We Failed in the 1918 Pandemic. We’re Still Failing Now.

by Scott Wagner

Illustration by Gabriela Sibilska

Pandemics are the nightmares that haunt doctors, nurses, and public health officials. They toss and turn at night fearing the outbreak of a novel disease for which we have no immunity. Their nightmares are borne from a single historical source: the 1918 influenza pandemic, which infected nearly a third of the global population and killed between 50 and 100 million people worldwide.


As the medical community has grown from adolescence to full maturity, it has looked back on the pandemic of 1918 as an adult looks back at childhood monsters under the bed. When we were young, we feared them; now, fully-grown, we see them as quaint. In 1918, viruses had yet to be discovered. Doctors commonly attributed the disease that became known as the “Spanish Flu” to a bacterium called “Pfeiffer’s bacillus,” now known as Haemophilus influenzae. That diagnosis provided little aid to physicians, however, as antibiotics had not yet been developed either. There were no major international or federal responses to the pandemic; in the absence of higher leadership, local authorities were left to fend for themselves.


The 1918 influenza was a particularly deadly virus that could kill victims within 24 hours and disproportionately targeted healthy adults. It was a heavyweight boxer attacking a featherweight health system. And while an outbreak like it could happen again, public health officials seemed confident it wouldn’t. No virus since the 1918 strain has had the same combination of virulence and transmissibility that made it so deadly. Even if one did appear, we would be ready. We now have centralized global health organizations like the WHO that can monitor potential outbreaks and advise political leaders. Domestically, the US federal government has developed stronger emergency response infrastructure through organizations like the CDC, NIAID, and FEMA. Locally, medical knowledge and equipment are state-of-the-art. Ventilators can assist patients struggling with respiratory infections, and antibiotics and antiviral cocktails can combat most disease variants. All that would buy time for researchers to develop a vaccine that would defeat the new disease once and for all. If a novel virus struck, we would be prepared. There was no reason to fear the monster under our childhood beds, not with all our maturity and sensibility.


Unfortunately, the inadequate response to the current coronavirus pandemic shows that there were monsters under our beds that we didn’t account for. 1918 may be worlds apart from 2020, but locally, federally, and globally, public health officials and politicians are making the same mistakes their predecessors made one hundred years ago.


Oakland Municipal Auditorium, used as a temporary hospital in 1918 | Library of Congress via AP

Across the board, political leaders were slow to respond to the influenza crisis of 1918. Focused on their own political projects, they failed to understand the threat posed by influenza. With the First World War still raging, the United States continued to send soldiers across the country and across the Atlantic despite reports of influenza. Agents of death became agents of disease, spreading the virus to every major US city. But local leaders shrugged. Medical authorities at Camp Kearny in San Diego classified the flu cases as the “common garden variety.” Dr. J.S. McBride, the Seattle Health Commissioner, thought the outbreak was merely “a form of la grippe.” As influenza cases began to spread through Philadelphia, physicians called for the cancellation of a Liberty Parade scheduled for 28 September. The city’s mayor, Thomas B. Smith, did nothing. He had been arrested for conspiracy to commit murder earlier that month, and spent more time listening to his lawyers than his public health advisers. The parade went ahead with an estimated 200,000 in attendance. Influenza cases spiked exponentially over the next week, forcing the city to adopt quarantine measures on 3 October.


Even after leaders grasped the necessity of quarantines, political infighting and ignorance hamstrung public health responses. After shutting down the city of Seattle in early October, Mayor Ole Hanson declared that “the epidemic would be ended within five days.” Influenza cases continued well into 1919. Minneapolis and St. Paul argued over divergent containment strategies, with Minneapolis choosing to shut down public places and St. Paul pursuing a strategy of isolation and containment. In San Diego, the health board tried to impose a closure of public facilities despite a lack of approval from the city council. Eventually, the State Board of Health had to step in to enforce the closure. Political leaders failed to act, and when they did, they acted haphazardly. The virus had broken the bureaucracy.


