National Archives

Nurse Donna – my late mother – had two favorite home remedies other than chicken soup for almost every disease: fresh air and a saltwater gargle.

Until the COVID-19 pandemic erupted, I had no idea from where these seemingly strange ideas came. Both, as it turns out, are remnants of the Spanish flu that killed an estimated 675,000 Americans in the years 1918 and 1919.

The Spanish flu was still fresh in the minds of the medical community when my mother was attending the Swedish School of Nursing in Minneapolis in the 1940s. The Spanish flu differed from what we are all living through today mainly in that it was deadlier, and killed the young far more than the old.

It struck “so fast and so viciously, eluding treatment and defying control,” the National Archives records. “Some victims died within hours of their first symptoms. Others succumbed after a few days; their lungs filled with fluid and they suffocated to death. The flu did not discriminate. It was rampant in urban and rural areas, from the densely populated East coast to the remotest parts of Alaska. Young adults, usually unaffected by these types of infectious diseases….”

Canadian and U.S. scientists in a 2013, peer-reviewed study in PlosOne reported “a peak of mortality at the exact age of 28 during the pandemic.” European scientists writing in the peer-reviewed journal Influenza and Other Respiratory Viruses in 2010 found the Spanish Flu “principally affected men and women between 15 and 44 years of age.”

Today, those hit hardest by COVID-19 are over the age of 54. According to the latest U.S. Centers for Disease Control (CDC) data, 1,169 people under age 54 have died COVID-19 related deaths in this country. More than 10 times as many age 55 and older – 11,961 to be exact – are dead.

Narrow the death count to those age 44 and under, and the number of dead drops to 418.  More than 96.8 of the U.S. dead from COVID-19 are age 45 and older. The death toll there is staggering.

Fatalities for those under the age of 45 are more in line with deaths from seasonal flu, which has annually killed 12,000 to 61,000 people per year, according to CDD numbers.

To put these numbers in perspective with today’s pandemic, the 2017-2018 flu produced a monthly average death toll of 287 people under age 49, according to CDC data. 

Much of the difference in death rates between the young and the old is explained by the fact that as people age they are more likely to struggle with the underlying health issues the CDC notes – obesity, diabetes, heart disease and more.

Some studies have concluded that up to 99 percent of the victims of COVID-19 suffered from these so-called “co-morbidities.” The death of older people with pre-existing conditions is not unusual with infectious diseases.

According to CDC estimates, about 94 percent of the people killed by the 2017-18 flu were over the age of 49. The deaths underline the repeated warnings given Americans about the need to exercise and maintain a healthy body weight as they age.

As for gargling with saltwater, which was long thought to reduce both viral symptoms and viral shedding, the jury is still out all these years later. A 2019, peer-reviewed study in Scientific Reports found that there might actually be something to what was once considered an “old wive’s tale.”

“When individuals infected with similar viruses (rhinovirus, coronavirus, enterovirus and influenza virus) were compared, 30 percent more individuals had reduction in viral shedding…in the intervention arm,” the researchers reported. “This could explain both the reduction in the duration of illness and (35 percent less) transmission to household contacts in the intervention arm.”

They noted, however, that the sample size for their experiment was small and a whole lot more research is needed.

A slice of history from the National Archive

Fresh air

When it comes to fresh air, a whole lot more is known. Air as a dilutant and a buffer is the foundation of today’s social distancing campaign.

The reason why is simple. To spread, viruses need to be able to move from animal to animal in some way. Generally – other than contact transmission from objects – the closer together the animals, the easier it is for the virus to move from one to another.

Kissing allows viruses to pass more easily than talking. The “close talker” transmits a greater number of viruses than someone six feet away.

As a general rule, the more viruses you come in contact with the better the viruses’ odds of infecting you. The Centre for Evidence-Based Medicine at Oxford University notes that number of viruses to which people are exposed might increase not only the risk of catching a disease but also influence its severity.

“The link to the initial dose and subsequent severity of the disease is linked with the 1918-19 Spanish Flu pandemic,” the Centre reported. “Simulation models showed that the infectious dose was related to the number of simultaneous contacts a susceptible person has with infectious ones; that severe cases of influenza result from higher infectious doses of the virus; and over-crowded places are the ideal environment for a susceptible person to be exposed to very high infectious doses of influenza.”

The problem with virus-filled, overcrowded places explains why hospitals and clinics were an early focal point for the spread of COVID-19.

“We are learning that hospitals might be the main COVID-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. Patients are transported by our regional system, which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance,” Italian doctors reported the New England Journal of Medicine as the coronavirus was ravaging that country.

