Public Health – Dave Kenney

The Roots of Vaccine Skepticism

Smallpox vaccinations in Minneapolis, 1904. Via the Minnesota Historical Society

Some reluctance is historically understandable, even if it’s currently misguided.

One day in early 1901, a Minneapolis health inspector named Luxton visited the city workhouse to administer smallpox vaccine to all inmates who had not previously been vaccinated. Deadly smallpox was spreading rapidly across the nation, and had recently taken hold in Minnesota. The race was on to prevent the epidemic from getting out of hand. Public health officials in the state had no legal authority to force vaccinations on those who objected, but that didn’t stop them from occasionally wielding what were supposed to be prohibited powers against the powerless. The inmates at the workhouse fell into the powerless category.

While most of the men Luxton encountered that day submitted, one did not. “A muscular fellow with a determined look in his eye” declared that he was not about to let the vaccinator touch his arm. Luxton offered to administer the vaccine to the man’s leg instead. The man agreed. But it turned out the man was a trickster. He had a wooden leg. He insisted that Luxton do as promised, and perform the vaccination on the artificial limb. Luxton was not amused. He called in a couple jailkeepers and had them strip down the man and subdue him while vaccine was administered against his will. The story, which ran in the Minneapolis Tribune, served the health department’s purpose. It reassured readers that the city would do whatever it took to protect good people from the less good—those on the margins—who, by implication, could not be trusted to do the right thing.

It’s one of many such stories from our past that help explain why some people might be reluctant to get vaccinated against COVID-19.

A recent study conducted by the Pew Research Center shows that only 42 percent of African American adults plan to get the coronavirus vaccine. That compares with 60 percent of Americans overall who are inclined to do so. Black people have plenty of reasons to be skeptical about the government’s public health intentions. Many are well aware of the Tuskegee syphilis study and other racial outrages perpetrated over the years in the name of medical advancement. And they are not alone. Other Americans marginalized due to race, ethnicity, and economic circumstances have reason to be wary as well. The forced vaccination of the man with the wooden leg is just one example from Minnesota’s early 1900s smallpox epidemic of how social inequities can taint efforts to protect public health.

The homeless and transient—those described by one St. Paul health official as belonging to the “lower world”—were among the first be singled out for coerced vaccination. Raids on Twin Cities lodging houses, dingy buildings packed with low-wage working men, became increasingly common. When a smallpox case was discovered at lodging house on South Washington Avenue in Minneapolis, a phalanx of city health workers moved in and “thoroughly fumigated and vaccinated” all lodgers, while police guarded the doors “to prevent exit or egress.” In this and other similar cases, health authorities got around restrictions on forced vaccination by threatening forced quarantines.

Recent immigrants were also subjected to early and uncompromising vaccination. In early 1901, the neighborhood known as Little Italy on St. Paul’s upper levee found itself under a “state of siege” when a child there was diagnosed with the most virulent strain of smallpox. In explaining the need to strictly enforce vaccination in the community, the St. Paul Globe explained that the residents of Little Italy were “clannish” and “little given to the most ordinary rules of cleanliness.”

Communities of color were likewise targeted with heavy-handed treatment during the epidemic. In northern Minnesota, federal authorities threatened to withhold treaty payments to members of the White Earth Nation of Ojibwe if they did not get vaccinated. In Minneapolis, health officials raided an African American social club on Hennepin Avenue and prevented all members from leaving until they submitted to vaccination. These were not isolated incidents. Although authorities in Minneapolis acknowledged that smallpox made no distinction between toney Lowry Hill and downtrodden Bohemian Flats, they insisted it made sense to focus their attention on “poorer quarters” where the disease was most likely to spread. Such explanations provided little comfort to those who felt besieged by both disease and unequal treatment by the government.

This is not to say the inequities that surfaced during Minnesota’s mostly-forgotten turn-of-the-century smallpox epidemic can explain away the wariness that some people now have about the COVID-19 vaccine. Too many things have changed since the early 1900s to draw clear parallels. For one thing, there was no formal process to ensure the safety and efficacy of vaccines back then. Now there is. Beyond that, we have little reason to suspect that our current local, state, or federal authorities will stoop to forcing or coercing or anyone to take the coronavirus vaccine against their will. But public health missteps, no matter how infrequent or dated, add up in the collective memory. We should keep that in mind. It’s no surprise that some people think twice before saying yes to the latest vaccine.

The War Over Pandemic School Closings in Minneapolis (1918 Version)

Minneapolis Tribune, October 21, 1918

At least no one’s threatening to throw school board members in jail—yet.

