The Peter Attia Drive - #107 - John Barry： 1918 Spanish flu pandemic—historical account, parallels to today, and lessons

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.720 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay, here's

00:00:48.080 today's episode. Welcome back to another special COVID-19 episode of the drive. Joining me on this

00:00:55.440 episode is author and historian John Barry. John is the author of arguably one of the most important

00:01:00.920 books I've ever read in my life, The Transformed Cell. And we talk about that very briefly at the

00:01:05.720 outset, but that's not the reason we speak today. Rather, today we are discussing a book that John

00:01:10.540 wrote in 2004, the New York Times bestseller, The Great Influenza, the story of the deadliest

00:01:16.180 pandemic in history. We talk about a lot of things here, obviously related to the Spanish flu.

00:01:21.640 Many of you have probably heard about this somewhat in the previous couple of months. Obviously this

00:01:27.440 was on a per population basis, probably the greatest pandemic in human history, perhaps comparable only

00:01:33.880 to the black plague. But of course it has many parallels to the pandemic we are in now. I think

00:01:41.640 history will show that the current pandemic is not a fraction of the Spanish flu, but nevertheless,

00:01:47.320 there are parallels that can be drawn. This is a discussion that goes into many of the details

00:01:53.480 of the pandemic, which is complicated because it really had three separate waves. And we get into

00:01:59.280 some of the history of what may have accounted for that. The other thing I found interesting about this

00:02:02.680 discussion is that there were a number of things that John had changed his mind on from when he wrote

00:02:06.620 the book. And that to me is always the marker of a great thinker is someone who can go where the data

00:02:10.880 go and not necessarily be wed to something that they put in print. And I think anybody who's ever

00:02:15.280 tried to write something down and put something out there, it does become a little bit harder to

00:02:19.500 go back and look at that and realize that maybe you didn't look at it correctly. But certainly when

00:02:23.480 it comes to, for example, the origin of the Spanish flu, John's thinking has changed and we do get

00:02:28.720 into that. Again, I'll keep the intro brief. I think the discussion will speak for itself. And so

00:02:33.520 without further delay, please enjoy my conversation with John Barry.

00:02:42.700 John, it is such an honor to be sitting here talking with you because as I alluded to in the

00:02:49.400 email, when I randomly reached out to you last week, you are someone whose work I've been familiar

00:02:54.760 with for a very long time because a book that you wrote with my mentor, Steve Rosenberg, has arguably

00:03:02.060 been one of the most influential books in my life, The Transformed Cell.

00:03:05.880 Kind of you to say. I give Steve full credit for that book. He didn't need me. It's the only thing

00:03:11.240 I've ever collaborated on in my life. He was very generous in giving me credit for that. But I did

00:03:17.640 learn, for those of you who don't know Steve, we're talking about Steve Rosenberg, who is at the

00:03:23.420 National Cancer Institute and was one of the leading pioneers in immunotherapy, developed, I guess,

00:03:29.700 the first immunotherapy that actually worked for cancer. He also was the lead investigator on the

00:03:37.160 first true gene therapy experiments in the United States. And I guess the world too, in terms of

00:03:44.600 approval, there were a couple of disapproved experiments prior to that.

00:03:50.720 Yeah. And so that book was published in 91 or 92, right?

00:03:54.500 Yeah. Yes.

00:03:55.720 So I didn't come across it until 1997. It was in my first year of medical school.

00:04:01.860 I read it and it's just one of those moments that I think people have once in a while in life. And it

00:04:07.460 just sort of changed everything for me. It gave me a complete sense of how I wanted to think about

00:04:12.260 the world and problem solving and all these sorts of things. And I read it probably five times when

00:04:17.740 we're done with the podcast. I'm going to show you my original copy because three years later,

00:04:21.680 I would actually get a copy from Steve signed. I have since purchased a dozen copies whenever I

00:04:27.360 find one on eBay or Amazon. This is an embarrassing thing to admit. I would insist anyone I dated read

00:04:33.980 the book. I just felt like they needed to understand that degree of obsession. And that definitely

00:04:39.660 minimized the number of dates I had to go on, but it was incredible. And then, and then, as I mentioned

00:04:44.560 to you earlier, I went and spent time with Steve in my third year of medical school and then went there

00:04:50.700 for two years later. And it's, I still view my time at NIH as one of the most blissful periods

00:04:57.080 of my life, because it's a period where you could be completely immersed in trying to solve a problem.

00:05:01.420 And when you're at that age and you have no other responsibilities, it's magical.

00:05:05.980 It is. I haven't talked to Steve lately. As you probably know, he and Tony Fauci are very close

00:05:10.220 friends. They arrived, I think on the same day. I didn't realize it was that close. That's interesting.

00:05:14.540 Oh yeah, they're quite tight. Let's talk a little bit about how that,

00:05:17.840 you basically got a doctorate level course in immunology in the late 80s, early 90s. And then

00:05:23.620 a little over a decade later, you would go on to write arguably the greatest account of

00:05:29.240 the forgotten pandemic. How did you get interested in the Spanish flu?

00:05:33.840 Well, first, I don't think that's a high bar. There aren't that many books about the pandemic.

00:05:38.620 So I would hope I'd say the greatest on the pandemic, considering the paucity of competition.

00:05:46.780 It's a funny thing. I wanted to write a book and go into this and one of the acknowledgements,

00:05:52.400 but there were four different acknowledgements as things developed. The first was book initially

00:05:57.280 came out. Then there was one to update it for H5N1. Then there was one to update it for 2009's

00:06:03.800 pandemic, which was barely registered. And then there was one at the 100th anniversary in 2018.

00:06:12.220 So this story may have been erased for space in the interim. But initially, I wanted to write a

00:06:19.260 book on the home front, World War I, culminating in the events in 1919, which I consider one of the

00:06:24.780 most interesting years in American history. I knew exactly how I wanted to approach that subject.

00:06:29.240 It was a very, very big book. And as a writer, I live on my advance. My prior book, Rising Tide,

00:06:36.360 was a bestseller, but bestsellers are not necessarily as lucrative as some people think.

00:06:42.600 I was living on an advance, and I didn't think I could get an advance. The book, the way I conceived

00:06:48.860 it, would have been taking me seven years at least, maybe a little longer. You just figure how much it

00:06:54.560 cost to live decently for seven years, plus pay your research expenses. And you're talking about

00:07:00.980 a lot of money. I didn't think I could get an advance that large for that book. But I thought

00:07:05.720 I could write a book on the pandemic, which interested me. And probably two years and no more than two and

00:07:12.420 a half years, I drafted a proposal and gave it to my agent. Then I changed my mind, told him I didn't

00:07:20.420 want to write the book. But an editor approached him after a story in the New Yorker appeared about

00:07:27.080 digging up bodies to try to reconstruct the virus or find the virus. Anyway, they made an offer,

00:07:34.820 which I didn't accept. If I'd wanted to write the book, it would have been enough. I got mad at my

00:07:41.280 agent. I told him I didn't want to write the book. Then another editor came along and offered

00:07:45.420 more money. I thought, well, that's too much money for a book I can write in two years that will help

00:07:50.660 me support the other one. So I accepted. The problem was it took me seven years, a little over

00:07:56.320 that. The same advance divided by seven is a lot less than the advance divided by two. So at the end,

00:08:02.800 I was looking at life as a graduate student. For the first five and a half years that I was working on

00:08:07.340 the book, I wanted to throw the whole thing out the window. Oswald Avery, one of the characters in

00:08:12.800 the book kept me going. Avery came up with one of the most consequential discoveries in any science

00:08:19.800 of the 20th century, arguably the single most important one. He discovered that DNA carried

00:08:25.000 the genetic code. Solving that problem, which actually grew out of his research on influenza

00:08:32.080 and pneumonia, put him through hell for 25 years, had a nervous breakdown, didn't publish for more than

00:08:39.600 a decade. Thinking of what he went through made what I was going through almost trivial.

00:08:46.600 I would think of him almost every day. Finally, after five and a half years,

00:08:51.280 books sort of came together. I was obviously happy with what I produced at the end and

00:08:56.560 the reception it got. It is a beautiful book. I probably read it in 2007, so that would have

00:09:02.680 been probably about three years, I guess, after it came out. Truthfully, this is another very

00:09:07.720 embarrassing story. About six months ago, I realized I just had too many books and I needed

00:09:12.780 to start just getting rid of them, giving them away. You're not going to tell me you threw mine

00:09:16.720 out or gave it away. I did. I donated it to a library. I got rid of literally 80% of the books

00:09:24.180 I had. I remember doing this like six months ago, kind of flipping through books. It's like a trip

00:09:30.480 down memory lane. I don't know if you've ever done this, but you go through and if you're one of

00:09:33.840 these guys like me who hoards books, you go through and you think, God, I remember I read.

