July 1, 2020

E. Rosalie Li, interdisciplinary public health Johns Hopkins Bloomberg School of Public Health

The chief message from 1918, uttered through anguish and brokenheartedness, teaches a simple yet perilous if forgotten lesson: Tell the truth. Do that — and you just might live.

The world held just 1.7 billion people back then. No less than 675 thousand Americans and 50 million people worldwide perished as a virus prowled through one-third of the entire human population. Outbreaks often catch humanity unaware, bringing societies to their knees. They require us to respond with a multipronged offense and defense that must happen at breakneck speed.

Not preparing is gambling with your continued existence. If you get lucky and make it through, you will probably lose many more people than if you had planned. Perhaps that made mass death so shocking; history had told us to expect an outbreak with war. We had prepared for that.

That was the case in 1918. The brittle relationship between the public and its leadership fractured entirely under the strain of outbreak and war. It was not their lack of preparation that damned their response so much as the complete absence of truth by any definition.

The press and health officials addressed the issue with “either reassurance or silence.” President Woodrow Wilson never issued a statement on influenza throughout the pandemic.

Spain had the distinction of remaining neutral in the First World War. When word of it reached Americans, long after their President knew of it, they called it the “Spanish flu.” Contrary to what the name suggests, which also created confusion back then, the virus originated somewhere closer to home.

Unlike the US and other countries, the Spanish press remained free and honestly reported a bewildering epidemic that some mistook for the bubonic plague. The victims often developed blue skin before they died. Juxtaposed with silence about it elsewhere, Spain's horrifying coverage led Americans to believe that Spain had been ground zero. Still, the Spanish press called it the “French flu,” suspecting it had come from France.

The misleading monikers show precisely why we avoid locations when naming unknown diseases today. We later learned the actual origin was likely the United States. It is just as well; we probably would not have admitted it back then.

The index patient, sometimes called patient zero in popular culture and cinema, Private Albert Gitchell of the US Army, fell ill on March 4, 1918. By day’s end, over one hundred soldiers died of the same sickness.

The American President, Woodrow Wilson, had a tight lid on the media, so the public would not be privy to this information. He believed in the necessity of keeping morale high for the war effort. This belief led him to exert authoritarian control over the press. The outbreak inconvenienced his focus on the war, reflecting the federal response.

No national or centralized response ever arrived to help people struggling around the US. The state-level government received no guidance. The media echoed his response because they faced legal reprisal for printing the truth.

Rumors were the sole source of public education. “It is our job to keep people from fear. Worry kills more than the disease,” or so they said. Famously, Philadelphia lied to its citizens repeatedly as the deaths climbed. The city public health director announced, “the disease has about reached its crest. The situation is well in hand.”

The deaths continued to climb, and he continued to repeat that they had reached the peak, and the media never pushed back on the upward-trending death counts. The actual height of the Philadelphia epidemic claimed 759 deaths in one day.

People knew things were not well, so the concerted effort by the authorities to assure and calm people had the opposite effect. Even the perception of withholding information can damage the trust between the public and those in power.

Unable to tell which parts were true, the public lived in fear. It is the scarcity of information, and not the free flow of it, that threatens trust and a stable society. No one will comply with life-saving measures if trust disintegrates. Mistrust then threatens society, so there can be no cause great enough to justify deceiving the public.

Leaders who pettily squabble may take lives as surely as if they had fought them in war. The most precious resources in a pandemic are the truth and time — and there is never any to waste.

When the virus rolled through the country, it struck unprepared cities that expected little more than the seasonal flu. Entire families died in their homes, only to be found later, but that was not the only misfortune suffered. Our nation’s future seemed in jeopardy because, although societies frequently overcome catastrophes, the absence of trust is terminal.

Eleanora Berns was thirteen years old when she caught the pandemic flu. She left school and slipped into a weeklong coma with high fevers. Her family packed her with ice and opened her bedroom window to let in the freezing December air.

The nurse caring for her needed a fur coat to be in the same bedroom as Eleanora. Somehow, Eleanora recovered, but not overnight. She missed school for the rest of the year. Her hair fell out, leaving bald patches, and she remained weak for months. The nightmare pandemic everyone said was no cause for alarm haunted her for the rest of her life.

She lived until just before her 102nd birthday, seeing decades that 50 million others would not. Eleanora is one story among a tragic sea of millions.

Cities argued over what to do and when to do it. The Surgeon General tried to secure senior medical students for the sick. An unclear pathway to approval meant no medical students would fill the dwindling healthcare workers’ shoes.

Medical doctors and nurses were dying and falling ill in high numbers. One Minnesota hospital reported that half of its nursing staff had influenza over three weeks. Health officials disagreed over the merits of isolation for controlling the outbreak.

The Secretary of the Minnesota State Board of Health argued for leaving schools open, so children could access a school nurse. A city health commissioner objected, highlighting that thirty nurses could not care for 50,000 children stricken with the flu.

The Secretary opposed it.

Still, those who favored remaining open were overruled on the city level. Schools closed, and streetcars reduced their passengers by 40% and required a specific number of open windows — an unpopular mandate given that this all transpired in the winter of 1918.

