Spanish flu

Returning to Normal: Lessons from the “Spanish Flu”

katiefoss On Epidemics
Published on December 14, 1918 in The Lima Times-Democrat

With the eased CDC guidelines on mask-wearing for those vaccinated, the lifting of mandates and safety restrictions have varied significantly. Public health authorities and individuals have speculated on the timeline for a “return to normal” and what that entails: how to reopen, the adjustment to social situations, and overall experiences for this transition. Much like this moment, people in 1918-19 faced similar questions as the influenza/pneumonia crisis subsided.

From 1918 through 1919, influenza infected at least one-third of the world, causing more than fifty million deaths, with over 675,000 in the U.S. Despite its name, “Spanish Flu” likely emerged in Haskell County, Kansas in March 1918. This deadly influenza and pneumonia combination first appeared at Camp Funston and the nearby Haskell Institute – a boarding high school for indigenous students. As war raged on in Europe, domestic outbreaks of the virus continued throughout April and May, receiving very little media coverage. To most Americans, the “Spanish Flu” seemed to begin in the summer, as newspapers told of rising cases in Asia, Germany, Spain, England, and other countries. When the flu returned to U.S. soil in September, notably at Fort Devens, Massachusetts, it was perceived as the first American wave. As outbreaks spread across cities and states, its news coverage competed with and sometimes paralleled the overseas battles.

Surgeon General Rupert Blue and the U.S. Public Health Service periodically put out information and guidelines on influenza – distributed through local and national newspapers. Similar to the COVID-19 pandemic, approaches and restrictions varied geographically.With only print media, content was limited to the broad scope of the national papers or nearby outbreaks in local newspapers. In other words, people knew little about what was going on outside of their own communities.

As cases rose, most towns and cities closed theaters, pool halls, and other businesses, banned dances, concerts and gatherings, and discouraged crowding in public spaces. But even this was inconsistent. Minneapolis, Minnesota closed down. Across the river, the city of St. Paul stayed open. Responses across schools also diverged, as school boards held special meetings, debating the best way to proceed. According to Alexandra Stern, Martin Cetron, and Howard Markel, most schools closed for periods up to fifteen weeks. However, Chicago, New York, and New Haven were among the cities that remained open, using medical inspection and individual quarantine to reduce transmission. Businesses that remained open marketed their adherence to safety protocol. At the end of October in 1918, Seattle’s Bon Marché department store took out full-page ads to lay out precautions taken against influenza, which included masks on the salon employees, the removal of chairs in restrooms, and a trained nurse on staff in the infants’ department “advising mothers how to protect their families from influenza.”

An ad from Seattle’s Bon Marché department store, laying out precautions taken against influenza, which included masks on the salon employees, the removal of chairs in restrooms, and a trained nurse on staff in the infants’ department. Published on October 26, 1918 in The Seattle Star.

After the Surgeon General recommended mask-wearing in September 1918, Red Cross volunteers across the country produced identical gauze face coverings. Mask requirements were inconsistent by town. Boulder Springs, Colorado fined $100 to “any one caught not wearing a facial adornment in the form of a mask” as reported in The Anaconda Standard local newspaper. Yet in an Indiana town, children at school were exempt from mask-wearing. Private businesses also mandated masks. For example, Lima, Ohio’s Hotel Norval Domino Room advertised music and dancing in the local paper, stating, “Flu masks required.” While most hospitals required masks, Brooklyn’s Kings County Hospital banned employees from wearing them, even when cases rose among its nurses and doctors. 

Published on October 10, 1918 in the Des Moines Tribune

Concerns about transmission for mass transportation prompted epidemic rules for streetcars. Seattle staggered business hours to prevent overcrowding on streetcars required one-third of the windows to be open, enforced by police surveillance. In Portland, all streetcar windows had to be removed for additional ventilation. Children were altogether prohibited from riding on streetcars in Topeka, Kansas until the ban was lifted in February 1919. At Camp Gordon, Georgia, roads were sprayed with “a special antiseptic oil” to reduce the spread of germs through dust. Other rules addressed the sick and dying. New York City passed a law requiring landlords to provide heat of at least 68 degrees. Upstate, influenza victims had to be buried within twenty-four hours of death.

