The 1918 flu is even more relevant in 2022 thanks to omicron

Over the past two years, historians and analysts have compared the coronavirus to the 1918 flu pandemic. Many of the mitigation practices used to combat the spread of the coronavirus, especially before the development of the vaccines, have been the same as those used in 1918 and 1919 — masks and hygiene, social distancing, ventilation, limits on gatherings (particularly indoors), quarantines, mandates, closure policies and more.

Yet, it may be that only now, in the winter of 2022, when Americans are exhausted with these mitigation methods, that a comparison to the 1918 pandemic is most apt.

The highly contagious omicron variant has rendered vaccines much less effective at preventing infections, thus producing skyrocketing caseloads. And that creates a direct parallel with the fall of 1918, which provides lessons for making January as painless as possible.

In February and March 1918, an infectious flu emerged. It spread from Kansas, through World War I troop and material transports, filling military post hospitals and traveling across the Atlantic and around the world within six months. Cramped quarters and wartime transport and industry generated optimal conditions for the flu to spread, and so, too, did the worldwide nature of commerce and connection. But there was a silver lining: Mortality rates were very low.

In part because of press censorship of anything that might undermine the war effort, many dismissed the flu as a “three-day fever,” perhaps merely a heavy cold, or simply another case of the grippe (an old-fashioned word for the flu).

Downplaying the flu led to high infection rates, which increased the odds of mutations. And in the summer of 1918, a more infectious variant emerged. In August and September, U.S. and British intelligence officers observed outbreaks in Switzerland and northern Europe, writing home with warnings that went largely unheeded.

Unsurprisingly then, this seemingly more infectious, much more deadly variant of H1N1 traveled west across the Atlantic, producing the worst period of the pandemic in October 1918. Nearly 200,000 Americans died that month. After a superspreading Liberty Loan parade at the end of September, Philadelphia became an epicenter of the outbreak. At its peak, nearly 700 Philadelphians died per day.

Once spread had begun, mitigation methods such as closures, distancing, mask-wearing and isolating those infected couldn’t stop it, but they did save many lives and limited suffering by slowing infections and spread. The places that fared best implemented proactive restrictions early; they kept them in place until infections and hospitalizations were way down, then opened up gradually, with preparations to reimpose measures if spread returned or rates elevated, often ignoring the pleas of special interests lobbying hard for a complete reopening.

In places in the United States where officials gave in to public fatigue and lobbying to remove mitigation methods, winter surges struck. Although down from October’s highs, these surges were still usually far worse than those in the cities and regions that held steady.

In Denver, in late November 1918, an “amusement” lobby — businesses and leaders invested in keeping theaters, movie houses, pool halls and other public venues open — successfully pressured the mayor and public health officials to rescind and then revise a closure order. This, in turn, generated what the Rocky Mountain News called “almost indescribable confusion,” followed by widespread public defiance of mask and other public health prescriptions.

In San Francisco, where resistance was generally less successful than in Denver, there was significant buy-in for a second round of masking and public health mandates in early 1919 during a new surge. But opposition created an issue. An Anti-Mask League formed, and public defiance became more pronounced. Eventually anti-maskers and an improving epidemic situation combined to end the “masked” city’s second round of mask and public health mandates.

The takeaway: Fatigue and removing mitigation methods made things worse. Public officials needed to safeguard the public good, even if that meant unpopular moves.

The flu burned through vulnerable populations, but by late winter and early spring 1919, deaths and infections dropped rapidly, shifting toward an endemic moment — the flu would remain present, but less deadly and dangerous.

Overall, nearly 675,000 Americans died during the 1918-19 flu pandemic, the majority during the second wave in the autumn of 1918. That was 1 in roughly 152 Americans (with a case fatality rate of about 2.5 percent). Worldwide estimates differ, but on the order of 50 million probably died in the flu pandemic.

In 2022, we have far greater biomedical and technological capacity enabling us to sequence mutations, understand the physics of aerosolization and develop vaccines at a rapid pace. We also have a far greater public health infrastructure than existed in 1918 and 1919. Even so, it remains incredibly hard to stop infectious diseases, particularly those transmitted by air. This is complicated further because many of those infected with the coronavirus are asymptomatic. And our world is even more interconnected than in 1918.

That is why, given the contagiousness of omicron, the lessons of the past are even more important today than they were a year ago. The new surge threatens to overwhelm our public health infrastructure, which is struggling after almost two years of fighting the pandemic. Hospitals are experiencing staff shortages (like in fall 1918). Testing remains problematic.

