| First of all, two caveats.
1) If you haven't been following this, and haven't read part 1, you are likely to find this discussion mind-bogglingly tedious, and will probably ask, what is the point? To avoid descending into that state, I would recommend that you read Part 1, to get the big picture of what the controversy is about, and the accompanying implications for public health policy in a pandemic.
2) This is NOT meant to be an exhaustive examination of the issues raised by John Barry and Osterholm, and the rebuttals by Markel and colleagues, but only a look at a few snippets of information that happened to come my way. Having said that, I do think it is possible to at least make some sense of most of the important points raised in JAMA and CIDRAP. Whether you can come to any conclusions, and what these conclusions are, I will leave to your own judgment!
In the article he wrote for CIDRAP, John Barry had this to say, as a preamble:
I support many (though not all) of the proposed interventions, but I do not support analysis based on weak data - especially when those data that are flatly contradicted by better information. Yet that is what could happen in this case.
His position appears to be endorsed by Osterholm, who said "I believe Markel and colleagues did not address the important challenges that Barry presented.....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. I believe John Barry makes a clear and compelling case below that Markel has not met that standard. We must."
Barry focuses on 2 cities New York and Chicago, but feels some justification to extrapolate his concerns to the other 41 cities studied as well:
By pure happenstance, I am familiar enough with events in New York and Chicago to make a judgment on the quality of his assessment of those two only, and I do not know how valid his findings are in the other 41 cities. But his interpretation of data in Chicago and New York does not inspire faith in the rest of his analysis.
Essentially, as far as I can determine, Barry made 2 claims, that there is no evidence to support that
1) New York city imposed isolation and quarantine in the 1918 pandemic, and
2) Chicago imposed any NPI early (Day -2, ie 2 days before the excess mortality was double the baseline) as defined in the JAMA study ie school closures, banning of gatherings, and isolation and quarantine.
CHICAGO
I'm going to take the second question first, cos it has a rather short answer. For Chicago, Barry complains that one cannot determine what action was taken on what date, because no specifics were given in the paper, and the 1,144-item bibliography's "size obscures rather than elucidates" He did, however, look up a source, with the following findings: ...according to the Chicago health department's 100-plus-page "Report of an Epidemic of Influenza in Chicago During the Fall of 1918," which is not in Markel's bibliography, only two actions were taken on day minus-2: The state banned public funerals and the city issued orders for teachers to inspect schoolchildren. These actions fall far short of the authors' metrics.
Yesterday, I did have this query, whether 2 of the citations in the bibliography, the 1919 and 1923 editions of the Report of the Department of Health of the city of Chicago, by JD Robertson, might actually be the primary source documents that Markel used.
As it turned out, not only WERE they the primary documents for the various NPIs that Chicago implemented together with the dates of implementation, the reference that Barry cited, "Report of an Epidemic of Influenza in Chicago During the Fall of 1918," was in fact one of the chapters within the report itself!
The following are clipped from scanned copies of the cover of the report, and page 40 showing where the chapter starts (click to enlarge)
 
It would appear that Barry has mistakenly taken the title of one chapter of the report, to be the title of the whole report itself...maybe...
NEW YORK
For New York, the issues are a little more complex, because it isn't just a matter of determining whether New York did or did not implement quarantines during the pandemic, but there are additional issues that I believe require scrutiny. But still, first things first.
Was quarantine implemented in NY?
According to Markel et al, there is abundant data including numerous newspaper accounts of the actions of health authorities in relation to quarantine, but the primary evidence that quarantine was in fact used as a public health measure came from the fact that the NY City Board of Health met on Sep 17, 1918 and changed the Sanitary Code to make influenza and pneumonia reportable diseases, and the minutes of the meeting reflected that. This is NOT disputed by Barry. It is the interpretation of this act, making a disease reportable, that is at issue.
Markel and colleagues maintain that in New York at the time, making a disease reportable had a very specific meaning, namely that those diseases that were reportable were also actionable, requiring the isolation of cases. This is reflected in newspaper accounts appearing the next day.
The following is a clipping from the Sep 18, 1918 copy of the NY World. It's a little hard to read, but I did want to include the image here.
 Here's part of the text:
The Department of Health is sending to-day the following letter to all resident physicians: "Your attention is herewith called to the fact that influenza, acute lobar pneumonia and bronchial or lobular pneumonia have been included among the infectious diseases which are required to be reported by physicians and superintendents of hospitals and dispensaries.
"These diseases were made reportable by action of the Board of Health in amending section 86 of the Sanitary Code. You attention is called to section 89 of the Sanitary Code, which requires prompt isolation of persons affected with infectious disease and such other action as is or may be required by the regulations of the Department of Health"
The New York Times also reported on this, with the headline "Must Report all Spanish Influenza". There are other interesting points about this article which I will return to later.
