With the current Covid-19 pandemic causing upheaval the world over, can we look to the past to learn lessons? Here, Mac Guffey continues a series considering lessons from the 1918 Influenza Epidemic, an epidemic that infected around a third of the world’s population and killed some 40 million people (exact estimates vary from 15 million to 50 million or more). He will consider the question: Can something that happened over a hundred years ago in a society so vastly different from today provide any useful guidance regarding the Covid-19 Pandemic?
Here, part 3 in the series considers the importance of effective leadership. Mac looks at how the cities of St. Louis, Milwaukee, and Minneapolis managed to have lower rates of infection when compared to other comparably sized cities thanks to effective leadership.
If you missed it, the first article in the series considered what happened during the 1918 Influenza Pandemic and the lessons we can draw on the economy (here) and part 2 considered the healthcare lessons from the pandemic by contrasting a successful and less successful approach (here).
A 1918 poster warning about ‘Spanish Flu’ and how it could impact war production for World War I.
The federal government’s role regarding the public health is generally an advisory one. By and large, the real business of public health and safety is basically a local matter. State, county, and city health departments operate under a rag bag of rules and regulations that vary from community to community based on a community’s prior public health experiences. (Garrett L. , 2020)
Because of this, the way the 1918 Influenza Epidemic unfolded across the United States actually provides a tremendous series of independent case studies about what worked and what didn’t work.
The determining factor – community mortality rates.
Thirteen years ago, Anthony Fauci* and David Morens did just that and wrote an article about the 1918 Influenza Pandemic for The Journal of Infectious Diseases. It was subtitled “Insights for the 21st Century”.
In their article, they made several key points. One - historical evidence about pandemics suggests there are no predictable cycles; therefore, countries need to be prepared for the possibility of a pandemic at all times. Two - if a novel virus as virulent as that of 1918 were to reappear, a substantial number of potential fatalities could be prevented with aggressive public-health and medical interventions.
But the best antidote, they said, was prevention - through vigilance, predetermined countermeasures, and planning. (Morens & Fauci, 2007)
Morens’s and Fauci’s recommendations were partially based on the similar way several major urban areas truly “met the moment and prevailed” with the lowest mortality outcomes during that exceptionally virulent second wave of the 1918 Influenza Epidemic.
It was all about leadership.
Lesson Three: Leadership – ‘Vigilance, Predetermined Countermeasures, and Planning’
In addition to St. Louis (covered in Parts 1 and 2 of this series and reviewed here for comparison), Milwaukee, and Minneapolis also registered lower mortality rates than most urban areas of a comparable size during the 1918 Influenza Pandemic.
These cities also encountered many of the same problems and challenges during that pandemic that we’ve faced across the nation in 2020 – disruptive citizens, pushback from churches, schools, and businesses, and failures to comply with mask and distancing mandates.
However, the way those city leaders approached these problems and challenges had a major impact on the civilian death rates in their cities.
