Sheltering-in-Place, Berkeley, CA. March 23, 2020. Let’s think about the COVID-19 crisis in a cold-blooded, sociological, and historical way. Rough estimates seem to be that between 200,000 and 1,700,000 will die of COVID-19, depending on how completely authorities shutdown in-person interaction. Dr. Anthony S. Fauci, the trusted face of the national response, said on March 20 that Americans would need to maintain maximal social distance–or, more correctly, physical distance–for at least several weeks.
Seattle Police to Enforce Face Mask Rule (National Archives, 165-WW-269B-25)
Those would be several weeks of extended economic destruction, school hours lost, severe family stress for many, cratering of civic institutions, and considerable social and emotional pain. The alternative, not locking down as severely and only partly “flattening the curve,” would mean more medical system chaos and tens or hundreds of thousands–some might argue millions–more lives lost. What is the trade-off between the social and economic destruction caused by the lockdown versus lives lost?
Making this calculation seems brutal. Do we not believe that each and every life is invaluable – “valuable beyond estimation: priceless”? No. If we really did, we would have 40 MPH speed limits and make cancer treatments free to all who cannot pay. Our society makes trade-offs. (One rough cost-benefit calculation is here.)
Properly speculating about the answer to the trade-off question requires some sense of what the consequences of the current shut down may be. Perhaps a look at the last great pandemic, the 1918 so-called “Spanish” influenza, can help. Here, I first review some lessons from the 1918 flu (based on an admittedly quick skim of the literature and archives, so sure to have some error) and then explore what they might imply for understanding the trade-off today.
1918: Managing the Crisis
About 675,000 Americans died of the 1918 (and 1919) flu. In percentage terms, that is equivalent to over 2 million Americans today, which is about the high end of the COVID-19 estimates. Yet, there was not nearly as much attention given to that pandemic as to this one, probably because World War I was winding down around then, perhaps also because Americans were more used to epidemics, and perhaps because authorities downplayed it. Most of the time, newspapers printed war headlines above flu headlines. (And the Dow Jones actually rose in 1918.)
Then, as today (but for different reasons), local government, particularly cities, took the lead. Many instituted bans on group activities that were unprecedented in scale. One study of 43 cities’ responses from September, 1918 through February, 1919 found that the most common steps were to close the schools and shut down indoor venues like saloons and theaters, as well as to quarantine the ill and their contacts. These measures lasted up to 10 weeks, but on average only four. Generally, the earlier and longer cities suppressed group activity, the more lives saved. Some cities, in addition or instead, fined spitting, required face masks or use of handkerchiefs, and tried other tactics. But there was resistance to the bans, especially by businesses, but also by citizens. San Franciscans pretty much ignored an order to wear face masks once the number of deaths started falling. Relaxing the bans, however, let flu cases rise again. A review of these procedures concludes that “it was exceedingly difficult to get an urban population to stay at home” or, for that matter, to get people to practice good hygiene.
Newspaper archives provide a view of the developments in real time. Through September of 1918, the New York City Health Commissioner saw “no cause for alarm” even as cases started to mount (including the transfer of ailing then-Secretary of the Navy Franklin D. Roosevelt from a ship to his mother’s home). By October 5th, however, “DRASTIC STEPS TAKEN TO FIGHT INFLUENZA HERE” read The New York Times headline. Those drastic steps involved staggering the hours of business openings, including theater start times, so as to thin out crowds in the streetcars. The newspaper also reported that the Jefferson Market Court fined 125 men $1 each for spitting in the streets. The next day, the head of Mt. Sinai Hospital challenged the city’s health commissioner for downplaying the pandemic’s seriousness, especially the shortage of nurses and beds. By October 12th, new cases numbered 4,293. By the 16th the commissioner acted; he had the theaters closed and banned meetings. But he still refused to close the schools. Then the pandemic eased. The Times reported on the 1st of November that cases dropped by 2,000 from the day before. On the 3rd, the distancing measures were rescinded, after being in place about two weeks. The flu resurged some in January, but the worst was over for New York. Not so elsewhere. For example, on November 9th, the Times reported, “PLAGUE CLOSES UP ST. LOUIS, Non-Essential Business to Suspend a Week.”
