1918 Flu Pandemic, Revisited - Part 1

Published Mar 8, 2021, 2:10 PM

Now that we’ve lived through a year of a global pandemic, our approach to looking at the 1918 flu pandemic had shifted. We’re revisiting the events of 1918 with new perspective, comparing then to now. 

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Welcome to Stuff You Missed in History Class, a production of I Heart Radio. Hello, and welcome to the podcast. I'm Tracy V. Wilson and I'm Holly Fry. We're coming up on the one year anniversary of the World Health Organization's announcement that COVID nineteen could be characterized as a pandemic. That happened on March eleven, and then a couple of weeks after that, Holly and I talked on the show about what it was like to be living through such a massive and worldwide, clearly historic event while also hosting a history podcast, and we re aired our previous episode on the flu pandemic as a Saturday classic because it seemed relevant what was happening. I don't think either of us really foresaw that we might be in a place to do kind of a one year later episode, not even a little like. I have a friend who was a nurse at Boston area hospitals. I mean, Boston was one of the early hard hit places, and she talked about getting a briefing at work saying that we were probably looking at eighteen months to two years of pandemic. But like, there's a big difference between intellectually having that possibility in your mind and actually living through it. So I researched and wrote our episode on the eighteen flu pandemic that we aired as a Saturday Classic after the COVID nineteen pandemic started. I wrote that back in and over the last year, I have wandered over and over is this what it was like in night? And how would I have approached that episode differently if I were working on it today instead of seven years ago. Uh. We don't typically revisit older episodes in this way, but the last year has just profoundly reshaped the way I have thought about that earlier pandemic. To me, it's a really good example of how your own perceptions and your own knowledge and experiences influence your understanding of history. Uh. So we're going to take another look at the flu pandemic. Um. I do want to note here that theeen flu pandemic was global, and so is the COVID nineteen pandemic. But a big part of today's episode is how my own lived experience has shifted my my understanding of that earlier event and drawn my attention to totally different parts of the eighteen pandemic. Then, we're on my mind back in so by definition this gives things a more US centric focus. I cannot tell you how how a person's lived experience in another place would have changed their understanding. UM. I also didn't start out thinking this was going to be a two part episode, but it is turned out there was a lot to talk about that we did not touch on back much or at all. Okay, so we're going to do a quick review here as we lead in. The nineteen eighteen flu pandemic stretched from early nineteen eighteen into the spring of nineteen twenty, although the largest peak was between October of nineteen eighteen and January of nineteen nineteen, with a smaller but still significant peak between February and April of nineteen nineteen. It's estimated that one third of the world's population contracted the flu during this pandemic. About six hundred seventy five thousand people died in the United States, worldwide estimates very considerably. At the time, the global death toll was estimated at twenty million people, but today's estimates are more like thirty million to fifty million people, and sometimes even more so. Illnesses like the f are often particularly lethal for the very old and the very young, and that was true of the nineteen eighteen flu. But then in addition to that, it also disproportionately killed young, otherwise healthy adults, people who were in their twenties and thirties. And since this pandemic took place in the last months of World War One, its effects on troops were extreme. The virus just moved through entire ships and entire military units in waves. For example, in June and July of nineteen eighteen, more than two hundred thousand of the two million British troops in France all got too sick to report to duty. In our earlier episode on this pandemic, we talked about how in nineteen eighteen the world had the germ theory of disease, but not antibiotics. We knew which specific micro organisms caused some diseases, including tuberculosis, malaria, and cholera, but not influenza. We had vaccines for some diseases as well, including smallpox, rabies, cholera, and typhoid, but again not influenza. It wasn't just that researchers didn't know which specific pathogen caused influenza. They were also headed down the wrong track on that. The prevailing theory before the pandemic was a bacterium known as Phifer's bacillus that was named after its discover Richard Friedrich Phifer. During the nineteen eighteen pandemic, it became clear that this bacillus was not the cause of the flu. A huge number of people became ill, but they had no sign of this bacillus and their cultures. Today, this basilus is actually called Hemophilius influenzae, and while it does not cause influenza, it's not the fluvirus. It does cause things like pneumonia, cellulitis, and meningitis. We also talked about nineteen eighteens public health recommendations like stay home if you're sick, avoid crowds, cover coughs and sneezes, wash those hands thoroughly and often. In other words, a lot of the exact same things that we've all been hearing for the last year, most of which are also what everyone should still be doing even when there is not a pandemic. Yeah, I have a lot of feelings