Joe Fuller: Welcome to the Managing the Future of Work podcast from Harvard Business School. I’m Harvard Business School professor and visiting fellow at the American Enterprise Institute, Joe Fuller. This episode is one of the series of special dispatches on the sweeping effects of Covid-19 on our economy, society, and the future of work. In addition to our regular podcast episodes, we will be bringing you shorter and more frequent interviews with business leaders, policy makers, and leading scholars on the coronavirus.

John M. Barry is a historian and distinguished visiting scholar at the Center for Bioenvironmental Research of Tulane and Xavier universities in New Orleans. He’s the author of The Great Influenza: The Story of the Greatest Pandemic in History, originally published in 2004, but now unsurprisingly a bestseller. What can we learn from the 1918 pandemic, which killed between 50 [million] and 100 million people worldwide? As much of the world reopens, Professor Barry joins us to discuss the great pandemic of 1918, the lessons we can draw from it, and his prognosis for the future. John, thanks for joining us on this Covid dispatch from the Managing the Future of Work podcast.

John Barry: You’re very welcome.

Fuller: John, until recently, the great influenza of 1918–1919 was a subject of interest to historians and students in public health, but was not something in the popular imagination. You wrote one of the definitive accounts of it. How did you get interested in it in the first place?

Barry: Well, oddly enough, it was an accident. I had planned to write a book on the home front during World War I, culminating in the events of 1919, one of the most interesting years in American history. But actually I didn’t think I could get an advance to write that book the way I wanted. I figured it was going to take a minimum of seven years and probably longer. I was always interested in the pandemic, almost became a scientist of medical research, and figured I could do that book very quickly, and it would subsidize research for the larger book. Unfortunately, the influenza book took me seven years, so it didn’t work out that way. And for five and a half years, I wanted to throw the whole thing out the window. But at just about that time, it sort of came together. And, obviously, I’m glad that I did do it.

Fuller: Sounds like a rather typical gestation period for a serious book. Well, there have been a lot of analogies drawn between this pandemic and that one. When you think about it, what are the things that you think are analogous, that are relevant? And where do the comparisons break down and become deceptive?

Barry: Well, they’re both animal viruses come to humans. They’re both respiratory viruses. They transmit in almost exactly the same way. Oddly enough, in both cases, the pathology is unusual for a respiratory virus, but they are similar to each other. Both—the 1918 virus, unlike other influenza viruses, could infect practically every organ, and this virus seems to be infecting a lot of organs. The biggest difference is—well, two major differences. One, in virulence. The 1918 was thankfully much, much more virulent. If we were facing something like that today, the worst-case scenarios would be truly terrifying, probably hundreds of millions of people dead. The second difference—and this is really a major one in terms of management and lockdown, economic impact, and so forth—is timing. The incubation period for influenza is one to four days, and most people get sick at two. You’re usually sick three to five days. You don’t shed virus much after that. Here, the incubation period is two to 14 days. Most people get sick at five to six days. You’re sick for several weeks. You shed virus much longer than influenza. So the whole cycle is stretched out much, much, much longer. In 1918, and in seasonal influenza, the disease would hit a particular community and largely be gone after six to 10 weeks. And here, it’s stretched out almost indefinitely. And, in fact, because of our interventions, which I certainly support to save lives, that has stretched it out even beyond its natural length.

Fuller: Talk a little bit about the response in 1918 and what we learned from it. Of course, we read stories—and they’re featured in your book—of different cities that took different courses of action: the famous parade in Philadelphia that seemed to be a turbocharger for infections there, whereas other cities like St. Louis took more conservative steps right off the bat. What lessons can we draw, both in terms of what we’ve done and the wisdom of it in terms of the rapid ramp-down of the economy and widespread self-quarantine and isolation? And what lessons also can we derive about this period now when we’re trying to restart things?

