SALT LAKE CITY — When the new coronavirus began ravaging the world, most people had no idea just how much damage a viral outbreak could do to the world’s health, wealth and social fabric.
But a 2004 book by John M. Barry titled “The Great Influenza” chronicles how the 1918-19 influenza outbreak became the deadliest pandemic in history, and it offers both insight and warnings about how to mitigate future pandemics, which the author concludes are inevitable.
It was the book former President George W. Bush reportedly read that caused him to charge Homeland Security personnel with formulating an ambitious pandemic response plan that included a national stockpile of face masks and ventilators, and a process to fast-track vaccines and other treatments in 2005.
While some of that became a reality, many of those things Barry warned about were not heeded, including allocating resources to vaccine development in U.S. labs and making sure all governments report viral and disease outbreaks accurately to the World Health Organization.
Among the issues he cited was the fact that China’s decision to “initially lie and hide” the 2003 SARS outbreak put the world at risk. He asserted that if WHO, led by the U.S., didn’t find a way to make sure all countries accurately report disease outbreaks, an influenza-like virus would, once again, sicken and kill record numbers of people, despite 100 years of medical advances.
The book provides details into everything from the rise of American medicine to how lingering effects of influenza could have led to President Woodrow Wilson’s abrupt decision to accept the Treaty of Versailles to end World War I when he’d consistently advocated for a much different end to the war.
What is striking about Barry’s book is how many similarities there are between the 1918-19 pandemic and the COVID-19 pandemic of 2020. But it is also interesting to look at the differences, and the lessons that Americans didn’t necessarily learn.
The most notable similarity is the controversy over masks.
In 1918, masks were just as controversial as they are in 2020. The difference is that masks were mandatory during the influenza outbreak, and — with the exception of Salt Lake, Summit and Grand counties plus Logan and Springdale — Utah and much of the country has relied on only mask recommendations.
The rejection of some to wearing masks as a way to slow the spread of COVID-19 is something that has blindsided Utah and national public health officials.
“I don’t think any of us anticipated a mask debate,” said Utah epidemiologist Dr. Angela Dunn. “It seems so simple.”
The reasons for rebelling against mask mandates in 1918 and mandates or recommendations in 2020 are very similar. Most often cited by opponents is that they see the requirement as an erosion of individual liberties. Others suggest masks may cause illness or that they’re ineffective in stopping the spread of any disease, including COVID-19.
Part of the issue cited is the lack of trust some currently have in health officials, governmental leaders and the media.
But officials in 1918 and 1919 actually issued mask mandates, according to Utah news reports, and for those who violated the rules, there were fines and sometimes arrests and jail time, including a Park City man who was arrested at a restaurant for not wearing a mask. He was held in jail for three days before winning his freedom.
Greg Smoak, the director of the American West Center and an associate professor of history at the University of Utah, said the resistance and debate over the efficacy of masks may be similar, but the masks themselves were quite different.
“They were essentially gauze that would be tied behind your head,” Smoak said of the masks used in 1918-19. “They were old-school surgical masks, and there was a huge debate over them.”
In San Francisco, an “anti-mask league” formed in opposition to a city mandate in the third wave early in 1919. Eventually, city leaders ended the mandate.
“There were even bombings in response to mask mandates,” Smoak said.
Also, just like people in 2020 are searching for ways to boost their immune systems and mitigate any impact the coronavirus might have on them, people in 1918-19 shared all kinds of home cures and remedies, some of which are remarkably similar.
Among those, gargling with disinfectant or breathing in eucalyptus oil or camphor oil, the main ingredient in Vicks Vapor Rub, Barry’s book says.
Distrust and fear
Dunn understands why some people might feel like they’re getting conflicting information.
“Anytime we have a new virus circulating, the information and our knowledge about it is going to change over time,” she said. “Some people see that as being dishonest, when in reality, it’s just that we’ve learned new things.”
