The Eighteen of 1918–1919: Black Nurses and the Great Flu Pandemic in the United States

Abstract

This article examines the role of Black American nurses during the 1918–1919 influenza pandemic and the aftermath of World War I. The pandemic caused at least 50 million deaths worldwide and 675 000 in the United States. It occurred during a period of pervasive segregation and racial violence, in which Black Americans were routinely denied access to health, educational, and political institutions. We discuss how an unsuccessful campaign by Black leaders for admission of Black nurses to the Red Cross, the Army Nurse Corps, and the Navy Nurse Corps during World War I eventually created opportunities for 18 Black nurses to serve in the army during the pandemic and the war’s aftermath. Analyzing archival sources, news reports, and published materials, we examine these events in the context of nursing and early civil rights history. This analysis demonstrates that the pandemic incrementally advanced civil rights in the Army Nurse Corps and Red Cross, while providing ephemeral opportunities for Black nurses overall. This case study reframes the response to epidemics and other public health emergencies as potential opportunities to advance health equity.

In 1918, Aileen Cole and Clara Rollins ached to become Red Cross war nurses.¹ Cole, aged 24 years, had recently passed her registration exams, and Rollins, 34, had years of nursing experience.² The two boarded with other nurses in a Washington, DC, brick row house near Freedmen’s Hospital, where they had all graduated from the rigorous nurse training school. The Red Cross had enrolled Cole and Rollins on paper, but had done nothing else: the US Army and Navy, for which the Red Cross served as the official recruiter, did not accept Black nurses.³

In October, the influenza pandemic brought change. The Red Cross called up Cole, Rollins, and several other Black nurses for civilian duty, and sent them to West Virginia to battle pandemic influenza.⁴ This 1918–1919 pandemic was responsible for at least 50 million deaths worldwide and 675 000 in the United States.⁵ It also created opportunities for previously excluded Black nurses, including the first 18 to serve in the Army Nurse Corps (ANC) between December 1918 and August 1919.⁶

Although Black nurses’ roles in World War I and the pandemic have been noted by numerous historians, this article represents the first effort to move these nurses from periphery to center, and to critically analyze their struggle to serve as a seminal episode in the long and ongoing movement for civil rights and racial health equity.⁷ Using archival materials, news reports, census records, and published literature, we highlight how Black nurses fulfilled a critical need for skilled care during the pandemic and the war’s aftermath, but received little recognition. We also show how nurses and Black community leaders viewed this service as a political act. We present this story as a historical case study of nursing and racism in a public health emergency, while raising transhistorical questions: Do public health emergencies spur advancements in health equity? Or do they merely allow exploitation of already-marginalized persons? Although a single case study cannot offer definitive answers, it can provide valuable insights.

BLACK WOMEN AND NURSING

Throughout US history, Black women have nursed the sick. Enslaved women cared for members of slaveholding families while nursing their own communities. Antislavery crusaders Sojourner Truth and Harriet Tubman nursed soldiers and civilians during the Civil War.⁸ After this war revealed shortcomings in hospital nursing care, nurse training programs began and admitted a few Black women. Many programs were based on Florence Nightingale’s model of a hospital-based school, which provided instruction in scientific methods of sanitation and patient care.⁹ Students worked in hospitals for 24 to 36 months, while receiving room and board.¹⁰

Even before the US Supreme Court’s 1896 Plessy v Ferguson decision permitting racially “separate but equal” public facilities, exclusion of Black Americans from schools and hospitals had become widespread.¹¹ Southern nursing schools barred Black students, and Northern ones admitted very few.¹² In the 1900 US Census, approximately 10 000 men and women identified themselves as professional or trained nurses, but this number included only 201 Black Americans.¹³

