>> Hello, and welcome to this author interview. Once again, this is Howard Bauchner, editor-in-chief of JAMA, and this is Conversations with Dr. Bauchner, and I’m here with Frank Snowden. Welcome, Frank. >> Oh, thank you very much. I’m delighted to be here. >> Frank joins us from Italy, and we will get into that in a second. Frank is the Andrew Downey Orrick professor of history and professor and chair — was the chair of the history of science and medicine department at Yale, and he joins us because of a remarkable book, which I’ve learned is sold out on Amazon, which was published just recently entitled Epidemics and Society.

I assume when this book was published in the fall, you did not anticipate what would happen around the world in January, Frank. >> You’re absolutely right, and it took me completely by surprise, and although, like many people, I imagined that there would be some sort of pandemic challenge — people have been predicting that a long time — but I had no idea that this would happen now, at all. >> Yeah, it’s an amazing coincidence. It’s Epidemics and Society: From the Black Death to the Present, and we’ll go through details of the book and then how it compares to COVID-19. But Frank, could you tell people what it’s like in — why are you in Italy? >> Right.

>> And why are you in Italy, and then what’s it like? Been — you’ve been in Rome since the end of January. So why are you in Italy, and then what’s it been like in Rome for the last two months? >> Yeah. I’m in Italy for — originally for a different purpose, which was that I wanted to make use of the newly opened papers — the Vatican just opened the papers to scholars — of Pope Pius the 12th, and I was very interested in his papers with regard to the Holocaust and then to the Cold War just after the Second World War, but my whole plans were upended by the coronavirus outbreak, and I’ve stayed on, and I’ve devoted myself to coronavirus, really, either as research, and that is to keep up to date with it as best I can, and to think and talk with my head together by thinking and talking with various people in the hope that maybe something — in a small way, something that I’ve learned in 40 years of thinking about infectious diseases could be useful.

And so I’ve been doing hours of interviews every day for the last month, and I’ve found that to be — really seems to me an important, I guess, therapeutic when you’re in lockdown to feel that you’re maybe doing something useful, and also to talk with people all around the world gives you a sense of not being enclosed so much. So but most importantly, it’s a sense of maybe to provide some sort of context for people who haven’t an experience in this field and would want some sort of idea of how this could be happening to the world. So I’ve been putting my head together with people trying to think about that and discuss it. So that’s what I’m doing now. >> We’ll get into, you know, how the information in the book relates to coronavirus pandemic, but what’s it like in Italy now? >> The situation now is that the lockdown is more severe than in most countries in the industrial world, and that is to say that you aren’t allowed to go outside for any purpose except to purchase food and medications, and there’s nowhere else you could go to purchase anything because that’s about all that’s open. And to do that, you have to do two things: one, stay within a radius of a few hundred yards of your home, and you have to carry with you a document stating while you’re outside — why you’re outside and where you’re going so that if the police stop you and it happens that where you are doesn’t correspond with what you said you were doing and where you were going, you can be very heavily fined.

So you can’t visit anyone. You can’t meet anyone outside. You’re supposed to be six feet apart at all times from any other human being, and people are — they’re clearly very concerned. One humorous side was the observation of the local newspaper, Il Messaggero in Rome, The Messenger, and it said this is — thinking of compliance with these very strict orders, it said this is the first time in three millennia that the people of Rome have ever been obedient. [Laughter] In any case, I have a sense then, even from my brief outings, that there is a real seriousness of purpose, and that is encouraging and I think corresponds to the fact that the Italian epidemic — it looks as though — let us keep our fingers crossed — the state is beginning to get a handle on it and the numbers are beginning — the incidence seems to be slowing down, which is very, very happy thought.

>> I spoke to Mauricio Ciccone, who I interviewed a live stream from Lombardi about three weeks ago, and I think he — >> I saw that. >> Yeah. He, with a few other people, single-handedly made the United States pay attention and stay away, because it was this really impassioned conversation from someone who’s world-renowned and respected saying you have no idea what’s coming, and I think it really made people in the United States, intensivists really understand that whatever they thought was coming they were ill-prepared for, and I’ve listed him on my short list of heroes.