about handwashing because I used to work in in like food safety education. Uh and when things started um trending towards pandemic in February and March of last year. I definitely noticed when I would be in a public restroom, suddenly people were at the sink for as long as I was, and I was like, wow, this is let's keep the cleep up this habit for the rest of our lives. Uh. There were, though some notable differences in the public health recommendations in en though at least in terms of US culture, the idea that spitting on the ground is rude and unsanitary was really fairly new in nineteen eighteen. The first anti bidding campaigns had gotten underway just a couple of decades before that to try to prevent the spread of tuberculosis. Common drinking cups and shared towels were also frequently found in public places, so back in eighteen, in addition to those recommendations that feel pretty familiar today, there were also slogans like spit spreads death and advisories to avoid those common cups and towels. Public health officials also advised people to wear masks, in which brings us to the biggest, most obvious thing we'd approach way differently now versus back in our treatment of masks in the earlier episode is essentially just a sentence. We said that public health authorities recommended that people wear them, and that in some places they were even required by law, but that this was not effective. We described that lack of efficacy coming from virus particles being too small to be blocked by simple fabric, which is true and which actually came from a US Department of Health and Human Services website that was written about the nineteen eighteen pandemic. But as has been discussed at length in the last year, well fitting masks made of tightly woven cloth can stop respiratory droplets that are carrying those virus particles. That is not necessarily true of the masks that were being worn in nineteen eighteen, though those were typically made of gauze, which is a very thin fabric with an open weave. Some of them were made from cheese cloth, which also has a similar open weave. Even with multiple layers, these fabrics might leave you with a relatively porous mask. If you look at photos from the nine eight pandemics, sometimes you'll see people's facial features through their masks pretty clearly. Sometimes you can see the gauzy holes in the material. Sometimes people also cut holes in their masks to smoke, or if they didn't have gauze or cheese claw, they made masks out of materials that were way too thin to do any good at all. They almost looked like wearing a translucent veil instead of a mask. Like I saw one photo of Red Cross nurses and it was literally only attached over the bridge of their nose and had this filmy, diaphanous quality, and I was just like, that's not helping. No, what's interesting too, because I mean, even then, cheesecloth was being used in kitchens to strain things, so you knew stuff could go right through it, so it's an interesting choice. UM. A publication called an Experimental Study of the Efficacy of Gauze Masks, which was published in the American Journal of Public Health in nineteen twenty, looked at whether the masks themselves were effective, and the authors concluded that a gauze mask that had enough layers to actually block respiratory droplets was also very hard to breathe through, and a person's exhaled breath just escaped around the sides of the mask instead. So if you're hearing a stock about this and you're thinking Wait a minute. Didn't you talk about gauze masks being effective in that episode on Wullie and Dah and the pneumonic plague. That answer is yes, but those masks had a layer of cotton wool in the middle of all that gauze. Pneumonic plague is also caused by bacteria. Bacteria are much larger than viruses, and those masks efficacy was really clearest among healthcare professionals who would have been wearing the masks in addition to other precautions, and probably also with better mask discipline and more thorough hygiene steps than the general public would have had. Back to that paper, the author cited five reasons why mask mandates did not seem to slow the spread of the disease in the pandemic quote. First, the large number of improperly made masks that were used, set and faulty wearing of masks, which included the use of masks that were too small, the covering of only the nose or only the mouth, smoking while wearing, etcetera. Third, wearing masks at improper times when applied compulsorily, masks were universally worn in public on the streets in automobiles, etcetera, where they were not needed, but where arrest would follow if not worn, and they were very generally laid aside when the wearer was no longer subject to observation by the police, such as in private offices and small gatherings of all kinds. This type of gathering with the attendant social intercourse between friends and office associates seems to afford particular facility for the transfer of the virus. Another study in ninety one concluded that quote the face mask as used was a failure. The important bit there is the as used, and that included things like the stuff we just talked about and people re wearing the same masks until they were just filthy. The general advice on mask cleanliness back in was to boil them regularly, in some cases daily. This study also notes that the masks did nothing to protect the eyes, and that the tear ducks had been pinpointed as a possible way that the virus could get into a person's respiratory tract. We also did not talk about resistance to mask mandates in that earlier episode. We sure will after we first pause for a little sponsor break. The most famous group of mask resisters