As historian Darlene Clark Hine has shown, Black communities responded to such exclusion by pooling resources to establish Black hospitals and hospital-based nurse training programs. Between 1891 and 1907, 12 such nurse training programs opened for Black women, including ones at New York’s Lincoln Hospital, Chicago’s Provident Hospital, and Freedmen’s Hospital in Washington, DC.¹⁴ In 1908, Black women nurses formed the National Association of Colored Graduate Nurses (NACGN). By the 1910 Census, 3010 Black women and about 200 Black men self-identified as professional or trained nurses.¹⁵

In the 1910s, trained Black female nurses nevertheless faced steep obstacles. Most Whites and some Black men, according to Hine, viewed them through a “triple index of inferiority”: as nurses (not doctors), women (not men), and Black (not White).¹⁶ In 1916, the American Nurses Association began requiring membership in a state nursing association. Associations in 16 states and the District of Columbia excluded Black nurses, effectively barring them from membership in the American Nurses Association.¹⁷

RACE AND CITIZENSHIP IN WORLD WAR I

When the United States entered World War I in 1917, many Black Americans, including those in health professions, volunteered for military service or joined voluntary patriotic organizations. Some did so to prove they were loyal Americans who deserved the full benefits of citizenship.¹⁸ “Racially, this war spells for us the most glorious word in the vocabulary of freedom—opportunity,” C. V. Roman, MD, a professor at Meharry Medical School, stated.¹⁹ Over 100 Black physicians served as US Army Medical Corps officers, along with 12 Black dental officers, 639 Black infantry officers, and 400 000 Black enlisted men.²⁰ Fourteen Black women served as navy clerks.²¹ The War Department appointed Emmet J. Scott, former Secretary of Tuskegee Institute, as its special assistant for Negro affairs.²² Scott worked as an intermediary between Black Americans and the military on issues from discrimination to Black troop morale.²³

However, Black nurses were barred from serving. The American Red Cross, a quasi-governmental humanitarian organization, recruited about 23 000 nurses for the ANC and the Navy Nurse Corps.²⁴ The organization restricted enrollment to graduates of reputable hospital-based nursing schools who had passed a physical examination and obtained a positive character reference from a supervisor.²⁵ By 1917, most trained Black nurses could meet these qualifications.²⁶ But in 1911, the Red Cross had voted to exclude Black nurses from enrollment, citing a surgeon general’s statement that the army would be unable to provide suitable (i.e., segregated) quarters for these nurses. In 1917, the Red Cross reversed this policy. Then, after NACGN President Adah Bell Thoms protested that no nurses were actually being enrolled, Red Cross nursing leader Jane Delano informed Thoms that she was ready to enroll 150 qualified Black nurses, with the same “pay and allowances” as White nurses, for assignment to a training camp for Black soldiers.²⁷ But these assignments failed to materialize.

In 1918, prominent Black leaders vociferously challenged this inaction. National Urban League Secretary Eugene Kinckle Jones wrote Scott, and Tuskegee Institute President Robert Moton wrote the Red Cross leadership, to call for the immediate enrollment of Black nurses. Their exclusion “reacts in a certain sort of indifference on the part of colored people which ought not to be when the country needs every ounce of effort along every available line,” Moton stated.²⁸ In its annual meeting, the NAACP also voted to allow its secretary to act to “forward acceptance by the War Department of Colored nurses overseas.”²⁹

These actions elicited a response from Delano. She wrote Jones that she had “deferred” enrollment of Black nurses, “on the advice of colored people with whom I have consulted, feeling that if their assignment to duty was delayed for any great length of time it would make the nurses restless and discontented.”³⁰ But now Delano promised to begin their enrollment immediately—with one condition. Although each enrolled Black nurse, like any other Red Cross nurse, would receive a numbered badge, Black nurses’ badge numbers would be preceded by an “A” to prevent them from being assigned to duty “without reference to their color.”³¹

