When a virulent disease upended Katherine Anne Porter’s life, the author turned to writing to process her experience.
“All the theaters and nearly all the shops and restaurants are closed, and the streets have been full of funerals all day and ambulances all night,” Porter wrote.
While the scene may sound familiar in 2020, that excerpt is from “Pale Horse, Pale Rider,” Porter’s 1937 collection of short stories largely based on her experience surviving the 1918 influenza pandemic, commonly known as “The Spanish Flu.”
October marked 102 years since the deadliest month in American history when 195,000 Americans succumbed to the Spanish Flu. The peak of the pandemic came in the fall of 1918 and by the end of 1919, the disease left a total of 50 million deaths, 675,000 of whom were Americans.
Despite its immense toll, with influenza deaths surpassing those of coinciding World War I, Emory pediatrician and medical historian Dr. Hughes Evans noted that knowledge of the 1918 pandemic was not widespread until recent decades.
“For a long time, people called the 1918 epidemic America’s forgotten epidemic because it was as if it never happened,” Evans said. “No one talked about it, no one taught about it, no one read about it.”
“It’s useful to make a comparison [between 1918 and 2020] only to say that the virus is the public health crisis of the century,” said Dean of the Rollins School of Public Health Dr. James Curran. “We’ve not had anything like this in a hundred years that has such worldwide impact and such consequences — economic consequences, other health consequences, international consequences.”
While the specific origin of the 1918 strain of influenza is unknown, the first outbreak occurred in March 1918 at Camp Funston in Kansas, according to John M. Barry’s “The Great Influenza: The Story of the Deadliest Plague in History.” Troop movement during World War I facilitated its spread throughout Europe and the world, likely mutating along the way to become deadlier to humans by its second wave.
The disease was later dubbed the “Spanish flu,” which was largely due to Spain’s reporting of the sickness when no other countries did, according to infectious disease expert Dr. Robert Gaynes of the Emory School of Medicine.
“When it began to occur in Spain, they reported it,” Gaynes said. “People erroneously believed it started there.”
Today, the World Health Organization uses “Spanish flu” as an “example to be avoided” in the naming of new diseases, advising against including geographic locations in names of viruses. President Donald Trump’s use of “China virus” to describe COVID-19 has endured similar criticism.
Unlike most viruses, including COVID-19, the 1918 influenza largely impacted young and healthy people. Gaynes said as fear grew about the swiftly acting disease, the phrase “well at breakfast, sick at lunch and dead by dinner” became popular.
Medicine at the time, according to Evans, was in its “pre-virology days.”
“They knew it was a respiratory infection,” Evans said. “They thought it was probably bacterial, although I think there was some vague understanding that there may be something else going on.”
In Georgia, the disease first appeared in September 1918 at Camp Gordon, a temporary military training camp outside of Atlanta. Military officials placed the camp under quarantine, with reports of “iron-clad sanitary precautions being forced on each man at the camp.” Nurses were in short supply.
However, by Oct. 4, 1918, the Georgia State Health Board issued a warning as influenza showed “a considerable presence,” advising that “the epidemic now sweeping the country must be intelligently met or a vast toll of suffering and many deaths will result.”
In Atlanta, doctors reported 230 influenza cases in early October and the city instated a “ban on public gatherings” as the police force was “instructed to keep vigilant watch over persons who expectorate in the streets.” As the Red Cross opened work rooms to sew masks, health authorities assured the public that there was “no reason for alarm.”
The Atlanta History Center noted public outcry in October 1918 as movie theatres closed to prevent the spread, citing former President Woodrow Wilson’s own continued patronage. Outdoor entertainment like the Georgia state fair and college football games, however, continued with masked crowds, as they do today.
By the end of October 1918, The Atlanta Constitution ran the headline “Influenza Showing Decrease in State.” A health official credited the “early closing of schools, churches, theaters, and other places of public assembly” for the “relatively small number of cases in Georgia.” By November, the Atlanta city health officer announced the threat had subsided.
In the Georgia State Board of Health report for 1918, officials wrote, “We will never know how many succumbed to the disease in Georgia, but the death rate has been high.” With 30,768 instances recorded, influenza was listed as the leading cause of death.
According to Oxford College’s Dean of Campus Life Joseph Moon, Emory College chose its original location in Oxford, Georgia, because it was away from coastal marshes that harbored diseases like malaria, although influenza spread would theoretically not have been impacted.
In 1918, when it was still a white men’s college, Emory began its last school year on Oxford campus. There is a gap in University records for that time, for which archivists credit the move to Atlanta and World War I. Oxford campus partially converted into a military training camp during this time.
At the end of the school year, Atlanta University, now Clark Atlanta University, extended its academic calendar by two weeks in the summer “to make up for time lost in the fall on account of the influenza.”
The newly amalgamated Emory University School of Medicine and School of Nursing were active in treating the outbreak both in Atlanta and abroad, mobilizing medical resources as Emory’s schools are today with COVID-19.
The School of Nursing’s 1918 annual report stated “very few cases” of influenza were recorded among nurses at the school and “none were serious,” although the house physician “contracted the disease and died.” The school was “very much handicapped this year for want of lecturers,” although the report was unclear about the purpose of doctors’ absences.