during the nineteen eighteen pandemic was the San Francisco Anti Mask League. San Francisco had actually been the first city in the United States to implement a mask mandate. It was a four week mandatory mask law that started on October nineteen eighteen, and it ended on November twenty one of that year. Of full page ad ran in the San Francisco Chronicle that read, quote wear a mask and savior life. This ad was signed by the mayor, as well as civic and business leaders and health officials. The Red Cross distributed about a hundred thousand masks to residents of San Francisco over the course of about a week. People who were seen in public without a mask were fined five or ten dollars or imprisoned for up to ten days. There were a lot of arrests, although many were because the person hadn't known about the mask law or just didn't have a mask, but that was not the case for everyone. On October, health officer Henry D. Miller escorted James Whisser to a pharmacy to purchase a mask. The details here are a little bit fuzzy, but Whisser refused to either buy or where one UH. It's not clear which thing happened first, but these two things happened. Whizzer struck Miller with a sack of silver dollars, and Miller fired his gun in the air. Miller kept firing as Whisser beat him up in the street. Miller's shots hit Whisser and two bystanders, and Whisser and Miller both faced charges after this altercation. Some of the mentions of this that have floated around in UH in the last year have sort of made it sound like Miller just unprompted shot somebody for refusing to wear a mask. They kind of leave out the fact that that person hit him with a sack of silver dollars and was beating him up in the street, which sounds painful. Yes, yes, not that any of that is okay, but it definitely is not as simple as like this guy shot somebody for refusing to wear a mask. So, as we've said before, this was at the very end of World War One, and a lot of the messaging around this first mass mandate in San Francisco was framed around wartime patriotism and the idea that stopping the disease would help protect the troops. So when the armistice was signed on November eleventh, of night, that stopped most of the active fighting and mask compliance in San Francisco started to drop. Then, when the mask order expired at noon on the twenty one, there were bells and whistles that were sounded all around the city. People gleefully ripped off their masks. They were very happy to be done with this mass situation. Some people set their masks on fire. The mask law in San Francisco was just one part of the city strategy to control the flu. Other steps included closing dance halls and ordering street cars to keep their windows open unless it was raining, and eventually banning public gatherings and closing the schools. Churches were advised to move their services outdoors. Judges held court sessions outside as well, and all this together seems to have reduced the rate of infection in San Francisco during the pandemic's worst spike in the fall of eighteen eighteen. But when flu cases started spiking again in San Francisco at the end of nineteen eighteen and early nineteen nineteen, the city's tried to reinstate this mask mandate, and that is when the Anti Mask League formed in response. They were also called masks slackers thanks to a Red Cross poster about masking which read quote the man, or woman or child who will not wear a mask now is a dangerous slacker. The Anti Mask League really politicized the idea of mask wearing, and they held a rally that was attended by two thousand people at the Dreamland Rink. The city eventually repealed the second attempt at a mask mandate under pressure from the Anti Mask League, and then overall, San Francisco's response to this later wave of the flu was not as effective as the earlier one had been, so this example is just from San Francisco, but a similar pattern played out in other cities as well. Most of the U S cities that mandated mask wearing during the nineteen eighteen pandemic were in the western part of the country. Compliance with the mandates was often spotty at best, but resistance tended to be more along the lines of that's ridiculous or how silly, rather than forming an organized group to push back against it. And a lot of the complaints about the masks will probably sound pretty familiar. People found them uncomfortable to wear and hard to breathe through, and as we noted earlier, if you actually had enough gauze layers to be effective, that probably was really hard to breathe through. Public health officials also worried that the appearance of masked people out and about would lead to panic, or that wearing a mask might lead people to be less vigilant in other ways. That's an argument we have heard in the last year. It was clear then as it is now that masking really needed to be combined with other steps like so distancing and staying away from crowds. But there are lots of pictures from nineteen eighteen of huge groups of masked people standing shoulder to shoulder. Another recurring question that Tracy has had over the last year was the US response to the nineteen eighteen pandemic. Such a chaotic and ineffective patchwork, with different cities and states taking totally different steps to try to control the spread, and with a bunch of contradictory and confusing messaging about all of it. Basically a big old mess, because I think, um to most of us, that's what this has seemed to be. Sure feels like a big old mess to me. Yeah, The short answer to all of Tracy's questions and probably yours. I think most of us have had a similar was the last before The answer is yes, yeah. So the US response to the nineteen eighteen pandemic