Lessons from the 1918 Flu Pandemic

I had a little bird, its name was Enza

I opened up the window, and in flew Enza.

Nursery Rhyme, 1918

A little over a century ago, near the end of WWI, humanity suffered one of its most devastating pandemics in recorded history. Today, few people living have memory of this deadly disease, which killed between 50-100 million lives worldwide. Putting it in perspective, in 1 year, the Spanish flu claimed more lives than the Great War did in 4.

This nearly forgotten pandemic is often referred to as the “Spanish flu,” which is a misnomer. For, this flu neither originated from Spain nor was it most deadly there. Spain was a neutral country during the War and therefore it was the only nation reporting honest statistics, while the belligerents of the War censored or lied about their data. Thus, the name “Spanish flu” stuck.

Now, in 2020, we are in the midst of a new pandemic, COVID-19. It may be useful to look back in history to appreciate how a pandemic spreads and how best to deal with it.

In the spring of 1918, a new virus emerged out of a small town in Kansas. It spread quickly in military boot camps, sickening thousands and killing hundreds of young and otherwise healthy new military recruits. The flu traveled on packed trains to the East Coast and then by crowed troop ships to Europe. The flu went out of control in the trenches at the front-line, and somehow managed to jump over the “no man’s land” to begin infecting the German soldiers! It then spread through Eastern Europe, Middle East, Africa, and onto Asia. Within months, it was a worldwide pandemic. The contagiousness of this deadly disease is poignantly illustrated in the 1918 nursery rhyme.

There are some similarities between the Spanish flu and the current COVID-19 pandemic. Both are “novel,” meaning humans had not seen this virus before and thus had no natural immunity to it, making it more contagious and lethal than the common flu.

But there are important differences between the 1918 pandemic and the current one. In 1918, the medical world had no clue that a virus was the etiologic agent of the flu. Scientists went fervently searching for a needle in a haystack, without knowing what the needle looks like. A medical team isolated a bacterium and made a vaccine against it. Needless to say, it failed. Today, not only do we know the culprit of COVID-19, we have already sequenced the virus’ genome, and phase 1 study of a vaccine has already begun.

In 1918, we were in the midst of a world war, during which soldiers by the millions lived and traveled in close quarters, facilitating viral transmission. Back then, we had no effective respiratory care (no ICU, no ventilator) and had no treatment for infections (no antibiotics). Today, we live in a very different world. No one expects a repeat of 1918 calamity and death toll.

On the other hand, modern medicine has its limits. To date, we still have no proven antiviral agents against this virus. We can only manage the devastation of the infection with supportive care (ICU, ventilator, and ECMO).

Unfortunately, medical resources are not limitless. For example, there are a finite number of hospital beds, and even smaller number of ICU beds. In a place like the San Fernando Valley (population 1.7 million), I estimate that there are perhaps no more than 300-400 ICU beds total. If the virus strikes in full force, and infects just 20% of the population (340K), and suppose just 3% of the affected require ICU care (10K), we will run out of life-saving resources in an instance.

The fact is that we do not have millions of empty hospital beds waiting for an epidemic, and we cannot, like China, build 2 new thousand-bed hospitals in a few weeks. The United States currently ranks 32 worldwide in terms of hospital beds per capita (2.89 beds per 1000 population, compared to 13 in Japan). One can see how easily the system can be overwhelmed by a quick influx of the sick.

The mortality rate of COVID19 is estimated between 0.5% and 3%, meaning that the great majority of people will survive it. But that statistic depends on having access to medical care. If the medical system is overwhelmed beyond capacity, not only will many flu patients not receive care, many patients with other everyday diseases (such as heart attack and stroke) will be left untreated, contributing to the deadliness of this pandemic.

If that were to happen, the most dreaded scenario in medicine will have to take place - rationing. In certain hospitals in the United States, doctors have already run out of ICU beds and ventilators. The next patient in line will not live. That is not a possibility. It is reality that has already occurred in Italy.

Access to care - or lack thereof - is the true danger of COVID19.

How then, do we deal with this potential disaster? There is a simple solution. It’s called social distancing.

At this stage, the cat is already out of the bag and there is no way to contain the virus completely, but we can slow its rate of spread. The RO of the Coronavirus is 3. In other words, 1 person can easily infect 3 others. Therefore, the more we avoid contact with others, the less chance of its spread. By slowing down the rapidity of the pandemic, one allows the medical system to deal with the influx of the sick as a steady trickle, not as a tsunami. This is the so-called “flattening the curve” that people are talking about.

Does social distancing work? Of course it does. Unlike computer virus, a real-life virus cannot go where people do not go. If you lock yourself in your house and no one visits you, your chance of getting the virus is ZERO. It’s that simple.

There are unfortunately misinformed folks defying social distancing recommendation, thinking that they would survive even if infected. While that may be true (mortality rate for those <30 is extremely low), their being infected only fans the fire of the pandemic.

A simple question to ask the skeptics is this: while they themselves might not die, do they really want to kill their spouse, parents, and grandparents in the process?

We can refer to history to learn the effectiveness of social distancing. In 1918, despite warning of new cases of flu, the city of Philadelphia held a previously planned parade of 200,000 people. Within a week, 4,500 citizens of the city were dead. St. Louis, in contrast, closed school and banned all public gathering, and they fared dramatically better. Even though there were still cases in St. Louis, the city had effectively “flattened the curve” and avoided the tsunami.

A more recent example can be seen in Wuhan, ground zero of COVID19. In that city of 11 million, lockdown began on 1/23/20, rendering the huge city a virtual ghost town. Within a few weeks, rate of new cases already began to slow. Today, Wuhan reported ZERO new case of the COVID-19, proving that social distancing works.

Eventually, all pandemics will run its course and go away, but it will take time. It is what we do during that time that makes the difference in how many people will die, and how many will live.

This process will necessarily be very painful, both psychologically and financially. But the pain is temporary and well worth it, considering how many lives it will save. Today, we live with abundance of modern amenities (Amazon, Blue-apron, Netflix, YouTube, etc.) that folks didn’t have in 1918. We can weather this storm much easier than in 1918. In fact, with a refrigerator filled with food and a bathroom packed with toilet papers, this is not a lock-down, but a mini "staycation."

As of this week, I have already canceled all my non-emergency surgeries and stopped seeing patients in the office except for those with truly urgent issues. I have also advised all my patients, friends, and family to isolate themselves in their home and not to leave the house unless their life depends on it.

In the end, no one will ever die from being out of toilet paper or hand soap. But if you venture out and stand in line with hundreds of other potentially infected people at Costco, you might increase your chance of dying, if not from catching the virus, from fistfights over toilet paper.

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