In order to analyze the development and mitigation of the COVID-19 pandemic, we naturally look back to the most prominent global pandemic of modern times: the Spanish flu of 1918.  The virus wreaked havoc around the world a century ago, leaving tens of millions of dead bodies in its wake, including more than half a million Americans at a time when our population was less than a third of today’s level.

 

While it is reasonable to acknowledge the broad fact that even more lives would have been lost had it not been for social distancing interventions in 1918, as we now consider how to lift similar restrictions currently imposed, we need a more nuanced understanding of when, where, and how social distancing prevailed a century ago, as well as when, where, and how it did not.

 

Based upon the data of the Spanish flu pandemic, general consensus has emerged around a strong correlation between proactive measures and a lower death toll; the contrast between Philadelphia and St. Louis in 1918 has become ubiquitous.  First referenced in an academic journal some 13 years ago, it has been featured regularly in analyses and articles over the past 2 months as a lesson on how American society should treat a pandemic.

 

The story goes like this:

 

Philadelphia (at the time the third largest city in America behind only New York and Chicago) downplayed the severity of the Spanish flu and went ahead with a World War I victory parade (really part of a public relations campaign supporting a war-bond drive) and gathered over 200,000 people at the end of September.  Within a week, 2,600 people had died and city hospitals were overflowing.  By the time the city reacted and started closing down public gatherings, which lasted for 4-5 weeks, it was already too late to stop the contagion.  Thousands more died, with an ultimate death rate of almost 1% of the city's entire population.  Almost all of the Philadelphia deaths occurred during that period of peak devastation, with only a slight resurgence of the virus 2 months later.

 

St. Louis, on the other hand (at the time the sixth largest city in America), reacted more quickly.  The city cancelled a similar parade and instituted large-scale social distancing measures to stop the spread of the virus.  The measures worked and St. Louis had one of the very best performances of any city.  An excellent historical piece in St. Louis Magazine provides more color to this recounting - of particular interest is the resistance to the precautions recommended by the German-born Commissioner of Health.

 

Point taken.  But the underlying academic research behind these anecdotes tells a much richer story than the binary contrast distilled in today’s media, which treats pandemic deadliness as a single variable equation dependent only on social distancing.  While the literature certainly does evidence a general correlation between proactive social distancing and less death, there are outlying data points as well that can shed light on how to proceed in the safest and most responsible way today.  National Geographic did a robust job graphing many cities, illustrating the timing, frequency and duration of social distancing measures as well as the shapes of the curves and the overall death toll.

 

For example, the least deadly city in 1918 was Minneapolis, which had 2,670 deaths per million.  New York City, which accounts for more than 20% of ALL deaths nationwide in 2020, is projected to ultimately have a bit more than half that amount: ~1,500 deaths per million.  So already we can begin to see a dramatic difference in the impact of the pandemic.

 

Minneapolis utilized two rounds of social distancing interventions in 1918, which surely contributed to its superior performance.  But other cities that used even more aggressive interventions still had higher proportional death tolls.  The current media paradigm treats social distancing as a life-saving on/off switch, which is not accurate.  (Nor is the blanket dismissal of the benefits of social distancing on the part of the “liberation” protestors.)  Neither in 1918 nor in 2020 does one size fit all, as usual in a country as vast as the U.S.

 

Ultimately, there is one unescapable conclusion that must be acknowledged when using 1918 as a blueprint for today.  Only the completely delusional would conclude that the COVID-19 epidemic is as deadly as the Spanish flu.  In fact, it’s a whole order of magnitude less so.  The Spanish flu claimed 675,000 American lives out of a population of 106.5 million (6,338 deaths per million), whereas COVID-19, even in the current worst-case IHME projection, will barely exceed 5% that figure: 114,000 deaths out of 331 million, or 344 deaths per million.  The more likely middle projection of ~74,000 deaths would yield a rate of only 223 per million, which is proportionally less than Spain, France, Italy, and the UK.  Of the large EU states, only Germany will have fared better.  Said otherwise, the Spanish flu’s death rate of 6,338 deaths per million is almost as high as the total death rate in America today, which is 8,638 per million.  We are not talking apples and oranges, but apples and watermelons.

 

When smaller, less densely populated states consider how to proceed, this data should not be lost on them.  As mentioned earlier, over 20% of the entire nationwide death toll of COVID-19 belongs to New York City.  A century ago, New York was also the most populous city and had the highest death toll.  But New York’s deaths accounted for less than 4% of the total.  The top 20 cities during the Spanish flu had an combined death rate of just under 5,000 per million.  The rest of the country was at about 6,600 per million.  Compare that to COVID-19, in which the top 20 cities have a combined death rate of 507 per million, versus the rest of the country at approximately 150 per million.  Not only is the disease an order of magnitude less deadly overall, but rural communities are much, much, safer than they were in 1918.

 

Protecting states and local communities from a pandemic is a complicated multivariable equation.  The federal government has set reasonable guidelines for a phased return to normal life.  Flouting those recommendations (because… “freedom!”) is unwise.  Pointing to the data of 1918 and insisting on cautiously replicating the terms of those stay-at-home orders is also unwise.

 

The answer lies somewhere in the middle.  Local/state governments who know the terrain should craft the most appropriate timeline to safely ease restrictions in their communities on a case-by-case basis, in close cooperation with civic, medical, religious, commercial, and other social leaders.

 

There is no single solution that Washington can impose.  Tight-knit communities with a culture of respect and social cohesion are most likely to prevail.  Beating a pandemic ultimately comes down to solidarity and local control, in the best American tradition.