Lessons from the 1918 Influenza Epidemic: Part 4 – Conclusions – ’Such a big event, so little public memory’

With the current Covid-19 pandemic causing upheaval the world over, can we look to the past to learn lessons? Here, Mac Guffey continues a series considering lessons from the 1918 Influenza Epidemic, an epidemic that infected around a third of the world’s population and killed some 40 million people (exact estimates vary from 15 million to 50 million or more). He will consider the question: Can something that happened over a hundred years ago in a society so vastly different from today provide any useful guidance regarding the Covid-19 Pandemic?

Here, part 4 in the series considers some personal tales of the Great Flu of 1918 – and reflects on how little that flu is remembered today. After all, if we knew more about it, maybe the 2020 Flu Pandemic would have been less destructive.

If you missed it, the first article in the series considered what happened during the 1918 Influenza Pandemic and the lessons we can draw on the economy (here), part 2 considered the healthcare lessons from the pandemic by contrasting a successful and less successful approach (here), and part 3 looked at the importance of effective leadership (here).

Policemen in Seattle wearing masks made by the Red Cross, during the flu epidemic. December 1918.

My mom, who has long since passed away, was the first person to ever tell me about the “Spanish Flu” as she called it. Her uncle died from it in 1919 – several months after he returned from World War One. She was five at the time.

She had a photograph of him kneeling beside her in his “doughboy” uniform. He was quite a guy, I guess. Served with distinction, survived multiple “over-the-tops”, gas attacks, trench strafings, and came home to die in the third and last wave of the infamous influenza pandemic. 

He was one of the 675,000 American casualties of that virus.

Across America during the fall and winter of 1918-19, many such tragic memories were made. Here are a few from Mike Leavitt’s The Great Pandemic of 1918 State by State. (Leavit, 2006)

In Hartford, Connecticut, Beatrice Springer Wilde, a nurse, recounted the tragic story of four Yale students she treated. They had become ill while traveling and decided to get off the train in Hartford. Their last steps were taken from the train station to the hospital. Within twenty-four hours, all were dead. 

Bill Sardo, a funeral director in Washington, D.C., remembered:

"From the moment I got up in the morning to when I went to bed at night, I felt a constant sense of fear. We wore gauze masks. We were afraid to kiss each other, to eat with each other, to have contact of any kind. We had no family life, no church life, no community life. Fear tore people apart." 

All public gatherings were banned in Seattle, Washington including church services. Many of the local ministers complained until the mayor said publicly, “Religion which won’t keep for two weeks, is not worth having.” 

The town council in Rapid City, South Dakota made spitting on the sidewalks illegal. A local police officer was seen spitting shortly thereafter. He was arrested and fined $6 for committing the offense. No one was exempt.

Augusta, Georgia was the hardest-hit city in the state. The nurses in the local medical facilities were also struck down by the pandemic. As a consequence, nursing students were put in charge of shifts at a local hospital. Schoolteachers were enlisted to act as nurses, cooks and hospital clerks, and an emergency hospital was constructed on a local fairground. In Athens, Georgia, the University of Georgia indefinitely suspended classes.

An Ocala, Florida man named Olson traveled to Jacksonville, Florida for a carpentry job. Jacksonville was inundated with the flu at the time, and despite a citywide quarantine and the use of gauze masks, Olson contracted the flu. Eager to return to his hometown and family, he slipped past the quarantine and caught a train back home, taking the virus with him. Within days of his return, he had infected his family, and his neighborhood.

James Geiger, the U.S. Public Health Service Officer for Arkansas continuously downplayed the influenza threat to the state - even after he caught the flu, and his wife died from it.

Alaska & Authors

The 1918 pandemic also swept through Native American communities in Alaska killing whole villages. One school teacher later reported that, in her area, three villages were wiped out entirely. Others, she said, averaged as many as 85% deaths and probably 25% of those were too sick to get firewood and froze to death before help arrived. When the pandemic passed, because many were so sick that they were unable to fish or hunt and store food for the winter, they died of starvation. Some were forced to eat their sled dogs, and some sled dogs, unfed and hungry, ate the dead and the dying.

This last story from 1918 is about the effect this epidemic had on one of America’s best known authors - Katherine Anne Porter. 

Porter, who would later earn a Pulitzer Prize for her short stories, was one of the thousands who became ill during the epidemic in Denver, Colorado. Porter contracted influenza while working as a journalist for the Rocky Mountain News. She could not be admitted to the hospital at first, because there was no room. Instead, she was threatened with eviction by her landlady and then cared for by an unknown boarder who nursed her until a bed opened at the hospital. Porter was so sick that her newspaper colleagues prepared an obituary, and her father chose a burial plot. That near-death experience changed Porter in a profound way. She said afterward, "It just simply divided my life, cut across it like that. So that everything before that was just getting ready, and after that I was in some strange way altered." Her book, Pale Horse, Pale Rider, is a fictionalized account of her experience in the 1918 pandemic.