was almost completely decentralized. The Centers for Disease Control had not been established yet. That happened in nineteen forty six, and the World Health Organization was established two years after that, so it did not exist either. US Surgeon General Rupert Blue, who was also head of the Public Health Service, also did very little to try to curb the pandemic. He directed the National Academy of Sciences to try to identify the pathogen that was at work, but then he also denied funding requests for research into that very thing. Blues efforts to organize a federal response were essentially non existent until September, when the illness had been circulating for months and cases and deaths were increasing rapidly. Cities and states repeatedly asked the federal government for direction and help, and they got very little. Although the Public Health Service did eventually print about six million posters, articles, and signs, it was well into the pandemic before this happened, and as we're going to talk about it just a little bit. A lot of the information that they contained really wasn't exactly use. All. Presidential press briefings were not nearly as common in nineteen eighteen as they are today. But President Woodrow Wilson never gave any kind of public statement about the pandemic or took any steps to try to direct a federal response to mitigate it. His focus was really on the war, and this was true even as White House staffers started to get sick. Donald Frey, who was an aid with the US delegation to the Paris Peace Conference, died of the pandemic flu, and Wilson himself contracted the flu and was seriously ill during the Paris peace Conference. The social safety net that has been providing at least some relief in the US during the COVID nineteen pandemic also did not exist yet at this time. The Supplemental Nutrition Assistance Program, or SNAP, is a monthly benefit to help low income US citizens by nutritious foods, and this grew out of the government's first food stamp program, but that was not established until nineteen thirty nine. There were union workers who had some kind of unemployment compensation as part of their union contracts in nineteen eighteen, but in general, unemployment insurance did not exist yet. The first of many state unemployment bills was introduced in Massachusetts in nineteen sixteen, but all of these bills failed until Wisconsin finally passed one in nineteen thirty two. Unemployment insurance didn't really become widespread in the US until after that point. During and after the Great Depression, Medicare and Medicaid also did not come into existence until nineteen sixty five. Congress did approve a one million dollar budget for the Public Health Service in nineteen eighteen to try to address a serious shortage of doctors and nurses. Many had been called up or had volunteered for military service before the pandemic started, and the military still didn't have nearly enough medical personnel, and regardless of whether they were doing military or civilian work, medical professionals were hard hit by the pandemic, terribly understaffed, working in close proximity to people with a contagious respiratory illness, and wearing often ineffective protective equipment. Every week, the Journal of the American Medical Association printed pages and pages of obituaries so this million dollar Public Health Service budget was meant to help fill this gap by recruiting a thousand doctors and seven hundred nurses. The Public Health Service worked on this in conjunction with the Red Cross. The Red Cross already had a coordinated national plan for recruiting nurses before the government even got involved with this. Really, in the US, the vast majority of aid during the pandemic was coming from charities and religious organizations and private citizens, not from the government. Passing this legislation was a challenge. So many representatives were ill or otherwise absent that the House didn't have a quorum. With fewer than fifty representatives actually there, the two parties worked out a unanimous consent agreement to push this legislation through. The final bill was approved by both the Houses and Senate on October. Surgeon General Blue had not asked for funding before this, but after the bill passed, he protested that one million dollars would not be enough. Even so, the Public Health Service ultimately returned one and fifteen thousand to the Treasury because it simply did not recruit enough people to use all of the allocated money. So we mentioned a moment ago that Some of the communication around the pandemic was also not particularly effective in the US, and we will get to that after a sponsor break. Because of the war, US officials were generally more focused on maintaining morale and avoiding panic in nineteen eighteen than they were on fighting the pandemic. In the US, as well as in many parts of Europe and Asia, the news was also subject to wartime censorship, and this is why this pandemic was nicknamed the Spanish Flu. Spain was neutral in the war and it wasn't really censoring its news about the flu, so to some people it seemed like this disease had come from Spain, when really Spain was just the place that was being most transparent about what was happening in the United States. This also tapped into isolationism and xenophobia, branding a deadly illness as having come from somewhere else and stigmatizing people who got sick as somehow connected to this supposedly foreign invader. And obviously, this type of mothering nickname is not unique to the nineteen eighteen pandemic. The nineteen sixty eight flu pandemic was known as Hong Kong Flu. The worldwide HIV epidemics started out as gay related immune