S1E30: A Second Wave? / Howard Markel

“So when will it come back? You know, I’m a historian, so I’m uncomfortable with predicting the future, but as a doctor, if I were making a prognosis, I would say it’s going to come back.” — Dr. Howard Markel

“It does get weary when you see the same mistakes being made over and over and over again. And many of the mistakes of past pandemics are being made today, particularly in how we’re administering and reacting to it.“ — Dr. Howard Markel

With states gradually starting to re-open, many are wondering whether we will face a second wave of infections. In today’s episode, Dr. Celine Gounder speaks with Dr. Howard Markel, a physician and medical historian at the University of Michigan School of Public Health. They ask the question: can history help us prepare for the future? They discuss the lessons that the Influenza Pandemic of 1918 can teach us about COVID-19, and consider whether the history of the 1918 pandemic is repeating itself in present day.

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder: I’m Dr. Celine Gounder. And this is “Epidemic.” Today is Friday, June 19th.

Back in 2005, Dr. Howard Markel was in his office at the University of Michigan wrapping up his week before the Fourth of July holiday.

Howard Markel: And it was late in the afternoon, and I was getting ready for a long weekend when my secretary said, “Uh, Dr. Markel, the, the Pentagon is on line seven.” Which made me shake my head a little bit of wonder because the Pentagon is never on line one, two, three, four, five, six, or seven.

Celine Gounder: It was a physician calling from the Defense Threat Reduction Agency. By the time Howard got that phone call from the Pentagon, he’d already been studying pandemics and quarantines for almost twenty years.

Howard Markel: I’m a physician and a historian of medicine. I’m the George E. Wants distinguished professor of the history of medicine and director of the center for the history of medicine at the University of Michigan.

Celine Gounder: The Pentagon was worried about what would happen if there were a bird flu pandemic. This was back when a virus called H5N1 was going around.

Howard Markel: The federal government under George W. Bush was very interested in this issue and very concerned. And of course, influenza, pandemics happen with regularity. And we were overdue for a really bad one.

Celine Gounder: So they asked Howard to join a team of doctors and historians who were going to try to figure out if there were any lessons the military could take away from the last big pandemic… back in 1918.

Howard Markel: They wanted us to look at something called “escape communities.” So these communities shut their doors very early on in September of 1918, and didn’t open them for several months. And when they shut their doors completely, they had no cases of flu and no cases of deaths from flu. And these are about seven communities. One was a school for the blind. One was Princeton University. My favorite was Gunnison, Colorado, a little mining town nestled in the Rockies that could easily shut its doors from outsiders. And Yerba Buena Naval, a military base in San Francisco Bay.

Celine Gounder: Howard had a team of twelve researchers working for him.

Howard Markel: For historians, that’s like the Manhattan project, because when I, when I write a book, it’s me, I do my own research. And, you know, I don’t have 12 people that I’m ordering around by cell phone, you know, at a command center.

Celine Gounder: Howard and his legion of researchers looked at those so-called escape communities and said, well…

Howard Markel: You know, this is really not all that practical. I mean, you could put everyone on ship somewhere, but that would be a pretty bad message to people who want to harm us. If everybody that protects us is on our, on ships, you know, sequestered away. That might not be the best thing, but that’s when it came up, at least I had the idea and my colleague, Captain Marty Cetron, who is the director of global migration and quarantine at the Centers for Disease Control… Marty Cetron had the idea at the same time.

Celine Gounder: That idea would become a household phrase during the coronavirus pandemic…

Howard Markel: And if there was a cartoon, there would be light bulbs above our head

Celine Gounder: In this episode of “Epidemic,” we’re going to find out what that light-bulb moment was… and what Howard and Marty’s research can tell us about what’s around the corner when it comes to coronavirus this year.

Howard and Marty first met working together on that Pentagon project about escape communities. While that concept didn’t really pan out… they came across another idea to study from the 1918 pandemic.

Howard Markel: We thought, well, the real action, the real thing to study, are regular American cities. These cities, the way the popular history is told and the way people read about it is that, “Oh, the flu came and it killed everybody. And then it went away.” Well, no, it was much more complicated than that. And not everybody had the same terrible experience. So some cities, in America, for example, had a very low mortality rate and morbidity rate, meaning people that get sick from flu. And others had an astounding rate. So we wanted to find out, what did the good cities do differently than the bad cities, if they did at all, to see what might’ve worked and what could work in the future.

Celine Gounder: So they went back and looked at how different cities across the United States handled the pandemic.

Howard Markel: Back in 1918 though, most cities were overwhelmed by the number of cases and the rapidity with which it took over, the way it fanned out across the country from East to West in a matter of weeks.

Celine Gounder: Cities like Boston, New York and Philadelphia were especially hard hit.