00:09:38.440 Sometimes for me, it's like I have a photographic memory. I can say that, or photograph's the wrong

00:09:41.820 word, but sort of a temporal memory where I can say, I remember reading this in November of 2006

00:09:46.520 and I remember what I was doing and I read this on a vacation here and blah, blah, blah. It was

00:09:52.220 actually a very cool experience going through and doing that. The irony of it is about six months ago,

00:09:56.900 I'm sort of thumbing through my paperback copy of your book and I was like, yeah, this is a great

00:10:02.600 one. But you know what? If I read it again, I'll just do it on Audible and maybe I'll have to go

00:10:07.400 back and buy another copy so I can, I think the events of the last couple of months have reminded

00:10:11.880 us of the importance of that. So I've thought a lot about how much I want to, there's so much I

00:10:16.540 want to talk with you on this topic, John. It's something that I think is relevant to where we are

00:10:21.300 today, which is, I guess, April 15th, but it's going to be an equally relevant discussion a year from

00:10:27.280 now and it would have been a very relevant discussion a year ago if we'd had it and if we'd known

00:10:31.740 how important it would have been to have learned from it. But let's assume for a moment that most

00:10:36.260 of the people listening to this either aren't familiar with the story or maybe haven't read

00:10:39.840 your book. And let's start at the beginning because we're talking about a virus, a swine flu virus. So

00:10:47.100 it's different from the virus that's on everybody's mind today, which is a coronavirus. This is a

00:10:51.120 different class of virus, but a comparable idea in that it's a virus that originates in a pig in this

00:10:57.780 case. Well, actually, I kind of dispute that. Well, I was about to say, actually, I was going to say,

00:11:01.460 I actually do want to touch on today the difference between what you thought at the time,

00:11:05.680 which is where this originated in Haskell County in Kansas. And I know that in the previous

00:11:09.720 couple of years, you've actually come to another point of potential view on that. So I want to touch

00:11:14.540 on that, but is that as good a place as any to start? Sure. Okay. Sure. Well, I guess we could

00:11:20.140 provide some more background. The 1918 pandemic, a virus, respiratory virus, jumped from animals to people.

00:11:28.000 We don't know what animal jumped from. The influenza virus has eight separate gene segments.

00:11:34.360 As of most viruses, most organisms have a genetic code carried on a continuous single strand, whether

00:11:41.300 it's RNA for a lot of viruses or DNA for some viruses and more advanced organism. But we know seven of

00:11:48.320 those eight gene segments are avian. One looks like it was mammalian, not necessarily a pig. So we don't

00:11:55.700 really know what mammal it passed through. And we're not certain that it passed through a mammal at

00:12:03.200 all. So to designate it as swine flu, I'm not sure I'd agree. In fact, there's very good evidence that

00:12:10.280 people gave the 1918 virus to swine rather than the other way around. But having said that, the pandemic

00:12:18.780 killed between 50 and 100 million people, you adjust for population, that's 220 to 440 million people

00:12:26.280 today, it killed two thirds of them in a remarkably short period of time, generally 14 or 15 weeks from

00:12:34.220 late September through December 1918. It was a very mild, spotty first wave in the spring of 1918, which did not

00:12:43.580 spread worldwide and was very hit or miss in the countries that did hit. Then there was a third

00:12:49.120 wave in 1919, began in February, I guess, extended through the spring. And that's basically the story

00:12:58.540 of the pandemic in very, very short order. So let's go back to Haskell County, Kansas. We're in the final

00:13:05.780 year of World War I. So we're kind of latter part of the winter, early part of the spring 2018.

00:13:11.240 And some doctors there kind of noticed something, right?

00:13:15.720 Right. The first report anywhere in the world, any language that I could find of a lethal form

00:13:22.580 of influenza was actually in Haskell County, Kansas, southwestern part of the state near the Texas border.

00:13:31.520 There was a very astute physician in that county named Laurie Minor, who reported this lethal form of

00:13:39.420 influenza to the U.S. Public Health Service, although that account was not actually published until

00:13:45.020 April. You know, I found the record. Since it was the only report in the spring in public health

00:13:52.900 reports, I decided to check out the weekly newspapers, figuring there would be some delay in publishing

00:13:58.260 the report and found out there was several months delay. Anyway, you could trace by name

00:14:05.440 people whose families had someone suffering from pneumonia who went from there to Fort Riley for

00:14:15.480 training as soldiers or visiting somebody there. You use several people by name and they arrived in early

00:14:22.740 March and like clockwork right after their arrival, a couple of days, the first reports of influence in that

00:14:29.520 camp. So I thought that might be the site of origin, rural Kansas, and actually published a scientific

00:14:37.320 article in the Journal of Translational Medicine, which was run by Franco Marincola, whom you may know.

00:14:44.600 I know Franco very well. Yeah.

00:14:46.200 Okay. Close friend of mine, still is. And that actually got some attention and had some credibility with

00:14:52.480 some, but since the book was published and since that article was published, there's been a lot of

00:14:57.960 research on influenza. We found out that China actually did not have a grievous experience in 1918.

00:15:09.440 So based on the fact that they did not suffer huge numbers of deaths, it strongly suggests that there was

00:15:18.280 prior exposure to that virus. So I think it's more likely that it started in China. There are other

00:15:24.020 hypotheses out there, including Vietnam and France, for that matter, France in 1915. We will never know

00:15:30.580 where it actually did start. At any rate, roughly half the army camps in the U.S. were infected in the

00:15:37.740 spring, even though not very many civilian communities were, although New York City and Chicago or

00:15:42.480 Los Angeles didn't suffer a single influenza death in the spring. The studies that were contemporary, there

00:15:50.260 are several numerous ones, both in the United States and Britain by a Nobel laureate named McFarlane Burnett in

00:15:57.560 Australia. These studies all concluded that it was most likely that influenza was carried to Europe by American

00:16:04.780 soldiers in the spring of 1918. That happened to be a pretty mild wave. There were not a lot of deaths.

00:16:12.020 It wasn't noticed at all in any civilian community in the United States at the time. Retrospectively,

00:16:19.300 there have been some that have been identified. And over the course of the summer, my speculation is that

00:16:26.980 the virus mutated, became much more virulent. And in mid-September, it simultaneously in lethal form

00:16:38.120 hit Africa and Boston. But actually, the first lethal wave of the influenza occurred in Switzerland.

00:16:45.800 That was noted in July. There was a U.S. military intelligence report from Switzerland, which said

00:16:51.740 this disease is being called influenza, but it's actually the Black Death of the Middle Ages.

00:16:57.120 Can we pause there for a second, John, and put this in some context? So we talk about sort of the

00:17:04.620 sort of pandemics to end all pandemics. And I just want to kind of put this in context. Is it safe to

00:17:11.040 say that the bubonic plague of the 14th century, if my memory recalls, is the greatest pandemic of them

00:17:18.280 all? Yeah, easily. In terms of proportion of the population who were killed, an estimated quarter to a

00:17:25.780 third in Europe, the subtitle of my book is the deadliest pandemic in history. And that's true in 1.00

00:17:32.280 the sense of the numbers of people killed. But as a percentage of the population, there's no doubt

00:17:37.120 the plague of the Middle Ages killed many, many more than influenza did.

00:17:43.760 So do you think that the same virus that killed a reasonable number of people starting in Haskell

00:17:51.680 County is the same? And by the way, that's the same virus that probably went to France with the

00:17:57.100 soldiers. Do you think that is the same virus that came back in October of 2018? And as you pointed out,

00:18:05.400 basically knocked out two thirds of its victims? Or do you think it was a totally different virus?

00:18:11.960 Well, I think the evidence is overwhelming that it's the same virus.

00:18:15.340 It's a staggering mutation between these two.

00:18:17.860 Right. There are people I respect, or at least one word. It's not so much that they think it's

00:18:22.920 different virus. They're yet to accept the fact that it's the same virus. I can go into detail as

00:18:28.460 to why I'm convinced it's the same virus, if you like. I would love that.

00:18:32.500 Okay. Number one, in New York City, there was a careful study of the spring outbreak. Even though

00:18:40.000 relatively few people died, it was exactly the same signature of demographics, which is very,

00:18:47.860 unusual for influenza. In 1918, the peak age for death was 28. It's a so-called W curve. Usually

00:18:56.240 influenza kills the very young and the elderly. That was not the case in the spring, and it was not

00:19:01.920 the case in the fall. And both of those patterns are highly unusual. That's number one. Number two,

00:19:09.060 in fact, I actually did write an article for Journal of Infectious Disease on this.

00:19:14.180 The first wave exposure was very protective against second wave illness. A couple of NIH

00:19:21.340 epidemiologists helped me write that paper. Alona Simonson and Cecile Vabug, very good

00:19:27.660 epidemiologists on influenza. The first wave provided between 59% and 89% protection against illness.

