COVID-19 Chapter 20: Looking forward by looking back

who are already facing excruciatingly difficult circumstances. For those who receive hospice care at home, many have not had a chance to spend cherished time with children, grandchildren, siblings, and friends who are unable to visit due to travel restrictions,

border closures, and the risk of virus exposure. This also means that family members who would ordinarily jump in and lend a hand with the intensive responsibility of twenty four to seven care for a loved one who is dying, are less available to provide the kind of practical and

emotional support families need. Many who are terminally ill also receive hospice care in nursing communities, and that has proven especially challenging As a result of state restrictions to protect this population from devastating outbreaks, family members and hospice support staff are rarely permitted to visit nursing community residents in person right now, although family members are occasionally able to schedule window or outdoor visits, these are typically limited to

thirty minutes or so. They are dependent on whether and difficult or impossible to coordinate for those who are bedbound, and unfortunately, window and outdoor visits are incredibly confusing for people who have dementia and frustrating for those with hearing and visual deficits. Telephone and video visits are typically not optimal or possible for the same reasons. So imagine that

you're living in a nursing community. Anticipation builds as you're willed to an outdoor visiting area where your wheelchair is locked in place six feet away from your son or sister or best friend you haven't seen in six months. You can't hear what they're saying because you're too far away.

You can't watch their lips because they are wearing masks, can't hug them, and aren't allowed to sit with them and enjoy your favorite lunch they picked up on the way to visit someone inside inners in community during the pandemic in the state of Colorado. Your loved one must be actively dying to qualify for what we're calling compassion visits. Occasionally, hospice support team members are permitted to visit during this

short window of time. When people are dying, their greatest need is almost always to spend time with those who are closest to them, reflecting on memories, verbalizing expressions of love, offering forgiveness, seeking reconciliation, and sharing hugs and kisses. There's usually some level of fear about the dying process, concern regarding a finish business, and a desire to address these issues.

When family members, friends, and support staff can be present to offer reassurance, calm anxiety, answer questions, and respond to unmet emotional and spiritual needs, the dying process is more peaceful for the person who is dying and also for

family members and other companions during the process. It's important to know that when we're actively dying, that period of time when in person compassion visits are allowed, we can generally hear what's going on around us, but are minimally responsive and don't have the energy to engage in conversation. During this especially tender time, I encourage family members and friends to keep talking to their loved one and watching for subtle signs of response, usually a facial movement or

eyes opening briefly. The difficult part of limiting family visits to the last few days of life is that most of us want opportunities to interact, to have important conversations before our loved one is actively dying and becomes minimally responsive. This is often not possible with current guidelines. That's heartbreaking for family members and friends, and also difficult for healthcare

staff to witness. In fact, it compounds and complicates screeting process, not only now, but likely for years to come.

own kids de facto case managers and service providers. Each kid enrolled in special education services gets an Individualized Education Plan or IEP written for them every year. This year we had to amend every IP with a remote Learning contingency plan within the first month of school. During that time, the district changed their attendance plan and we had to adjust our servicemnts written on each IP as we rewrote

our contingency plans. And the worst part for me and probably all of my colleagues as well, is that all this paperwork and bureaucracy comes at the expense of getting to actually spend time with our students. By far, the most important part of being a special education teacher is forming relationships with the students in our resource classes and our caseloads, but so much of our energy has been

spent rewriting legal documents and organizing legally mandated meetings. I have some students I haven't even met all year, Even now that our district has gone back to full time in person. I actually had to hold an IPU eating last week for a student I haven't met at all. Fortunately, that student's guardian was very understanding and was able to

be a strong advocate for them. Any teacher can tell you that it feels like very little actual teaching and learning has been happening since about March of twenty twenty, but in special education it's been particularly difficult. We're now back to school all day, every day with masks and social distancing, and it's becoming more and more clear just how much we lost being unprepared for a pandemic. All we can do now is try to make up as much lost ground as we can.