Lesson Four: Conclusions – ‘Such a big event, so little public memory’

Will and Ariel Durant, the husband and wife co-authors of that massive eleven-volume study The Story of Civilization, also wrote a thought-provoking short work entitled, The Lessons of History. On page eleven they ask:

As his studies come to a close the historian faces the challenge: Of what use have your studies been?... Have you derived from history any illumination of our present condition, any guidance for our judgments and policies, any guard against the rebuffs of surprise or the vicissitudes of change? (Durant, 1968)

While that quote is certainly apropos for this last article in a series entitled “Lessons from the 1918 Influenza Epidemic”, it’s not for that reason that I selected it. 

It’s for a far more personal reason.

When I grew up and became a historian, that epidemic in 1918-19, despite my personal connection to it, was never a topic in my teaching curriculum.

And it should have been. 

As an educator, I admit now that I was remiss in not teaching about pandemics and our nation’s susceptibility to them. Had I done so, perhaps one of my students (and there were many) would have gone on to do something in that field. Or perhaps, the 2020 Pandemic would have been less traumatic for all of them.

Every experience that we’ve had in 2020 - our delayed response to the threat of a pandemic - our overwhelmed medical personnel and inadequate supplies - the quarantines - the public pushback and even the key community “stakeholders” – was there in 1918. 

But no one paid attention. It’s unfortunate that we never seem to seek (or adequately teach) the lessons that the past provides us - until it’s too late. We are NOW facing the greatest threat to our Democracy and to our existence as a nation that the United States has faced since the Civil War. The lessons from the 1918 Influenza Epidemic would have helped us in so many ways.

During my research for this series, I came across a 2018 comment that someone left at the end of an article on the Philly Voiceblog during the 100th Anniversary of the 1918 Influenza Pandemic – “Such a big event, so little public memory.” (McGovern & Kopp, 2018)

Indeed. How many five-year-olds will lose a favorite uncle this time?

Food for thought.

Why do you think there is so little public knowledge of the 1918 Great Flu Pandemic? Let us know below.

Read more from Mac Guffey in the Amazing Women Airforce Service Pilots of World War Two here.

Works Cited

Durant, W. a. (1968). The Lessons of History. New York, New York: Simon and Schuster.

Leavit, M. (2006, January thru July). The Great Pandemic of 1918: State by State. Retrieved May 3, 2020, from Flu Trackers.com: https://flutrackers.com/forum/forum/welcome-to-the-scientific-library/-1918-pandemic-data-stories-history/14750-the-great-pandemic-of-1918-state-by-state

McGovern, B., & Kopp, J. (2018, September 28). "In 1918, Philadelphia was in 'the grippe' of misery and suffering". Retrieved April 10, 2020, from Philly Voice: https://www.phillyvoice.com/1918-philadelphia-was-grippe-misery-and-suffering/

Lessons from the 1918 Influenza Epidemic: Part 1 – ‘the threat of an outbreak you may not have experienced’

With the current Covid-19 pandemic causing upheaval the world over, can we look to the past to learn lessons? Here, Mac Guffey starts a series considering lessons from the 1918 Influenza Epidemic, an epidemic that infected around a third of the world’s population and killed some 40 million people (exact estimates vary from 15 million to 50 million or more). He will consider the question: Can something that happened over a hundred years ago in a society so vastly different from today provide any useful guidance regarding the Covid-19 Pandemic?

The first article in the series considers what happened during the 1918 Influenza Pandemic and the lessons we can draw on the economy today, namely the current controversy about reopening the economy after only several weeks of quarantine.

US troops with influenza in 1918 at U.S. Army Camp Hospital No. 45, Aix-Les-Bains, France, Influenza Ward No. 1.

On December 1, 1862, President Abraham Lincoln wrote some advice for the nation’s legislators in his Second Annual Message to Congress. 

The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew and act anew. [1]

Embroiled in the chaos of America’s first and only civil war, Lincoln’s advice to Congress to do what today we call “think outside the box” was almost futuristic in its suggested application. But to think outside the box requires one to know what’s already IN the box.

That’s where the world is right NOW in 2020 – trying to think anew and act anew - as the Covid-19 Pandemic upends the entire globe medically, socially, economically, and politically. 

But humanity is desperate. 

