Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 100

Great UCSF Grand Rounds today: bit.ly/2Z9eOB9 I interview John Barry, author of "The Great Influenza: The Story of the Deadliest Pandemic in History", now #1 nonfiction paperback @nytimes. Watch if you can (65 min); summary below.

2/ Brief local update first: For first time since March, some worrisome signs in SF, though not nearly as dire as TX, AZ, FL. (SoCal’s not great either.) @UCSFHospitals: 13 pts, 4 vented. Fig shows “W” pattern over last 2 wks, not surging but definite bump since early June.

3/ SF: cases also up (36/d, vs 23/d last wk; Fig L), & small bump in hospital pts (Fig R). A bit misleading since some are pts transferred from two outbreaks elsewhere: Imperial County in SoCal & nearby San Quentin prison bit.ly/2ZcN7XY (w/ >500 infected, incl 51 staff)

4/ Regions are so interconnected – surges in one can create surges in others. Looks like San Quentin outbreak is traced to prisoners transferred here from Southern CA. This outbreak has potential to lead to Bay Area’s first real surge. Will follow carefully; more info tomorrow…

5/ On to Grand Rounds: in prior GRs, we’ve had many disciplines: various clinical (ICU, hospitalists, ID, hematologists, peds), epidemiologists, statisticians, trialists, virologists, immunologists, experts on disparities & race…even a futurist.

Today: a historical perspective

6/ @ 3:45: So many parallels w/ Covid...

1918, U.S. was entering WWI; Pres. Wilson was laser-focused on war effort. Passed Sedition Act: criminal to say/write “disloyal” things, no matter whether it was true or false. Per Barry: “There was fake news, and it came from the govt.”

7/ @ 7:10: Barry reads one of the most poignant sections of the book (below), a letter by Dr. Roy Grist, who described the scene as influenza ripped through military recruits at Camp Devens, just north of Boston, a base meant for 36,000 men, but which held 45,000 in late 1918.

8/ @ 14:20: Influenza mostly struck and killed younger people, “>90% of the excess mortality was in people under 65 years old.” The great physician/researcher Harvey Cushing wrote that the victims were “doubly dead” because they died so young.

9/ @ 15:20: I asked Barry why he dove so deeply into story of science/medicine. “Blood & gore doesn’t interest me intellectually…I write about power & the people who have power to influence…events.” Scientists (& politicians, “as we are unfortunately learning”) have that power.

10/ @ 23:15: In 1918, no one knew that influenza pandemic was caused by virus; dominant theory was that it was caused by a bacteria (Haemophilus influenza). In retrospect, H. Flu (& other bacteria seen on cultures and microscopy) were secondary infections; virus found yrs later.

11/ @ 24:15: Remarkably, Woodrow Wilson never mentioned the influenza pandemic during his presidency. “He was brilliant… but every fiber of his being was focused on the war.” When told that many soldiers were dying of flu, he callously said they might die on battlefield anyway.

12/ @ 28:00: Entire government was silent on the pandemic or dismissed it as “just the flu.” “Nobody said it was a hoax; people were dying” (so you couldn’t deny it)... “But people realized they couldn’t believe anything they were being told, which only caused more fear.”

13/ @ 30:45: Barry tells story of the now-famous Liberty Bond Parade, Sept 28, 1918 in Philadelphia. Medical leaders urged cancellation, but it went forward: hundreds of thousands marched, huddled together, singing…. And “like clockwork, influenza exploded” – thousands died.

14/ @ 32:15: Re: Liberty Bond Parade, Barry is a bit forgiving of Wilson: “You can argue that we were at war and Wilson had some justification.” But he was less charitable toward Donald Trump. Of the recent rally in Tulsa, he said, “Now, you only have incompetence and stupidity.”

15/ @ 32:50: Barry describes the scene in Philadelphia, w/ residents hanging crepe outside houses to signal a dead body inside. “You literally had priests driving horse-drawn carts through the city, calling on people to bring out their dead.” Mass graves were dug, coffins reused.

16/ John Barry tells poignant story of a 5-year-old child who (w/ coffin shortage) was buried in a large macaroni box. In a single year, 1918, children under the age of five died at a rate equal to 23 years of deaths (in normal years) of kids under 5, for all causes.

17/ @ 35:00: Wilson catches influenza in Versailles, leads to a change in his personality – likely due to neuro effects of flu. Led to erratic behavior in negotiating Treaty of Versailles – so tough on Germany that historians have attributed rise of Hitler to the treaty’s terms.

18/ @ 38:30: We discuss masks, quarantine, & other treatments in 1918. Basically, nothing worked, probably including masks. They tried crazy stuff, incl. IV hydrogen peroxide (yes, IV cleanser) – study was published in JAMA! No ICUs, mech vent. Even oxygen wasn’t widely available

19/ @ 44:00: 1918 by the numbers: # of worldwide deaths often cited as 20M. More recent analyses: ~50-100M died, equivalent to 220M-440M today.

In U.S., 1918 flu pandemic killed about 675,000, equivalent to ~2M today. Far higher than worst-case projections for Covid-19.

20/ @ 46:00: some good came from 1918 pandemic. Transformation in medical education (birth of modern medical schools, like @UCSF), discovery of vaccines, early molecular biology, insights that led to discovery of DNA. Also importance of counting cases & data-driven public health.

21/ @ 53:00: Barry wrote: “San Francisco was a rare exception; its leaders told the truth & the city responded heroically.” His explanation: “maybe an accident of leadership, maybe it had to do with the 1906 earthquake." SF still got hit in 1918, but “trust did not disintegrate.”

22/ @ 56:00: One of the big differences, 1918 vs. 2020: tech. “But they did have telephones, telegraphs,” so information (and falsehoods) still traveled – “rumor spreads pretty fast.” There were conspiracy theories, incl. that it was germ warfare from Germany (via Bayer Aspirin).

23/ @ 51:00: Barry: “The number one lesson that came out of 1918 was to tell the truth…. The problem is that you have to have someone to execute the plan.” Asked about Covid, he said, “I tend to quote Hegel: ‘We learn from history that we do not learn from history.’”

24/ Impressively, Mission Local (our SF neighborhood paper, @MLNow), which covers these Grand Rounds each week, was out with their excellent Grand Rounds summary in a few hours, along with always-great pic bit.ly/2Z9axh4

25/ That’s it; again, video bit.ly/2Z9eOB9 is well worth your time.

Today marks 100 days since I launched these tweets. Sadly, likely we're in 2nd or 3rd inning. But at least we’re playing ball.

Tomorrow, weekly roundup, with more on the surges. Stay safe till then.