the PCR test. The idea is to catch cases of COVID nineteen that wouldn't have been apparent, you know, because they don't show symptoms. And we work in a school, so we test teaching staff and all the pupils twice a week now, although the government guidance changes pretty much every week, so sometimes we're telling people to swab their tonsils four times, sometimes it's five, Sometimes it's just two

on each tonsil, sometimes it's just upper nostril. We're really playing it by ear and it seems quite inconsistent the guidance. So we're just learning to try and be as accurate as we can under the changing circumstances. And we're all absolute beginners. My own degree was in French. I have no medical background. The only people that are test center with a medical or scientific background are our labtape technicians, and they taught us to be really meticulous and careful

when we process the samples. We've seen some hilarious things. Some of the kids have asked what the tonsils are. Some of them swab the outside of their neck or we handed them the swab. The kids are very resilient and they're adapting remarkably well to this situation. I think it's other people who are having a hard time here in the UK. The public sector is a big support

network for people, especially in poorer communities. We need places like schools, ordinary state schools and libraries health centers to stay open, but it's difficult because of the pandemic and we have to turn people away who are actually quite lonely without those services. And in terms of our rollout of mass testing, it's focused on key workers, for example, those who work in factories for food production, supermarkets, healthcare

and education. But it's mostly run by volunteers and redeployed council workers. So sometimes we worry that we're not really qualified to be conducting tests and giving people these very crucial test results. And recently, the most striking thing that I've found is that older people who I work with in the test center, who guide our students through the swabbing process, have been comparing the effort we're all making

collectively against COVID nineteen as a war effort. And you know that these are the people who they can remember their parents being involved in, you know, the war effort of the Second World War, and they're right you know, much like how women during war time moved to working in factories elements they never worked in before. Those of us who work in the public sector in the UK, who are employed by the local councils have been sent to deal with this crisis. We test people, We try

and pick up on asymptomatic cases of COVID nineteen. We have jobs now where we're responsible for maintaining health and safety, avoiding cross contamination, and so much like a war effort, what I've seen here in the UK, especially among teachers and ordinary low level government workers, the wonderful ways in which ordinary working people can really pull together in times of crisis. And it's been amazing to see how it's brought people together, even though of course there's a lot

of hardship. Ultimately, just like with a war effort, everybody has pushed their limits and found something to do. I love working in the test center. It's actually really good fun and it makes me feel like a scientist.

of the current COVID nineteen pandemic. With so many articles and podcasts and books and news programs and so on making comparisons between what's happening today and how things transpired in nineteen eighteen, and many of these comparisons are apt

in some ways. What happened in nineteen eighteen is eerily reflected in the events of twenty twenty and twenty twenty one, and neither of us has gotten up the nerve to re listen to The very first episode of this podcast, and We Never Will Never Will I was released in twenty seventeen on the nineteen eighteen influenza So pre COVID, and several listeners who have listened to it have pointed out just how spooky it is to hear in light of this current pandemic.

impacts of the pandemic. But one of the biggest questions that remains unanswered is well, what happens now right, And of course we can't actually answer that question, and we're not really going to, but we can do the best that we can by looking at what happened in the nineteen eighteen influenza pandemic. Granted, the world was a very different place back then compared to today, but there are key lessons that we learned from the nineteen eighteen pandemic.

So how well did we apply them to this current COVID nineteen pandemic. And if we use the aftermath of the nineteen eighteen influenza pandemic as like a rough roadmap for a post COVID future, what are the limitations in those kind of comparisons? And what can we learn from the similarities between these two pandemics and from their differences.

the nineteen eighteen influenza pandemic. And I talk with John on May twenty fifth of this year, and we will let him introduce himself right after this break.

so forth. So I stayed involved in the area, you know, pretty regularly. I was on a federal government's Infectious Disease Board of Experts as the only non scientist on EDAM, and currently I have a title of Distinguished Scholar at the Tulane University School of Public Health and Tropical Medicine.

different diseases. So can you remind us of some of these similarities as well as some of the differences, things like, you know, the groups affected, the backdrop of World War One and what influence that had, case fatality rate, duration, et cetera.