deficiency, and the racist nickname China virus has stuck around long after the current pandemic. Disease was officially named COVID nineteen. Since there was no centralized agency formalizing public health advice in nineteen eighteen, people were also hearing a lot of contradictory information about what to do and how to protect themselves, and in most parts of the US, they were also hearing that things weren't that bad, that everything was under control, and that nobody needed to be alarmed. It was just the flu more direct and assertive public health messaging that we talked about in San Francisco back before the break that was far less common than messaging that really minimized the threat. For example, Surgeon General blues first public communication about the pandemic was published on September twenty second of nine eight It ran under the title Surgeon General's Advice to avoid Influenza, and it was full of very basic health advice like avoiding crowds, covering coughs and sneezes, choosing and chewing your food well, avoiding tight clothes, and quote don't let the waste products of digestion accumulate. Okay, basically, don't leave crap lying around basic sanitation and extremely basic sanitation and health steps. Then, on October sevent as cases and deaths were really climbing dramatically, Blue issued more of a question and answer statement that was more specifically about the pandemic. He described this flu as quote, a very contagious type of cold accompanied by fever, pains in the head, eyes, ears, back or other parts of the body, and a feeling of severe sickness. And most of the cases these symptoms appear after three or four days. The patient then rapidly recovering. Some of the patients, however, developed pneumonia or inflammation of the ear or meningitis, and many of these complicated cases die. He also put a lot of focus on how many other epidemics there had been before and how quote, the proportion of deaths in the present epidemic has generally been low. In this piece, Blue recommended that if a person was having to care for both sick and healthy family members, they should wear a mask and an apron or gown while with the sick person and remove all of that before coming into contact with the rest of the family, and he recommended that everyone eat a good diet, get plenty of rest, keep windows open, reduce overcrowding in their homes, and avoid crowds while out in public. The overall tone of this whole thing was far more reassuring and again pretty basic, than it was urgent. As another example, Philadelphia Public Health Director William Kruzen repeatedly suggested to residents of Philadelphia that everything was under control and that the number of infections had peaked. In September of nineteen eighteen, he decided not to cancel a liberty loan parade that was to promote war bonds. That parade had been scheduled for the twenty eight and he carried on with it, even though an outbreak had started at the Philadelphia Navy Yard just nine days before that. Within seventy two hours after the parade, every hospital bed in Philadelphia was full and sick patients were being turned away. Meanwhile, Cruisin kept up the refrain that everything was under control and the worst was over. As the daily deaths in Philadelphia climbed to two hundred and then three hundred, and then peaked at more than seven hundred. Teams were dispatched to collect bodies from homes and literally could not keep up with the deaths. Cruising banned public meetings, and close churches, schools, and theaters only after Philadelphia was experiencing hundreds of deaths today. And it wasn't just government officials who were down playing the pandemic. A lot of newspapers carried daily or weekly updates of how many new cases and deaths had occurred, along with news about how there were shortages of doctors and nurses, and shortages of coffins and other obviously serious problems. But at the same time, they also repeated this refrain that this pandemic was just the flu, or, to use a term of the day, it was just the grip, that people didn't need to be alarmed. That Surgeon General's advice to avoid influenza that included like the world's most rudimentary Basic Sanitation information UH that ran next to newspaper reports about outbreaks and deaths. Lists of precautions often framed things as preventing the spread of colds, tuberculosis, pneumonia, and the flu, sort of lumping the pandemic in with these other illnesses as though it was nothing unusual. Even Philadelphia's news coverage framed Cruisin's ban on public gatherings as not being for public health reasons or any cause for alarm that one is particularly weird like then then why by then if it wasn't for public health reasons. So this effort to avoid panic by downplaying the severity of the pandemic was not effective. People's friends and family members were dying. Morgues were past capacity, there were not enough coffins. People were being buried in mass graves. And in the face of all this, people naturally were not calm, and they also stopped trusting what they were hearing from official sources because those sources were clearly not being honest with them. Historian John M. Berry, author of The Great Influenza, The Epic story of the deadliest plague in history, has written on this phenomenon a lot, and was a subject matter expert in two thousand five and two thousand six when the CDC was putting together an influenza pandemic plan. In article in The Washington Post, he's described as telling a reporter that he felt like his job was to bang on the tell the truth, Tell the Truth drum because lying to the public for the sake of keeping calm and maintaining order in nineteen eighteen not only did not work, but