Dr. Howard Markel, Director of the Center for the History of Medicine at the University of Michigan
This is not one overarching story, but thousands of stories with separate outcomes. It is difficult to concisely answer the question of how all Americans attempted to protect themselves and what this global disaster meant, in human and scientific terms. Record keeping in 1918 was vastly different compared to this era. This is a tale of many cities, towns, and hamlets, multiplied by all kinds of individual experiences. Looking at American society in 1918, it was a very different country compared to today, with 50% of Americans living in rural settings. We need to be familiar with the social, cultural, and economic history of the region of study and try to understand the differences and similarities.
Differences between 1918 and today: Some of the striking differences between 1918 and today include:
- The train was the rapid form of transportation.
- The telegraph and telephone were the rapid forms of communication.
- Less than 50% of the population was city dwelling.
- There was a different kind of 24-hour news cycle; at that time there were as many as two to five daily newspapers.
- People wanted and needed their news information from written sources.
- There was a wide spectrum of quality among health agencies.
- The legal understanding of privacy, and civil and constitutional rights was different.
- Mass vaccination programs have changed. Public support and trust of these measures and medical professionals have changed, especially in regard to vaccines.
- As far as the political landscape of 1918 goes, the majority of Americans had different views of federal and local government in their lives.
- Civics or Government courses have left the high school curricula. At that time, these were routinely drummed into the heads of young Americans. This must have had an impact on what people thought of their responsibilities.
- Daily commercial transactions were different: there were no supermarkets, refrigeration was primitive, there was a limited supply of preserved foods, and there was daily market-going activity at multiple locations (e.g., grocer, butcher).
- Finance: there were no credit cards or personal checking accounts, which meant far more frequent visits to the bank. In 1918, there was almost exclusively a cash economy. Closure of banks might be explained as a response to a pandemic, but it could have been perceived that the closure meant the bank did not have funds.
- Nonpharmaceutical interventions included closures of schools and public parades. Banks would have been one of the last institutions to close, and of course, saloons were the very last institutions to close.
Modern developments: Today our modes of travel and communication have changed:
- We have a high volume of commercial aviation, instead of mass transit such as railways and steamships.
- There is immediate access to the Internet and personal computers.
- We have advances in medical technology and therapeutics that have changed the landscape of how to approach a pandemic.
- Connectivity means many financial transactions can be done from home.
However, America’s least wealthy still have the most difficulty getting access to these things. Those with the most limited resources are often hardest hit by natural disasters or pandemics.
The greatest differences between 1918 and today are the state of medical care and the role of hospitals. In the early 1920’s, even the best of medical centers or hospitals amounted to basic nursing care. Intravenous fluids and mechanical ventilators were not available. Many other facilities were makeshift institutions. Gyms, school halls, or armories were commandeered to set up cots, which would never be the case today. When the flu crisis was over, very little was done to rectify problems in basic health care that were identified during the crisis.
Physical experience: The “flu” term is overused. Many people say they have the “flu” when really it is a common cold or virus. “Stomach flu” is really overused. Influenza A or B is not subtle. Symptoms include high fever, muscle aches, hacking cough. Postviral symptoms include continued difficulty in breathing and painful chest wall muscles. The word influenza has its origins in fifteenth-century Italy, where the cause of the disease was ascribed to unfavorable astrological influences. An evolution in medical thought led to its modification to influenza di freddo, meaning “influence of the cold.”
As bad as a bout of real seasonal influenza is, the H1 strain was far worse. It killed two percent or more of those stricken. In 1918, postmortem examinations helped understand if it was a case of flu. The performance of those autopsies was harrowing. Influenza defiled the lungs with bloody, frothy fluid. Instead of floating, the lungs plummeted to the bottom of water buckets during autopsies. The bronchials were fluid-filled, which explains the air hunger patients experienced. They frequently died from suffocation within 24–48 hours of developing symptoms. Some died later from secondary infections.
Psychological effects: Youngsters were sent away from homes because they were either sick and required isolation, or were well and needed to be protected from those sick in their household. Some were isolated from the outside world in orphanages. Newspapers carried long lists of the dead, with only names and dates of death.