San Francisco’s turn also came later. On October 15th, the Health Board took simple steps: keeping street-car windows open and “urgently” requesting that people “refrain from dancing in public places” and to “avoid congregating in crowds,” for example. Three days later the health board ordered schools, churches, theaters, dance halls, “all places of amusement,” as well as fraternal lodges, to shut down. And a week after that “WEAR YOUR MASKS! COMMANDS DRASTIC NEW ORDINANCE,” blared a Chronicle headline. Everyone on the street or in a group of two or more, even at home, had to wear gauze masks or else face serious fines or imprisonment. About three weeks later, the Board allowed schools and churches to re-open, although with masks required; that caveat was, as I noted above, soon ignored.
Holding Outdoor Court in S.F. (Note: no masks, no 6 feet; National Archives 165-WW-269B-13_
The flu hit rural areas were yet later. On November 9, Nevada City, in California’s Sierra foothills, closed saloons and pool halls on a Sunday for the first time in 50 years. On January 27, the Chicago Tribune reported that authorities were arresting everyone who attended the Murray (Kentucky) Baptist Church services in violation of the flu regulations. Flu and flu rules were delayed in rural America, but the final death rates were higher there.
1918: Consequences
The long-term societal consequences of having lost about one-half of one percent of the population–many aged 20 to 40, not just the elderly–and of the disruption from moderate distancing policies are not clear. Historians of medicine have described changes to science, to the professions, and to public health. Demographers have found that having been in utero during the pandemic disadvantaged people as adults and may have even disadvantaged their descendants (e.g., see here, here, here, and here). But beyond that–and considering the broad predictions being made today about the effects of COVID-19 (see below)–there is surprisingly little research about the 1918 flu’s social consequences.
Perhaps that is because the needed data are not available, or because such consequences were dwarfed by those of World War I, or because the effects were not great.
Historian of the 1918 flu John Barry has described a widespread breakdown in trust of government because officials lied, underplaying the threat (see story about New York, above). “The lying and the lack of trust cost a lot of lives,” said Barry. Yet, such a cultural change seems not to have lasted, at least not as much as the loss of confidence that the Great War produced.
American life sprang back seemingly little affected by the plague. In 1920, Americans by a landslide voted in as president an old-fashioned Republican, Warren G. Harding, who campaigned on a “return to normalcy; . . . not revolution, but restoration . . .not surgery, but serenity; . . . not experiment, but equipoise.” Expansion of the federal government during the Great War–for example, nationalizing the railroads and controlling food prices–was reversed. The post-war recession, which was to be expected, gave way to the “Roaring ‘20s” and the “Jazz Age.” Working-class movements quieted down, partly because of Red Scare suppression. Cultural historians, focused on writers and artists, have often described the 1920s as a period of disillusionment, but that, too, was about the war. Historians of race have noted the violence returning “colored troops” encountered when they started claiming their rights, but that, too, was a consequence of the war. A few historians of the 1918 flu (e.g., here) have written of Americans’ “amnesia” about the 1918 flu, implying a suppression of the memory. Instead perhaps, aside from families tragically affected, the flu just did not leave much of an imprint.
Three general statements about the 1918 pandemic seem valid:
* The experience of death and disease is roughly comparable to what is projected today for COVID-19.
* Restrictions on group activities were in place, although not as severe or widespread or as for long as those projected today: no discussion of a six-foot distance, not nearly as many activities curtailed, and for not nearly as long. Moreover, sustaining public adherence became difficult.
* For American society as a whole, the long-term consequences of the catastrophe were surprisingly mild or surprisingly invisible.
COVID-19: Managing the Crisis
It is early days yet and any instant history will soon be outdated, but the emerging shape of the pandemic is familiar, including: under-preparedness; wishful thinking at the top; surging infections and deaths first in the metropolitan areas but later in the hinterlands; and local and state authorities taking charge in varied ways.
Differently than in 1918, the constraints on business and social activity in the New York region, California, Illinois, and Washington, exceed those of 1918 and could last much longer. The economic toll of the restrictions, which in 1918 seemed focused on particular businesses like movie theaters and saloons, may be orders of magnitude greater.
