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

Episode Date: April 17, 2020

n this episode, John Barry, historian and author of The Great Influenza: The Story of the Deadliest Pandemic in History, describes what happened with the 1918 Spanish flu pandemic, including where it likely originated, how and why it spread, and what may have accounted for the occurrence of three separate waves of the virus, each with different rates of infection and mortality. While the current coronavirus pandemic pales in comparison to the devastation of the Spanish flu, John highlights a number of parallels that can be drawn and lessons to be learned and applied going forward. We discuss: What got John interested in the Spanish flu and led to him writing his book? [2:45]; Historical account of the 1918 Spanish flu—origin, the first wave in the summer of 1918, the death rate, and how it compared to other pandemics [10:30]; Evidence that second wave in the fall of 1918 was a mutation of the same virus, and the immunity immunity protection for those exposed to the first wave [18:00]; What impact did World War I have on the spread and the propagation of a “second wave”? [21:45]; How the government’s response may have impacted the death toll [26:15]; Pathology of the Spanish flu, symptoms, time course, transmissibility, mortality, and how it compares to COVID-19 [29:30]; The deadly second wave—The story of Philadelphia and a government and media in cahoots to downplay the truth [35:50]; What role did social distancing and prior exposure to the first wave play in the differing mortality rates city to city? [44:45]; The importance of being truthful with the public—Is honesty the key to reducing fear and panic to bring a community together and combat the socially-isolating nature of pandemic? [46:15]; Third wave of Spanish flu in the spring of 1919 [51:30]; Global impact of Spanish flu, a high mortality in the younger population, and why India hit so much harder than other countries [55:15]; What happened to the economy and the mental psyche of the public in the years following the pandemic? [59:20]; Comparing the 2009 H1N1 virus to Spanish flu [1:02:10]; Comparing SARS-CoV-2 to the Spanish flu [1:04:20]; What are John’s thoughts on how our government and leaders have handled the current pandemic? [1:08:00]; Sweden’s herd immunity approach, and understanding case mortality rate vs. infection mortality rate [1:10:40]; What are some important lessons that we can apply going forward? [1:13:00]; Does John think we will be better prepared for this in the future? [1:16:00]; and More Learn more: https://peterattiamd.com/ Show notes page for this episode:  https://peterattiamd.com/johnbarry Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

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Now, without further delay, here's today's episode. Welcome back to another special COVID-19 episode of The Drive. Joining me on this episode is author and historian John Barry. John is the author of arguably one of the most important books I've ever read in my life, The Transformed Cell, And we talk about that very briefly at the outset, but that's not the reason we speak today. Rather, today we are discussing a book that John wrote in 2004, the New York Times bestseller, The Great Influenza, the story of the deadliest pandemic in history. We talk about a lot of things here, obviously related to the Spanish flu. Many of you have probably heard about this somewhat in the previous couple of months. Obviously, this was on a per population basis, probably the greatest

pandemic in human history, perhaps comparable only to the Black Plague. But of course, it has many parallels to the pandemic we are in now. I think history will show that the current pandemic is not a fraction of the Spanish flu, but nevertheless, there are parallels that can be drawn. This is a discussion that goes into many of the details of the pandemic, which is complicated because it really had three separate waves. And we get into some of the history of what may have accounted for that. The other thing I found interesting about this discussion is that there were a number of things that John had changed his mind on from when he wrote the book. And that to me is always the marker of a great thinker is someone who can go where the

data go and not necessarily be wed to something that they put in print. And I think anybody who's ever tried to write something down and put something out there, it does become a little bit harder to go back and look at that and realize that maybe you didn't look at it correctly. But certainly when it comes to, for example, the origin of the Spanish flu, John's thinking has changed and we do get into that. Again, I'll keep the intro brief. I think the discussion will speak for itself. And so without further delay, please enjoy my conversation with John Barry. John, it is such an honor to be sitting here talking with you because, as I alluded to in the email when I randomly reached out to you last week, you are someone whose work I've been familiar with for a very long time because a book that you wrote with my mentor, Steve Rosenberg,

has arguably been one of the most influential books in my life, The Transformed Cell. Kind of you to say. I give Steve full credit for that book. He didn't need me. It's the only thing I've ever collaborated on in my life. He was very generous in giving me credit for that. But I did learn, for those of you who don't know Steve, we're talking about Steve Rosenberg, who was at the National Cancer Institute and was one of the leading pioneers in immunotherapy, developed, I guess, the first immunotherapy that actually worked for cancer. He also was the lead investigator on the first approved gene therapy experiments in the United States. And I guess the world too, in terms of approval, there were a couple of

disapproved experiments prior to that. Yeah. And so that book was published in 91 or 92, right? Yeah. Yes. So I didn't come across it until 1997. It was in my first year of medical school. I read it and it's just one of those moments that I think people have once in a while in life. And it just sort of changed everything for me. It gave me a complete sense of how I wanted to think about the world and problem solving and all these sorts of things. And I read it probably five times. When we're done with the podcast, I'm going to show you my original copy because three years later, I would actually get a copy from Steve signed. I have since purchased a dozen copies whenever I find one on eBay or Amazon. This is an embarrassing thing to

admit. I would insist anyone I dated read the book. I just felt like they needed to understand that degree of obsession. And that definitely minimized the number of dates I had to go on, but it was incredible. And then, and then, as I mentioned to you earlier, I went and spent time with Steve in my third year of medical school and then went there for two years later. And I still view my time at NIH as one of the most blissful periods of my life because it's a period where you could be completely immersed in trying to solve a problem. And when you're at that age and you have no other responsibilities, it's magical. It is. I haven't talked to Steve lately. As you probably know, he and Tony Fauci, very close friends, they arrived, I think on the same day. I didn't realize it was that close. That's interesting. Oh yeah, they're quite tight. Let's talk a little bit about how that,

you basically got a doctorate level course in immunology in the late 80s, early 90s. And then a little over a decade later, you would go on to write arguably the greatest account of the forgotten pandemic. How did you get interested in the Spanish flu? Well, first, I don't think that's a high bar. There aren't that many books about the pandemic. So I would hope it would say the greatest on the pandemic considering the paucity of competition. It's a funny thing. I wanted to write a book and go into this in one of the acknowledgments, but there were four different acknowledgments as things developed. The first was what initially came up.