The extensive network of public health organizations we have today was meant as a firewall against bureaucratic malfeasance during a pandemic. But these experts hold no real power. They are there to advise; leaders are there to enact. A 2017 CDC manual on containing pandemic influenza states that “decisions are made by state and local officials [with] guidance from the CDC and governing authorities.” That guidance is a paper tiger when it goes unheeded. Despite warnings from health experts as far back as November, our political leaders shirked responsibility. Xi Jinping muffled information on the severity of the virus outbreak in Wuhan in December and January. Italian officials downplayed the potential impacts of coronavirus until the disease erupted in the northern parts of the country. President Donald Trump confidently predicted in February that the number of cases in the United States were “going to be down to close to zero.” Our leaders acted politically; unfortunately, the coronavirus is not a political animal.


Prompt and proper decision-making is nothing without the organizational infrastructure to support it. In 1918, there were few large-scale organization efforts. Everything was left in the hands of local officials. What resulted was a system of immense scarcity and a multitude of competitors striving against each other for limited resources. Perhaps the greatest shortage was in medical professionals—namely, nurses. Many nurses had been sent abroad to contribute to the war effort, and many of those that remained started to come down with cases of influenza themselves. In Philadelphia, one dispatcher received 3,100 urgent requests for nurses. Only 193 were provided. City officials were forced to reach out to religious groups and request uncloistered nuns to help administer medical treatment. Other cities relied on Red Cross volunteers who had taken home hygiene courses and had spent at least 72 hours working in a hospital setting.


Seattle police in masks made by the Red Cross, December 1918

The shortages did not stop at medical professionals and equipment. Cities hit hard by the influenza ran out of space in their morgues. Historian John Barry describes how in both military and civilian hospitals, bodies were “stacked like cord wood” in the halls. In overcrowded hospitals in Philadelphia, “bodies were being tossed from the cellar into trucks, which when filled carted them away.” They weren’t carted to funeral homes or morgues, thoughthere weren’t enough coffins in the city. Cemeteries and funeral homes began charging exorbitant prices for simple burials. Others simply told family members to bury their own dead.


Shortages abound once again. The United States has some 173,000 ventilators, according to a study from Johns Hopkins University, but a Harvard Medical School study suggests that 31 times that number might be necessary. In hotspots such as Detroit and New York City, shortages are already forcing doctors to choose who gets a ventilator and who fights the virus on their own. In Spain and Italy, medical workers have run out of clean gowns. Instead, they use garbage bags. Bandannas and handkerchiefs have become ineffective understudies to N95 respirators. The shortages in medical supplies will soon be replaced by a shortage of medical professionals as doctors and nurses are themselves infected with the coronavirus. The scarcities continue even after death. New York City has started burying coronavirus victims on Hart’s Island to make room for new bodies in the morgue.


A strong international or federal response could help alleviate some of the pressures. But we also have a shortage of leadership. The European Union has again become Fortress Europe as countries try to preserve their already-limited medical supplies. French President Emmanuel Macron has demanded that all French production of isopropyl alcohol, a key ingredient in hand sanitizer, remain in France. In the United States, the federal government has been conspicuously absent in organizing a response to the pandemic. Trump dallied in invoking the Defense Production Act, which would have allowed him to order private business to produce necessary medical supplies to fight the virus. Senior adviser Jared Kushner refused to direct the strategic national stockpile towards key hotspots by arguing that “the federal stockpile is ours, not the states’.” In previous times of crisis, the federal government has stepped in to coordinate emergency response efforts and provide relief to those in need. Trump has decided that now, in the middle of a global pandemic, is instead the time to fall back upon the false sanctity of conservative small government and let the states fend for themselves.


The hardest battle is not even against the virus itself; it’s against the insidious creep of misinformation and the erosion of public trust that inevitably follows. The 1918 influenza struck at a rare high-water mark of censorship in the United States. Nothing could be allowed to suppress morale on the home front, not even an influenza pandemic. A day after Camp Meade went into quarantine to stop the spread of influenza, The Philadelphia Inquirer erroneously reported that the outbreak was insignificant and would not require quarantine. When Health Director Dr. William Krusen banned public gatherings in Philadelphia, newspapers illogically insisted the order was not “a public health measure.” The people could no longer trust the press, so they instead looked to health officials for consistency and guidance. They received neither. Multiple urban areas including New York and St. Paul demanded that any physician who diagnosed an influenza case impose a full quarantine on that household. Individuals became reluctant to report symptoms for fear of quarantine and the stigma associated with it. Other cities opted for widespread closures of businesses and bans on public gatherings, yet these too were often inept or inconsistent. In Minnesota, social distancing orders were announced in advance. The night before the bans went into effect, revellers packed bars and theatres before entering their forced hibernations. Business owners lost thousands of dollars in revenue during the closures; meanwhile, crowds continued to swarm in churches, department stores, and trolley cars. And still, the body count grew higher.