00:19:35.160 That compares to a vaccine today, which in the last 20 years has ranged from 10% to 62% protection. So

00:19:44.000 it's much better than a modern vaccine. Number three, when they reconstructed the virus and stuck it in

00:19:50.420 ferrets, it was highly lethal, much more so than any other influenza virus.

00:19:56.540 Sorry, John, that's from the first batch, meaning the first wave.

00:19:59.820 No, they reconstructed the genome. Jeff Taubenberger

00:20:03.500 sequenced the genome by extracting it from slides from lung tissue at the Armed Forces Institute of

00:20:11.480 Pathology. He's now at NIH. Taken from patients who died in the first wave or the second wave?

00:20:17.280 Second wave. Well, actually, he's now found, that's another reason,

00:20:21.180 he's now found a sample as early as May, which is the same virus.

00:20:26.360 Ah, well, that would be the most compelling of all of these things, correct?

00:20:29.920 Well, I mean, just the, perhaps. I think the epidemiology, demographics, I think the

00:20:37.300 immune protection it afforded is pretty compelling evidence, particularly the immune protection.

00:20:42.620 But certainly the fact that they've got a sample from May, which is the same virus,

00:20:47.280 that's pretty good evidence as well. Interestingly, in terms of immune

00:20:51.160 protection, the first wave protected against the second wave, but neither first nor second wave

00:20:56.920 exposure protected against the third wave, which started in February, 1919.

00:21:02.940 We're going to include a bunch of figures to accompany this podcast, John, because I think that

00:21:07.500 as you describe these things, I mean, those of us who have spent time reading about it can picture

00:21:12.880 what you're describing, which are these three peaks. You've got this first little peak in the spring of

00:21:17.940 of 18. And then it's, if you just saw it by itself, it would look devastating just based on the absolute

00:21:23.960 numbers. But then it is so dwarfed in a relative sense by what comes about in September to December

00:21:30.280 of that same year, which, I mean, basically is like Everest next to Kilimanjaro. And then you do have a

00:21:37.140 third peak, which is even bigger than the first peak, probably by 3x that takes you into 2019.

00:21:42.540 2019. So I want to come back to sort of implications of that as we go forward. But

00:21:48.060 one of the things about this that is interesting when we look back is we don't think of the world

00:21:54.140 as being very connected in 1918. There were no airplanes, you had to cross by ship and do all of

00:22:01.020 these things. You just wouldn't think that this thing could go as much as it did. And yet there are

00:22:07.300 some really nice videos out there that show you a temporal view of where infections popped up over

00:22:13.300 time. And it's kind of amazing how quickly that second wave grows. What is your sense of the movement

00:22:21.880 of the second wave of that? How did it, and then maybe we can just for simplicity focus on the United

00:22:26.680 States, but I do want to come back and understand places like India that were just decimated.

00:22:30.820 First, you don't need steam power to move a pandemic. In the 1600s, influenza managed to cross

00:22:40.260 the Atlantic Ocean and devastate Virginia and Massachusetts, not to mention the Native American 1.00

00:22:46.200 population. Guns, germs, and steel is sort of a great example of this, yeah.

00:22:51.100 Right. Or better than guns, germs, and steel, you've got McNeil, and then you've got one of my favorite

00:22:58.120 books of all time, which I highly recommend to everyone, by McFarlane Burnett. I mentioned him

00:23:04.120 earlier, Nobel laureate, called The Natural History of Infectious Disease, which is just an incredibly

00:23:08.660 good book and quite accessible to a layperson. So we were talking about timing. My guess is the virus

00:23:16.020 seeded itself largely around the world and then erupted. It takes a while to get a pandemic started,

00:23:23.380 but once it got going, it was moving pretty fast. Although the army, which has very good data and

00:23:32.080 had great epidemiologists in their study, which wasn't published until the 1930s, they had tremendous

00:23:38.320 amounts of data. It took a while to assemble it all and publish it. They said that in their army camps

00:23:45.280 beginning in late July and early August, in retrospect, they could identify a steadily increasing

00:23:54.400 uptick in pneumonia in the camps, which if they put it on a graph was essentially a log advance,

00:24:02.640 whatever the appropriate terminology is to describe that increase. And then it erupted, of course.

00:24:07.780 And this was noticed in their camps, independent of the return of the virus to the United States,

00:24:16.940 which first occurred in Boston and a naval facility or essentially a naval barracks,

00:24:24.120 and then spread to Camp Devens, which is about, I guess, 30 miles northwest of Boston, maybe a little

00:24:31.040 more than that, where that was the first army camp that really exploded with the deadly form

00:24:36.760 of the disease. How much was the transition of the first to the second wave and the propagation

00:24:44.100 of the second wave made worse by the war? I mean, I'll start on pointing out the two issues. One is

00:24:51.140 just the proximity and physical nature of war and sort of the fact that soldiers could become such

00:24:57.320 effective conduits and vectors, but also in terms of the media's response to this or the government

00:25:02.340 response to this. Well, in terms of the government response, it was major. I'll talk about that.

00:25:06.760 In terms of the war spreading the pandemic, I think it accelerated it a little bit, maybe by a few

00:25:15.000 weeks or something like that. The outbreak in New York City, for example, preceded any outbreak

00:25:20.900 in army camps. It's also another reason why I backed off my Haskell hypothesis. Haskell did precede New

00:25:29.100 York City by a couple of weeks, but it's hard to figure out how it would have gotten from Haskell

00:25:34.360 to New York City, although it certainly could have happened. Anyway, with New York having a well-defined

00:25:40.660 spring outbreak and Chicago also, it's pretty clear it would have gotten everywhere eventually and

00:25:48.100 sooner rather than later. And whether you have 10 people getting off a ship from New York to England or

00:25:55.640 France, or whether you have a few thousand soldiers getting off a ship really doesn't make that much

00:26:02.900 difference in spreading the pandemic. Just difference in timing, but with a reproductive number close to

00:26:10.440 two, you'd catch up pretty fast, even if you start with one index case, much less 10 or 20. So I think the

00:26:17.880 war accelerated the spread, but I don't think it's responsible for the spread. It just happened a

00:26:24.040 little bit faster. In terms of the other question about the response, that was a major factor and I

00:26:32.260 think the death toll possibly, certainly in the fear and in some cases chaos that was generated.

00:26:39.380 The government had created this infrastructure because of the war. The federal government, I believe,

00:26:47.780 more than any other time in its history, including the McCarthy period or the Civil War,

00:26:53.060 was determined to control the thought of Americans. And they had a law that made it punishable by 20 years

00:27:01.300 in jail to, quote, utter, write, print, or publish any disloyal, scurrilous, or profane language about the

00:27:10.340 government of the United States. So you could curse the government, you just broke the law.

00:27:15.460 They weren't kidding about this. They actually sent a congressman to jail for 15 years under the law.

00:27:20.740 This was upheld by the Supreme Court. It's where the line came about, you can't shout for fire in a

00:27:26.980 crowded theater. That came from that Supreme Court decision upholding that law. They also had a

00:27:33.220 propaganda arm called the Committee for Public Information, which was determined to, quote,

00:27:40.740 keep morale up, unquote. And the architect of that committee said, truth and falsehood are arbitrary

00:27:46.420 terms. There's nothing in experience to tell us that one is superior to the other. Went on to say all

00:27:52.740 that mattered was the impact of what you're saying. So that propaganda arm was going to

00:27:59.380 minimize anything that might depress the American public because they feared that would affect the

00:28:06.020 war effort. So the pandemic fitted into this construct. By the way, that makes me feel not so

00:28:12.260 bad about the world we live in today. It suggests that history can repeat itself and maybe the pendulum

00:28:17.940 can swing back a bit. I go around quoting Hegel. Everybody quotes Santiana. I like Hegel. Hegel

00:28:24.500 said, what we learned from history is we learned nothing from history. Just contrarian. Anyway,

00:28:32.740 as a result of this approach to maintaining morale, in quotes, a national public health leader said,

00:28:41.460 this is ordinary influenza by another name. It was referred to as Spanish influenza, even though it didn't

00:28:46.820 start in Spain. Another national public health leader said, you have nothing to fear if proper

00:28:53.060 precautions are taken. But people pretty soon and throughout the country, most localities, the local

00:29:00.260 public health commissioner echoed these approaches. The press was complicit. It was fake news because they

00:29:08.340 were not reporting the truth because they were only saying nice things. But everybody knew it wasn't

00:29:14.580 influenza by another name, ordinary influenza by another name. There were deaths in less than 24

00:29:19.860 hours after the first symptoms. That was unusual, but it certainly happened. What was the typical

00:29:26.580 course? I mean, you mentioned that the R-naught reproductive number approached two, which made it 1.00

00:29:32.020 more contagious even than garden variety influenza. But its real superpower was not that it was a more

00:29:38.100 aggressive spreader. It's the actual pathology of the disease that's probably its superpower.