In 2020, political leaders, both locally and nationally, have attempted to earn public trust with regular press conferences. This is a stark contrast to how the outbreaks in 1918 and 1919 were handled.
In 1918, Wilson was convinced that the public wouldn’t support the war effort unless the newspapers did, Barry wrote. Therefore, Congress enacted laws that punished anyone who spoke against the war effort, and the press was heavily censored. Wilson never actually made a public statement about the influenza outbreak, which ultimately claimed the lives of an estimated 675,000 people.
The inability of the government to give the public honest information bred distrust and fear.
“So the problems presented by a pandemic are, obviously, immense,” Barry wrote in his afterword. “But the biggest problem lies in the relationship between governments and the truth. Part of the relationship requires political leaders to understand the truth — and to be able to handle the truth.”
The undermining of trust isn’t just an issue of trusting one’s own government. It’s an issue of trusting information collected by global groups.
Barry points out that while many governments were prepared for the 2009 pandemic, many political leaders ignored the plans. He said Mexico, Brazil and China all had issues with how they responded to the outbreak because they refused to acknowledge realities. Mexico ended up losing $9 billion because of its mishandling of the 2009 pandemic.
The void of information in 1918 led to many misunderstandings about how it started and how widely it spread. It’s now believed that nearly one-third of the world’s population was infected and 50 million people died.
Smoak points out that the reason the influenza outbreak was dubbed the “Spanish flu” was because Spain was neutral in World War I, and so its government didn’t censor media reports about the illness.
“Because Spain is neutral, there aren’t those controls over the press,” he said. “Information about the virus gets widely reported, hence the name the Spanish flu. It got tagged as the origin (of the outbreak), but it’s not. That’s related to censorship and control of the press.”
Influenza outbreaks among U.S., British and French troops wasn’t reported, and the realities of how it was transmitted around the world weren’t widely known until years later, according to Barry. The influenza outbreak is believed to have actually started in Kansas.
During the Influenza pandemic there were a number of conspiracy theories, including the assertion that the Germans had created the virus to help them in the war, Barry’s book says. There was even suspicion of Bayer aspirin, and in some small towns, people with German surnames or accents were harassed, and one door-to-door salesman was even killed.
In 2020, the conspiracies also abound, starting with the assertion that the virus was made in a lab in Wuhan, China. Some of the theories include the involvement of Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Disease, and former President Barack Obama.
So why do some find conspiracy theories more comforting than scientific theories or facts?
“Conspiracy theories are very comforting to people because they are simple explanations for complicated problems,” Smoak said. “They shift responsibility.”
He said Americans are uniquely susceptible to conspiracy theories.
“We’ve grown up with national mythology that teaches us American exceptionalism,” he said. “If something bad happens, it couldn’t be our fault. There has to be some other explanation for it. And these modern conspiracy theories also play into people’s ideas of science fiction — germs escaping from labs. People wouldn’t have thought about that in the 19th century.”
The truth, however, is often too simple to bring any comfort.
“The more simple answer is that this is a natural process that has occurred countless times throughout human history,” Smoak said, “and it will continue to occur.”
The poor and parades
Just like 2020, the hardest hit were the poorest, including migrant and communities of color. Because quarantine was key to controlling the outbreak 100 years ago, just as it is today, those who live in smaller, more crowded conditions often don’t have a way to separate the sick from the well.
Political unrest gripped the country in 1918, which was caused by Wilson’s decision to enter World War I, and in 2020, it is a racial reckoning. This can create a climate in which the loss of freedom, fear of illness and grief is caused by both human and economic losses.
Smoak said historians cringe when they hear, “Those who fail to study history are doomed to repeat it.”
“We wish that people could learn from history,” he said. “But memories do fade, and people move on.”
There are some marked differences as well. Unlike COVID-19 — which is most deadly to those over 65 and with underlying health problems — the influenza pandemic struck down those in their prime, between the ages of 20 and 45.
The influenza outbreak of 1918-19 brought about many changes, both in the way public health officials learned to handle infectious diseases and in what researchers hoping to isolate causes and cures learned through their work, Barry noted.
