gel sanitizer is widely available throughout shared facilities such as office buildings. The population quickly tapped into virus-prevention mode as soon as the news of the virus circulated from Mainland China. Not wearing a mask is shunned in Hong Kong, and the population takes pride in responsible, virus-preventative everyday behavior. According to a poll by SCMP, the majority of Hong Kong residents believe they have only themselves to thank rather than the government if the city wins its battle against COVID-19.

Hong Kong tests all people entering the country and requires them to home quarantine for 14 days. Hong Kong only recently implemented severe travel bans, denying entry to non-residents on March 25. There was, however, a 14-day required home quarantine for people arriving from Mainland China, which was then expanded to arrivals from nearly anywhere in the world. While a delay in requiring home quarantine for European and American visitors led to a second wave of cases, that surge has already begun to flatten. People in home-quarantine wear electronic bracelets that track location. While there were initial glitches with the technology, the spirit of the law is broadly respected and violations are enforced. Three people have already been sentenced to jail time for breaking the quarantine.

To put the coronavirus pandemic in perspective, consider what happened when the bubonic plague struck London in 1665:

The onset of the disease could be sudden, says Yale historian Frank Snowden: “You actually have people afflicted and in agony in public spaces.” Trade and commerce swiftly shut down, and “every economic activity disappeared.” The city erected hospitals to isolate the sick. “You have the burning of sulfur in the streets—bonfires to purify the air.”

Some 100,000 Londoners — close to a quarter of the population, equivalent to two million today — died. Some sufferers committed suicide by “throwing themselves into the Thames,” Mr. Snowden says. “Such was their horror at what was happening to their bodies, and the excruciating pain of the buboes” — inflamed lymph nodes — that are the classic symptom of the bubonic plague. Social order broke down as the authorities fled. “Death cart” drivers went door to door, collecting corpses for a fee and sometimes plundering the possessions of survivors.

The plague’s violent assaults on European cities in the Middle Ages and Renaissance periods created “social dislocation in a way we can’t imagine,” says Mr. Snowden, whose October 2019 book, Epidemics in Society: From the Black Death to the Present — a survey of infectious diseases and their social impact — is suddenly timely.

I interviewed Mr. Snowden, 73, over Skype. We’re both home in lockdown, I in California and he in Rome, where he’s gone to do research in the Vatican archives. In the mid-14th century, Italy was “the most scourged place in Europe with the Black Death,” he notes. In the 21st century, it’s among the countries hardest hit by Covid-19.

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Isolation as a defense against infectious disease originated in the city-states of Venice and Florence. Italy was the center of Mediterranean trade, and the plague arrived in 1347 on commercial ships. The dominant theory at the time was “miasmatism” — the atmosphere was poisoned — perhaps by visitors’ garments — and people get sick “when they breathe that in, or absorb it through their pores,” Mr. Snowden says. “That is, there is some emanation, and it can be thought to be coming from the soil, or from the bodies” of sick people.

After plague visitations, the Venetian navy eventually began to force sailors arriving at the harbor to disembark on a nearby island, where they remained for 40 days — quaranta — a duration chosen for its biblical significance. The strategy worked when it was enforced as disease-ridden fleas died out and the sick died or recovered. Mr. Snowden notes that Americans returning from Wuhan, China, in early February were “detained on army bases for a quarantine period” — 14 days rather than 40.

“We can see the roots of many aspects of modern health already in the Renaissance,” he adds. Another example is the wax “plague costume” worn by physicians. It resembled modern-day medical garb — “the protective garments that you see in the hospital for people dealing with Ebola, or this sort of space suit” — but with a long beak containing resonant herbs. They were thought to “purify the air that you were breathing in.” The costume “did, in fact, have some protective value,” Mr. Snowden says, because the wax repelled the fleas that carried the disease.

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The plague was more traumatic than a military assault, and the response was often warlike in its ferocity. One response was a “sanitary cordon,” or encircling of a city-state with soldiers, who didn’t allow anyone in or out. “Imagine one’s own city, and suddenly, in the morning, it’s cordoned off by the National Guard with fixed bayonets and helmets on, and orders to shoot if we cross,” Mr. Snowden says. Cordons were regularly imposed in European cities in times of plague risk, leading to terror and violence. In the 18th century, the Austrian army was “deployed to prevent bubonic plague from moving up the Balkan Peninsula and into Western Europe” by halting travelers who might be carrying it.

The sociologist Charles Tilly (1929-2008) famously argued that “war makes the state” — that borders and bureaucracies were forged by necessity in military conflict. Plague had similar effects, requiring “military commitment, administration, finance and all the rest of it,” Mr. Snowden says. In addition to a navy to enforce quarantines, “you needed to have a police power,” a monopoly on force over a wide area. Sometimes “watchmen were stationed outside the homes of people who had the plague, and no one was allowed in or out.”

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Infectious disease can change the physical landscape itself. Mr. Snowden notes that when Napoleon III rebuilt Paris in the mid-19th century, one of his objectives was to protect against cholera: “It was this idea of making broad boulevards, where the sun and light could disperse the miasma.” Cholera also prompted expansions of regulatory power over the “construction of houses, how they had to be built, the cleanliness standards.”

We’ve been hearing about pandemic models and policy responses lately. With that in mind, James Thompson discusses the logic of failure;

At a Royal Society lecture in 1990 I was charmed by a diffident presentation given by Prof Dietrich Dorner who described not his success in modelling the future, but the difficulties subjects had when they tried to manage fairly simple models.

His first example was extremely simple. Subjects had to turn a control dial so as to get a small target to move from the top of the screen to a line drawn horizontally across the middle. Clearly, the solution was to turn the knob clockwise so that the target sank down to the mid-line. This proved difficult. Dorner had arranged the system so the target only moved after a delay. Most subjects found this very confusing. They kept turning the dial to get the target down, only to find that after a period of no response the target suddenly shot down past the desired mid-line to the bottom of the screen. Irritated and confused, subjects then twisted the dial anti-clockwise, thus making it shoot back to the top of the screen. It took many corrections and much time to get the target onto the desired mid-line. A minority of subjects made just one cautious movement and then waited to see what happened. Such subjects were able to place the target onto the mid-line quickly and with very few moves.

This was a beautiful illustration of the key feature of executive power, that even if what you command has a real effect on a complex system in the real world, it is usually a delayed effect. Oil tankers take time to turn around.

I’ve discussed The Logic of Failure twice before.