But I spoke to him this morning, and he actually indicated that he thought, at least in Lombardia, there was greater capacity to deal with the events on a day-to-day basis than there had been in the past. >> Precisely. The hospitals are not overwhelmed in the way that they were even a week ago, and this I think is really good news and much to be celebrated.

>> So you write the book, you publish it in the fall, and now you’re living through a pandemic. It’s an extraordinary circumstance, convenience of events. What has struck you about this pandemic vis-à-vis what you’ve written about in the book? >> I suppose this pandemic is more like the Spanish influenza than any other event that I can think of this kind, and one is struck by the ease with which it has spread through the world, in part because of many circumstances — the kind of world we’ve built — but also, I’m very struck by the lack of preparedness. It seems as though the world was totally unprepared for this in ways that are difficult to comprehend since ever since 1997, with the avian flu outbreak, there has been a surge of epidemiologists and virologists saying that another pandemic challenge is an inevitable part of our future. And one can see this in 2005 and ’06, just after SARS, that the US Congress passes and establishes a national pandemic preparedness plan, and the World Health Organization does the same, the 50 states do that, and then there are also preparedness plans by major companies, and yet — I guess it’s human nature — soon afterwards, there’s a feast and famine element, and these plans were sort of put away, even though Anthony Fauci in 2005 said to the US Congress that if you’re living in the Caribbean, you would expect — a meteorologist could tell you that the coming of a hurricane was inevitable.

They couldn’t tell you when and how powerful it would be, but it was inevitable, and virologists now can tell you that another — this is 2005 — epidemic was coming, and it was inevitable. You didn’t know how powerful or when it would strike, but it was inevitable, and that seems a very dire situation that people or governments all around the world should have taken very seriously, and yet there seemed not to be when ebola struck out — struck the world once again, the world wasn’t ready — taken by surprise — and just afterwards, in 2018, as you know, the World Health Organization appointed a commission to look at global preparedness and appointed the former Prime Minister of Norway to lead this investigation, and they produced a very report under the title, in 2019, “A World At Risk,” and so it is amazing to see, and this is not — I’m not pointing a finger at any one country.

It seems to be pretty — a global circumstance. As we know, in the United States, health system budgets were slashed, and in Italy as well. Just because I’m here, I say that, and it’s an important set case at the moment that the budgets were slashed. There was no movement to build surge capacity within the hospital system. And so I suppose this lack of taking science seriously is what disturbs me most about the onset of this, because it seems to me that around the world, there is a great deal of skepticism about science, that in this country — Italy, that is to say — the Five Star movement has, really, contempt for science. We can see — and this isn’t a partisan matter, because under President Bush, there was a lot of preparedness efforts to deal with diseases, and that seems to be different under the present administration, which is not — is — when the World Health Organization said this is something that should be called COVID-19, there were so many who said, well, no, we’re not going to call it that.

We’re going to call it the Chinese virus or the Wuhan virus, and not — in addition to being stigmatizing, it’s also saying to the scientists of the world we’re not really going to take your concern seriously. It’s rather like climate science, and we’re going to contest that as well. So this is something that deeply worries me, and it seems to me that this confirms Bruce Aylward’s comment when he was asked when he came back up from his mission for the WHO to China a few weeks ago, and we said, “What do we really need to do to prepare?” and he said the first thing we need to do or nothing else will work is to change our hearts and minds, that is, a new mindset is necessary. >> Right. Just to remind people, Bruce leads the WHO international efforts around many different issues, and particularly focused now on coronavirus pandemic. Just one comment on something you said. I think people have come to know and — know the wisdom of Tony Fauci.

He’s done many live streams with us. He wrote our first viewpoint on the subject. He called me up and said, Howard, I think I should write something about this. I think this is going to be a struggle for the US and the world, and he was prescient in that comment. >> Okay. >> I want to go back to something that comes up all of the time, and I think you are probably as knowledgeable about this as anyone else. Could you talk a little bit for a few minutes about the Spanish flu? People talk about it all the time or allude to it but don’t really then fill in the blanks.

