A Medical Historian Looks Back On The 1918 Flu Pandemic : Short Wave The 1918 flu outbreak was one of the most devastating pandemics in world history, infecting one third of the world's population and killing an estimated 50 million people. While our understanding of infectious diseases and their spread has come a long way since then, 1918 was notably a time when the U.S. practiced widespread social distancing.

Letters From The 1918 Pandemic

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MADDIE SOFIA, BYLINE: You're listening to SHORT WAVE from NPR.

KWONG: Hey, everybody. Emily Kwong here. Today, we're going back, oh, about 100 years or so to the flu outbreak of 1918, another huge pandemic. But to do that, we need the help of someone who really understands this time period.

HOWARD MARKEL: Well, it's been amazingly busy. When you are a historian of quarantine and epidemics and a worldwide pandemic occurs, it's sort of like your busy season. It's like being an accountant during tax season.


MARKEL: You're - everybody wants to get ahold of you.

KWONG: Including us. Dr. Howard Markel is the director of the Center for the History of Medicine at the University of Michigan. 1918 is a moment he's studied a lot because it's the most severe flu pandemic the world has ever seen. The virus infected one-third of the world's population back then, killed at least 50 million people. Obviously, we're nowhere near that today, and COVID-19 is a very different kind of disease. But there are lessons we learned 100 years ago that we're embracing now to contain the spread of this virus. For Howard, it's like one of his books has come to life.

MARKEL: A lot of these social distancing measures were things that I've been thinking about for - gosh, for almost 15 years. But I was much more comfortable thinking about them in my head than seeing them enacted around the country and around the world.

KWONG: So today, we time travel to the historic flu pandemic of 1918 and crack open the family archive to read some very, very old letters.


KWONG: Today, we're speaking with medical historian Dr. Howard Markel about the 1918 flu. Quick primer on science at that time - this flu broke out post-germ theory. So doctors knew that microbes caused infectious disease, but they were kind of in the dark about how viruses worked. And the U.S. responded in a way that might sound a little familiar.

MARKEL: Even though it was the 20th century, there was very little that doctors could do for their patients in terms of interventions. There was no medicines that really helped influenza patients. There were no IV fluids. There were no respirators. There was no vaccine. And widespread, for the community, all you really had were quarantine and isolation, and then there was also school closures and public gathering bans. And then there were a great many public service announcements - you know, wash your hands, don't cough or sneeze on people.

KWONG: Right. And you've described these before as nonpharmaceutical interventions, these practices of isolation and quarantine and limiting public gatherings. And when it came to pharmaceutical interventions, you're saying there weren't a lot around that time.

MARKEL: Well, pretty much, there were none.

KWONG: None.

MARKEL: I mean, you could take aspirin to lower your fever. But time was your best friend in that if your body fought off the infection, you would come out the other end. But if your body could not fight off the infection - your immune system either was not strong enough to fight it off or sometimes, particularly in the young people, they got what we think is a cytokine storm, where the immune system was so turned on that it caused damage to the body it was trying to protect. And there are doctors I've spoken to, who are treating COVID-19, witnessing a very similar phenomenon in those who do get sick and die.

KWONG: Yeah. It's interesting to hear these comparisons because, on the one hand, we've come such a long way in terms of modern medicine, but on the other hand, you know - is there a way in which you see us as kind of in a 1918 mindset by virtue of not having a vaccine?

MARKEL: Well, yeah. I mean, in a way, we're kind of pulled back to the 1918 era because not only do we not have any vaccines, we don't have any effective antivirals that could treat people who get sick. On the other hand, we have intensive care units with ventilators. And within hours, scientists at NIH figured out which protein would be the most antigenic to develop a vaccine.

KWONG: Right.

MARKEL: So I'd much rather have a pandemic today than in 1918 - let me put it that way. But what we are doing are really old-fashioned public health measures. We're actually hiding from the virus by doing these social distancing measures, hoping to buy time to a point where a vaccine may be ready.

KWONG: Yeah. So one thing that your research has really focused on when it's come to 1918 is that when social distancing was implemented early and continuously, it saved lives. And is there a lesson to be learned from that at the moment we're in right now, where you have states figuring out for themselves what to do and choosing different strategies?

