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The Second Wave

By Paul Root Wolpe

Seattle police officers during the 1918 flu epidemic

Image courtesy of Wikimedia Commons

In 1918, an influenza epidemic swept the world, infecting about 500 million people globally and killing between 20-100 million victims – the true count will never be known. The total death likely exceeded all those killed in World War I, soldiers and civilians alike. Over 675,000 people died in the United States alone, greater than the entire population of the city of Pittsburgh at the time.

The flu spread like wildfire in the Spring of 1918, raging through Europe in March and April. While the death toll was tragic and high, by the summer most thought the epidemic was over. However, the virus mutated over the summer, and a second wave, beginning in September, was devastating. 195,000 Americans died of influenza in October alone.

But what was equally astonishing was that the epidemic did not only take the very young and old, traditionally vulnerable to influenza, but the young and healthy as well. It took people in the prime of their lives. The medical establishment was not used to young, seemingly healthy 25-35 year-olds dying by the millions. And their death were agonizing – blistering fevers with nasal hemorrhaging and pneumonia, they would eventually drown from within, their lungs filled with fluid.

The end of WWI in November slowed down infection, and once again the world thought it was over. But in January 1919, a third wave started in Australia and spread back to Europe and the US, almost as deadly as the second.

There were complicating factors in the 1918 flu that worsened the spread and impact of the disease. Early 20th century medicine could not cope with the epidemic. Wartime packs people together, and nations were reluctant to impose quarantine during the war.

Image courtesy of Pixabay
As we weather the Spring of the COVID-19 epidemic, there are lessons to learn from the epidemic of 1918. Not all cities in the US fared the same. An analysis of 43 US cities from September 1918 to February 1919 found that the cities that implemented social interventions like school closure and public gathering bans the earliest fared the best; they had greater delays in reaching peak mortality, lower peak mortality rates, and lower total mortality.

In other words, social distancing had a profound impact on how many people died. New York City, whose health department at the time was renowned for being innovative, rigidly enforced isolation and quarantine procedures. Pittsburgh, on the other hand, delayed implementation and Pennsylvania eventually rescinded public gathering bans; while New York ranked 15th of the 43 cities studied in a measure of mortality burden, Pittsburgh scored 43rd.

We are now in the process of slowly opening up workplaces, allowing people to once again venture out into public places. Luckily, we are entering the summer, which will give schools a “free” few months for the pandemic to settle before they have to make the difficult choice of whether to open for the Fall semester.

But what if we have a second wave? What if we start to see cases rising as we move into late August, September? At what point will we be certain we are seeing the start of a second wave, rather than a normal fluctuation in cases? Will we have the political will to shut everything down again, after all the pain of this first wave?

Shoppers in London during the current epidemic

Image courtesy of Wikimedia Commons

The mental health implications of emerging from weeks of isolation, only to have everything shut down a second time, will be profound. And if, as in 1918, the second wave is much worse than the first (and here it is important to emphasize that there is no reason currently to suggest it will be), then the impact on our social fabric in individual psyches will be even more devastating. The mental health system is stressed under the current COVID wave, how much more so if a second wave comes, and especially if the toll is even greater?

Clearly, we need to balance jobs, economic welfare, and the importance of social intercourse with protecting the public health. But COVID-19 has already demonstrated its killing potential, and, at the time of this writing in mid-May, does not seem to be slowing down in any significant way in the US. It will take an enormous act of will for the nation to come to halt again in the Fall, should COVID-19 follow the pattern of the 1918 influenza epidemic. And we will need to assure that countries have the resources not only to deal with the physical challenges, but the mental health challenges as well. Let’s hope we, as a nation, find a way to avoid repeating the tragedy that befell the planet just over 100 years ago.

Additional reading/listening
  1. Political Rewind: The Anatomy Of A Decision (GPB Podcast featuring Dr. Wolpe, 2020)
  2. 3 ways to protect your mental health during – and after – COVID-19 (Karen Rommelfanger & Alvaro Fernández Ibáñez, 2020)

Editor’s Note: We will be continuing our discussion of the mental health effects of the ongoing COVID-19 pandemic with next week’s post. 


Paul Root Wolpe, Ph.D. is the Raymond F. Schinazi Distinguished Research Chair in Jewish Bioethics, a Professor in the Departments of Medicine, Pediatrics, Psychiatry, Neuroscience and Biological Behavior, and Sociology, and the Director of the Center for Ethics at Emory University. He spent 15 years as Senior Bioethicist for the National Aeronautics and Space Administration (NASA), where he still serves as a bioethical consultant. He is the Editor-in-Chief of the American Journal of Bioethics Neuroscience, and sits on the editorial boards of over a dozen professional journals in medicine and ethics.

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Wolpe, P. R. (2020). The Second Wave. The Neuroethics Blog. Retrieved on , from


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