And ominously, as in the fall of 1918, Americans fatigued by restrictions and a seemingly endless pandemic are increasingly balking at following the guidance of public health professionals or questioning why their edicts have changed from earlier in the pandemic. They are taking actions that, at the very least, put more vulnerable people and the system as a whole at risk — often egged on by politicians and media figures downplaying the severity of the moment.

Public health officials also may be repeating the mistakes of the past. Conjuring echoes of Denver in late 1918, under pressure to prioritize keeping society open rather than focusing on limiting spread, the Centers for Disease Control and Prevention changed its isolation recommendations in late December. The new guidelines halved isolation time and do not require a negative test to reenter work or social gatherings.

Thankfully, we have an enormous advantage over 1918 that offers hope. Whereas efforts to develop a flu vaccine a century ago failed, the coronavirus vaccines developed in 2020 largely prevent severe illness or death from omicron, and the companies and researchers that produced them expect a booster shot tailored to omicron sometime in the winter or spring. So, too, we have antivirals and new treatments that are just becoming available, though in insufficient quantities for now.

Those lifesaving advantages, however, can only help as much as Americans embrace them. Only by getting vaccinated, including with booster shots, can Americans prevent the health-care system from being overwhelmed. But the vaccination rate in the country remains a relatively paltry 62 percent, and only a scant 1 in 5 have received a booster shot. And as in 1918, some of the choice rests with public officials. Though restrictions may not be popular, officials can reimpose them — offering public support where necessary to those for whom compliance would create hardship — and incentivize and mandate vaccines, taking advantage of our greater medical technology.

As the flu waned in 1919, one Portland, Ore., health official reflected that “the biggest thing we have had to fight in the influenza epidemic has been apathy, or perhaps the careless selfishness of the public.”

The same remains true today.

Vaccines, new treatments and century-old mitigation strategies such as masks, distancing and limits on gatherings give us a pathway to prevent the first six weeks of 2022 from being like the fall of 1918. And encouraging news about the severity of omicron provides real optimism that an endemic future — in which the coronavirus remains but poses far less of a threat — is near. The question is whether we get there with a maximum of pain or a minimum. The choice is ours.

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Social distancing won’t just save lives. It might be better for the economy in the long run.

Spanish flu: How social distancing helped the economy in 1918 - Vox

A study of the 1918 Spanish flu pandemic finds that cities with stricter social distancing reaped economic benefits.

For much of the past month, some commentators have defended the effort to promote social distancing, including the near-shutdown of huge swaths of America’s economy, as the lesser of two evils: Yes, asking or forcing people to remain in their homes for as much of the day as possible will slow economic activity, the argument goes. But it’s worth it for the public health benefits of slowing the coronavirus’s spread.

This argument has, naturally, led to a backlash, explained here by my colleague Ezra Klein. Critics — including the president — have argued that the cure is worse than the disease, and mass death from coronavirus is a price we need to be willing to pay to keep the American economy from cratering.

Both these viewpoints obscure an important possibility: The social distancing regime may well be optimal not just from a public health point of view, but from an economic perspective as well.

Economists Sergio Correia, Stephan Luck, and Emil Verner released a working paper (not yet peer-reviewed) last week that makes this argument extremely persuasively. The three analyzed the 1918-1919 flu pandemic in the United States, as the closest (though still not identical) analogue to the current crisis. They compare cities in 1918-’19 that adopted quarantining and social isolation policies earlier to ones that adopted them later.

Their conclusion? “We find that cities that intervened earlier and more aggressively do not perform worse and, if anything, grow faster after the pandemic is over.”

The researchers refer to such social distancing policies as NPIs, or “non-pharmaceutical interventions,” essentially public health interventions not achieved through medication, like quarantines and school and business closures. The key to the paper is their observation that, in theory, NPIs can both decrease economic activity directly, by keeping people in certain jobs from going to work, and increase it indirectly, because it prevents large-scale deaths that would also have a negative impact on the economy.

“While NPIs lower economic activity, they can solve coordination problems associated with fighting disease transmission and mitigate the pandemic-related economic disruption,” they write. In other words, social distancing measures that save lives can also, in the end, soften the economic disruption of a pandemic.

The data here comes from a 2007 paper in the Journal of the American Medical Association, where a group of researchers chronicled what specific policies were put in place between September 8, 1918, and February 22, 1919, by 43 different cities. The most common NPI the JAMA researchers identified was a combination of school closures and bans on public gatherings; 34 of the 43 cities adopted this rule, for an average of four weeks.