After ten days of closures, the cases declined from 218 on the day of the shutdown to 24 new cases the day officials forced the city to re-open. The public protested new regulations and changes imposed, many of which burdened daily life. Bars and nightclubs created secret back entries for patrons to avoid detection. Open defiance happened commonly, requiring enforcement.

Our complaints are remarkably consistent across time. Police dispersed crowds and sporting events that ignored that ban on large gatherings, further upsetting citizens. Some venues stayed open for the public that wanted things to remain open. Quickly, they realized that people stay home until a location controlled the threat. It meant their economy also depended on successful mitigation.

A historical review found precisely what this suggests. Cities that controlled the spread had a better long-term economy and lost far fewer people. How an area responded affected them for decades.

Most American cities learned about the critical need to protect healthcare workers and the problem of mask shortages. Healthcare workers’ deaths mean more deaths from all causes because no one can care for the sick. In the 2015 Ebola outbreak, healthcare workers died at a rate 11 to 32 times higher than the public.

A 2007 study, the Lessons Learned from the 1918–1919 influenza pandemic in Minneapolis and St. Paul, Minnesota (Ott et al., 2007), found:

Here, one official had sown doubt about the need for masks. That was the response of one state health official on masks. At the same time, the Surgeon General was trying to secure medical students as replacements for the thinning healthcare worker population, which would dwindle faster thanks to the doubt cast by public debate.

We can reasonably pardon leaders of the past, long before the time of evidence-based practice and policy. All relevant commenters should share their reasoning, and all must reach a consensus, even if everyone does not feel satisfied.

It is their job to do this, not an optional nicety. That will take maturity, something far more scarce than imagined, visible even in recent modern political discourse. In 1918, people swayed toward masks on their own, but it easily might have gone the other way. Hence, people sought masks despite the lack of mandate and contrarian opinions, and not because of it.

Political consensus could have eased the stress, confusion, and fear that gripped people. The federal government left the national supply chain unmanaged and did not consider how many masks the public might wear. Doctors and nurses died as a result.

The U.S. devolved into a place of sheer terror-filled people who had no idea what to believe and a President who failed to acknowledge the problem with clear, concise, honest commentary.

Locations like military training camps supplied the ideal breeding ground where the virus could easily travel from person to person. The military canceled the draft in September 1918 because sick soldiers filled the camps, and they could not take or place anyone.

Still, denial reigned supreme. The President failed to see the country’s need for a visible, strong leader. High-ranking officials, like the Surgeon General and Public Health Director of Chicago, continued to reassure Americans that all was well, even as they dug mass graves.

Chicago saw mortality reach 40% at one hospital. Simultaneously, the city’s public health commissioner dismissed concerns, saying, “Worry kills more people than the epidemic.”

Paternalism justified the federal government’s dishonesty and misrepresentation. Paternalistic decision-makers saw the public as unable to handle the truth. Leaders repeated that fear and worry were worse than the sickness itself. In their minds, it was a leader’s job to protect people from the truth they could not handle.

Well-intentioned though it may be, the intent had little bearing on its effect in the crisis. That effect was terrifying and confusing to the public. This includes action by the media, which played an essential role in the state-sponsored disinformation. Reports described the sickness as that of seasonal influenza by another name. The press said it was mostly those who neglected their sleep that died. They dismissed all fear.

The government under President Wilson ensured people heard the message that people had “no occasion for panic” because this had a lower fatality rate. The Sedition Act gave him control over the messages the media published.

There are two ways to assess deadliness: fatality rate or death toll. Diseases with a low fatality rate can kill millions and millions of people. Ebola can break out and infect a small group, infecting 50 people and killing 29. Seasonal flu may have a death rate of 0.1% and kill tens or hundreds of thousands yearly in the US.

Each virus qualifies as deadly differently. While Ebola kills fewer people than viruses like measles or influenza, many fear Ebola far more. Measles and influenza are also far more likely to kill the average person. It is also the case that a low fatality rate is a feature of a pandemic, not a comfort. High-fatality rate diseases may be less likely to cause a global epidemic because of visible, severe symptoms that help containment.

People may be less likely to travel if they feel unwell, or they may simply die, rendering them immobile. These elements can make it harder for an infectious disease to launch into pandemic status. Suffice it to say that officials took an inadvisable stance by reassuring the public, no matter how one examines it. Even if they had been correct, it gambles credibility because no one knows what will happen.

One old newspaper reads, “A new name for an old familiar disease,” repeating the idea that no cause for alarm existed. Paid advertisements like those from Vicks VapoRub read, “Simply the Old-Fashioned grip masquerading under A New Name,” with Grip referring to the nickname “La Grippe,” for the disease.

The Sedition Act gave Wilson broad powers to make the press say whatever he deemed best. People were every bit as observant as today, and it terrified them. People saw with their eyes the surrounding devastation.

No one understood why this one was so much worse than others or why it killed seemingly healthy young adults. Unbeknownst to people infected with the virus, their bodies rallied defenses, but when the site of infection is in the lungs, the situation requires a delicate balance. Something about this influenza strain provoked a far more aggressive response than the seasonal flu. It might have been that younger people had more robust immune systems, so the self-destruction was worse than for the elderly.