The reopening of society and lifting of restrictions was just as varied and confusing as it is now, if not more so. No effective vaccine existed to slow the spread, cases were inconsistently tracked, and the influx of soldiers from overseas complicated quarantine orders. “Returning to normal” in 1919 meant the reopening of society: schools, businesses, gathering places, taking part in dances and other activities that had been postponed, and gradual dissipation of fear. At the same time, for life to truly feel “normal,” soldiers had to return home and adjust to post-war life. It didn’t happen overnight.

While May 2021 does not directly parallel early 1919, the transition out of the influenza pandemic can provide insight and reassurance as to this moment. Reopening occurred over months. Just as most cities were beginning to close, Boston and others that had been hit earlier, started reopening as the end of October, with modified Halloween activities to acknowledge the somber post-epidemic tone. Across the United States, though, restrictions were temporarily halted on November, 11, 1918, as parades erupted to celebrate Armistice.

“Impromptu Allentown Armistice Day Parade,” November 11, 1918
Allentown Morning Call Newspapers, Public domain, via Wikimedia Commons

Many towns then resumed restrictions, relaxing them toward the end of December or in early January, taking different approaches. News coverage on the pandemic turned optimistic before the crisis subsided. On New Year’s Day, a writer for the Lexington Herald-Leader observed, “Life is getting back into normal again, the influenza ban is about to be entirely lifted and school work to be resumed.” There’s never been uniform agreement about what to do during a pandemic or how to reopen. Public health authorities and regular people disagreed in the past and continue to do so now, with questions that resonate now: Are masks still necessary? When can sporting events resume? Will spectators be permitted? Are children safe at school? Town leaders took different approaches to relaxing quarantine and mask rules – some opening everything at once, with others easing up gradually.

In the first months of 1919, stories of enjoying the first dance after restrictions were lifted appeared next to announcements of illness and deaths. Likewise, news and social media in 2021 have juxtaposed vaccinated reunions with COVID tragedies, especially for countries that have struggled with the vaccine rollout. As society reopens, there needs to be public physical and digital spaces for remembering and mourning, and preparation for the inevitable outbreaks that will continue. Months after Seattle lifted its restrictions, the 1919 Stanley Cup Final had to be canceled on April 1st after multiple players and a team manager developed influenza, ending the series in a 2-2 tie. Assuming the Tokyo Olympics go forward, similar disruptions are likely for unvaccinated athletes and teams. Until global vaccination rates consistently high and cases decrease significantly, we too will continue to experience outbreaksand deaths.

The biggest takeaway from the “Spanish Flu” is the light at the end of the tunnel. While we need to grieve lives lost, the world has pushed through before and will do so again. Disease outbreaks have and can produce some positive changes, from improved waterways and sanitation to emergency preparedness plans. Remote learning and working, access to technology, and innovation in education are among the significant improvements that will hopefully continue forward. Lastly, the last fifteen months have sparked new interest in the history of epidemics and pandemics. The experiences and moments of COVID need to be preserved and disseminated for future generations to remember this crisis.

What Polio Can Teach Us About This Pandemic

katiefoss On Epidemics , , , ,

Most historical comparisons to our current crisis have been to the “Spanish Flu.” And while several of my essays challenge some of the parallels put forth, I understand why people have been so quick to return to 1918 for answers. Its global reach and profound impact on the U.S. and most of the world feel somewhat similar.

Yet in focusing on this comparison, we miss the series of epidemics that might in fact paint a closer image to our current reality. Throughout the 1940s and 1950s, poliomyelitis emerged periodically in epidemic form, reaching its peak in the summer of 1952. Less than a year later, Jonas Salk’s vaccine was approved for a mass trial, which would prove effective.

What can these polio epidemics teach us about COVID-19? The diseases themselves are not similar. Polio is caused by a three types of a human enterovirus that spreads through contact or contaminated food and water. COVID-19 is a a novel coronavirus, transmitted by respiratory droplets.