As we in Minnesota get ready to send our kids back to school—either in-person, virtually, or through some combination of the two—we should try not to let our hopes get the best of us. If history is any guide, we will eventually be forced to acknowledge what we already know: that pathogens do not respect school calendars. The experience of the Minneapolis public school system during the height of the 1918 “Spanish flu” provides a sobering reminder of how reality tends to stomp on our best intentions.

The influenza pandemic that arrived in United States in the spring of 1918 did not hit Minneapolis until the fall of that year. But when it did arrive, it spread quickly, and it convinced public health officials to act. On October 11, 1918, the city health department ordered all places of public gathering—churches, theaters, dance halls, pool halls, and schools—closed indefinitely, until the pandemic was under control. The shut-down put Minneapolis’s top health official, Dr. H.M. Guilford, in direct conflict with the city’s school board, whose members felt they knew what was best for children, teachers, and staff. And what was best, they insisted, was that kids keep going to school, the flu be damned.

Many of the school board’s arguments for keeping students in school—some of which later proved dubious—sound familiar today: the disease did not seem to be nearly as dangerous to children as it was to adults; kids were actually safer in school than they were playing on their own in “streets and alleys;” schools should not be forced to close while some businesses, including bars, remained open. About a week into the shut-down, the school board voted to defy the health department and reopen the schools, but Guilford refused to budge. The board’s members backed down two days later when faced with possible arrest.

But as the schools remained closed, public sentiment against the shut-down grew. Guilford finally relented. Minneapolis’s public schools reopened on November 18, five and half weeks after they were ordered to close. While celebrating the reopening, school superintendent B.B. Jackson sought to preemptively shift the blame for any influenza outbreak that might occur in the coming weeks. If the flu took hold in the schools, he said, it would be the fault of the “questionable activities” of the children themselves. Jackson also acknowledged that Guilford had warned the board that reopening “would not be wise.”

And, as it turned out, Guilford was right.

Two weeks later, schools throughout the district were reporting an alarming number of influenza absences. In one school alone, Fulton Elementary in North Minneapolis, 126 students were out with the disease. The latest spike seemed to confirm that the “Spanish flu” was not, as many people believed, an illness that skipped over children. Guilford responded by re-closing the schools until the end of the year. This time the school board raised hardly any objections. When the schools reopened at the start of the new year, the 1918 wave had effectively dissipated. Students resumed their education with few disruptions.

Comparisons between the 1918 influenza and the COVID-19 pandemic are admittedly imperfect. The “Spanish flu” was deadlier than the disease caused by the new coronavirus. Minneapolis’s schools had to shut down suddenly, while classes were underway, and did not have a chance to institute the kind of safety measures that our schools will use this fall. But the events of the fall of 1918 still carry an important lesson for those of us hoping that this coming school year will move forward without major disruptions. Unfortunately, it probably won’t.

Freedom’s NOT Just Another Word for “F#@% You”

Brainerd fluoride opponents, 1979. Photo via Minnesota Historical Society

Self-proclaimed liberty lovers have always had a problem with public health.

If you want to sample COVID-19-era grievances in Minnesota, just make your way to the Twitter accounts of some of the state’s most prolific social media “freedom fighters.” (I’m tempted to identify a few for your reading enjoyment, but I’m no masochist.) These days, Minnesota’s self-proclaimed liberty lovers seem most exorcized about Gov. Tim Walz and his brandishing of dictatorial powers. A few samples:

If @GovTimWalz tries to enforce mandatory mask…there’s going to be push back…go ahead arrest me… fine me…put me in jail…but there will be a response for draconian rule and violating the Constitution.

The Sheepeople of America have dropped to there [sic] knees over the Corona Virus which has a death rate of the Flu…If you’re to [sic] stupid to believe this [is] not a plan for destroying American capitalism then you deserve to be exploited and abused in Socialism….I will never kneel.

Liberals get so pissy when people won’t buy their crap. It’s why they need the power of the government to make you buy it. They already run the schools, Hollywood, sports, the culture….it’s not enough until YOU comply. Well, fuck off, I’m not complying.

For these people, freedom, not public health, is the primary concern. They believe personal liberty should supersede all efforts to contain the coronavirus. And while they may feel oppressed by liberal sheepeople intent on muzzling them with masks, they can at least take solace in the knowledge that resistance to public health initiatives—even those judged now to be huge successes—has always existed in Minnesota.

But unfortunately for them, their side usually loses—at least in the long term.