00:29:43.380 And I use that term horribly because evolutionarily, that's not a superpower for a virus. A superpower

00:29:49.700 virus would kill nobody. It would have an R-naught of infinity and kill no one. That would be the best 1.00

00:29:54.180 virus if you were thinking about it from Darwin's point of view. But this was a deadly virus. What was

00:30:00.820 the typical clinical course? The typical course was ordinary influenza. But in the West, the case

00:30:07.860 mortality was about 2%, much worse than that in the less developed world, not because Western medicine

00:30:14.580 was any better, but because in the West, people had some cross protection from having been exposed to

00:30:20.580 other influenza viruses. And in the less developed world, that was not the case. They were, quote,

00:30:26.180 virgin populations, unquote, naive immune systems. But the 1918 virus, like coronavirus, but unlike

00:30:36.820 most influenza viruses, could bind to cells in the upper respiratory tract, which made it easily

00:30:43.060 transmissible. But it also could bind directly to cells deep in the lung, which meant you were starting

00:30:49.220 out essentially with viral pneumonia. Those were the awful pathologies where some of the symptoms

00:30:57.780 in the book, I quote one physician writing, a colleague, that people were turning so dark blue

00:31:03.380 from lack of oxygen that he couldn't distinguish colored soldiers from white soldiers, African-American,

00:31:09.780 I'm quoting him. That, of course, spread rumors of the Black Plague and when people's pallor

00:31:16.100 turned so in that color. And that virus also, unlike most influenza viruses, could pretty much

00:31:23.380 attack any organ. It was initially misdiagnosed as typhoid, as dengue, as cholera. Nosebleed was

00:31:31.300 quite common in some army camps. They reported 15% of the soldiers had nosebleed. It was also possible

00:31:37.380 for people to bleed from their mouths and from even their eyes and ears, which are, of course, other

00:31:43.540 mucosal membranes. So that's pretty scary, particularly for a layperson. So to be told this

00:31:51.300 is ordinary influenza by another name, when you're seeing symptoms like that and you're seeing people

00:31:56.500 die rapidly, it gets your attention. And what it means is you stop trusting anything that you're

00:32:02.900 being told by anyone in authority. I think society is based on trust. When trust evaporates,

00:32:09.540 society begins to fray. And in some places, it got pretty bad. There were reports of people

00:32:16.900 starving to death, not because of lack of food, but because no one had the courage to

00:32:23.140 bring them food. This happened in cities like Philadelphia, which I focused on in the book.

00:32:28.580 But also, according to the Red Cross, reports of that, things like that happening in rural communities

00:32:34.580 occurred as well. The story of Philadelphia is an interesting one. And I really want to

00:32:38.500 come back to it as a case study and then contrast it with other cities. Obviously,

00:32:43.060 you contrast it quite eloquently with St. Louis, but also San Francisco and others. I want to talk

00:32:47.140 about that. But going back to the pathology of this illness, it really seems like, I mean,

00:32:51.700 typical influenza, you get a little bit of a, I think of it as sort of a, you stun the immune system.

00:32:56.740 You get this immune paralysis that can often result in a superimposed bacterial infection and all

00:33:02.660 of these other things that come to bear. And anybody, therefore, who's susceptible to super

00:33:07.780 infection, meaning people who are hospitalized already in a nosocomial environment, I mean,

00:33:12.260 those things sort of become problematic. But as you pointed out, there was something really distinct

00:33:16.900 about this pattern of victim here, especially in 1918 in that second cohort, which is, this was

00:33:25.140 knocking off people in their thirties, the way we would normally see people dying in their seventies and

00:33:31.140 eighties. And the idea being here that it was. Peak age for death was 28. Suggesting that the

00:33:37.140 stronger your immune system was, the worse you are. Exactly. Same thing people are dying of today,

00:33:43.860 acute respiratory distress syndrome. Your immune system releases, as you know, cytokines, which the

00:33:51.140 immune system has some very lethal weapons. The virus, when it was in the lung, the immune system

00:33:56.900 attacked it with everything it had. And the battlefield was a lung, which was being essentially wiped out

00:34:02.660 in the effort to destroy the virus. Exactly the same thing is happening today. And those people who are

00:34:10.820 dying of coronavirus. Now, I will say probably a majority of people in 1918 died of secondary bacterial

00:34:18.020 pneumonia. There are some people who think that 95% of the deaths were bacterial pneumonia. I think that is

00:34:25.940 mistaken. It's difficult to quantify how much was bacterial pneumonia and how much was directly because

00:34:36.100 of the virus. My guess would be a third to 40% would be directly virus, but that's a guess. I certainly

00:34:44.100 think it's a lot more than 5%, as some have hypothesized. And just the anecdotal reports from

00:34:52.020 very good pathologists suggest that that was not the case. And even today, bacteria and pneumonia

00:34:59.380 following influenza has an 8% case fatality rate with all the antibiotics we have. Back then, it was 35%.

00:35:06.820 That's actually unbelievable. I didn't realize it was that high today, by the way. 8% today seems

00:35:12.740 a pretty high number. But to your point, these people are already incredibly compromised based

00:35:18.260 on what they've been through to get there. So let's go to Labor Day 2018. Set the stage again,

00:35:24.820 just to remind people where we are. You had this awful virus that ripped through the United States

00:35:31.540 in some pockets. In the spring, it killed, what, maybe 25,000, 50,000 Americans by that point?

00:35:38.660 I've never put a number on that or seen a number on that. It's really hard to say.

00:35:44.260 Yeah. I mean, directionally, it's like less than a tenth of the total population that would

00:35:49.780 ultimately die, which was about 650,000 Americans, correct?

00:35:53.380 Roughly, yeah. 650, 675 are the numbers that I've seen, yeah.

00:35:59.220 So now fast forward, we've just enjoyed a summer of relatively low mortality domestically. The virus,

00:36:06.340 of course, has been doing something else abroad. I don't think people realize it at the time,

00:36:11.060 but the war is about two months from being over. Right. That was not common knowledge.

00:36:16.580 No. Quite diverse. People were gearing up for

00:36:19.940 spring offensive in 1919 to end the war. And in Philadelphia, they need to raise money.

00:36:26.100 There's a bond that basically the government has to borrow money and there's no better way to sort of

00:36:32.100 do this than to kind of showcase what the money is going to buy you and have a parade, right?

00:36:36.420 Right. Correct. And in fact, it wasn't just Philadelphia. It was around the country,

00:36:41.300 September 28th. It was a Liberty loan parade, a lot of cities. But in Philadelphia, by then,

00:36:47.380 the virus had already established itself. And the medical community was unanimous that the parade

00:36:53.620 should be canceled. They were writing, telling reporters this. Reporters were writing stories about

00:37:00.020 it. Editors were killing the stories. As I said earlier, the press was largely complicit with the

00:37:07.220 morale boosting approach that the government took. The local public health commissioner was part of a

00:37:13.540 corrupt political machine. He's a perfectly good person, but didn't have the backbone to stand up to

00:37:18.180 it and tell you how corrupt that machine was. It elected a United States Senator a few years later,

00:37:23.780 and the Senate, controlled by the same party, refused to seat the guy. That's pretty corrupt

00:37:31.540 when the U.S. Senate won't seat somebody, wins an election when he's a member of the party that controls

00:37:37.300 the Senate. Anyway, the parade went forward and pretty much like clockwork, 48, 72 hours later,

00:37:45.940 influenza exploded in Philadelphia. It became one of the hardest hit cities in the country.

00:37:50.500 Within three weeks, 4,500 are dead.

00:37:54.100 Something like that. In total, about 14,500 over the course of the pandemic.

00:37:59.220 And getting back to the press to tell you how complicit they were. So when they finally

00:38:04.420 closed schools, banned public gatherings, closed saloons, theaters, no church services, stuff like

00:38:11.460 that, one of the local papers actually said, this is not a public health measure. You have no cause for

00:38:18.980 alarm, unquote. I mean, how stupid did they think people were? But that contributed to the breakdown 1.00

00:38:26.980 of society, contributed to the fear and the terror. When you can't believe anything you're being told,

00:38:33.940 and obviously by then everybody knew perfectly well that was a public health measure. People were dying

00:38:39.300 all around them. How did that information get around? Because obviously we take for granted today how

00:38:44.660 electronic information basically, I mean, it creates so much noise that it's hard to know the signal.

00:38:51.460 But back then you had a very different problem, which is if you lived in Los Angeles at that time,

00:38:58.820 what would be telling you that people are dying like flies in Philadelphia if the formal media is not

00:39:06.260 doing anything about it?

