News & Views: COVID-19 and the 1918 Influenza Pandemic — Learning from Our Ancestors

As we all come to terms with a new, and hopefully short, definition of “normal” during the COVID-19 pandemic, many may be wondering why this virus is being treated differently and why “social distancing” has become a recent buzz word.

A look back to a century ago can offer some insights — both regarding what we can learn from our ancestors as well as, perhaps, a sense of “walking in their shoes” for a moment.

The viruses

We all know influenza virus changes regularly, as we point to this characteristic of the virus when we describe the need for annual flu vaccination. Indeed, in some conversations, we go so far as to describe the difference between an epidemic and a pandemic – the former being those small annual changes (antigenic drift) and the latter, a larger event caused when the genomes of bird, human or pig influenza viruses combine to form a new influenza virus (antigenic shift). The new virus becomes a concern if it has two characteristics. First, it is capable of infecting people and causing illness or death. Second, it can be spread from one person to another. Because all people are susceptible, when these two things happen, the stage is set for a pandemic to occur. (See this Vaccine Makers Project animation, “Antigenic Drift: How the Influenza Virus Adapts.”)

When explaining COVID-19, the antigenic shift of influenza that causes a pandemic offers a familiar example. But, COVID-19 is not influenza, which means we do not have the history of experience that we have with the family of influenza viruses. We do not know how long from exposure to infection, average length of infection, etc. We also don’t have treatments or vaccines, so we are left with long-forgotten methods of trying to stem the spread of this disease, like social distancing.

In the 1950s, children were kept from pools and churches in an effort to stave off polio infections. Like in the current situation, the virus was known but treatments were limited and prevention, in the form of a vaccine, was not an option. In 1918, the situation during the influenza pandemic was worse for two reasons. First, influenza virus had not yet been identified. Best guesses at the time were that a bacterium, called Haemophilus influenzae, was causing the severe illness being witnessed. (Influenza A, the type of influenza that causes pandemics, was not identified as a virus until 1933, well after the pandemic was over.) Second, the world was in the midst of a war. With World War I raging, the stage was set for a clash between biology and history.

The response

As we are all painfully learning, social distancing involves measures to keep people apart as a way to slow the spread of a virus to which everyone is susceptible. But, in 1918, the war not only prevented social distancing, it increased movement from area to area and country to country. In addition to crowded quarters with large numbers of people and increased movement, WWI had other effects on the influenza pandemic as well. As such, lessons from a century ago are worth considering today:

When people share close quarters, viruses spread. In 1918, influenza swept through military camps. Haskell County, Kansas, was one of the first locations in the U.S. identified for the spread of the new virus. Indeed, it is one of three global locations considered as the potential origin of the virus. The other two theories include a British military camp in France or in a community in China. Wave two of the U.S. experience of the pandemic also started at a military base, specifically Camp Devens outside of Boston.

When people move, viruses move with them. The movement of troops was not the only way influenza spread during the 1918 pandemic. A popular patriotic act to raise money for the war effort was the sale of bonds, called Liberty Loans. In September 1918, a Liberty Loan Parade was held in Philadelphia, despite knowledge of widespread influenza at nearby military camps. About 200,000 people attended the parade. Within days, 2,600 people had died, and much of the city was shut down, including schools, churches and theaters.

Coordination of medical efforts at the national level is essential. In 1918, the Centers for Disease Control and Prevention (CDC) did not exist. Nor did disease surveillance. Said another way, clinicians did not have a list of diseases they were required to report when diagnosed. While the Public Health Service (PHS), led by the U.S. Surgeon General, existed, it did not serve the role of a centralized coordinating body — at least at first. Once the dire nature of the situation was realized, the PHS instituted weekly reporting, assigned state coordinators, started educational campaigns, and oversaw the closing of gathering places. Unfortunately, the lack of a centralized data collection agency delayed the start of these efforts and, surely, cost lives.

Decisions should not be politically based. As the U.S. and other countries were concerned about letting the enemy know their troops were weak and ill, information about the severity of illness among troops was withheld. This approach, while possibly helpful to the war effort, prevented understanding of the spread and severity of the virus, likely resulting in significantly more deaths during the pandemic. Related to this, because Spain was neutral in the war, they shared more information about what was happening. As such, people thought the virus originated in Spain, and the nickname “Spanish flu” was coined.

Clear and truthful communication is critical. In 1918, the Sedition Act was meant to maintain morale at home and present a strong front for enemy forces. This Act made any spoken or written word against the U.S. government a prosecutable crime. Unfortunately, under the guise of this Act, information about the pandemic was also held back. Public health officials and healthcare providers were prohibited from freely discussing the medical situation, and as described by John M. Barry (2017) in the Smithsonian Magazine article, “How the Horrific 1918 Flu Spread across America,” the severity was downplayed in media reports. For example, over a period of four days in Arizona more than 8,000 soldiers were hospitalized, but a nearby newspaper described the infection as “same old fever and chills” (Barry, 2017).

In 2020, we are not in the throes of a world war, social distancing is an option, and information sequestering is not an issue, albeit the spread of misinformation and disinformation is. Along these lines, it is important to encourage patients to learn from history and assure them that our public health officials are operating from a position of knowledge gained through historical experiences. Likewise, promote the notion of following guidelines and position your practices or workplaces to enable patients to easily do so when it comes to interacting with you. Finally, implore patients to get information from trusted sources, like the CDC and the World Health Organization, and to vet information that is received second or third hand, especially through social media. Encouraging patients to vet information will not only enhance their critical evaluation skills, but it will also decrease the ability of bad information to stoke fear during this time of uncertainty.

Additional resources

The following resources can provide more information about the 1918 influenza pandemic:

• The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry
  • Amazon
  • Barnes & Noble
• Going Viral: The Mother of All Pandemics, a podcast by Mark Honigsbaum and Hannah Mawdsley
• How the Horrific 1918 Flu Spread Across America by John M. Barry, Smithsonian Magazine, 2017

The following VEC resources are tools that can help with vetting information:

• Evaluating information: What you should know
• Website evaluation cards – print | order
• Logical fallacies: What you should know

The following resources offer additional information about the COVID-19 pandemic:

• Centers for Disease Control and Prevention (CDC)
• World Health Organization (WHO)
• Printable version of “Parents PACK” article