How much Americans will conform as the weeks pass is an open question; it did not start well. During the week of March 16-19 about half of the Gallup Poll’s sample said that they were avoiding public places and avoiding get-togethers–half is not enough–although about 80 percent said that they were likely to comply with an order to shelter in place for a month–probably not long enough. Then, how patient will Americans be after a couple of weeks of cabin fever and delayed paychecks and children loosed from schooling. Will they become less compliant or perhaps more so as the deaths mount? The sorts of steps Asian countries took would be difficult or impossible to sustain here, even if the national government had been responsive early enough. One possible short-term consequence, then, is a rising tide of scofflaw behavior, perhaps accompanied by hoarding and dealing, and maybe worse, depending on how well authorities keep goods in stores and money in people’s hands.
More critical, of course, is the economic shutdown. As I write, the stock market as plunged over one-third since the start of the year, telling us what investors think about the future; officials estimate an expected unemployment rate of 20-30 percent; and many small businesses can expect to sink, dragging gown their low-paid employees with them. Great economic crises can wreak lasting damage on families and communities, as did the Great Depression; it can even create threats to political stability.
The policy trade-off, then, involves calculations how much shutdown for how long against how many lives lost. We have not, cannot, and will not treat every life lost as worth whatever the cost. So where will the serious policymakers draw the line? Flatten the curve a lot, or some, or just barely? One alternative proposal floating around (e.g., here) is to have only the elderly and immune-compromised, they who are much more vulnerable and whose care would be much more difficult, shelter in place for months while re-opening public life for other Americans. The latter would struggle through COVID-19 as if it were a difficult bout of the flu. But there are skeptics (e.g., here) that the so-called “tiered” plan would suffice to halt this pandemic.
Deciding what trade-off to make may depend in part on what we imagine the long-term consequences of a catastrophic health pandemic, like the 1918 flu, would be. It’s too early, but the prognostications are here. Politico alone solicited dozens.
COVID-19: Long-Term Effects?
There are possible political effects. All eyes turn now to government, to mayors, governors, and Washington for guidance and help. (It’s probably been a while since someone endorsed tax-rebel Grover Norquist’s wish to “shrink [government] down to the size where we can drown it in the bathtub.”) Will the COVID-19 experience lead to more appreciation and support for government programs, as the New Deal seemed to do–assuming that the programs are coming? Or will it lead to more distrust, as John Barry suggested the 1918 flu did? That probably depends on where things are a year from now.
The crisis threatens associations of civic society: churches, judo studios, museums, bowling leagues and softball teams, community theaters, RV clubs, folk-dancing nights, and many more, down to informal breakfast clubs that meet at the local diner. The financial crunch is clearly a threat to many places that Americans join together–perhaps not to the Metropolitan Museum or to Starbucks, but to thousands of others who do not have big endowments or reserves. And then there is another possible threat looming, that distanced people will decide that if they cannot enjoy the social life of the group, why keep it going? For a society that rests so much on voluntary associations, this is a worry.
Predictions about other social and cultural consequences of COVID-19 are all over the place. Some commentators fear that our physical distancing will become habitual and will expand loneliness. Others fear that we will become too dependent on communications technology, that we might like “virtual all too well” and come to prefer electronically mediated rather than in-person contact. (I should note that another popular meme that seems to have gone into isolation is the one about e-communications dissolving social bonds.) Sociologist Theda Skocpol expects widening economic inequality, a more grounded baleful prediction.
Quite a number of the Politico prognosticators had sunny forecasts: COVID-19 will create more solidarity, more faith in experts, more joining hands, a “healthier digital lifestyle,” an appreciation of government that will bring democratic socialism or an anger at government that will finally rouse the working class to grab their pitchforks, and so on.
If the 1918 flu is any guide, the long-term consequences of even a horrific pandemic that takes a half or a full percent of the population are likely to be subtle at most, especially if it is over within a year or so. I am skeptical of shifts in culture, consciousness, or interpersonal life. Maybe working remotely will finally, after years of unrealized forecasts, become significant. Maybe the serious healthcare reform will get a lift. But, it is hard to foresee anything radical.
Where, then, to find the optimal point between an all-out and a soft-touch distancing policy? On the one end are health experts like Fauci recommending several weeks of extreme isolating, what one essayist describes as dropping the hammer. At the other end is what may be Trump’s latest position (as of March 23, 4:30pm, PDT), that two weeks (or less) of a lockdown is more than enough. This is a profoundly difficult practical and moral decision to be made. Such choices are presumably why decision-makers get paid the big bucks. I wish I had more faith in our decider-in-chief.
MADE IN AMERICA 