00:39:07.300 Well, you wouldn't necessarily know what was happening in Philadelphia, particularly

00:39:11.620 back then, because it's funny. I didn't write a lot about Phoenix in the book, but it was too

00:39:17.460 redundant with what had happened in Philadelphia, a little bit different. But I did a lot of research

00:39:21.700 in Phoenix. And interestingly, when the disease first hit Boston, they were writing about it. When it was in

00:39:30.660 New Orleans, they were writing less about it. When the disease was actually in Phoenix, you could not

00:39:38.180 find a word about it in the Phoenix paper. You know, on page 14, they had a death notice of somebody. That

00:39:44.820 was about it. There was not in the headlines hardly ever. So it was strictly rumor. And again, that

00:39:52.500 contributed to the level of fear. You didn't know what was going on, which gets into maybe to jump

00:39:59.860 ahead or not. When the Bush administration started the pandemic preparedness planning and the Bush

00:40:07.700 administration launched a major initiative, $7 billion bill, did all sorts of things, vaccine

00:40:14.100 technology investment, research, create vaccine manufacturing, began the national stockpile. Anyway,

00:40:21.620 I was asked to participate in some of the early groups, which were coming up with so-called non-pharmaceutical

00:40:29.300 interventions. What are you doing? You don't have drugs. And my message in these groups was always

00:40:33.860 that the step one is to tell the truth, that people can deal with reality. They can't deal with when you

00:40:41.060 let their imaginations run loose. That's when you really get into trouble. If you give them the straight

00:40:45.940 facts that it's much easier to handle. In a monster movie, it's always scarier before the monster appears on

00:40:54.820 the screen. Imaginations are very powerful things. Let's go back to Philadelphia. I've seen video

00:41:00.420 footage of what can only be described as horrifying because as terrifying as and uncertain, I guess,

00:41:06.020 as the last couple of months have been with respect to the unknowns around the coronavirus.

00:41:11.780 When you look at morgues that can't accommodate corpses, and when you also understand how little people

00:41:21.540 understood about microbiology at the time, and so they know enough to know that this is contagious,

00:41:26.580 they know enough to know this is respiratory contagious, but as you pointed out, there's a

00:41:32.180 breakdown in society from not knowing how and when and if you can help someone else. And what do you do

00:41:38.820 when someone dies? I mean, there are these stories of bodies that just were left out on the street

00:41:43.300 because the risk of actually having to go out and take care of a body and dispose of it could potentially

00:41:49.220 expose you to more. And I mean, to me, that's, again, 14,000 deaths doesn't sound like an enormous

00:41:56.340 number. I mean, New York will likely eclipse that. New York City, obviously adjusted for population,

00:42:01.220 Philadelphia would have been more in that time. But it's in part the speed with which it happened,

00:42:06.100 and also just the fear of who's next. And I think the other thing is seeing these young people dying

00:42:14.980 in a way that you just, you aren't used to. I guess if I'm going to play devil's advocate for a

00:42:20.100 moment, without the benefit of hindsight, is there an argument that one could make that says,

00:42:25.620 look, the public health officials or the people who should have been doing the right thing

00:42:29.540 didn't want to create an unnecessary panic in the other direction without knowing more? I'm sure this

00:42:36.180 is an argument that you've heard a hundred times. What is the counterpoint to that, if there is one?

00:42:40.900 As you say, that's the counterargument. But I think I already articulated the argument in favor

00:42:47.380 of the truth. Number one, the imagination is more powerful. Number two, if you ever expect the public

00:42:52.740 to do something you want the public to do, you better have credibility. And once you lose credibility,

00:43:00.820 you can't regain it. If you start out telling the truth. Even by the way, when the truth is,

00:43:05.860 we don't know. I mean, to me, that's the biggest challenge the government has, right?

00:43:09.300 Well, that's okay too. If you say, we don't know, but we'll know when this test is performed and we

00:43:17.220 have the results, you can go down the line as to why you don't know. And you can then say when we

00:43:24.580 will know. So you provide information and you can retain your credibility, even if you don't know.

00:43:32.420 I think that's the only way to go. My standard line is I don't like the phrase risk communication

00:43:40.100 because it implies managing the truth. You don't manage the truth. You tell the truth.

00:43:45.460 You know, I would be in these working groups and I mentioned D.A. Henderson earlier, D.A. and I became

00:43:51.540 friends because we were always in agreement, it seemed, in these groups, sometimes opposed by others.

00:43:58.900 But on that one point of telling the truth, I never got any pushback from any of these groups

00:44:06.260 I participated in. The national pandemic plan, which was the outgrowth of those working groups,

00:44:14.980 certainly incorporates the idea of transparency, as does every state plan. The problem is

00:44:21.060 someone has to go out and execute that pandemic plan. Someone has to go out, face the camera,

00:44:28.420 and tell the truth. Obviously, that has not happened. There are other countries where it has

00:44:35.380 happened, including Germany, which has done light years ahead of us in ending the coronavirus,

00:44:40.900 or Singapore, and no doubt other countries, just not in the United States.

00:44:46.420 Going back to the Philadelphia story, how would you contrast that with what happened in St. Louis,

00:44:51.540 which you use as a counterpoint? Well, St. Louis intervened very early in terms of

00:44:58.420 what we call social distancing now. And at least partly as a result of that, they had a much more

00:45:05.620 benign experience than most other cities on a per capita basis. It's not clear to me that 100% of that

00:45:12.980 is attributable to social distancing. We don't know. Nobody's ever looked. The information's

00:45:19.860 ascertainable, but I didn't have time to do the research. Whether or not they had a spring wave,

00:45:24.020 for example, which I am convinced, I think you've demonstrated, did provide protection against the

00:45:30.100 fall wave. New York City, for example, didn't do anything. They did less than any other city. They

00:45:34.900 didn't close schools. They didn't close saloons. They didn't close theaters. They didn't do anything.

00:45:39.380 And yet New York City had a relatively benign experience, I think because of its spring wave.

00:45:46.020 Same thing in Chicago. Now, whether that was true in St. Louis, I don't know. But St. Louis did act early

00:45:51.780 and aggressively in terms of social distancing measures. They were less extreme than what we're

00:45:57.460 doing now. But they were imposed early and early action is very important. If you do it before the

00:46:06.500 virus is widely disseminated in the community, it can be effective. If you wait until people start

00:46:13.380 dying all around you, by then the virus is everywhere and those measures are not going to be

00:46:19.060 nearly as effective if they're effective at all.

00:46:21.220 San Francisco had some interesting policies, right? Weren't they so strict on how they enforced

00:46:27.060 masks that the police had authority to shoot a person in public who was not wearing a mask?

00:46:30.900 I missed that. I'm not saying you're wrong. They did require, by law, people wear masks. There were

00:46:38.980 several cities that did that. The thing that makes San Francisco interesting, they were the only place

00:46:45.620 I know of that really did tell the truth. I'm sure there must have been at least some other places.

00:46:51.380 Certainly, I didn't study every ball of 100 biggest cities in the country. But in San Francisco, the

00:46:57.140 mayor, labor leaders, business leaders, medical community all made a joint statement. Huge, tight,

00:47:06.740 full page in the newspaper, wear a mask and save your life. Now that is a very different message

00:47:14.020 then this is ordinary influenza by another name. You have nothing to fear. Proper precautions are

00:47:19.780 taken. So wear a mask and save your life. This is a life-threatening disease and you better take

00:47:26.100 action. They honestly believe the masks were the effective. They did next to nothing or probably

00:47:32.580 nothing. San Francisco actually suffered, forgot the exact number, but they were fourth or fifth

00:47:38.020 highest excess mortality in the country. But what that message did do was secure the community.

00:47:48.900 The community did trust what the leaders were telling them. And the community, instead of fraying

00:47:55.620 as a society, in some cases almost breaking down. In San Francisco, that city functioned better than any

00:48:02.660 other place that I know of. In the sense that, for example, when schools were closed, teachers

00:48:08.180 volunteered as ambulance drivers, whatever was needed, as opposed to running and hiding, which was

00:48:15.460 happening in other cities where the leadership lied. And as a result, people felt it was everybody

00:48:23.380 for himself or herself or their families and the hell with the community.

00:48:27.380 So after the pandemic, despite the fact that San Francisco had a very high death toll,

00:48:33.940 the Chronicle wrote an editorial saying that in our long history of the city, despite the tragedy,

00:48:41.700 this will be one of the most glorious episodes in our history because of the way the community came

00:48:46.740 together and functioned. I don't know of another city anywhere that could have made a claim like that.