Then there was one to update it for H5N1. Then there was one to update it for 2009's pandemic, which was barely registered. And then there was one at the 100th anniversary in 2018. So this story may have been erased for space in the interim. But initially, I wanted to write a book on the home front, World War I, culminating in the events in 1919, which I consider one of the most interesting years in American history. I knew exactly how I wanted to approach that subject. It was a very, very big book. And as a writer, I live on my advance. My prior book, Rising Tide, was a bestseller, but bestsellers are not necessarily as lucrative as some people think. I was living

on an advance, and I didn't think I could get an advance. The book, the way I conceived it, would have been taking me seven years at least, maybe a little longer. You just figure how much it costs to live decently for seven years, plus pay your research expenses. And you're talking about a lot of money. I didn't think I could get an advance that large for that book. But I thought I could write a book on the pandemic, which interested me. And probably two years and no more than two and a half years, I drafted a proposal and gave it to my agent. Then I changed my mind, told him I didn't want to write the book. him I didn't want to write the book. But an editor approached him after a story in the New Yorker appeared about digging up bodies to try to reconstruct the virus or find the virus. Anyway,

they made an offer, which I didn't accept. If I'd wanted to write the book, it would have been enough. I got mad at my agent. I told him I didn't want to write the book. Then another editor came along and offered more money. I thought, well, that's too much money for a book I can write in two years that will help me support the other one. So I accepted. The problem was it took me seven years, a little over that. The same advance divided by seven is a lot less than the advance divided by two. of the advanced divided by two. So at the end, I was looking at life as a graduate student. For the first five and a half years that I was working on the book, I wanted to throw the whole thing out the window. Oswald Avery, one of the characters in the book, kept me going. Avery came up with one of the most consequential discoveries in any science of the 20th century, arguably the single most important one. He discovered that DNA carried the genetic code. Solving that problem, which actually grew out of his research on influenza

and pneumonia, put him through hell for 25 years, had a nervous breakdown, didn't publish for more than a decade. And thinking of what he went through kind of made what I was going through almost trivial. And I would think of him almost every day. Finally, after five and a half years, books sort of came together and I was obviously happy with what I produced at the end and the reception it got. It is a beautiful book and I probably read it in 2007. So that would have been probably about three years, I guess, after it came out. And truthfully, this is another very embarrassing story. About six months ago, I realized I just had too many books and I needed to start just getting rid of them, giving them away.

I got to tell me you threw mine out or gave it away. I did. I donated it to a library. I got rid of literally 80% of the books I had. And I remember doing this like six months ago, kind of flipping through books. And it's like a trip down memory lane. I don't know if you've ever done this, but you go through and if you're one of these guys like me who hoards books, you go through and you think, God, I remember I read like, and sometimes for me, it's like, I have a photographic memory. I can say that or photographs the wrong word, but sort of a temporal

memory where I can say, I remember reading this in November of 2006 and I remember what I was doing and I read this on a vacation here and blah, blah, blah. And so it was actually a very cool experience going through and doing that. But yeah, the irony of it is about six months ago, I'm sort of thumbing through my paperback copy of your book and I was like, yeah, this is a great one, but you know what? If I read it again, I'll just do it on audible and maybe I'll have to go back and buy another copy. So I can, I think the events of the last couple of months have reminded us of the importance of that. So I've thought a lot about how much I want. There's so much I want to talk with you on this topic, John. It's, it's something that I think is relevant to where we are today, which is,

I guess, April 15th, but it's going to be an equally relevant discussion a year from now. And it would have been a very relevant discussion a year ago if we'd had it and if we'd known how important it would have been to learn from it. But let's assume for a moment that most of the people listening to this either aren't familiar with the story or maybe haven't read your book. And let's start at the beginning because we're talking about a virus, a swine flu virus. So it's different from the virus that's on everybody's mind today, which is a coronavirus. This is a different class of virus, but a comparable idea in that it's a virus that

originates in a pig in this case. Well, actually, I kind of dispute that. Well, I was about to say, actually, I was going to say, I actually do want to touch on today the difference between what you thought at the time, which is where this originated in Haskell County in Kansas. And I know that in the previous couple of years, you've actually come to another point of potential view on that. I want to touch on that. But is that a good place as any to start? Sure. Okay.

Sure. Well, I guess we could provide some more background. The 1918 pandemic virus, respiratory virus, jumped from animals to people. We don't know what animal it jumped from. The influenza virus has eight separate gene segments. As for most viruses, most organisms have a genetic code carried on a continuous single strand, whether it's RNA for a lot of viruses or DNA for some viruses and more advanced organism. But we know seven of those eight gene segments are avian. One looks like it was mammalian, not necessarily a pig.

So we don't really know what mammal it passed through. And we're not certain that it passed through a mammal at all. So to designate it as swine flu, I'm not sure I'd agree. In fact, there's very good evidence that people gave the 1918 virus to swine rather than the other way around. But having said that, the pandemic killed between 50 and 100 million people. You adjust for population, that's 220 to 440 million people today. It killed two-thirds of them in a remarkably short period of time, generally 14 or 15 weeks from late September through December 1918. It was a very mild, spotty first wave in the spring of

1918, which did not spread worldwide and was very hit or miss. And the countries that did hit, then there was a third wave in 1919, began in February, I guess, extended through the spring. And that's basically the story of the pandemic in very, very short order. So let's go back to Haskell County, Kansas. We're in the final year of World War I. So we're kind of latter part of the winter, early part of the spring 2018. And some doctors there kind of noticed something, right? Right. The first report anywhere in the world, any language that I could find of a lethal form of influenza was actually in Haskell County, Kansas, southwestern western part of the state near the Texas border. There was a very astute physician in that county

named Laurie Minor who reported this lethal form of influenza to the U.S. Public Health Service although that account was not actually published until April. I found the record. Since it was the only report in the spring in public health reports, I decided to check out the weekly newspapers, figuring there would be some delay in publishing the report and found out there was a several-month delay. Anyway, you could trace by name people whose families had someone suffering from pneumonia who went from there to Fort Riley for training as soldiers or visiting somebody there. You used several people by name, and they arrived in early March, and like clockwork, right after their arrival,

a couple of days, the first reports of influenza in that camp. So I thought that might be the site of origin, rural Kansas, and actually published a scientific article in the Journal of Translational Medicine, which was run by Franco Marincola, whom you may know. I know Franco very well. Yeah. Okay. Close friend of mine, still is. And that actually got some attention and had some credibility with some, but since the book was published and since that article was published, there's been a lot of research

on influenza. We found out that China actually did not have a grievous experience in 1918. So based on the fact that they did not suffer huge numbers of deaths, it strongly suggests that there was prior exposure to that virus. So I think it's more likely that it started in China. There are other hypotheses out there, including Vietnam and France, for that matter, France in 1915. We will never know where it actually did start.