For decades after the development of vaccines, a persistent minority of Minnesotans resisted any efforts by authorities to institute mass vaccinations. As the anti-vaccination St. Paul Globe saw it, too many liberty-loving Minnesotans were happy to “assert the right to jab a virulent virus into the person of his neighbor, willy nilly.” In 1903, anti-vaccination activists used the language of personal freedom to win the repeal of an existing state law requiring children be vaccinated against smallpox. But that early anti-vaccination victory was short-lived. Twenty years later, a severe smallpox outbreak hit the Twin Cities, and suddenly vaccines didn’t seem so bad.

Around that same time, opponents of another public health measure—the chlorination of Minneapolis’s water supply—were making similar arguments. Over the years, Minneapolis had experienced multiple typhoid epidemics caused by polluted Mississippi River water. But in 1910, the city started treating its drinking water with a disinfectant, hypochlorite of lime. Libertarians, more tolerant than others of fecal contamination, argued against the treatments, but the Minneapolis Tribune dismissed them as “well poisoners” and “child murderers.” It didn’t take long for even the most adamant chlorination skeptics to admit that non-lethal drinking water was probably in everyone’s best interest.

The pasteurization of milk was another public health priority that Minnesota’s leave-us-alone contingent attempted to undermine. When several Minnesota communities, including Minneapolis, instituted compulsory dairy pasteurization to control communicable diseases, opponents mobilized. One of their most common arguments was that housewives should be free to purchase unpasteurized dairy products. The inability to buy raw cream struck one Minneapolis Star reader as especially “undemocratic.” Although opponents succeeded in stalling the movement for a few decades, “universal pasteurization” became state law in 1949.

But libertarian opposition to public health efforts may have reached its apex in the early 1950s, when communities throughout Minnesota started adding cavity-fighting fluoride to their water supplies. Prominent conservative activist Donald F. Raihle spoke for many like-minded Minnesotans when he called community fluoridation a violation of “the fundamental principle that no person or agency shall have authority over the body of a human other than himself.” Raihle and his fellow fluoride fighters continued to agitate throughout the 1950s, but their efforts ultimately proved futile. A state law passed in 1967 mandated fluoridation in most Minnesota cities. Brainerd, the state’s last prominent fluoride holdout, started treating its water in 1980 under court order.

Of course, libertarian opposition to public health measures never completely vanished. Anti-vaxxers, raw milk-drinking “food freedom” fighters, and fluoride conspiracy theorists still make their presence felt with various degrees of effectiveness. But they remain, at best, minority voices. As polls taken during our current public health crisis suggest, most Minnesotans continue to believe that tempering personal liberty makes sense if the goal is an undeniable public good—like, I don’t know, saving lives? It’s possible that the Minnesotans who believe Tim Walz is tyrant shepherd leading his flock into liberal captivity will ultimately win the battle of public opinion, but the historical record suggests they won’t.

What We’ve Lost: Grandma’s

While we’ve lost way too many lives to COVID-19, we also have lost many things that we previously took for granted.

The inaugural running of Grandma’s Marathon between Two Harbors and Duluth took place 43 years ago today, on June 25, 1977. Only 150 runners participated in that first race. The winner was Olympian and Duluth native Garry Bjorklund. The gentleman in this photo, Alex Ratelle, was, at 52, the oldest runner in the 1977 race. He finished fourth. He went on to compete in 21 straight Grandma’s.

Photo via Duluth News-Tribune

Riding the Waves

Are we in COVID-19’s first wave? Second wave? From 1918 to 1920, Minnesotans endured four waves of the “Spanish flu.”

On the Monday before Thanksgiving 1918, business leaders in Albert Lea, Minnesota, declared victory of sorts on the front pages of two local newspapers. “Good cheer is in order,” they proclaimed. “Smile and the world will smile with you.” Indeed, they and nearly everyone else in Albert Lea had legitimate reasons to give thanks. For one thing, the Great War in Europe had recently come to an end. But Albert Lea’s businessmen seemed especially giddy about something else: the apparent defeat of what had become known as the “Spanish flu.” Over the previous two months, the influenza virus responsible for a global pandemic had sickened hundreds of people in the city and killed at least 14. But now the disease seemed to be retreating, and the businessmen were in the mood to celebrate. “Life is coming back to what it used to be,” they asserted. “We shall soon forget there ever was an influenza epidemic. Why shouldn’t we? Restrictions that were placed upon communities several weeks ago have been removed. In other words: the ban has been lifted.”