By the November 11 armistice, the Red Cross had enrolled 77 Black nurses but still had not assigned any to military duty.³² This slow response stemmed from “delays in the provision of separate quarters and mess for these women,” according to Julia Stimson, later ANC superintendent.³³ This rationale however, holds little weight considering that White army nurses were often quartered in hastily erected shacks or tents that offered scant protection against rain, cold, or German bombardment.³⁴ The more likely reason is that army and navy officials, imbued with anti-Black racism, did not want any Black women in their Nurse Corps. This explanation is consistent with the poor, sometimes cruel treatment experienced by Black troops.³⁵ Moreover, many Americans viewed military nurses as needed symbols of wholesome womanhood in the masculine war zone, and prevailing racist ideologies held that only White women could truly embody feminine virtue.³⁶

PUBLIC HEALTH AND FLU OPEN DOORS

Thoms had advised Black nurses, when barred from military service, to look for other ways to serve during the war. “[T]he service we render in our own communities will count for just as much, if wisely directed,” she had counseled.³⁷ Frances Reed Elliott, the first Black nurse enrolled by the Red Cross (Badge 1-A), embodied this strategy. Elliott, the orphaned daughter of a White plantation heiress and a Black-Cherokee man, had graduated from Freedmen’s in 1913.³⁸ In 1917, she applied to the Red Cross’s Town and Country Nursing Service, which sent nurses to do public health work in underserved communities.³⁹ The Red Cross did not initially accept Elliott, but, in an unusual move that reflected recognition of her exceptional abilities, sponsored her in public health nursing courses at Columbia University. Elliott then became a visiting nurse at New York’s Henry Street Settlement, and during the war worked for the US Public Health Service near an army cantonment in Chattanooga, Tennessee, before the Red Cross enrolled her and assigned her to Jackson, also in Tennessee.⁴⁰ When influenza struck, Elliott began nursing both Black and White patients. According to one account, Elliott learned to drive a car so she could reach patients in remote areas. Eventually, Elliott herself developed influenza with cardiac complications and returned to Freedmen’s as a patient.⁴¹

In October 1918, the Red Cross also sent Rollins and Cole, along with Cole’s Freedmen’s classmate Susie Boulding, to nurse influenza patients near Charleston, West Virginia.⁴² Cole had grown up in Piqua, Ohio, and had lost her mother at age 13 years. She had attended Oberlin College, but had dropped out because lack of funds had forced her to work full-time in domestic service while attending school. Freedmen’s had provided a second chance.⁴³ The school’s rigors and small size inspired close bonds among students. In 1918, Cole and Rollins lived in the home of Rollins’ elder sister, an 1897 Freedmen’s graduate; Cole and Boulding had graduated together in a class of only 20 nurses.⁴⁴ The close relationships between this trio must have been reassuring as they headed to Appalachia.

When Cole, Rollins, and Boulding arrived in Charleston, the pandemic was raging. Upon entering a high school that had been converted into an influenza hospital, they found all of the patients dead on their cots.⁴⁵ A Major Maxwell greeted them, and said, “I’ll bet you young nurses had your hearts set on going overseas, wearing romantic Red Cross uniforms, to nurse our soldiers, didn’t you?” Cole recalled. Instead, Maxwell said he was sending the nurses to camps where miners were “dying like flies.” The flu had slowed coal production—vital for keeping troop transports running—and in some areas coal cars had reportedly become “as scarce as hen’s teeth.”⁴⁶ On October 23, one coal company in Preston County reported 190 out of 200 workers sick with flu.⁴⁷ Major Maxwell immediately sent Cole to this remote area.

