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The Caucus

The horrors of 1918: What the Spanish Flu can teach us about COVID-19

  • 7 min to read
Spanish Influenza

Such a tiny thing, a virus.

So small, they cannot be seen by light, even through a microscope. But like molecules of water, we knew they were there before we laid eyes on them.

We had watched them carve canyons through our civilization.

One of us they washed away was named Clara Rosenfeld. She was a 31-year-old Philadelphian on Oct. 22, 1918, when the H1N1 virus behind that year’s global flu pandemic killed her. She left behind two boys, ages 5 and 10, and a girl, 7.

More than 101 years later, the girl’s daughter, Karen Zeitz, was in her South Philadelphia home, just a few miles from where her grandmother died, getting worrisome news from her doctor at the dawn of a new viral pandemic.

Zeitz, 71, had been exhibiting some of the symptoms of infection caused by the novel coronavirus. Her doctor told her it didn’t sound like she had it. That was the good news. The bad news was, even if she did, her doctor had no access to tests.

“That scared me more than anything. That means we don’t know how many people are really carrying it,” Zeitz said.

The virus that killed her grandmother in what’s come to be known as the Spanish Flu pandemic was deadlier than coronavirus. It ravaged a world without intensive care units, gene sequencing or instant global communication. It predated the first flu vaccine by more than 20 years.

Yet the coronavirus has already upended life around the globe, dealt a serious blow to the world economy and could kill millions worldwide. The new normal of social distancing and self quarantines — a change that came about in the United States with startling rapidity — will likely last months, not weeks, and even when it’s over, that might not be the end.

* * *

The Spanish Flu’s deadliest wave wasn’t it’s first; it roared back twice, enabled by the same advantage this novel coronavirus has: a human species with no acquired immunity.

“If (coronavirus) keeps on this path, it could kill 20 million people worldwide,” said Maciej Boni, an epidemiologist at Penn State University who works at the Center for Infectious Disease Dynamics.

While cautioning that epidemiological predictions are “not a weather forecast,” he said one scenario is the virus slows down in May or June, people begin to congregate and life returns to normal. But then, as the weather cools, the virus will almost certainly return.

Like the coronavirus outbreak, the Spanish Flu pandemic first emerged early in the year. It faded that summer, and people thought the danger had passed. There was a world war to worry about and bar owners who needed to reopen, and restaurants eager to see their customers return.

They did.

Despite warnings from doctors, elected officials allowed public events to resume, including the Liberty Loan Parade to sell war bonds in Philadelphia. Soon after the parade, hundreds of people a day were dying from the resurgent flu.

By the epidemic’s end, 20,000 Philadelphians were among the 50 million to 100 million who had died worldwide. In the United States, the flu’s 675,000 victims outnumbered Americans killed by the Kaiser’s soldiers in World War I and Hitler’s in World War II, combined.

War might be the only human activity that comes close to a global assault by a deadly, novel virus.

* * *

Pandemics ripple through history like gravity waves, warping the fabric of existence in ways later generations can scarcely see, even if they think to look — a missing chair at a grandparent’s house, a childhood memory never formed, a lost lesson from a life unlived. These individual absences occur with any premature death. It’s the pandemic’s scale that’s different.

Zeitz’s mother rarely talked about Clara’s death, but it seemed ever-present, Zeitz said.

“It was just devastating. I think there was a sense of being shell-shocked in a moment, and that’s the rest of your life,” Zeitz said.

The experience offers a reminder of what health experts have been saying for weeks: that whatever shocks the current reaction to coronavirus might bring, the alternative can be far worse.

“The path of the epidemic is partially within our control,” Boni said. “We can flatten the curve and slow down the epidemic.”

“The curve” refers to the bell-shaped line that tracks each wave of a pandemic. The less people do early on, when the trend lines begin bending upward, the higher the curve will rise before reaching its zenith.

The higher that peak, the more stress on critical institutions. Let it get too high, and hospitals beds will fill while doctors and nurses fall ill. The ranks of public safety personnel — police, fire, EMS — could thin to the breaking point.

Most Americans likely haven’t ever wondered about the aggregate capacity of their community’s hospitals. They might soon find out, said Dr. Amesh Adalja, senior scholar at Johns Hopkins University’s Center for Health Security.

The mortality rate of coronavirus COVID-19 is lower than that of the Spanish Flu or SARS, but it spreads quickly. Allegheny County Health Director Dr. Debra Bogen warned March 17 that 40% to 60% of Western Pennsylvanians could contract the disease, according to the Tribune-Review. Other health experts have said the global infection rate could reach 70%.

A vaccine is likely to take 12 to 18 months to test and deploy, experts said.

“While most people are going to have mild symptoms, some won’t,” Adalja said. “We may be putting hospitals into critical stress modes.”

Though medical technology today is exponentially more effective than what was available to doctors in 1918, the basic facts of quantity — number of beds, available personnel — remain as limiting today as a century ago.

