influenza pandemic 1918 Soldiers suffering from influenza at the hospital in Camp Funston, Kan., in 1918. Troops from the camp carried the virus to other Army bases during World War I. (New York National Guard/National Archives)

COVID-19 Societal Response Similar to the 1918 Flu Pandemic

We are living in uncertain times with a coronavirus outbreak that emerged in Wuhan, China, that has now became a global pandemic whose resultant disease is known as COVID-19. There has been a lot of comparison between the ongoing pandemic and the 1918 influenza pandemic, and a lot of that comparison is unwarranted. However, history has a lot to tell us if we take the time to look. A brief look at media reporting today and newspaper reporting and photographs of the 1918 influenza pandemic illustrates we are repeating history in many ways as far as how society is responding to this scourge. COVID-19 has changed many things in our daily lives, but the biggest takeaway is that we will emerge from this in time and hopefully learn from our collective experience to be better prepared.

Before going forward it is important to state that even though the worldwide COVID-19 rate and transmissibility rates are similar to 1918, COVID-19 is not an influenza strain. Another difference between these two pandemics is the age demographics of the resultant fatalities. Tragically and uncharacteristically of influenza, the 1918 pandemic was a killer of those between 15 and 35 years of age without underlying medical conditions. Whereas, the fatalities of COVID-19 have predominately been those near or over the age of 65, especially those with underlying medical conditions: respiratory conditions, heart disease, diabetes, high blood pressure, and/or suppressed immune systems. So far, case histories have shown that a small percentage of younger people are suffering from COVID-19 but, worldwide, mortality rates increase with age.[1] This speaks to the fact that younger people are not immune and can become infected and infect others, whether they are symptomatic or not.

It is noteworthy to mention that much has changed in the past 100 years including advancements in worldwide surveillance of established and novel infectious diseases, intensive care capabilities, antibiotic and antiviral developments, vaccine process improvements, and the speed of information technology, all of which help fight a pandemic. In fact, since the 1918 (Spanish Flu) pandemic, the influenza pandemics of 1957 (Asian Flu), 1968 (Hong Kong Flu), and 2009 (Swine Flu) have decreased in virulence and fatalities, and much of that can be attributed to the past 100 years of medical developments, innovative treatments, and well-trained medical professionals.

As COVID-19 becomes an expanding worldwide scourge, many in the U.S. think we are experiencing unprecedented societal and life changes unheard of in American history. Walter Rauschenbusch, an American theologian, once wrote, “History is never antiquated, because humanity is always fundamentally the same.” How we are responding to COVID-19 is not unique to pandemic history or humanity, we just need to look back a little over 100 years to recognize that fact.

Today, one of the most visible changes in our lives is the wearing of masks (See Graphic 1) and the practice of social distancing and self-quarantine if infected, or having come in contact with a confirmed case. In many places and countries, the wearing of masks during the 1918 influenza pandemic was compulsory as headlined in The Morning Bulletin, which read “Wearing of Masks is Made Compulsory in Alberta [Canada]”;[2] the subheading read that masks had to be worn outside the home. Today we are also seeing a large ramp-up in production of medical countermeasures like masks, respirators, ventilators, and gloves but shortages remain. In 1918, the major form of protection was a cloth mask that was often hand-sewn by members of the American Red Cross.

Graphic 1 – Photos of left is mask making in New York City in 1918 (credit: U.S. Library of Congress. Photo identifier: LC-DIG-anrc-05418) and photo on right is mask making in Boston, Massachusetts in 1918 (credit: U.S. National Archives and Records Administration. Photo identifier: 165-WW-269B-26).

Today we are watching public schools and universities close for the remainder of the year in the U.S. and the world with the hope to return to normal operations in the fall. In an article from the summer of 1918 it was reported that “in Leeds, Manchester Heights, Herts, Egham, Sheffield and Birmingham certain schools and factories have been closed.”[3] Later in the year, it was reported in Wellington, New Zealand that “schools and colleges are closed indefinitely.”[4] Like today, children not attending school had to be kept busy with activities. (See Graphic 2)

Graphic 2 – Photos of boys working on projects in Denver, Colorado in 1918 (credit: U.S. Library of Congress. Photo identifier: LC-DIG-anrc-02490)

Today, internet providers are working hard to provide stable and expanded access to a growing number of home-based students and teleworking adults but the internet has also proven to be a vital tool to keep the population informed of changing conditions.[5] In the growing pandemic of 1918, the telephone infrastructure was a key reporting mechanism. Even so, this robust communication tool was impacted by absenteeism as reported in an October 1918 London article, “The influenza is responsible for a large increase in sick leave in the London Telephone Service, about 1,000 operators being absent from duty owning to illness.” Many of these operators were women. The 1918 influenza added yet another barrier to these women who worked outside the home and their caregiving role of that era. (See Graphic 3).