so called these two for Sarus kobe two. Both viruses could bind to cells deep in the lung, which is unusual for influenza and doesn't happen with the common cold the other coronaviruses that we're familiar with. It. So you can start off with a very serious condition if you have a heavy load of virus deep in the lung. Both viruses buying to cells in the upper respiratory tract, which is why they are easily transmissible stars. COVID two

is much more transmissible than influenza. Ordinary seasonal flu is going to a reproductive number about one point two eight. The nineteen eighteen pandemic was about one point eight. COVID nineteen is about two point five to three, And in fact, the variants that have developed or higher than that, or would be if you didn't do anything to stop transmission. The target audience you might say, or target victims. In nineteen eighteen, probably two thirds of the dead were people

aged eighteen to fifty. Obviously, COVID nineteen is primarily people over sixty five. The difference in age groups it has certainly had tremendous impact in terms of the public response and the politicization of the disease. If most of the deaths two thirds of the deaths were people eighteen to fifty, you wouldn't hear anybody talking about let's try herd immunity, heard immunity I wouldn't work anyway for a variety of reasons. But I'm getting off the subjects. So let's say, uh,

both viruses in terms of similarity. Both of them, in fact, affect virtually every organ, quite literally from the testes to the brain. If anything, in nineteen eighteen there was even more neurological complications. And we're seeing today the two biggest differences other than the one I already mentioned, virulence, The nineteen eighteen pandemic was much much, much more virulent. People could die in less than twelve hours. They could die

with horrific symptoms. Now, most of the deaths were secondary bacterial pneumonia infections, which antibiotics would help with today. But even today, the case fatality rate for bacteria in pneumonia following influenza is about center eight percent, So that's roughly a quarter of what it was back in nineteen eighteen. It's still quite high for that disease. That aside, there were many many deaths that were directly caused by the virus so called long covid. That same phenomenon occurred in

nineteen eighteen. You know, worldwide, nineteen eighteen probably killed fifty to one hundred million people. If you adjust for population, that's sequel to two hundred and twenty five to four hundred and fifty million people today. So even if we did nothing with COVID nineteen except just let it run loose. The projections would not come up with anything like that kind of death toll, thank god. And another very important

difference is duration, which you mentioned. Influenza just moves much quicker, but much much faster in every area. Incubation period, how long you're sick, how long your shed virus, how long to recovery, all those things are much faster in nineteen and influenza, whether it's seasonal influenza or nineteen eighteen. In that sense, nineteen eighteen was just like ordinary infla, it's

just much faster. So in nineteen eighteen, probably as much as two thirds of the dead died in a period of really weeks, maybe fourteen weeks or so in the fall of nineteen eighteen, And in any particular place it was faster than that, because influenza then would go through a community in six to ten weeks, it would peak, and when it was gone, it was essentially gone. So

there were waves in nineteen eighteen, but they were very discreet. Obviously, COVID nineteen has been around for much much longer now. Certainly a lot of that is because we interfered and tried to stop transmission, which I certainly applaud and saved hundreds of thousands of lives in the United States alone, And that has stretched out the length of time we had to deal with the virus, no question. But even if we had not done anything but let the virus run,

we would still be dealing with it. So that's pretty much a rundown of these similarities and differences.

it or detract from it. This included any bad news which they felt was bad from around and as a result, there was a lot of fake news in nineteen eighteen, but it all came from the government, and the government was saying things like, this is ordinary influenza by another name.

What people knew was ordinary influenza by another name. If you know, someone's dying in less than a day after the first symptoms, sometimes in less than twelve hours, and people dying in such large numbers, you know, everybody knew it was an influenza by another name. Nonetheless, the government continued to insist upon that, and in almost every local community they echoed that refrain, although nobody believed it, but

it was not. There was no partisanship the entire country, probably more so than at any other time in American history. There was an effort by the federal government to control the way people thought, and also probably more so than any other time in American history. They were successful, but it wasn't partisan this time around. Obviously, it became highly partisan.

people have to believe what you're saying. They have to trust you, and without telling the truth, people are not going to trust you. You know, some countries around the world did tell the truth from the beginning and did

implement NPIs with extraordinary effectiveness. Well, Australia has had a total of nine hundred and nine deaths, which if you adjust for population, would be equivalent to twelve thousand deaths in the United States, and we are as we're speaking at five hundred and seventy nine thousand deaths in the United States. It's the same virus, they have, the same tools, they have the equivalent of twelve thousand deaths. We have

five hundred and seventy nine thousand deaths. The difference is leadership.

and so forth. And one of the newspapers that actually said, this is a direct quote, this is not a public health measure. You have no cause for panic or alarm. It's not a public health measure. I mean, how stupid did they think their readers were. All that did was tell people they couldn't believe anything that they were in the newspaper, which, of course back then was the source of information. You know, the result was it spread terror.