00:48:53.940 Which is really a counterintuitive claim when you think about both the general statement one would

00:49:00.100 make about pandemics, which is unlike natural disasters, acts of war and terrorism. Pandemics

00:49:06.020 tend to divide people, not unite them due to the isolation and fear. And then secondly, this pandemic

00:49:12.260 happens to be the worst of the bunch. You'd think that if anything, this would have decimated

00:49:16.660 communities. And yet you have this counter example. Do you think it is this culture of abject honesty

00:49:24.420 from the outset that played the main role in that? I think that was a factor. I think in most disasters,

00:49:31.060 people do come together. I live in New Orleans. Well, that's what I'm saying. Most disasters,

00:49:35.060 yes. I'm saying, but there's something unique about these pandemics that people talk about saying,

00:49:38.500 no, actually these do more harm than good in terms of social cohesion.

00:49:43.380 Well, you know, if you look back at the plague and so forth in the Middle Ages, the terror that was

00:49:48.420 out there, a quarter to a third of population being killed. Yeah, I would say that's true. Plus 1.00

00:49:54.820 the unknown factor. So you had everything working against you in the Black Death. I think it's almost

00:50:02.740 like a controlled experiment supporting my hypothesis that telling the truth is the best way to go and

00:50:11.460 that it can pull people together and make even in a pandemic people function as they do in other

00:50:18.980 disasters, trying to help each other. The reality is I can't prove it quantitatively, but in terms of

00:50:27.300 anecdotally, I'm in the French Quarter, which is deserted. There are not a heck of a lot of full

00:50:33.780 time residents in the French Quarter. There are some, but people around here, neighbors whom I

00:50:40.820 don't really know a few blocks away, they're asking me if my wife and I go for walks. They're asking if

00:50:46.420 there's anything they can do for me. I have a couple of people who are younger. I'm over 70, so is my wife.

00:50:51.940 You know, they volunteered to get groceries for us. I have a neighbor next door who's a dentist who

00:50:58.100 immediately went to his office and donated all his masks and gloves to a local hospital. He's unusual

00:51:05.620 in this, also in the sense that he did a medical rotation with interns in addition to his dental

00:51:12.420 school. So he's volunteered to go to hospitals and perform procedures that he's capable of doing and take

00:51:18.820 some of the stress off healthcare workers, which of course exposes himself to a lot of risk.

00:51:24.660 I get the sense around here that people are coming together. Again, it's anecdotal and it's

00:51:30.740 very localized even if I'm right, but that's the attitude nationally. That's a pretty big plus.

00:51:38.820 I want to pivot for a second and talk about two things we can do them in either order you prefer.

00:51:42.820 One is I want to visit India a little bit because I was kind of astonished at the mortality in India. 1.00

00:51:49.060 It's almost hard to fathom. And then the second unrelated thread is really the, I don't know much,

00:51:54.900 or I don't recall much about the factors between the second and the third wave. So in either order,

00:52:01.540 you want to talk about those as we continue through this journey.

00:52:04.260 Well, we can go in either order you want and because it may be a short discussion.

00:52:09.220 Let's stay on the domestic thread and talk about how much of the dying down of the second

00:52:15.700 wave before the resurgence of the third, because it doesn't appear to have been

00:52:20.660 just seasonal. Or do you think that the seasonality was the main driver of that?

00:52:24.260 No, I very definitely do not think of seasonality. I think the virus change. As I said earlier,

00:52:31.460 either first or second wave exposure seemed to protect against the third wave. So that suggests

00:52:38.260 a reasonably dramatic shift in the virus and what is referred to, as you well know,

00:52:44.500 Anderson drift. I should have said drift instead of shift in the

00:52:49.860 field of influenza. That's actually a meaningful term of art. I can't prove that. Come to think of it,

00:52:56.340 I don't believe that Jeff Taubenberger, who's the one who's done all the sequencing of old viruses.

00:53:03.220 I don't know that he's got a viral sample from 1919. Maybe he does. I should ask him. It'd be very

00:53:08.180 interesting. By then, most of the samples, not all of them, but most of the samples came out of the army.

00:53:15.620 By the spring of 1919, there probably weren't that many soldiers.

00:53:19.540 Dying of influenza, they would have been discharged. So they may not have samples.

00:53:24.180 So I think the virus drifted enough to escape the immune system. It was lethal by any standard.

00:53:32.740 1919 was lethal by any standard except the fall wave in 1918. It was the second worst year of the

00:53:40.260 century or that we know of in terms of influenza deaths. What was the morale of the country like

00:53:46.500 at that point when you have no reason to believe this isn't going to continue indefinitely? I sometimes

00:53:52.980 find it interesting to try to imagine going back in time, not knowing how the story ends and thinking,

00:54:01.460 how could you concoct a story here that is really frightening? And to me, it would be,

00:54:06.900 as you're in the midst of the third killing wave, this is the new norm.

00:54:11.940 Probably most Americans were relatively unaware of the first wave at all.

00:54:16.500 So to them, it probably was the second killing wave. That doesn't take away from the point you're

00:54:22.020 making. And honestly, I don't know. In the book, I was trying to focus. If you ask me what I write

00:54:27.300 about, I will tell you, I write about power. I may be the only person who sees it that way.

00:54:32.900 The influenza book, in terms of characters that I was trying to focus on the scientists,

00:54:38.020 because they were the ones who had power to confront the pandemic. And to a lesser extent,

00:54:43.060 actually, I focused on the politicians because they affected the course of the pandemic by lying

00:54:49.220 to the public and so forth. So I did not spend much time. Well, particularly, I didn't look at

00:54:54.580 newspapers and things like that for sources because that was fake news back then, because they were

00:55:01.700 working with the government to minimize things. The war ended. There were so many other things going on.

00:55:07.620 I don't really know the answer to your question. Certainly, there was concern. I don't get the

00:55:12.660 sense from the little research that I did in the area that there was a kind of terror erupting

00:55:20.020 that accompanied the second wave. But I really don't know.

00:55:23.300 And what to make of India, about 20 million fatalities in India, correct?

00:55:28.260 At least. In fact, the original estimate of the death toll, which was in 1927,

00:55:36.580 study by the American Medical Association, a guy named Edward Jordan, an infectious disease expert,

00:55:42.340 looked at the entire world. And they originally estimated 21.7 million people died.

00:55:48.980 That was largely because they extrapolated the case mortality rate from the West where they had

00:55:54.260 semi-good data to the rest of the world, which turned out to be wrong.

00:55:58.580 My speculation, clearly, those populations that had not seen influenza viruses before had

00:56:06.340 terrible mortality. Forget about case mortality. In an isolated island in the Pacific, Western Samoa,

00:56:12.500 22% of the entire population died. Not case mortality, 22% of the entire population. And that's a very good

00:56:20.500 number. We know exactly how many people died there. In India, it's hard to imagine that that country had

00:56:27.540 not been exposed to influenza viruses throughout the country. And yet, I can't think of another

00:56:33.060 the possible explanation for their tremendous death toll. And you can look at British Army. You've got

00:56:41.780 Indian troops in the same camp as Caucasian, British troops. And the case mortality for the 0.68

00:56:48.820 Caucasians is 9%. And the case mortality for the Indians at the same place at the same time is over

00:56:59.220 20%. And it's not because medical care was any different, because medical care didn't make any

00:57:03.780 difference. All they could do was supportive care and keep you hydrated. That was about it. Maybe ice you

00:57:09.060 down if you had a fever. There could have just been genetic differences. There could have been

00:57:14.420 certain things about the way this virus binds. Maybe this was a virus that could have disproportionately

00:57:20.260 affected Southeast Asians, potentially more than Caucasians, just based on properties of how the

00:57:26.180 virus worked. Or to your point, which I think is seemingly the more logical or the Occam's razor here

00:57:32.180 would be just a difference in immune preparedness. Exactly. The naive immune system. But we don't really

00:57:40.020 know, I've seen epidemiological studies, which range as high as 30 million in India, but I haven't really

00:57:46.740 seen a good hypothesis explaining why. All told about four to five percent of the world's population died.

00:57:54.740 Does that sound about right? Well, you can do the math. It's pretty simple. 1.8 billion people.

00:58:00.260 So 50 million dead would be about two and a half percent, roughly. 100 million would be about five

00:58:09.220 percent. The thing is, two thirds of the dead were aged 18 to 45. So when you look at that demographic-

00:58:18.980 Yeah, that's a staggering impact on life expectancy.

00:58:21.380 Yeah. On aggregate life expectancy.

00:58:23.620 Yeah. And particularly when you throw in the period, the short period of a few months during

00:58:30.820 which most of those people died. And then you go into other narrower demographics. And according

00:58:37.460 to Metropolitan Life, over three percent of all the factory workers in that age group died. Not case

00:58:45.780 mortality. Three percent of the entire population of factory workers in that age group died in a period

00:58:52.020 of weeks. Pregnant women, there are a whole series of studies which range from 21 percent to 71 percent

00:58:58.020 case mortality. Minors, according to Metropolitan Life, over six percent of all minors in that age group

00:59:06.260 died, again, in a very narrow period. And it's even shorter than that 14 or 15 weeks because influenza

00:59:13.060 would pass through a particular community anywhere from six to 10 weeks. So the time frame is very

00:59:19.620 compressed when people are dying. So it was a pretty horrific period to live through.