St. Louis
As just a quick review, St. Louis was led by a strong-willed and capable health commissioner, Dr. Max C. Starkloff, who had the foresight to actively monitor the news as the influenza contagion spread westward. The city’s medical and political communities were quickly prepared for the inevitability that the epidemic would find its way to St. Louis. His first action was to issue a request through the influential St. Louis Medical Society that physicians voluntarily report to his office any and all cases of influenza they discovered. (St. Louis Globe-Democrat, 1918)
When St. Louis physicians reported their first cases of influenza, he asked the city’s Board of Aldermen to pass an emergency bill declaring influenza a contagious disease. This gave the mayor the legal authority to declare a state of public health emergency. The bill also levied stiff fines for physicians who failed to report any new cases of the disease. (St. Louis Globe-Democrat, 1918)
Starkloff and St. Louis Mayor Henry Kiel then executed an open-minded, flexible approach to quarantining, school closings, and other social distancing measures. They also maintained a unified front despite persistent pushback from various St. Louis constituencies. Because of the quick and sustained action by its leaders, St. Louis experienced one of the lowest excess death rates in the nation. (University of Michigan Center for the History of Medicine, 2016)
Milwaukee
Even with two influenza waves between October and December 1918, the magnitude of Milwaukee’s brush with the 1918 Influenza Epidemic was still less severe than other U.S. cities of a comparable size. In the aftermath, Milwaukee Health Commissioner George C. Ruhland believed there were three reasons for the better outcomes. (Milwaukee Health Department, 1918)
The first reason was the readiness of the public to comply with any regulatory measures. For that Ruhland credited the Milwaukee medical community’s plan to engage the public. With the support of the city’s newspaper editors, the group began an immense public education campaign - with printed literature in six languages, including English. They created flyers and speaker’s notes, selected respected physicians and city notables as speakers, and requested the area clergy to discuss the flyers from the pulpit. If citizens, business owners, and city government all understood exactly what they were facing, there might be greater cooperation and acceptance should any draconian measures be necessary to blunt the epidemic. (Milwaukee Sentinel, 1918)
The second reason Ruhland listed was the timing of the closing orders and the generally widespread compliance from Milwaukee’s citizens. What’s interesting is that because of the two waves – October and December - Ruhland’s team actually tried two different approaches to see which one worked better. The October approach involved mandated closings - all places of amusement, churches, public gatherings, and eventually the schools. (Milwaukee Journal, 1918)
However, as the number of new cases in Milwaukee declined, some citizens and business owners believed the influenza threat was almost over. They got together and sent a number of requests to Ruhland to lift the bans on public gatherings. He refused. As more businesses clamored for relief, Ruhland publicly pointed out the consequence of overconfidence in other cities - reopening prematurely resulted in another wave of the infectious disease. (Milwaukee Journal, 1918)
Despite Ruhland’s gradual reopening however, a resurgence of the virus occurred in December 1918.
This time, to avoid outright closures, Ruhland shifted the responsibility to the public. He recommended masks be worn in public, set restrictions to the amount of personal space surrounding people in public - every other row was vacant in theaters and churches, retail customers surrounded themselves with six square feet of vacant space – and then he left it up to the people to govern themselves. The citizens, for the most part, ignored the self-restrictions, and that idea failed. (Milwaukee Journal, 1918)
The conclusion Ruhland came to after these two experiences have important ramifications for the world pandemic today. While closures don’t prevent influenza, they are very necessary in order to flatten or prevent the severe spikes in the number of influenza cases that can occur over a short period of time. It’s the severe spikes, he said, that overwhelm the available hospital facilities, healthcare workers, and medical supplies. Preventing those spikes flattens the mortality curve because those who do fall ill have access to better – not desperate - healthcare. (Milwaukee Wisconsin Department of Health, 1918)
The last factor that helped contribute to the lower mortality rates was the overall cooperation from all the community “leaders” during the epidemic – city government, physicians, hospital administrators, businessmen, the Red Cross and other relief agency leaders. Thanks to that cooperation, all necessary decisions were implemented rapidly and immediately. (Milwaukee Health Department, 1918)
In this city of 450,000 people, more than 30,000 of them came down with the flu during those two waves in 1918. Thanks to leadership vigilance, predetermined countermeasures, and planning, fewer than 500 died.
Minneapolis
“Spanish influenza does not exist in Minneapolis and never has, but it probably will reach here during the fall,” the City of Minneapolis Health Commissioner, Dr. H. M. Guilford, told residents on September 19, 1918. (Minneapolis Morning Tribune, 1918)
Less than a month later, the flu epidemic struck the city. By then, Guilford had a plan ready. The health department ordered all schools, churches, and non-essential businesses closed indefinitely. The measure was unanimously endorsed by the Minneapolis city council. The council also stipulated that the city’s department of health had the full authority to issue any closure orders with or without the consent of Minneapolis’s mayor or the council. (Minneapolis City Council, 1918)
Pushback, however, was almost immediate.