Mistrust turned to fear, and fear turned to rage. Shipyard laborers constructing wartime necessities refused to work for fear of catching the virus. At Groton Iron Works, more than half of the workforce simply stayed home. Unable to trust the advice of health experts, frightened Americans turned to quack doctors and miracle cures like Schenck’s Mandrake Pills and Miller’s Antiseptic Snake Oil. Mandatory mask orders in Minnesota, Seattle, and San Diego were met with scorn and derision. Anti-mask demonstrations were held in San Francisco, flouting the ban on public gatherings in the process. Elsewhere, men cut holes in their masks for cigarettes, forgoing protection from influenza to administer their preferred method of poison. Theatre owners filed lawsuits against city and state governments, arguing that health officials had no right to shut down their operations. New regulations ordered by Dr. McBride in Seattle were lambasted by the Post-Intelligencer as “another [ex]cess of regulative zeal.” By the end of 1918, health officials were not just fighting a disease they didn’t understand; they were fighting the baser fears and insecurities of a public they were ostensibly supposed to protect.


A cartoon from North Carolina State Health Bulletin mourning 13,644 dead. October 1919

Confusion and miscommunication are creeping in once again. Doctors have been scrambling to understand the new coronavirus, but progress seems slow in the era of the instant news cycle. Too late did doctors realize that the virus can be spread through asymptomatic carriers, torpedoing early identify-and-isolate measures. Finding those asymptomatic carriers requires widespread testing; however, numerous countries still lack a high quantity of fast and reliable testing kits, much less the leadership and infrastructure necessary to distribute them. Our insufficient understanding of the virus has led to inconsistent responses worldwide. In the United States, some states acted promptly and closed all public places upon the first outbreaks of the virus. Others like Florida kept their beaches open for spring breakers who wanted to party at the end of the world. Each discrepancy and disparity further erodes public trust. On 2 March, US Surgeon General Jerome Adams warned that wearing a face mask could “increase your risk of getting [the virus].” On 7 April, Los Angeles Mayor Eric Garcetti ordered all residents to wear face coverings when leaving their homes until further notice. Early models forecast the potential for between 200,000 and 1.7 million deaths from the coronavirus in the United States alone. Now, thankfully, those models have been revised down to between 100,000 and 200,000 deaths, but the massive shift has raised questions on the utility of the models themselves. The question begins to creep into our minds, subtle at first but growing louder by the day: do our leaders know what they’re doing?


We are still early in this crisis. Most places are complying with social distancing orders—for now. But already some politicians and business leaders are calling for an easing of strict shutdown measures in order to get the economy up and running. Texas Lieutenant Governor Dan Patrick claimed that “there are lots of grandparents out there in this country” who would happily risk their lives in order to reopen the economy. Where Jesus died for our sins, Grandpa dies for our stocks. Others are using the shutdown to find new ways to make a profit. Conservative radio host and conspiracy theorist Alex Jones claimed that his Superblue toothpaste “kills the whole SARS-corona family at point-blank range,” proving that quackery is immune to scientific advancement. Even the president of the United States is lauding the potential curative powers of hydroxychloroquine, an anti-malarial drug that has yet to be proven effective against coronavirus in clinical trials. “What do you have to lose?” the president said. “Take it.” People all over the world are stuck in their homes seeking consolation and guidance anywhere they can find it. Instead, they are finding misinformation. We trust our government and our public health officials to protect us, but are they up to the task?


We live in a world of monsters now. Political leadership is absent. Organizational infrastructure has fallen into disarray. Communication has eroded public trust rather than buttressing it. These monsters have been under our beds since 1918, but we refused to see them. We trusted in our advanced medical knowledge and high-tech life-saving equipment to compensate for the flaws in our public health bureaucracy. Our trust was misplaced.


In a way, though, we are lucky. As impactful as the coronavirus is, it does not appear to be as deadly or virulent as the 1918 influenza. But viruses are constantly mutating; new strains are always emerging. And we might not be so lucky the next time one strikes. We cannot take the monsters under our bed for granted. We have to be ready for the next nightmare.

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INTERZINE | 2020