Barry: There were a couple of lessons that come out of 1918 that relate to your question. The first is actually, to tell the truth, transparency. Because of events of 1918, when the Bush administration—George W. Bush administration—launched a major initiative on pandemic preparedness—a $7 billion bill, most of it going to vaccine technology and manufacturing capacity of scientific research, but also to fund a planning process as to what to do in a pandemic. I was asked to participate in the early meetings, to sort of conceptualize it. And in those meetings, I explained that I thought the most important lesson from 1918 was transparency. Nobody disagreed with me. That recommendation is written into the federal preparedness plan, right at the top. It’s written into every one of the 50 state plans as well. That did not happen in 1918. The result was, people died who otherwise would not have died. And, in addition, actual panic—to some degree, terror—spread in a lot of communities that would not have otherwise happened. The second lesson relates more directly when we’re comparing St. Louis and Philadelphia. Almost every city in 1918 did intervene, issue closing orders, and so forth. And by analyzing what occurred in each of those cities, it sort of validated the obvious. But doing that is important. Those cities that intervened early tended to have a better outcome than those cities which intervened late. If you intervene late, by then the virus has already disseminated in the population. If you intervene early before that happens, you have a much better chance of short-circuiting spread that would otherwise have occurred at a much faster pace. St. Louis is a classic case of intervening relatively early and maintaining that intervention for a pretty long time. Philadelphia, because of the war, there was... actually nationally the same day, a lot of cities had Liberty Loan Parades. But at that time, the virus had already arrived in Philadelphia, was already spreading enough that the medical community urged the politicians and the health commissioner to cancel the parade. By that time, in fact, the national draft had already been canceled because the army camps were either already overwhelmed with sick soldiers, or they were concerned that bringing people inside the army camps would bring the disease into the camps. Nonetheless, in Philadelphia, that parade went forward. They had several hundred thousand people in the streets. And just like clockwork, 48, 72 hours later, disease exploded in the city. Going back to transparency, Philadelphia was by no means the only city where lies were told, but it’s a pretty good example. Well after the parade, at a time when you actually had priests driving horse-drawn carts through the streets, calling upon people to bring out their dead, the city was digging mass graves. And they finally—belatedly—issued closing orders in schools, church services, all public gatherings. Of course, theaters and bars and restaurants and so forth closed. One of the newspapers went so far as to say, “This is not a public health measure. You have no cause for panic or alarm.” Obviously, the readers looking around them, seeing people dying and sick, knew perfectly well it was a public health measure. But that’s sort of emblematic of the extremes to which those in control were trying to reassure people. And, of course, it was counterproductive. All that message said was, you can’t believe anything you read in the newspapers or anything anybody in authority tells you, which contributed, of course, to spreading panic. I mean, there was panic in Philadelphia. In other cities, it wasn’t necessarily quite that bad, although, in the overwhelming majority of cases, they downplayed it to an extent that was pretty contemptible and counterproductive. You did not, however, have what we are having, now—a significant proportion of the population that doesn’t take it seriously, or thinks that it’s being overhyped. And the reality of the disease everywhere made it crystal clear that it was not being overhyped.

Fuller: Because of its mortality and rapid spread.

Barry: Right.

Fuller: How did cities and businesses start to reopen? Now, you mentioned earlier the very different characteristics of the two viruses in terms of the incubation period and the length at which people are shedding virus and, therefore, might be a carrier of the infection forward. But what can we learn from the aftermath?

Barry: Well, that’s an area where I don’t think 1918 really is that much of a precedent, for a couple of reasons. Number one, the duration was much less. Number two, no city that I know of—well, actually one city, but there, the order only lasted for four days, one of which was Armistice Day, so businesses were closed anyway—but other than that one city, and that again, only for four days, they didn’t issue the kind of general closing orders that we’ve issued here in many states. The only things that were closed were places of public gathering. Ordinary business activities proceeded. There was tremendous absenteeism, enough that it certainly interfered with those business activities. Where we have good data—which would be, for example, shipyards because they were war industries—in shipyards, the workers were, on a daily basis, were told that they were as important as soldiers on the front line. They had medical care at work, which was not available in the civilian community. Nonetheless, the absenteeism, even in shipyards, often exceeded 50 percent. People were either sick themselves, taking care of somebody sick, or simply afraid. In other industries, although I can’t cite data—in most cases, the statistics just don’t exist—but I’m pretty confident that the absenteeism was considerably higher than in shipyards. So that obviously had significant impact on the economy. According to MetLife, over 6 percent of the entire population of miners aged 18 to 45 died. And we’re talking, remember, an incredibly compressed time period, six to 10 weeks in a particular area. So if you’re seeing that many of your coworkers drop dead, you’re not too eager to go to work. So coal mines basically stopped functioning in much of the country. And, obviously, that also had repercussions for the economy. But again, because of the brevity, and because there were no general closing orders, it’s not really a precedent for coming out of Covid-19. I think when the virus disappeared from a community, things got relatively back to a relative normal quite quickly.