With the company doctor, Cole traveled through Preston County in “a rattling old Ford” to deliver aspirin, medicinal whiskey, and cough syrup to patients. Nobody mentioned segregated quarters.⁴⁸ The miners, she remembered, “had never had nursing service, but they were so glad to see us.”⁴⁹ The company then offered Cole a permanent position at a high salary. Such a welcome was unusual in a region known to be inhospitable to Black persons, but influenza created unusual circumstances.⁵⁰

As the pandemic peaked, trained Black nurses outside the Red Cross also gained opportunities. “The demand for nurses has been so great that we have been unable to furnish adequate supply,” Thoms told the New York Age. “A number of our nurses have been sent to homes that hitherto have not been opened to colored nurses.” These homes included the estates of Newport socialites.⁵¹ A family in Winnemucca, Nevada, reportedly paid a Black nurse $30 a day for her services—half the monthly salary of a White army nurse.⁵² Carnegie Steel in Pittsburgh, Pennsylvania, hired 16 Black nurses to care for employees sick with flu. By the end of the crisis, Pittsburgh restaurants that had refused the nurses service reportedly insisted on participating in a farewell reception “since these nurses had rendered their community such good service.”⁵³

Photograph of the Camp Sherman Nurses. Courtesy, Special Collections and University Archives, University of Massachusetts Amherst Libraries Printed with permission.

Despite the fact that influenza blazed through many military training camps, neither the army nor navy made such an about-face.⁵⁴ At Camp Sevier, in Greenville, South Carolina, “about fifty per cent of the nurses were off duty, sick, and the hospital contained about three thousand patients,” Chief Army Nurse Sayres L. Milliken later wrote. But “fully seventy-five per cent of the nurses were women of Southern birth, and had very positive objections to working with colored nurses.” However, Milliken hired several Black nurses on a temporary basis to meet the “imperative” need. They were allocated a separate quarters and mess, assigned to “subordinate” positions, then dismissed three weeks later.⁵⁵ Black nurses also served temporarily during the pandemic at Camp Pike, Arkansas, and likely several additional installations.⁵⁶

In other camps, Black nurses were not welcome. On October 9, after Camp Sherman in Chillicothe, Ohio, reported 115 flu deaths in 36 hours, newspapers printed a plea from chief nurse Katherine Leary: “Don’t stop to telephone and write if you are a graduate nurse, but jump on the first train and come to Camp Sherman.”⁵⁷ A Black nurse from Columbus, Ohio, responded immediately. But when she arrived, Leary turned her away. The nurse then “came back to the Superintendent’s office and saw between twenty and thirty [W]hite nurses accepted,” the NAACP magazine The Crisis reported.⁵⁸ Mary Waring of the National Association of Colored Women wrote Scott:

This unpatriotic head nurse turned this trained nurse away while colored soldiers were falling in the ranks from influenza, dying in the hospitals for lack of nurses; and suffering unattended because of the epidemic which made the usual nursing force inadequate. Are colored nurses to be forever humiliated?⁵⁹

Scott queried the ANC, prompting a statement from Leary that “we had a sufficient number of help and did not need the services of more.” Leary wrote that she had told the nurse “that later on we would have quarters for colored nurses, and that we would be glad to have her when we needed her services.”⁶⁰ In this preantibiotic era, attentive nursing care proved the only effective treatment of curbing symptoms of influenza and preventing deadlier secondary pneumonia infections.⁶¹ Camp Sherman “had the highest death rate of any [army] camp in the country” during the fall pandemic.⁶² The fact that a trained nurse was rejected during this emergency speaks volumes about the intensity of racial discrimination that Black nurses faced.

THE FIRST EIGHTEEN

Two days after the armistice, when the army finally reversed its stance on Black nurses, Cole was one of the first called up.⁶³ She was sent to Camp Sherman, along with Rollins, Boulding, and five other Freedmen’s graduates: Sophia A. Hill, Marion H. Brown, Nancy Jeanette Minnis, Lillian Spears, and C. Jeannette West; along with Lillian Ball, a graduate of Battle Creek Sanitarium and Hospital Nursing School.⁶⁴ The army sent nine others, also from leading Black nurse training schools, to Camp Grant near Rockford, Illinois: Eva Clay, Willie DePriest, Virginia R. Steele, Mabel Williams, Magnolia Diggs, Nettie B. Vick, Frances A. Stewart, Pearl Helen Billings, and Anna E. Oliver Ramos.⁶⁵ All took the officer’s oath and were subject to military discipline, although military nurses at this time served without rank, commission, or officer-grade pay.⁶⁶