Howard Markel: But the cities that were, uh, in the West and particularly in the Midwest and South that had a few weeks advance notice compared to the Eastern seaboard cities.

Celine Gounder: Howard saw that St. Louis was an example of a city that got it right.

Howard Markel: For example, a man named Max Starkloff, who was the Commissioner of Health in St. Louis, was a very talented man who could get different parts of the city working in one direction. He was very conversant with the mayor, with the Superintendent of Schools. He was a very good public communicator to get people on Board to do what he suggested, and they had one of the best records in terms of morbidity and mortality in the country. He also canceled their Liberty Bond parades and so on, and a lot of other public gatherings, and they had a very good record.

Celine Gounder: Remember, this is all happening during the First World War.

Howard Markel: In a lot of cities, the health commissioners conflated doing the right thing by flu with the patriotism of going off to fight World War I. And so it was part of your civic and patriotic duty not to do things that you were advised not to do. And in fact, the word “slacker” actually originated in World War I. It was the word for men who didn’t want to go off to war and people who didn’t cooperate with the influenza regulations.

The penalties of being a slacker are severe.”

Celine Gounder: Many cities were trying to support the war effort at the time. They threw big parades to honor the troops and sell something called Liberty Bonds to help fund the war. But not every city followed St. Louis’s lead.

Howard Markel: Well, Philadelphia was interesting because it almost did everything wrong. In Philadelphia, where they had Liberty Bond parades, and a lot of people were gathering and coughing on one another; the mayor was fighting with the health commissioner, and they were both fighting with the governor, and they did things late and in a haphazard way, they had a very bad record. So leadership matters quite a bit.

Celine Gounder: Comparing what happened in St. Louis, Philadelphia, and dozens of other cities, Howard and his team started to see what worked.

Howard Markel: It was quite clear: early was the best. And that makes sense, because if you look at an epi curve, there’s sort of an inflection point where it starts going from an arithmetic mean to exponential. It just goes up, up, up, up, up in cases because there are so many people who are sick and infecting others, so if you can act before that inflection point, early, that’s good.

Celine Gounder: Howard also saw that there was no one magic bullet to controlling the pandemic. Cities that had the lowest death rates implemented multiple methods.

Howard Markel: Layering, doing more than one because none of these methods are perfect. They’re all like layers of Swiss cheese and they have big holes in them. People escape from quarantines. People don’t wear face masks. People go and have public gatherings or what have you. So there’s holes. So if you can layer each like a piece of Swiss cheese over one another, you can cover those holes better. And then finally you have to do them for a long period of time. Because you’re only hiding from the virus. You’re not protecting yourself other than that. And when you come out of hiding, if the virus is still there, people will catch it. And that’s probably the hardest part of these measures. You know, they’re incredibly disruptive, as we found out, to the economy, to people’s lives, to employment rates, to all sorts of things.

Celine Gounder: Early action… layering multiple measures… and enforcing social distancing for long periods of time. That was the public health strategy that Howard and his team found worked best to slow the virus… but not stop it all together. There’s another term for this you’ve likely heard. Are you the one who coined the term “flattening the curve”?

Howard Markel: Well, you know, there were a lot of us, and it wasn’t a “me” effort. It was a “we” effort, but, um, yeah, kind of. Funny story.

Celine Gounder: Howard and Marty were working late one night, going over these epidemiological charts showing the curve of infection rates.Different charts showed when different cities implemented or relaxed their social distancing measures. Howard and Marty were flipping through a PowerPoint presentation.

Howard Markel: You’ve seen pictures of epidemic curves, you know, it’s a large hump going up very, very quickly; very, very high, and then going down. So it was a lot of work, and we were in his office late at night eating very bad takeout food that had come in those awful styrofoam containers. And I had some type of noodle dish, and they had all flattened into one giant noodle. I said, “Look, okay, you could flatten the noodles, just like the curve.” And that’s my side of the story. I think other people might have a different version, but that’s the version I’ve been telling.

Celine Gounder: This story might be too good to fact check, but the concept of flattening the curve has taken over all of our lives lately.

Howard Markel: So the idea of flattening the curve was the hypothesis that I worked on with Captain Marty Cetron, and we wanted to know: would it be possible to flatten that curve, as it’s now called, to stretch out the cases over time, to decrease the burden on our hospitals and infrastructure.

Celine Gounder: Sounds familiar, right? This is what we’ve been hearing from experts like Dr. Tony Fauci and Dr. Deborah Birx since February. But now almost every state has started to re-open in some form. And Howard saw what happened when cities started to do the same back in 1918.

Howard Markel: We found that twenty-three of the cities released their breaks too early, because, you know, the citizens got restless. They got tired of not going out. They got tired of their kids being home all the time, and they pressured their mayors or health commissioners, or even their governors to release the brakes—I don’t know if that sounds familiar to you or your listeners—and they suffered another spike in cases because the virus was still circulating and sometimes that spike was worse than the first one. So that’s also a very cautionary tale for what’s going on today.