Fuller: Your book The Great American Influenza starts with a history of the development of medical science in the United States that I found quite interesting. And we tend to think of the US as the inheritor of a great tradition of medical research and effectiveness. And that was actually, as you indicate in your book, something that really only started emerging in the early 20th century, with a few figures surrounding everything from the generosity of John D. Rockefeller to Johns Hopkins University. Did the Great Pandemic in 1918 spur a lot of innovation in medicine? And how do you think it might affect the way we think about public health and the path of science going forward in the aftermath of Covid?

Barry: Yeah, I think in 1918 it did. The scientists were ... they didn’t even know what a virus was in 1918. They knew very small particles that could pass through the smallest filters existed, but they didn’t know whether or not they were a different kind of organism or just really small bacteria. Identifying, defining what a virus was actually came out of research started during the pandemic, but not until 1925—a guy named Thomas Rivers, who was trained at Hopkins and at Rockefeller. And I think there was an extraordinary amount of very good science that eventually came out of the pandemic. They already understood vaccines. They did things like convalescent serum, which we’re trying now. They made some pretty good vaccines, but they didn’t know what the pathogen was. So they were aiming at a different target. However, if you get an anti-pneumococcal vaccine today, it’s a straight line to send, then, if something developed in the middle of the pandemic. Today, also, I think there will be a tremendous spur in biomedical research. Some of those things may not last—I think there’s much more cooperation today among scientists than is ordinary, more interdisciplinary research today than is ordinary, trading of information from people who are normally competitors. I’m on a Google group of scientists. I hardly contribute anything to it, but I learn a lot. But more than 200 scientists in over 30 countries—who didn’t really know each other in advance—all of them have published in the best scientific journals. I guess some of them knew each other. But the point is that they’re really trying to address problems in this Google group jointly. I’ve talked anecdotal, but I talked to some people at University of California, San Francisco, which, of course, is a ... and also Stanford and so forth, same thing’s happening. They formed a group of people who normally don’t work together, just trading ideas, trying to get to solutions. How much that will last after this is not clear. But I think to young people, they are seeing science as something exciting and worthwhile. Maybe they would have gone to business school five years ago when they got ... and maybe now they’ll go to medical school or a PhD in microbiology or something like that.

Fuller: Well, we hope they don’t turn their back on Harvard Business School at least, which is the home of this podcast.

Barry: Well, I knew that. That’s why I said that. I hadn’t forgotten. But to finish my thought, the other issue is funding. The government is going to be more strapped for money probably than at any time in our history, including possibly right after World War II, when we obviously had a huge deficit. It is not clear yet what kind of funding NIH [National Institutes of Health] will get. And the same probably goes for every government and advanced nation in the world—or not advanced nations, but they all support scientific research. How much pressure will be put on that area? I don’t know. There may be more joint efforts with the private sector. All that has to be shaken out. But I do think there will be a significant spur from young people inspired to go into science, who might otherwise have gone to business school or Wall Street or something like that, or law.

Fuller: John, how did the pandemic affect both international relations, but also world trade? Obviously, it was coming to the end of World War I, so there were lots of different distortions. But was there a lasting effect in terms of restrictions on travel, or did it distort globalization in some other ways?

Barry: Not really. I mean, you had ... the war was the controlling force of every policy decision, certainly in the United States. And that was it. And [President Woodrow] Wilson never made a single public statement, nor do I know of any private statement really about the pandemic.

Fuller: So that would be President Woodrow Wilson, who was president at the time?

Barry: Correct. From a policy perspective, things like travel restrictions. There were a couple of isolated places, small towns in the country, that did try to isolate themselves. A couple of them did it successfully. Gunnison—in Colorado, which was actually, I think, somewhat of a small rail center—was actually one of them. You couldn’t get off a train at Gunnison unless you were willing to be quarantined. And they blockaded the roads in, and things like that. And they did escape the brunt of it, although, obviously, eventually they stopped all that and they did get some influenza later. There were a couple of islands, completely shut themselves down, but that was not the result of some national policy. That was a local decision.

Fuller: There’s a commonly restated “fact” about the 1918 pandemic, which I’d like to check if it’s just an urban legend or not, that it asymmetrically affected younger, fitter people.

Barry: Oh yeah, definitely. Two-thirds of the deaths were 18 to 45.

Fuller: That’s obviously quite different from what we see with this.

Barry: Right.

Fuller: What do you think explains that asymmetry? And were there other populations that were particularly heavily affected? You mentioned miners, of course, and shipbuilders.