Could you give us a kind of history lesson, a short history lesson, about the Spanish flu? >> Well, I’ll do my best. The Spanish influenza — there’s still debate about where and how it started. The three candidates really are that it came from China or that it started in Kansas or that it started in France at the British military and hospital base at Étaples, and so those are three different candidates. What they have in common is something that’s terribly part of the world we’re living in now: that it had in part to do with our relationship with the animal world and zoonoses — that is, animal diseases spilling over to human beings — and all three of those putative origins envisage precisely that happening, which reflects new relationships. As we become such a numerous and economically powerful species, our relationships with animal habitat and with wild animals have taken on different forms, and many more contacts are taking place. So that’s something that really needs to be considered — our relationship with wildlife now — because Ebola started that way, and the coronavirus also started that way.

So that’s a major issue now. And then it was spread quickly. From Étaples, it spread like wildfire with the British soldiers perhaps being demobilized for health reasons and the ones who survived their ordeal in France and in the United States. Of course, the movement of troops to the Western Front spread the disease, and it was entirely, of course, a disease that was completely unknown. I believe Rupert Blue, the US surgeon general at the time, said that Florentine doctors understood the bubonic plague in the 15th century just as well as physicians understood the Spanish influenza in 1918. So it came in three waves, the third being the really extraordinary wave of 1918, late 1918, November, and then into the new year, and it’s caused a total mortality — it’s extraordinary to think of, but the estimates have been going up from — constantly, and now most people think it caused a minimum of 50 million deaths and perhaps as many as a hundred million, which is to say many times more than the First World War itself.

It’s interesting to see that an important factor in it, though, was, ironically, not just the war, but also the peace, because when the soldiers returned home, they brought the disease — >> Yeah. Yeah. >> — back with them and spread it like wildfire in the United States. For example, to take one example, but as you can imagine, the — when soldiers returned, there would be parties to celebrate and welcome them back there, and there would be parades, and those spread the disease.

There was a terrible parade in Philadelphia where hundreds of thousands of people began to be ill very soon afterwards. Some of the — other places in major cities took a lot of measures that look like today — the masking, social distancing, the making sure that major events where people congregate were canceled. Church services no longer took place. Those sorts of things were very important parts. The way of fighting it was not a million miles away from the way — the conception of how deal with the coronavirus. So that’s interesting. One of the other striking features of it, though, is that it was largely — it’s even — there’s a famous book called the — America’s Forgotten Pandemic, which is to say how in the world could it be that a disease that caused perhaps 100 million deaths would not have lasting long-term memory seared into our institutions and to our economy and so forth, and yet it was quickly forgotten, partly because it was overshadowed by the war and peacemaking afterwards, partly because it didn’t besiege communities in the way that, say, bubonic plague does or coronavirus, also, but was something that swept through, left devastation in its trail, but in just a few weeks was gone.

And it’s striking that if you look at Britain, there is exactly — there are so many monuments to remember the First World War and the bravery of the soldiers. There’s exactly one monument to remember the heroes of the Spanish influenza, the doctors and nurses who put their lives on the line to care for patients and colleagues in this epidemic. It was something we see today — that there is a horrendous mortality — >> Yeah. >> — among caregivers was a prominent feature, and I’m hoping this one — people ask me, well, what would my sense of what might happen in this coronavirus, and I say, well, one thing I do hope — in the arts that at least we will memorialize and remember the people in the coronavirus who are the real heroes of the epidemic — doctors, nurses, orderlies, and also, I would add a group people don’t think of so much, but the shopkeepers and attendants who are keeping us going and alive during this epidemic.

Dealing with the public is not a safe position to be in at this time. >> Now when I — I was listening to NPR on the way in, and they were talking about grocery deliveries, which have largely been maintained in the United States, and every time I go shopping, which is in the mornings, because I qualify for the senior time period, — >> Yes. >> — I thank people for working. >> Yeah. >> I mean, you know, we don’t have the capacity to deliver food to 300 million people in the United States. People are going out shopping, and those supply lines, even though people have run out of some numbers of items, has not been that prominent. People largely have been able to get what they need. Now you did talk — you talk about some of the elements from 1918 that we use today: social distancing, you know, some forms of quarantine. You know, it’s so painful in the United States because of the dramatic delay in testing that we really used — needed to use 100-year — essentially 100-year-old approaches because we couldn’t identify who was sick and who wasn’t with the coronavirus.

