RWJF Investigator Award Recipients Create Treasure Trove of Data about American Responses to 1918–1919 Influenza Pandemic

    • July 27, 2010

If an influenza pandemic of the magnitude of the Spanish flu hits the United States again, how would public officials respond?

Would they quarantine everyone with a runny nose? Would they insist that parents keep all children out of school? Would they shut down the World Series? What about wedding receptions, parades and festivals?

Who would take these actions, how would they do so, and would they be effective?

New research by Howard Markel, M.D., Ph.D., and Alexandra Minna Stern, Ph.D., recipients of Robert Wood Johnson Foundation (RWJF) Investigator Awards in Health Policy Research in 2007, helps answer these and other questions about how public health officials should respond to future pandemics of influenza and other infectious diseases.

In their research, Markel and Stern—director and associate director, respectively, of the Center for the History of Medicine at the University of Michigan—conducted extensive archival research into how 43 cities responded to the influenza pandemic of 1918 and 1919. They also studied other factors including demographic and housing characteristics, morbidity and mortality patterns, political circumstances, the supply of health care facilities and medical personnel, and compliance with public health measures.

Lessons from the past, they say, can inform public health policies of today.

“We found that cities that acted earlier and that used a layered response for a long period of time were more successful at combating the flu,” Markel said.

That strategy proved effective in St. Louis, where a prescient and authoritative health commissioner by the name of Max Starkloff took quick action to ban public gatherings when the flu virus arrived and enjoyed the full backing of the local mayor.

The city’s excess death rate was far lower than it was in Philadelphia, one of the cities struck first by the pandemic. In Philadelphia, officials were slow to respond to the crisis, fought with each other over public health strategies, and ceased interventions before the pandemic had subsided.

The response in Philadelphia was “messy, disorganized and late,” Stern says.

The modern-day moral of this tale of two cities? Prompt and clearly communicated government actions—and communal cooperation—matters.

“Popular accounts portray the influenza as some sort of dark cloud right out of an old-fashioned horror movie that killed everything in its path,” Markel said. “But that’s simply not true. Different communities did different things and experienced different results. To me, that’s very exciting. We don’t just have to sit by and watch; there are things we can do.”

Markel and Stern Advise Officials to Prepare for Flu Pandemic Before it Strikes

Markel and Stern say public officials should start preparing now for a future pandemic—such as more severe or ubiquitous versions of the H1N1 virus that hit the country last year or the avian flu that struck several years ago—to ensure that they can act quickly and effectively in implementing non-pharmaceutical interventions such as public gathering bans, school closures and quarantines.

Non-pharmaceutical interventions can slow the spread of the disease if carried out effectively. They can also give officials a precious commodity during a pandemic: time to implement pharmaceutical responses. Vaccines, Markel and Stern note, can take months to produce en masse.

Governments also need to develop action plans that vary depending on the ubiquity and severity of the pandemic, Markel says, adding: “We need better categorization, better international health regulations, and clearer chains of command.”

Public officials now have the benefit of Markel and Stern’s research into the United States response in 1918 and 1919, when an estimated 650,000 people died in this country and some 50 million people died worldwide.

Although the history of the pandemic has long been studied by other historians and epidemiologists, much material remained unexamined. Markel and Stern dug deep through federal, state and local records—as well as personal papers and scientific literature—to create as detailed a reconstruction of the American experience with the Spanish flu as possible.

“A lot has been written about it,” Markel says. “But there’s so much material that has never even been looked at, let alone reviewed. And there are a great many lessons, warnings, and caveats that can have huge payoffs for us as we set our health policies for future contagious events.”

Times, of course, were different when the Spanish flu hit.

Health officials had few pharmaceutical tools at there disposal. There were no vaccines to inoculate people against the virus or anti-bacterial medications to treat deadly complications such as pneumonia. Hospital care as it is known today did not exist. Society has also made significant advances in transportation, communications, technology and other areas in the last century.

But much of American life remains the same, Stern says. “We still have cities, counties, states and federal governments responding to crises. And we have multicultural, multi-ethnic urban populations that are going to be involved in these responses and comply or not comply.”

Markel and Stern completed the RWJF Investigator Award grant period in June and are now analyzing their research and sharing information.

Last year, they published a paper about the effectiveness of school closures in Health Affairs. This year they have co-authored an article in Public Health Reports about cities that opted to intensify medical inspections at schools rather than close them. And they also co-authored a guest editorial about lessons learned from the pandemic in a special supplement issue to Public Health Reports about the influenza pandemic of 1918–1919 that they co-edited with Dr. Martin S. Cetron of the U.S. Centers for Disease Control and Prevention.

More articles are to come, they say. And the next major item on the to-do list? A study of a more recent era: the H1N1 influenza pandemic of 2009.