In October 2019, the Mütter Museum opened Spit Spreads Death: The Influenza Pandemic of 1918-19. When the exhibit opened, Spit Spreads Death was a fascinating review of the impact of the 1918-19 influenza pandemic in Philadelphia. A companion exhibit on the evolution of germ theory, Going Viral – Infection through the Ages, debuted soon after. While these were important subjects in their own right, these exhibits achieved a new level of relevance with the novel coronavirus (COVID-19) pandemic.
Three docents at the Mütter Museum have experienced the current pandemic in ways they never would have imagined when first introduced to the exhibit on the "Spanish Flu." Tosef Miller, David Schwarzkopf, and Julie Rakestraw are here to talk about their experiences at the Museum, initially guiding tours through the exhibit and then personally experiencing COVID-19.
When did you become a docent at the Mütter? What was your motivation for doing so?
Tosef Miller (TM): My five year anniversary is soon! In 2015, I got involved in the education department’s youth programs for minorities interested in STEM. I became a docent in 2016 with encouragement from the education department. I had no idea what I was getting into— I was so shy! People from my hometown would be shocked to know I do a lot of public speaking now. Growing up, I was that kid who never talked. I remember times my family took me to Rita’s, told me I could get whatever I wanted, and then said I had to order it for myself. I couldn’t do it! So they’d eat ice cream in front of me and I went without any!
David Schwarzkopf (DS): I became a docent 3-4 years ago after 40 years as a physical therapist. I wanted an opportunity to combine my interest in history, medicine and science and involvement with the Mütter Museum provided a perfect combination. I love to bring in the stories of the people who were once alive and are now worthy of our respect for their contributions to our understanding. My goal is to bring their stories to life for today’s visitors.
Julie Rakestraw (JR): My family has been visiting the Mütter for years and I was always fascinated by the people behind the artifacts. When I retired from DuPont in 2019, I finally had the time to become more involved and to bring information about the displays to others. After shadowing and practicing, I completed my first tour on March 2 of this year.
Did you participate in the Spit Spreads Death commemorative parade in September 2019? Who was your named pandemic person; did that person survive the pandemic?
TM: I was the Access Lead for the parade. It was my job to make sure everyone who couldn’t walk the whole three miles of the parade got to join in at the climax. I held a custom sign for a family whose relative passed away, but we didn’t have records of the death certificate. The family couldn’t make it, so I held the sign to honor their relative in their place.
Can you describe your initial response to the Spit Spreads Death exhibit? What part of the exhibit most resonated with you as you did the initial tours?
TM: Figuring out how to do tours for the exhibit was initially quite challenging because there are not a lot of physical items to describe. Most of the museum is organized like an old-fashioned medical school, with thousands of objects on display to maximize knowledge. I could stand in one corner of the museum for a half hour and still not get to everything. Those objects often elicit strong feelings when the audience sees them, but they aren’t self-explanatory. So in most of the museum, the docent’s job is to give a backstory and explain what exactly the audience sees. Once they know that, they can interpret the object.
In Spit Spreads Death, the objects on display themselves tell a story. The docent doesn’t need to tell it. The newspaper clippings, interviews with families affected by the pandemic, parade video, and chorus chanting the names of the deceased are all stories the audience can interpret without the docent’s help. They tell a story of profound, collective loss. They tell a story of how communities rebuild in the face of extreme uncertainty. They tell a story of how ripples of this pandemic still affect the world today.
Figuring out how to keep myself relevant and valuable in this section of the museum was a challenge. I found myself rattling off scary statistics, which captured people’s attention and memories, but wasn’t a satisfying tour to present. So I tried to engage with the guests in a less academic, more individual way. Spit Spreads Death wants visitors so share their stories, so I always start by asking if anyone had a relative affected by the 1918 pandemic.
If there wasn’t anyone with a relative story, I focused on connecting the emotions of the exhibit to the present-day world. I would ask a volunteer to type in their address to see how many people died on their street. It makes people curious and they think of their neighbors differently.
Later, I watched my own neighbor die of coronavirus and get taken away in a van. It was so sad, especially because I didn’t understand what was happening at first. I was just like, “Why is there a van parked outside my house? Who are those people in blue PPE suits?”
