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 3 – Leadership – ‘Vigilance, Predetermined Countermeasures, and Planning’

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 3 in the series considers the importance of effective leadership. Mac looks at how the cities of St. Louis, Milwaukee, and Minneapolis managed to have lower rates of infection when compared to other comparably sized cities thanks to effective leadership.

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) and part 2 considered the healthcare lessons from the pandemic by contrasting a successful and less successful approach (here).

A 1918 poster warning about ‘Spanish Flu’ and how it could impact war production for World War I.

The federal government’s role regarding the public health is generally an advisory one. By and large, the real business of public health and safety is basically a local matter. State, county, and city health departments operate under a rag bag of rules and regulations that vary from community to community based on a community’s prior public health experiences. (Garrett L. , 2020)

Because of this, the way the 1918 Influenza Epidemic unfolded across the United States actually provides a tremendous series of independent case studies about what worked and what didn’t work.

The determining factor – community mortality rates.

Thirteen years ago, Anthony Fauci* and David Morens did just that and wrote an article about the 1918 Influenza Pandemic for The Journal of Infectious Diseases. It was subtitled “Insights for the 21st Century”. 

In their article, they made several key points. One - historical evidence about pandemics suggests there are no predictable cycles; therefore, countries need to be prepared for the possibility of a pandemic at all times. Two - if a novel virus as virulent as that of 1918 were to reappear, a substantial number of potential fatalities could be prevented with aggressive public-health and medical interventions. 

But the best antidote, they said, was prevention - through vigilance, predetermined countermeasures, and planning. (Morens & Fauci, 2007)

Morens’s and Fauci’s recommendations were partially based on the similar way several major urban areas truly “met the moment and prevailed” with the lowest mortality outcomes during that exceptionally virulent second wave of the 1918 Influenza Epidemic.

It was all about leadership.

Lesson Three: Leadership – ‘Vigilance, Predetermined Countermeasures, and Planning’

In addition to St. Louis (covered in Parts 1 and 2 of this series and reviewed here for comparison), Milwaukee, and Minneapolis also registered lower mortality rates than most urban areas of a comparable size during the 1918 Influenza Pandemic. 

These cities also encountered many of the same problems and challenges during that pandemic that we’ve faced across the nation in 2020 – disruptive citizens, pushback from churches, schools, and businesses, and failures to comply with mask and distancing mandates.

However, the way those city leaders approached these problems and challenges had a major impact on the civilian death rates in their cities.

St. Louis

As just a quick review, St. Louis was led by a strong-willed and capable health commissioner, Dr. Max C. Starkloff, who had the foresight to actively monitor the news as the influenza contagion spread westward. The city’s medical and political communities were quickly prepared for the inevitability that the epidemic would find its way to St. Louis. His first action was to issue a request through the influential St. Louis Medical Society that physicians voluntarily report to his office any and all cases of influenza they discovered. (St. Louis Globe-Democrat, 1918)

When St. Louis physicians reported their first cases of influenza, he asked the city’s Board of Aldermen to pass an emergency bill declaring influenza a contagious disease. This gave the mayor the legal authority to declare a state of public health emergency. The bill also levied stiff fines for physicians who failed to report any new cases of the disease. (St. Louis Globe-Democrat, 1918)

Starkloff and St. Louis Mayor Henry Kiel then executed an open-minded, flexible approach to quarantining, school closings, and other social distancing measures. They also maintained a unified front despite persistent pushback from various St. Louis constituencies. Because of the quick and sustained action by its leaders, St. Louis experienced one of the lowest excess death rates in the nation. (University of Michigan Center for the History of Medicine, 2016)

Milwaukee

Even with two influenza waves between October and December 1918, the magnitude of Milwaukee’s brush with the 1918 Influenza Epidemic was still less severe than other U.S. cities of a comparable size. In the aftermath, Milwaukee Health Commissioner George C. Ruhland believed there were three reasons for the better outcomes. (Milwaukee Health Department, 1918)