But the other thing you mentioned, and you touched on it and then moved on, but I want to go back to it, because it’s an issue that’s emerging now in the United States: this notion of waves. You talked about it. >> Yeah. >> So even though it’s the Spanish flu of 1918, it didn’t end in 1918. Could you talk a little more about this — these waves? >> Yes. The — what seems to have happened is that the early waves in 1918, the first in the spring, was rather by comparison benign and seems not to have been a major, major cause of mortality, but the speculation now seems pretty clear that it probably — that the virus mutated between the spring and the autumn, and then it was this autumn catastrophe of November that coincided largely with the end of the war that was the cataclysm that — and it’s — a feature of it that’s pronounced is the curve of the mortality.

That is to say that it seemed a very unnatural event because it didn’t affect the very young and it didn’t effect — >> Right. >> — the very — the elderly in the population, but there was this great W-shaped curve, nodding U, that spiked in the middle with young people and the soldiers, of course, but not only soldiers, but young people in the prime of life, the bread earners of families, and 600,000 and more Americans died in the war, but the Spanish influenza killed many more Americans than the war did, just as most other countries experienced exactly the same. So this was extraordinary mortality and morbidity, and yet there is the sense that somehow it didn’t affect the world in the way that this coronavirus seems to be having a more lasting effect, despite — we don’t know what its mortality and morbidity will be.

I shudder to think, but clearly it’s going to have major, major long-term effects on our economic relationships, on the economy, on the relationship between the industrialized country and emerging markets and international supply links. All sorts of things are going to be influenced by this coronavirus. Political outcomes of major proportions will probably also be in the offing. And so it’s interesting to start to think about why some of these pandemics have left a huge footprint and others seem not to, and it’s not simply a matter of counting the dead or the people who have been afflicted, because even Asiatic cholera, which had a small mortality, was the most feared disease pandemic of the 19th century, and it left a huge impact on the sanitary movement. Our sewers, our [inaudible], our drink — safe drinking water, housing regulations, paved roads, all kinds of — the germ theory of disease all partly emerged out of this major cataclysm that was much smaller than the Spanish influenza. And so it’s interesting to try to tease out why that these pandemics are not just interchangeable causes of death, but each one is experienced by society in a very different way that needs to be looked at on its own.

>> Well, I’m hoping, obviously, and we’ll come back to this that the legacy of this pandemic is preparedness, but — >> That’s what I’m hoping. >> — that is perhaps the best of what could come out of this, because we will face it again, and if it’s not in my lifetime or your lifetime, it will be in our children’s lifetime. It is — [ Inaudible Speaker ] — inevitable, just as a hurricane was. I was struck by your comment, and this came up in my live stream with Nicholas Christakis, about who died in the Spanish flu versus now.

We really know that largely children under 20 are being spared, which is not typical for flu at all in the US. >> Right. >> That doesn’t mean there won’t be some deaths in that age range, but they are largely being not only spared, they are generally been quite healthy, and then obviously older individuals with comorbid conditions have, in every data set, emerged as those at the highest risk, with very high case fatality rates for people who need hospital care, and it’s the one point I want to make repeatedly. We don’t have good denominator data. We don’t know the true case fatality rate. The case fatality rates that are being produced are really case fatality rates of people who seek care.

They’re not people — not everyone who is infected. We simply don’t have denominator data. >> Exactly. >> And so I think we should be careful in — when we talk about 10% case fatality rate, what it truly means. >> Yes. >> But you commented on Spanish flu that it was this middle-age group. It wasn’t the very young or the very old. Are the data good enough to know that that was really the group that were affected, and were there not enough old people then to know if it would have impacted old people? >> Well, it seems that the data under — under that, there’s a consensus on that, and there are fairly robust data, so I think we can take that as pretty much an established truth about this pandemic, and then the — I suppose the immediate question was, “How could this be?” and it seems as though there are a number of the strongest immune systems, a sort of autoimmune reaction that led to a cytokine storm.

>> Yeah. >> And therefore are their lungs fill with blood and they drown to death on their — and suffocate is the way that young people in the prime of life often experienced this horrible disease, and the discussions of autopsy are extraordinary into what the findings were in people’s — young people’s lung, which is consistent with that. There’s also probably, of course, the good epidemiological reasons and that it was the young people who were brought together on transport ships and in military camps and at the Étaples, so the war is part of the reason that it affected young people so much.