The Camp Sherman nurses were assigned to segregated but otherwise adequate quarters and met with Chief Nurse Mary M. Roberts upon arrival. Roberts “received them very cordially,” Cole dutifully reported to Red Cross nursing leaders (who often directed nurses to write them about their experiences).⁶⁷ Roberts, however, remembered these events differently. When the order came for a “colored unit” of nurses, she later wrote, “I was quite sure I was about to meet my Waterloo.” She recalled telling the nurses they should “not expect to share in the social activities of the [W]hite nurses” but that she “considered it an opportunity for them, not only individually but racially, and that I would make every effort to give them credit for every good thing they did.”⁶⁸

The nurses initially cared for flu patients, but as influenza deaths subsided their duties shifted.⁶⁹ Both camps were being transformed into demobilization centers, where thousands of soldiers were processed for discharge.⁷⁰ In early 1919, the camps’ hospitals also began receiving the 50 000 severely wounded, gassed, and disabled soldiers from hospitals overseas.⁷¹

The nurses served successfully in wards that included both Black and White patients, even though their White supervisors refused to view them as equals.⁷² Rollins became especially popular. Roberts later recalled that when she tried to move Rollins to a new ward, the patients in her old ward petitioned Roberts to request that she remain. “They always called her ‘the major’ and the day before she left camp they had a special ceremony and made her a Lieutenant Colonel,” Roberts wrote.⁷³ Brown earned accolades for her work in the operating room, and Ball, the only trained masseuse at the camp, found that “her color did not matter since her services were needed,” according to Mabel Keaton Staupers, a classmate of Cole and Boulding’s and, later, NACGN president.⁷⁴ Nevertheless, Roberts wrote that these nurses “showed little executive ability.” (She had also avoided assigning any to supervisory posts where they would have had opportunities to demonstrate such ability.) Anne Williamson, chief nurse at Camp Grant, stated that the nine Black nurses she had supervised were “serious minded, quiet, business like young women, well qualified to take charge of wards, had our colored patients been segregated.”⁷⁵ These supervisors’ comments reveal the limitations and prejudice the Black nurses faced.

Black communities viewed the 18 nurses more highly. At both camps, they were welcomed by Black officers and members of the local community.⁷⁶ In March 1919, Mattie McGhee, widow of civil rights pioneer Frederick McGhee, sent The Crisis a photo of the Camp Sherman nurses, with an attached note stating: “These young women willingly responded to the call when the country needed them, some of them giving valiant service during the Flu Epidemic, under the American Red Cross. Having been assigned to military duty they have faced every difficulty and are winning many small battles for the race.” She added that the chief nurse had reported: “They have done well with a vengeance.”⁷⁷ This note and photograph were never published, but the May 1919 issue of The Crisis featured a photo of the Camp Grant nurses in their Red Cross capes.⁷⁸ These documents indicate that prominent Black Americans viewed the nurses’ work as important to the larger political struggle.

The 18 nurses expressed similar sentiments in a signed August 1919 letter to NACGN. They had sought to demonstrate that they were “morally efficient as well as professional,” they wrote. “We were practical and technical in all of our work, our work stood the test, we had obstacles to confront us, but we fought our way victorious. We left the army with commendation, that we have raised the standard of the nursing profession twenty years higher.”⁷⁹ At the NACGN annual meeting, even as attendees discussed the postwar race riots endangering US Black communities, Thoms allowed this upbeat letter to be read.