Graphic 3 – Photo on the left is of a masked typist working in New York City in 1918 (credit: U.S. National Archives and Records Administration. Photo identifier: 165-WW-269B-16) and the photo on the right is a sick mother and unattended child in 1918 (credit: U.S. Library of Congress. Photo identifier: LC-DIG-anrc-02548).

Today we are experiencing closures of businesses, theaters, and restaurants, and even reduced manning levels within government facilities and mass transit services. This is eerily like an October 1918 article on the pandemic’s impact to Washington, D.C., which reported, “The flu has reached into every department of the government here. Never before has the Nation’s capital faced such an epidemic of disease.”[6] The article further reported, “Sunday all churches held services outdoors. Schools and colleges are all closed.  Theaters and movies are shut. All mercantile establishments, excepting those engaged in war work, food and drug stores, are open only a part of the day. Street cars are wide open; no windows are allowed closed, even in rain.  Railroads running from Maryland and Virginia must keep coach windows open.”[7] (See Graphic 4).

Graphic 4 – Photos on the left is of a street car in Seattle, Washington in 1918 (credit: U.S. National Archives and Records Administration. Photo identifier: 165-WW-269B-11) and the photo on the right is a poster inside a trolly car in Cincinnati, Ohio in 1918 (credit: U.S. National Archives and Records Administration. Photo identifier: 165-WW-269B-22).

Today, the seams of our healthcare system are fraying due to overworked health professionals and depleted medical resources. The strain on the health community and the need to pivot to COVID-19 resulted in cancellation of many elective/non-critical appointments and surgeries. The same strain on the healthcare system and pivot occurred 100 years ago as reported in an October 1918 article from Ontario, Canada: “The capacity of all hospital is taxed to the limit. Surgeons are co-operating to fight the epidemic by refusing to perform any operation unless it is of the most urgent character.”[8] (See Figure 5).

Graphic 5 – Photo on the left is in St. Louis, Missouri is of patient movement drills in 1918 (credit: U.S. Library of Congress. Photo identifier: LC-DIG-ds-01290) and the photo on the right is of influenza serum injections in Seattle, Washington (credit: U.S. National Archives and Records Administration. Photo identifier: 165-WW-269B-9)

Within the past month, the mayor of New York City directed his staff to identify alternate facilities that could serve for medical use.[9] Recent reporting stated that even college campuses were turning now empty dorm rooms into overflow space for COVID-19 patients.[10] Makeshift hospitals and walled isolation wards were built in Wuhan, China, to tend to the growing caseloads of infected patients and the U.S. is currently in the midst of doing the same with sports field houses, university dorms, and hotel rooms. Actions like this in 1918 were common as reported in an article in October 1918 in Wellington, New Zealand, which reported, “The town hall and several schools and church buildings are being utilized for hospital purposes.”[11] In Spokane, Washington, an article in October 1918 reported that “a large building in which several hundred beds may be placed is being sought by health authorities for a temporary hospital should the Spanish Influenza epidemic grow greater than can be handled with present hospital accommodations.”[12] (See Graphic 6)

Graphic 6 – Photo of a makeshift isolation hospital in New Haven, Connecticut in 1918 (credit: U.S. Library of Congress. Photo identifier: LC-DIG-anrc-02679) and Walter Reed Hospital in Washington D.C. in 1918 (credit: U.S. Library of Congress. Photo identifier: LC-USZ62-39224).

Almost daily we are watching government officials dictate mandatory closures and shelter-in-place orders to entire city and state populations, which is remarkable, but this too also occurred in 1918. A headline from October 1918 in The Seattle Daily Times read “Churches, Schools, Shows Closed – Epidemic Puts Ban on All Public Assembles.”[13] Another headline from October 1918 in The Marietta Journal and Courier read “Schools and Churches Are Closed on Account of Flu – Theaters Also Close: Epidemic Still Raging.”[14] A November 1918 headline in St. Paul Pioneer Press read “Influenza Lid To Go On City Today – Schools, Churches, Places of Amusement, Saloons, and Soda Fountains Affected.”[15]