At any rate, roughly half the army camps in the U.S. were infected in the spring, even though not very many civilian communities were, although New York City and Chicago were. Los Angeles didn't suffer a single influenza death in the spring. The studies that were contemporary, there were several numerous ones, both in the United States and Britain by a Nobel laureate named McFarlane Burnett in Australia. These studies all concluded that it was most likely that influenza was carried to Europe by American soldiers in the spring of 1918. That happened to be a pretty mild wave where not a lot of deaths wasn't noticed at all in any civilian community in the United States at the time. Retrospectively, there have been some

that have been identified. And over the course of the summer, my speculation is that the virus mutated, became much more virulent. And in mid-September, it simultaneously in lethal form hit Africa and Boston. But actually the first lethal wave of the influenza occurred in Switzerland. That was noted in July. There was a U.S. military intelligence report from Switzerland, which said this disease is being called influenza, but it's actually the Black Death of the Middle Ages. Can we pause there for a second, John, and put this in some context? So we talk about sort of the sort of pandemics to end all pandemics. And I just

want to kind of put this in context. Is it safe to say that the bubonic plague of the 14th century, if my memory recalls, is the greatest pandemic of them all? Yeah, easily in terms of proportion of the population who were killed, an estimated quarter to a third in Europe. The subtitle of my book is The Deadliest Pandemic in History, and that's true in the sense of the numbers of people killed. But as a percentage of the population, there's no doubt the plague of the Middle Ages killed many, many more than influenza did.

killed many, many more than influenza did. So do you think that the same virus that killed a reasonable number of people starting in Haskell County is the same? And by the way, that's the same virus that probably went to France with the soldiers. Do you think that is the same virus that came back in October of 2018? And as you pointed out, basically knocked out two-thirds of its victims or do you think it was a totally different virus? Well, I think the evidence is overwhelming that it's the same virus. It's a staggering mutation between these two. Right. There are people I respect or at least one where it's not so much that they think it's different virus, they're yet to accept the fact that it's the same virus. I can go into detail as to why I'm convinced it's the

same virus, if you like. I would love that. Okay. Number one, in New York City, there was a careful study of the spring outbreak. Even though relatively few people died. It was exactly the same signature of demographics, which is very unusual for influenza. In 1918, the peak age for death was 28. It's a so-called W curve. Usually, influenza kills the very young and the elderly. That was not the case in the spring, and it was not the case in the fall. and both of those patterns are highly unusual. That's number one. Number two, in fact, I actually did write an article for Journal of Infectious Disease on this. The first wave exposure was very protective against second wave illness. A couple of NIH epidemiologists helped me write that paper, Alona Simonson and Cecile

Vabou, very good epidemiologists on influenza. The first wave provided between 59% and 89% protection against illness. That compares to a vaccine today, which in the last 20 years has ranged from 10% to 62% protection. So it's much better than a modern vaccine. Number three, when they reconstructed the virus and stuck it in ferrets, it was highly lethal, much more so than any other influenza virus. Sorry, John, that's from the first batch, meaning the first wave. No, they reconstructed the genome. Jeff Taubenberger

No, they reconstructed the genome. Jeff Taubenberger sequenced the genome by extracting it from slides from lung tissue at the Armed Forces Institute of Pathology. He's now at NIH. Taken from patients who died in the first wave or the second wave? Second wave. Actually, he's now found, that's another reason, he's now found a sample as early as May, which is the same virus. Ah, well, that would be the most compelling of all of these things, correct? Well, I mean, just the perhaps. I think the epidemiology demographics, I think the immune protection it afforded is pretty compelling evidence, particularly the immune protection. But certainly the fact that they've got a sample from May, which is the same virus, that's pretty good evidence as well. Interestingly,

in terms of immune protection, the first wave protected against the second wave, but neither first nor second wave exposure protected against the third wave, which started in February 1919. Well, you're going to include a bunch of figures to accompany this podcast, John, because I think that as you describe these things, I mean, those of us who have spent time reading about it can picture what you're describing, which are these three peaks. You've got this first little peak in the spring of 18. And then it's, if you just saw it by itself, it would look devastating just based on the absolute numbers, but then it is so dwarfed in a relative sense by what comes about in September to December of that same year, which basically is like Everest next to Kilimanjaro.

Then you do have a third peak, which is even bigger than the first peak, probably by 3x that takes you into 2019. I want to come back to implications of implications of that as we go forward. But one of the things about this that is interesting when we look back is we don't think of the world as being very connected in 1918. There were no airplanes. You had to cross by ship and do all of these things. You just wouldn't think that this thing could go as much as it did. And yet there are some really nice videos out there that show you a temporal view of where infections popped up over time. And it's kind of amazing how quickly that second wave grows.

What is your sense of the movement of the second wave of that? How did it, and maybe we can just for simplicity focus on the United States, but I do want to come back and understand places like India that were just decimated. First, you don't need steam power to move a pandemic. In the 1600s, influenza managed to cross the Atlantic Ocean and devastate Virginia and Massachusetts, not to mention the Native American population. Guns, Germs, and Steel is sort of a great example of this, yeah. Right. Or better than Guns, Germs, and Steel, you've got McNeil, and then you've got one of my favorite books of all time, which I highly recommend to everyone, by McFarlane Burnett. I mentioned him earlier, Nobel Laureate, called The Natural History of Infectious Disease,

which is just an incredibly good book and quite accessible to a layperson. So we were talking about timing. My guess is the virus seeded itself largely around the world and then erupted. Takes a while to get a pandemic started. But once it got going, it was moving pretty fast. Although the Army, which has very good data and had great epidemiologists in their study, which wasn't published until the 1930s, they had tremendous amounts of data.

It took a while to assemble it all and publish it. They said that in their army camps, beginning in late July and early August, in retrospect, they could identify a steadily increasing uptick in pneumonia in the camps, which if they put it on a graph was essentially a log advance, whatever the appropriate terminology is to describe that increase. And then it erupted, of course. And this was noticed in their camps independent of the return of the virus to the United States, which first occurred in Boston in a naval facility or essentially naval barracks and then spread to Camp Devons, which is about, I guess, 30 miles northwest of Boston, maybe a little more than that, where that was the

first army camp that really exploded with the deadly form of the disease. How much was the transition of the first to the second wave and the propagation of the second wave made worse by the war? I mean, I'll start on pointing out the two issues. One is just the proximity and physical nature of war and sort of the fact that soldiers could become such effective conduits and vectors. But also in terms of the media's response to this or the government response to this. Well, in terms of the government response, it was major. I'll talk about that in a second. In terms of the war spreading the pandemic, I think it accelerated it a little bit, maybe by a few weeks or something like that. The outbreak in New York City, for example,

preceded any outbreak in army camps. It's also another reason why I backed off my Haskell hypothesis. Haskell did precede New York City by a couple of weeks, but it's hard to figure out what it gotten from Haskell to New York City, although it certainly could have happened. Anyway, with New York having a well-defined spring outbreak and Chicago also, it's pretty clear it would have gotten everywhere eventually and sooner rather than later. And whether you have 10 people getting off a ship from New York to England or France, or whether you have a few thousand soldiers getting off a ship, really doesn't make that much difference in spreading the pandemic. Just difference in timing, but with a reproductive number close to two, you'd catch up pretty

fast, even if you start with one index case, much less 10 or 20. So I think the war accelerated the spread, but I don't think it's responsible for the spread. It just happened a little bit faster. But I don't think it's responsible for the spread. It just happened a little bit faster. In terms of the other question about the response, that was a major factor in, I think, the death toll, possibly. Certainly in the fear and, in some cases, chaos that was generated.

The government had created this infrastructure because of the war. The federal government, I believe, more than any other time in its history, including the McCarthy period or the Civil War, was determined to control the thought of Americans. And they had a law that made it punishable by 20 years in jail if you, to quote, utter, write, print, or publish any disloyal, scurrilous, or profane language about the government of the United States. So you could curse the government, you just broke the law. They weren't kidding about this. They actually sent a congressman to jail for 15 years under the law. This was upheld by the Supreme Court. It's where the line came about, you can't shout for fire in a crowded theater. That came from that Supreme Court decision upholding that law.