If you can't believe what you're being told and you're facing this very dangerous, even you know, horrific threat, then you were thrown entirely upon your own devices. Can't trust anybody. Fear is everywhere, and it spread fear and panic. And you know, in Philadelphia again it's an example when they were heads of volunteer efforts were calling for volunteers repeatedly, nobody was showing up. I think that was a direct

result of the loss of trust. You know, I think society essentially is based on trust, and if without trust, I think society begins to at best fray and at worst fall apart. And in Philadelphia, society certainly began to pray, and maybe even worse than that.

even disinformation. And this makes it really challenging to determine what is the truth, you know, and what is fiction.

find it. Again, that wasn't the case in nineteen eighteen. There were a couple of places, but they were pretty unusual where the public officials in that city were very truthful. San Francisco would be a primary example of that, but very unusual.

gathering in groups, social distancing, and so on. How did the nineteen eighteen influenza affect like public health infrastructure or the general perception of public health among the public.

in terms of false reassurance. Because of the war, you know, there wasn't really a relationship with the so called public health infrastructure. You know, pretty much every city tried to organize, certainly the larger cities did, you know, and they would have break the city into districts and so forth, and put people in charge of the districts, and it all sounded very good on paper. But the actual service to

those districts left a lot to be desired. You know, it was just so overwhelming, and they just didn't have the people for it. In terms of numbers of personnel, that huge percentage of the doctors and nurses were actually in the army. They had been drafted or volunteered. So the war really affected everything in terms of what happened inside the United States and how it was handled. In terms of the spread of the disease, I think the war was a very minor factor. You know, there are

people who think it's spread around the world. I think they're not thinking through what they're saying. We've had influenza pandemics that managed to cross the ocean in the sixteen hundreds, when it took weeks to cross the ocean, so you don't need an airplane. And of course much of the world, I mean all the world in nineteen eighteen, you know, Africa, South America, they were not at war, and they suffered

grievously from the pandemic. You know, I think the only impact the war had was it probably accelerated the spread in Western Europe a little bit, maybe more than a little bit, but we're still only talking about a few weeks difference.

they were less intrusive than what we went through. You know, no businesses were affected unless they were or like a saloon or a theater, because essentially every business practically was regarded as you know, essential war and so forth. All the factories remained open, and you know, there was a

tremendous amount of absenteeism. You know where we had data from war industries like shipbuilding, it was generally between forty percent and sixty percent of the workforce was absent, either sick or caring for somebody sick or just afraight, and you know minds. For example, according to Metropolitan Life Insurance, over six percent of all the miners aged eighteen to fifty died. And you're talking about dying in a matter of weeks again, But when it was over, it was over.

So we you know, having gone through this horrific experience for a period of weeks, everybody and the disease then disappeared and people went back to normal very quickly at the same time, almost to the day practically, obviously it would be a little different from depending where you are geographically and where the pandemic hit. But the war ended on November eleventh, just about the time in a lot of cities, a lot of parts of the country, the second wave of the pandemic ended. So you had this

tremendous exuberance at the end of the war. So things did return to normal quite rapidly. You don't build permanent new habits over a period of a few weeks.

And given the difference between the nineteen eighteen influenza and the COVID nineteen pandemic, do you think that the duration, the longer duration of COVID nineteen, might make this pandemic live in our collective consciousness a bit more vividly for a bit.

But yeah, having gone through this for more than the year certainly will have impact on everybody who went through it, and I think we'll remember and write about it more so than in nineteen eighteen. I think there'll be a lot of novels coming out of it, and a lot of nonfiction books, more so than in nineteen eighteen. Again, what behaviors, How much our behaviors will change, That's not entirely clear, but I think it will change at least somewhat.

terms of actual work you can. Just as today. Basically every scientist that had anything to contribute turned his or in a few cases her attention to influenza, and again it moves so quickly. It was the first wave that was hit or missed entirely, missed a lot of places. Where it did hit, it was extremely mild, and also to a scientific assessment at the time, it had a tendency to Peter Robbin. You know, nobody started work on anything in the first wave. There was no reason to.