“The experience of 1918 put in place certain health care infrastructure,” Smoak said. “Influenza wasn’t a reportable disease in 1918.”
Dunn said despite the fact that officials are grappling with some of the same issues, there were many lessons learned by the medical community that had an impact on containing COVID-19 outbreaks in America.
“One direct parallel is not to allow parades” in Utah this year, Dunn said. “When we were thinking of guidelines, parades came up so much. We just kept going back to 1918, and saying, ‘We cannot repeat this and have a surge because of a parade.’
“Very specific examples like that have helped.”
On Sept. 28, 1918, a parade held to support an effort to sell war bonds caused an explosion of the virus, which made its way to the cities through the movement of U.S. troops, most likely the Navy. Even as Philadelphia health officials were warning that people should avoid crowds, politicians refused to cancel the parade, according to Barry’s book.
Two days before the parade, hospitals admitted about 200 people suffering from influenza — 123 of those were civilians. Three days after the parade, every single bed in the city’s 31 hospitals was filled. Philadelphia would become one of the hardest hit cities, as the epidemic exploded from a few hundred civilian cases to hundreds of thousands of cases, Barry noted. Hundreds died every day, and even as officials were quoted in papers saying the epidemic had peaked, new records of sick and dying were recorded.
But it wasn’t just learning lessons on how the virus spread.
Barry pointed out that the number of people who rely on restaurants for food doubled in the century between the influenza outbreak and the writing of his book. As he points out, if all of those restaurants shut down, which they did during 2020’s COVID-19 outbreak, it would do much more damage to the economy than it did in 1918-19.
Barry also noted that the globalization of the economy means the supply chain could be very easily interrupted, and suggested the U.S. needed to look at producing more medical supplies, including vaccines, in the U.S.
Because hospitals are now run like businesses, there are actually fewer hospital beds per capita than there were in 1918, he said. It is not profitable to have empty hospital beds, so most facilities only have as many beds as they can utilize.
That, he said, could be a problem in a future pandemic, especially when it came to intensive care unit beds — an issue that was illustrated when COVID-19 numbers spiked in New York and New Jersey.
Some of the most ominous warnings had to do with health care, including the development and stockpile of vaccines and viral treatments.
“Of course, if developing a universal vaccine (for influenza types) were easy, it would have been done, but for decades few resources went to such research,” he wrote. Barry said the U.S. government doesn’t always spend its money wisely.
He said prior to the emergence of H5N1 — or bird flu — the U.S. government was spending more money on West Nile virus, which in its “deadliest year killed 284.” Influenza, on the other hand, was killing as many as 56,000 Americans.
That’s changed, but he said influenza deserves even more research money and effort than it receives today.
Dunn said public health is chronically underfunded in most places, in part because it’s easy to forget about how critical it is when there are no major issues.
And 2020 isn’t without its lessons.
Dunn said public health officials and politicians are learning that they have to work together to help people understand how to best care for each other when it comes to infectious disease.
“It reinforced the need to form good partnerships with the public before a pandemic hits,” she said. “When we are faced with a really big health threat, you already have that baseline of trust to build on. You’re not doing it in the middle of a crisis.”
Barry’s closing sentiments underscore why it is so critical that political leaders earn and keep public trust.
“As horrific as the disease itself was, public officials and the media helped create the terror — not by exaggerating the disease but by minimizing it, by trying to reassure,” he said.
“If there is a single dominant lesson from 1918, it’s that governments need to tell the truth in a crisis. … You don’t manage the truth. You tell the truth.”
Lastly, Barry admonished ordinary people not to let their fear in a pandemic undermine their humanity.
“As Victor Vaughan — a careful man, a measured man, a man who did not overstate to make a point — warned, civilization could have disappeared within a few more weeks,” he wrote. “So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society.
“Society cannot function if it is every man for himself. By definition, civilization cannot survive that.”