What we can relate to is the mystery surrounding the disease. As with COVID-19, with polio, you never knew who would become ill or how bad it would be. Approximately 72% of polio cases were asymptomatic. Those who felt sick usually had mild symptoms. Only a small percentage developed the paralytic form, experiencing either temporary or permanent paralysis of a limb, limbs, the diaphragm, or multiple affected sites–its course unknown. And although it was characterized as a disease of children, adults also contracted polio, particularly in the later epidemics. [Note: I’m speaking in past tense here to refer to the mid-century outbreaks. Polio cases are still emerging in Afghanistan, Nigeria, and Pakistan).

What we can take from the periodic polio epidemics in the first half of the century are ways of living that are accustomed to interruption, the importance of a unified public response, and a healthy respect for disease itself. No one knew when polio would come to town. But when it did, local spots quickly closed down to reduce the spread of disease. People were quarantined and isolated as needed, sometimes even at camps. Movie theaters, public pools, and other gathering places shut down, as parents were advised to avoid having children mingle in new groups. Polio also led to local school closings for short periods, which were opened back up when it was believed that the threat had passed.

No one proposed that polio was a hoax or questioned the severity of the threat. The National Foundation for Infantile Paralysis (NFIP), founded by President Franklin D. Roosevelt and his business partner, Basil O’Connor, united the nation in the fight against poliomyelitis. NFIP campaigns provided education and raised money for rehabilitation and research toward a vaccine. During outbreaks, the NFIP provided additional health professionals and resources, including rocking beds, iron lungs, and other equipment, through coordinated efforts between the local and national levels.

We know the work of the NFIP was successful, demonstrated in the number of people helped and the production of two effective vaccines. At the same time, the NFIP also modeled what can be accomplished in terms of care and research when a nonprofit organization receives long-term public and governmental support.

Polio reminds us of the enigma that is disease. Privilege has shielded developed countries from experience with contagion, causing people to forget its power. In the early to mid-20th century, most people wouldn’t openly resist public health efforts to curb outbreaks. Rather, they were grateful for scientific progress against disease and celebrated the diphtheria antitoxin, each new vaccine, and the introduction to antibiotics.

It is problematic to only look to the 1918 influenza pandemic for lessons. Its first wave was largely unknown, meaning that the experiences of the Spanish Flu were limited to just a few months. As I outlined in earlier essays, we can’t even compare today’s mask mandates to restrictions of that pandemic (and yes, I’ve heard of the Anti-Mask League of San Francisco). Since World War I very much dominated public agenda and therefore, the pandemic seemed to both appear and conclude quickly. Instead, we should learn from the polio experiences. We can remember that we have done this before and can do it again. But, as in the past, we need to support health professionals, public health experts, and those working to develop a vaccine.

Appeared in Vogue and other media outlets

Why We Can’t Compare the “Spanish Flu” Waves to This Pandemic

katiefoss On Epidemics ,
The 3 Waves of the “Spanish Flu”
Most people had no idea that the first wave was happening, thus a faulty comparison to now.
Centers for Disease Control and Prevention / Public domain

We’ve heard the predictions of multiple COVID-19 waves for months. Our current stage is being disputed, with some people calling this the 2nd wave, while others argue that we’ve haven’t left the first. Regardless, the comparison between this pandemic and the “Spanish Flu” has been ongoing throughout this crisis. This focus on the waves of the 1918-19 influenza pandemic has particularly been used as a PSA of what not to do now. However, as I wrote in my post “Your Wise Friend Was Wrong” about a “Spanish Flu” meme that was circulating, this ahistorical comparison assumes too many similarities between then and now. Yes, we can and should learn from historical outbreaks, but we have to first understand what was known about disease at the time and what was communicated to the public.

Influenza (also called “la grippe”) was a familiar disease in 1918, predictably seasonal and usually mild. Doctors were not required to report deaths from influenza to the U.S. Public Health Service, even though it became epidemic in several years, including 1915-16. Influenza was not usually fatal, at least not for those outside of vulnerable populations.

The First Wave (from a contemporary understanding)

The H1N1 virus that attacked in 1918-19 was unique in its frequent complication of a deadly pneumonia and its high mortality among young adults. Outbreaks of this influenza/pneumonia likely first occurred in Kansas, at Camp Funston and the nearby Haskell Institute. Throughout the next two months, other military camps experienced high numbers of cases. These clusters of disease and death received almost no media coverage, other than a few stories that presented the outbreaks as isolated incidents, downplaying the severity of this new threat.