Today we are seeing the growing impacts of COVID-19 on police and fire departments in the U.S. This was first illustrated by more than two dozen firefighters who were quarantined in early March in Kirkland, Washington, due to their exposure to a COVID-19 infected nursing home.[16] There have been many other cases of police and firefighters who have been quarantined or sickened since. Due to the high-contact nature of police, fire, and paramedic duties, a growing number of them will be infected and sickened by COVID-19. In fact, on March 22, 2020, it was reported that over 1,000 police officers were out sick[17], which was also seen during the 1918 pandemic. (See Graphic 7) An article in The London Times from October 1918 reported, “Yesterday, 1,400 members of the Metropolitan Police force were incapacitated from duty by influenza… Over a hundred members of the London Fire Brigade are on this sick list. At the Hackney fire station seven men out of 11 are laid up and the motor pump cannot be turned out for fires.”[18]

Graphic 7 – Photo on the left is of masked policemen in Seattle, Washington in 1918 and the photo on the right is of a masked policeman directing traffic in New York City in 1918 (credit: U.S. National Archives and Records Administration, Photo identifiers: 165-WW-269B-25 and 165-WW-269B-7A, respectfully).

In mid-March 2020, news emerged from Iran in which the health minister reported that Iranian deaths from COVID-19 were occurring on average every 10 minutes as caseloads continued to rise.[19] It was also reported in an online article that in New York City a COVID-19 victim was dying hourly on average.[20] Caseloads in U.S. hospitals are becoming so great that patients are being turned away and, for those who are admitted, record keeping may become challenged as hospital and mortuary staffs are stretched further. An example of this was seen in 1918 as reported in mid-October when The Philadelphia Inquirer reported that “families of those who died without medical attention could not obtain physician’s certificates of death.”[21]

In the past month, satellite images revealed the disturbing news of mass grave burials of COVID-19 victims in Qom, Iran.[22] These types of hasty burials are indicative of an overwhelmed healthcare system and the need to bury the dead quickly to free mortuary space and follow religious practices. Sadly, this too occurred in 1918, when the death rate and the amount of unrefrigerated bodies spiked following a large public parade, which forced officials in Philadelphia, Pennsylvania, to dig mass graves.

In a March 2020 interview with a northern Italian resident, he reported, “My brother’s daughter-in-law’s father passed away after five days in ICU. He was buried the next day. There was no burial ceremony. Only his daughter and his wife could attend the burial…  People dying alone in hospitals are placed naked in bags and then put in coffins, placed in churches, waiting to be buried. No relatives allowed in most cases. No burial services.” Close parallels were seen in 1918 when it was reported in August 1918 in The Fort Wayne Journal-Gazette that “there were many burials yesterday of bodies for which no undertaker could be secured. However, the conditions at cemeteries were little changed, many bodies awaiting graves to be opened for their internment.”[23]  The 1918 death rate in Fort Wayne, Indiana, at that time was so great that a company turned over “one of its buildings for casket making” as coffins were becoming in short supply.[24]

As it was in 1918, and as it is today, federal, state, and local officials in the United States are making difficult decisions that are affecting our economy and daily lives in countless ways. They are trying to walk the fine line between public morale, safety, personal freedoms, economic implications, and livelihoods. There is no good answer to any of this, but often a list of bad options. For now, well-worn guidelines that have gotten us through pandemics before include:

  • Wash your hands well and often
  • Wear personal protective equipment – masks, glasses, and gloves
  • Don’t touch your mouth or eyes
  • Cough or sneeze away from others
  • Adhere to robust social distancing in public
  • Shelter-in-place if directed by officials
  • Self-quarantine if showing symptoms or have come in contact with confirmed cases
  • Be considerate of others by not hoarding resources
  • Look out and support each other, especially the elderly

A fundamental truth is, just like what occurred 100 years ago and what this article hopefully illustrates, we will emerge from this pandemic and our words and actions will be studied 100 years from now. Again, hopefully, we will learn from our collective experience and be even more prepared for a possible resurgence of COVID-19. As a minimum, our experience today should serve as a warning to be ever vigilant and prepared for the emergence of the next novel infectious disease, which could have a far worse impact on our collective humanity.

 

Disclaimer:  The author is responsible for the content of this article. The views expressed do not reflect the official policy or position of the National Intelligence University, the Department of Defense, the U.S. Intelligence Community, or the U.S. Government.

