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“1919 vs. 2020”

We had this discussion the other day about a questionable claim regarding the effects of social distancing policies during the 1918/1919 flu epidemic, and then I ran across this post by Erik Loomis who compares the social impact of today’s epidemic to what happened 102 years ago:

It’s really remarkable to me [Loomis] that the flu of a century killed 675,000 Americans out of a population of 110 million, meaning that roughly works out to the 2.2 million upper range guess of projections for COVID-19 by proportion of the population. And yet, the cultural response to it was primarily to shrug our collective shoulders and get on with our lives. . . . Some communities did engage in effective quarantining, for instance, and there were real death rate differentials between them. But to my knowledge anyway, sports weren’t cancelled. The World Series went on as normal (and quite famously in 1919!). There was no effective government response at the federal level.

Moreover, when it ended, the Spanish flu had almost no impact on American culture. There’s a very few references to it in American literature. Katherine Anne Porter’s Pale Horse Pale Rider. Hemingway mentions it in Death in the Afternoon. There’s a good John O’Hara story about it. And….that’s basically it? . . .

Now, yes it is true that the years of 1918 and 1919 were fast-paced years in the U.S. Over 100,000 people died in World War I . . . [but] while the war and its aftermath obviously were dominant features of American life at the time, there’s hardly anything in there that would erase the memory of a situation where nearly 7 times as many people died as in the war.

So what is going on here? . . . Americans were simply more used to death in 1919 than in 2020. People died younger and it was a more common fact of life then. Now, don’t underestimate the science in 1919. The germ theory was pretty well-established. Cities were being cleaned up. People knew that quarantining worked. The frequent pandemics of the 16th-19th centuries were largely in the past. But still….between deaths in pregnancy and deaths on the job, deaths from poisonings of very sorts and deaths from any number of accidents in overcrowded and dangerous cities, people died young. . . .

I remember thinking about this in the 1970s and 1980s, when we were all scared of being blown up in a nuclear war. (Actually, I’m still scared about that.) My reasoning went like this: (1) The post-1960s period was the first time in human history that we had the ability to destroy our civilization. (2) This seemed particular horrifying for my generation because we had grown up with the assumption that we’d all live long and full lives. (3) If it wasn’t nuclear war, it would be biological weapons: the main reason that the U.S. and the Soviet Union didn’t have massive bioweapons programs was that nuclear weapons were more effective at mass killing. (4) It made sense that the ability to develop devastating biological weapons came at around the same time as we could cure so many diseases. So, immortality and potential doom came together.

Regarding 1918, remember this graph:

Just pretend they did the right thing and had the y-axis go down to 0. Then you’ll notice two things: First, yeah, the flu in 1918 really was a big deal—almost 4 times the death rate compared to early years. Second, it was only 4 times the death rate. I mean, yeah, that’s horrible, but only a factor of 4, not a factor of 10. I guess what I’m saying is, I hadn’t realized how much of a scourge flu/pneumonia was even in non-“pandemic” years. Interesting.

These are all just scattered thoughts. There must be some books on the 1918/1919 flu that would give some more perspective on all this.

37 Comments

  1. Greg Jensen says:

    It’s probably worth considering what a “normal” year’s morality looked like at that time. According to these NCHS data (https://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf), 8 of the top 10 causes of death in 1917 were health-related (non-vehicular accidents and premature births were the other 2), for a combined total of around 900k deaths that year, or about 1275 deaths per 100k. Of those, about 165 per 100k were pneumonia/flu. 1918 was worse, but only by a factor of 3-4 for pneumonia/flu (589 per 100k). Intuitively, a fourfold increase in a type of death is tragic but not culture-altering. By comparison, we no longer live with death from communicable disease as a major feature of daily life. Our current norm for pneumonia/flu deaths is on the order of 15 per 100k, almost an order of magnitude less per capita. The familiar causes of death in the 21st century are largely non-communicable (e.g. heart disease and cancer). So relative to current expectations and the society we’ve built upon them, the worst-case scenario for a pandemic is much more shocking today than it was 100 years ago.

    • Andrew says:

      Greg:

      Yes, good point. I’d noticed that the other day, and I copied the graph into the above post to emphasize the point. When I saw that graph, I was surprised that the fabled epidemic was only a factor of 4 increase in deaths from that cause.