“We lack expertise on epidemic conditions,” they added, though one of the main things made most obvious by the many studies of the Spanish flu pandemic, which killed an estimated 50 million to 100 million people worldwide, is the danger of close contact.

The Spanish flu’s death count was about 300 times the COVID-19 death rate to date, but the current pandemic has only begun.

During the Spanish flu, Massachusetts State Guard Surgeon General William A. Brooks ‘”wrote that ‘The efficacy of open air treatment has been absolutely proven, and one has only to try it to discover its value,’ a paper on the “The Open-Air Treatment of PANDEMIC INFLUENZA” reported in the 2009 American Journal of Public Health. 

“Coincidentally, in 1918 a British soldier, Patrick Collins, reached a similar conclusion. When Collins developed the first signs of influenza, he dragged himself and his tent up a hill away from his regiment. There he sweated, shivered, and was delirious for several days, sustained only by his rum ration. He was one of the few survivors of his regiment.”

But the risk of the spread of disease in places densely packed with humanity was well known even before the Spanish flu pandemic and should come as no surprise in New York City or Boston now.

“The idea that cities, crowding, and epidemics went together was by no means new in the early 1900s,” researcher Nancy Tomes wrote in a 2010 paper published by Public Health Reports. “For centuries, observers had noted that where many people packed in together, diseases often followed. Yet in size and complexity, the new industrial cities of the early 20th century posed an extreme challenge. The scale and scope of public gathering places increased dramatically between 1890 and 1918. The second industrial revolution directly or indirectly led to a vastly expanded public school system, huge factories and office buildings, extensive public entertainments (amusement parks, nickelodeons, dance halls), and, last but not least, mass transportation systems that connected all these elements together. By the early 1900s, the interlinking of public spaces created a vast highway along which the deadly germs could quickly travel.

“The influenza pandemic underlined the difficulty of policing those public spaces. Influenza was a ‘crowd disease’ as opposed to a ‘house disease’ (an illness rooted in defective household plumbing or careless housekeeping)….From its outset, the pandemic was linked with crowded places, from troop ships to movie theaters. Although isolation of the sick was essential, quarantine measures had to be accompanied by broader measures aimed at regulating the congestion of public spaces.”

Little has changed to this day except for an increase in population density in some of the world’s more crowded places. COVID-19 has exploded in New York City, home to more than 28,000 people square mile, and Boston, home to near 14,000 per square mile. 

The population density in Boston is only slightly less than that of Hong Kong, widely thought of as a teaming sea of humanity. With 18,500 people per square mile, Hong Kong’s human density pales when compared to that of NYC. Boston, meanwhile, packs people in almost twice as densely as Seattle, which is nearly as dense-packed as Los Angeles these days. 

In Alaska, it should come as no surprise that about 77 percent of the cases have been reported in the Anchorage and Fairbanks metropolitan areas, where neighborhood population densities range from less than 1,000 per square mile to more than 7,000, and people concentrate in supermarkets.

The official Anchorage density of 175 people per square mile is wildly skewed by the fact it is calculated against the size of the entire borough which includes the half-million acre Chugach State Park and hundreds of thousand of acres of public land held by Chugach National Forest or the U.S. Bureau of Land Management. The officially reported density of Anchorage is less than that of the tiny Resurrection Bay port community of Seward.

Urban disease

What Anchorage does have is enough of urban America to make it Alaska’s COVID-19 hotspot as are other major cities in other states. The Center for Spatial Data Science at the University of Chicago rates the top-10 hotspots of the moment as NY-NJ, New Orleans, Seattle, Detroit, Chicago, Denver, San Francisco, Boston, Miami and Atlanta.

The data make it abundantly clear that the best way to avoid COVID-19 is to stay away from other people. And the farther away from them the better until the pandemic ebbs.

If you must be close to them – say to go get groceries – the studies would also indicate, the less time you spend around them and the fewer potentially contaminated surfaces you touch, the better.

A study in The New England Journal of Medicine reported the virus can survive for up to 72 hours on stainless steel or plastic. Those stainless-steel platforms in the self-checkout lines at the supermarket and the rubber gloves worn by checkout personnel in some supermarkets would both appear prime surfaces for carrying COVID-19.

Researchers at the University of North Carolina Chapel Hill have warned that the virus can survive for hours on gloves and other personal protective equipment.

“Only a small amount of infectious virus was lost on an N95 respirator within the first two hours, and virus was detectable for up to 24 hours,” they reported. “On gowns, (it) was detectable for up to 24 hours….Virus was still detectable at four hours on scrub fabric. Survival on latex and nitrile gloves was comparable…..”