[1] Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. ePub: 18 March 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6912e2
[2] “Wearing of Masks is Compulsory in Alberta” The Morning Bulletin, Alberta, Canada.  October 26, 1918.
[3] “Spanish ‘Flu’ Spreads Over All of Europe” The Fort Wayne Journal-Gazette, Fort Wayne, Indiana. August 7, 1918.  Page 8.
[4] “New Zealand Disorganized” The Age, Melbourne, Victoria, Australia. November 15, 1918. Page 8.
[5] “U.S. internet well-equipped to handle work from home surge” Frank, B., Sunday, 15 Mar 2020. As accessed on March 22, 2020, https://www.stamfordadvocate.com/news/us/article/U-S-internet-well-equipped-to-handle-work-from-15131415.php
[6] “Nation’s Capital Battles for Life Against Flu” The Hutchinson Gazette, Kansas. 20 Oct 1918, Page 11.
[7] “Nation’s Capital Battles for Life Against Flu” The Hutchinson Gazette, Kansas. 20 Oct 1918, Page 11.
[8] “Ontario Reports No Abatement in Epidemic ‘Flu’”, The Gazette, Montreal, Quebec, Canada. 16 Oct 1918, Wed. Page 3.
[9] “Live Blog: Coronavirus updates live: Restrictions on daily life grow as U.S. death toll climbs — NYC mayor orders officials to seek facilities for medical use”, NBC News, as accessed on March 22, 2020 at https://www.nbcnews.com/health/health-news/live-blog/coronavirus-updates-live-u-s-cities-close-public-buildings-global-n1160106/ncrd1160906#liveBlogHeader
[10] “Colleges offering dorms as hospital overflow for virus cases”. ABC News. March 18, 2020, as accessed on March 23, 2020 at https://abcnews.go.com/Politics/wireStory/
[11] “New Zealand Disorganized” The Age, Melbourne, Victoria, Australia. November 15, 1918. Page 8.
[12] “Seek Emergency Hospital Plant for Flu Victims” The Spoksman-Review. October 10, 2918.
[13] “Churches, Schools, Shows Closed – Epidemic Puts Ban on All Public Assembles”.  The Seattle Daily Times, Washington.  October 5, 1918. Page 1.
[14] “Churches, Schools, Shows Closed – Epidemic Puts Ban on All Public Assembles”. The Marietta Journal and Courier, Georgia.  October 11, 1918.
[15] “Influenza Lid To Go On City Today – Schools, Churches, Places of Amusement, Saloons, and Soda Fountains Affected.” St. Paul Pioneer Press, Minnesota. November 4, 1918.  Page 1.
[16] “25 firefighters had helped patients at Life Care Center” Selsky, A. Associated Press.  March 2, 2020.  As accessed on March 22, 2020 at https://www.firefighternation.com/2020/03/02/washington-firefighters-under-quarantine-after-covid-19-exposure/
[17] McCrathy C., Moore, T., “NYPD’s COVID-19 cases near 100, as hundreds more cops call out sick” New York Post, March 22, 2020.
[18] “Deaths in London and the Country – Effects on Telephone Service”.  The Times London, London, England. 28 Oct 1918. Page 3.
[19] Parisa H., Rueters, on March 19, 2020, as accessed on March 21, 2020, https://www.foxnews.com/world/person-dies-coronavirus-every-ten-minutes-iran
[20] “Coronavirus killing more than one person every hour in New York” Tribune Online, March 21, 2020.  As accessed on March 22, 2020 at https://www.msn.com/en-za/news/other/coronavirus-killing-more-than-one-person-every-hour-in-new-york/ar-BB11vLxh
[21] “Scientific Nursing Halting Epidemics” The Philadelphia Inquirer, Philadelphia, Pennsylvania. 15 Oct 1918. Page 22.
[22] Howell, E., “Satellite images show Iran’s mass graves for coronavirus victims.”, March 13, 2020. Space.Com, as accessed on March 21, 2020 at https://www.livescience.com/iran-coronavirus-graves-satellite-images.html
[23] “Camden Needs More Doctors and Nurses” The Fort Wayne Journal-Gazette, Fort Wayne, Indiana, August 7, 1918. Page 8.
[24] “Camden Needs More Doctors and Nurses” The Fort Wayne Journal-Gazette, Fort Wayne, Indiana, August 7, 1918. Page 8.
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Mitchell E. Simmons Ph.D. MSA MSME, Lieutenant Colonel, United States Air Force (Retired) is the Program Director in the School of Science and Technology Intelligence at the National Intelligence University in Bethesda, Maryland. Dr. Simmons has almost 25 years’ experience in acquisition, engineering, and infrastructure vulnerability within and supporting the Intelligence Community. His expertise includes physical and functional vulnerability of hardened and deeply buried targets and critical infrastructure from traditional and asymmetric threats. The author is responsible for the content of this article. The views expressed do not reflect the official policy or position of the National Intelligence University, the Department of Defense, the U.S. Intelligence Community, or the U.S. Government.

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