The first reason was the readiness of the public to comply with any regulatory measures. For that Ruhland credited the Milwaukee medical community’s plan to engage the public. With the support of the city’s newspaper editors, the group began an immense public education campaign - with printed literature in six languages, including English. They created flyers and speaker’s notes, selected respected physicians and city notables as speakers, and requested the area clergy to discuss the flyers from the pulpit. If citizens, business owners, and city government all understood exactly what they were facing, there might be greater cooperation and acceptance should any draconian measures be necessary to blunt the epidemic. (Milwaukee Sentinel, 1918)

The second reason Ruhland listed was the timing of the closing orders and the generally widespread compliance from Milwaukee’s citizens. What’s interesting is that because of the two waves – October and December - Ruhland’s team actually tried two different approaches to see which one worked better. The October approach involved mandated closings - all places of amusement, churches, public gatherings, and eventually the schools. (Milwaukee Journal, 1918)

However, as the number of new cases in Milwaukee declined, some citizens and business owners believed the influenza threat was almost over. They got together and sent a number of requests to Ruhland to lift the bans on public gatherings. He refused. As more businesses clamored for relief, Ruhland publicly pointed out the consequence of overconfidence in other cities - reopening prematurely resulted in another wave of the infectious disease. (Milwaukee Journal, 1918)

Despite Ruhland’s gradual reopening however, a resurgence of the virus occurred in December 1918.

This time, to avoid outright closures, Ruhland shifted the responsibility to the public. He recommended masks be worn in public, set restrictions to the amount of personal space surrounding people in public - every other row was vacant in theaters and churches, retail customers surrounded themselves with six square feet of vacant space – and then he left it up to the people to govern themselves. The citizens, for the most part, ignored the self-restrictions, and that idea failed. (Milwaukee Journal, 1918)

The conclusion Ruhland came to after these two experiences have important ramifications for the world pandemic today. While closures don’t prevent influenza, they are very necessary in order to flatten or prevent the severe spikes in the number of influenza cases that can occur over a short period of time. It’s the severe spikes, he said, that overwhelm the available hospital facilities, healthcare workers, and medical supplies. Preventing those spikes flattens the mortality curve because those who do fall ill have access to better – not desperate - healthcare. (Milwaukee Wisconsin Department of Health, 1918)

The last factor that helped contribute to the lower mortality rates was the overall cooperation from all the community “leaders” during the epidemic – city government, physicians, hospital administrators, businessmen, the Red Cross and other relief agency leaders. Thanks to that cooperation, all necessary decisions were implemented rapidly and immediately. (Milwaukee Health Department, 1918)

In this city of 450,000 people, more than 30,000 of them came down with the flu during those two waves in 1918. Thanks to leadership vigilance, predetermined countermeasures, and planning, fewer than 500 died.

Minneapolis

“Spanish influenza does not exist in Minneapolis and never has, but it probably will reach here during the fall,” the City of Minneapolis Health Commissioner, Dr. H. M. Guilford, told residents on September 19, 1918. (Minneapolis Morning Tribune, 1918)

Less than a month later, the flu epidemic struck the city. By then, Guilford had a plan ready. The health department ordered all schools, churches, and non-essential businesses closed indefinitely. The measure was unanimously endorsed by the Minneapolis city council. The council also stipulated that the city’s department of health had the full authority to issue any closure orders with or without the consent of Minneapolis’s mayor or the council. (Minneapolis City Council, 1918)

Pushback, however, was almost immediate. 

