Health and the Holidays

In the annals of public health there is probably no moment more notorious than the ill-timed parade in Philadelphia that became a super-spreader event for the 1918 influenza pandemic.

The long shadow of this disaster prompted New York last year to cancel the St. Patrick’s Day Parade and curtail the Macy’s Thanksgiving Day Parade to a one-block television production with no live spectators.

So the revival this Thanksgiving of that iconic parade is at once thrilling and unnerving, reflecting both the city’s effort to come back and the challenge as COVID-19 continues to circulate.

“We can’t wait to help New York City and the nation kickoff the holiday season with the return of this cherished tradition,” said Will Coss, executive producer of the parade.

You must be vaccinated to march in the parade, but not to join the throngs watching it go by.

Spectators are instructed to wear masks. But there was no explanation from Mayor Bill de Blasio on why he is imposing a vaccine mandate to attend the revived New Year’s Eve celebration in Times Square but not to attend the Thanksgiving Day Parade, which will kick off from the American Museum of Natural History, proceed down Central Park West, turn east on Central Park South and then down Sixth Avenue to Macy’s.

Estimates of spectators along the route during pre-pandemic parades range as high as 3.5 million. Certainly, anyone who has ever attended knows the crowds can be large, deep and densely packed.

It is hard to predict turnout in year two of the pandemic. But if estimates of holiday travel prove an indicator of parade attendance, too, then the crowds could be close to pre-pandemic levels.

The weather forecast suggests a sunny and mild day with temperatures in the 50s.

Public Health History

Estimates of parade crowds, an imprecise art even in past years when they were mostly a way to illustrate enthusiasm, take on a deeper significance against the backdrop of public health history.

On September 28, 1918, as influenza spread through Philadelphia, the city allowed a massive parade to promote Liberty Loans, bonds to help finance the war effort. The parade was two miles long and led by John Philip Souza and a marching band.

“No measures were taken that day to limit contact among the 200,000 spectators who massed along Broad Street to cheer on the marchers,” writes Dr. Scott Gottlieb.

Gottlieb, a former FDA commissioner, brings up this 103-year-old event in his new book, “Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic,” to highlight recent studies which compared the spread of flu in St Louis and Philadelphia.

They provide convincing evidence, Gottlieb explains, that mitigation efforts like masks, social distancing and avoiding large crowds had a major impact on reducing spread when applied in a timely manner.

“The Liberty Loan parade was a fateful gathering, timed at precisely the moment that the flu was about to explode,” he writes. “The parade was the tinder that ignited an epidemic in Philadelphia that would rage out of control. It would become the largest known ‘super-spreading’ event of the 1918 pandemic.”

The situations are not identical, of course. First, COVID-19 is not the flu, which Donald Trump had to be reminded of repeatedly. Moreover, three quarters of New Yorkers have received at least one dose of vaccine, as compared to none in Philadelphia in 1918.

Nevertheless, between the parade, holiday travel and the gathering around indoor tables for turkey dinner, Thanksgiving this year offers the virus excellent conditions to spread just at a moment when cases have already been climbing in New York City since November 1.

“Not Return to Normal”

“We are in a pandemic,” said Denis Nash, distinguished professor of epidemiology at the CUNY School of Public Health. “That’s the thing people need to remember and behave accordingly. It’s not return to normal, although I understand why people want that and think that. It’s the messaging they’ve been getting.”

Nash urges everyone to be attentive not only to their own safety but to the risk of becoming a carrier who then exposes other, more vulnerable people, like the elderly or immune compromised.

A key, Nash said, is to “have a thoughtful conversation” about the various tools for keeping people safe. “It’s as if our leaders are thinking that vaccination is the only strategy. But we actually have a lot of tools.”

Keeping the size of gatherings down, for example, and gathering outdoors if possible. Nash also recommends using the commercially available rapid test kits to identify infection in time to avoid exposing others.

One of Nash’s recommendations for a safe Thanksgiving dinner with friends and family is, for those who can, to reduce their risk of acquiring the virus by reducing interactions in public – “laying low,” as Nash put it – between now and Thanksgiving.

Which brings us back to the parade. Being outdoors is safer, Nash notes, but attending the parade also creates risks beyond the crowd along the route. Getting to and from the parade, for example, and perhaps that stop for eggnog, or other imbibing, after.

Nash said he was relieved to see the mayor had required vaccination to attend New Year’s eve because this not only reduces the risk of unvaccinated people bringing the virus to the celebration, but also protects them from acquiring the virus at the celebration and then getting severely ill.

“If there is a super-spreading event the people who are most likely to have the worst outcome are those people who are unvaccinated,” Nash said.

Asked whether that same logic applied to the Thanksgiving parade, Nash said: “I don’t know what the differentiating factor is.”