They also had a propaganda arm called the Committee for Public Information, which was determined to, quote, keep morale up, unquote. And the architect of that committee said, truth and falsehood are arbitrary terms. There's nothing in experience to tell us that one is superior to the other. Went on to say all that mattered was the impact of what a viewer was saying. So that propaganda arm was going to minimize anything that might depress the American public because they feared that would affect the war effort. So the pandemic fitted into this construct. By the way, that makes me feel not so bad about the world we live in today. It suggests that history can repeat itself and maybe the pendulum can swing back a bit. I go around quoting Hegel. Everybody quotes Santiana. I like Hegel. Hegel said, what we learned from

history is we learned nothing from history. Just contrarian. Anyway, as a result of this approach to maintaining morale, in quotes, a national public health leader said, this is ordinary influenza by another name. It was referred to as Spanish influenza, even though it didn't start in Spain. Another national public health leader said, you have nothing to fear if proper precautions are taken. But people pretty soon, and throughout the country, most localities, the local public health commissioner echoed these approaches. The press was complicit. It was fake news because they were not reporting the truth because they were only saying nice things. But

everybody knew it wasn't influenza by another name, ordinary influenza by another name. There were deaths in less than 24 hours after first symptoms. That was unusual, but it certainly happened. What was the, but it certainly happened. What was the typical course? I mean, you mentioned that the R-naught, the reproductive number approached two, which made it more contagious even than garden variety influenza, but its real superpower was not that it was a more aggressive spreader. It's the actual pathology of the disease that's probably its superpower. And I use that term horribly because evolutionarily, that's not a superpower for a virus. A superpower virus would kill nobody,

would have an R-naught of infinity and kill no one. That would be the best virus if you were thinking about it from Darwin's point of view. But this was a deadly virus. What was the typical clinical course? The typical course was ordinary influenza. But in the West, the case mortality was about 2%, much worse than that in the less developed world, not because Western medicine was any better, but because in the West, a lot of people had some cross protection from having been exposed to other influenza viruses. And in the less developed world, that was not the case. They were, quote, virgin populations, unquote, naive immune systems. But the 1918 virus, like coronavirus, but unlike most influenza viruses, could bind to cells in the upper

respiratory tract, which made it easily transmissible. But it also could bind directly to cells deep in the lung, which meant you were starting out essentially with viral pneumonia. Those were the awful pathologies where some of the symptoms in the book, I quote one physician writing a colleague that people were turning so dark blue from lack of oxygen that he couldn't distinguish colored soldiers from white soldiers, African-American, I'm quoting him. That, of course, spread rumors of the Black Plague when people's pallor turned so in that color. And that virus also, unlike most influenza viruses, could pretty much attack any organ. It was initially misdiagnosed as typhoid, as dengue, as cholera. Nosebleed was quite common in some army camps. They reported 15% of

the soldiers had nosebleed. It was also possible for people to bleed from their mouths and from even their eyes and ears, which are, of course, other mucosal membranes. That's pretty scary, particularly for a lay person. So to be told this is ordinary influenza by another name, when you're seeing symptoms like that and you're seeing people die rapidly, it gets your attention. And what it means is you stop trusting anything that you're being told by anyone in authority. I think society is based on trust. When trust evaporates, society begins to fray. And in some places it got pretty bad. There were reports of people starving to death, not because of lack of

food, but because no one had the courage to bring them food. This happened in cities like Philadelphia, which I focused on in the book, but also according to Red Cross reports that things like that happening in rural communities occurred as well. The story of Philadelphia is an interesting one, and I really want to come back to it as a case study and then contrast it with other cities. Obviously, you contrast it quite eloquently with St. Louis, but also San Francisco and others. I want to talk about that. But going back to the pathology of this illness, it really seems like, I mean, typical influenza, you get a little bit of a, I think of it as sort of a, you stun the immune system. You get this immune paralysis that can

often result in a superimposed bacterial infection and all of these other things that come to bear. And anybody therefore who's susceptible to super infection, meaning people who are hospitalized already in a nosocomial environment, I mean, those things sort of become problematic. But as you pointed out, there was something really distinct about this pattern of victim here, especially in 1918 in that second cohort, which is this was knocking off people in their 30s the way we would normally see people dying in their 70s and 80s. And the idea being here that it was- Peak age for death was 28. Suggesting that the stronger your immune system was, the worse you are?

Exactly. Same thing people are dying of today, acute respiratory distress syndrome. Your immune system releases, as you know, cytokines, which the immune system has some very lethal weapons. The virus, when it was in the lung, the immune system attacked it with everything it had. And the battlefield was the lung, which was being essentially wiped out in the effort to destroy the virus. Exactly the same thing is happening today in those people who are dying of coronavirus. Now, I will say probably a majority of people in 1918 died of secondary bacterial pneumonia. There are some people who think that 95% of the deaths were bacterial pneumonia. I think that is mistaken. It's difficult to quantify how much was bacterial pneumonia and how much was directly because of the virus. My guess would be a third, 40% would be directly virus, but that's a guess. I certainly think it's a lot more than 5% as some have hypothesized. And just the anecdotal reports from very good pathologists suggested that was not the case. And even today, bacteria and pneumonia following influenza has an 8%

case fatality rate with all the antibiotics we have. Back then, it was 35%. That's actually unbelievable. I didn't realize it was that high today, by the way. 8% today seems a pretty high number, but to your point, these people are already incredibly compromised based on what they've been through to get there. Let's go to Labor Day 2018. Set the stage again, just to remind people where we are. You had this awful virus that ripped through the United States in some pockets in the spring. It killed, what, maybe 25, 50,000 Americans by that point? I've never put a number on that or seen a number on that. It's really hard to say. put a number on that or seen a number on that. It's really hard to say.

Yeah. I mean, directionally, it's like less than a 10th of the total population that would ultimately die, which was about 650,000 Americans, correct? Roughly, yeah. 650, 675 are the numbers that I've seen, yeah. So now fast forward, we've just enjoyed a summer of relatively low mortality domestically. The virus, of course, has been doing something else abroad. I don't think people realize it at the time, but the war is about two months from being over. Right. That was not common knowledge.

