Professor tomes so what are we going to do today . I promised you that i would do show and tell from my own research, and the timing turned out that doing a Historical Perspective on pandemic preparedness might seem like a very interesting topic to discuss. I have been getting a lot of calls from journalists lately, and it is kind of, why in the middle of a pandemic are they calling people like me . So this is a good thing for us to talk about. This is a history methods course, it is about how you become a historian, and what you do for a living. You may remember the first week of class, we talked a little about the reaction you may sometimes get from family members when they hear you are a history major or minor or even taking a history course, that, why is this useful knowledge . Why are you bothering with all this old stuff . I get those questions a lot because of my Research Specialty in the history of health and medicine. Science is so much better today, why should we bother looking at past diseases and how we responded . My goal today is to give you an example of why bother, and why i am proud to be a historian, why i am psyched about what i do. That is objective number one. I said the first week of class, i want to make you proud of being a history major, so here is my way of saying i am proud to what i do. The second goal is to talk specifically about pandemics, in terms of what we have been talking about in this class. How were forms of Public Outreach used to try and contain and mitigate a major epidemic . My work has been on public education, or you might call it propaganda. Can you move over a little bit . There you go. We have talked about the word propaganda. It has a lot of negative associations. For much of the 20th century, it did not have negative associations. Propaganda is often public information. It is trying to get public messages out to people that could help them in a time of emergency. That is what we are going to look at today, the methods of outreach that were available in probably the most significant Global Pandemic of the 20th century. I know a lot if you saw 1917, the movie about world war i, and that was a routable war, with war with the trench warfare. A lot of people died. The film is an amazing recreation of conditions in wartime. You remember world war i is the first world war, in that combatants spend multiple continents, and it inspired kinds of propaganda. Remember draft posters we looked at from both the british and the u. S. Side, uncle sam for example . What you are less likely to know is that as that war around to ground to its horrible close, a terrible influenza pandemic broke out. It is still not clear where it came from, but it spread quickly, first to troops and then civilians, and it ultimately killed more people than did world war i. Just to give you a sense of comparison, we were able to isolate, the h1n1 novel form from the spanish flu pandemic. World war i combat deaths, 8. 5 million. Thats bad. But look at the influenza death toll. 50 million is now the estimate. It could be even higher than that. More lives lost in the influence influenza pandemic that were lost in world war i, and as a point of comparison, in our lifetime, hivaids has been a tremendous killer, killing nearly 2 million during the course of the aids epidemic. Influenza, and publichealth circles, they still refer to it as the big one because the death tolls were so hot. So high. You may think, that was a sad story and lots of people died, but that is the point of but what is the point of studying an old pandemic . After all, science is so much better today. We can just find a cure. Right . How are we doing with curing the coronavirus . No, we are not doing so well, in part because this is Mother Nature issuing a major challenge to us, as a new virus forms that people dont have immunity to. The coronavirus and the response to it in many ways is revisiting a lot of the same issues that came up with the world war i pandemic. And the reasons we are having trouble with coronavirus today are very similar to problems they encountered with this new influenza in 1918 and 1919. But here is a stranger fact. And that is that the methods we use today to control coronavirus are drawn from the same Public Health playbook they used in 19181919. The basics are the same. We have not evolved from what was available in the world war i era. And it is precisely because the methods are the same that there has been a growing interest in the history of the 19181919 pandemic. It was not always that case that the case that people played much attention to this pandemic. Paid much attention to this pandemic. Let me show you this book called americas forgotten pandemic was published in 1987. There is very little historical work. He talked about amnesia, that no one talked about it anymore. I am here to tell you that, especially in the last 20 years, it is forgotten no more. There is an upsurge in research and interest in this pandemic, out of an impulse to try to learn how to manage current epidemics more effectively. In other words, our Public Health folks are now preparing for a new pandemic by looking back, it is called a look back, a methodology look methodology used in public a look back at previous pandemics to seek what worked and what didnt work. Probably Health Emergency preparedness has become a major subfield in Public Health. It has grown a lot since 9 11. You may remember some bioterrorism involved in 9 11, but it also reflects the gradual recognition that, for a variety of both economic factors and environmental factors, we are getting more and more novel diseases emerging. This has a lot to do with the ecology between people and animals. This also has a lot to do with global transportation, meaning that a novel disease that breaks out in wuhan can travel very quickly through not just trains and cars, but airplanes now can travel very quickly. This is a list of major Public Health concerns just in the past 20 years, sars, mers, ebola, zika and covid19. Starting with sars, there was a growing sense among policy leaders that they needed to start planning ahead, thinking that, if a novel pandemic breaks out, how are we going to control it, especially if it spreads