The “friendly fire” from the body’s attack on the virus destroyed the delicate tissue that formed tiny sacs in the lungs called alveoli. Oxygen enters the bloodstream through the skin so thin that it reminds one of a butterfly’s wing.

Victims of the 1918 pandemic lost their ability to breathe; they drowned with no way to stop it. The surface meant for releasing carbon dioxide and taking in oxygen became a battleground, often leaving it unrecognizable. Cases of the pandemic flu were sometimes mistaken for bubonic plague because of the deep blue color they took on as they struggled to get oxygen into the blood through their remaining healthy lung tissue.

People lined the hallways of overflowing hospitals because there were too many in need of care. Some would die and slump over where they sat. A bloody froth drained from the nose and mouth, pooling on the floor. The scene was visible to onlookers awaiting the same fate.

Tuberculosis may have driven up death rates too. If the others did not drown in their blood—bacteria could take root in the injured lung tissue and grow uncontrollably. The outcome was a body utterly in peril with no way to stop it. Medical doctors traveled east, searching for instructions on how to treat this new illness. They hoped those who had battled it before would have insight. Instead, they received this advice:

President Wilson abdicated his duties to the American people and intentionally blinded the public by controlling the press during the pandemic and war.

He failed to lead, strategize, plan, or be honest with the public, who had a right to know the truth. While US doctors who had been to war said the pandemic “beats any sights they had in France after a battle,” this silence persisted. The US government’s official line may have gaslit some 675,000 Americans into their graves.

Present-day public health experts faced similar accusations of drumming up coronavirus fear in the media, but that wasn’t what happened. Government officials downplayed the crisis they knew to be critical unquestionably, breaking every list on the “do not do” column from the Crisis and Emergency Risk Communication Handbook.

Then, having led some to misunderstand the nature of the crisis, the public heard that the cure shouldn’t be worse than the disease — speaking about distancing, shutdowns, and masks — an argument seen in 1918. It’s the same argument.

Just as the 1918 public’s complaints seem frozen in time, I’m not sure politicians have changed much either. We’ve repeated every mistake made in 1918, even when it makes little sense. American decision-makers and media outlets compared the coronavirus to the flu — I’m assuming seasonal, though they never say — as they did in 1918 as a part of the state-sponsored disinformation.

Despite the cold viruses sharing the Coronaviridae subfamily Coronaviridae with the new coronavirus, they made this comparison. The comparison doesn’t suggest a person has an over-familiarity with phylogenetic distance, but maybe that explains it. Either comparison would have been inadvisable.

The newspapers from the time seemed to conflict with every other line. First, it says, “Nothing New” and calls the disease “the Old Grip,” with Grip being another name for “flu.” That’s consistent. Then the article stresses to “always call a doctor” but also “no occasion for panic.” Why are we calling the doctor if everything is OK?

Next, the writer breaks into the history of epidemics, starting in 412 BC. The writer assures them only people who neglect their sleep die. Was this an effort by a reporter to sneak a message past the administration that forbids accurate reporting?

If not, this sounds like someone walked into another’s home unexpectedly, shouting, “Do not panic!,” and “This is not a burglary, and it’s not one of those home invasions, either.”

Citizens who dared to publish the truth about the pandemic were jailed, but the threat failed to deter everyone from speaking. Curious scientists from a place called “The Hopkins” defied the President’s code of silence around the pandemic.

The school had abandoned old medical practices in favor of evidence-based treatments. Johns Hopkins University accepted female and minority students into its schools of nursing and medicine and refused to hire clergymen as professors, as was the practice.

Mark Twain warned this new breed of scientists that none could “have full confidence in a college that didn’t know how to spell ‘John.’” It would appear the beloved author was wrong because these unlikely researchers stepped into the American leadership void.

Perhaps they felt some boldness since President Wilson finished his Ph.D. there— Wilson hated there if you’re curious. In a letter to his fiancée, the future president wrote, “I need not bore you about all this; I am sufficiently bored for both of us.”

He had strong feelings about his professors, calling one an “ignorant specialist” who spent too much time “burrowing into his own research, not enough in preparing pithy lectures.”

“Specializing mania” was how he described scholars there. One could not help but wonder if he had spent less time lamenting his lack of interest in the material if we had had a very different pandemic.

The medical doctors and research scientists led with honesty and evidence and spoke the truth, even when those in power did not want people to hear it. The Dean of the School of Public Health, William Henry Welch, was a military doctor who recognized it was “some new kind of infection or plague.”

The pandemic taught costly lessons that we paid for dearly with human life. We owe it to those who suffered needlessly tragic ends to learn something from their deaths, knowing that there would come a day when a new virus appeared.

That day has come. So many lessons from 1918 appear forgotten as we repeat every last one. Unsurprisingly, America has begun to look bleak once more, shattered beneath ill-conceived pandemic response and economic decline.

It may be a surprise that I’m not worried the world will end soon. I have a great deal of hope. The scientists from “The Hopkins” devoted to finding and speaking the truth still exist. They were there for us once. I feel quite certain, should we require it, they would be there for us once more.