Celine Gounder: Howard calls these cities that saw two peaks or two waves of the virus “double hump cities” because of the shape made by their epi curves in that PowerPoint slide deck.

Howard Markel: And what was so interesting about these double-humped curves, these cities that had double humped epi curves, is that each city acted as its own control. When the measures went on, cases went down when the measures went off, cases went up, and then when you put the measures on again, they went down. So it wasn’t just a temporal association. It was probably a causal association, or as close as you can come when you’re not doing a double blind experiment in the laboratory.

Celine Gounder: Howard isn’t saying that infection rates weren’t going down because of changes in the seasons, or that the virus just got tired and went away. It was the social distancing that was flattening the curve.

Howard Markel: So it was very clear that these measures worked. They weren’t temporarily-related, but they only bought you time. They did not cure things.

Celine Gounder: So, if we look back at what happened in 1918 and 1919… what’s next for us in this pandemic?

Howard Markel: So when will it come back? You know, I’m a historian, so I’m uncomfortable with predicting the future, but as a doctor, if I were making a prognosis, I would say it’s going to come back. And whether it’s August or September or even October, November is the big question.

Celine Gounder: That’s because it did come back in 1918.

Howard Markel: Yeah. September to December wave of 1918 and the January to April wave of 1919, were technically the second and third waves.

Celine Gounder: And just as they started to loosen social distancing back then… the same as we’re doing now. Many states, like Arizona, Texas, Florida, Georgia, and Oklahoma, are seeing record high numbers of cases after loosening social distancing measures.

Howard Markel: There’s, you know, almost 30,000 new cases yesterday and the day before. Now we are getting better testing, but still we were getting more cases in some places; it’s getting worse, not better. We also know in different parts of the world, like the developing world, it’s raging.

Celine Gounder: And this is the problem. Social distancing only buys us time… it doesn’t cure anything. So when we restart the economy and start going out again, the virus is still there, waiting.

Howard Markel: And so let’s say 50 million people actually have had it, but they didn’t come to medical attention necessarily. And they didn’t get tested because it was mild or whatever. And I’m probably underestimating it, but let’s say 50 million. That means there’s still 300 million Americans who have no protection immunologically against coronavirus.

Celine Gounder: And that’s assuming infection with COVID confers long-term immunity.

Howard Markel: That means there’s a lot of, uh, fresh, fresh meat for the coronavirus to attack. It’s like the concept of safe versus safer sex. We had to change that back in the nineties. Cause there’s, there’s no such thing as ultimately safe sex, and there’s no such thing as ultimately safe activities, as long as this virus is still circulating, and it’s really very much of an odds game.

Celine Gounder: So Howard thinks a second wave is likely, assuming we’re even done with the first wave of the pandemic. On June 16th, Tony Fauci told The Wall Street Journal that he thinks we’re still at the beginning of the pandemic.

Howard Markel: Look, let me put it this way. I was reading the paper this morning and Tony Fauci said, “this is a nightmare and this isn’t over yet.” Okay. Well, I’ve known Tony for, you know, twenty-five years or more. He’s a brilliant scientist. He’s a brilliant clinician, and he does not exaggerate. He is not an extremist. And so, you know, the government is blessed to have one of the, one of the greatest minds in infectious diseases and public health working for them, and if he says that, we are well advised to listen. I don’t think we’re over by a long shot, and I’m not an extremist either. I’m pretty, I try to be pretty calm about this, but I don’t think we’re out of the woods yet.

Celine Gounder: But there is something we have today that they didn’t back in 1918. We have the science to develop a vaccine.

Howard Markel: And so we’re hoping that we can come up with a vaccine quickly enough because universal vaccination is our best and safest bet against this viral foe. There’s no question about that.

Celine Gounder: So until that vaccine… a treatment… or a preventive medication is available, our tools are public health measures like social distancing… and more targeted measures… like testing, contact tracing, and isolation of potentially infectious persons. An analysis by researchers at Columbia University in May found that if the United States had started social distancing measures two weeks sooner, nearly 54,000 lives could have been saved. As we’re recording this episode, more than 113,000 people have died from COVID in the United States.

Howard is passionate about his work.

Howard Markel: Because it has allowed me to do or to participate in just so many exciting things. Having said that it does get weary when you see the same mistakes being made over and over and over again. And many of the mistakes of past pandemics are being made today, particularly in how we’re administering and reacting to it.

Celine Gounder: Howard has written about this in the past. Something he calls global amnesia. Why does that set in? Why do we forget the lessons we should have learned from prior pandemics?