very fast and has a high mortality rate . So agencies like the centers for disease control, even the department of defense, started spending money to hire historians and other rto archeovirologists to get them to investigate the pandemic im going to talk about today. People go back and look at the bubonic plague in 14th century europe, they look at initial disease exchange with native peoples when the europeans came with columbus, but of all they cks, the one on the influenza pandemic has probably gotten the most attention. Because in many ways, it is the first modern, Global Pandemic in the sense of what we are experiencing today. One of the historians who got invited to participate in this look back was me. I want to be clear, i have been a bit player in this. Other historians have been much more at the forefront of organizing this. I would call out my colleagues at the university of michigan, Howard Markel and alexander stern, as leading this team, but they invited me in to help because of my historical specialization in popular publicHealth Education. That is my book. In some circles i am known as the germ lady. One reason i get calls from journalists is they will google germs, and the gospel of germs comes up. What was this book about . I wrote it a long time ago, 1998, it has been in print ever since. I was interested in how ordinary people came to believing the existence of something they couldnt see, a germ, a microbe, and then to alter the way they behaved, like not shaking hands, the kinds of stuff we are now doing. How did they learn to do that . They were very purposeful in publichealth campaigns to teach people how to avoid giving each other germs, and treating Communicable Diseases. What i call the gospel of germs in this book is in many ways the foundation of containment actresses we still use today. How do you minimize the sharing of microbes between human beings . I always like to give students something a fancy phrase so you can sound really smart when youre talking to other people. Nonpharmaceutical interventions, npi, and publichealth circles anything that doesnt involve a vaccine or drug is a nonpharmaceutical intervention. So all the stuff i was looking at, and by the way there are no antibiotics and relatively few vaccines in this time period, that way you avoid getting sick was by practicing good habits. Easier to say is the phrase social distancing measures. You go online or read the newspaper and they are talking about that all the time now. When they tell us not to shake hands or sneeze into your elbow, that is a social distancing method, exactly the same stuff they were telling americans to do at the turn of the last century. Why is this important . Because even though we have made astounding improvements in health sciences, we still cannot cure a virus. There are limited medications to this day to slow down a viral and action. So when we are faced with a novel virus, using these tactics is one of the most important ways we have to keep able from getting sick and dying. So if you have a highly contagious epidemic on your hands, your best at is to try to your best bet is to try and slow its spread, and these techniques are very, very valuable. That was a lesson publichealth experts learned in world war i that still use today. My work has been studying, first just basic germ education, then specifically world war i and how they tried to ramp up like Health Education in the face of the pandemic. That is what i am going to show you more of. Let me give you a quick overview of the 19181919 pandemic. It started in fall 1918. There were outbreaks in different parts of the world. It is still not clear which one is first. There is a lot of arguing about that. What we are sure of is that it did not start in spain. It became nicknamed the spanish flu not because it started in spain, but because spain was not a combatant in world war i, so their newspapers werent being as careful about reporting early stages of the pandemic. They ran a story about it and somehow got associated, it is the spanish flu. It spread first among troops and jumped into civilian populations. It was compared to the normal flu, and they understood there was an influenza just like we have that comes every year at a certain point, this particular flu was much scarier. It was very contagious, spread easily from person to person, and its death rate was higher than the usual flu. Also, the normal influenza usually kills fragile people that can be very young or very old, people who already had systems under stress. The spanish flu was terrifying, because it killed people your age. It did not concentrate just on the very young and very old. In Public Health circles, they talk about the dreaded w shape. That is the w. You can see the normal influenza pattern is a u shape, the very young, the very old. Look at 1918, a big spike up that could change Life Expectancy in the United States, because so many young people had their lives shortened dramatically as a result of the influenza pandemic. This just gives you, this is from publichealth report, published after. You see the extraordinary spike in death rates due to this pandemic. What did publichealth experts know about influenza in 1918 . Compared to the last big influenza epidemic in the 1890s, they learned a lot. For one thing, they had convincing Laboratory Proof of something you may have heard of as the germ theory of disease, the idea that Communicable Diseases are caused by microbes, bacteria and viruses. A lot of work shows that it is not some mysterious thing in the air that made you sick, it is this microorganism that, in the case of bacteria, they could see under a microscope and prove ties to specific diseases, a huge step forward toward understanding what the nature of specific disease was. They were able to see with the current microscopes of the time see a bacteria, but they were not able to see a virus. The difference, let me show you this very quickly, a little contagion 101, viruses are tiny compared to bacteria. The analogy is that a virus is the size of a mouse and a bacteria is the size of a person. Viruses are more primitive but more deadly in that they insert their cells into your cells and replicate. They mutate