Other cities eschewed these policies in favor of mandatory isolation and quarantine procedures: “Typically, individuals diagnosed with influenza were isolated in hospitals or makeshift facilities, while those suspected to have contact with an ill person (but who were not yet ill themselves) were quarantined in their homes with an official placard declaring that location to be under quarantine,” the JAMA authors write, detailing New York City’s approach.

Another 15 cities did both isolation/quarantines and school closures/public gathering bans.

The 2007 paper found a strong association between the number and duration of NPIs and pandemic deaths, with more and longer-lasting NPIs associated with a smaller death toll. Correia, Luck, and Verner, in their new paper, replicate this finding.

But they take it a step further. They study the impact of changes in mortality due to the 1918 pandemic on economic outcomes.

“The increase in mortality from the 1918 pandemic relative to 1917 mortality levels (416 per 100,000) implies a 23 percent fall in manufacturing employment, 1.5 percentage point reduction in manufacturing employment to population, and an 18 percent fall in output,” they conclude. In other words, a big outbreak spelled economic disaster for affected cities.

Then they combined this analysis with an analysis of the effects of NPI policies. They find that the introduction of social distancing policies is associated with more positive outcomes in terms of manufacturing employment and output. Cities with faster introductions of these policies (one standard deviation faster, to be technical) had 4 percent higher employment after the pandemic had passed; ones with longer durations had 6 percent higher employment after the disaster.

The takeaway is clear: These policies not only led to better health outcomes, they in turn led to better economic outcomes. Pandemics are very bad for the economy, and stopping them is good for the economy.

A few notes of caution

It’s important to always approach this kind of study with a degree of skepticism. The 1918 pandemic was not a planned experiment, so researchers’ ability to determine the degree to which the pandemic, or the policies adopted in response to it, affected economic outcomes is always going to be somewhat limited.

The researchers acknowledge that their biggest limitation is the non-randomness of policy adoption by cities. Presumably cities with strict responses to the pandemic were different from cities with laxer responses in ways that went beyond this one incident. Maybe the stricter cities had better public health infrastructure to begin with, for instance, which could exaggerate the estimated effect of social distancing interventions.

The authors argue that because the second and most fatal wave of the 1918 pandemic spread mostly from east to west, geographically, these kinds of dynamics weren’t at play. “Given the timing of the influenza wave, cities that were affected later appeared to have implemented NPIs sooner as they were able to learn from cities that were affected in the early stages of the pandemic,” they note.

The best explanation of differences in policies, then, is how far a city is from the East Coast of the US. They control for a big factor that might affect Western states more (the boom and bust of the agricultural industry as World War I drew to a close) and find few other observable differences between Western cities with strong policies and Eastern policies with weak ones. But the notion that these cities are comparable is a key part of the paper’s research design, and one worth digging into as the paper goes through peer review and revisions.

The economy isn’t everything

The message that there isn’t a trade-off between saving lives and saving the economy is reassuring. If there were such a trade-off, the debate over coronavirus response would be in the realm of pure values: How much money should we be willing to forsake to save a human life? That’s a thorny choice, and finding that we don’t actually have to make it — as this paper suggests — is comforting.

It’s worth emphasizing, though, that if we did have to make that choice, it would still be an easy decision. The lives saved would be worth more.

In another recent white paper, UChicago’s Michael Greenstone and Vishan Nigam estimate the social value of social distancing policies, relative to a baseline where we endure an untrammeled pandemic. To simulate the two scenarios, they rely on the influential Imperial College London model of the coronavirus pandemic — a paper that found that an uncontrolled spread of coronavirus would kill 2.2 million Americans.

Then they throw in an oft-used tool of cost-benefit economic analysis: the value of a statistical life (VSL). Popularized by Vanderbilt economist Kip Viscusi, VSL involves putting a dollar value on a human life by estimating the implicit value that people in a given society place on continuing to live based on their willingness to pay for services that reduce their risk of dying.

Usually, this involves a “revealed preferences” approach. A 2018 paper by Viscusi, for example, used, among other data sources, Bureau of Labor Statistics Census of Fatal Occupational Injuries to measure how much more, in practice, US workers demand to be paid to take jobs that carry a higher risk of death.

Greenstone and Nigam allow VSL to vary with age — understandably, older people are less willing to pay to reduce their odds of death than younger people — but set the average VSL for an American age 18 and over to $11.5 million.