We have copies of over 700 death certificates for museum guests to keep. The death certificates are for people who died in Philadelphia during the peak day of the virus— all hospital beds were filled. I challenge people under 25 who visit the museum by asking them “Who here can read cursive?” It’s always entertaining for the older guests to watch the young ones struggle to decipher handwritten cursive. Student groups love it because there’s always one kid in the class who can read it, and so suddenly everyone is shoving their death certificate in that kid’s hands and asking, “What does it say? What was her name? Where did she live?” When I was finally feeling better from coronavirus, it hit me how close to dying I had been. I wondered what font my death certificate would use. I wondered if 100 years from now, kids would be able to read it. Or would they say, “Times New Roman is so hard to read… Why isn’t this Comic Sans? Where are the emojis?”
DS: The Spit Spreads Death exhibit and experience were so overwhelming for the children on my school group tours. To help them process it and give some perspective, I talked about the annual flu season and the SARS epidemic which began in 2002. We also discussed the importance of their immune systems and ways they might be able to increase their immune response. The teachers loved it when I focused on getting enough sleep (most high school students don’t), improving their nutritional habits by eating well, and hand washing. The visual of the impacted neighborhoods also seemed to resonate most as the students looked at where their families lived.
JR: The coronavirus had just been acknowledged in China when I first started in January 2020. Even over the 2 months of 2020, I noticed a huge shift in the attitudes towards the Spit Spreads Death exhibit. Initially, it was viewed as something interesting that happened over 100 years ago and we were now able to see some of the artifacts like the use of whiskey in medicine. Then people began to ask questions about whether it could happen again, and whether it might happen here.
I highlighted the exhibit of the Christmas presents that had been bought by a young mother before her death in 1918. That display, showing presents that her family had left in the attic for years afterward, really showed the human side of the tragedy. Then I would discuss the rise in numbers of students at a school for orphaned children, including some who still had a living parent but were just too expensive or time-consuming to have at home.
When the Museum reopens, it will be important to connect the losses this year with the stories of people in Philadelphia who were impacted not just directly by the virus but economically as well.
As the calendar turned to March 2020, and the coronavirus was well known to be circulating in Europe in addition to China and other places distant from us here in Philadelphia, how did the narratives change in your tours? What kind of questions did you receive?
TM: A lot of times, students see the name Spit Spreads Death and chuckle at the innuendo. But after coronavirus reached the news, no one laughed or commented on the name. They listened intently as soon as I said pandemic. People were scared, but they were also looking for answers. Spit Spreads Death had some of those answers.
I would say on my tours, “This flu is what coronavirus is today. In a few weeks, you guys will see. Everyone had to wear masks and it was illegal to spit in public. Kids got a badge for turning someone in for spitting.” Some teachers rolled their eyes when I said coronavirus! I’m sure they were sick of alleviating fears of coronavirus in their classrooms. At that point in time, even among College staff, many people thought coronavirus was blown out of proportion. Some people disliked that I compared coronavirus to the 1918 flu and saw the comparison as feeding into mass hysteria, but I’m sure their stance has changed! Now, the societal parallels are crystal clear.
JR: By mid-February, the interest shifted to how the virus spreads and the impact of big crowds as centers of contagion. The graphic showing a ward full of patients and overwhelmed medical staff in 1918 differed from the news out of China and then, by March, New York City only in appearance of modern clothing and equipment. The human cost was no longer history from their great-grandparents’ lives but was happening in 2020.
The pile of pine boxes in the corner representing what was used when funeral homes ran out of traditional coffins and pictures of piled bodies suddenly seemed current. In April, we were seeing trucks full of bodies on the news and it seems unreal to me that we are repeating this historical event.
With the world experiencing increasing spread before the US really acknowledged the presence of the virus here, did you change your approach to tour groups or take any additional precautions?
TM: I stopped signing up for interactive touch exhibits on the weekends. I was very scared to go anywhere but work and home in case I caught coronavirus and infected my home care clients. I have a reputation for being germaphobic, so I don’t think it was surprising to anyone when I sent an email saying “I’m alarmed. How are we supposed to wipe down touch objects between visitors? The way it’s done now seems unsafe.” One of the key components of the previous Civil War exhibit’s touch object lesson is about how wood couldn’t be sterilized, so it felt ironic to be a public health institution handing out unclean objects to guests to handle in the early stages of the US pandemic.
