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editorial
. 2021 Jun;111(6):996–998. doi: 10.2105/AJPH.2021.306270

Pandemics and History: Context, Context, Context

Judith Walzer Leavitt 1,
PMCID: PMC8101584  PMID: 33950732

Morens et al. (p. 1086) present a comprehensive medical comparison between the 1918 influenza epidemic and the COVID-19 epidemic in the United States. As scientists, they focus on the viruses and on the science. They identify some similarities and differences, using current knowledge and reflection to find precedent for some of the issues that matter today.

As a public health historian, I examine the uses and meanings that comparisons of epidemic experiences can offer. From the historical perspective, it is essential to locate an epidemic within its full temporal, social, political, economic, and cultural context. It is not sufficient to find, for example, that face masks were used at two different times unless we examine also the significance and meaning those masks had to the people who considered using them. The 1918 epidemic took place during and immediately after World War I, when mask wearing was viewed as a patriotic act. During the 2020 epidemic, powerful political forces have deemed mask wearing an affront to personal liberty.

I draw on my own work on the history of public health in Milwaukee, Wisconsin, to illustrate the importance of the sociopolitical context of the 1918 influenza outbreak.1 Then, public health in the United States was largely a local matter. Milwaukee, a city of more than 467 000 people in 1918, fared extremely well with influenza compared with other large American cities. With New York City at 452 excess deaths per 100 000 population, Boston, Massachusetts at 710, San Francisco, California at 673, and Philadelphia, Pennsylvania at 748, Milwaukee’s rate of 292 was exemplary. Among the 18 American cities of more than 350 000 people, only Minneapolis, Minnesota surpassed Milwaukee with its record 267.2

Why was Milwaukee so successful? Public health officials in Milwaukee built a public–private coalition to combat influenza when it arrived in September 1918. Health Commissioner George C. Ruhland acted quickly, consulting the state board of health, which held police powers necessary to protect the public’s health. Ruhland requested all physicians to report cases of the disease and appointed an advisory committee of two physicians and two businessmen. He sought money from the common council to prepare hospitals and clinics to receive the sick and enlisted the support of numerous voluntary and religious organizations. He focused his efforts on isolation, the most traditional method of fighting infectious diseases. The health department mobilized an extensive advertising campaign teaching the public how to avoid contagion. In multiple languages in this heavily immigrant city, posters with advice appeared throughout city neighborhoods, newspapers carried lengthy daily accounts and advice, and churches and factories sponsored “four-minute talks” to keep people up-to-date. Ruhland met personally with physicians, clergy, business people, theater managers, newspaper editors, and club representatives. The entire city rallied.

In October, as flu cases increased, Ruhland and his advisors instituted more radical measures. They outlawed public gatherings and closed theaters, movies, public dances, and churches; then they shuttered schools. People were permitted to buy drinks at the neighborhood saloons, but not to stay inside to drink them. The Visiting Nurse Association and women’s organizations helped to staff city hospitals and clinics, as did teachers who were idle from their normal duties. Ordinary life was disrupted; businesses lost money; people could not work. After 23 days, Ruhland lifted many of the restrictions, but the victory was short-lived. When cases increased in December, Ruhland again banned public gatherings, closed schools, and imposed a half-capacity rule on theaters and churches. Though reluctant, the public accepted this second round of restrictions. Ruhland allowed some Christmas and New Year’s Eve parties to proceed, although he insisted that attendees wear gauze masks. In the new year, influenza waned, schools reopened, and social events were again permitted.

Throughout the crisis, Ruhland consulted with the business community, interacted with health care professionals and hospitals, and scrupulously maintained transparency in his interactions with the public. He credited Milwaukee’s relatively low mortality rate to the extreme cooperation of the public and the support of doctors and nurses. In a very short time, the health commissioner had mobilized an army of volunteers, coordinated the efforts of community organizations, plastered the city with educational literature, isolated the sick, and assuaged the doubts of businesspeople and politicians who feared personal loss from the emergency regulations.1

Milwaukee’s actions to quell influenza were similar to or exactly the same as methods tried by other cities.3 Along with liberty bond parades (which in Philadelphia demonstrably spread influenza),4,5 masks carried patriotic value and gave the public a way to exhibit and celebrate their loyalty. Yet Milwaukee’s efforts were more successful than elsewhere. Ruhland’s achievement did not rest solely on his medical advice or scientific knowledge, which was shared around the country. It was the municipal specificity—the political and social context in which the epidemic occurred—that can help to explain Milwaukee’s success. The high level of central coordination and community cooperation might not have been accomplished, even in wartime, unless previous experiences had paved the way. History matters.

Milwaukee had suffered a disastrous smallpox epidemic in 1894, when the city streets had been filled with rioters and disorder reigned for a full month. At the height of that epidemic, the health commissioner had been impeached and thrown out of office, and the social chaos led to a serious reduction in health department funding and authority.6,7 The turmoil of 1894 informed the 1918 efforts for public cooperation. There were important lessons of what not to do and incentives to remedy lack of transparency and increase public education and trust.