Those findings would indicate that if you decide to wear gloves or a mask, you should be careful about how you take them off and wash your hands thoroughly after. Hand washing is a proven way to rid yourself of contamination.

The gloves should go in the trash before you wash your hands. Tossing or thoroughly washing the mask – if you choose to wear one – is likely also good idea given a report from Chinese doctors that, “strikingly, a significant level of infectious virus could still be detected on the outer layer of a surgical mask on day 7, indicating SARSCoV-2 is extremely stable on this surface.”

Reusing masks could, it would appear, make them a little like the filter in a shop vac continuously accumulating fine particulate matter. If you then touch the face of a mask that has been sucking up COVID-19 and rub your eyes the consequences could be severe.

Still, the CDC is now recommending “wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.”

The agency does add that “it is critical to emphasize that maintaining 6-feet social distancing remains important to slowing the spread of the virus.  CDC is additionally advising the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others.  Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.”

That recommendation is premised on the idea that people will use masks properly and they thus they will cause no harm but could help. There is, however, debate within the medical community as to the real-world effectiveness of masking.

The Centre for Evidence-Based Medicine has questioned the premise that masks are risk free.

“Thinking you’re protected, means you may put yourself at higher risk, and as individuals, we will change our behaviour in response to the perceived levels of risk,” they wrote. “We are more careful if the level of risk is high and less careful if it is low. Measures we can take can include washing hands, avoiding touching, social distancing, school closures and self-isolating when unwell. You may also end up touching your face more often.

“A mask can (also) become dirty with excessive moisture, and contaminated with airborne pathogens. And because your voice is muffled; individuals may have to get closer to people, particularly the elderly, to hear from you.”

As to whether or not masks actually work, the Centre observed that “evidence from 14 trials on the use of masks vs. no masks was disappointing: it showed no effect in either healthcare workers or in community settings. We could also find no evidence of a difference between the N95 and other types of masks but the trials comparing the two had not been carried in aerosol-generating procedures.”

None of the studies are particularly good, however, because masks as a preventive measure against the societal spread of disease have simply not been well studied, they said.

Against this backdrop, the advice from a group of working doctors from the Harvard Medical School, Brigham and Women’s Hospital, Massachusetts General Hospital might be worth considering.

“We know that wearing a mask outside health care facilities offers little, if any, protection from infection,” they wrote in a “Perspective” for the New England Journal. “Public health authorities define a significant exposure to COVID-19 as face-to-face contact within six feet with a patient with symptomatic COVID-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching COVID-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.”

That sort of advice hasn’t stopped some San Fransisco Bay-area counties from ordering face masks be worn by anyone who goes out in public. Whether that will make the pandemic better or produce unintended consequences that will make it worse remains to be seen.

Marin County Mayor London Breed hinted at worries about the latter in an interview with a local TV station. He expressed fears of mask shaming and confrontations.

“If you’re not a police officer, don’t act like one” he said. “We don’t want people to confront one another.”

But tensions are already growing.

“Facebook, Twitter and Nextdoor have become gathering grounds for social distance shamers – and for those who shame the shamers. I’ve heard about comments that have been shut down because the disputes have grown so tense,” writes the Chicago Tribune’s Mary Schmich.

My Swedish Hospital-educated mother would never have approved. Instead of arguing, she would have suggested we get out, get some fresh air, and quit worrying so much, which was another of her big cure-alls.

What she would have thought about wearing a mask while out getting that fresh air, I do not know. What my science-obsessed father would have thought is clear, but then he would probably be more upset about the world ranting at Sweden because of its more liberal approach to slowing the spread of COVID-19.

Not because Sweden’s policy of advising people on how to minimize the spread of the virus while allowing business to continue somewhat normally is better. It could well end up being worse despite the present claims to possible success.

Whichever way it is destined to go, my father would have been glad to see Sweden doing what it is because in science one needs a control against which to measure outcomes to overcome the human tendency toward confirmation bias. There is really no way to measure the success of economy-stifling, COVID-19 lockdowns in this and other countries without some idea of what happened in some place that didn’t order all but essential employees to stop going to work and stay home.

But then confirmation bias seems to have become something of the order of the day in the U.S. From President Donald Trump on down to the homeless on the street, facts have increasingly come to be defined by what people want to believe and not by what can be proven via the scientific method.

If evidence, which is often contradictory, doesn’t fully support their conclusions, they stack it. And if stacking isn’t enough, they simply make things up.

It’s probably good my father died a long time ago and doesn’t have to witness some of what is going on today. I don’t know that he could have endured it.

I can almost hear my mother telling him, “You need to get out and go for a walk. The fresh air will do you good.”