The Minneapolis Board of Education disagreed with the shut-down order and reopened the schools. The Superintendent of Schools, B. B. Jackson, argued that the leading medical authorities across the nation had determined that epidemic influenza was not a children’s disease. Guilford however, refused to give ground and at his request, the Minneapolis Chief of Police met with the school board and persuaded them to close the schools once again. (Minneapolis Morning Tribune, 1918)
In spite of the school board resistance and a later protest by the owners of amusement businesses, Guilford kept the city closed down until November 15, when the number of new influenza cases reached what he deemed an acceptable level. At that point, schools and businesses were allowed to reopen. (University of Michigan Center for the History of Medicine, 2016)
However, in early December, the number of Influenza cases spiked again – this time, it was among the school populations. Guilford reinstituted the school closures until the end of the month, but he added an important caveat: All students would be required to undergo a thorough examination to ensure that he or she was free of any illness before being allowed to return to the classroom. (University of Michigan Center for the History of Medicine, 2016)
Strong leadership, sustained adherence to science, and a unified front both politically and medically throughout the 1918 Influenza Epidemic enabled Minneapolis to keep the mortality rate of its citizens lower than most urban centers of a comparable size.
Conclusion
One of the more important “negative” leadership lessons from the 1918 Influenza Epidemic was the ‘too little, too late” actions by many public officials at the national, state, and local levels that exacerbated the spread of that deadly pandemic. (Mihm, 2020)
That was not the case in St. Louis, Milwaukee, or Minneapolis. Doctors Stackworth, Ruhland, and Guilford each showed vigilance by tracking the progression of the epidemic in other cities, in the military camps nearby, and mandating that their local medical communities report every new case of influenza. They all formed teams, set sound policy directions, communicated and educated about them, and implemented effective, predetermined countermeasures.
However, the greatest insight that 1918 epidemic provides for our 21st century health crisis is the determination of those leaders to maintain the aggressive public-health and medical interventions they put in place for the well-being of their citizens in the face of political, economic, and public pushback.
History Is Now
After taking office in 2017, the Trump administration fired the government’s entire pandemic response chain of command, including the White House management infrastructure, and disbanded the National Security Council’s pandemic team and a State Department program designed to identify outbreaks and other emerging threats around the world. (Garrett L. , 2020)
Then, in late December or early January 2020, Trump and his administration were informed by intelligence officials of a contagion raging in Wuhan, China. The administration, however, publicly treated the epidemic as a minor threat that was under control, at least domestically, and repeatedly assured the public that the risk to Americans was very low.
By the end of January, there were about 12,000 reported cases in China, and growing rapidly by the day. At this point, the U.S. had a handful of confirmed cases, but there was almost certainly already significant community spread in the Seattle area.
Finally, on January 27, the White House created the Coronavirus Task Force (publicly announced on January 29) and declared a public health emergency on January 31. At that point, the federal government began to put in motion the executive, legal, and regulatory pandemic response procedures already on the books. (Wallach & Myers, 2020)
On March 24, 2020, the U.S. death toll from the Covid-19 Pandemic stood at 705 Americans. (CDC, 2020) That day, President Donald Trump said in his then daily Coronavirus Task Force briefing:
“There is tremendous hope as we look forward and we begin to see the light at the end of the tunnel. Stay focused and stay strong and my administration and myself will deliver for you as we have in the past." (Woodward & Yen, 2020)
Trump’s ‘hope’ versus the ‘vigilance, predetermined countermeasures, and planning’ of Starkloff, Ruhland and Guilford.
As of June 1, 2020, America’s death toll stands at over 106,000 coronavirus-related deaths. (CDC, 2020)
Food for thought.
Now, read part 4 here: Lessons from the 1918 Influenza Epidemic: Part 4 – Conclusions – ’Such a big event, so little public memory’
What lessons do you think we can learn from the 1918 Influenza Pandemic? Let us know below.
