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History has warnings about how to return to normal after a pandemic

St. Louis Red Cross Motor Corps personnel wear

St. Louis Red Cross Motor Corps personnel wear masks as they hold stretchers next to ambulances in preparation for victims of the influenza epidemic in 1918. Credit: AP/Library of Congress

ALBANY — The images are jarring: People wearing protective masks, "closed" signs on shops in locked-down cities, and public service messages pleading, “Help Stop This.”

It might appear like today, but those are scenes from 1918, when as many as 50 million people worldwide died of a strain of influenza. The question then as now — when the number of COVID-19 virus cases are declining — is whether the public’s commitment to quell a virus will outlast growing frustration and complacency that could allow the virus to come roaring back, historians said.

“I think you can say the worst is over,” Gov. Andrew M. Cuomo said recently, but he warned against dropping our guard. “We're on the first wave,” Cuomo said as the number of new cases declined. “Everybody is assuming, ‘Well, once we get through this we're done.’ I wouldn't be so quick to assume that. This virus has been ahead of us from day one. We've underestimated the enemy and that is always dangerous.”

The lessons of the 1918 influenza epidemic that may prove relevant today, according to historians, include proof that social distancing and isolation work to curb the spread of the disease and that there is a need to push back on public and political pressure to restore life to normal before the virus is contained.

“I think we are kind of in a race to see how long we can get people to tolerate this,” said Nancy Tomes, distinguished professor of history at the Stony Brook University and author of “The Gospel of Germs: Men, Women and the Microbe in American Life.”

In 1918, people lost that race.

The influenza surfaced as early as February or March, but in a small and mild way mostly on military bases as the nation ramped up its World War I effort. In warmer months, the flu seemed to fizzle.

“Most Americans were not aware of the first wave in the spring of 1918 … in general, it passed unnoticed,” said Nancy K. Bristow, history professor at the University of Puget Sound who wrote “American Pandemic: The Lost Worlds of the 1918 Influenza Pandemic.”

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“There were no social distancing or quarantine or closure orders during that first wave. It was the second wave, that began in late August, that most people think of when they think of the pandemic, and it is this wave which first causes the public health efforts.”

“The spring wave was intermittent,” said John M. Barry, public health professor at Tulane University. “The fall wave was everywhere in the world. Everywhere.”

School and theaters were closed as were most workplaces that didn’t contribute to America’s production for World War I. Police arrested men for the once-common habit of spitting on sidewalks, handshakes were discouraged, safer sneezing and coughing practices were publicized on billboards, and lessons in using handkerchiefs would soon be taught in schools,

But the efforts were not soon enough, firm enough, or broad enough. War fervor and patriotism pushed aside concern about the virus.

On Sept. 3, 1918, a “Win-the-War-for-Freedom” parade in Boston drew sailors and civilian workers to the streets. Flu cases showed up the next day in Cambridge, then all Boston, then most of New England.

Several days later, Philadelphia held its Liberty Loan Parade to sell war bonds, with 200,000 people jammed shoulder to shoulder.

“Within 72 hours of the parade, every bed in Philadelphia’s 31 hospitals was filled,” according to the magazine of the Smithsonian Institution in a 2018 centennial article. “In the week ending October 5, some 2,600 people in Philadelphia had died from the flu or its complications. A week later, that number rose to more than 4,500.”

Other Liberty Loan parades were held nationwide despite headlines about mounting deaths. An Oct. 1, 1918, headline in Duluth, Minn., proclaimed: “Flu Will Not Stop Big Game … Advance sale of tickets is of record size”; and a derisive “Ban is on Fun” headline when Halloween was canceled in many communities.

By the time it burned out, the influenza had killed 675,000 Americans, compared with 116,516 killed in combat in World War I. As many as 50 million died worldwide.

A recent study of 43 cities in the 1918 pandemic found social distancing worked, said Howard Markel, a physician and distinguished professor of the history of medicine at the University of Michigan School of Public Health.

“When they pulled the brakes, the cases went down. When they released the brakes, too early, the cases went up again,” Markel said. “And the second hump was more severe.”

Today, even as the national death toll tops 20,000 and Long Island toll alone is over 6,500, Cuomo said he is being pressured to return the state to some sort of normalcy. The tension comes from business operators who have lost millions of dollars, unemployed workers who have lost savings, and families who have lost loved ones without proper funerals. Cuomo’s executive orders to essentially shutter the state’s economy has been extended to at least May 15.

President Donald Trump on Thursday laid out guidelines for reopening the American economy, calling for a phased approach. Trump told governors earlier in the day in a conference call: “You’re going to call your own shots. We’re going to be standing alongside of you,”

“I think the message is that if you go out of lockdown too soon you can set the cycle back off again,” Tomes said. “You have to give a cushion time … there may be as many as third of a people who are positive who don’t have any symptoms. You need to build in extra time to keep people away from each other so the last cycle of infected people can play out.”

“When we go out of lockdown is everyone going to be careless? I think it’s an open question,” Tomes said. “What we see of modern people exposed to scary things is there is only so long you can live in a hyper-state of awareness … I would predict coronavirus fatigue will set in at some point and people will say either, ‘I can’t do this anymore, I’m about to lose my mind’ or, ‘It’s over and we don’t need to worry.’ And there are lots of other reasons, like the economy.”

It’s already happening for many. When Cuomo ordered all but essential businesses to be shut down on March 20, 15,000 businesses appealed including golf courses and gun shops seeking to be deemed “essential” and stay open. Suffolk County created a squad of police to directly order stores not deemed essential to close. Lawsuits were filed by employers in several states alleging the orders were unconstitutional, even as New York’s deaths topped 7,800 or well over twice the toll from the Sept. 11, 2001, attacks. Basketball hoops were removed from public parks in New York City to end games after requests then warnings were ignored.

“In some communities, there is growing resistance to the prohibitions across time,” Bristow said. “Sometimes that will encourage leadership to relieve and remove the restrictions earlier than they should. This frequently leads to a resurgence of illness, and sometimes to a reimposition.”

Markel also sees another concern for when today’s restrictions are lifted.

“Different states are doing very different measures, it’s haphazard,” he said. “I would, as a doctor, prefer to see a more uniform approach, otherwise we will seeing ping-ponging of this as people travel.”

Tomes worries the lessons haven’t all been learned.

“My common sense, historical impression is that when there is a scary disease, people are careful,” she said. “But when it goes away, it’s back to normal … the idea of a rebound and second wave is a smart thing to worry about. It is a bugger.”

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