Barry: Professions, where obviously miners have lung burdens as well, probably from being in the mine. So the environmental factors weighed into places that suffered the most, like Pittsburgh, which I think led the country in excess mortality, heavily industrialized with a lot of pollution at that time. But in terms of the age, the peak age for death was 28. Normally, influenza kills the very young and the very old. Influenza in 1918 certainly killed the very young. Children under the age of five, there the deaths in a period of weeks again, equaled what would be the equivalent today of all-cause mortality for kids in that age group over a period of 23 years.

Fuller: Wow.

Barry: So it took an incredible bite out of the population of very young children. If you go to the next cohort—kids aged five to nine—it equaled all-cause mortality today over a period of 14 years. That’s a pretty dramatic difference. And psychologically, you can imagine if you’re a parent losing that many children, it’s extremely difficult. It’s something that leaves a scar. I think the leading hypothesis for why young people or young adults and up to their 40s died—when normally that population escapes influenza almost entirely, unless they have a comorbidity—is the immune system. The immune system changes over time. It’s strongest when you’re a young adult, and what was happening, at least part of the process, was that the 1918 virus, like Covid-19, not only could bind to the upper respiratory tract, which made it easily transmissible, but unlike other influenza viruses, it could also bind to cells deep in the lung, and again, that’s like Covid-19. So in 1918, you’re essentially starting out with viral pneumonia, if it’s binding to your cells deep in the lung. The immune system has many weapons. It threw every weapon it had at the virus, creating what is referred to as a cytokine storm and the battlefield was the lung. And the lung was being wiped out, or at least its functions was being destroyed in the effort to destroy the virus. I said at the beginning that the pathology of the two viruses, Covid-19 and the 1918 influenza virus, are very similar, and those cytokine storms are exactly what is causing people to die today. Ironically, the older population, their immune systems are not strong enough to defeat the virus entirely, but they’re strong enough to create that cytokine storm and kill it once it gets into the lungs, kind of a catch-22.

Fuller: A theme that some columnists—and I’m thinking specifically of David Brooks, the New York Times—have articulated in columns about the influenza is that the great influenza wasn’t the subject of lots of reflection and authorship and whatnot after it passed. And he attributes that to some sense of both obviously widespread grief, but also of people not really feeling good about the way they had behaved or the way things had unfolded. Do you share that sense? And is that part of the aftermath of the great influenza?

Barry: I’ve never come up with a satisfactory explanation myself as to why there is so little written about it. That may be contributing factors, what he just said, what he wrote. And I don’t know that that explains it or anything explains it. In terms of scholarship, I can perhaps explain it, that until relatively recently—and I’m talking about maybe 30 or now 40 years, I guess we’re in 2020—historians tended not to write about what nature did to people. They wrote about what people did to people. So in the profession of historians, that’s not what they did in the late, about three-quarters of the way through the 20th century. Then you sort of saw a birth of environmental history and broader looks at history. But much before that, I don’t think historians really looked at anything except people. And again, what people did to people. In terms of fiction, I wouldn’t disagree with what you said or what David Brooks said, but it still leaves me very puzzled. John Dos Passos, who’s one of my favorite writers, he got influenza on a troop ship, one of the worst places you could possibly get it. They were essentially floating coffins. And yet, in his entire body of work, he’s wrote about two sentences about influenza. There’s, of course, Pale Horse, Pale Rider, which is a novella. It’s not even a full-length novel, by Katherine Anne Porter. It’s a great piece of writing, but that’s it. There are a couple of short stories in The New Yorker by William Maxwell. Oddly enough, there was a lot of pulp fiction in the ’20s written about influenza and not literary fiction. I don’t know how much of it survived, and I haven’t actually read it. Someone else told me about it. So it didn’t completely disappear. And in 1933, when the Nazis entered Berlin, Christopher Isherwood, who wrote The Berlin Stories that became the movie Cabaret, he compared the Nazis entrance to influenza. He said you could feel it like influenza in the bones. So 15 years after the fact, he expects his readers to recognize the sense of dread deep down that influenza caused. And I’m sure they did. But again, that’s a passing reference. I will never be able to figure out, I don’t think, why there’s so little literature on that subject. One would have expected at least some number of full-length novels in every language.

Fuller: John, has anything surprised you by the way either the public has reacted or policy makers or other major institutions like companies, in light of the fact that we do have the reference point of the great pandemics and some intervening, very serious episodes of influenza, not nearly as serious as 1918?