quickly, one reason they are so difficult to control. Even to this day, we have limited pharmaceutical treatment for viral diseases. We can slow some of them down, but we are not able to cure the flu. And today we rely on vaccines to control things like the flu. Bacteria are much bigger and they are a singlecell microorganism, they can do incredible damage to the body, but eventually, effective drug treatments were found for biotic for bacteria. Antibiotics only work for bacteria, they dont work for viruses. They are easier to disrupt their machinery. To go back to what they knew in 19181919, they had a suspicion there was an infective particle smaller than a bacteria but couldnt see it under the microscopes of the day. They did experiments to prove that it was there. I can go into how they figured it out. They didnt know whether influenza was caused by a bacteria or a virus. They had a lot of scientists try to figure out what was the x germ causing the influenza pandemic. They failed. The candidates they came up with turned out not to be the real h1n1. Not until electron microscopes were invented in the 1930s could you actually see a virus under a microscope. And it wasnt until the 1990s that our tools of extracting the influenza virus and replicating it dna, that our tools were good enough that we could actually extract it and replicate it dna. So we know a lot more about it now than they did back then. There is a cool story there about archeovirology, how they got samples from people who died about the flu, it is really creepy. But interesting, i could tell you on another occasion. What did they know then . They knew it was communicable. They are sure it is a germ disease, they just dont know if it is a bacteria or virus. They would love to know but they dont find out in the end, it doesnt make a lot of difference, because the way you protect against a bacteria and protect against a virus are basically the same. So the social distancing methods that, as the pandemic spread, people were supposed to use to keep from catching it, were essentially the same ones used for any upper respiratory infection by this time. They understood that influenza as an upper respiratory infection with spread through coughing, sneezing, spitting. Men spit a lot back during the state. That is a habit that we have thankfully given up. They spit a lot. Also, if you shared glasses or utensils, sometimes that is called fomite. Its an object that carries that is a really weird word, like if i had coronavirus and you touch my phone, that is fomite. You should not mess with another persons phone right now, you should know that. So a virus can live temporarily on a surface and be transmitted that way, and various kinds of casual contact. You all are hearing now, dont touch your face, dont touch your nose. They basically had figured out that this stuff is getting on your hands and that could make you sick, so try to practice careful hygiene so you are not spreading germs. And they already had this idea not just about influenza, but about a lot of other diseases. One thing they realized soon, remember that w i showed you, is that this 1918 strain of influenza seemed much more deadly than the usual, annual influenza. And experts today are still arguing. They have reconstructed the virus they got out of people who died from the spanish flu, and some say there is nothing particularly scary about this, it looks like ordinary flu. It wasnt the virus, it was the social context that this was wartime, people were malnourished. Remember 1917 . You would get a lot of icky stuff in those trenches, and wartime hygiene made a lot of people vulnerable and perhaps that is why it was so deadly. That argument is ongoing. I am a historian and not a virologist. I dont know. My guess is they are never going to firmly determine why this virus caused that w shape. Yes . Is there a specific reason it was affecting people in their 20s and 30s compared to the normal flu . Professor tomes i dont know, and that is the puzzle of this. That is so unlike the normal flu. That age group, we now, would have been the military, the young men and troops. We also, in the civilian population, killed a lot of young people as well. Maybe the nutrition overall, even though it was the home front, maybe people werent fed as well, but i am not sure they have really come up with a good answer yet for why it took that w shape. And the uncertainty about this carries over into other nuances. There is always this worry it is going to happen again, and we dont know why. Fortunately, it does not appear in the coronavirus to be doing that w shape so far. Whatever the cause, we dont know. What is it was it the mutation that made it so bad or was it the underlying wartime conditions . What we do know is that compared to the annual influenza, the 1918 version was really, really scary in its symptomology. People would come down with an extremely high fever, they would develop a really severe upper respiratory infection, often compounded by nausea and diarrhea. In the worst cases, it was such a devastating assault on the lungs that lung tissue was destroyed, and essentially people were dying from the fact they could not get enough oxygen into their lungs, their lungs were that damaged. There was also a secondary problem, and this is true with flu this day. The virus weakens you and then a bacteria comes along. In the case of the influenza pandemic, it was pneumonia. I have other viral or bacterial either viral or bacterial would come in and if the flu hadnt killed you, that pneumonia would do it. Yes. Can you hold on a second . Were there any immunities to this virus . Professor tomes a very good question. When you do have a virus, you may then have an immunity to it. One of the theories about why this was so bad is that in fact it had been almost 20 years. The one in the early 1890s may have been this strain, and then the people who had that immunity either lost it or died off, so it was basically a virgin population that had not an ex posed to this particular flu, so you would not have good immunity from having been exposed. That is my possible explanation as to why a lot of people didnt have immunity to this particular strain. It is hard to exagger