Today politicians, public health officials, and economists debate whether to roll back social distancing and other containment measures by Easter in order to open the economy. Our nation faced similar challenges in 1918. The start of the influenza pandemic began in March 1918, with more than 100 reported cases at Camp Funston in Fort Riley, Kansas. That pandemic, the worst in modern history, occurred in three waves, infecting a third of the world’s population and killing 50 million people, including 675,000 in the United States alone. The movement of troops at the end of World War I contributed to the spread of influenza, with the second wave in the fall of 1918 being the most deadly. The third wave subsided in the summer of 1919, 15 months later.
The lessons of the 1918 influenza pandemic remain relevant to a COVID-19 response today for three reasons.
First, the costs of an unmitigated pandemic overwhelms. More people died of the 1918 pandemic in 15 months than from four years of conflict in World War I. To put that early 20th Century pandemic in perspective, a proportionally rough equivalent pandemic today would kill 200 million people, including 2 million in the United States.
Second, pandemics may have multiple waves until a sufficient number of individuals become immune, either by surviving infection or through effective vaccination. How the global community’s current approach to slowing the novel coronavirus pandemic will result in future waves remains to be seen, but the risk is real. China, for example, has reported their caseload shift from sustained community transmission to ongoing imported cases, requiring continued high-level alertness to detect, contain and prevent a large second wave. Having initially been considered a model for containment efforts, Hong Kong recently reported an increase in cases, largely the result of imported cases from overseas. Waves of pandemic disease are typical in many infections. The seventh pandemic of cholera, for instance, began in 1961 and continues to cause outbreaks today, sometimes with devastating consequences as was the case in Haiti in 2010 and Yemen in 2017-2018.
Third, a domestic approach to blunt pandemic disease must align with international containment and mitigation efforts more broadly; not only is this the right thing to do, but subsequent waves can be more deadly than the first, as America experienced in 1918. In other infectious diseases, this is often the case. Studies of the genomic lineage of cholera in Africa, for example, demonstrate that since the infection was introduced to the continent in 1969, it is not inherently entrenched there, but has been repeatedly re-introduced from Asia. As a result, public health interventions in Asia are essential to cholera control in Africa and, likely, globally.
It is nearly impossible to contain a pandemic by addressing an outbreak in only one nation.
There are significant structural deficits in global public health that will accelerate transmission of COVID-19 and put the U.S. at risk of future waves.
First, like the 1918 influenza, war will continue to facilitate the transmission of today’s pandemic. The grinding conflicts in Syria, Yemen, Libya, Afghanistan, and the Democratic Republic of the Congo represent potential unmitigated hot spots for innocents caught in the war zones. These countries do not have central governments or functional health systems. There is often damaged health infrastructure, a lack of laboratory capacity, and few skilled health workers serving populations with low literacy rates and pervasive food and water insecurity.
Second, social distancing is not feasible for any prolonged period of time in many instances. As a result of war and insecurity, millions of people are forced to migrate to internal displacement camps or to cross borders as refugees. Turkey, Lebanon, Jordan, Bangladesh, and Ethiopia for example, all host large refugee populations. These refugees, living in dense, insecure camps and temporary shelters will find it materially impossible to self-quarantine or socially distance themselves to mitigate the spread of COVID-19. The undomiciled and incarcerated face similar challenges to self-quarantine and social distancing. Approximately 1.4 million Americans will spend some time in a shelter in a given year. Worse yet, given the economic collapse, there may well be a surge in homelessness in the months ahead.
Third, health care systems and public health systems in most low- and middle-income countries will be unable to cope with the capacity demands of the pandemic because of chronic neglect of surveillance and outbreak response infrastructure, and a major deficit in both the built environment and the health workforce. While some progress has been made in creating platforms for diagnosing and treating HIV globally, other pandemic diseases like tuberculosis (TB) demonstrate the failures of public health delivery, despite longstanding diagnosis and treatment protocols. This failure has consequences: 1.5 million people die from TB each year – making it the world’s top infectious killer. India, China, Indonesia, Philippines, Pakistan, Nigeria, Bangladesh and South Africa account for two thirds of these new tuberculosis cases, illustrating the limitations of existing global health systems. COVID-19 could devastate many countries in Africa and South Asia, creating massive and unmitigated hotspots across continents and much of humanity.
Given the likelihood of emerging hotspots and the lack of aggressive containment measures, there is a real risk that multiple waves of COVID-19 could extend throughout this year and into 2021. The United States has become the current epicenter of the pandemic with the world’s highest caseload. The administration must better control the current spread, reduce the risk of subsequent waves, and help lead a global response not only to alleviate the suffering of the world’s most vulnerable but also to protect the homeland.
R. David Harden is managing director of the Georgetown Strategy Group and former assistant administrator at USAID’s Bureau for Democracy, Conflict and Humanitarian Assistance, where he oversaw U.S. assistance to all global crises. Follow him on Twitter at @Dave_Harden.
Louise C. Ivers MD, MPH, DTM&H is the executive director of Massachusetts General Hospital Center for Global Health, associate professor of Global Health and Social Medicine at Harvard Medical School, and a practicing infectious diseases physician. Follow her on Twitter at @drlouiseivers.