The COVID-19 Pandemic in Historical Perspective: An AJPH Dossier

In times of crisis, many of us are strongly drawn to history. We turn to it for desperately needed perspective, ideally for useful lessons from the past and even at times for reassuring bases of optimism in what seem the darkest of times. In the time of COVID-19, many are turning to the authors of epidemic and pandemic history in the hope that they will do for us what medical historian Henry E. Sigerist did for his generation in the dark days of worldwide depression and World War II, that is, to give us perspective on the present by allowing us to see it through the lenses of time and social evolution.¹

With this in mind, AJPH has encouraged historical essays to help place the COVID-19 pandemic in perspective. In this issue four such essays, along with five accompanying editorial comments, address the pre-vaccine challenges with which we have already been grappling: attempting to understand the complex epidemiology of the pandemic and hoping to learn important lessons from it, trying to collect data to solidly ground epidemiological analyses, pursuing social mitigation measures in the hope of buy-in and success, and facing head on the implications in terms of national reputation of our country’s substantial failures thus far in dealing with COVID-19.

Siddarth Chandra et al. (p. 430) alert us to what may turn out to be the extraordinarily complex epidemiology of COVID-19 by looking carefully at waves of excess mortality during the “1918” influenza pandemic. They analyze monthly data on all-cause mortality in 83 Michigan counties and find evidence for up to four waves of excess mortality over a two-year period, including a severe spike in early 1920. They also find that some counties had two waves in late 1918, whereas others had only one, and that the 1920 wave was propagated differently than the two 1918 waves.

Most significantly, they find that the twin waves in 1918 were very likely related to the imposition and then the lifting of an order banning public gatherings and that what in some counties was a steep “echo” wave in early 1920 took its largest toll on isolated indigenous communities that had avoided infection in 1918 and 1919. By leaving open the question of whether the same pathogen was involved in all four waves, Chandra et al. demonstrate how challenging close historical epidemiological study can be.

In his related editorial comment, Svenn-Erik Mamelund (p. 405) homes in on some of the clear lessons that can be drawn from Chandra et al. for a better understanding of COVID-19: that more infections and deaths are likely as the northern hemisphere enters winter season and that there are likely to be later waves in 2021 and possibly also in 2022 that, without vaccine intervention, could be as bad as or worse than earlier ones.

Morabia (p. 438) focuses on the US Public Health Service’s 1918–1919 house-to-house morbidity and mortality survey to understand how that survey was done and what data were collected for analysis. He finds that 146 203 individuals were surveyed in 18 localities across the United States in fall and winter 1918 and that the data collected indicated that, assuming the survey missed asymptomatic cases, perhaps 50% of the population was infected between August 1, 1918, and February 21, 1919, and the case fatality rate was perhaps 1%. Because the survey included questions about economic status, race, and crowding, findings indicated that incidence and mortality were higher among the poor and that in many areas Whites were apparently more infected but died less than people of color. Impressed with the design, logistics, and analytical sophistication evident in 1918, Morabia laments the current disinterest of the United States in mounting an updated version of that earlier survey.

In their editorial comment, Miguel Hernán and Raquel Yotti (p. 414) underscore both scientific and methodological progress that has been made over time and the current failings of the United States by describing the very sophisticated survey recently undertaken in Spain, the ENE-COVID survey led by the Instituto de Salud Carlos III. They conclude that a close comparison between the American survey of 1918–1919 and the Spanish survey of 2020

reflects as much the advancement of scientific knowledge as the social improvements of the last 100 years . . . [specifically the benefits from] 21st-century telecommunications and [Spain's] distributed health care system with universal coverage (p. 414).

J. Alexander Navarro and Howard Markel (p. 416) focus on social mitigation measures that were widely adopted in the United States during the 1918–1919 influenza pandemic and political pushback to those measures that was also widespread. Measures adopted by cities and states included closure of theaters, movie houses, and churches; mandatory face mask ordinances; shutting down of schools; and shuttering of saloons. However, citizens, business owners, clergy, and local political figures and legislative bodies expressed increasing impatience with public health edicts and agitated, petitioned, and voted to have them rescinded.

But the parallels between 1918 and 2020 end there because, as Navarro and Markel note, “In 1918, arguments over various closure orders overwhelmingly revolved around questions of efficacy, equity, and duration of the measures” (p. 420), and “given that public health was accepted as the domain of state and local jurisdictions, any opposition to these orders was concomitantly local” (p. 420–421). As Navarro and Markel point out, “By contrast, the response to the COVID-19 pandemic has become a national partisan battle” (p. 421), and “opposition to public health measures . . . [has] now become a symbol of political allegiance to the [former] president” (p. 421).

In their editorial comments, John Fabian Witt (p. 411) and Allan Brandt (p. 409) endorse Navarro and Markel’s broad historical parallels and divergences but also note subtle discontinuities between 1918 and 2020. Witt, a professor of law and history, argues persuasively that we are now witnessing an “almost entirely unprecedented partisan pushback against public health measures by the courts” (p. 411). In 1918, the power to regulate public health emergencies was deeply embedded in American law and consistently upheld by the courts. But in 2020, Witt notes, Americans have filed hundreds of constitutional challenges to pandemic regulations. He adds:

As of this writing, the most significant decision in the line of constitutional cases arising from the COVID pandemic comes from the US Supreme Court, which the day before Thanksgiving 2020 issued an unprecedented decision blocking New York State’s emergency pandemic limits on the size of religious gatherings. . . . A century ago, analogous claims that California’s influenza regulations infringed on religious freedoms made no headway at all (p. 412).

Brandt, a public health historian, also points out subtle but important discontinuities between 1918 and 2020. We now live in an age that, instead of respecting science, engages in widespread scientific denialism and is characterized by a new information ecosystem dominated by fractured sources of knowledge.

In the fourth historical essay of this set, historian of Chinese public health Ruth Rogaski (p. 423) draws an ironic analogy between China in the early 20th century and the United States in the early 21st. A century ago, China, after having long been a powerful empire, had come to be regarded as “the Sick Man of the Far East” because it was burdened by opium addiction, infectious disease, and an ineffective government. But in 1911 China began to redeem itself by tackling an epidemic of pneumonic plague, an airborne disease, with a dramatically restructured system of public health, and from that point forward, it closely linked the goals of national advancement with major public health improvements. By ironic contrast, the powerful United States finds itself in the early 21st century burdened by opioid addiction, COVID-19, and a national government that has been completely ineffective in dealing with the pandemic, all of which has led observers in China to call the United States “the Sick Man of the West.”

As Liping Bu (p. 407) notes in her editorial commentary,

Rogaski’s study suggests that viral tragedies, such as the Manchurian plague and COVID-19, are also opportunities for national health transformation, as when China took a new approach to public health in the 20th century. COVID-19 has exposed the deficiencies of the US health system….[but] will this sad revelation spur health reform in the United States? (p. 408).

It is worth reflecting on Bu’s question and generalizing its implications. History can provide perspective, suggest analogies, and even hint at optimal paths of action. But historical knowledge and insight cannot by themselves provide wisdom or dictate best choices. More historical essays are on the way, including expected papers on vaccine uptake and resistance, as we move to the next phase in the world’s grappling with the worst global pandemic in a century. Those living in the present must decide on a course of action. Our contemporary and future leaders will, it is hoped, make wiser choices in contending with COVID-19 once they have a clearer sense of its place in history.