The Minneapolis Board of Education disagreed with the shut-down order and reopened the schools. The Superintendent of Schools, B. B. Jackson, argued that the leading medical authorities across the nation had determined that epidemic influenza was not a children’s disease. Guilford however, refused to give ground and at his request, the Minneapolis Chief of Police met with the school board and persuaded them to close the schools once again. (Minneapolis Morning Tribune, 1918)

In spite of the school board resistance and a later protest by the owners of amusement businesses, Guilford kept the city closed down until November 15, when the number of new influenza cases reached what he deemed an acceptable level. At that point, schools and businesses were allowed to reopen. (University of Michigan Center for the History of Medicine, 2016)

However, in early December, the number of Influenza cases spiked again – this time, it was among the school populations. Guilford reinstituted the school closures until the end of the month, but he added an important caveat: All students would be required to undergo a thorough examination to ensure that he or she was free of any illness before being allowed to return to the classroom. (University of Michigan Center for the History of Medicine, 2016)

Strong leadership, sustained adherence to science, and a unified front both politically and medically throughout the 1918 Influenza Epidemic enabled Minneapolis to keep the mortality rate of its citizens lower than most urban centers of a comparable size.

Conclusion

One of the more important “negative” leadership lessons from the 1918 Influenza Epidemic was the ‘too little, too late” actions by many public officials at the national, state, and local levels that exacerbated the spread of that deadly pandemic. (Mihm, 2020)

That was not the case in St. Louis, Milwaukee, or Minneapolis. Doctors Stackworth, Ruhland, and Guilford each showed vigilance by tracking the progression of the epidemic in other cities, in the military camps nearby, and mandating that their local medical communities report every new case of influenza. They all formed teams, set sound policy directions, communicated and educated about them, and implemented effective, predetermined countermeasures.

However, the greatest insight that 1918 epidemic provides for our 21st century health crisis is the determination of those leaders to maintain the aggressive public-health and medical interventions they put in place for the well-being of their citizens in the face of political, economic, and public pushback.

History Is Now

After taking office in 2017, the Trump administration fired the government’s entire pandemic response chain of command, including the White House management infrastructure, and disbanded the National Security Council’s pandemic team and a State Department program designed to identify outbreaks and other emerging threats around the world. (Garrett L. , 2020)

Then, in late December or early January 2020, Trump and his administration were informed by intelligence officials of a contagion raging in Wuhan, China. The administration, however, publicly treated the epidemic as a minor threat that was under control, at least domestically, and repeatedly assured the public that the risk to Americans was very low. 

By the end of January, there were about 12,000 reported cases in China, and growing rapidly by the day. At this point, the U.S. had a handful of confirmed cases, but there was almost certainly already significant community spread in the Seattle area.

Finally, on January 27, the White House created the Coronavirus Task Force (publicly announced on January 29) and declared a public health emergency on January 31. At that point, the federal government began to put in motion the executive, legal, and regulatory pandemic response procedures already on the books. (Wallach & Myers, 2020)

On March 24, 2020, the U.S. death toll from the Covid-19 Pandemic stood at 705 Americans. (CDC, 2020) That day, President Donald Trump said in his then daily Coronavirus Task Force briefing:

“There is tremendous hope as we look forward and we begin to see the light at the end of the tunnel. Stay focused and stay strong and my administration and myself will deliver for you as we have in the past." (Woodward & Yen, 2020)

Trump’s ‘hope’ versus the ‘vigilance, predetermined countermeasures, and planning’ of Starkloff, Ruhland and Guilford.

As of June 1, 2020, America’s death toll stands at over 106,000 coronavirus-related deaths. (CDC, 2020)

Food for thought.

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

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

References

CDC. (2020, April 30). “Coronavirus (COVID-19) pandemic – Overview: statistics”. Retrieved May 2, 2020, from Bing.com: https://www.bing.com/search?q=death+toll+coronavirus&form=EDNTHT&mkt=en-us&httpsmsn=1&msnews=1&rec_search=1&plvar=0&refig=60ce389eba704e0788409300929840cb&PC=HCTS&sp=1&ghc=1&qs=EP&pq=death+toll&sk=PRES1&sc=8-10&cvid=60ce389eba704e0788409300929840cb&cc=US&

Garrett, L. (2020, January 31). Trump Has Sabotaged America’s Coronavirus Response. Retrieved April 28, 2020, from FP (Foreign Policy): https://foreignpolicy.com/2020/01/31/coronavirus-china-trump-united-states-public-health-emergency-response/

Markel H, L. H. (2007). " Nonpharmacuetical interventions implemented by U.S. cities during the 1918-1919 influenza pandemic". JAMA, 298:647.