References
CDC. (2020, April 30). “Coronavirus (COVID-19) pandemic – Overview: statistics”. Retrieved May 2, 2020, from Bing.com: https://www.bing.com/search?q=death+toll+coronavirus&form=EDNTHT&mkt=en-us&httpsmsn=1&msnews=1&rec_search=1&plvar=0&refig=60ce389eba704e0788409300929840cb&PC=HCTS&sp=1&ghc=1&qs=EP&pq=death+toll&sk=PRES1&sc=8-10&cvid=60ce389eba704e0788409300929840cb&cc=US&
Garrett, L. (2020, January 31). Trump Has Sabotaged America’s Coronavirus Response. Retrieved April 28, 2020, from FP (Foreign Policy): https://foreignpolicy.com/2020/01/31/coronavirus-china-trump-united-states-public-health-emergency-response/
Markel H, L. H. (2007). " Nonpharmacuetical interventions implemented by U.S. cities during the 1918-1919 influenza pandemic". JAMA, 298:647.
Mihm, S. (2020, March 3). Lessons From the Philadelphia Flu of 1918: Prioritizing politics over public health is a recipe for disaster. Retrieved April 22, 2020, from Bloomberg Opinion: https://www.bloomberg.com/opinion/articles/2020-03-03/coronavirus-history-lesson-learning-from-1918-s-flu-epidemic
Milwaukee Health Department. (1918). Bulletin of the Milwaukee Health Department 8, no. 10-11. City of Milwaukee, Health. Milwaukee: np.
Milwaukee Journal. (1918, October 10). "City closed to fight flu,” Milwaukee Journal, 10 Oct. 1918, 1. Milwaukee Journal, p. 1.
Milwaukee Journal. (1918, December 2). "Schools closed to stop flu". Milwaukee Journal, pp. 1, 6.
Milwaukee Journal. (1918, October 26). "Weather Cause of Deaths". Milwaukee Journal, p. 2.
Milwaukee Sentinel. (1918, October 11). "City Starts Big Battle On Influenza". Milwaukee Sentinel, p. 6.
Milwaukee Wisconsin Department of Health. (1918). Forty-second annual report of the Commissioner of Health City of Milwaukee. Milwaukee: np.
Minneapolis City Council. (1918). Proceedings of the City Council of the City of Minneapolis, Minnesota, from January 1, 1918 to January 1, 1919. Minneapolis City Council, Proceedings of the City Council of the City of Minneapolis, Minnesota, (p. 536). Minneapolis.
Minneapolis Morning Tribune. (1918, October 20). "Clash Over School Order Due Monday". Minneapolis Morning Tribune, p. 1.
Minneapolis Morning Tribune. (1918, September 20). “No Spanish Influenza in City, Says Guilford”. Minneapolis Morning Tribune, p. 2.
Morens, D. M., & Fauci, A. S. (2007). The 1918 Influenza Pandemic: Insights for the 21st Century. Journal of Infectious Diseases, Volume 195, Issue 7,, 1018-1028.
St. Louis Globe-Democrat. (1918, September 20). “Doctors Here Must Report Influenza,” St. Louis Globe-Democrat, 20 Sept. 1918, 2. St. Louis Globe-Democrat, p. 2.
St. Louis Globe-Democrat. (1918, October 6). “No Quarantine Here against Influenza, Says Dr. Starkloff". St. Louis Globe-Democrat, p. 8.
University of Michigan Center for the History of Medicine. (2016, September 19). City Essays. Retrieved April 21, 2020, from American Influenza Epidemic of 1918 - 1919: A Digital Encyclopedia.: http://www.influenzaarchive.org.
Wallach, P. A., & Myers, J. (2020, March 31). “The federal government’s coronavirus response—Public health timeline - part of the Series on Regulatory Process and Perspective”. Retrieved April 4, 2020, from Brookings: https://www.brookings.edu/research/the-federal-governments-corona
Woodward, C., & Yen, H. (2020, March 28). ”Fact check: Donald Trump is a rosy outlier on the science of the virus”. - Saturday, March 28, 2020. Retrieved April 20, 2020, from Associated Press Website: https://apnews.com/
Wright, J. (2020, March 3). Four disastrous mistakes that leaders make during epidemics. Retrieved April 15, 2020, from The Washington Post: https://www.washingtonpost.com/outlook/2020/03/03/four-disastrous-mistakes-that-leaders-make-during-epidemics/