MARKEL: There's two lessons. Those cities that did these social distancing measures the best, in an organized, layered, long - and they started them early - manner, came out with far better economic health than those that did not.

The second lesson is that 23 of the 43 cities we studied, the natives got restless after a while. They wanted to go back to their normal lives. And if you looked at the epidemic curve, it looked as if the cases and deaths were falling. But if they weren't low enough, the virus was still circulating and you got a second hump, another upward tick in cases and deaths, sometimes worse than the initial hump their epidemic curve. And each city was basically acting as its own control group because when the brakes went on, the cases went down. And then when the brakes went off too early, the cases went back up again. So that's something to think about.

KWONG: Right.

MARKEL: I mean, you know, epidemics are living, social laboratories. They involve many, many actors, not least of which is the microbe in question. Different microbes infect people in different ways. Different people behave differently before an epidemic than during an epidemic, in the middle of an epidemic when they're tired of it. So yeah, I mean, historians are going to be busy on this one for a long time to come. I could think of, you know, a dozen or more dissertation topics (laughter) for my students without even working very hard. So this is going to be uncharted water scientifically, microbiologically, medically, politically - almost every way you can think of.

KWONG: And you've discussed key differences between 1918 and now. But is there any difference that you hadn't added - that you wanted to mention?

MARKEL: Well, it is a lot easier to social distance today if you have a salary, if - you know, if you're not worried about economic loss. Think about how we're all working. A lot of us are working from home thanks to the Internet and the computer. I mean, (laughter) I just turned 60 the other day.

KWONG: Happy birthday.

MARKEL: Thank you. I know I'm going to sound like an old dude.

KWONG: (Laughter).

MARKEL: But I got to tell you - when I was growing up in the '60s, this was like science fiction, "Star Trek" kind of stuff.


MARKEL: You know, like, you're talking at a screen and the screen is talking back at you. I mean, this is just miraculous. And when I say this, I sound - I can hear my grandparents saying, oh, yeah, we had the radio and that was just great, you know, and it was for them (laughter).

KWONG: So it's my turn to talk about my family tree 'cause, I don't know about you, we have a lot of armchair genealogists in my family, and I promise this is relevant because my aunt has actual letters from 1918 written by her great-great-great-grandmother. Anna Sharp LaRue Smith writes about living in New Jersey, gardening and also dealing with this pandemic alongside her neighbors. And reading these really helped me understand and empathize with people who lived through this time period. So I decided to share them with Howard.

Here's one of her letters from 1918, so, like, just when the virus is really starting. She writes, (reading) I miss Frank - who's her son - coming up. But it isn't like it used to be here. I've always been glad to see all my friends and will be, but I am not as able to entertain as I have been. Well, I hope you will regain your strength and be able to keep things straight and write me whenever convenient. I must close with love to all, from Mother.

Then some more letters come. And one of the last letters she writes, she says, (reading) we all have colds, the tickly coughing kind. Don't seem to affect our appetites. Can't be on our feet very much. The time is coming that I will have to keep my bed more. The flu is still with us. Two deaths at Barley Sheaf (ph) last week. I received a letter from Baker (ph) saying Mami (ph), his youngest daughter, has died with it. They laid her beside her mother nearby where they live.

This was one of her last letters to her daughter-in-law, and she died the following March in 1919. My aunt believes that she did perhaps die of the flu.

MARKEL: Oh, yeah. You know, here's one little thing to offer about when will life ever go back to the way it was. So you had flu in '18, fall of '18, winter of '19 and another wave in '20. What happens in the 1920s? F. Scott Fitzgerald called it the grandest, gaudiest spree in American history, when you had the stock market roaring and business roaring and women declaring independence from their men in a way that was really quite exciting and scandalous. You had great music and entertainment. Life not only came back to normal; it roared into what we would call the 20th century. So that makes me positive that we will survive. And I have faith in the ingenuity of the human mind and the ability to rebuild, even from situations that seem quite disastrous and final. History tells us that happens.


KWONG: A big thank-you to Dr. Howard Markel, who joined us via Skype. Today's episode was produced by Brit Hanson and edited by Viet Le. Berly McCoy checked the facts. I'm Emily Kwong. Thanks for listening to SHORT WAVE from NPR.


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