“There was a shortage of medical personnel in Philadelphia (in 1918). The doctors were all in Europe,” treating deployed soldiers, Jeff Albert, 73, of Dresher, said.

Albert’s grandfather, Joseph, was a strapping 25-year-old living in South Philadelphia in 1918. He was a boxer — amateur, the family believes — and the father of two young boys, Howard and Arthur.

Viruses don’t discern, though. They don’t offer deferments like the one that allowed Joseph to stay home and support his family during the war. They don’t ask questions.

Joseph Albert died on Oct. 22, 10 days after Clara Rosenfeld. He fell victim to one of the crueler aspects of that H1N1 strain. While most flu bugs are worse for the very young or very old, the Spanish Flu was particularly deadly to the very healthy.

One reason the flu was so deadly, researchers believe, is that it triggered a “cytokine storm” in which an infected person’s body overproduced immune cells to fight the disease. The overproduction flooded the body, causing the lungs to swell and fill with fluid, opening the door to pneumonia. The healthier a person’s immune system, the more likely it might be to drown them.

The 1918 pandemic did more to the Alberts than kill Joseph. It split their family. Howard went to live with his father’s parents. Arthur stayed with their mother.

* * *

Many of the details about Joseph’s life were lost until Jeff Albert and his wife Karen began doing genealogical research recently. They commemorated his life in a Sept. 28, 2019, march in Philadelphia to honor the city’s Spanish Flu victims — a parade Karen Zeitz also took part in.

A few months later, word of a new virus began trickling out of Asia.

“It’s certainly striking,” Jeff Albert said, as he and his wife isolated themselves at home about 20 miles north of where his grandfather died. “We’re basically sitting in our apartment, asking ourselves, ‘Where can we go,’ or even, ‘Can we go?’”

If worse comes to worst, an American in 1918 might have had one advantage over their descendants today. People in the modern United States — at least since the civil rights movement — are generally of the mindset that “bad things won’t happen to them,” Boni said.

For Americans of the early 20th century, children died at a far higher rate, and many had seen their family and friends sent to a shockingly horrific war that even the president, Woodrow Wilson, had resisted entering. They were the children and grandchildren of men who fought the Civil War, the bloodiest conflict in U.S. history (though even that death toll fell short of the Spanish Flu’s).

The actions local officials are contemplating today would have sounded almost alien just a few weeks ago.

During his March 13 news conference announcing Pittsburgh’s first emergency measures, Mayor Bill Peduto laid out a range of options available to local leaders, from limiting public gatherings (the first step they took) to closing bars and restaurants (a step taken shortly thereafter) to a full quarantine of the city.

“We have a solid plan for what we need to do this week. What we need to do next week, there is not a mayor, a public safety director, a chief of staff in this world who can tell you,” Peduto said. “It is so fluid.”

Compounding the challenge is the lack of a coordinated, national approach to this unfolding crisis. The federal government has been far more slow-footed than health professionals would like, leaving cities and states to figure out their responses on their own.

“What we’ve been looking for is federal guidance,” Adalja said. “We’ve seen governors and local officials stepping in in the absence of that.”

Peduto and Public Safety Director Wendell Hissrich began planning Pittsburgh’s emergency response in early February, around the time China locked down Wuhan in the early days of the outbreak.

Peduto’s level of alarm rose while attending a National League of Cities conference in Washington, D.C., on March 10-11. The league announced less than a week later that two attendees tested positive for COVID-19, prompting Peduto to self-quarantine for 14 days after returning to Pittsburgh.

* * *

While they were in Washington, President Donald Trump continued to downplay the growing pandemic. “We’re doing a great job with it. And it will go away. Just stay calm. It will go away,” he said on March 10.

Health officials, however, knew otherwise. Alarmed by the White House’s resistance to speaking plainly about the blooming pandemic, they warned local officials through back channels, Peduto said.

“The CDC officials, they were saying to mayors and local elected officials, ‘SOS. We need your help. It’s up to you. This is not getting the attention it needs, and we are going to be in a much worse situation,’” Peduto recalled.

“Our response was, ‘When?’”

Their answer: “Today. Today. You need to take action today,” Peduto said.

That was a tipping point, Peduto said. Philadelphia canceled its St. Patrick’s Day Parade on March 10. Pittsburgh followed a day later. The day after that, a Thursday, as Trump continued to insist, “It’s going to go away,” the NBA, National Hockey League and Major League Baseball, among others, announced they were canceling or postponing their seasons.

As they’ve announced these society-altering steps, however, public health officials have said again and again that the arc of this crisis will be bent by individuals making the right decisions.

Those decisions seem so small — almost painfully insignificant. What is 6 feet of social distancing in an outbreak that spans hemispheres? What is one fewer hand-scrubbing in a city on lockdown?

The idea behind it isn’t novel, though. It’s the knowledge that even vanishingly small things can together have immense consequences.

Take, for example, a virus.