Based on the Imperial College projection that social distancing would save about 1.76 million lives over the next six months, Greenstone and Nigam estimate that the economic value of the policy is $7.9 trillion, larger than the entire US federal budget and greater than a third of GDP. The value is about $60,000 per US household. Even if the Imperial College model is off by 60 percent and the no-social-distancing scenario is less deadly than anticipated, the aggregate benefits are still $3.6 trillion. And this is likely an underestimate that ignores other costs of a large-scale outbreak to society; it focuses solely on mortality benefits.

VSL is sometimes attacked from the left as craven, a reductio ad absurdum of economistic reasoning trampling over everything, including the value of human life itself. But coronavirus helps illustrate how VSL can work in the opposite direction. Human life is so valuable in these terms that social distancing would have to force a 33 percent drop in US GDP before you could start to plausibly argue that the cure is worse than the disease.

That social distancing likely won’t cause a reduction in GDP relative to a scenario where there’s a multimillion-person death toll, as indicated by the 1918 flu paper, makes the case for distancing policies that much stronger.





Bill Gates says the world is entering ‘uncharted territory’ because it wasn’t prepared for a pandemic like COVID-19

5 Books Bill Gates Wants You to Read This Summer | Time

  • Microsoft cofounder Bill Gates said the world was entering into “uncharted territory” because it was not prepared for a pandemic like COVID-19, the disease caused by the novel coronavirus.
  • Speaking to “BBC Breakfast” by video chat on Sunday, Gates said the world should’ve invested more in mitigating a global health crisis.
  • “There is the period where the virus shows up in those first few months,” he said. “Were the tests prepared? Did countries think through getting their ICU and ventilator capacity up?”
  • He added that once the crisis is over “very few countries are going to get an A grade” for their handling of the outbreak.

Microsoft cofounder Bill Gates said the world was entering into “uncharted territory” because it was not prepared for a pandemic like COVID-19, the disease caused by the novel coronavirus.

Gates, who has been warning about the risk of a pandemic disease for years and who has poured millions into fighting the new coronavirus outbreak, told “BBC Breakfast” on Sunday that the world should have invested more into mitigating a global health crisis.

“Well, there was a period when I and other health experts were saying that this was the greatest potential downfall the world faced,” he told the BBC in an interview on Sunday, highlighting his previous warnings against the possibility of a deadly pandemic.

“So we definitely will look back and wish we had invested more,” he said, “so that we could quickly have all the diagnostics, drugs, and vaccines. We underinvested,” he said.

The 67-year-old billionaire warned that in the period before COVID-19 became a public-health crisis, countries could have better prepared their testing capabilities and made sure hospitals were stocked with ventilators and other necessary health supplies.

“There is the period where the virus shows up in those first few months,” he said. “Were the tests prepared? Did countries think through getting their ICU and ventilator capacity up?”

He added that once the crisis is over “very few countries are going to get an A grade” for their handling of the outbreak.

“Now, here we are, we didn’t simulate this, we didn’t practice,” he said. “So both in health policies and economic policies, we find ourselves in uncharted territory.”

Gates has become an outspoken advocate for preparing for a global health crisis like COVID-19.

Speaking to the Financial Times earlier this month, Gates said that COVID-19 was the “biggest event that people will experience in their entire lives” and world leaders and global policymakers have “paid many trillions of dollars more than we might have had to if we’d been properly ready.”

He told FT he was confident that lessons learned from this outbreak would encourage people to better prepare for next time but lamented that the cost this time around was too high.

“It shouldn’t have required a many trillions of dollars loss to get there,” he said. “The science is there. Countries will step forward.”





The recession risk

Illustration of Benjamin Franklin on a 100 dollar bill wearing a medical mask

Economists are growing more certain both the U.S. and the world are going to have a recession in 2020, Axios markets editor Dion Rabouin reports.

The big question: How bad will it be?

  • The answer depends on how quickly the outbreak can be contained and how fast people regain confidence to participate in activities they once enjoyed.

What’s happening: Economists and investment banks continue to write down their expectations for growth this year, as more economic activity is halted “until further notice.”

  • The shutdown of the NCAA’s annual March Madness basketball tournament and Austin’s South by Southwest festival are just two examples of mass gatherings that were expected to generate billions of dollars.
  • And that’s to say nothing of the millions of dollars that Chinese and European tourists would have spent, but who are temporarily banned or reluctant to come to the United States.

The bottom line: Businesses had pulled back on spending even before the year began, as a result of the U.S.-China trade war. That left consumer spending as the only thing holding up the economy, and the COVID-19 outbreak will kick that leg out from under us for an unknown period of time.