      • Another thing is that the US isn’t necessarily one of the worst hit places.

        According to Wikipedia and the citations therein Tahiti lost 13% of its entire population in 1 month. Western Samoa lost 22%. In Indonesia about 1.5 million out of 30M were killed (5% or 5000 per 100k) or about a factor of 10 worse than the US.

        In Iran between 8 and 22% of the population died.

        https://en.wikipedia.org/wiki/Spanish_flu

        So it was a HUGE deal globally, even if it was only 4x compared to normal in the US.

  2. jim says:

    I listened to a book on the 1918 epidemic. It was huge – at least 20 discs – and badly written and poorly read. But the information was good if you could deal with the lame drama. There was a long section on the biology of viruses the immune system that was probably the best part of the book.

    Another good popular book on epidemiology – a bit old now but still relevant – is “The Coming Plague” (~2005). It describes several epidemics around the world, including HIV, hanta virus, ebola and several others. I can’t recall if it covers historical epidemics like the plague, but I remember it as relatively sophisticated for a popular book and well written.

  3. Dave says:

    Wealthier societies tend to demand more safety. When the US was poorer, a larger percentage of Americans were willing to put up with risky jobs to earn a paycheck, for instance.

    Plus it was harder to avoid risks of infection back then. There was no instacart to scale grocery delivery, and very few people could effectively work from home. There was also no public unemployment insurance, so people probably felt more obliged to work. And agreed that people were more used to death and hardships back then. Seems like these things would lead to different preferred trade-offs.

    • Martha (Smith) says:

      Dave said, “And agreed that people were more used to death and hardships back then.”

      As an example, here is a summary of an account by a (Canadian) cousin of my mother from 1919: The cousin was about 12 then, the second oldest child and the oldest daughter in a family of seven children. Her father had been killed in WWI the previous year. The family lived on a small war-widow’s pension, supplemented by some food donations from relatives with small farms, each of whom took in one of the older boys each summer to help on their farm, in return for being fed for the summer and taking some of the harvest home. Her mother came down with what appeared to be the flu. The daughter fetched the town doctor, whose diagnosis was indeed the flu. Realizing that the daughter was in charge of the household duties while her mother was ill, he told her to feed her mother chicken soup to help her keep up her strength. So when the doctor left, the daughter proceeded to make chicken soup. The first step was to go out to the henhouse and get a chicken. The next step was to kill the chicken. She had never killed a chicken before. At this point, the enormity of the situation got to her; she sat down on a bench, and started crying. A neighbor woman heard her crying, came over, took the chicken out of sight of the girl, killed it, and brought it back to the girl, plucking it as she walked. She handed the dead, half-plucked chicken to the girl, who then proceeded to finish the plucking and make the chicken soup to feed to her mother (and then, of course, had to tend to the rest of the household tasks that needed to be done.)

    • Rahul says:

      People evaluate new risks normalized by their baseline risks.

      This would seem to explain most of the blog posts observations? Back then we just lived in a much riskier society.

      • Dave says:

        I think this is fair too. But it’s hard to disentangle lower risk baselines from societal wealth. Poorer countries are more willing to put up with higher pollution and riskier working conditions than we are now, but we were more willing to put up with safety issues and pollution when we were poorer too. Poorer countries to some extent also benefit from technological advancements of wealthier countries, in terms of vaccines and safety technologies too, so even their baseline now may not be as bad as our baseline when we were at the same level of real GDP/capita.

        In some sense, you can think of it as moving up a tech stack. As workers and even countries move from agricultural and manufacturing focus to knowledge and information work, those occupations are both more lucrative and less dangerous. It certainly seems reasonable for a poor country to favor higher risk in exchange for less poverty relative to a rich country’s preferences, because the rich country can afford better safety precautions or to outsource the dangerous labor.

    • Clyde Schechter says:

      Also, back then, the largest sector of the economy was agriculture–and even temporary disruptions in that work could have led to mass starvation as the food supply was marginal even in the best of those times. Otherwise put, a much larger proportion of the workforce was engaged in what are today considered “essential” jobs. Only in the modern world do large portions of the workforce do jobs that are unrelated to sustaining human survival.

  4. Joshua says:

    I would guess that people back then had less of a sense they could control the outcome of a pandemic, infectious disease. They probably had less of a sense that they had control over getting infected.