The second wave shows up in the middle of September and it's gone by the middle of November, depending on where you are. Even today, with every tool we have available to us, we are scientists would not have been able to respond that quickly, and of course back then they didn't have the tools. Nonetheless, it was a tremendous amount of scientific progress made that was sparked by the pandemic.

We didn't know what a virus was in nineteen eighteen, knew there were these tiny, tiny organisms, but didn't know if they were just like bacterias, a small bacteria, whether it's entirely different kind of organism. And easily the most important discovery that you can link to the pandemic is a discovery that DNA carried the genetic code, which launched the entire field of molecular of biology, and that actually didn't come until nineteen forty four. But there are other things.

If you get a pneumonia shot today and bacteria and pneumonia vaccine, that is a straight line descendment of something that was developed in the middle of the pandemic. So and you know, there was a lot of other scientific work as well.

soldiers in combat. So it's the same age group, the same demographics, say uh, and you know, ten million civilians. And it was spid one of the stupidest wars ever fought without a doubt, with the worst generalship. Talk about waste. So I think that was an important part of the attitude of the Roaring twenties, the fatalism, the let's party, nothing else matters. Also, you added in the United States,

in utter collapse of agricultural prices. You know, the US during the World War One had fed France, Germany, Britain and so forth. Because all their farmers were in the army. US farmers greatly expanded the physical acreage that they were farming, and they were tremendous overproduction. When the war ended and prices utterly collapse, the farm economies went into depression right after the war and stayed there. Then you had a

serious recession in nineteen twenty in nineteen twenty one. Only after all that did you get to the Roaring twenties. So I think, you know, the pandemic had a little bit of impact on it, but it was much more the other things, particularly the war.

be fun, I hope for everybody. So psychologically, I think it'll be a lot different, but in terms of you know, activity, there'll probably be some similarity.

today than it was one hundred years ago. So can you talk a little bit about some of these limitations in applying lessons learned from the nineteen eighteen influenza pandemic to today's reality.

pretty much modeled on the federal plan. So transparency has written high up their highest priority of every state pandemic plan. The problem is, as you know, as every football coach will tell you, got to go out there and execute the United States and execute, you know, for political reasons. Unfortunately,

other countries did execute. So I don't I think the lessons from nineteen eighteen are absolutely valid and been validated by the experiences both in the United States and other countries where they've done it.

If the SAR is one virus had become easily transmissible between people, then we would be in a totally different place than we are now. So given the fact that there are going you know, and influenza viruses that are going to jump species from animals to humans, they're still out there. There are just a lot of There are viruses we've never heard of. There are other coronaviruses, you know, there are a lot of threats and the public health lesson. You know, hope the next time around people will have

learned that telling the truth matters. You know. The only time in Trump's entire presidency that he cracked fifty percent in approval rating was a couple of days after he declared war on the virus in March at twenty points. The only time people you don't want to rally around a leader, you know, the irony is for political purposes. The best thing he could have done was take on the virus and deal with it. Might very well have been reelected instead. He said the federal government is a

backup in a national crisis. When the head of the federal government says the federal government is a backup, I mean that is not leadership. That is the absence, the

abdication of leadership. Even if you love Trump, you have to admit that we needed a national response, and I think even the most politicized response in the future may take that into account and next time around and realize that the public health lessons from nineteen eighteen, which is I've made pretty clear, I think have been confirmed this time around that they are not only the best thing in terms of the public health, but did the best thing politically.

need to be honest. They need to be truthful about what they know and what they don't know. This is the only way that they will earn the trust and respect of the public and get the public's cooperation to participate in these non pharmaceutical interventions which save lives. And if you don't tell the truth, then you lose the

trust of the public along with their cooperation. The COVID nineteen pandemic has provided us with many examples of countries that told the truth and were able to successfully implement these broad public health measures that helped keep cases lower.

But there are just as many, if not more, examples of countries that did not do a good job of telling the truth, Countries where leaders failed their people by downplaying the virus or using it for political gain, undermining the public health health efforts to control the COVID nineteen pandemic.

to the public to a very great degree. Essentially, all of the information was tightly controlled and any bad news was restricted with the line that bad news was bad for morale.

