The lessons learned from 1918 flu fatigue, according to historians

Two decades after surviving an influenza pandemic that devastated the United States, Katherine Anne Porter recounted her experiences in one of the best-known accounts of the period—the 1939 novella Pale Horse, Pale Rider.

In her story, Porter describes how many young people felt as though their lives were threatened by the dual strike of a deadly virus and World War I. Miranda, the main character, recovers from influenza, but sinks into depression as she attempts to rejoin society. The novella ends on a note of optimism, however, where Miranda dreams of a world with no war and no more plague, and she'd have time for "everything."

Historians say it's unclear when the 1918 flu actually did end—and that's partly because Americans were as tired of the flu as they are now after two years of COVID-19. Although cases continued to spike in 1920 and beyond, much of the historical record of the pandemic is from its first two years. Porter's novella is one of the few written accounts of its enduring trauma and formal efforts to document the disease ultimately failed because Americans in the early 20th century simply wanted to forget the flu.

Similarly, two years into the COVID-19 pandemic, fatigue has grown—alongside arguments about when to loosen public health measures like mask and vaccine mandates. But historian Nancy Bristow, who wrote about the novella in her book American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic, says that while going back to a pre-pandemic normal may be appealing, history shows it could have harmful implications both for this pandemic—and the next one.

"That drive to not have to do what we've been doing carries with it a great potential to forget," she says. "The ways in which Americans continue to think that these kinds of things won't happen to us, that kind of American exceptionalism, you can only do that if you are a nation that is very, very capable of forgetting moments of its past."

Fatigue sets in over public health measures

Flu historians like Bristow point out that these two pandemics can't quite be neatly compared. The world was dramatically different in the early 20th century—war was widespread, there were no influenza vaccines, and the U.S. didn't have as robust a health care infrastructure to care for those who fell ill then. The virus also targeted younger populations and the pandemic response wasn't politicized nearly as much as it has been now.

But there are some similarities. During the early waves of the 1918 flu, there was a patchwork of public health responses from states and local authorities—and the outcomes of their various approaches to flattening the curve was clear. Cities like New York that implemented public health measures early had low death rates. Meanwhile, cities like Philadelphia that waited to implement health measures—and those like San Francisco that relaxed their measures too early—had higher death rates. (Here's how U.S. cities flattened the curve during the 1918 flu pandemic.)

Then, like now, there was also confusion about when to change or relax measures, says Thomas Ewing, a historian based at Virginia Tech. In Denver, Colorado, officials rescinded their mask mandate in November 1918 when the first outbreak of influenza had tapered down, but then a second wave hit the city, causing many to question if the mandate should be reinstated.

"In both pandemics, there's been a lot of confusion, there's been uncertainty, there's been resistance, there's been conflicting, contradictory recommendations," Ewing says.

For example, in December 1918, the U.S. Public Health Service—the government agency in charge of the pandemic response—worried that the public was relaxing its attitude toward the pandemic despite resurgences. In response, the Surgeon General issued a reminder to take precautions like masking and social distancing.

At the time, plenty of individual people flouted mask mandates but there wasn't much organized opposition to masking. One exception was the Anti-Mask League in San Francisco, which was formed in early 1919 after the city reinstated a mask mandate a mere two months after lifting it. The league held at least one public meeting with nearly 2,000 attendees to denounce the ordinance, according to the University of Michigan Center for the History of Medicine's Influenza Encyclopedia.

Bristow says that most of the pushback to public health measures was largely economic rather than political. Some city public health officials and politicians pointed to one another's policies to curry favor in midterm elections, but the debates were largely over details like whether to reopen businesses before churches, rather than opposition to the measures as a whole.

Still, as the influenza pandemic dragged on, public health interventions became even patchier. Masking policies were rescinded even as the country continued to see occasional spikes in cases—including when several cities recorded death rates in 1920 comparable to the first wave in 1918. Then, like now, there was some resistance to bringing back public health measures, like mask mandates.