There may also be an immunological fact that perhaps there was a crossover immunity that older people had experienced. There was a terrible calamity in the 1890s, and perhaps the older people who had lived through that had a crossover immunity that the — and the younger people simply didn’t have that protection. That, I think, is another factor. >> Frank, there’s a really interesting question, and it hasn’t come up in any of my discussions across my desk despite many — reading many, many submissions. Are there lessons from other epidemics? Not the Spanish flu epidemic, but are there lessons from other epidemics, or is that the first modern epidemic where we have better data historically or where people see — saw it as there were some modern approaches that we understood, but are there lessons from other epidemics that may inform what we should do now? >> I think absolutely there are. One, the psyche of human beings, which is stigmatization and the way that drives epidemics forward, and one can see this from the time of the Black Death was a time of extraordinary violence when, for example, there were anti-Semitic pogroms at Strasbourg.

The — there was a population of 12,000 Jews. They were all rounded up and taken to the Jewish cemetery and offered the option of either conversion or being killed on the spot. Half of them refused conversion, and they were burned alive in the Jewish cemetery. The flagellant movement — these people who went on these processions, whipping themselves — but they also directed their feelings outward, and they also turned on other people, and there was a great deal of violence that followed in the wake of that movement. You can read in some of the literature — the first Italian novel by Alessandro Manzoni, called The Betrothed, shows in the city of Milan in 1630, when Milan was at war with Spain, that Spaniards were found who were totally innocent — they weren’t soldiers.

They weren’t spies. They just happened to be in the wrong place at the wrong time. They were rounded, up tortured, and they confessed under torture. Then their bodies were broken on the wheel and they were burned alive because they were accused of spreading this disease by poison and poisoning the wells and so on. So one sees this. One also — it’s part clearly of, coming more close to our own times, HIV/AIDS, where there was a great deal of blame casting at the homosexual population, and in between, Asiatic cholera created lots of waves of xenophobia. You can see, for example, cartoons and journals of the period of immigrants arriving with on the bowsprit of a ship — with death there on the bowsprit and soldiers and vigilantes coming to the beaches to turn away immigrants from the United States.

There is then this — tuberculosis had not as much of that, but it was the case that people began, particularly, paradoxically — when people understood more, there was — with the germ theory of disease, when it was determined that tuberculosis wasn’t a hereditary disease, as it had been thought before, but was something that was a germ, a disease, as they thought at the time, of filth, and the working classes were — held that. Then there was a lot of social tension on a class basis. Also, in a place like New York, on an ethnic basis, because it was the immigrant groups, the ethnic groups that were more likely to be dangerous in that respect. So there was stigma and not, and now I’m afraid with the coronavirus, we don’t really seem to have learned that lesson, and it seems strange, in that it’s also simply a matter of thinking logically, as the World Health Organization has been, about stigma — that stigma simply isn’t prudent, because what happens then is that the people with the disease don’t come forward, don’t see physicians, and therefore it’s a major driver of the disease. That was seen definitely through the course of the HIV/AIDS epidemic in the United States. The stigma actually made the disease much worse.

So it’s counterproductive in that sort of way, and it’s ethically reprehensible, but nonetheless, we see once again this stigma against Asian people, as if there was something in someone — in an Asian person’s DNA that made them terribly dangerous, and so Chinatowns around the world emptied out, and in the United States, which is particularly — one doesn’t like to stir this demon, because we have such a history in our own country of the Chinese Exclusion Act, and during the Second World War, the internment camps for Japanese-Americans. You’d think that we would be, in a sense, inoculated against that particular form of ethnic prejudice, but we don’t seem to be, and there are these awful stories of assaults on even Chinese schoolchildren in the United States. And this isn’t true only, of course, in the United States. The — one finds in Italy, where I am at the moment, that there are sort of right-wing populist groups that — the same sorts of people in Italy who in Britain might have been Brexiteers and in Italy have a different sort of political orientation, but they have said that — this is a point without any evidence at all — that this was a disease of immigration, and we must close borders and we must hunt for the case — the index case of this disease, and that person will be guilty, and we can blame them, and clearly it was an immigrant and Le Pen’s — is making that same sort of — there’s upsurge of a sort of violent nationalism and xenophobia and nativism in lots of respect.