    Perhaps oroe went to a ballgame because they had less knowledge that doing so could be a matter of life sbd death.

    With more of a feeling of agency, it only stands to reason that people would have more of an investment in utilizing that agency.

    Should we wish we were more hardy like our 1918 ancestors, who cared less about children dying whole working in sweatshops, or about black men being lynched from a tree, or about a woman being raped by her husband?

    • confused says:

      >>I would guess that people back then had less of a sense they could control the outcome of a pandemic, infectious disease. They probably had less of a sense that they had control over getting infected.

      I’m not sure. As Andrew points out in the original post, people knew about germ theory in 1918. And the concepts of quarantine and contagion are much older than even germ theory.(The leading view then was that influenza was bacterial, caused by “Pfeiffer’s bacillus”, Haemophilus influenzae).

      But there was no CDC or WHO then – there was no one who could be expected to have prevented it, at the national or international level. There was no human agency to blame (even though WWI activities actually appear to have made a huge difference with regard to speed of spread and perhaps severity of the second wave).

      And death by “natural causes” below the age of, say, 65 was vastly more common then. It just wasn’t as shocking against their background as COVID is against ours, even though COVID is probably less deadly.

      • Martha (Smith) says:

        Confused said,
        “And death by “natural causes” below the age of, say, 65 was vastly more common then.”

        Even as late as the 1940’s, infant mortality in the U.S. was much higher than it is now. (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5714a6.htm). Cemeteries had special sections called “Babyland” for infant deaths. (Now we have NICU’s that save many infant lives.)

        • confused says:

          This is definitely true.

          I was really thinking about deaths after the real danger zone from infant mortality, but before old age, though.

          It was not nearly as high as infant mortality – low life expectancies in the past were largely driven by infant mortality – but now, deaths from infectious disease among adults under 65 are incredibly rare.

          I am sure they still do happen – the US population is large enough that every unlikely thing will happen – but with the exception of AIDS, it’s not really a risk we are even conscious of. Many people don’t even bother to get flu shots, etc. And I’m not even talking about people who are anti-vaccine, but just not bothering because ‘who cares, it’s just the flu’.

  5. Prasanth says:

    I wonder what your take is on how the CDC calculated flu deaths. As a doc certainly we see the seasonal effects of flu season particularly with hospitalizations but comparing C19 deaths with flu deaths is comparing apples and oranges. CDC uses a case series of hospitals and then add on estimated deaths from folks who died outside the hospital. The excess mortality with C19 which would spike the number of deaths from C19 seems a fairer comparison to the flu

  6. Martha (Smith) says:

    Andrew said, “I remember thinking about this in the 1970s and 1980s, when we were all scared of being blown up in a nuclear war.”

    I remember when I was a kid in the 1950’s we had regular air-raid drills in elementary school. Somewhat like a fire drill, but instead of going outside, we went down to the basement, where each class had its assigned space to sit (with the covers of used pads of paper between us and the cold floor) until the “all-clear”.

  7. confused says:

    Re the factor of 4 thing: I think the difference here is that ‘normal-year’ pneumonia and influenza deaths were heavily among the oldest, whereas the 1918 flu hit younger adults hard. It had a really strange mortality curve with age.

    But yes, the fact that all but the oldest modern American adults, with the exception of health care workers, Peace Corps etc., have basically never had to worry about infectious disease (other than perhaps HIV/AIDS) has to make a *huge* difference in the societal reaction.

    Another factor: there was no “flatten the curve to preserve healthcare resources” then, because there were no ICUs, and healthcare in general could do so much less. There weren’t even antibiotics to help with secondary bacterial pneumonia.

    And yeah, the US was less severely hit than most places. 675,000 deaths in the US comes out to something like 0.6-0.7% of the total population (1920 census was ~106 million) whereas 50 million estimated deaths out of a world population of ~1.8 billion is over 2.7%.

    And some estimates say 50-100 million! So at the upper end, it could have killed as much as 5% of the *total world population*.

  8. Bill Spight says:

    Yes, death was a closer companion to people in everyday life in the early 20th century. Childhood death and death in childbirth in Europe and America was not as common is it had been in the late 19th century. In the 19th century the development of railroads killed a lot of people. While such deaths were tragic, people generally accepted them as part of the cost of progress. Fact of life, as our current President might say. In the early 20th century my grandfather was inoculated with smallpox instead of getting a vaccination. My father’s brother died before my father was born. The 1918 flu pandemic occurred at the tail end of the Great War. People already were aware that during wartime disease was usually the major killer, if not the greatest one. In everyday life, a scratch could kill. The specter of death was everywhere. People lived with that fact.