But by the end of 1920, the influenza pandemic had begun to ebb. Although the nation saw yet another small wave of cases and deaths in 1922, there was far less attention paid to those deaths because, unlike COVID-19, historians say that the influenza pandemic hadn't been in the headlines every day for years. Meanwhile, physicians and public health experts also expressed optimism that future bouts would be less severe.

Bristow wonders if resistance to public health measures would have grown to the extent the U.S. has seen in the COVID-19 pandemic had they been allowed to continue.

"Here we're seeing that played out," she says of the COVID-19 pandemic. "Americans don't like to be told what to do."

Fatigue leads to forgetting

Living with the constant worry of catching influenza during the early waves of the disease had proven taxing on society. Like Porter's novella, blues songs from the era mourned the catastrophic scale and powerful impact the influenza pandemic had on American lives. One of the best known was Essie Jenkins' "1919 Influenza Blues," whose chorus lamented the virus killed the rich and poor, and would kill even more people as part of God's plan.

That narrative resonated with those suffering the most from the pandemic, whose lives were remade by the experience.

But as the pandemic began to ebb, others began to feel an optimism for the future, and longed to move past it. Historians say this may be why formal efforts to research the causes of the pandemic and take steps to prevent the next one ultimately failed.

In the first year of the influenza pandemic, there was every indication that the U.S. Congress would do just that. Lawmakers at the state and federal level were concerned about future outbreaks and the public clamored for them to act. In 1919, Congress introduced a Flu, or Anti-Flu, Bill, which would have appropriated roughly $5 million for the investigation of the epidemic, with an eye to preventing future outbreaks.

The law, however, soon lost steam. By 1920, the amount lowered to $250,000 as politicians objected to sending more funds to the U.S. Public Health Service—which was largely seen as having failed. Ultimately, no appropriation was made, which Nichols says "is part of the larger takeaway that the U.S. did not enact meaningful public health changes in the wake of the pandemic."

Likewise, the scientific community couldn't sustain efforts to investigate the virus that caused the influenza pandemic. In 1922, an editorial published in the Journal of the American Medical Association argued that there was a need to continue this research. While some scientists remained dedicated to that cause, by 1925, another editorial in the same journal noted that the "intense general interest in influenza … died down rather quickly."

Nichols argues the country could have learned lessons about the importance of providing social safety nets and addressing health care inequities had it followed through on this research. Marginalized communities were at higher risk of dying from influenza in 1918 just as they are now with COVID-19—and yet there remain gaps in the country's health care infrastructure that leaves them vulnerable to disease.

Ewing agrees. He notes there was little attention to these vulnerabilities in 1918—but in 2020, the research is overwhelming, especially now as the lingering effects of COVID-19 start to manifest.

Will we return to normal?

The good news, Bristow says, is that it seems there's one lesson the country has learned from the 1918 influenza pandemic and that's in record-keeping.

There is very little historical record or archival information from 1918. There was no real attempt to memorialize those who died in the 1918 pandemic because people just wanted to get past the trauma. Bristow says she had to sift through primary accounts from journals and newspaper headlines to write her 2017 book.

That seems not to be the case this time around. From the beginning of the COVID-19 pandemic, libraries, historical societies, and local organizations began working to collect any and all records. Those records include individual testimonies, as well as efforts to find out how entire communities have been affected through interviews with grocery store workers, volunteer COVID-19 testers, children and their parents grappling with virtual learning, and more. There have also been a few temporary memorials to honor the victims of COVID-19.

That attention to collecting records could be useful for making policies in the future that could help the country cope with the inevitable next pandemic. Or it could just collect dust if Americans again want the trauma from the pandemic to disappear from memory.

Ewing predicts the strong desire to get past the pandemic will translate to a lack of commemoration or change, but Bristow tends towards optimism.

"No one has escaped completely unscathed," she says. "But will that make us more humane with one another, more caring of one another? My hope is that trauma that everyone has experienced at some level will make for a more robust reckoning in the aftermath than we saw in 1918."

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