As our communities increasingly lock down, history provides vital insights about the importance of honest government communication, trust in officials and proactive efforts to get ahead and stay ahead of a public health emergency. Considering the 1918-19 influenza epidemic can remind us what it takes to collectively sacrifice for the greater good. It also suggests that at times of crisis state and local leaders have been particularly important, especially when there are tensions between state and national responses.
The Great War provided the context and propelled the martial language and approaches to the spread of influenza in 1918. That novel virus probably originated in Kansas in early 1918 and reached New Zealand by late spring. Influenza ultimately infected roughly 20 percent of the world’s population, killing some 50 million people in 15 months (more than the Black Death in the Middle Ages, more than all those killed in WWI and World War II combined) and approximately 675,000 Americans (when the population numbered 103 million).
When it swept across the United States, the country was in the midst of a draft, with widespread anti-German sentiment, and with a wartime state suppressing free speech. In response, politicians and officials, hyper-nationalist patriots, journalists and public health chiefs alike spouted lines about minimal risk. They suggested the disease resembled the common cold and objected to public health measures that would infringe on their freedoms or the U.S. war effort.
But when the disease’s true damage became more apparent, cities like St. Louis took action — canceling and postponing large events, gatherings, schools and limiting public transportation. These efforts, what we’d now call social distancing, worked to slow spread.
Officials in Philadelphia did the opposite. They blithely followed the lead of the Wilson administration. Not only did they “stay open,” they towed the patriotic wartime line, despite hundreds of emerging flu cases, and held an enormous Liberty Loan Parade on Sept. 28, 1918. Within three days, virtually every bed in Philadelphia’s 31 hospitals was brimming with patients. By Oct. 5, some 2,600 people had died. Within a week, the death toll was up to 4,500. On the worst days, nearly 800 died; the clergy could not keep up with the pickup of the dead. By Oct. 3, city officials rapidly shut virtually everything down. But it was too late. The damage was done.
National officials were slow to act, with even U.S. surgeon general Rupert Blue arguing that “there is no cause for alarm if precautions are observed.” At the end of September, as the spread took immense tolls, the Army canceled the nationwide draft call, but no blanket federal policies were announced. It was not until Oct. 8 that Blue issued a recommendation (not an order) for the use of closure policies. Military officials advised President Woodrow Wilson to continue troop transports despite considerable numbers of ill soldiers and sailors. Even by mid-October the surgeon general continued to assert that mild cases barely needed attention. It was his belief that “the present generation has been spoiled by having had expert medical and nursing care readily available.”
But cities like St. Louis took a different approach from Philadelphia or the federal government. The city tracked influenza closely, the mayor granted the health commissioner special powers and by Sept. 21 they advised citizens not to congregate in large groups. Within days of the first cases appearing, St. Louis leaders waged a “war” against influenza. They closed schools, theaters, movie houses, limited use of street cars and banned public gatherings of more than 20 people, then they followed with church closures. These measures did not stop the suffering. There were more than 31,000 influenza cases and nearly 3,000 deaths, but the mortality rate was the lowest of the 10 largest cities in the country. St. Louis was able to spread its cases out over time to not overwhelm the health-care system.
Portland, Ore., provides an intermediate example. It shows how even a slow or gradual response is better than none at all. And it reminds us how important it is for local and state officials to be brave in the face of criticism and the painful costs of closure decisions.
The first case apparently arrived in the region in mid-September, when sick sailors arrived in Washington state from Philadelphia. The flu spread to Camp Lewis in Washington, then to Fort Stevens near Astoria, Ore. Astoria locked down fairly rapidly because of how fast they reached 100 documented cases. In Portland, Mayor George Baker and others weren’t sure if it was the flu or just the common cold. They were not eager to preemptively shut down. The first clear case did not arrive until Oct. 4. Local leaders confronted individuals and groups, from ministers to theater owners, who vehemently opposed anti-crowding measures and quarantine laws. Schools, stores and theaters remained open. Gatherings continued.
But as more people fell ill, Portland’s widespread denial began to wane. The flu’s ravages could no longer be understated or underreported. Even when the federal government finally issued recommendations, they were minimal, so it fell on cities and states to take action themselves.
Eventually Portland politicians and health officials held firm, as did state officials, who cited federal recommendations and built on them (erroneously claiming recommendations had the power of orders) to justify their more draconian efforts. Stores were ordered to halt special sales (which they were running to try to keep businesses afloat but were drawing crowds); essential business hours were restricted; people under quarantine had signs posted on their doors and were surveilled; and there was serious talk of closing all businesses.
Portland’s gradual shift to more stringent sequestration policies, mixed later with periodic reopenings as infections slowed, seemingly minimized the peaks of illness and death. But it also appears to have drawn out the duration of the epidemic relative to other similarly sized cities, from fall 1918 through winter 1919. Portland provides an example in which eventually public health data, disease and putting human life first overcame market-based urges to operate the city as usual.
Why was there such a discrepancy between federal and state responses to the pandemic? Because it unfolded during World War I, and the military conflict abroad exacerbated the problem by allowing misinformation and racism to flourish in place of federal government action, leaving states and localities no choice but to act.
Because most Western nations were involved in the war, they attempted to control information, hide data about infection as well as mortality and pushed hyper-patriotic activities. The media was prevented by sedition laws from printing truthful stories about the disease that might undermine the war effort (such as by noting troops not being combat ready due to illness and spreading the flu nationally as well as internationally). Thus, citizens were ill-informed and even tended to deny the flu, waving it off as “three-day fever.”
That the illness became known as the “Spanish flu” was as much a part of wartime politics and racist propaganda as anything related to public health. Because it was neutral in the war, the Spanish press openly covered the serious influenza suffered by King Alfonso XIII and others, while combatant nations failed to openly discuss the illness. The British and later American press derisively called it the “Spanish flu” or “Spanish lady” (though the Spanish sometimes called it the “French flu,” Germans termed it the “Russian pest,” while Russians deployed the phrase “Chinese Flu”), and attributing it in part to the climate and hygiene in Spain.
Framing the illness as “foreign” combined with hyper-patriotic wartime pressures to make Americans slower to respond and implement lifesaving preventive measures, especially at the national level. But this was self-defeating. In 1918-19, the influenza death rate in the United States was about 0.65 percent, and at times wartime factories that remained open had 50 percent of their workforce out sick.
Then as now, all the action really happens at the state level. Proactive local and state leaders in California, Washington state, New York, Minnesota, Oregon and Ohio, among others, rather than the federal government are leading the way, if only because they are facing the most immediate impact of the virus’s spread.
If their efforts prove successful, the worst of the spread, deaths and economic damage can be mitigated. If not, or if the Trump administration undermines these policies before they have had time to be effective, history hints at a much worse fate looming around the corner.