Mihm, S. (2020, March 3). Lessons From the Philadelphia Flu of 1918: Prioritizing politics over public health is a recipe for disaster. Retrieved April 22, 2020, from Bloomberg Opinion: https://www.bloomberg.com/opinion/articles/2020-03-03/coronavirus-history-lesson-learning-from-1918-s-flu-epidemic

Milwaukee Health Department. (1918). Bulletin of the Milwaukee Health Department 8, no. 10-11. City of Milwaukee, Health. Milwaukee: np.

Milwaukee Journal. (1918, October 10). "City closed to fight flu,” Milwaukee Journal, 10 Oct. 1918, 1. Milwaukee Journal, p. 1.

Milwaukee Journal. (1918, December 2). "Schools closed to stop flu". Milwaukee Journal, pp. 1, 6.

Milwaukee Journal. (1918, October 26). "Weather Cause of Deaths". Milwaukee Journal, p. 2.

Milwaukee Sentinel. (1918, October 11). "City Starts Big Battle On Influenza". Milwaukee Sentinel, p. 6.

Milwaukee Wisconsin Department of Health. (1918). Forty-second annual report of the Commissioner of Health City of Milwaukee. Milwaukee: np.

Minneapolis City Council. (1918). Proceedings of the City Council of the City of Minneapolis, Minnesota, from January 1, 1918 to January 1, 1919. Minneapolis City Council, Proceedings of the City Council of the City of Minneapolis, Minnesota, (p. 536). Minneapolis.

Minneapolis Morning Tribune. (1918, October 20). "Clash Over School Order Due Monday". Minneapolis Morning Tribune, p. 1.

Minneapolis Morning Tribune. (1918, September 20). “No Spanish Influenza in City, Says Guilford”. Minneapolis Morning Tribune, p. 2.

Morens, D. M., & Fauci, A. S. (2007). The 1918 Influenza Pandemic: Insights for the 21st Century. Journal of Infectious Diseases, Volume 195, Issue 7,, 1018-1028.

St. Louis Globe-Democrat. (1918, September 20). “Doctors Here Must Report Influenza,” St. Louis Globe-Democrat, 20 Sept. 1918, 2. St. Louis Globe-Democrat, p. 2.

St. Louis Globe-Democrat. (1918, October 6). “No Quarantine Here against Influenza, Says Dr. Starkloff". St. Louis Globe-Democrat, p. 8.

University of Michigan Center for the History of Medicine. (2016, September 19). City Essays. Retrieved April 21, 2020, from American Influenza Epidemic of 1918 - 1919: A Digital Encyclopedia.: http://www.influenzaarchive.org.

Wallach, P. A., & Myers, J. (2020, March 31). “The federal government’s coronavirus response—Public health timeline - part of the Series on Regulatory Process and Perspective”. Retrieved April 4, 2020, from Brookings: https://www.brookings.edu/research/the-federal-governments-corona

Woodward, C., & Yen, H. (2020, March 28). ”Fact check: Donald Trump is a rosy outlier on the science of the virus”. - Saturday, March 28, 2020. Retrieved April 20, 2020, from Associated Press Website: https://apnews.com/

Wright, J. (2020, March 3). Four disastrous mistakes that leaders make during epidemics. Retrieved April 15, 2020, from The Washington Post: https://www.washingtonpost.com/outlook/2020/03/03/four-disastrous-mistakes-that-leaders-make-during-epidemics/

Lessons from the 1918 Influenza Epidemic: Part 2 – Healthcare – Two cities - Two outcomes - One reason

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 2 in the series considers the medical readiness lessons for today, by contrasting the very different approaches of Philadelphia and St Louis in the 1918 Influenza Epidemic.

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: Available here.

With masks over their faces, members of the American Red Cross remove a victim of the 1918 Influenza Epidemic from a house at Etzel and Page Avenues, St. Louis, Missouri. St Louis managed the Epidemic better than many other US cities.