Literature: There are very few biographies of famous people who contracted influenza. An example includes F. Scott Fitzgerald. He contracted influenza and was disappointed that it caused him to not be able to go overseas. He did not write about it in his later works.
Thomas Wolfe wrote a literary masterpiece about the death of his brother. More fabled is how influenza altered the decision-making abilities of President Woodrow Wilson and his chief aide, Colonel Edward House. Both were in Europe to attend the Paris Peace Conferences—the famed gathering where Wilson hoped to sell his 14 Points and establish a League of Nations. Colonel House, who arrived in Europe just weeks before the Armistice, contracted a severe bout of flu as he was negotiating with the other nations. In late February, as he was recuperating from his serious illness, Colonel House noted that, “When I fell ill in January, I lost the thread of affairs and I am not sure that I have ever gotten fully back.” To make matters worse, when Wilson was in Paris in mid-March, to work with the Big Four in the final stages of a comprehensive peace treaty, he, too, was stricken by influenza. Volumes have been written on how influenza may have altered the terms and negotiations of the Treaty of Versailles as it ravaged the bodies and thoughts of Woodrow Wilson and Edward House, among others.
While social historians of medicine warn against focusing too heavily on the illnesses of great men or the landmark cures of great doctors, the fact remains that when a world leader is struck down by influenza, in the midst of a pandemic that is accompanied by other global crises, the microbes’ power can be amplified above and beyond the symptoms it produces or the death it causes.
A masterpiece: In another case, influenza had the power to create a literary masterpiece through the experience and pen of a brilliant writer named Kathryn Ann Porter. At the time of the pandemic, Porter found herself in Denver as a newspaper reporter for the Rocky Mountain News. Both Porter and her Army lieutenant lover contracted the flu. Porter’s case was dire and her death seemed certain. Porter recovered months later only to learn that the love of her life died.
Almost twenty years later, she published one of the most eloquent descriptions of how flu tore family life asunder—through the eyes and emotions of a young girl named Miranda. Her magisterial novella, Pale Horse, Pale Rider, should be required reading for all who wish to know something about the social impact and personal impact of contagious disease; it also serves as a remarkably accurate description of what life was like in the U.S. during 1918. In the novella, Miranda makes a harrowing recovery from her grave illness, thanks to the attentive care of her nurses and physicians, only to learn (as Porter discovered in real life) that her new-found love, Adam, died of influenza at the camp hospital. Yet in a wonderfully optimistic declaration, Porter’s alter-ego, Miranda, concludes:
“No more war, no more plague, only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with the shades drawn, empty streets, the dead cold of tomorrow. Now there would be time for everything.”
Conclusion: Like Porter’s Miranda, I remain ever hopeful that there will be time for everything—including productive, ethical, and socially appropriate strategies that mitigate the microbial threats that inevitably loom on our horizon.
Richard Hatchett:
Wide array of public health agencies: There is concern in the policy making arena about the attempt to develop guidance. Local public health agencies may not realize the degree of support they could receive from the public health community. The challenge is to think of ways to mobilize pillars of support so that communities don’t feel that they are making profound decisions alone, absent of input from other institutions that will be there to support them. Whether or not we are prepared for the next pandemic, we are better positioned. We have tremendous mechanisms in the absence of direct face-to-face contact, so we must figure out how to take advantage of ways to stay connected. Even while disconnected, there is opportunity to mitigate. One way we begin to understand the psychosocial impacts is when we consider the impact of dozens of deaths in a single school.
Howard Markel:
Death issue: In 1918, the childhood mortality rate for children under five-years-old was one in five. Every household knew of a child who died at a very young age, often of a contagious disease or dehydration issues. Back then, the care of the ill was almost exclusively at home. Today, death has been taken out of the household. Very few people have seen someone die today. In 1918, it was probably 90%. Death issues need to be talked about. For example, what should we do if public gatherings for funerals are cancelled? How will that affect people? There are social effects of quarantine, although now we have some resources to mitigate the effects. Public health departments (municipal, state, and federal) are all funded very differently. Post 9-11, bioterrorism preparedness efforts have been good for public health, because they are not mutually exclusive problems. Whether man-made or ecological, the strategies we need to use to address these problems are not that different.