No. People were gearing up for spring offensive in 1919 to end the war. And in Philadelphia, they need to raise money. There's a bond that basically the government has to borrow money and there's no better way to sort of do this than to kind of showcase what the money is going to buy you and have a parade, right? Correct. In fact, it wasn't just Philadelphia. It was around the country, September 28th, there was a Liberty Loan parade, a lot of cities. But in Philadelphia, by then the virus had already established itself and the medical

community was unanimous that the parade should be canceled. They were telling reporters this, reporters were writing stories about it, editors were killing the stories. As I'd said earlier, the press was largely complicit with the morale-boosting approach that the government took. The local public health commissioner was part of a corrupt political machine. He's a perfectly good person, but didn't have the backbone to stand up to it and tell you how corrupt that machine was. It elected a United States Senator a few years later, and the Senate, controlled by the same party, refused to seat the guy. That's pretty corrupt when the US Senate won't seat somebody,

wins an election when it's a member of the party that controls the Senate. Anyway, the parade went forward, and pretty much like clockwork, 48, 72 hours later, influenza exploded and Philadelphia became one of the hardest hit cities in the country. Within three weeks, 4,500 are dead. Something like that in total, about 14,500 over the course of the pandemic. And getting back to the press to tell you how complicit they were. So when they finally closed schools, banned public gatherings, closed saloons, theaters, no church services, stuff like that, one of the local papers actually said, this is not a public health measure. You have no cause for alarm, unquote. I mean, how stupid did they think people were? But that contributed to the breakdown of

society, contributed to the fear and the terror. When you can't believe anything you're being told, and obviously by then everybody knew perfectly well that was a public health measure, people were dying all around them. How did that information get around? Because obviously we take for granted today how electronic information basically, I mean, it creates so much noise that it's hard to know the signal. But back then you had a very different problem, which is if you lived in Los Angeles at that time, what would be telling you that people are dying like flies in Philadelphia if the formal media is not doing anything about it? Well, you wouldn't necessarily know what was happening in Philadelphia, particularly back then, because it's funny. I didn't write a lot about Phoenix in the book, but it was too redundant with what had happened in Philadelphia, a little bit different. But I did a lot of research in Phoenix. And interestingly, when the disease first hit Boston, they were writing about it. When it was in New Orleans, they were writing less about it.

When the disease was actually in Phoenix, you could not find a word about it in the Phoenix paper. On page 14, they had a death notice of somebody. That was about it. It was not in the headlines hardly ever. So it was strictly rumor. And again, that contributed to the level of fear. You didn't know what was going on, which gets into maybe to jump ahead or not. When the Bush administration started the pandemic preparedness planning, and the Bush administration launched a major initiative, $7 billion bill, did all sorts of things, vaccine technology, investment research, create vaccine manufacturing, began the national stockpile. Anyway, I was asked to participate in some of the early groups, which were coming up

with so-called non-pharmaceutical interventions. What do you do when you don't have drugs? And my message in these groups was always that the step one is to tell the truth, that people can deal with reality. They can't deal with when you let their imaginations run loose, that's when you really get into trouble. If you give them the straight facts, that is much easier to handle. In a monster movie, it's always scarier before the monster appears on the screen. Imaginations are very powerful things. seen video footage of what can only be described as horrifying because as terrifying as and uncertain, I guess, as the last couple of months have been with respect to the unknowns around the coronavirus. When you look at morgues that can't accommodate corpses, and when you also understand how little people understood about microbiology at the time. And so they know enough to know that this is contagious. They know enough to know this is respiratory contagious. But as you pointed out, there's a breakdown in society from not knowing how and when and if you can help

someone else. And what do you do when someone dies? I mean, there are these stories of bodies that just were left out on the street because the risk of actually having to go out and take care of a body and dispose of it could potentially expose you to more. And I mean, to me, that's again, 14,000 deaths doesn't sound like an enormous number. I mean, New York will likely eclipse that. New York City obviously adjusted for population. Philadelphia would have been more in that time. adjusted for a population. Philadelphia would have been more in that time. But it's in part the speed with which it happened and also just the fear of who's next. And I think the other thing is seeing these young people dying in a way that you just, you aren't used to. I guess if I'm

going to play devil's advocate for a moment without the benefit of hindsight, is there an argument that one could make that says, look, the public health officials or the people who should have been doing the right thing didn't want to create an unnecessary panic in the other direction without knowing more? I'm sure this is an argument that you've heard a hundred times. What is the counterpoint to that if there is one? As you say, that's the counter argument, but I think I already articulated the argument in favor of the truth. Number one, the imagination is more powerful. Number two, if you ever expect the public to do something you want the public to do, you better have

credibility. And once you lose credibility, you can't regain it. If you start out telling the truth. Even by the way, when the truth is we don't know. I mean, to me, that's the biggest challenge the government has, right? Well, that's okay too. If you say we don't know, but we'll know when this test is performed and we have the results, you can go down the line as to why you don't know. And you can then say when we will know. So you provide information and you can retain your credibility even if you don't know. I think that's the only way to go. My standard line is, I don't like the phrase risk communication because it implies managing the truth. You don't manage the truth, you tell the truth.

You know, I would be in these working groups, and I mentioned D.A. Henderson earlier. D.A. and I became friends because we were always in agreement, it seemed, in these groups, sometimes opposed by others. But on that one point of telling the truth, I never got any pushback from any of these groups I participated in. The national pandemic plan, which was the outgrowth of those working groups, certainly incorporates the idea of transparency, as does every state plan. The problem is someone has to go out and execute that pandemic plan. Someone has to go out, face the camera and tell the truth. Obviously that has not happened. There are other countries where it has happened, including Germany, which has done light years ahead of us in ending

coronavirus or Singapore and no doubt other countries, just not in the United States. Going back to the Philadelphia story, how would you contrast that with what happened in St. Louis, which you use as a counterpoint? Well, St. Louis intervened very early in terms of what we call social distancing now. And at least partly as a result of that, they had a much more benign experience than most other cities on a per capita basis. It's not clear to me that 100% of that is attributable to social distancing. We don't know. Nobody's ever looked. The information's ascertainable, but I didn't have time to do the research, whether or not they had a spring wave, for example, ascertainable, but I didn't have time to do the research, whether or not they had a spring wave,

for example, which I am convinced, I think it demonstrated, did provide protection against the fall wave. New York City, for example, didn't do anything. They did less than any other city. They didn't close schools. They didn't close saloons. They didn't close theaters. They didn't do anything. And yet New York City had a relatively benign experience, I think because of its spring wave. Same thing in Chicago. Now, whether that was true in St. Louis, I don't know. But St. Louis did act early and aggressively in terms of social distancing measures. They were less extreme than what we're doing now, but they were imposed early and early action is very important. If you do it before the virus is widely disseminated

in the community, it can be effective. If you wait until people start dying all around you, by then the virus is everywhere and those measures are not going to be nearly as effective if they're effective at all. San Francisco had some interesting policies, right? Weren't they so strict on how they enforced masks that the police had authority to shoot a person in public who was not wearing a mask? I missed that. I'm not saying you're wrong. They did require by law, people wear masks.

There were several cities that did that. The thing that makes San Francisco interesting, they were the only place I know of that really did tell the truth. I'm sure there must've been at least some other places. Certainly I didn't study every ball of a hundred biggest cities in the country, but in San Francisco, the mayor, labor leaders, business leaders, medical community all made a joint statement. Huge, tight, full page in the newspaper, wear a mask and save your life. Now that is a very different message than this is ordinary influenza by another name. You have nothing to fear, proper precautions are taken. So wear a mask and save your life. This is a life-threatening disease and you better take action.