Another interesting point along those same lines is that although there has been intense fake news and politicization of public health during the COVID nineteen pandemic, we also have the Internet, which makes it both easier and in some ways more difficult to find factual information. But it's at least out there if you're looking for it. That was not the case in nineteen eighteen, when if a newspaper printed that this is just ordinary influenza, you had nowhere else to

turn to get information. But that doesn't mean that people in nineteen eighteen blindly believed what they read. They saw the devastation around them, and they knew that they couldn't rely on their government or their newspapers to tell the truth. They were on their own.

In terms of the viruses, both the influenza virus of nineteen eighteen and SARS covi two are respiratory viruses that can infect deep in the lungs, and both can cause significant disease in virtually any organ of the body, but SARS covy two is much more transmissible and has an overall longer duration compared to influenza virus, which has a

shorter incubation and transmissibility period. We also have seen big differences in the age groups affected, with primarily eighteen to fifty year olds affected in nineteen eighteen, and of course today COVID has hit people over sixty five much harder than other age groups, and these characteristics of the two different viruses have affected the outbreak and spreads that we

have seen, as well as the public response. Since influenza had such a shorter duration, we saw it burn through towns and cities in a matter of weeks, leaving millions dead in its way, while the COVID nineteen pandemic has continued to rage for months, and the fact that older individuals are more likely to become severely ill and die from COVID compared to the eighteen to fifty year olds that were affected in nineteen eighteen, that certainly has contributed

to the public response to the COVID nineteen pandemic, allowing some decision makers to write off the severity, which would likely never have happened if we had seen the same mortality rate in younger individuals. Overall, the nineteen eighteen pandemic killed between fifty to one hundred million people, which adjusted for today's population, would be around I think two twenty five to four hundred and fifty million, a death told that thankfully we haven't come close to during this pandemic.

what we've seen in this pandemic. And on top of that, much of the world was at war during nineteen eighteen, which certainly didn't lend itself to free and open collaboration, But nonetheless, so many scientific advancements that we rely on today can be credited in some way to the nineteen eighteen influenza pandemic. Early last year, many individuals and laboratories pivoted to working on coronaviruses when it became clear that this current pandemic was very serious, and the same thing

happened in nineteen eighteen. During and after the nineteen eighteen influenza pandemic, nearly anyone whose work was tangentially related began working on influenza, and the work sparked by that pandemic led to things like the pneumonia vaccine, or the entire field of molecular biology, and so many other scientific accomplishments. Today, we have seen both collaboration and innovation on a scale

like never before. So who knows what kind of scientific achievements may come in the future as a result of the work that started during this pandemic.

The nineteen eighteen influenza, like I said, would burn through a city or town in a matter of weeks with this intense onslaught of cases and deaths, and then nothing. And this is why we see these discrete waves in the pandemic of nineteen eighteen. This rapid spread meant that compared to COVID nineteen, very few businesses were substantially affected or affected for very long. There were some shutdowns in

nineteen eighteen, but they didn't last that long either. During the COVID nineteen pandemic, our day to day lives have changed, in many cases dramatically, and this change was not weeks long like it would have been in nineteen eighteen. We're going on over a year now. Of course, the longer duration of COVID nineteen has been due in part to these non pharmaceutical interventions drawing out the pandemic, but that's for a very good cause, reducing the number of cases

and deaths. But what is undeniable is that for nearly a year and a half, the CODEVID nineteen pandemic has been sown into the fabric of our lives, in the way we talk to each other, in the way we view other people, in the way we think about our future, both in the mundane like meal planning for two weeks at a time, and in the more abstract like what's important to me about my job, my home, my life. We all probably have some muscle memory of what it's like to live in a non pandemic world, but I

think it will take some getting used to. In the nineteen twenties, the world was coming out of a brutal, deadly war and a devastating pandemic, both of which targeted this younger generation. Most of all, The result was a combination of survivor's guilt and a readiness to get back to normal, not to forget what happened, but just a desire to live and experience new things, and that in part is what kind of led to the Roaring twenties. But I think that we may see some things similar

in the years to come. But just as the people who lived through the nineteen eighteen pandemic never forgot its impact, I hope that we remember some of the lessons of the COVID nineteen pandemic and actually apply them to the future, because this won't be the last pandemic, maybe even likely even within our lifetimes.