The great global pandemic of the modern era is the "Spanish flu" pandemic of 1918. It is estimated that more than a quarter of the world's population has contracted the disease and tens of millions have died. In the past few weeks, many have indicated it as a model of the severity of COVID-19 degradation. It is estimated that the fatality rate of the Spanish flu was between 2% and 3% of those infected. It is roughly comparable to mortality during the epidemic in Wuhan, China.
In 1918, the world had little of what we would consider today as modern medicine. There were no antivirals, although there are no antivirals approved to treat COVID-19 yet. There were no antibiotics, which do not directly fight a virus but can help in secondary infections. There were no fans. The world was therefore mainly dependent on public health strategies going back centuries or even millennia: cancellation of public events, closure of schools, quarantine of the sick.
The lack of effective government communication or the simple denial of everything that was going on played a big role in the worsening of the crisis. It was at the height of the First World War. Governments have actively censored reports of the spread of the global pandemic in order to maintain morale during wartime.
Here is the point I am coming to. What impact has this had? The lack of communication, the speed of the interventions?
A 2007 study used modern methods to examine 43 cities in the United States that used non-pharmaceutical interventions (various types of social distancing) and measure when they intervened and whether it correlated with subsequent deaths. The bottom line is that the timing had a big effect on the mortality in the city. Quote from abstract: "These results contrast with conventional wisdom that the 1918 pandemic quickly spread to every community, killing everyone in its path. Although these urban communities lacked effective vaccines and antivirals, cities that were able to organize and carry out a series of conventional public health interventions before the pandemic does not spread entirely in the city appear to have an associated mitigated epidemic experience. "
The details are technical. You can create a free account at JAMANetwork and download the PDF of the full study if you want or just read the abstract. But these two sets of graphics tell much of the story (click on the image to get a full size image if the text or numbers are too small.)
The bottom line is that for cities to limit the number of dead, they must act early and have a good mix of interventions. If they waited too long, no matter what they were doing. The death toll is said to be considerably higher.
One last point. We should not consider this to mean that cities should ban public events or close schools now. There is a whole methodology for knowing when it made sense to act, how long after the first appearance of the virus in the city, etc. This is a question for epidemiologists and propagation models. However, the study clearly shows that non-pharmaceutical public health interventions made a big difference and that even relatively brief delays had big consequences measured by much higher deaths.
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