So that’s a very worrying trend and one that — as Dr. Tedros, the director-general of the World Health Organization has been saying, there’s this horrible misinformation epidemic that accompanying this pandemic, and the information epidemic is driving the biological pandemic forward, and therefore it’s really dangerous, and one must be extremely careful not — to not accept the statements that it’s a Chinese virus or that it’s due to immigrants in Italy or the same in France and so on. So I think that’s another lesson of this, and hopefully when you’re having your good hope that after this is over that preparedness would be — go into effect, a sustained preparedness — I would add that — no longer the feast and famine, but something that was sustained part of our lives, that this — part of that would be the — an intense campaign of education to teach the perils of bigotry on ethnic lines and scapegoating was — when in fact, in times of disease, patients from — that — who contract contagious diseases are guilty of nothing more than being at the wrong place at the wrong time.

So I’m hoping that that will be something that people really understand in our country and around the world. So that would be — changing our hearts and minds in that respect, too, would be a wonderful thing to have happen. >> Yeah. I do think preparedness has worked. I’m always hesitant to think of Taiwan and Singapore as the best examples. They’re very small countries. But Korea is a much larger country and generally has done quite well. They had learned quite a bit from SARS and, you know, they were up with very aggressive testing, case-finding, tracking, and quarantine very, very quickly — something the US tragically, tragically was not able to do. >> Yeah. >> Many other countries weren’t able to do it, but that — >> Italy is one of them, too. >> That was — without doubt, the great tragedy is the waste of six, eight, or ten weeks because of just an extraordinary number of failures in the US.

[ Inaudible Speaker ] The last question, Frank. It’s become much more of a topic. Much discussed in the US is the wearing of masks. You know, JAMA had published an article — I looked at it early this morning — six weeks ago that there was asymptomatic spread, so I’m surprised that a number of leading societies and authorities are saying, “Well, there’s asymptomatic spread. Maybe we should be more conscious about wearing masks in public.” Certainly many health systems are now asking all employees to wear masks. Not every health system, but many.

Obviously we need more masks for this to be the case, although there’s many homegrown versions. What’s going on with wearing masks for the public in Italy? >> Right. Initially, the word that was put out was that it was kind of a service to the health care community not to wear masks because there simply weren’t enough. The supply was so restricted that it should be — they should be reserved for those who need them most was what we were told initially, and so I for one didn’t buy a mask for that very reason, and then soon after, the advice changed, and — >> Oh, it did change. >> But initially, it was that, but people didn’t seem — they weren’t compliant with this, because you could see that there weren’t — when finally the idea was that you should buy them, there weren’t any masks to be had. There was not a run on toilet paper here.

There was a run on masks and gloves, and I went to the pharmacist and asked for gloves and masks, and they laughed at me. You know, you won’t find one anywhere in Rome. Well, that didn’t turn out to be true in the end — you’ll be glad to know I have both masks and gloves now — but that did take a couple of weeks to happen. >> And are more people wearing masks in public than in the past? >> Oh, oh, absolutely. >> They are. >> There’s — when you go out on the streets, I would say, at least in the neighborhood where I live, 80% of the people and more are wearing masks, and people grumble a little bit if you’re in the line at the supermarket and you’re not — >> Yeah.

>> — wearing — >> This is Howard Bauchner, editor-in-chief of JAMA. What a pleasure to talk with Frank Snowden, the Andrew Downey Orrick professor emeritus of history and history of medicine at Yale. We’ve been talking both about his book, his experience, his current time in Italy. This has been Conversations with Dr. Bauchner. I want to remind our listeners on Monday, there will be a live stream with Preeti Milani. We’ll go through her update article that will be published either tomorrow or on Monday. It will be all clinical — less history, all clinical current events. But Frank, I really want to thank you for joining me today, and I really want to make sure you stay healthy. >> Thank you so much, and you do the same, and it’s been a great pleasure.

>> And I look forward to your book on coronavirus epidemic/pandemic. >> Oh, well, thank you very much. I do, too. [Laughter] >> All right-y. Bye-bye, everybody. >> Yeah. >> Thanks, Frank. >> Goodbye..

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