JR: When I did my tour on March 2, I was very conscious of using my pocket hand sanitizer, keeping my hands away from my face, and minimizing the surfaces I contacted. In ordinary times, I always hold the handrail on the stairs (many years of DuPont safety meetings) but I did not touch it at all that day. I washed my hands thoroughly before and after the tour. I also spent more time with the group talking about the importance of good hygiene practices.
Please provide any details that you’re willing to share on your personal experience with COVID-19, Including initial symptoms, disease progression, or any unusual symptomology you experienced. Did you go to the hospital and were you admitted? How long did it take to fully recover, if you feel that you have done so?
TM: I woke up with an ominous feeling Friday, March 20th. I considered refusing to go to my essential job due to an instinct I couldn’t name. A strong force told me that due to circumstances beyond my control, today would be my last unrestricted, free day. I decided to buy a week’s worth of vegan Chinese food —a huge burden to my fragile finances — on my way home from work in case I couldn’t feed myself next week.
That evening, my Goth housemate had never looked closer to death. They had just returned from NYC. They were pallid, even for a Goth. They wobbled into the kitchen, saying they could not eat or drink anything without vomiting. I coaxed them into trying a mango lassi. It seemed to settle their stomach— the first food or drink to stick for 24 hours. Their countenance instantly became bright again. Defensively, they insisted they didn’t have coronavirus; it was just a typical sinus infection mixed with allergies. I listened to the denial in horror as I didn’t believe it for a minute. The writing was on the wall. My house had coronavirus.
A week of sleeping more than usual quickly spiraled into dangerous territory. I was young, a mediocre gym rat, lacked a cough and my thermometer lied— so I believed I was fine, because that’s what American news was reporting. I remember being confused about how to tell if I should go to the hospital or not. Everything just says “go if you experience dizziness, shortness of breath, or confusion.” I told my housemates, exasperated, “It’s a respiratory illness; by definition you have difficulty breathing… What metric am I supposed to use to judge?” The typical response is “go if you have blue lips” but my thoughts were, “By the time my lips turn blue, I won’t have any idea that they’re blue, and I am beyond an ER waiting room. I need an ambulance ASAP. So that’s not a useful metric.”
Well, I was right to be concerned. I was too sick to judge how sick I was, even without blue lips. It was like nothing I’d ever felt before— reality became dreamlike. I never fully “woke up” each day. I lost my electric toothbrush for over a week— I had no idea where it went. Eventually, I went to do laundry, and my toothbrush, toothpaste, and a bunch of spoons were in my hamper. Logically, I know it must have been me that put them there, but I had no memory of when or why I did. Little things in my kitchen shuffled around, too, so I could only shrug when my roommate asked me what I did with the sugar jar lid. We were equally confused when it appeared on the very top shelf of the pantry, so high I must have gotten on a chair to put it there. I was demented. I was having moments like the stereotypical “What’s the remote control doing in the fridge?”
I was lucid enough, at times, to be aware of how sick I was. I remember trying to call Mazzoni Center, but the opening message had changed. It was several minutes long and I couldn’t listen long enough to dial the extension for the medical clinic. The words didn’t make sense. I sat on the couch angrily, telling my roommate I couldn’t listen to the whole menu. She shrugged and told me to redial. We were all sick— and lucky if we saw each other once a day. The four or six hours I was awake per day were not necessarily aligned with anyone else’s waking moments.
In hindsight, it was obvious I needed medical attention. But I didn’t have a cough, so I didn’t know. I developed strange symptoms— I got pink eye and puffy eyelids. My hair died, so I buzzed it and shaved my beard. My face skin simultaneously peeled and developed acne. My pee turned orange and concentrated before any of the lethargy hit, when my symptoms were still limited to “I think I’ll take a nap today.” My legs ached. I became very greasy. Did I feel feverish? Yes, but I don’t know an exact temperature because it took a few days for me to realize my thermometer was broken.