We don’t have the lives to waste on actions that merely repeat past failures or the time to ignore proven medical measures to chase quack medical solutions or the economy to endure all these haphazard plans born of desperation or political expediency.

But do we actually have any idea of what has gone before? Do we know what’s been tried and failed or what’s been tried and worked or what was never tried at all during a pandemic of THIS magnitude?

Ironically, we do – the 1918 Influenza Epidemic. 

In 2008, Thomas Garrett, then an economist with the Federal Reserve Bank of St. Louis, published a study on “Pandemic Economics: The 1918 Influenza and Its Modern-Day Implications”. The third paragraph of his study contains this common sense recommendation.

Certainly an event that caused 40 million worldwide deaths in a year should be closely examined not only for its historical significance, but also for what we can learn (in the unfortunate chance the world experiences another influenza pandemic). [2] 

But the relevant question is: Can something that happened over a hundred years ago in a society so vastly different from today provide any useful guidance regarding the Covid-19 Pandemic? 

With Garrett’s suggestion as a goal, this article is the first of a four-part series to answer that question. Using the 1918 Influenza Pandemic as our foundational model, this series will examine that event using the three top issues or questions that have emerged during the 2020 crisis. We’ll see how the government and the people in 1918 handled similar challenges, and what, if any, lessons from the past can help us in the present.

Starting with the current controversy about reopening our economy after only several weeks of quarantine, we’ll also take a look at two other 2020 issues: healthcare and government leadership in the 1918 pandemic. 

The final article in this series will present some conclusions from the lessons of 1918 and offer some anecdotes that give voice to those who experienced this same type of crisis more than a hundred years ago. 

If we must think anew and act anew, then we must do so with knowledge – not ignorance.

Lesson One: ‘the threat of an outbreak you may not have experienced’

The United States (and the world), due to social distancing and stay-at-home restrictions during the Covid-19 Pandemic, hasn’t come near the mortality levels of the 1918 Influenza Epidemic. In fact, we’ve even flattened the rate of infection and mortality curves projected by most, if not all, of the statistical models used for the 2020 crisis.

Because of this good news, public health experts, state governors, the Trump administration, business owners, and Americans from all walks of life are now debating the question uppermost in everyone’s mind: How long do the restrictions need to continue before we can reopen the economy?

Despite the statistical success, Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said on CNN’s “State of the Union” that the answer to reopening the economy “depends”.

“It is not going to be a light switch. It is going to be depending where you are in the country, the nature of the outbreak you’ve already experienced, and the threat of an outbreak that you may not have experienced.” [3]

Whether Fauci intended it or not, the end of his statement - “and the threat of an outbreak that you may not have experienced” – actually contains a double meaning. For 2020, it means those areas of the country that were spared the Covid-19 virus thus far, which was his point.

But the unusually deadly 1918 epidemic suggests a far darker meaning for us – the possibility of another wave of outbreaks that could be far more murderous than the first. What made the 1918 Influenza Epidemic so unusual - and so devastating for humanity - were those two subsequent waves of infection in the fall of 1918 and the winter of 1919.

The first wave – spring 1918 

The great influenza pandemic first hit Europe, the United States, and Asia, in 1918 and raged across the globe for two years from January 1918 to December 1919. [4] However, early reports of the virus were almost dismissive.

On page one of the February 6, 1918 Malone, New York newspaper were several updates on area residents at home and abroad. One of the updates was about Lieutenant Clarence M. Kilburn, an infantry officer serving with the First Division in France.

Letters received by his wife and mother – the last one dated Jan. 14th - stated that the lieutenant was still in a hospital in France. He had been in the hospital since Thanksgiving, first with an infection of the bowels and then with influenza which followed. [5]

The April 4, 1918 Port Jervis, New York newspaper – The Evening Gazette – had an article on page six about new U.S. recruits training and marching at Camp Dix - the new World War I military training and staging ground built in New Jersey in 1917. Tucked away at the very end of that article was a short blurb about the March health report for Dix, the largest military reservation in the Northeast. 

Camp Dix. . . The March health report was a setback for the high health mark maintained at the camp for six months. Weather of considerable variance in temperature and humidity coming and going suddenly was responsible for the increase in pneumonia cases, according to Lieutenant Colonel G.M. Ekwurzel, division surgeon. The sudden changes in temperature, coupled with a week of consistently damp weather in early March when the sun failed to break through for days, brought on a camp wide attack of influenza. Many of the pneumonia patients were among those first bothered with influenza. [6]

These initial outbreaks had all the signs of a seasonal flu. But there were two important differences; this particular strain was highly contagious and particularly virulent.