What about Barry's claim, that New York did NOT impose isolation and quarantine?
John Barry, in his letter to JAMA, claimed that Health Commissioner Royal Copeland never imposed the measures that he told reporters he was going to impose. Barry cited 3 pieces of evidence, 2 of which involved the absence of isolation and quarantine being mentioned in a) an article in the NY Medical Journal by the health commissioner's assistant, and b) the health department's annual report.
Suffice it to say that absence of evidence is NOT the same as evidence of absence, and that IMO the reason why you have to look at multiple sources is BECAUSE each source is not necessarily complete.
However, it is the third claim made by Barry that to my mind is most significant and deserves a little more detailed examination. This is a direct quote from his letter to JAMA:
Although the health department had made some effort early in the summer to monitor individual cases coming off ships, the commissioner argued against isolation and quarantine: "[E]ven if we went through some Utopian method of policing to confine every person to his or her home, it is doubtful whether the epidemic could be measurably diminished."3
The citation is: Copeland RS. General survey of the influenza epidemic. NY Med J.1918;108(17):715-718.
Markel in his rebuttal said Barry had quoted Copeland out of context, that Copeland was NOT talking about isolation of cases and quarantine of contacts, but "rather the futility of potential home confinement of all New Yorkers and universal closure of public places". Barry countered this in the CIDRAP article:
It's one thing to surveil three or four people coming off a ship. It's another to wait for a case to be reported (and hope cases are in fact being reported) and then try to isolate dozens, then quickly hundreds, then thousands of influenza cases. No wonder Copeland debunked the idea, as he did in the quotation used in my letter to JAMA. Markel accuses me of taking this quote out of context. Rather than argue with him, I will happily fax the articles to anyone who requests them (print quality of the articles prevents including a link here) so readers can judge for themselves.
Well, the following is a copy of the article. I didn't get it from Barry, as he appears to be traveling, but still it worked out in the end! I am putting up the relevant page, so that, as Barry said, "readers can judge for themselves".
For those who may have a challenge with viewing images, here's the relevant text:
As to closing the theatres, moving picture shows and the like, a discriminating attitude has been adopted, those places being shut down which were found upon inspection to violate the sanitary laws and to be favorable to the breeding of disease. Had we adopted a universal order with respect to the closing of theatres and moving picture shows, we should then logically have closed every department store, every office and factory, every restaurant, and cabaret show, and every club. The disease is one which is spread to a large degree by contact in the home, and even if we went through some Utopian method of policing to confine every person to his or her home, it is doubtful whether the epidemic could be measurably diminished.
Did the NY Commissioner of Health lie?
One of the central arguments that Barry uses to support his claim that quarantine was not implemented, is that Copeland lied about it, to reporters from the different newspapers, as well as to the JAMA, which in a Sep 28, 1918 article said "Citizens who have contracted the disease are quarantined and the health department is prepared to compel patients, who may be so situated as a menace to the community to go into hospitals."
What is the argument used to support this idea? I'm a little unclear on this point, but it appears to center around the issue that Copeland was a homeopath not an MD (which btw was not unusual in those days. Even today, most public health officials in the US are NOT MDs), and that he was appointed by a corrupt political elite.
In addition Barry in the CIDRAP article proposes various reasons why Copeland might lie about quarantine, one of which had to do with what was happening in Jersey City:
The same day that New York made influenza reportable (Sep 17), Jersey City imposed an actual quarantine. The Times reported both actions. It is easy to imagine that this put pressure on Copeland. At any rate, the same day the information about Jersey City was published, he told the Times that New York City was using "strict isolation and quarantine," in effect calling Jersey City on quarantine and raising it on "strict isolation."
Now is there any EVIDENCE that was what happened, that the fact that Jersey City had imposed a quarantine placed Copeland under so much pressure that he lied about it? Well, the said NY Times article on Sep 18th, "Must report all Spanish Influenza" is available here. Again, judge for yourself.
EPILOGUE
Let there be no doubt, that I wrote this with great sadness, and a heaviness of spirit that goes beyond my usual concerns about pandemic preparedness, planning and policy. I'm no scholar by any stretch of the imagination, but I was brought up on a diet of books and lessons, of inquisitiveness and even argumentativeness. I believe in respecting different opinions. As a dear friend once said, "If we are exactly the same, one of us is redundant."
My efforts are minor on the grand scheme of things, compared to all the great achievements of John Barry, Howard Markel, Mike Osterholm, Marty Cetron, and others. I have no soapbox to stand on, in this debate, except to wish everyone well, and that our energies can be directed towards the greater common goal, of getting the world prepared for the eventual pandemic, to whatever degree we can, and however imperfect our efforts may be.
That is the least, and the best, we can do.
There is no Plan B. |