They honestly believed the masks were the effect of. They did next to nothing or probably nothing. San Francisco actually suffered, forgot the exact number, but they were fourth or fifth highest excess mortality in the country. But what that message did do was secure the community. The community did trust what the leaders were telling them. And the community, instead of fraying as a society, in some cases, almost breaking down. In San Francisco, that city functioned better than any other place that I know of in the sense that, for example, when schools were closed, teachers volunteered as ambulance drivers, whatever was needed, as opposed to running and hiding, which was happening in other cities where the leadership lied. And as a result, people felt it was everybody for himself or herself or their families in the hell with the community.

So after the pandemic, despite the fact that San Francisco had a very high death toll, the Chronicle wrote an editorial saying that in our long history of the city, despite the tragedy, this will be one of the most glorious episodes in our history because of the way the community came together and functioned. I don't know of another city anywhere that could have made a claim like that. Which is really a counterintuitive claim when you think about both the general statement one would make about pandemics, which is unlike natural disasters, acts of war and terrorism, pandemics tend to divide people, not unite them due to the isolation and fear. And then secondly, this pandemic happens to be the worst of the bunch. You'd think that if anything,

this would have decimated communities. And yet you have this counterexample. Do you think it is this culture of abject honesty from the outset that played the main role in that? I think that was a factor. I think in most disasters, people do come together. I live in New Orleans. Well, that's what I'm saying. Most disasters, yes, I'm saying. But there's something unique about these pandemics that people talk about saying, no,

actually, these do more harm than good in terms of social cohesion. Well, if you look back at the plague and so forth in the Middle Ages, the terror that was out there, a quarter to a third of the population being killed. Yeah, I would say that's true. Plus the unknown factor. So you had everything working against you in the Black Death. I think it's almost like a controlled experiment supporting my hypothesis that telling the truth is the best way to go and that it can pull people together and make even in a pandemic, people function as they do in other disasters, trying to help each other. The reality is I can't prove it quantitatively, but in terms of

anecdotally, I'm in the French Quarter, which is deserted. There are not a heck of a lot of full-time residents in the French Quarter. There are some, but people around here, neighbors whom I don't really know a few blocks away, they're asking me, my wife and I go for walks. They're asking if there's anything they can do for me. A couple of people who are younger, I'm over 70, so is my wife, you know, they volunteered to get groceries for us. I have a neighbor next door who's a dentist who immediately went to his office and donated all his masks and gloves to a local hospital. He's unusual in this also in the sense that he did a medical rotation with interns in addition to his dental school. So he's volunteered to go to hospitals and perform procedures that he's capable of doing and take some of the stress

off healthcare workers, which of course exposes himself to a lot of risk. I get the sense around here that people are coming together. Again, it's anecdotal and it's very localized, even if I'm right. But that's the attitude nationally. That's a pretty big plus. I want to pivot for a second and talk about two things we can do in either order you prefer. One is I want to visit India a little bit because I was kind of astonished at the mortality in India. It's almost hard to fathom. And then the second unrelated thread is really the, I don't know much, I don't recall much about the factors between the second and the third wave. So in either order, you want to talk about those as we continue through this journey. Well, we can go in either order you want, because it may be a short discussion. Let's stay on the domestic thread and talk about how much of the dying down of the second

wave before the resurgence of the third, because it doesn't appear to have been just seasonal, or do you think that the seasonality was the main driver of that? just seasonal, or do you think that the seasonality was the main driver of that? No, I very definitely do not think it's seasonality. I think the virus changed. As I said earlier, either first or second wave exposure seemed to protect against the third wave. So that suggests a reasonably dramatic shift in the virus and what is referred to, as you well know, shift in the virus, what is referred to, as you well know, the Andeson drift. I should have said drift instead of shift in the elder influenza. That's actually a meaningful term of art. I can't prove that. Come to think of it, I don't believe that Jeff Taubenberger, who's the one who's done all the sequencing of old viruses, I don't know that he's got a viral sample from 1919. Maybe he

does. I should ask him. It'd be very interesting. By then, most of the samples, not all of them, but most of the samples came out of the army. By the spring of 1919, there probably weren't that many soldiers dying of influenza. They would have been discharged. So they may not have samples. So I think the virus drifted enough to escape the immune system. It was lethal by any standard. 1919 was lethal by any standard except the fall wave in 1918. It was the second worst year of the century, or that we know of in terms of influenza deaths. What was the morale of the country like at that point when you have no reason to believe this isn't going to continue indefinitely? I sometimes find it interesting to try to imagine going back in time, not knowing how the story ends and thinking, how could you concoct a story here

that is really frightening? And to me, it would be as you're in the midst of the third killing wave, this is the new norm. Probably most Americans were relatively unaware of the first wave at all. So to them, it probably was the second killing wave. That doesn't take away from the point you're making. And honestly, I don't know. In the book, I was trying to focus, if you ask me what I write about, I will tell you I write about power. I may be the only person who sees it that way. The influenza book, in terms of characters, that I was trying to focus on the scientists because they were the ones who had power to

confront pandemic. And to a lesser extent, actually, I focused on the politicians because they affected the course of the pandemic by lying to the public and so forth. So I did not spend much time, well, particularly, I didn't look at newspapers and things like that for sources because that was fake news back then because they were working with the government to minimize things. The war ended, there were so many other things going on. I don't really know the answer to your question. Certainly there was concern. I don't get the sense from the little research that I did in the area that there was a kind of terror erupting that accompanied the second wave, but I really don't know. And what to make of India, About 20 million fatalities in India, correct?

At least. In fact, the original estimate of the death toll, which was in 1927, studied by the American Medical Association, a guy named Edward Jordan, that infectious disease expert, looked at the entire world, and they originally estimated 21.7 million people died. That was largely because they extrapolated the case mortality rate from the West, where they had semi-good data, to the rest of the world, which turned out to be wrong. My speculation, clearly those populations that had not seen influenza viruses before had terrible mortality. Forget about case mortality.

In an isolated island in the Pacific, western Samoa, 22% of the entire population died. Not case mortality, 22% of the entire population. And that's a very good number. We know exactly how many people died there. very good number. We know exactly how many people died there. In India, it's hard to imagine that that country had not been exposed to influenza viruses throughout the country. And yet, I can't think of another possible explanation for their tremendous death toll. And you can look at British Army. You've got Indian troops in the same camp as Caucasian British troops. And the case mortality for the Caucasians is 9%. And the case mortality for the Indians at the same place at the same time

is over 20%. And it's not because medical care was any different because medical care didn't make any difference. All they could do was supportive care and keep you hydrated. That was about it. Maybe ice you down if you had a fever. There could have just been genetic differences. There could have been certain things about the way this virus binds. Maybe this was a virus that could have disproportionately affected Southeast Asians, potentially more than Caucasians, just based on properties of how the virus worked? Or to your point, which I think is seemingly the more logical

or the Occam's razor here would be just a difference in immune preparedness. Exactly. The naive immune system. But we don't really know. I've seen epidemiological studies, which range as high as 30 million in India, but I haven't really seen a good hypothesis explaining why. All told, about 4% to 5% of the world's population died. Does that sound about right? Well, you can do the math. It's pretty simple, 1.8 billion people.