Camp Funston, Kansas reported outbreaks of influenza in early March. A military installation of 54,000 troops, Camp Funston reported that within the first two days of the outbreak 522 men reported sick and by the end of the month, 1,100 troops were hospitalized and thirty-eight of them died from pneumonia complications. [7]

The virus continued spreading throughout Europe, but the number of cases from that spring outbreak of influenza in the U.S. dwindled over the summer. But the first wave was actually a warning of things to come. Unfortunately - like 2020 - these early warning signs were minimized, dismissed, or ignored - because things got better.

Or so the world thought.

The second and third waves 

In August 1918, an even more virulent strain of the influenza virus appeared simultaneously in the shipping ports of Brest, France, Freetown, Sierra Leone, and Boston, Massachusetts. Medical historians now believe this strain was caused by a mutation of the initial virus.

For the next three months – September through November – the virus killed millions worldwide. An estimated 195,000 Americans died in October alone. [8]

The last - but no less deadly - wave started in Australia in January of 1919. This one, however, spread more slowly because World War I was over, but it, too, eventually reached the U.S. in December.

After three waves of this pandemic, an estimated thirty-three percent of the world’s population was infected and the worldwide death toll stood at over 45 million people - 675,000 of whom were Americans. [8]

Contributing factors to the high mortality rate

What made the 1918 Influenza Epidemic so devastating for humanity - were those two subsequent waves of infection in the fall of 1918 and the winter of 1919. 

Why were they so deadly?

While there are a host of biological reasons for the virulence of the virus, war and human decisions also played key roles in exacerbating the spread.

Like all wars in America’s history to 1918, disease killed more soldiers than battles. Recruits in all those wars came from every part of the nation, and they were crowded together in training camps, winter camps, and on ships. They brought with them their own local viruses and immunities, as well as their susceptibilities to other local viruses to which they’d never been exposed. 

But this war was the first truly WORLD war – one that involved soldiers from every continent on the globe. This international mingling increased every soldier’s exposure to a host of local viruses from other soldiers to which they had no immunities. Combine these human petri dishes with crowded training camps and trench living conditions, and it’s a recipe for a medical pandemic. This exposure is similar to that found on public transportation, cruise ships, and during air travel in 2020.

As these soldiers in 1918 went abroad, came home, or went on liberty, they infected civilian populations with similar results.

Many cities and states tried to enforce some degree of social distancing restrictions in 1918 by passing regulations regarding public gatherings and travel in attempts to stay the epidemic. In many places theaters, dance halls, churches and other public gathering places were shut down – some for over a year. One U.S. town even outlawed shaking hands! [9]

Quarantines, however, were few and those that existed were enforced with little success. Some communities were so desperate to isolate themselves that they put armed guards at the town limits to turn back any travelers who might bring an infection. But on the whole, the efforts were unsuccessful. [9]

One historian, Dr. James Harris, who studies both infectious diseases and World War I, came to this conclusion: The reluctance of public health officials to impose quarantines during the first two waves was partly to blame for the high mortality rate.

“Little was done those first two thirds of the pandemic. There was the wartime context, pushback to social distancing, people moving around the globe on a massive scale.” [7]

The failure of public health officials to do what they knew was in the public good because of sensitivity to political or public opinion further endangered the lives of the very people they were hired or elected to protect. 

Philadelphia, in 1918, provides a graphic example. 

By mid-September 1918, the virus was running rampant throughout the various military installations, training camps and staging areas in and around Philadelphia. Despite overwhelming evidence to the contrary, Philadelphia’s director of public health, reassured the public. The September 14th edition of the Harrisburg Telegraph reported on page six that “Dr. Wilmer Krusen, Philadelphia health director, does not see any danger in the Spanish influenza at present.”  [10]

Then came the Fourth Liberty Loan Parade.

Scheduled for September 28, the parade and a subsequent concert were organized to promote the sale of “Liberty Bonds” – a way to get the public to buy war bonds to help the government finance the war.

However, as the date approached, the medical community of Philadelphia pleaded with Dr. Krusen to cancel the parade and concert. According to Sam Dunnington’s 2017 post on the blog site: HiddenCity: Exploring Philadelphia's urban landscape:

Dr. Wilmer Krusen found himself under pressure from the city’s medical establishment to cancel the event. Krusen was Philadelphia’s director of Public Health and Charities. Several doctors had called on him earlier that month to quarantine 300 sailors that had recently arrived at Philadelphia’s Navy Yard. The servicemen had come from Massachusetts, where a virulent outbreak of influenza had already caused the Army to cancel a draft call. Krusen refused to quarantine the men. As concerns about influenza grew, the medical community encouraged the cancellation of the Liberty Loan parade in the interest of avoiding crowds and ideal transmission conditions. [11]

Again, Krusen refused. On September 28, over a hundred thousand citizens and soldiers watched or took part in the parade and concert.