But the people of Albert Lea, like people everywhere—in Minnesota, the United States, and the rest of the world—were soon to learn that there was no way to truly defeat a virus to which few people were immune and for which there was no vaccine. The “Spanish flu” ebbed and flowed, but it never really went away.

The pandemic’s first wave hit the United States in the spring of 1918, but it was mild, and pretty much skipped over Minnesota. The second wave arrived in September 1918, and it was that one that walloped Albert Lea and so many other communities in Minnesota and the rest of the United States. Municipalities responded by setting up emergency hospitals, quarantining households where the disease appeared, closing schools, shutting down certain businesses, and banning public gatherings. Citizens chafed at the restrictions, but they generally recognized the need for patience. After two weeks of restrictions in Albert Lea, the Freeborn Standard summed up the city’s glum mood. “Yesterday was probably the longest Sunday people here ever spent,” it lamented. “There was no church nor moving pictures to pass the time, and added to that it rained all day.” Still, the newspaper cautioned its readers that “every care must be exercised until the malady is entirely stamped out.” No wonder then that, a few weeks later, the city’s business leaders were eagerly declaring that the disease was vanquished.

But they were wrong. There were more waves to come.

The first sign that the influenza would persist came in mid-December, when an outbreak occurred at a local boarding school, Luther Academy. The city responded by briefly banning dances and imposing a few other restrictions, but the spike in cases was short-lived. The December uptick, which also occurred in other Minnesota cities including Minneapolis, turned out to be the last gasp of the “Spanish flu’s” second wave.

The pandemic’s third wave hit the United States in March and April of 1919, but Albert Lea, like most communities in Minnesota, avoided the worst of it.

It wasn’t until January of 1920—15 months after the “Spanish flu” first emerged in Albert Lea— that the city experienced the fourth wave. This final surge, which affected communities throughout the United States, is often forgotten today, but it serves as a grim reminder that viruses, with little to stop them, can reemerge at any time. In Albert Lea, the fourth wave turned out to be less deadly but at least as pervasive as the second wave of autumn 1918. Once again, the disease emerged at Luther Academy and quickly spread into the community. The city cancelled its winter sports carnival, banned public gatherings, and shut down all dance halls, movie theaters, lodges, schools, and houses of worship. It set up a new emergency hospital in a Masonic hall, which quickly became what the Albert Lea Tribune called “one of the busiest places in the city.” Although the fourth wave, which continued through most of February, apparently killed only a small number of people in Albert Lea, it still did considerable damage statewide. Statistics compiled by the state board of health shortly after fact showed that more than 2,100 Minnesotans died of influenza in January and February 1920, the two months that encompassed the fourth wave. Those numbers almost certainly represented an undercount.

As it turned out, the businessmen who predicted in the fall of 1918 that the people of Albert Lea would “soon forget there ever was an influenza epidemic” had engaged in wishful thinking. While life in the city did return to a certain level of normal once the “Spanish flu’s” second wave petered out, the deadly disease continued to lurk until it reemerged more than a year later.

Today, as Minnesota loosens restrictions imposed during a new pandemic, the century-old experience of Albert Lea—and the similar experiences of countless other communities in Minnesota and elsewhere—can instruct us. It’s natural to identify with those business leaders who in 1918 called on the people of Albert Lea, shell-shocked by the “Spanish flu,” to stop “moping around” and “look on the bright side life.” After all, we want to get on with our lives, too. But we, unlike those southern Minnesota optimists, also need to temper our expectations. The new coronavirus is not done with us, and probably won’t be for a long while. It may not be as deadly as H1N1 virus behind the “Spanish flu,” but it has a longer incubation period, which means it will probably burn through communities more slowly than the “Spanish flu” virus did. And once it completes its burns, it will almost certainly hang around until conditions are right for a resurgence. That’s how the influenza pandemic played out a century ago. We should be ready for the very real possibility that, at least in this respect, history will repeat itself.

Good Grief: Why Pandemics Aren’t Funny

Until COVID-19 got me thinking about previous pandemics, I didn’t realize there even was such a thing as the 1958 “Asian flu.” But Charlie Brown did.

Published by MINNPOST on May 1, 2020

On March 9, 1958, a global flu pandemic unofficially became a national joke. When Americans turned to the funny pages of their Sunday morning newspapers, they found Charlie Brown, the sad sack hero of Minnesotan Charles Schulz’s Peanuts comic strip, lamenting his shortcomings on the hockey rink.

“I don’t feel good,” Charlie Brown told his nemesis, Lucy. “I think maybe I’m getting the Asian flu.”