Walking up the stairs was exhausting. At times, I had to crawl on all fours to get back to my bedroom. I’d lay on the floor at the top, nauseous and waiting to catch my breath before rising to my bed. My roommate’s 15 year old elderly cat slept less than I did. He would finish his nap first! My balance was also very poor— it was like I had just woken up, jumped out of bed, and hadn’t yet steadied myself. So I could still walk and do things, I was just clumsy and not aware of my entire body. Some parts still felt asleep.
My appetite was voracious— I am a 24 year old black hole. Coronavirus did not take that away from me. I never lost my appetite. I think that is why I am alive today. I could still smell and didn’t really get any sinus issues. Things still tasted fine to me— but apparently, my taste was affected. For Passover, my roommate bought a sauce with horseradish and beets. I dumped a bunch on my matzah and ate it— then noticed my roommates staring at me in horror. It was too spicy for them to eat. All I tasted was beets! The horseradish tasted crunchy and mild to me.
Getting tested was a nightmare. None of my friends with cars would drive me. They made up excuses because they were scared. It hurt my feelings. I understand why they said no, as they thought I was asking them to die. My friend who believed the virus was a overblown came in handy— they went well out of their way to get a Zipcar and drive me. They don’t think the virus is overblown anymore, of course. We were both scared when we waited in line, the people covered in PPE looked like aliens. When I held up my ID, the tester just said, “Oh, another Bayada.” She said it in an approving way, like she admired Bayada as a company. But it made me double take and wonder how many other “Bayadas” had come this morning and were sick, too. How many of us were in the same situation, dropping like flies?
DS: Although I knew that coronavirus was circulating in Europe, I had been invited to represent my family for the Stumble Stones exhibit in Switzerland to honor Jews who had left Germany during WWII. This was a very important event, so I left March 4 on a trip to Switzerland, Germany and Ireland. I returned by March 9 and became symptomatic March 16. My COVID-19 symptoms lasted until March 27. I had fevers of 103-104 degrees F and Tylenol® would bring my temperature down to just over 100 degrees F. I was nauseous and had no interest in food or drink. My husband insisted that I keep drinking and his care is likely the only way that I avoided hospitalization. My husband did not become symptomatic and we are not sure if he was infected. Still, now in early May, I throw up if I eat beef or pork. I had hallucinatory smells. Everything smelled like garlic, so I sprayed my lemongrass scented cleaner everywhere to rid myself of the perpetual garlic odor.
I thought it would pass and didn’t think it was coronavirus because I had no respiratory symptoms. When I finally went to the doctor after five days of high fevers, the simple test in the office said that I did not have coronavirus. However, 4-5 days later, a positive test result was reported.
JR: I was not tested but my immediate family is pretty sure that we have all been exposed. My son lives in Brooklyn and experienced the now-reported "COVID toes" during his first week at home. In February, my daughter was very sick during her rotation in the Emergency Department of a local hospital and learned later that patients did receive two-week delayed positive coronavirus tests. I had a slightly elevated temperature, dry cough, and rash on my throat and chest a week after my red-eye flight from Phoenix in mid-March. My husband reports he had a few days of not feeling well about a week after the rest of us returned home.
In hindsight, we were very glad to have followed social distancing and stayed from people during that period that we were likely all contagious.
Have you been tested for antibodies, and would you be willing to or have you already donated serum as a potential treatment?
TM: I signed up to donate antibodies with the Red Cross, Penn, and Jefferson, but only the Red Cross has gotten back to me. I had an appointment Friday, May 15th, to donate. I haven’t been tested, but know that I have them because I take the Septa to my job at UPS. The train stations aren’t being cleaned because the Septa employees are sick. So the train windows and seats are covered in blood droplets from people’s coughs, plus the usual unidentifiable body fluids and bedbugs. Anyone who gets on the train at this point either has coronavirus and COVID-19 or has some immunity.
DS: After my recovery, I donated blood and plasma to Penn Medicine but will not receive a feedback report on whether antibodies were present. I am definitely curious about whether the antibodies will give immunity and for how long.