Howard Markel: Well, I think it would be interesting to talk to a social psychologist about that, but it is very normal. Once you’re in a terrible situation. And then you get out of it and you forget how bad it was. When I was a sexually transmitted disease doctor, and I would diagnose somebody, you know it was a close call, but you did not get AIDS this time, you did not get gonorrhea this time. I would always hear, “Oh, doc, I’ll never do that again. I’ll never practice unsafe sex again.” And the studies are quite clear that lasts about six weeks. And so we tend to forget the lessons that we should have learned. Infectious disease doctors don’t, and epidemiologists don’t, but society as a whole does because after almost every epidemic or pandemic, a post-mortem saying, you know, the quarantine hospital did not have enough beds, or Bellevue Hospital didn’t have enough respirators, or we didn’t have enough trainees. And then five, ten years go down the road and something else erupts, and you have the same exact problems.

Celine Gounder: Between the protests across the nation in support of Black Lives, calls for police reform, Bolton’s book release, and the election in the fall… Howard says it feels like that amnesia about the pandemic is already setting in.

Howard Markel: You know, we never really conquer infections. At best we wrestle them to a draw. And so we always have to be prepared for the next one. And we can always have to fund our local state, federal and global public health departments, because we know as sure as I’m sitting here, it’s not a matter of if, it’s a matter of when, and you know, all of us support our local fire departments. Well, I bet your house never burned down, but you still pay taxes to support the fire department because if it does, you want them there very quickly. And I think we have to look at our public health agencies in the same way, and we don’t.

Celine Gounder: Today we’re going to take a listener question that has a lot to do with our conversation with Howard just now. This is Julian Brophy in Sydney, Australia.

Julian Brophy: Hi. Our country has had reasonable success in reducing the transmission of COVID-19 over recent months and is now looking at starting to relax our social distancing. My question is whether this is a sensible thing to be doing at the moment given we have such low rates of transmission and is a possible option to keep up social distancing to further eradicate the virus from Australia? Or is that just not possible and that a second wave of the virus will be  inevitable? I really came to hear your thoughts and answers to this question. Thanks.

Celine Gounder: Julian, this is such a good question. It’s important to understand that imposing shelter-in-place orders for a couple months doesn’t eradicate the virus. There are still enough people out and about that the virus is still circulating.

Celine Gounder: That said, the situation in Australia’s a bit different from what it is in the United States. You suppressed your first wave of the virus. COVID cases peaked in Australia in April. They’ve remained relatively low since. In the U.S., COVID cases dipped in late May and early June, but they’re on the rise again. We’re still in our first wave.

Celine Gounder: Why was Australia able to suppress the first wave, but we haven’t? The Australian national government empowered its health agencies to take charge. Australian Prime Minister Scott Morrison let scientists and doctors lead the strategy and communication, which meant it wasn’t politicized the way it was here. Australia, like other countries in the region, was aggressive about testing and contract tracing early on. And Australia has paid leave and universal health care, which means people feel free to take time off work when they’re sick… and they have some place to go to get care when they need it.

Celine Gounder: As for the U.S. … the rising numbers… in the middle of the summer… when we’re all outdoors more… that doesn’t bode well for us. In the fall, when at least some kids go back to school, and we spend more of our time indoors around other people, we will inevitably have a second wave… perhaps on top of the first.

Celine Gounder: The goal of the lockdowns is to suppress the virus and prepare for next steps to contain it. Wearing masks, staying 6 feet apart from others, testing, contact tracing, and isolation… these are measures that allow you to reopen the economy while preventing a huge surge in transmission. Those are our only tools to reopen the economy until we’ve got a vaccine… or therapies that effectively prevent or treat COVID. The problem is that this has become a very black or white discussion: either you’re for wearing masks and social distancing… or you’re for throwing the economy wide open. And no one is talking about that middle ground: how to reopen safely.

Celine Gounder: If a foreign power invaded the U.S., we’d be encouraging Americans to enlist to defend our nation. That’s exactly what we need to be doing now: recruiting and hiring legions of contact tracers… to fight the virus… across the country. We need to be arming them… with testing… and places to send potentially infectious people… to separate and isolate them from healthy family members and others in the community… while getting them the care and support they need.

Celine Gounder: This isn’t the time for “slackers.”

Celine Gounder: It’s the time for strength and resolve. Wearing a mask? That’s a pretty small price to pay in service of your family, your community, and your country.

Celine Gounder:  “Epidemic” is brought to you by Just Human Productions. We’re funded in part by listeners like you. We’re powered and distributed by Simplecast.

Today’s episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Sonya Bharadwa, Annabel Chen, and Julie Levey.

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And check out our sister podcast “American Diagnosis.” You can find it wherever you listen to podcasts or at americandiagnosis.fm. On “American Diagnosis,” we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health; in season 2, the opioid overdose crisis; and in season 3, gun violence in America.

I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”