  9. Manuel Valdés says:

    Comparing “life expectancy loss” could also explain the apparent indiference that some people have towards death.

  10. Russell W says:

    I did read that campaigns during the Spanish Flu led to Americans spitting in public at a much lower frequency. I’m good with that cultural change :)

  11. Steve says:

    It is important to remember that in 1918, WW I was happening and the Wilson Administration had effectively imposed censorship over anything war related. They censured discussion of the Spanish flu as did most of the European governments. In fact, the reason it is called the Spanish flu is because Spain, being neutral in ww1, allowed their papers to discuss the flu. There was also a large wartime propaganda effort which downplayed the flu. So, I think drawing any conclusions about how society was tougher back then or more use to death etc. is dubious. The World Series went on because the Wilson Administration didn’t want to reveal weakness to Germany. I am sure, like everything, the cultural reaction to the Spanish Flu was the result of a combination of factors, but the censoring of the public discussion at the time has skewed our perception of its significance because the typically historical documents have scant references to it.

    • iguy says:

      Yes exactly. There was extremely strong controll of the press (like decade-long jail sentences for opposing the war effort) which essentially prevented discussion of the epidemic, while it was raging. Whether people shrugged or not is hard to tell — in print, they were all smiling, by decree.

      And (IMO) the lack of a paper trail, combined with the huge effects of the war, meant that it could be easily overlooked later. Never quite forgotten obviously, but they didn’t exactly erect monuments about it in every village square.

      • Ben says:

        Yeah, I like this explanation. Also trying to pull the virus apart from the war and make a comparison seems misguided — it was part of the war (going from Dale’s post: https://statmodeling.stat.columbia.edu/2020/05/10/1919-vs-2020/#comment-1334655).

        Maybe this is a stretch, but: “And yet, the cultural response to it was primarily to shrug our collective shoulders and get on with our lives”

        Like I don’t know how to judge a cultural response how how the author is judging it. I’m pretty sure I knew about WW1 before I knew about the Spanish flu, so I guess I have that personal experience that agrees with this. But a good chunk of what I first learned about wars would have come from video games and movies, which are mostly either propaganda or might as well be.

        So maybe if indeed the cultural impact wasn’t so big, maybe that is because nobody figured out how to build a marketing campaign off it.

    • JFA says:

      Maybe… but how much censorship could there have been if several major US cities took steps to combat the flu. “Hey everybody, schools and bars are closed but we’re not telling you why”? I’ve read stories about how all countries somehow suppressed knowledge/extent of the flu, but I wonder if too much is being made out of it since people would have known about it no matter what the government did (unless you do some North Korea level of suppression). Also, the flu’s third wave went through the spring of 1919, and Armistice Day was on November 11, 1918 (which was in the middle of the second wave).

  12. Dale Lehman says:

    A couple of additional perspectives from a recent book written by a colleague about the 1919 epidemic in my local small city:

    “The 1918 influenza pandemic killed 50 to 100 million people globally, yet quickly receded from memory. In the United States, the “Forgotten Epidemic” infected about one-quarter of the population and killed approximately 675,000 Americans between September 1918 and January 1919. Historians theorize that people chose to forget about the fear and sadness of these few months because they chose instead to celebrate the end of World War I. Trench warfare literally created the influenza pandemic, mutating a relatively minor H1N1 avian strain first recorded in Kansas in March 1918 into a more lethal virus. This second outbreak followed soldiers and sailors from European war zones around the world between August and November. Military vessels with infected men arrived in U.S. port cities and internal transportation networks carried these men to army and navy cantonments throughout the nation. Civilians working on these bases or interacting with enlisted men on furlough spread the infection into the general population. Influenza reached epidemic proportions on the East coast first and spread quickly in some cities due to the unlucky coincidence of massive parades held to raise war funds during the Fourth Liberty Loan Drive.”