I have been reflecting on how everyone will rethink their lives and activities. Hand washing has always been a big part of my protocol due to my PT training. My awareness of what’s in the air around me has definitely increased. I have many friends in the Philadelphia restaurant and art world and really look forward to getting back to those activities and hugging my friends. But I expect that I may go to restaurants only once I am convinced that sufficient safety precautions are in place, including requiring reservations and social distancing.
JR: I did not go to the doctor so was not tested and am not eligible to donate. I did sign up for the NIH study and am waiting to learn if I will be selected to be tested.
Knowing what you do now, how will you change your presentation of the Spit Spreads Death?
TM: I usually asked guests if they have any relatives who had the 1918 flu. I now plan to ask if any have coronavirus stories they want to share and I’ll try to relate it to an experience someone from 1918 had.
I’ll also compare how the first responders and healthcare workers from them died in huge numbers, and the same happened today, where they make up a large percentage of the deaths.
Depending on how fast the coronavirus vaccine comes out, I’m going to compare it to the 20 years it took to get a functional flu vaccine.
Some things in the museum are upsetting— seeing people cry is not unusual. So I’m going to try to curb any coronavirus discussions if I sense a guest is overwhelmed emotionally. But if someone shares a story of a relative lost, I’m going to thank them for sharing. The Spit Spreads Death exhibit is a memorial to those lost in a pandemic and is a good place to let someone’s memory live.
I adored the Civil War exhibit. I was angry and heartbroken it was removed. I initially saw Spit Spreads Death as lacking from a docent’s perspective. Now, I’ve done a 180 degree turn. I think this exhibit is brilliant. It could not have come at a more perfect time. The creators of Spit Spreads Death left the museum with an enormous legacy. Spit Spreads Death not only commemorated the fallen in the 1918 pandemic; it saved lives in the 2020 pandemic. There could not be a more satisfying way to say to the fallen, "Your death wasn’t for nothing; your memory saved your great grandchildren. And, you motivated them to help others.” I get teary just thinking about it. Walking around in a mandatory mask now is not fun, but it is heartening to know we aren’t the only ones to go through this. There is an enormous human connection to the pictures of people walking around with masks on 101 years ago.
Will you say anything different about Going Viral – Infection Through the Ages?
TM: The pandemic has brought misinformation to more people’s attention online. By now, we’ve all seen the facebook mom pages full of medical inaccuracies— stuff like, “Essential oils can prevent any disease!” I can bring that up, and say, “This is a great example of miasma theory! At one point, it did agree with science. Many people still believe alternative theories of disease, like miasma theory, instead of germ theory.”
The other parting message I try to leave guests with is about the next pandemic— antibiotic resistant organisms. The next pandemic is already on the calendar. Many times guests see diseases in the museum and think“Thank god we can cure that now!” But that will not be true soon. Many nasty diseases are going to make a comeback in our lifetimes. The next pandemic may be an old pandemic. It will not be a novel disease, it will be a disease we have known for ages. Now that we have all experienced a pandemic, I think my statement will hold a little more weight with people. Before, people could acknowledge the truth of that statement. Now, people can feel the truth of that statement. It’s got emotions attached. We look at the people in the museum with wonder about what it was like to live back then. But we should also look at them and see the future.
I also think I will ask guests what they think the future of disease prevention looks like. We compare a plague doctor outfit to a modern white coat. What does future PPE look like? We are at a turning point in medicine.
The pandemic showed us the flaws with current PPE— N95 respirators are uncomfortable, inefficient after a short period of time, require a lot of resources to produce, and contaminate our oceans. Surely there is a better way. And surely the museum guests can help find that answer.
DS: I intend to focus more on the theory of Miasma and the smell of the "bad air" from the barrel in the corner. In refugee camps, there is often a lack of clean water and insufficient, nourishing foods. Areas in the US have these concerns as well.
The pictures of the virus that caused the Spanish Flu will continue to be fascinating and I look forward to discussing the coronavirus structures in comparison.
JR: I will focus more on the impact of the disease on healthcare professionals, the families of those who died, and on the changes to how society functioned. I have friends who have cried their entire commute home after working on the COVID floor of the hospital. The "new normal" that we are waiting to embrace is going to look a lot different from what we all took for granted when Spit Spreads Death first opened.