But Thoms’ view of the nurses’ service was tinged with bitterness. In the April–June 1919 issue of the Journal of the National Medical Association, she recounted:

The day after the armistice was signed, colored nurses began to receive telegrams thick and fast, advising them to be ready for overseas duty “if called.” They had been ready since the day the United States entered the war, if being willing, eager and PREPARED to serve whenever and wherever needed, is implied by being ready. At least as nearly ready as any other nurse, or as our own boys were when called to do their bit toward making the world “safe for democracy.” Naturally the “call” did not come for overseas duty, but a few were sent to camps here, where they were as happy as could be, to go, and are now serving with much credit.⁸⁰

Thoms’ words reflect the wisdom and weariness of one who had long been fighting for racial equality in nursing. She knew that while the 18 had broken the color line in the ANC, most of the country’s 3000 trained Black nurses had been left out.

CONCLUSION

This story might seem like just another example of “disillusionment and dashed expectations because of the resilience of White racism,” as military historian Chad Williams has characterized the typical historiographical framing of Black Americans’ experience during the World War I era.⁸¹ Indeed, Black nurses’ exclusion from wartime military service meant they were denied the status and benefits accorded nurse veterans. These nurses rose in status when suffrage advocates cited their wartime service in successfully arguing that women deserved the vote.⁸² World War I nurse veterans also gained access to state veterans’ bonuses, free treatment in veterans’ hospitals and lodging in veterans’ homes, inexpensive insurance policies, and Red Cross scholarships for postgraduate study in public health nursing, while developing powerful social and professional networks.⁸³ The exclusion of Black nurses from these manifold benefits exacerbated existing racial discrimination against them.

However, when the postwar lives of the first Black Red Cross nurses are examined, a more complex picture emerges. For these nurses, the wartime experience of “making a way out of no way,” in the words of the traditional Black folk saying, became a springboard for careers advancing Black women within the nursing profession and improving the health of Black communities.⁸⁴ Elliott moved to Detroit, Michigan, following her recovery from influenza and established a nurse training school at Detroit’s new Black hospital, Dunbar Memorial.⁸⁵ Cole became superintendent of nurses at Booker T. Washington Sanatorium in Harlem, the first private hospital in New York City established by Black physicians.⁸⁶ Then, in an era when few cities employed Black public health nurses, Elliott and Cole became public health nurses in Detroit and New York City, respectively, where they addressed crisis-level infant mortality and other community health problems.⁸⁷ Marion Brown, another of the 18, became assistant superintendent of nurses at Freedmen’s and president of the Freedmen’s Alumnae Association. In 1935, she worked with NACGN leaders to successfully pressure Catholic University—the only Washington, DC, university offering graduate nursing courses—to stop barring qualified Black nurses from admission to these programs. This victory enabled local Black nurses to advance to leadership positions and gain positions as public health nurses.⁸⁸

These nurses’ record of leadership and opening doors for others has transhistorical implications. It indicates that the opportunities created by a public health crisis may translate to lasting gains for members of marginalized groups. But the larger story also suggests that such meaningful expansion of opportunity only occurs when communities organize and unite to push for greater inclusion before, during, and after the crisis. Furthermore, it indicates that lasting gains from such “crisis opportunities” may take generations to manifest.

The full legacy forged by the first 18 did not become apparent until World War II. In 1940, when the United States began the peacetime draft, the navy refused to accept any Black nurses, and the army stipulated that it would only enroll Black nurses when and if “separate black wards” were opened in military hospitals. But the fact that 18 Black ANC nurses had served in a racially integrated military camp in 1919 had created a precedent. Staupers, as NACGN president, explicitly pointed to this precedent in objecting to this policy.⁸⁹ The army then agreed to accept a quota of 56 Black nurses, but only incrementally expanded these quotas until 1944, when an acute nursing shortage and organized campaigns for civil rights led by Staupers and others prompted the ANC to finally drop the quotas.⁹⁰ More than 600 Black nurses served in the ANC during World War II. Afterward, postwar fights for full racial equality within the nursing profession paved the way for Black women to rise to positions of national leadership in military and civilian nursing during the late 20th century.⁹¹ Although these later-serving nurses have received appropriate recognition, it is important to acknowledge that they stand on the shoulders of 18 Black nurses who scaled a wall of bigotry 100 years ago.