    “The local Board of Health met on October 11 and initiated a citywide quarantine the next day closing schools, churches, theaters and other places of public assembly. One week later, at the order of the State of Iowa, Mayor Saul mandated that citizens avoid all social gatherings, including card parties, house to house visits and funerals. Although businesses did not close, extra streetcars ran to avoid crowding, folks wore masks while caring for the sick, and people regularly learned how to avoid spreading the infection thru public health announcements. Nursing care proved more important than the talents of a physician, but because of the war, Dubuque faced a nursing shortage. Through the Red Cross and the Visiting Nurse Association, women volunteered to assist the households where entire families suffered with illness or ill parents could not care for their children. The newspapers published guidelines instructing how to nurse loved ones in the home, while the Sisters of Charity made nutritious broth and distributed it to ill families. In 1918, Dubuque citizens helped one another through the crisis but also relied on government to establish guidelines. Nationally, communities faired better when governments acted quickly to establish quarantines and discourage public assembly. They also needed to maintain restrictions long enough to curb transmission. Localities that ended social distancing too early, such as Des Moines, suffered a resurgence of the epidemic and needed to re-impose controls. Dubuque in 1918 only experienced about three weeks of quarantine because the virus infected many before the initiation of the closure order and gathering ban.”

    So, my two observations are: first, that the end of World War I might account for a lot of the difference. Second, perhaps there is not as much difference as you suggest. None of us (even me, at my advancing age) were around then, so we only have the records we can look up. No twitter streams, no facebook posts, no dozens of COVID models every day. I don’t think it is easy to compare our media-laden environment that we are currently experiencing with patchy records of a world 100 years away from here.

  13. Gerald Belton says:

    Even more recently, over 100,000 Americans (and 1 million worldwide) died in the Hong Kong Flu pandemic of 1968-1969. I was 12 years old and I have no memory of the pandemic. Schools certainly weren’t closed. And as for big events being cancelled… that was the year of Woodstock.

  14. statflash says:

    I don’t really like David Brooks, but he is usually at least reliable in terms of facts. Here he says the reason the 1918 Spanish Flu did not leave a big impact on culture is because Americans were ashamed of how they had become so callous toward the dying.

    https://www.youtube.com/watch?v=SCM92K0RiLk

  15. OB says:

    A plug for Laura Spinney’s “Pale Rider: the Spanish Flu of 1918 and How It Changed The World.” I happened to be reading this book in December, and am grateful for its perspective. This pandemic too will pass, with much sorrow. How we change will be our bequest.

  16. David Sholl says:

    “The Great Influenza” by John M. Barry is a superb history of the 1918 flu pandemic. The blurb from the Chicago Times on the cover of the paperback I have says “Monumental….powerfully intelligent..” and I have to agree.

  17. citywalker says:

    “Poverty, malnutrition, chronic illness, and co-infection were the powerful determinants of the precise tax that the 1918 influenza exacted from different populations. Indeed, the global pandemic itself was really a constellation of individual epidemics, each shaped by local socioeconomic and public-health conditions. In some countries, such as India and Iran, the co-factors (hunger, malaria, anemia) formed deadly nonlinear synergies with influenza and its secondary infections.”
    –Mike Davis, “The Monster at our Door: The Global Threat of Avian Flu”, 2005, Chapter 2

  18. Jonathan says:

    I recently read The great influenza : the epic story of the deadliest plague in history by John M. Barry. Not bad.

    I think one point which I didn’t see mentioned about the 1918 flu is that older people were more likely immune either entirely or partially because the version was similar to ones which circulated in the 1890’s. That meant the same group which died in the war and those younger were hit. So when you look at life expectancy, which was 49 in 1910, remember that was highly affected by infant/child and even older mortality among the younger generation from basic diseases we can cure or treat effectively today. So you had higher younger death, plus the war …

  19. Nigel says:

    In fact a similar comment was recently made in France about the flu in 1968-1970 (which in a month – December 1969 – killed more than 25,000 people, about the same as the total so far for Covid-19) that did not have any impact on prevention or planning for the health system in the 1970s. It was just forgotten as soon as it was over. At that time, nearly as many people (20,000) died in car accidents, so it was “comparable”, ie closer to a factor of 4 than 10.
    see this paper in Le Monde (sorry for the paywall and that it is in French):
    https://www.lemonde.fr/podcasts/article/2020/05/09/grippe-de-hongkong-en-1968-pourquoi-on-l-a-tous-oubliee_6039185_5463015.html

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