How do you anticipate you will change any behaviors in your life as we enter the ‘new normal’?
TM: I’m just grateful to be alive. I got coronavirus early— I can ride the trains and go grocery shopping without fear because I have some level of immunity. In a way, it’s a relief. The worst is over for me. My friends are still stuck inside every day, maybe for the next two years, terrified. Of course, I’m scared of infecting others, too. But since I worked in home care, I got used to washing my hands upwards of 20 times a day.
I am glad people are washing their hands more— I rarely shake hands with men because most men don’t wash their hands after they go to the bathroom! I’ve even seen doctors and laboratory PI’s walk out of the bathroom without washing their hands. Please, do better. Make your mother proud.
DS: Can crowds ever be safe? The flu vaccine helped and development of a vaccine for this coronavirus may as well. I’m rethinking flying on airplanes. As a longtime concert subscriber, I am unsure when I will feel comfortable returning to orchestral concerts. I wonder about the impact of continuing mutations of the virus and what level of immunity my illness will confer for how long.
JR: I now have a wardrobe of masks and have them placed strategically in my purse and car so that I don’t leave home without one. I view wearing a mask in public places as a way to make others more comfortable so they need to worry less about whether I could spread disease to them. I am more conscious than I was before about people coughing around me, and even though I suspect I have already have COVID-19, I haven’t had the next strain of flu or other virus.
My hope is that we recognize the importance of science and technical experts and that we become more committed to long-range thinking and planning. Development of effective medical treatments and vaccines is a massive challenge but it will be easier with sufficient investment in education, research and infrastructure. Thirty-second sound bites from uneducated people might make for good television but they don’t provide sufficient context or information for rational decision making.
Do you have any additional comments or advice you would like to provide?
TM: The flu is still a dangerous disease. My hope is that the vaccine for coronavirus will be included in the flu shot. More people will get the flu shot every year if the coronavirus vaccine is administered at the same time. And, I hope everyone reading this stays safe.
DS: From my personal experience, stay hydrated. Drink water often to help prevent even moderate dehydration. Modify your personal habits and diet to reduce your susceptibility. I had high blood pressure over my 40 years as a physical therapist. Now that my stress level is lower, I am off my medications and maintaining a healthy blood pressure.
As we develop a plan forward, I hope that the country considers and implements ways to help small rural hospitals in particular. A cousin who lives in Colorado was a doctor whose hospital closed, leaving the area residents with 100-mile drives to the nearest facility. Many hospitals spent huge amounts of money to prepare for COVID-19 patients and simultaneously stopped the elective procedures which provide necessary funding to support their operations. Development of funding policies to ensure the survival of local and specialty hospitals is key for healthcare.
Vaccine development takes time to make and distribute vaccines that are safe and effective. We need that to allow society to return to ‘normal’. I am hopeful that the Oxford labs working on SARS vaccines may provide a jumpstart. We also need sufficient personal protective equipment (PPE) and testing to allow us to return to normal.
Human/animal transmission of disease is a concern. Some people suggest that the original source of the Spanish Flu may have been cattle in Kansas, and it is highly suspected that the current novel coronavirus originated in bats. We need to think about our interactions with exotic animals particularly in markets in the developing world.
Healthcare professionals have been put under tremendous stress in the response to COVID-19. We need to continue to support them and to provide needed services and resources going forward.
JR: In addition, we need to develop a robust Public Health system in the US and ensure that we maintain its strength and vitality. Mental health problems are already being discussed as part of the burden of the pandemic and we need to increase the availability of understanding and treatment. The isolation and confinement mandated by social distancing in addition to economic stress of lost jobs and businesses are a potent combination for difficulties.
We need to ensure we have excess capacity in the healthcare system and managed stockpiles of equipment and medicines to manage when it is needed. The COVID-19 pandemic was not unexpected, but had been predicted for years and transmission of a zoonotic virus to humans was often listed as the likely cause.
Globally, we need to modify our practices to reduce this possibility to stave off the next pandemic but to simultaneously prepare to reduce its impact.
The global supply chains for key items are currently being re-examined as well, which will hopefully result in systems which are more resilient and focus less on immediate cost-savings to provide overall sustainability, quality and availability.