Professor: We can learn from 1918 flu pandemic

Photo courtesy Library of Congress via The Associated Press
In this November 1918 photo, a nurse takes the pulse of a patient in the influenza ward of the Walter Reed hospital in Washington. Science has ticked off some major accomplishments over the last century. The world learned about viruses, cured various diseases, made effective vaccines, developed instant communications and created elaborate public-health networks. Yet in many ways, 2020 is looking like 1918, the year the great influenza pandemic raged.


When talking about the current COVID-19 epidemic, many tend to mention the 1918 flu pandemic that also swept across the world.

“Both viruses spread rapidly to all areas of the world, although some people in 1918 had partial immunity to that strain of influenza,” said Ann Carmichael, a professor emerita at Indiana University-Bloomington’s Department of History and Philosophy of Science and Medicine. “They were older and/or lived in some rural areas where the strain of influenza prior to 1889-91 still circulated. So, 1918 was devastating for younger adults.”

The 1918 flu pandemic was caused by an H1N1 virus with genes of avian origin, according to information from the Centers for Disease Control and Prevention. Although there is not universal consensus regarding where the virus originated, it spread worldwide in 1918 and 1919.

About 500 million people, one-third of the world’s population, became infected with this virus. The number of deaths was estimated to be at least 50 million worldwide, with about 675,000 occurring in the United States.

The pandemic was first recognized in Indiana with a case found Sept. 20, 1918, in Evansville. By mid-October, influenza cases were being seen across the state.

Newspapers in Dubois County talked about the influenza almost daily, though numbers tend to not be listed. A display at the Dubois County Museum states that there were 120 deaths in Dubois County when the influenza first broke out.

More than 150,000 Indiana residents were infected with influenza between September 1918 and March 1919, according to the CDC; more than 14,000 Hoosiers died.

Many historians believe the virus emerged in the U.S. in the plains states, and that the Army and U.S. Public Health Service knew as early as late March of 1918, Carmichael said. “Training camp commanders put sick soldiers on trains and sent them to other camps, sending the virus across the company. By September, the civilian community was blind-sided, because what was happening was subject to military censorship. This was not a unique American response — all the countries at war hushed up the early phase of the epidemic.”

Photo courtesy Library of Congress via The Associated Press
In this 1918 photo, volunteer nurses from the American Red Cross tend to influenza patients in the Oakland Municipal Auditorium, used as a temporary hospital.

The pandemic is also known as the Spanish flu, though the exact origin of the flu is not fully known.

“It became the Spanish influenza because Spain didn’t join the war, and thus reported the flu in newspapers months before others did,” Carmichael explained.

World War I was still underway at the time of the 1918 outbreak.

“Americans were at war in Europe,” Carmichael said, “and typically blamed the enemy — Germans, often called ‘the Boche.’ It’s a common human response, to channel fear and anxiety on a human enemy.”

Indiana’s director of public health at that time, John Hurty, took various actions.

“Indiana had a particularly good, well informed director of public health,” Carmichael said. “So examples from Indiana are much like the best available advice elsewhere. Hurty imposed a ban on public gatherings, spitting in any public area, including streets, use of a handkerchief when coughing or sneezing, open air public transportation — trolleys, railroad cars, etc. — no matter what the outside temperature. Public conveyances to be cleaned repeatedly.”

Publicly shared locations like schools, theaters, churches were closed, “at least at the moment when the number of funerals shocked and alarmed a community,” Carmichael said.

“But all the way through the 1918 epidemic, the government-at-war prioritized anything activities-related to the war effort,” she said. “Those companies or places (mining communities, for example) linked to the war effort suffered far higher illnesses and deaths.”

The actual illness experience then and now is similar, although the influenza had a much quicker start.

“You knew you were ill within a day or so of being infected, [and[ by day three, you were seriously ill,” Carmichael said. “COVID is peculiar. We still aren’t sure how long the incubation period is — five to 14 days is a long interval. But as in 1918, none of us knows whether we will be the ones to fall ill.

“With 1918 flu, when you did get sick, it was headache, difficulty breathing, body aches, fever — then, overwhelmed,” she said. “With 2020 COVID, many have suffered overwhelming fatigue, also thinking the worst was past after the first week ill, only to have worse illness return in week two.”

Some of the outcomes from the 1918 epidemic can and have helped with the current pandemic.

”Nurses after 1918 became a commonplace in medicine. There were nursing training programs and fewer constraints on married women, who were often not allowed to pursue nursing,” Carmichael said. “Hospitals clearly mattered, as did physicians trained in germ theory and other newer medical ideas; so did investment in hospitals and medical schools.”

And there was the emergence of the mask, which was invented by a Chinese physician during the plague pandemic in Manchuria in 1910 and 1911.

“Americans did not adopt the habit of masking in public, in epidemic outbreaks,” Carmichael said. “Most Asian societies don masks at the first admission of a disease threat. Masks do not protect the user, they protect others, thus decrease transmissions.”

There are lessons we can learn from the 1918 flu pandemic, Carmichael said.

“The absolute clearest ‘lesson’ is the need to protect the first-responders and medical personnel; 1918 completely overwhelmed hospitals and other spaces for medical care. In such conditions far more die,” she said. “A mask is an easy thing to wear to show that we, as individuals, care about the health of others around us in public spaces. It mystifies me that so many are opposed or indifferent.”

She cautions about possible societal fallouts and divisions, as seen in the 1918 pandemic.

“I hope we come out of this at least able to work together, as a people, one nation,” Carmichael said. “Influenza 1918 left deep divisions — between neighbors, within families, — in who held wealth in a community. For minorities, especially for African Americans, it was no longer possible to remain in the American South. Thus, the great migrations to northern cities.

“We don’t need more such divisions and smoldering hatreds.”

More on