Equally important in explaining Milwaukee’s success with influenza was the political reform that was ushered in when the Socialists won the 1910 mayoral and common council elections. Growing in opposition to corrupt and patronage-laden politics, a coalition of ethnic, middle-class, and labor interests joined together under a pragmatic Socialist banner to institute trustworthy, responsive government to address urban problems.8 Comprehensive and efficient health policies to improve public services, such as infant welfare programs and community clinics, drawing on the advice of experts, aimed to build a healthier city. By 1918, when the Socialists retained the mayoralty but no longer controlled the common council, progressive policies and programs that developed private–public cooperation had achieved citywide trust in local government’s attempts to ameliorate urban problems.9 Socialist mayor Daniel Hoan and wide-ranging community groups actively supported Ruhland in his work. In 1918, Milwaukee’s pub-lic health structure—a government department laced with pathways to voluntary agencies and community members, born from the struggles of the 19th century and the good-government amalgamations of the early 20th century—provided a stable base on which the city could build its defense against influenza. The specific history of Milwaukee’s public health activities and the need to overcome the failings of the past helped build the success of 1918. The health department learned the hard way of the importance of building trust and cooperation, which it reinforced through strong leadership and active communication with the community, to launch a successful attack on disease.

By contrast, the COVID-19 pandemic arrived in the United States at a relative low point in public trust of science and government.10 This made application of many of the lessons from 1918 difficult to apply. In 2020, there was already a significant history of political wariness of government programs and a diminution of financial support for public health departments at all levels.11 Thus, institutionally, it became difficult to mount a rapid response to a pandemic crisis. In addition, understanding the responses to the COVID-19 epidemic is incomplete without analysis of medical inequities based on race and class and the prominence of the Black Lives Matter movement.12,13 Unlike during the 1918 epidemic, African American health disparities and deaths are now a prominent and publicized feature.14 Because the health system does not serve all populations equally, many Americans feel they cannot trust medical advice about treatment and vaccinations. It is perhaps ironic that masks today, which are so politicized that many supporters of one political party will not wear them, are extremely effective against disease transmission, whereas in 1918, porous gauze masks were probably not very effective against the microscopic virus. But they were more reliably worn by people in 1918 who willingly trusted the word of government health officials. The lessons regarding control of the 1918 influenza epidemic, which depended on a public open to and even eager for government interventions, were received in a very different cultural and political arena in 2020.

Medical and scientific knowledge and capacities today dwarf those of one hundred years ago. Health officials can achieve great success with sophisticated laboratory research, vaccines, isolation, case tracing, and treatment. But they can still come up short, especially in a context of significant health inequities, if the political climate does not emphasize and encourage public trust in government and scientific efforts. Our current situation demonstrates that, as in the past, wide public cooperation based on public trust is an essential element of a successful response to an epidemic. Public trust and cooperation are as important today as in 1918.

ACKNOWLEDGMENTS

I thank Lewis A. Leavitt, MD, for consultation.

CONFLICTS OF INTEREST

The author has no conflicts of interest to report.

Footnotes

See also Morens et al., p. 1086.

REFERENCES

  • 1.Leavitt JW. The Healthiest City: Milwaukee and the Politics of Health Reform. New ed. Madison, WI: University of Wisconsin Press; 1996. [Google Scholar]
  • 2.Navarro JA, Markel H, editors. 2016. The American influenza epidemic of 1918–1919: a digital encyclopedia. Available at: http://www.influenzaarchive.org. Accessed February 10, 2021. [Google Scholar]
  • 3.Crosby AW. America’s Forgotten Pandemic: The Influenza of 1918. Cambridge, UK: Cambridge University Press; 2003. [DOI] [Google Scholar]
  • 4.Barry JM. The Great Influenza: The Story of the Deadliest Pandemic in History. New York, NY: Viking; 2004. [Google Scholar]
  • 5.Bristow N. American Pandemic: The Lost Worlds of the 1918 Epidemic. New York, NY: Oxford University Press; 2012. [Google Scholar]
  • 6.Leavitt JW. Public cooperation or resistance: a tale of smallpox in two cities. Biosecur Bioterror. 2003;1(3):185–192. doi: 10.1089/153871303769201833. [DOI] [PubMed] [Google Scholar]
  • 7.Rosner D, editor. Hives of Sickness: Public Health and Sickness in New York City. Rutgers, NJ: Rutgers University Press; 1992. [Google Scholar]
  • 8.Gurda J. The Making of Milwaukee. Vol 4. Milwaukee, WI: Milwaukee County Historical Society; 2018. [Google Scholar]
  • 9.Booth DE. Municipal socialism and city government reform: the Milwaukee experience, 1910–1940. J Urban Hist. 1985;12(1):51–74. doi: 10.1177/009614428501200103. [DOI] [Google Scholar]
  • 10.Gauchat G. Politicization of science in the public sphere: a study of public trust in the United States, 1974 to 2010. Am Sociol Rev. 2012;77(2):167–187. doi: 10.1177/0003122412438225. [DOI] [Google Scholar]
  • 11.Himmelstein DU, Woolhandler S. Public health’s falling share of US health spending. Am J Public Health. 2016;106(1):56–57. doi: 10.2105/AJPH.2015.302908. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Golestaneh L, Neugarten J, Fisher M et al. The association of race and COVID-19 mortality. EClinicalMedicine. 2020;25:100455. doi: 10.1016/j.eclinm.2020.100455. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Bassett MT. #BlackLivesMatter—a challenge to the medical and public health communities. N Engl J Med. 2015;372(12):1085–1087. doi: 10.1056/NEJMp1500529. [DOI] [PubMed] [Google Scholar]
  • 14.Gamble VN. “There wasn’t a lot of comforts in those days”: African Americans, public health, and the 1918 influenza epidemic. Public Health Rep. 2010;125(suppl 3):114–125. [PMC free article] [PubMed] [Google Scholar]

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