Barry: I could go into detail about the debacle of testing and supplies and everything else, but this is a pretty informed audience, and everyone in it I’m sure is quite familiar with that tale.

Fuller: John, in today’s epidemic, we’re seeing asymmetric impact on various groups; it’s been widely reported that instances of infection and mortality are higher, for example, in the African American community and also more obviously in people suffering from other disease states, some comorbidities that make them more vulnerable to this. Was that also true in 1918?

Barry: Yeah, there were different impacts on different socioeconomic groups. There was some very good pioneering epidemiological studies that correlated the number of people in a household living by square footage … disease, both morbidity and mortality. And the obvious results that you would expect were exactly what happened: the less square footage per person in a household, the greater the disease. That often involve race, but not always. One of the striking things about 1918 is how different the virus was in different places. It’s a rapidly mutating virus—possibly mutation rates, or the direction of mutation, accounted for that. But I mean, even to the extent, this is something that I’ve urged people to explore, but I have actually ... I’m not a scientist, but I’ve published a few peer-reviewed things in pretty good scientific journals. And my collaborators on those papers, I tried to get them interested in some of these things. But the earlier you got hit by the virus, the more likely you were to die. And this was true, both in a particular city. If you got hit in the first week it was in the city—compared to the fourth, fifth or sixth week it was in the city—you were more likely to die. And that’s true as it spread as a general rule—it’s not hard and fast as a general rule—as it spread across the country. That was true. There were also subgroups with comorbidity, like almost every other disease, that had an impact. For example, there were at least a dozen studies of pregnant women, which found case mortality rates ranging from 21 percent to 71 percent. So yes, there were very definite differences from one group to another, from one city to another. It was not at all uniform. And, of course, the biggest difference we’ve already discussed, that was the age group.

Fuller: So John, just to conclude, based on your study of the history and what you’ve observed so far about this pandemic, what kind of advice would you give? What do we need to do now to minimize the impact?

Barry: Regarding what can be done, it is crystal clear that compliance with public health advice makes a significant difference. In 1918, there was a study of army camps, 120 of them, roughly 2 million men. Ninety-nine of the camps imposed some kind of quarantine, isolation, other measures. Twenty-one did not. There was no difference—not just not statistically significant—there was no difference between the camps that did and did not impose quarantine and other measures for the larger group. But the epidemiologist who actually did that study was puzzled by that and went much deeper and discovered that these measures, of course, had to be in place for multiple weeks. And he discovered that only a tiny handful of camps rigidly enforced the measures they imposed for the entire length of time. And for those camps that enforced the measures, there was significant benefit. But there was leakage in the vast majority of camps, and it destroyed what benefit they might’ve had. But there were so few of these camps that actually did it right, that the numbers were lost in the larger sample size of 2 million men. By the same token, I said earlier, in the Bush administration I was asked to participate in the early conceptualizing of the pandemic plan. The very first meeting, they invited the infection control chief from the single hospital in the world that had the best record in terms of protecting health care workers from SARS. Twenty-one percent of the cases of SARS were actually health care workers, in Toronto 51 percent of the cases were health care workers. And this infection control chief made the point that every hospital knew what procedures to follow. He just made sure that his staff did the right thing all the time, every time. They just did what everybody knew how to do, they did it right. They complied, which goes back to Vince Lombardi blocking and tackling and so forth. You do it right. As we come out of lockdown, the measures that have been recommended work. Probably the single most important one is social distancing. There’s been a lot of examination of transmission. The data is difficult to tease out, but I believe there is a consensus forming that face-to-face communication, people talking to each other, is one of the most important modes of transmission. You keep that six feet, and you can intervene in that. The other things, there is work on influenza transmission, pretty good scientific studies, that a combination of hand washing and masks limit transmission. Even in the absence of adequate testing and tracing, which unfortunately a lot of the states don’t have yet, you can impact the course of this disease. But you have to do it. Compliance is necessary, discipline is necessary. If we do things right, then we can maintain an edge on this disease. They’ve done it in countries all over the world; we have not done it yet in the United States. And if we don’t do it, we still have the risk of this disease exploding.

Fuller: All right, John. Thanks so much for joining us on this Covid-19 dispatch from the Managing the Future of Work podcast.

Fuller: Thank you for listening to this special episode of the Managing the Future of Work podcast. To find out more about our project on the future of work and for more information on the coronavirus’s impact, visit our website at hbs.edu/managing-the-future-of-work and sign up for our newsletter.