John M. Barry is author of The Great Influenza: the story of the Deadliest Pandemic in History and a professor at the Tulane University School of Public Health and Tropical Medicine.
All 50 states have now started to come out of lockdown, in many cases without meeting White House guidelines and without adequate testing and contact tracing capacity. So how can we minimize deaths in this new reality — and prevent a potentially explosive new wave? Lessons of the past — and what we have learned from our present condition — provide some guidance.
First, Americans should consider what they have accomplished. Most states locked down in mid-March. Three weeks later on April 7 — roughly the date when statistics began to reflect the effects of controls — deaths totaled 12,757, with cases and deaths doubling every 6.5 days. Had the disease maintained that pace, some 500,000 Americans would have died by now; worse, the virus would have been so widely disseminated that control would have been impossible and we might have eventually exceeded the worst-case projections of 2 million deaths.AD
Instead, at this writing, we are approaching 100,000 deaths. This is a terrible number compared with that in such countries as South Korea, which reacted swiftly and suffered only 264 deaths in a population of 51 million; or even Germany, which started slowly but quickly got ahead of the virus and has seen 8,219 deaths in a population of 83 million. But it also represents enormous progress given our initial trajectory.
We have also flattened, though not turned fully downward, the pandemic curve, and according to a Morgan Stanley model, we have extended the time it takes to double cases to 46 days.
In the 1918 influenza pandemic, many U.S. cities closed for business, then reopened too soon, and when the disease surged back, had to close down again. Some cities did this three times. To avoid that, and more importantly, to avoid a surge so large that it might become uncontrollable, we should consider our experience from 1918, from SARS and from current observations to guide our path.AD
In 1918, a study of Army training camps compared the few installations which made no attempt to control the flu with those that imposed isolation and quarantine, but also failed to sustain rigid enforcement over a period of weeks. The study found no difference in either sickness, deaths, or even peak stress on camp hospitals — but the study also reported that the very few camps which had maintained rigid controls saw benefits. Civilians, who even in densely populated places are far more spread out today than soldiers were in overcrowded World War I barracks, should benefit from control measures.
SARS also teaches a lesson about best practices. Health-care workers accounted for 21 percent of SARS cases worldwide and 51 percent of cases in Toronto. At the George W. Bush administration’s very first meeting held to develop recommendations to mitigate a pandemic, the infection control chief from the single hospital in the world with the best record for protecting staff from SARS explained that he followed the same procedures as other hospitals, but he made certain his staff adhered to those procedures. They did not get sloppy. His people stayed healthy; elsewhere they got sick and many died.
The lesson in both cases: compliance matters.AD
Modern influenza studies also hold lessons. Influenza and covid-19 transmit the same way, and a careful study of seasonal influenza transmission found that a combination of masks and hand-washing reduced illness dramatically after six weeks, while an analysis of multiple studies of mask use and hand-washing during the 2009 swine flu pandemic concluded the same thing: the combination of the two provided significant protection.
Even more important in interrupting transmission is social distancing. Simply talking face to face seems to be a major mode of transmission. Although quantifiable data supporting that statement has not yet been extracted and analyzed, that is the view of an emerging consensus of public-health experts.
Distancing oneself, using masks, washing hands, taking such other preventive actions as avoiding public bathrooms (bowel movements and toilet flushing expel airborne virus), and, of course, staying home when sick are not magic bullets, but they all impact spread. As in army barracks in 1918, as in SARS among health-care workers, compliance matters.AD
Individuals who employ all these measures can greatly enhance their chances of avoiding infection, and, even in the absence of adequate testing and tracing, can have considerable impact on society-wide spread.
Such measures are not ideological, even if the great irony in this pandemic is that they have become so.