00:59:26.580 This is a question that might be a little bit outside of your area of expertise, but-

00:59:30.020 Oh, great. I'll pontificate. Happy to pontificate something I know nothing about.

00:59:34.500 Well, you might. Why did we roll into the 1920s with an enormous economic tailwind and

00:59:42.020 not hit a depression until a decade after this pandemic when you would think that something that

00:59:47.540 knocks out that much of a country's population would have actually precipitated the economic

00:59:54.340 downturn immediately following this? Why is it that by the time this thing rolls to an end in late 19,

01:00:00.740 1920, the country managed to resolve itself economically? Was that more on account of the war

01:00:08.020 being over? What do you attribute this to, if any thoughts?

01:00:10.820 There actually was a recession that was fairly deep, but very short-lived right after the war.

01:00:17.460 And indeed, after World War II, there was a lot of planning and anticipation of the same thing

01:00:23.380 happening after World War II. It didn't happen after World War II. It did happen after World War I,

01:00:29.460 but again, it was brief. You're talking about four million soldiers or more,

01:00:34.900 plus however many were in the Navy, suddenly thrown back into the workforce. So there was

01:00:42.660 great dislocation and unemployment, but it was pretty brief. You had pent-up demand. You had an

01:00:49.700 adjustment as factories went back to making civilian products instead of tanks or ships. So there was a

01:00:55.940 dislocation, but then it did pick up. In terms of the attitude, culture, people usually ask me what

01:01:04.340 impact I thought the pandemic had. Again, it's very difficult to quantify or be precise about my own

01:01:12.180 senses. People understood it was there. It was part of their consciousness. I think it may have contributed to

01:01:19.540 the sense of ennui in the 20s, that party today, because who knows what's happening tomorrow.

01:01:26.020 In 1933, when the Nazis rolled into Germany, into Berlin, Christopher Isherwood wrote Berlin

01:01:32.500 stories from which a great movie, Cabaret, came. He said you could feel it like influenza in the bones.

01:01:40.660 So he expected his readers to understand that sense of dread deep within you that you get just

01:01:48.580 from seeing the Nazis show up. I think that analogy, the fact that he made it, is a powerful statement.

01:01:55.540 By the same token, there's very little that was written about it. John Dos Pasos, one of my favorite

01:02:01.540 writers, got influence on a troop ship. It was a pretty bad place to get it.

01:02:05.860 And he hardly mentioned it in any of his novels. There's just not that much written about it,

01:02:11.460 which is a puzzlement, not only to me, but to a lot of other people.

01:02:16.420 In 2009, when H1N1 was coming, I'm guessing your phone was ringing a lot.

01:02:23.460 Yes.

01:02:24.260 What was the fundamental difference from a virology standpoint between the 2009 H1N1 swine flu,

01:02:31.780 and let's just think about the second wave version of that same virus?

01:02:37.380 Well, the reality is that 2009 was very, very strange because it was almost two entirely

01:02:44.660 different diseases. The overwhelming majority of people who got sick had a relatively mild case

01:02:52.180 of influenza. But for those who were seriously ill, it was 1918. That virus, H1N1, well, 1918,

01:03:01.700 was H1N1 virus also. But the 2009 virus could bind directly to cells deep in the lung.

01:03:07.940 What was the genetic similarity between those two? Do we know?

01:03:11.860 Well, I write about science, but I'm not a scientist. I know that it's referred to,

01:03:17.620 as you probably know, a triple reassortment of viruses, meaning that there were three different

01:03:23.460 influenza viruses that were involved in making up the genome of the 2009 virus. Some of it probably

01:03:32.980 went back, I think did go back to 1918. But most of the viruses, if not all of the human viruses

01:03:39.060 circulating today, have some of 1918 floating around in them. So I can't really answer your

01:03:44.740 question. Clearly, there had to have been a lot of cross protection from other circulating viruses.

01:03:51.620 You think the vaccination or the frequency with which people had influenza vaccines and continued

01:03:57.140 exposure to influenza and perhaps greater medical care?

01:04:01.300 No, I think it was simply the virus primarily. One thing that's also interesting about 2009, the

01:04:08.820 peak deaths. The age of the dead was very similar to 1918. I forgot the exact number, whether it was

01:04:15.780 27, 28, or 29, or maybe even 30. But the average age of the people who did die was very, very young,

01:04:23.700 much different from ordinary influenza and very similar in 1918, though most of them did have comorbidities.

01:04:31.780 Let's fast forward now to where we are. It's a different type of virus. It's a coronavirus,

01:04:35.700 not an influenza virus. They have things that are common. They have things that are different.

01:04:40.580 What have been your observations so far? I'm sure you have assimilated a great deal of information.

01:04:47.780 And though you're not a virologist, you're obviously incredibly erudite with respect to

01:04:53.140 your understanding of not just the biology of these things, but also the epidemiology of them

01:04:59.620 and the role that governments, media, et cetera, play. Let's just start with biology.

01:05:04.020 Let's say it's kind of you to say it. I don't know how much it's nice of you to say that. I

01:05:08.900 appreciate that. I hope what I say is correct. I know I believe it. I do sort of cross-reference

01:05:16.100 my thoughts with other people who are very involved in pandemic preparedness, vaccine production,

01:05:23.940 and so forth, and so forth, who I became friendly with back in the Bush administration and since then,

01:05:29.860 Obama administration as well. So if I have an idea, I will send them an email and ask them if I'm

01:05:39.460 going to embarrass myself if I say it. But to answer your question, as I said earlier,

01:05:47.700 coronavirus like 1918 can bind directly to the lung, cells in the lung. Obviously it's different

01:05:57.140 binding sites, but still it's deep in the lung as well as upper respiratory. That's the main similarity.

01:06:03.460 The main difference is the incubation period, which creates a nightmare for managing this virus.

01:06:11.860 Then we have questions about immunity. We don't know the answers to.

01:06:16.020 Sort of presume that I guess the work that I've seen recently suggests

01:06:22.180 that you can more or less semi-safely assume you're going to have immunity for a year

01:06:29.300 and maybe longer if you've survived the disease. In fact, I won't use Instacart because I think it's

01:06:36.980 unethical to expose people to the virus. The person who is getting groceries for me now

01:06:43.220 actually did have the disease and did recover. So she's kind enough to get groceries for me and I don't

01:06:50.180 feel an ethical problem asking her to help me because I think she probably does have immunity, recent 0.84

01:06:56.820 recovery. But in terms of the time, you know, the incubation period for influenza is generally two days.

01:07:03.140 It might run as long as four, but it's usually shorter. This is two to 14 days. The average

01:07:08.340 incubation period is five and a half to six days, triple the length of time for the average

01:07:13.780 incubation period for influenza. So that makes each generation is going to be that much longer.

01:07:20.020 The disease itself takes much longer to develop in the body. It takes much longer to pass through the body.

01:07:26.180 So the whole length of time, the duration is much, much longer than influenza. I said earlier in 1918,

01:07:34.260 or for that matter, seasonal influenza, it'll pass through a community normally six to 10 weeks.

01:07:40.740 And then, you know, hear about it until the next season or in 1918 until the next wave came.

01:07:45.940 And this is not going to be like that. Also, the social distancing, to the extent that it works and

01:07:53.780 it is working, is going to add further duration to that. The whole process of coming out of this

01:08:01.620 is just tremendously complicated. Do you think that the response to this has been

01:08:08.420 appropriate, has been overly aggressive, has been not aggressive enough in certain areas,

01:08:14.180 potentially New York? I mean, what's your overall take on this, on the response?

01:08:18.980 Of course, Trump is a disaster. Incomprehensible, his failure to respond, his failure to lead. 0.94

01:08:28.980 He said the federal government is a backup. I always thought leadership meant you are in front.

01:08:34.820 His failure to mobilize resources. Incredible that FEMA in 50 states compete for the same

01:08:42.020 law resources instead of FEMA taking over and allocating it through the states. 0.83

01:08:47.220 The obviously trivialization of the threat for two months. All these things are almost off the scale.

01:08:55.620 And then cutting out and saying he's withholding $500 million from the World Health Organization

01:09:00.980 in the middle of a pandemic. Stephen King would not be believed if he wrote these things in a novel.