American life in 1918 was busy, demanding, and non-stop. 

A world war was raging in Europe; military camps were springing up all over the country to accommodate the military’s demand for more soldiers. Factories (and even community clubs, organizations, and families) were busy turning out provisions needed by those boys going “over there”.

But the demands of this war also drained the nation’s supply of healthcare workers, medical equipment, and diminished the quality of available civilian medical care everywhere. So when the second wave of the 1918 Influenza Epidemic struck toward the end of September, the civilian hospitals and medical personnel were simply unprepared.

The state health officer for New Jersey announced on September 27th that the influenza “was unusually prevalent” throughout the state. Within the next three days, more than 2,000 new cases were reported. Newark’s medical facilities were so quickly overwhelmed that the city purchased a vacant furniture warehouse to be used as an emergency hospital. (Leavitt, 2006)

Makeshift hospitals like that one were hastily opened in almost every community to deal with the astronomical surge in people seeking medical help, but the virulence of this epidemic simply overwhelmed them all. 

One New Jersey physician recalled the outbreak: “There was no need to make appointments. You walked out of your office in the morning and people grabbed you as you walked down the street. You just kept going from one patient to another until late in the evening.” He treated more than 3,000 patients that month. (Leavitt, 2006)

Finally, in newspapers around the country, messages from desperate city health departments appeared:

. . . The spread of the Spanish Influenza is now a matter for the individual citizen. The city is doing what it can. Now it is up to the public. You can help keep the disease down. IT’S UP TO YOU—TAKE CARE OF YOURSELF  (Johnson City Health Department, 1918)

That 1918 directive – very pertinent in both substance and form as we currently battle our own pandemic of epic proportions – actually represented a capitulation of sorts by America’s city and state governments.

At that point, everyone was on his or her own.

Lesson Two: Healthcare - Two Cities - Two Outcomes – One Reason

The very virulence of the influenza virus that late summer and early fall doomed the unready medical system in this country almost immediately. The United States had 5,323 hospitals with just 612,000 beds available to accommodate a nationwide population of some 92 million people. Within forty-eight to seventy-two hours of almost every local outbreak, all of the hospitals in that area were filled beyond capacity. (U.S. Bureau of the Census, 1976)

During the initial outbreak of the Covid-19 Pandemic in spring 2020, the modern healthcare system in the United States came perilously close to the limits that 1918 crossed. How do we handle a second wave that’s as virulent or more so than our first wave?

As history would have it, there actually is an answer to that very question in the 1918 Epidemic. It’s a tale of two cities – Philadelphia and St. Louis.

Philadelphia

For the sake of establishing a timeline by which to compare these two cities, let’s reiterate the facts we discussed in “Lesson One” of this series about Philadelphia’s health director Dr. Wilmer Krusen’s disastrous decisions that led to Philadelphia’s high mortality rate.

Despite evidence to the contrary regarding the virus’ virulence in the various military camps surrounding Philadelphia, Krusen was quoted in a Harrisburg newspaper on September 14th that he didn’t see any danger in the “Spanish Flu”. (Harrisburg Telegraph, 1918)

Three days later on September 17th, the first cases of the flu in the city were reported. Krusen took no quarantine measures or other social precautions, and furthermore, he ignored pleas from the local medical community to cancel the September 28thparade through the city. Over one hundred thousand people witnessed and participated in the parade that day. (Hatchett, Mecher, & Lipsitch, 2007)

Within seventy-two hours, Philadelphia’s hospitals were overrun. As the disease spread, essential services collapsed. Nearly 500 policemen failed to report for duty. Firemen, garbage collectors, and city administrators fell ill. [1] But it wasn’t until October 3rd that the city finally closed schools, banned public gatherings, and took other citywide measures to suppress the epidemic. (Hatchett, Mecher, & Lipsitch, 2007)

Krusen’s fourteen-day delay between the first reported cases in the city and his decision to finally impose a quarantine played a major role in the deaths of well over 12,162 people from influenza and other influenza-related complications between October 1 and November 2, 1918. (Dunnington, 2017)

One of the findings Thomas Garrett noted in his 2008 study of the 1918 Influenza Epidemic was that healthcare actually becomes irrelevant if there are no plans in place to ensure that a pandemic does not incapacitate the healthcare system like it did in 1918. (Garrett, 2008)

St Louis

In St Louis, Dr. Max Starkloff, the St. Louis health commissioner, planned ahead.

