Medical historian Howard Markel remembers attending New York City’s St. Patrick’s Day parade back in 2000. As marching bands, dancers, and floats came down Fifth Avenue, sidewalks on either side were jam-packed with spectators. “There was also a great deal of drinking going on that begins hours before the parade,” he says. “And drunk people don’t make good decisions.” He left soon thereafter.
The health risks posed by the annual event, which typically draws some 2 million visitors and 150,000 marchers to Manhattan, became the focus of New York City’s coronavirus outbreak response this week, with New York City mayor Bill de Blasio insisting until Wedenesday that the iconic parade would go on, even as scores of other cities — including Philadelphia, Pittsburgh, Chicago and even Dublin — canceled their St. Patrick’s Day observances. Finally, shortly before midnight on Wednesday, New York State Governor Andrew Cuomo announced that, for the first time in more than 250 years, the parade would be postponed.
Confirmed cases of Covid-19, the disease caused by the novel coronavirus, have surpassed 1,300 in the U.S. as of March 12, but with delays in testing, actual figures are likely far larger. Health experts are stepping up their message urging strict social-distancing measures: quarantines for people who may have been exposed to the virus, closing schools, promoting telework, and banning or discouraging public gatherings.
New York’s insistence that its St. Patrick’s Day festivities would proceed stood out as an increasingly awkward exception to this lockdown approach, thanks not only to its size (it’s the largest St. Pat’s parade in the world) but its alcohol-fueled rowdiness. As in other places that host these citywide frat parties, the event is something of an epidemiologist’s nightmare: Packed sidewalks along the route mean it’s not uncommon for families admiring leprechaun-themed floats to stand inches away from attendees puking up the contents of their morning pub crawl.
(Since New York’s bars are still open, those pub crawls will continue this weekend, according to PubCrawl.com, which organizes bar-hopping excursions in several U.S. cities.)
Even without the booze, though, parades are especially concerning to health experts, as the coronavirus appears to spread easily when groups are in close quarters. The Centers for Disease Control and Prevention recommends that people maintain “social distance” (described as being at least six feet away from another person). The size and scope of the gathering matter little to Markel, who teaches the history of medicine at the University of Michigan. “Big parades, small parades, organized parades, disorganized parades — being in a crowd right now, particularly if you are in a high-risk group, is just not advisable,” he says. What matters more is “who is in the mix, and who you are standing next to.”
The lethality of combining of parades and pandemics was made tragically evident a hundred years ago. On September 28, 1918, as World War I was coming to an end, some 200,000 people flooded the streets of Philadelphia for a patriotic parade intended to raise $259 million in government bonds to help fund America’s war effort. But the U.S. had just experienced the first wave of a deadly influenza outbreak that had been sweeping the globe, and was at the beginning of a second wave.
Some 600 sailors in Philadelphia were infected just days earlier, likely having contracted the disease from returning troops. In the 24 hours leading up to the parade, 118 new cases were detected, according to a local newspaper report that didn’t run until later that afternoon, according to the Philly Voice.
Anxiety over what became known as the Spanish flu had yet to hit the public, and the city — ignoring warnings from physicians — went ahead with the parade. A week later, 2,600 were dead from the flu, and the number of cases rose to 4,500 the week after. Officials later closed schools, churches, theaters, and other public gathering places, but much of the damage had already been done.
More than 12,000 city residents would die in the next weeks, though Markel says the deaths can’t be entirely pinned on the parade itself. Philadelphia, like several other cities at the time, took several missteps, including trying to prevent panic early in the epidemic by downplaying its threat and assuring the public that the flu wouldn’t spread beyond military camps. When the virus rapidly spread, the city was unprepared. There weren’t enough beds among the city’s 31 hospitals, medical staff were overworked and catching the flu themselves, and it wasn’t until October 2 that the mayor committed $100,000 in emergency funding.
Other cities managed to limit mortality by taking more proactive social-distancing measures: In St. Louis, for example, city leaders closed schools, churches and theaters and banned gatherings of more than 20 people. “St. Louis did everything early and layered more than one intervention option, and for a long time,” Markel says. “And they had a wonderful health commissioner, Max Starkloff, who knew how to deal with the people, with the mayor, with the newspaper, and the school boards. It was that rare leadership that’s really important.”
That leadership paid off, as St. Louis experienced one of the lowest mortality rates among large U.S. cities. “Of the 31,500 who got sick in St. Louis,” KMOV4 reports, “only 1,703 died.”
While the coronavirus outbreak differs from the 1918 flu pandemic in several ways — from the viruses themselves to the advancement of medical technology — the threat posed by public gatherings remains. Witness the two-day biotech leadership conference that became the epicenter of a Covid-19 outbreak in Boston, responsible for at least 70 of 92 infections in Massachusetts as of Tuesday and many more in other states. “The virus raced through this two-day conference at a frightening speed that state health officials and company executives were unable to match,” the Boston Globe writes.
4. Esther Kim (@k_thos) and I have created this illustration of why it is critical that we #slowthespread of #coronavirus.— Carl T. Bergstrom (@CT_Bergstrom) March 7, 2020
Freely available for any use under the CC-BY-2.0 license. Please share broadly. pic.twitter.com/OAVeGnIIXt
That’s why Markel and other health experts so emphasize the significance of implementing social-distancing measures early to stem community spread and “flatten the curve,” or reduce and delay peak outbreak through control measures so as to not overwhelm hospitals.
So far, the ever-louder call to cancel everything has halted everything from festivals like South by Southwest and Coachella to Seattle’s public schools to the NBA season. In Washington state, Governor Jay Inslee also took extra measures to ban all large public gatherings in its largest metropolitan area, while King County officials are going even further and prohibiting events smaller than 250 people that don’t meet public health requirements like the CDC’s six-foot rule. Many more marquee public events are coming up as spring approaches in the U.S., like Washington, D.C.’s famous Cherry Blossom Parade. Markel says that while they don’t all have to be called off right now, city officials should prepare to heed the lessons of past outbreaks.
“It’s not an issue about preventing the spread — it never was,” he says. “It’s an issue of minimizing the number of patients. So why would do anything to increase your chance of a case?”