John Barry:
There are two great tragedies: The death of a child, or the death of a young child’s parent. Society saw a lot of both in 1918. There were many orphans in 1918. Several states put together orphan trains for adoption stops, which led to the establishment of the Child Welfare Department. I recently attended a tabletop exercise that included faith-based organizations. They can barely maintain the current agenda and feel that it would be almost impossible to take on additional tasks due to lack of resources. A problem we have is that volunteers are often double-counted. Plus, they may also be sick in the event of a pandemic. We need to think hard about parallel organizations that need help.
Howard Markel:
In talking with those in the front lines about potential problems down the road, the response is typically that they are very busy right now. This brings up a broader issue of the risk that people may tune out if a threat never does occur. Since we can’t say when a pandemic will happen, there may be a potential problem in getting people to do something about preparedness now.
Q: Thoughts on the public—we are expecting more from government. Will people be less patient and expect more than they did in 1918?
A: (Barry) The public does expect a lot more, and we expect technology to solve everything. I am appalled by the lack of attention paid to influenza in preceding decades. We have spent more on West Nile than influenza, which will never be as serious a threat. I believe that technology will eventually solve influenza. There has been enough work done to demonstrate that it is probable that we will have a vaccine that works for all influenza viruses. In general, people are not as self-sufficient as they used to be. The lack of flexibility today is a problem. We expect structures to do more for us and take care of us more than people did back then.
A: (Hatchett) It is true that people expect quite a bit from government. People have an affinity for magic bullets and an immediate vaccine. It is unfortunate that the single most effective intervention that people can take is individual action. This requires a tremendous imperative for government and public health authorities to communicate information effectively. It is critical that if we are to coordinate efforts to reduce transmission, people must take responsibility for their own actions and for their families. Individuals can reduce their own risk, and this must be a large component of our planning.
A: (Markel) Medical communities have a vested interest in pushing medicine. It is critical to understand what we have, what we can do, and what we hope to do.
Q: It is an unfair question about maintaining trust when it may be impossible to do. You spoke on the importance of truth-telling for maintaining trust. When the message is “we do not have enough masks” or “you are not the priority person for antivirals,” clearly, most human beings who hear that message will not trust because they don’t like the answer. What do you think can be done to maintain trust in that kind of situation?
A: (Hatchett) That is a powerful question. There is certainly concern about rationing medical resources. This became clear early on in our planning efforts. This situation would fracture public trust. The driving concern over the last year has been to look at the overall strategy and think about any conceivable way to sufficiently reduce transmission so that we can push the need to prioritize off the table. We plan to act aggressively in a coordinated fashion, using all available tools to reduce the degree of transmission so rationing does not need to be applied. This has not been done before. However, there is accumulating evidence from a variety of sources (historical, epidemiological studies, modeling studies) that we may be able to suppress transmission significantly.
A: (Markel) It is essential to be honest: say what you know and don’t know. The American people can handle that and do so all the time. There is a real difference between the political and medical worlds. In the political world, we are rewarded for staying on message. In the medical world, plans change depending on symptoms; we are always working with incomplete data sets. We are willing to change our minds as we get more information, and that is good medicine. This is essential to a crisis management plan.
A: (Barry) The need for rationing should be explained within the community. People are accepting when reasons for prioritizing are good. Nonsensical rationing cannot be explained, and we need to think hard about whether or not to do so.
Q: Regarding policy, is there going to be a federal policy that will be consistent across the nation? What can we do to have a consistent message?
A: (Markel) Looking at the broad history of public health, diseases are not a local phenomena and they don’t know boundaries or care about arbitrary states or jurisdictional lines. However, public health mechanisms in the U.S. are based on local incidences and phenomena. We need a global health department and standard criteria for how to manage disease outbreaks. It is a flaw that we rely on local and state health departments for protocols and policing.
A: (Hatchett) Local public health officials would welcome specific actionable guidance. HHS is working hard to develop guidance that can be released. At the federal level we recognize that issuing general guidelines has value and would be helpful.
Exercise: Note cards were turned in from audience members to collect thoughts and concerns from the group. A summary of these audience-generated questions and issues can be found in Appendix D of this document.
