July 9, 2020
As we face another week of COVID-19 spiraling out of control in the U.S., the need to find answers is urgent. It turns out that some answers are available and words of wisdom emerge from studies of the past in the book Pale Rider: The Spanish Flu of 1918 and How It Changed the World by Laura Spinney, as well as in a new analysis in Adam Kucharski’s book The Rules of Contagion: Why Things Spread--And Why They Stop. But although we have the knowledge, there seems to be a lack of leadership, empathy, and compassion to put the necessary guidelines in place. As a result, the American people continue to face the risks of the ongoing COVID-19 crisis.
Lessons from the Past
Author Laura Spinney’s gripping chronicle of the Spanish flu is filled with elements relevant to today’s pandemic. Among the book’s key takeaways:
- The pandemic stopped: The first and perhaps most important point is that in the absence of treatments and a vaccine the Spanish flu ran its course (mostly in 1918) and stopped.
- A historical note: The Spanish flu did NOT begin in Spain. The Spanish were simply the first to report it because other countries had a news blockade during the First World War. The first case was a military recruit in Kansas.
- Asymptomatic spread: It was recognized then that a key factor in the spread of the flu was spread from patients BEFORE symptoms emerged. This point, which has been hotly debated during today’s COVID-19 pandemic, is, in fact, a very well-established means of transmission.
- The danger of crowds: This was also known to be a particularly important—if not central—factor in the spread of infection. Mass gatherings were banned, to great advantage.
- The wearing of masks: Masks were strongly understood to be of major importance in preventing infection. A retrospective analysis published in 2007 confirmed that the early imposition of mask-wearing during the Spanish flu reduced the death toll by 50%, provided mask-wearing continued until “the danger passed.”
- Herd immunity: So-called herd immunity was not necessary to stop the pandemic. Ultimately, approximately 30% of the world population was exposed (far short of the approximately 70% proposed as necessary today). Other measures led to virus containment.
- The role of interferon: By studying a young patient with unusual susceptibility to the flu, it was possible to determine that the lack of interferon production in the body dramatically increased susceptibility. Interferon is the body’s first line of defense against viral infections. This is very much in line with two recent observations: 1) COVID-19 infection shuts down interferon production needed to fight the virus. A very elegant study shows this inhibition combined with the activation of the cytokine storm process; and 2) Several studies show the value of interferon treatment to help shut down COVID-19 infections. This approach has not been much emphasized thus far, but studies are ongoing.
- Neurological side effects: A striking feature of the Spanish flu was serious neurological side effects in survivors. Today, it has been disturbing to note that many individuals experiencing “mild” COVID-19 infections are now noting lingering and, in some cases, even worsening neurological issues involving both memory and coordination. A U.K. study in the news this week examined possible COVID-19-linked neurological issues. Interestingly, as with COVID-19, the loss of smell was noted with Spanish flu, along with the loss of color vision. (This may have inspired Spinney’s book title, which harkens back to the title of Katherine Anne Porter’s short story, “Pale Horse, Pale Rider,” a tale of influenza-stricken lovers that was informed by the author’s own illness.) Loss of smell has been striking for some otherwise asymptomatic COVID-19 patients. Fortunately, it appears to be mostly reversible.
These parallels between the Spanish flu of 1918 and today’s coronavirus pandemic are truly remarkable and underscore the old aphorism, “Those who do not learn from history are doomed to repeat it.”
The Rules of Contagion illustrates how real-time analyses can guide strategies to overcome a pandemic. The book examines the reproduction rate (R) of the virus. If the number is low (less than one), then a pandemic will tend to peter out. If greater than one, then the transmission to more and more people can occur. What determines the R value? The acronym DOTS:
- D: Duration of the infectious period. In the case of COVID-19, this is a concern because of the high level of virus-shedding for quite a few days in asymptomatic individuals. It is important to note that “super spreaders” can contribute much more than the average person. Rapid testing and tracing are absolutely essential to identify super spreaders. This is key to shut down spread.
- O: Opportunities for spread each day. Here, obviously, the concern is crowds.
- T: Transmission. The probability of transmission. Dramatically reduced by wearing a mask.
- S: Susceptibility to infection. This is a factor still not well understood in COVID-19. However, exposure of older individuals with risk factors, such as many of those living with myeloma, must be avoided.
Challenges Moving Forward
For COVID-19, there is no doubt that the lessons from the past noted above can really reduce the R value and shut down spread of the virus. This has happened already in the island nations of Iceland and New Zealand.
Some states have now achieved the same great results as these successful countries. To sustain and expand on those successes is the challenge. One idea is to create “travel bubbles,” such as created in the Tri-State area in the Northeast. However, dominating the news this week is the challenge of students and teacher returning to the classroom. Can it be done safely? And when?
Before we can move forward in the U.S.—back to school, work, travel and nightlife—we’ll need compassion from our leaders and our fellow men and women in issuing and adhering to the strict guidelines necessary to reduce the daily total of new cases.
I have great faith in the spirit of the American people to achieve at the personal level what has been frustratingly absent through lack of national leadership. Americans do care deeply about each other. During the Spanish flu pandemic, people often risked their own lives to help others, writes Laura Spinney. We, too, will get through this together!
Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.