So 50 million dead would be about 2. a half percent, roughly. 100 million would be about 5%. The thing is, two thirds of the dead were aged 18 to 45. So when you look at that demographic- Yeah, that's a staggering impact on life expectancy. Yeah. On aggregate life expectancy. Yeah. And particularly when you throw in the period, short period of a few months during which most of those people died. And then you go into other narrower demographics. And according to Metropole and Life, over 3% of all the factory workers in that age group died, not case mortality. 3% of the entire population of factory workers in that age group died in a period of weeks. Pregnant women, there are a whole series of studies which range from 21% to 71% case mortality. Minors, according to Metropolitan

Life, over 6% of all minors in that age group died, again, in a very narrow period. And it's even shorter than that 14 or 15 weeks because influenza would pass through a particular community anywhere from six to 10 weeks. So the timeframe is very compressed when people are dying. So it was a pretty horrific period to live through. This is a question that might be a little bit outside of your area of expertise, but- Oh, great. I'll pontificate. Happy to pontificate something I know nothing about. Well, you might. Why did we roll into the 1920s with an enormous economic tailwind and not hit depression until a decade after this pandemic, when you would think

that something that knocks out that much of a country's population would have actually precipitated the economic downturn immediately following this? Why is it that by the time this thing rolls to an end in late 19, 1920, the country managed to resolve itself economically. Was that more on account of the war being over? What do you attribute this to, if any thoughts? There actually was a recession that was fairly deep, but very short-lived right after the war. And indeed, after World War II, there was a lot of planning and anticipation of the same thing happening after World War II. It same thing happening after World War II. It didn't happen after World War II.

It did happen after World War I, but again, it was brief. You're talking about 4 million soldiers or more, plus however many were in the Navy, suddenly thrown back into the workforce. So there was great dislocation and unemployment, but it was pretty brief. You had pent up demand. You had an adjustment as factories went back to making civilian products instead of tanks or ships. So there was a dislocation, but then it did pick up. In terms of the attitude culture, people usually ask me what impact I thought the pandemic had. Again, it's very difficult to quantify or be precise about my own senses. People understood it was there.

It was part of their consciousness. I think it may have contributed to the sense of ennui in the 20s that party today, because who knows what's happening tomorrow in 1933 when the nazis rolled into germany into berlin christopher isherwood wrote berlin stories from which a great movie cabaret came he said you could feel it like influenza in the bones so he expected his readers to understand that sense of dread deep within you that you get just from seeing the Nazis show up. I think that analogy, the fact that he made it, is a powerful statement. By the same token, there is very little that was written about it. John Dos Passos, one of my favorite writers, got influence on a troop ship. It was a pretty bad place to get it.

And he hardly mentioned it in any of his novels. There's just not that much written about it, which is a puzzlement not only to me, but to a lot of other people. In 2009, when H1N1 was coming, I'm guessing your phone was ringing a lot. Yes. What was the fundamental difference from a virology standpoint between the 2009 H1N1 swine flu and let's just think about the second wave version of that same virus? Well, the reality is 2009 was very, very strange because it was almost two entirely different diseases. The overwhelming majority of people who got sick had a relatively mild case of influenza.

But for those who were seriously ill, it was 1918. That virus, H1N1, well, 1918 was H1N1 virus also. But the 2009 virus could bind directly to cells deep in the lung. What was the genetic similarity between those two? Do we know? Well, I write about science, but I'm not a scientist. I know that it's referred to, as you probably know, a triple reassortment of viruses, meaning that there were three different influenza viruses that were involved in making up the genome of the 2009 virus. Some of it probably went back, I think did go back to 1918, but most of the viruses, if not all of the human viruses circulating today, have some of 1918 floating around in

them. So I can't really answer your question. Clearly, there had to have been a lot of cross-protection from other circulating viruses. You think the vaccination or the frequency with which people had influenza vaccines and continued exposure to influenza and perhaps greater medical care? No, I think it was simply the virus primarily. One thing that's also interesting about 2009, the peak deaths, the age of the dead was very similar to 1918. I forgot the exact number, whether it was 27, 28, or 29, or maybe even 30, but the average age of the people who did die was very, very young, much different from ordinary influenza

and very similar in 1918, though most of them did have comorbidities. Let's fast forward now to where we are. It's a different type of virus. It's a coronavirus, not an influenza virus. They have things that are common. They have things that are different. What have been your observations so far? I'm sure you have assimilated a great deal of information. And though you're not a virologist, you're obviously incredibly erudite with respect to your understanding of not just the biology of these things, but also the epidemiology of them and the role that governments, media, et cetera, play. Let's just start with biology. Let's say it's kind of you to say, I don't know how much it's nice of you to say that. I appreciate

that. I hope what I say is correct. I know I believe it. I do sort of cross-reference my thoughts with other people who are very involved in pandemic preparedness, vaccine production, and so forth, who I became friendly with back in the Bush administration and since then, Obama administration as well. So if I have an idea, I will send them an email and ask them if I'm going to embarrass myself if I say it. embarrass myself if I say it. But to answer your question, as I said earlier, coronavirus, like 1918, can bind directly to the lung, cells in the lung. Obviously, it's different binding sites, but still steep in the lung as well as upper respiratory. That's the main similarity. The main difference is the

incubation period, which creates a nightmare for managing this virus. Then we have questions about immunity. We don't know the answers to sort of presume that, I guess, the work that I've seen recently suggests that you can more or less semi-safely assume you're going to have immunity for a year and maybe longer if you've survived the disease. In fact, I won't use Instacart because I think it's unethical to expose people to the virus. The person who is getting groceries for me now actually did have the disease and did recover. So she's kind enough to get groceries for me and I don't feel an ethical problem asking her to help me because I think she probably does have immunity, recent recovery. But in terms of the

time, you know, the incubation period for influenza is generally two days. It might run as long as four, but it's usually shorter. This is two to 14 days. The average incubation period is five and a half to six days, triple the length of time for the average incubation period for influenza. So that makes each generation is going to be that much longer. The disease itself takes much longer to develop in the body. It takes much longer to develop in the body it takes much longer to pass through the body so the whole length of time the duration is much much longer than influenza i said earlier

in 1918 or for that matter a seasonal influenza it'll pass through a community normally six to ten weeks and then you don't hear about it until the next season or in 1918 until the next wave came. And this is not going to be like that. Also, the social distancing, to the extent that it works and it is working, is going to add further duration to that. The whole process of coming out of this is just tremendously complicated. Do you think that the response to this has been appropriate, has been overly aggressive, has been not aggressive enough in certain areas, potentially New York? I mean, what's your overall take on this, on the response? Of course, Trump is a disaster. Trump is a disaster. Incomprehensible is failure to respond, his failure to lead.

He said the federal government is a backup. I always thought leadership meant you are in front. His failure to mobilize resources. Incredible that FEMA in 50 states compete for the same resources instead of FEMA taking over and allocating it to the states. The obviously trivialization of the threat for two months. All these things are almost off the scale. And then cutting out and saying he's withholding $500 million from the World Health Organization in the middle of a pandemic.