This article appeared at the bottom of page 2 of the Topeka State Journal on April 4, 1918. Coverage of (what we now identify as) the first wave was limited.

By the end of May, the outbreaks dwindled in the U.S.

Looking back, we now recognize these Spring outbreaks as the “first wave” of the influenza pandemic. However, in the moment, the lack of media coverage meant that most Americans had no knowledge of the rising cases. Most attention was directed to supporting the soldiers in World War I.

For the people of 1918, the influenza pandemic appeared to begin in June. Stories in The New York Times, Washington Post, and other U.S. papers reported on June outbreaks in China, Madrid, Morocco, India and Berlin and then throughout Europe in July. While cases appeared back in the U.S. at the end of the month, American media outlets only covered the epidemics elsewhere.

The Second Wave (but it seemed like the first)

It wasn’t until an eruption of U.S. cases in mid-September that the government and press publicly acknowledged that the epidemic had arrived. From September through November, the “Spanish Flu” raged throughout the United States. Quarantine was imposed at various degrees, as stores, public venues, and schools closed for 1-2 months. The people felt and lived this wave, as it affected the everyday lives of even the healthy.

The Third Wave

A third wave followed in the Spring, much of which was attributed to the mass transport of troops following the end of the war. Life didn’t shut down for this reemergence, however, at least not on a mass scale.

Why we can’t compare the pandemics

Outside of their available newspapers and magazines, the people of 1918 had very little media access. Information beyond what was in print simply wasn’t conveyed to the public, including the prevalence of influenza in Spring of 1918. To them, as presented in media, the first wave didn’t exist, the “Spanish Flu” began overseas, and even at the height of the epidemic, the war dominated all news.

With our abundant media outlets and individual-created content, we are in a different world than 102 years ago. We have known about COVID-19 since 2019, tracking its spread and watching its devastation. In other words, we cannot compare the notion of waves in 1918 as applying to this pandemic, at least not in the response of the public back then to now. What we can take away, however, is that the “Spanish Flu” eventually did subside, as will COVID-19.

Why the masks look the same in “Spanish Flu” pics: The rise of mask-wearing during the 1918 “Spanish Flu” pandemic

katiefoss On Epidemics ,

Vintage photos of masked individuals and crowds during the 1918 influenza pandemic have been circulating in news stories and on social media. What I find particularly interesting is that they all seem to wearing very similar masks, consisting of a white, rectangle and two ties, like this one worn by barbers:

Open air barber shop during influenza epidemic. National Archives and Records Administration / Public domain

Or this mask, covering the face of an elevator operator:

 Elevator operator in New York City, N.Y., wearing mask.
National Archives and Records Administration / Public domain

Why are they all so alike, especially considering the diversity of homemade and store-bought masks in our current reality?

Two factors explained the uniformity in masks then (and lack thereof now). First, many of the masks were created and distributed by Red Cross volunteers. And when people had to make their own masks, they could follow the straightforward, Red Cross-issued instructions that encouraged the use of white gauze and ties. Sample masks to be used as demos were sent to local chapters. Before masks were required, people were encouraged to use handkerchiefs, but this doesn’t appear to be as common as the gauze coverings.

“New mask design” from the Red Cross.
Published in The Washington Times on September 27, 1918

The Red Cross was heavily involved in directly and indirectly caring for influenza patients. Newspapers encouraged people to do their part to help the sick, especially ill enlisted men. And they did. Volunteers donated chicken, rags, pajamas, canned jellies and fruits, and other items.

And when did wearing masks become required during the Spanish Flu? Not as quickly as some “Spanish Flu as a Lesson”-type stories may lead you to believe (messages that have been using as cautionary tales for the current pandemic. I debunk one here). In 1918, many folks were still getting used to the concept of sanitary practices in the hospital. This April 1918 gem explains why nurses sometimes wear face masks to care for contagious patients.

Printed in the Rock Island Argus on April 10, 1918.

It wasn’t common practice for the general public to wear masks then (or now, at non-pandemic times). Doctors and nurses masked up during the spring outbreaks in the military camps (downplayed and ignored by media). No evidence suggests that regular people wore masks during this time.

