A Commentary by John Barry (author of The Great Influenza) in CIDRAP News and accompanying meta-commentary by CIDRAP Director Mike Osterholm highlight an interesting controversy about a JAMA article by Michigan’s Howard Markel and colleagues. Markel’s article was a detailed compilation of public health responses to the 1918 influenza pandemic in 43 cities in the US with the aim of telling whether any was associated with better community outcomes. The Markel paper bore the following conclusion:
These findings demonstrate a strong association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States. In planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment. (Markel et al., JAMA [abstract; annoyingly, article is subscription only; discussed in more detail by us here])
Barry’s book seemed to corroborate this for some of the major cities considered in this paper, particularly New York City. Now Barry is saying his review of the data suggests both his earlier judgment and Markel’s paper were in error on a key point: New York City did not practice isolation and quarantine. Moreover Barry alleges the same error is made in Markel’s data on the only other city Barry re-reviewed, Chicago, and these discrepancies raise doubts about the rest of Markel’s data. Barry broached these concerns in a letter to JAMA (also subscription only), but he was not satisfied with the authors’ response.
This isn’t just an academic squabble. Markel’s work, first discussed at an Institute of Medicine meeting, has been cited as support for CDC’s recommendations for community mitigation measures in a pandemic. Mike Osterholm was one of the earliest and remains one of the most informed and insistent warning voices on the possible serious consequences of an influenza pandemic. Without a vaccine for a pandemic strain, nonpharmaceutical interventions (NPIs) like school closing and isolation and quarantine are among the few things we can do at the moment, so there efficacy is of crucial importance:
Frankly, our one real hope is that all the other public health tools we have employed in past infectious disease epidemics will make a difference. These tools have largely tried to change individual and community-based behavior to avoid exposure to the infectious agent until after the epidemic has run its course. These are often referred to as nonpharmaceutical interventions (NPIs) and include familiar approaches such as isolation, quarantine, and social distancing. While all of us might believe that these measures will work, until recently very little evidence has been available concerning their efficacy in reducing either morbidity or mortality in an influenza pandemic. This is due in part to the infrequency of such pandemics (three in the last century) and an absence of systematic studies during those pandemics of our collective public health actions and their impact. (CIDRAP News)
The key point here is we shouldn’t say something works just because we have nothing else to offer. If you are a public health scientist you should have a better reason for recommending something. In the case of isolation and quarantine, there is an additional reason to be careful. These are measures that limit individual liberties. This might (or might not) be a trade-off worth making if the stakes are vital and they actually make a difference, but if taken they should be based on accurate information. It is not a matter of better being safe than sorry. Isolation and quarantine can also make things worse by inducing the sick or exposed to flee authorities, spreading the disease. Unfortunately, this administration (of which CDC is not only a part but under Director Gerberding a willing participant) has a bad record on social control and we have little trouble suspecting it might seize on any data to justify decisions it wishes to take by virtue of its own preferences.
Like Osterholm I read Barry’s critique with concern. You can judge for yourself by reading the details. Some of Barry’s points are not completely germane (e.g., that the New York Health Commissioner Royal Copeland was a homeopathic doctor and not an allopath; this doesn’t recognize the historical roles of various medical sects at the turn of the century and adds nothing to his argument), but his questions about specific documents are important and call into question the support for some of Markel and colleagues’ conclusions, conclusions that surprised some of us at the time. As so often, Mike Osterholm goes to the heart of the matter:
This concern does not disprove that NPIs altered the course of the pandemic. But we in public health will face overwhelming challenges with risk communication and credibility during the next pandemic. While we will surely recommend the use of NPIs at that time, we have an obligation to society to tell exactly what we know and explain the science that supports our conclusions. How will we ever be able to dismiss and even condemn the crazy things that some will try to do during a pandemic if we don’t base recommendations on the strength of our science? We must hold ourselves to that standard now and in the future.
Addendum: John Barry sent me the following response and wished me to post it for him:
I agree entirely with your observations in Non-pharmaceutical interventions for a pandemic: getting it right. If I may do a little fly-specking, however. You mentioned that my comment that Royal Copeland– Markel’s sole source of information, especially what the NY Times quoted him as saying– was a homeopath was irrelevant. I agree with you that that is a side issue, but that was not my key point re: his credibility. The key point is the fact that he was a Tammany Hall political hack– that and that he told 2 gatherings of physicians something different than what the told the NY Times. (For those of you who don’t know, Tammany Hall was the most corrupt political machine in American history.) Tammany had only in early 1918 regained control of New York, after reformers had rule dit for several years. Copeland would do anything Tammany wanted. This included eviscerating the New York City health department, which had been probably the best municipal health department in the world, by replacing public health experts with other patronage hacks. The reason he never closed saloons, theaters, and the like, which most other cities were doing, was not because of his public health judgment but because of the power those businesses had in the Tammany organization. Copeland’s loyalty was rewarded, and he later rose to the very highest reaches of the organization.