Instead of waiting for the virus to start, Starkloff started. 

First, he changed his thinking from IF to WHEN. By September 20th, Starkloff had already published a list of social “Don’ts” regarding behavior that could spread the “epidemic of influenza” that was happening in the east. (Evening Missourian, 1918)

He also alerted the local medical community to be prepared, and with their help set up a network of volunteer nurses to treat residents in their homes when the hospitals ran out of space. Members of the Red Cross Motor Ambulance Corps* were diverted from various camps to help transport civilian patients to the hospital and to deliver broth and food to those influenza patients being treated in their homes. (St Louis Post Dispatch, 2014)

Starkloff was ready.

When the first cases of the influenza epidemic were reported in St. Louis on October 5th, he and his staff moved rapidly. Two days later on October 7th, they closed schools, theaters, playgrounds and other public places. Quickly added to that list were churches and taverns, as well as restricted attendance at funerals. Streetcars were limited to seated passengers only – the usual crowds of standing riders were forbidden. (St Louis Post Dispatch, 2014)

These restrictions were enforced too. Despite significant pushback from local religious leaders and business owners who complained about the “draconian” measures and predicted dire economic consequences because of the closings, Starkloff and Mayor Henry Kiel remained firm. (St Louis Post Dispatch, 2014)

One Reason

What’s so staggering is the contrast in the mortality figures for these two cities. Philadelphia experienced 12,162 (or more) deaths in one month; St. Louis experienced 1,703 deaths over four months – the lowest mortality rate among the nation’s largest cities. (Hatchett, Mecher, & Lipsitch, 2007)

The one and only reason: In St. Louis, an intervention plan was in place and ready to go when the first cases were reported.

History is NOW

In a recent Washington Post interview, a frustrated ER nurse at Sinai Grace Hospital in Detroit, Michigan, Mikaela Sakal, described their struggle against the coronavirus:

Nobody prepared us for this, because this didn’t exist. These aren’t the kinds of scenarios you go over in training. Where do you put 26 critical patients when you only have 12 rooms? How many stretchers fit into a hallway? (Saslow, 2020)

The Covid-19 Pandemic is filled with healthcare anecdotes like this one.

While all kinds of “plans” supposedly have been designed to deal with a pandemic, there were no complete readiness plans that had been designed, practiced, corrected, approved, and waiting to be implemented. Even essential medical stockpiles of such common essentials as facemasks, hazmat suits, ventilators, or the machines to make them were wholly inadequate to handle the demands of this disaster.

And when a pandemic like 1918 DID hit in 2020, what occurred was panicky, uncoordinated, reactionary moves with no contingency plans for implementation problems, the long-term effects of each measure, or the necessary vs. available resources.

“Nothing went by the book,” Ms. Sakal explained angrily, “Every night, we had to come into work and rewrite the rules.” (Saslow, 2020)

When there is no virus vaccine, “readiness” becomes the major factor in the government’s ability to protect its citizens from a pandemic. Faced with spiraling mortality rates across vast populations over a short period of time, a “virus war” requires preparation, the ready availability of healthcare workers, hospital beds, and huge stockpiles of ready medical equipment to meet the massive demand.

More importantly, as the Philadelphia and St. Louis examples demonstrated, a national readiness plan uniting all of these elements is necessary.

Otherwise, healthcare becomes irrelevant, and 675,000 Americans could die.

Food for thought.

Now, read part 3 here: Lessons from the 1918 Influenza Epidemic: Part 3 – Leadership – ‘Vigilance, Predetermined Countermeasures, and Planning’ 

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

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