Former University Historian Gary Hauk wrote about a group of Emory doctors and nurses dubbed “The Emory Unit” who established Base Hospital 43 in France, where they treated influenza patients during the third global wave in 1919.
Barry underscored that during those past epidemics, “governors and mayors, and nearly all the newspapers insisted that this was influenza, only influenza.” Meanwhile, the Public Health Service sent out six million copies of an informational flyer whose “warning to avoid crowds came too late to do much good.”
According to Gaynes, the recurrence of influenza to this day is due to changes in molecules on the outside of the virus that specifically trigger mammals’ immune responses. In 1918, the shift of both at the same time caused such a virulent strain. The virus then causes a “cytokine storm,” where immune cells leak too much typically helpful liquid, which leads those afflicted to “essentially drown in their own fluid.”
Medicine was ill-equipped to respond. In the Georgia State Board of Health’s original statement, it incorrectly identified the cause of influenza as “influenza bacillus,” a bacteria scientists could inconsistently isolate from patients. Scientists developed a vaccine to treat the bacteria, and the board wrote that their “laboratory forces cannot begin to supply the demand for this vaccine.”
Barry wrote that “no medicine and none of the vaccines developed then could prevent influenza.” He added that due to the presence of improved antibiotics today, “modern medicine could likely prevent significantly more than half of those deaths” in a modern-day 1918 pandemic.
Despite such improvements, the danger of a potential epidemic still loomed.
“We were worried about a H1N1 flu epidemic a few years ago and no one thought it was going to be as bad as 1918 but we were concerned that it was going to be quite a disruption,” Curran said. “COVID has really been as bad as we were worried about H1N1 flu. … We have a new organism which seems to, in some cases, defy treatment and has kind of taken over the world.”
Evans highlighted that medicine has been “decreasing the deadliness” of COVID-19 by tailoring treatments for those infected. Curran emphasized that the over 5,000 patients admitted to Emory Hospital “do really quite well compared to the national average with COVID.”
In a recent interview, Barry underscored that COVID-19 is a slower spreading and less deadly disease than influenza, although they share similarities in respiratory transmission, ability to affect various organs and novel demands on public health.
Regarding long term effects, Barry added, “In 1918, there were complications that didn’t surface at all until the 1920s. We just don’t know.”
Doctors have reported strokes and seizures associated with COVID-19. Recent research has documented a range of neurological effects in hospitalized patients and there have been recent instances of “brain fog” after those infected recover.
Evans noted that masks in 1918 that were often made out of gauze or other thin fabrics likely did little to protect people. PBS’s “American Experience” compared wearing a mask to combat the 1918 influenza to “trying to keep out dust with chicken wire.” In contrast, modern masks significantly reduce COVID-19 spread.
Distancing procedures, however, have remained as effective a century later.
“The main method has always been there,” Barry said. “Social distancing is more important than anything else.”
World War I was a critical cultural context for the influenza outbreak as well. Barry wrote, “the preservation of morale itself became an aim” for the Wilson administration. When the pandemic threatened the war effort, Wilson “express[ed] concern about shipping troops to Europe,” but otherwise “continued to say nothing publicly.”
When state and city health officials spoke on the virus, they denied the severity of influenza to maintain wartime morale, quickly losing the public’s trust.
“It is impossible to quantify how many deaths the lies caused,” Barry wrote.
Curran expanded on this lack of government transparency, saying, “Public health is always political because we’re trying to save the lives of groups of people. … [There] are different political considerations that require consistent leadership at the state and federal level to bring people together.”
Throughout the COVID-19 pandemic, inconsistent directives on mask-wearing have stood in the way of establishing mask-wearing as the public-health norm. Georgia Governor Brian Kemp filed a lawsuit against Atlanta’s mask-mandate over the summer before dropping it in Aug. and shifting his position to allow local mandates. Georgia local governments have since passed 25 mask mandates.
In 1919, influenza receded despite the lack of an effective vaccine. According to Evans, influenza viruses “kind of just peter away.” With COVID-19, numerous people have asked Curran: When’s it going to be over? Where’s the magic bullet?
“It’s very clear the vaccine is not going to be the answer, it’s going to be hopefully another tool,” Curran said. “We don’t really know exactly what’s going to happen.”
Curran noted Emory’s ability to control COVID-19 case numbers, largely due to the accessibility of asymptomatic testing, contacting tracing, mandated masking and distancing on campus.
In September 1919, The Atlanta Constitution published an excerpt from the U.S. Health Service’s Flu Warning: “The most promising way to deal with a possible recurrence of the influenza epidemic is to sum it up in a single word, ‘preparedness.’ And now is the time to prepare.”
The COVID-19 pandemic is not our first. Yet even after 102 years, Americans were ill-prepared for another.
“This is the public health crisis of my lifetime and our century,” Curran said. “I think there will be a recognition of the shortcomings and needs for public health going into the future. Save your masks. I think that they’ll come in handy after COVID is over.”
Woodruff Health Sciences Center Historian Sally King, Head of Information Services for Woodruff Health Sciences Center Library Hannah Rogers, Woodruff Health Sciences Center Library Archivist Ashley Stevens, Oxford College Archivist Kerry Bowden, University of Georgia Librarian Eric Griffith and Rose Library Archivist John Bence helped with remote research.