Stephen King would not be believed if he wrote these things in a novel. So what else can you say about this guy? States have varied. I'm in Louisiana. I think the governor here, John Bel Edwards, has done pretty well reasonably early. I think the mayor of New Orleans also acted pretty early. I know thereardi Gras is blamed for Louisiana and New Orleans being a hotspot, which may be the case. But if you look at the timing, when Mardi Gras appeared and when February, I guess, 25th was Mardi Gras, there was not a single case in the state of Louisiana at that time that we knew of. There were probably cases. Obviously, there were, Mardi Gras spread any. But all that goes back to the testing debacle, which unfortunately, I think partly is a result of CDC. And I have high respect, high regard for CDC.

But on this one, not great. Then FDA and the bureaucracy, but also Trump and the failure to take this seriously, the failure to develop an infrastructure going forward. I've seen a number that says we're going to need 300,000 people for testing and contact tracing and so forth when we come out of that. This, I don't think one person's been hired for that at this point. We should be building that infrastructure up even while we're waiting for the testing capacity to develop. That should be done simultaneously. There are countries who've got this pretty right. And again, not just the

Asian countries like Korea and Singapore and Taiwan and Hong Kong, but Germany, very much like our country, except for the leadership. What Sweden is doing now, it's too soon to perhaps tell, but what's your take on the, for lack of a better word, the natural experiment going on in Sweden? Right. They're basically saying, look, we're going to pursue this through the landscape of herd immunity. While protecting the vulnerable. Yeah. We're going to take a selective approach to taking those people who are most at risk. Now we've had the luxury of watching how that's played out in

the rest of the world, but we're not going to shut our economy down. And they're what they're basically saying without saying it explicitly. And I don't know if they know that this is what they're saying. They're basically saying we completely disagree that the case fatality rate is one to 2%. We think that the infection fatality rate is 1% to 2%. We think that the infection fatality rate is probably closer to that of influenza, 0.1% to 0.2%, 0.3%, because we believe that there are far more asymptomatic people out there than we appreciate, therefore creating a much larger denominator. And that's synonymous with saying you're going to get to herd immunity quicker. Number one, they will get to herd immunity quicker if herd immunity.

Well, without catastrophic findings, yeah. The thing is the infection mortality rate and the case mortality rate or fatality rate are often used interchangeably, but they're not at all the same. They're not. That's right. If you did a serological study to find out how many people were infected with influenza, the numbers that influenza case mortality, I'm convinced, would drop from 0.1% way off the scale, way below that, because there are people who are exposed to the virus. I mean,

serological study infection rate, anybody whose immune system responds to a virus and which you can find serologically so there are certainly people who are infected by influenza or any other pathogen who never develop the slightest symptom or the slightest illness of any kind and normally a case fatality rate is just that it's case, meaning somebody has to be ill enough to present to a physician. So you can't really compare the infection fatality rate with the case fatality rate. Yeah, that's a very good point, John, is if you're going to do this apples to apples, you need serologic IFRs for both. Going forward, where can we bend the arc of history? Where do we five years from now look back and say, on April 15th, had we gone

down this path, it would have been a better outcome than if we'd gone down this path. What does that look like? Well, I mean, it's sort of the same thing. We still have an administration that has demonstrated no leadership and is foundering. In reality, it's not going to happen if Trump got out of the way and left it to Tony Fauci. In those working groups I mentioned earlier about what planning for a pandemic, what do you do? We discussed who should be a spokesperson and we were unanimous that it should not be any politician because any politician, Health and Human Services Secretary or President or anyone else, a substantial portion of the public, no matter how popular the politician was, was not going to believe him or was going to have some kind of inherent negative response

to anything that person said. So we sat around and we figured the perfect spokesperson would have been Everett Koop, but he was already dead. I think it was at the time. Then the second best would have been Tony Fauci. So we now have Tony Fauci. I think, were he allowed to be the spokesperson, that would go a long way toward figuring out what to do. I think controlling expectations is important. I think by trying to promise that we're coming out on this date or the next date, whatever it is, and then you don't do it, that makes compliance that much more difficult. It is what it is, as the saying goes. Trump's not going to change. He's not going to get out of the way. The economic concerns are real. The management of those concerns is extraordinarily difficult.

Obviously, we can't stay locked down month after month after month, but we do need to get that infrastructure in place for testing and monitoring. If we have enough social distancing to get ahead of the virus in the way that, well, we'll never get ahead the way South Korea and so forth have because we started so far behind, but we might get a little bit ahead of it. And of course, as you know, the Asian countries and elsewhere where they have been successful, the virus is surging again, still nothing like the numbers that we're seeing in the United States, but the virus is going to be with us probably forever. It will be a new human disease. Hopefully, natural immunity will provide significant protection in the future to everybody.

The second time around, the immune system sees the virus, it should be much more efficient in dealing with it. And then, of course, the hope for a vaccine. People seem to be pretty optimistic about that. So I didn't really answer your question, but. No, actually, I think you actually did. And then some, I think you provided kind of a greater insight around it. I guess the last question I'll ask you is, are you optimistic? Is there a silver lining here that this has been a large enough jolt to our systems that we will now not only go back and remember the forgotten pandemic, but perhaps put into place more of the pandemic preparedness stuff that people like you and others for whom you're not just new to this have talked about for many

years? I don't know if I'd call it a silver lining. People don't have to remember 1918 anymore. All they have to remember is 2020. Clearly, there will be a significant investment in monitoring emerging diseases, much more so than there used to be. In fact, West Nile, which I guess technically was an emerging disease, but it never killed more than 300 Americans a year. If you understood the natural history of that disease, it was never going to be a serious threat to human health. If you were a horse, you might be in trouble, but for humans, not so bad. And yet West Nile was getting more research money than influenza was when West Nile surfaced. That's a remarkable statistic.

Yeah. Influenza just didn't get the respect to quote Rodney Dangerfield, didn't get no respect. H5N1 surfaced and things changed. Suddenly, nations around the world took it seriously. As I said, the Bush administration passed a $7 billion bill to invest in pandemic preparedness. Had we had the investment over time that has come in the last 15 years, we'd probably have a universal influenza vaccine by now. But we didn't. Going forward, obviously, there'll be a lot of work on coronaviruses. Thankfully, SARS and MERS did emerge, or we wouldn't have the knowledge base we have now,

which has given us a huge head start on drugs and vaccines for this. You know, and probably there'll be some serious money spent on preparing for any emerging pathogen, which would probably be a virus, might conceivably be something else, most likely a virus, as I'm sure you know. There are plenty of animal viruses out there. And as development encroaches more and more upon what used to be the wild, we will encounter more of those viruses. And they're all threats.

we will encounter more of those viruses and they're all threats. John, I want to thank you for not just the work you've done leading up to this, but also just for taking the time today to talk about this. I know you're highly sought after at this time and you're probably tired of talking about this and there's probably other things you'd rather be doing to take your mind off this. But I enjoyed, very much enjoyed talking to you and to a former fellow, Steve Rosenberg. It was great. Well, again, be well, John, and I look forward to speaking again. Okay. Thanks. Take care. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you

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