Within seventy-two hours, Philadelphia’s hospitals were overrun with influenza cases. Between October 1 and November 2, the city registered 12,162 deaths from influenza - a number that does not include those that died from underlying conditions while fighting the virus. [11]

Dunnington concludes:

Krusen could have lessened the death toll by mandating a quarantine or canceling the parade, but he operated in an environment that made such decisions almost unthinkable. . . With Krusen, Philadelphians experienced the pandemic under a public health official that could not act in their best interests without risking becoming an enemy of the federal government. [11]

History NOW

The controversy about our current pandemic now raging across the United States is whether the social distancing and stay-at-home restrictions need to continue since the rate of infection seems to be tapering off.

Gerard Tellis, Neely Chair of American Enterprise, director of the Institute for Outlier Research in Business (iORB) and his research partner Ashish Sood of UC Riverside, along with Nitish Sood, a cellular and molecular biology student at Augusta University, have released a paper that parses the possibilities.

"The U.S. faces a unique challenge. All states have still not ordered lockdowns. So states that have and contain the disease may suffer contagion and relapse from those that don't or were late to do so. A uniform federal policy seems imperative." [12]

Our experiences during the 1918 Influenza Epidemic indicate that underestimating the first wave of an outbreak and continuing to yield to public and political pushback against quarantines and social distancing may lead to much higher mortality rates. 

As Fauci said, it’s “the threat of an outbreak that you may not have experienced” that should guide our decision-making - not politics or boredom.

Food for thought.

Now, read part 2 here: Lessons from the 1918 Influenza Epidemic: Part 2 – Healthcare – Two cities - Two outcomes - One reason

What lessons do you think we can learn from the 1918 Influenza Pandemic? Let us know below.

References

[1] Roy P. Basler, et al. eds. (1953). The Collected Works of Abraham Lincoln – Volume 5. New Brunswick, N.J.: Rutgers University Press, p 538.

[2] Garrett , Thomas A. (2008). “Pandemic Economics: The 1918 Influenza and Its Modern-Day Implications”. Federal Reserve Bank Of St. Louis Review - March/April 2008. p.76. 

[3] Sonmez, Felicia, Taylor Telford, Elise Viebeck. “Public health experts urge caution about push to reopen the economy”. The Washington Post – April 13, 2020, First edition.

[4] Rosenwald, Michael S. “History’s deadliest pandemics, from ancient Rome to modern America”. Washington Post – April 7, 2020, First edition.

[5] The Malone Farmer. (Malone NY), February 06, 1918. p.1. Lt. Kilburn recovered, survived the war, and returned home to Malone. He was elected to Congress in 1940 to fill the vacancy caused by the death of Wallace E. Pierce (R-NY). Kilburn served in Congress from February 1940 until January 1965.

[6] “Four-Week Recruits at Rifle Practice: Next Seven Days for 7,000 Soldiers Will Be One of Busiest and Most Interesting”. The Evening Gazette, (Port Jervis, NY) April 4, 1918. p. 6.

[7] Roos, Dave. “Why the Second Wave of the 1918 Spanish Flu Was So Deadly”. History Stories - March 3, 2020; Updated March 30, 2020. HISTORY. Archived April 2, 2020 from https://www.history.com/news/spanish-flu-second-wave-resurgence

[8] Centers for Disease Control and Prevention. “1918 Pandemic Influenza Historic Timeline”.  CDC Centers for Disease Control and Prevention. Archived April 4, 2020 from https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/pandemic-timeline-1918.htm

[9] “1918 Flu (Spanish flu epidemic)” About Avian Bird Flu - The Avian Bird Flu Survival Guide - May 21, 2008. Archived April 4, 2020 from http://www.avian-bird-flu.info/spanishfluepidemic1918.html

[10] “Well Known People”, Harrisburg Telegraph. (Harrisburg, Pa.) September 14, 1918. p.6.

[11] Dunnington, Sam. “A History Of Leadership During Philadelphia’s Epidemics”. HiddenCity: Exploring Philadelphia's urban landscape – July 21, 2017.

[12] Tellis, Gerald, et.al. “How long will the COVID-19 quarantine last? Business research provides insight”. Medical Xpress, April 8, 2020. Archived April 18, 2020 from https://medicalxpress.com/news/2020-04-covid-quarantine-business-insight.html