Lucy, as usual, showed no sympathy. She informed her downcast companion that the “Asian flu” was yesterday’s news. “What a guy!” she exclaimed as she walked away. “Everyone else got the Asian flu six months ago, and he’s just getting it now!”

Charlie Brown was left to deliver the punchline to himself. “Good grief!” he sighed. “I can’t even get sick right!”

It was a funny joke—at the time.

But decades later, with the benefit of hindsight, it doesn’t seem quite so funny. That’s because we know something now that Charles Schulz and his readers didn’t know back then. According to the Centers for Disease Control, the “Asian flu” pandemic of 1957 and 1958 killed an estimated 116,000 Americans and around 1.1 million people worldwide. It was one of the worst public health crises of the 20^th century. So how did it become the butt of a joke in the Sunday morning comic section? The answer lies in what was, at the time, a widespread public misunderstanding about the scope of the pandemic—a disconnect between perception and reality. It was the kind of disconnect that we should keep in mind today, as we try, in real time, to make sense of the havoc the new coronavirus is causing.

In March 1958, when the Peanuts comic strip appeared, the “Asian flu”—an influenza caused by a new strain of the H2N2 virus—was a well-known fact of life in the United States. It had emerged about a year before in Singapore and Hong Kong, and had spread to U.S. coastal cities in the summer of 1957. Scientists determined early on that very few Americans were immune to the new virus, and they raised public alarms about its potential lethality. (They also rushed to create a vaccine that played a crucial role in limiting the virus’ spread.) When the “Asian flu” arrived in Minnesota in September 1957, people were ready for the worst.

But the “Asian flu” never seemed to live up to its advance billing. State and local health officials reported occasional outbreaks, including one that clobbered Minneapolis’s North High School in October, but the information they shared with the public inadvertently downplayed the virus’ severity. Laborious testing protocols made it difficult to confirm that a patient with flu-like symptoms had actually contracted the “Asian flu,” so mortality statistics released to the public included very few “Asian flu” deaths. At the end of 1957, when the pandemic’s first wave had subsided, Minneapolis’s health commissioner reported a total of just 18 confirmed deaths from the new H2N2 virus—a sobering number, certainly, but nothing close to the numbers that Minnesotans had been primed to expect. And the national death toll was similarly underwhelming: about 6,000 deaths attributed to the new H2N2 virus throughout the entire United States.

So how do we explain the discrepancy between the 6,000 fatalities ascribed to the “Asian flu” at the time of the pandemic, and the 116,000 deaths that the CDC estimates now? It all comes down to how fatalities are tabulated and estimated. In an ongoing pandemic, death tolls are based on reports of fatalities officially attributed to the pathogen in question. But those real-time numbers almost always turn out to be undercounts. The true scope of a pandemic’s deadly toll becomes clear only after the fact, when experts use statistical modeling to determine “excess mortality”—the number of deaths beyond what would normally be expected. There’s nothing particularly controversial about using excess mortality to estimate the number of people killed in a pandemic. It’s generally considered the most accurate way to express results of what is admittedly an inexact science. And if you compare at-the-time death tolls of other pandemics with after-the-fact estimates based on excess mortality, you see discrepancies similar to the ones that showed up after the 1957-58 “Asian flu” pandemic.

In November 1918, as the second wave of the H1N1 “Spanish flu” pandemic wound down, federal officials reported that the virus had killed about 82,000 Americans. Today, the CDC puts the death toll at 675,000.

In July 2009, toward the end of the first wave of the H1N1 “swine flu” pandemic in the U.S., the government reported 302 deaths attributed to the virus. The CDC now estimates that more than 12,000 Americans died in that pandemic.

The lesson is simple: It’s nearly impossible to know how deadly a pandemic really is while you’re living through it.

If you find yourself wondering whether Minnesota’s relatively low number of confirmed COVID-19 fatalities (so far) suggests the coronavirus has been overhyped, remember the mistake Charlie Brown and Lucy made back in 1958. They dismissed the “Asian flu” as a nuisance to be laughed off when it was actually killing more than 100,000 Americans. But Charles Schulz and his Peanuts characters didn’t know any better. Nobody did back then. The true scope of the 1957-58 pandemic became clear only with the passage of time and the application of statistical modeling. Now all of us find ourselves in a similar moment of muddled perceptions. Whatever the numbers tell us today about infections and fatalities, they almost certainly represent a significant undercount. It’s a sobering thought, but it’s also a reminder of why we continue to put up with this unprecedented disruption of our lives.