COVID-19

COVID-19 and Opening the Country: Lessons from 1918 Philadelphia

By CHADI NABHAN, MD, MBA, FACP

Everyone has an opinion on whether and when we should open the country. Never in the history of America have we had so many “correct” theories and experts to pontificate on a new pandemic. But somehow, few seem to recall history or attempt to learn from it.

Over a century ago, almost 100 million people out of a world population of 1.8 billion lost their lives to the so-called “Spanish Flu”. At 8.5 million casualties, the death toll from World War I pales in comparison. In the US alone, we lost over 675,000 people in one year to this pandemic. In fact, we lost more people to the 1918 flu than to World War I, World War II, the Korean War, and the Vietnam War combined. It was estimated that 5-10% of young adults had died. Nothing has ever come close in devastating the world’s population.

In early 1918, Dr. Miner from Haskell County in Kansas encountered several patients with a severe form of the flu that faded away by March 1918. He was concerned enough to report his observations to the US public health services, who published his concerns but then ignored the issue; there were more pressing problems facing the world, namely World War I. But in Camp Funston, a military complex, soldiers were faced with such cold weather and inadequate clothing that 7,000 of them suffered from the flu and nearly 100 died. Still, these warning signs didn’t seem alarming enough to prevent 1.5 million soldiers from crossing the ocean and going to war in Europe.

With time, more soldiers became ill and the illness increased in severity. Fevers were so high that doctors would mistake the flu for malaria. Patients bled from their mouths, eyes, and ears. Lung damage was so severe that doctors proclaimed the virus worse than mustard gas. The immune system reacted with what we call today the “cytokine storm”, which destroyed gas exchange in the lungs, causing hypoxia and severe cyanosis. Scientists debated if this was indeed the flu or the Black Death. Autopsies showed extensive damage to the lungs, heart, and brain. Among US, British, and French soldiers, over 300,000 suffered from the illness with 23,000 deaths. Many admit these numbers underestimate the real figures.

This virulent and mutated flu re-entered the US after the war had ended. There wasn’t much that doctors and nurses could do back then except what we call today “supportive measures”. Some tried enemas, mustard plasters, castor oil, sulfur smoke, bleeding, and even heroin. Public health responses included fumigating buses, trains, luggage, and passengers. Campaigns to wear masks and avoid public gatherings were in full swing. Snake oil salesmen were everywhere. The social distancing we are experiencing now was alive and well back in 1918, but with no internet, Netflix, or Twitter.

As we consider reopening the country in the face of COVID-19, let’s remember what happened to Philadelphia in 1918. On September 28, 1918, the biggest parade in the city’s history at the time proceeded: the Philadelphia Liberty Loans Parade, designed to promote government bonds that were being issued to cover the cost of WWI. Nothing was going to stop this celebration—not even the 200 flu cases reported the day before. Some medical experts warned against the parade, but these warnings fell on the deaf ears of Dr. Wilmer Krusen, the top public health official in Philadelphia. He was unwilling to cancel the parade and appear unpatriotic. As Dr. Fleury of Tulane University said recently, “Morale trumped public health.”

aircraft hull
An aircraft hull travels the parade route in Philadelphia (U.S. Naval History and Heritage Command Photograph) from smithsonianmag.com

Over 200,000 people crowded along Broad Street, stretching for 2 miles through the City of Brotherly Love. Everyone wanted to show their support at all costs. Marching bands and uniformed troops were on hand, the latest American arsenals were shown, and in one report, each time the music stopped, a bond salesman singled out war widows in the crowd—a move designed to show compassion and ensure that Philadelphia met its quota on loans.

Within 24 to 48 hours of the parade, several hundred people became ill. Suddenly Krusen became vocal, announcing that the flu epidemic was now “present in the civilian population”. Hospitals in Philadelphia started to fill with patients. Families started offering bribes to nurses so that their loved ones could be admitted and secure a bed.  Within 72 hours, every bed in Philadelphia’s 31 hospitals was filled. Within 2 weeks, over 2,500 people had died.

One day, Philadelphia was celebrating the end of a deadly war, but on the next, it began waging a new war against an invisible virus. Twelve emergency hospitals opened to care for the sick and dying. Many healthcare workers succumbed to the disease in a city where a shortage of physicians and nurses was at its height. Retired doctors and medical students were called to help. By the first week of October, all public gatherings were banned in Philadelphia. Bars and restaurants were closed, and you could only get whiskey from drug stores. A gallon of whiskey was priced as high as $52 in some stores (that’s in 1918 currency).

The celebratory parade seemed like a distant memory now that Philadelphia was labeled “city of the dead”. There were more orphans than ever before, and families left their dead relatives outside their doors where they were picked up by city officials. You had to offer bribes to secure a grave for a loved one, and you might even be asked to dig the grave yourself. By October 18th, the worst appeared over and by October 27th, churches started to open. Bars opened by the 30th, followed by chaos and disorderly conduct. Within 6 weeks after the parade, almost one quarter of the people in Philadelphia had fallen ill. Estimates of 500,000 sick and 12,000 dead were claimed, but everyone knew these numbers didn’t reflect the real tragedy.

Krusen made a major decision by allowing the parade to proceed; he feared that cancelling it would propagate more fear and cause the public to panic. Some newspaper headlines questioned the skeptics, asking, “Why are you scaring everyone to death?” Adding this to a government demand to meet a bond quota to cover the cost of war, Krusen felt he had no choice but to proceed. He feared being pointed at as someone who overreacted, but in proceeding, thousands lost their lives. After the epidemic, Philadelphia officially reorganized its public health department, which Krusen continued to lead until he joined the Philadelphia College of Pharmacy and Science. He served as president of the school from 1927 to 1941, before his death in 1943.

As we ask ourselves if it’s necessary to keep schools, places of worship, bars, and restaurants closed, let us remember what happened to Philadelphia in 1918. As we ask ourselves if we should open back up the cities and beaches, let us recall the thousands that died in Philadelphia in 1918. A few hundred miles away, St. Louis cancelled its 1918 parade and the death toll in St. Louis did not rise above 700 people. It’s not a perfect randomized controlled study, but it’s the best example we have to inform a decision that will save lives in 2020.

I fear that, once cities and states relax the COVID-19 restrictions, we may risk the kind of tragedy that Philadelphia faced in 1918 after people flooded the streets. We should open the country at some point, but not until we are certain that we can responsibly continue vigilance and distancing, amongst other needed measures. Otherwise, thousands will die.

Chadi Nabhan (@chadinabhanis a hematologist and oncologist in Chicago whose interests include lymphomas, healthcare delivery, strategy, and business of healthcare.

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