In the summer of 1918, news media reported on the deadly disease as it spread through Asia and then Europe. However, nothing suggests that the U.S. prepped for influenza to come home. Articles focused on a different type of protection — the gas mask — needed to protect soldiers from poison gas attacks in the trenches.

Warnings of the impending influenza appeared in July. At the end of the month, 5 cases were documented at Camp Eberts in Arkansas, but incidence remained low for the next month. August newspapers documented illness and deaths aboard ships headed for the U.S.

As ships were being quarantined at New York and other ports, September 13th, Public Health Reports published the Navy’s preparation plan for handling the epidemic, including “Methods for the control of the disease.” Quarantine and isolation, at least for the Navy, were deemed “impracticable” due to the prevalence of healthy carriers. The final section advised mask-wearing for patient attendants and discouraged gatherings:

Published in Public Health Reports, September 13, 1918.

Excerpts of this report were published in newspapers across the country, paired with stories of rising cases, for the next few months.

By mid-September, influenza had become epidemic in some of the army camps and continued to spread across the country. On September 18, the Richmond Times-Dispatch reported that the local Red Cross chapter had requested 4,000 face masks for caregivers the previous day. The next day, a Connecticut paper recommended masks made from gauze for those near influenza patients.

Over the next two weeks, reports of Red Cross volunteers producing masks for nurses and other influenza attendants in military camps increased, as did cases of influenza. Still, there was no indication that regular people had started wearing face masks, nor had quarantine (outside of ports) been implemented.

Approximately 23,000 cases had erupted at military camps before soldiers were advised to wear masks while training. Female volunteers made them for the Red Cross, producing an average of 1 every 5 minutes. Cases of influenza reached epidemic levels in 26 states before it became common for even enlisted men to wear masks.

Like we’ve experienced in the last three months, society shut down before masks became required. Similar to now, restrictions varied by city and state. Flu mask ordinances were implemented primarily in November and December, as barber shops, theaters, and other crowded places began to open. In some places, everyone was required to wear masks. More often, though, care attendants, those in recovery, barbers, and elevator operators were required to don masks, while others were simply encouraged, especially those riding on street cars.

Contrary to numerous social media posts and contemporary articles on “Spanish Flu,” mask-wearing did not occur immediately, nor was it universally required and accepted. That said, the wide distribution of masks by the Red Cross made them much more accessible, especially for those enlisted and/or caring for patients.

Note: In researching for this blog post, I examined newspaper coverage using the search terms “masks” and “influenza” from March through December 1918 (and beyond). I weeded through numerous articles about gas masks. Even at the height of the pandemic, war news dominated media outlets.

Published in several news outlets, including the Fulton County News,
September 26, 1918

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Your wise friend was wrong. Analyzing the viral post about influenza and Armistice celebrations.

katiefoss On Epidemics , ,

This message has gone viral, warning people about the potential impact of easing up on social distancing restrictions too early:

Nicollet Mall in Minneapolis, MN, from the Minnesota Historical Society

The post appeared without naming the location. Yet, I have yet to identify where this information would have been true. The timeline does not make sense. Summer was not the deadliest time for the “Spanish Flu.” Fall was, peaking in October in both Europe and the U.S. The 3rd wave returned the following Spring, not immediately after armistice celebrations.

Furthermore, many countries did not implement “social distancing” measures because of turmoil due to the war. No one called it that either. Selective quarantine did occur in some places, but it was reactive, not proactive. In other words, even cities and states praised for the best responses didn’t shut down until cases had already emerged. Plans for reopening were already in place when the war ended.

As far as the deaths from war versus disease, it actually depends on the country. More Americans died from disease than combat. However, in England, approximately 700,000 people died from war, whereas 228,000 from influenza/pneumonia.

Besides the misinformation conveyed here, we need to take any comparisons between past epidemics and our current crisis with a grain of salt. This is not 1918 (or 1957-58, 1968, or 2009). We can certainly learn from the past from credible sources, but our technology, resources, and world are not the same.

Thank you to the folks who helped me track down the photo and original post. Iric Nathanson’s article contextualizes this photo.