01:09:07.700 So what else can you say about this guy? States are varied. I'm in Louisiana. I think the governor

01:09:15.300 here, John Bel Edwards, has done pretty well, reasonably early. I think the mayor of New Orleans also acted

01:09:21.700 pretty early. I know Mardi Gras is blamed for Louisiana and New Orleans being a hotspot,

01:09:28.500 which may be the case. But if you look at the timing when Mardi Gras appeared and when the February,

01:09:36.020 I guess 25th was Mardi Gras, there was not a single case in the state of Louisiana at that time that we

01:09:41.380 knew of. There were probably cases. Obviously, there were Mardi Gras spread any. But all that goes back to

01:09:48.180 the testing debacle, which, unfortunately, I think partly is a result of CDC. And I have high respect,

01:09:57.380 high regard for CDC. But on that one, not great. Then FDA and the bureaucracy, but also Trump and

01:10:06.020 the failure to take this seriously, the failure to develop an infrastructure going forward. I've seen a

01:10:12.660 number that says we're going to need 300,000 people for testing and contact tracing and so

01:10:17.940 forth when we come out of that. I don't think one person's been hired for that at this point.

01:10:24.020 We should be building that infrastructure up even while we're waiting for the testing capacity to

01:10:29.540 develop. That should be done simultaneously. There are countries who've got this pretty right. And again,

01:10:35.700 not just the Asian countries like Korea and Singapore and Taiwan and Hong Kong, but Germany,

01:10:43.300 very much like our country, except for the leadership.

01:10:46.980 What Sweden is doing now, it's too soon to perhaps tell, but what's your take on the,

01:10:51.700 for lack of a better word, the natural experiment going on in Sweden?

01:10:54.340 Right.

01:10:54.980 They're basically saying, look, we're going to pursue this through the landscape of herd immunity.

01:10:59.860 While protecting the vulnerable.

01:11:02.100 Yeah. We're going to take a selective approach to taking those people who are most at risk. Now

01:11:06.580 we've had the luxury of watching how that's played out in the rest of the world, but we're not going

01:11:10.900 to shut our economy down. And they're, what they're basically saying without saying it explicitly,

01:11:16.260 I don't know if they know that this is what they're saying. They're basically saying,

01:11:19.540 we completely disagree that the case fatality rate is one to 2%. We think that the infection fatality

01:11:26.420 rate is probably closer to that of influenza 0.1 to 0.2, 0.3% because we believe that there are far

01:11:34.100 more asymptomatic people out there than we appreciate, therefore creating a much larger 1.00

01:11:39.300 denominator. And that's synonymous with saying you're going to get to herd immunity quicker.

01:11:42.980 Number one, they will get to herd immunity quicker if herd immunity.

01:11:46.740 Well, without catastrophic findings. Yeah.

01:11:48.820 The thing is the infection mortality rate and the case mortality rate or fatality rate

01:11:54.740 are often used interchangeably, but they're not at all the same.

01:11:58.020 They're not. That's right.

01:12:00.180 If you did a serological study to find out how many people were infected with influenza,

01:12:06.340 the numbers that influenza case mortality, I'm convinced would drop from 0.1% way off the scale,

01:12:14.820 way below that because there are people who are exposed to the virus. I mean,

01:12:19.300 serological study infection rate, anybody who responds, whose immune system responds to a virus

01:12:26.180 and which you can find serologically. So there are certainly people who are infected by influenza or

01:12:33.860 any other pathogen who never developed the slightest symptom or the slightest illness of any kind.

01:12:39.220 And normally a case fatality rate is just that. It's a case, meaning somebody has to be ill enough to present

01:12:49.140 to a physician. So you can't really compare the infection fatality rate with the case fatality rate.

01:12:55.940 Yeah. That's a very good point, John, is if you're going to do this apples to apples, you need

01:13:01.620 serologic IFRs for both. Going forward, where can we bend the arc of history?

01:13:09.140 Where do we five years from now look back and say, on April 15th, had we gone down this path,

01:13:15.540 it would have been a better outcome than if we'd gone down this path? What does that look like?

01:13:19.140 Well, I mean, it's sort of the same thing. We still have an administration that

01:13:25.780 has demonstrated no leadership and is foundering. In reality, it's not going to happen if Trump

01:13:33.300 got out of the way and left it to Tony Fauci. In those working groups I mentioned earlier about

01:13:42.580 what planning for a pandemic, what do you do? We discussed who should be a spokesperson

01:13:49.940 and we were unanimous that it should not be any politician because whether any politician,

01:13:55.940 health and human services secretary or president or anyone else, a substantial portion of the public,

01:14:02.580 no matter how popular the politician was, was not going to believe him or was going to have some

01:14:09.860 kind of inherent negative response to anything that person said. So we sat around and we figured the

01:14:16.900 perfect spokesperson would have been Everett Koop, but he was already dead. I think it was at the time.

01:14:25.060 The second best would have been Tony Fauci. So we now have Tony Fauci. I think were he allowed to be

01:14:32.500 the spokesperson, that would go a long way toward figuring out what to do. I think controlling

01:14:38.660 expectations is important. I think by trying to promise that we're coming out on this date or the

01:14:45.300 next date, whatever it is, and then you don't do it, that makes compliance that much more difficult.

01:14:52.020 It is what it is, as the saying goes. Trump's not going to change. He's not going to get out of the

01:14:57.940 way. The economic concerns are real. The management of those concerns is extraordinarily difficult.

01:15:07.460 Obviously, we can't stay locked down month after month after month, but we do need to get that

01:15:13.620 infrastructure in place for testing and monitoring. If we have enough social distancing to get ahead of the

01:15:20.500 virus in the way that, well, we'll never get ahead the way South Korea and so forth have because we

01:15:25.780 started so far behind, but we might get a little bit ahead of it. And of course, as you know, the

01:15:31.700 Asian countries and elsewhere where they have been successful, the virus is surging again. Still

01:15:38.260 nothing like the numbers that we're seeing in the United States, but the virus is going to be with us

01:15:43.620 probably forever. It will be a new human disease. Hopefully, natural immunity will provide significant

01:15:51.060 protection in the future to everybody. The second time around, the immune system sees the virus. It

01:15:57.300 should be much more efficient in dealing with it. And then, of course, the hope for a vaccine.

01:16:01.700 People seem to be pretty optimistic about that. So I didn't really answer your question.

01:16:06.100 No, actually, I think you actually did. And then some, I think you provided kind of a greater insight

01:16:11.780 around it. I guess the last question I'll ask you is, are you optimistic? Is there a silver lining

01:16:18.740 here that this has been a large enough jolt to our systems that we will now not only go back and

01:16:27.780 remember the forgotten pandemic, but perhaps put into place more of the pandemic preparedness stuff that

01:16:34.180 people like you and others for whom you're not just new to this have talked about for many years?

01:16:40.900 I don't know if I'd call it a silver lining. People don't have to remember 1918 anymore. All they have

01:16:46.020 to remember is 2020. Clearly, there will be a significant investment in monitoring emerging diseases,

01:16:53.460 much more so than there used to be. In fact, West Nile, which I guess technically was an emerging disease,

01:16:59.620 but it never killed more than 300 Americans a year. If you understood the natural history of that

01:17:04.580 disease, it was never going to be a serious threat to human health. If you were a horse,

01:17:09.380 you might be in trouble, but for humans, not so bad. And yet, West Nile was getting more research

01:17:16.900 money than influenza was when West Nile surfaced. That's a remarkable statistic.

01:17:23.140 Yeah. Influenza just didn't get the respect, to quote Rodney Dangerfield, didn't get no respect.

01:17:30.660 H5N1 surfaced and things changed. Suddenly, nations around the world took it seriously. As I said,

01:17:39.380 the Bush administration passed a $7 billion bill to invest in pandemic preparedness. Had we had the

01:17:48.180 investment over time that has come in the last 15 years? We probably have a universal influenza vaccine

01:17:56.100 by now, but we didn't. Going forward, obviously, there'll be a lot of work on coronaviruses.

01:18:03.220 Thankfully, SARS and MERS did emerge or we wouldn't have the knowledge base we have now, which has given us

01:18:11.220 a huge head start on drugs and vaccines for this. And probably there'll be some serious money spent

01:18:20.660 on preparing for any emerging pathogen, which would probably be a virus. It might conceivably be

01:18:27.780 something else, most likely a virus, as I'm sure you know. There are plenty of animal viruses out there.

01:18:33.780 And as development encroaches more and more upon what used to be the wild, we will encounter more

01:18:42.500 of those viruses. And they're all threats. John, I want to thank you for not just the work you've

01:18:48.340 done leading up to this, but also just for taking the time today to talk about this. I know you're

01:18:52.340 highly sought after at this time and you're probably tired of talking about this and there's probably

01:18:55.940 other things you'd rather be doing to take your mind off this.

01:18:58.340 But I enjoyed, very much enjoyed talking to you and a former fellow, Steve Rosenberg. It was great.

01:19:05.300 Well, again, be well, John, and I look forward to speaking again.

01:19:08.180 Okay. Thanks. Take care.

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The Peter Attia Drive - April 17, 2020

#107 - John Barry： 1918 Spanish flu pandemic—historical account, parallels to today, and lessons

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