Go deeper: Listen to Dion discuss the risk of a recession with Dan Primack on the Pro Rata podcast.




The pandemic shaping the future

Illustration of a woman in a medical mask surrounded by a falling trend line, a house, a person in a hazmat suit with caution tape, and two hands shaking

The world that emerges from the coronavirus pandemic will be fundamentally different, Axios Future correspondent Bryan Walsh writes.

  • Why it matters: This crisis may prove to be as significant as the 2008 financial meltdown or even 9/11.
  • So the choices that businesses and governments are making now will have enormous social and economic ramifications.

The intrigue: U.S. health and government officials are facing the epidemiological equivalent of the “fog of war,” worsened by a massive American failure to act on weeks of warnings as the virus spread in China.

  • The Trump administration declared a national emergency yesterday, seven weeks after the first U.S. case was announced by the Centers for Disease Control and Prevention.
  • By failing to rapidly scale up testing, U.S. officials have added an additional — and partly unnecessary — layer of uncertainty about how to respond.
  • Harvard epidemiologist Michael Mina calls it “the most daunting virus that we’ve contended with in half a century or more.”

Flashback: As recently as the 1918 influenza pandemic, scientists lacked the ability to rapidly respond to an infectious disease outbreak.

  • Today, scientists can sequence a virus in days, develop rapid tests that can determine infection before obvious symptoms, and use complex mathematical models to predict future spread.

What we’ll find out in coming days:

  • The actual fatality rate of the virus.
  • How contagious it is, and the precise role that children — who seem outwardly unaffected by the disease — may play in transmission.
  • If the outbreak will naturally slow down when the weather warms, as tends to happen with influenza.

What’s next: For now, distance becomes the first line of defense. Schools and companies are shifting online — with potential consequences.

  • If companies are able to function relatively well with a largely remote workforce, expect lower levels of business travel.
  • After decades of emphasizing the efficiency of supply chains — which often meant complex international linkages and just-in-time inventories — businesses will look to build resilient supply chains.

The bottom line: The mobility — of people, capital and products — that we’ve taken for granted may not outlast the virus.







The Hospital and Healthsystem Association of Pennsylvania report found that hospitals also supported more than one in every 10 jobs.

Hospitals in Pennsylvania made a total economic impact of $136.1 billion in Fiscal Year (FY) 2018, according to a Hospital and Healthsystem Association of Pennsylvania (HAP) report released Tuesday.

Of the total economic impact, $60.5 billion were the result of “direct impact,” such as employee salaries, benefits, as well as goods and services for hospital operations. Another $75.6 billion were the result of “ripple impact,” such as additional economic effects of a hospital in a community.

HHAP also found that hospitals supported more than 650,000 jobs, accounting for more than one in every 10 jobs in the state and providing $32.3 billion in total wages. Nearly 300,000 jobs were directly associated with hospitals while 363,000 jobs were associated with “ripple effects” of health systems.

The study’s findings point to the significant economic impact provider organizations have in the Keystone State and the need to promote policies that foster continued growth, according to Sari Siegel, PhD, vice president of healthcare research at HAP.

“While overall growth projections are strong, some hospitals remain financially stressed. Our work illustrates that hospitals often are the backbones of their communities and closure could cause devastating economic ripples throughout a region,” Siegel said in a statement. “The findings of this report underscore the need for policies that bolster hospitals’ long-term sustainability.”

Pennsylvania hospitals have contributed significantly to the state’s economy in recent years and have also made headlines throughout 2019.

Hahnemann University Hospital, a Pennsylvania-based hospital, filed for bankruptcy and closed over the summer. A group of six Philadelphia-based health systems won the hospital at auction for $55 million in early August. 

The report was also released days after two Pennsylvania-based health systems, Tower Health and Drexel University, finalized a $50 million acquisition of St. Christopher’s Hospital for Children, a 188-bed pediatric medical center in Philadelphia.

There are 253 hospitals in Pennsylvania, according to HAP, with more than 37,600 staffed beds. The report also found that hospitals are among the 10 largest employers in 85% of counties across the state.

The total economic impact of Pennsylvania hospitals in FY 2018 grew by nearly $50 billion over the past decade, according to a HAP analysis of data collected from the Department of Health and Human Services (HHS).

Additionally, Pennsylvania hospitals received nearly $2 billion in research allocations from HHS and Patient-Centered Outcomes Research Institute in FY 2018.