it actually had the opposite effect. Minimizing the pandemic also meant that there was a big range and how serious people thought it was, especially if they were lucky enough that they didn't personally know anyone who had died. And you can see some of this in some of the popular media of the day. One example is the popular syndicated newspaper comic The Outbursts of Everett True. This is a two panel comic, with the first panel being the setup and the second panel being the punch line, often literally, because usually Everett would hit somebody. In one strip from the nine Pandemic, amasked, Everett says, quote, I think it's everybody's duty to help combat the spread of the contagion. And then another man says, quote, well, I don't think these muzzles do any good. If a person is going to get it, he's going to get it, and I'm going to take my chances. And in the second frame, Everett, having punched the other man's face in, says well, then take a tip from me, where one and improve the looks of that face, you owe that much to the community. In another strip, someone sneezes on Everett in the first panel, and in the second Everett has him trapped under a giant box and has sent someone to fetch the fumigating squad from the Board of Health. Somebody shared these comics and a group chat that I'm in and our response was all like, are you sure these are not from today? He's in the newspaper this morning. So apart from what people were hearing from the media and government sources and all of that, the actual measures being taken also really varied from place to place. We mentioned in that earlier episode we did on the pandemic that some cities shut down their public transportation systems and movie theaters, or they closed schools and churches, but we didn't mention that these closures often went on for weeks, or that because of the it's just the flu messaging. There were a lot of people who thought that this was an unnecessary and ridiculous overreaction. However, there were also business owners who supported these shutdowns. For example, in San Francisco, movie theater owners had already seen a huge drop in attendance before the city closed the theaters, and they were really hoping that this temporary total closure would get things under control faster. One paper that looked at this was non Pharmaceutical Interventions implemented by US cities during the nineteen eighteen and nineteen nineteen influenza pandemic. The paper was published in two thousand seven, and it looked at the steps taken by forty three cities between September eighteenth, nine eighteen and February twenty second, nineteen nineteen, that period that covered the pandemic's largest peak in the United States. All of these cities had populations of more than one hundred thousand people and were among the sixty six most populous cities in the United States at the time. The cities among those sixty six that weren't included in this study just didn't have accurate enough data to use. They looked specifically and information about school closures, the canceling of public gatherings, and the isolation and quarantine of sick people in their close contacts, and all the cities that they looked at did at least one of these. Most of them did more than one. The most common combination was closing schools and also canceling public gatherings within that September to February window. The median length for these closures was four weeks, but in some cases they went on much longer. So of the cities had at least some kind of non pharmaceutical intervention in place for twenty weeks or more. And this paper also concluded that these steps were generally effective at slowing the spread of disease, especially when cities took a layered strategy of taking multiple steps at once. The effect was greatest when restrictions went into effect earlier, before infections and deaths really started to climb, rather than afterward in response to those increases. For example, St. Louis, Missouri, put multiple steps in place early in the pandemic and fared much better than most of the other cities. Overall, cities that took multiple steps took longer to reach peak mortality, and they had lower peak mortality and lower total mortality rates than cities that did not. Various cities took other steps as well, beyond the cancelations, closures, and quarantines that were part of that study. We talked about San Francisco's multipart response earlier. For example, some other examples. In Portland, Oregon, the public library was closed, but then it reopened for book circulation only, with the chairs taken out of the circulation room and patrons being required to wait five feet apart from each other. Many cities shut down their bars and their pubs. At this point. The eighteenth Amendment to the Constitution, which prohibited the manufacturer, sale, and transportation of intoxicating liquors, had been passed, but it had not been ratified by the states. That didn't happen until January of n So in general, the nine eighteen bar and pub closures made prohibitionists really happy, but in some places, steps that were taken really didn't make any sense. In St. Paul, Minnesota, for example, buildings under six floors were prohibited from using their elevators because of the lack of fresh air. There was a lot of resistance to this, and some of it was definitely justified. Like shutting down the elevators made the buildings inaccessible for disabled people and discouraged people from going outside into the fresh air, which was believed to be necessary for health. Ultimately, the elevators were put back into operation and they had a limit of one person per five square feet of space to quote a two thousand seven article in Public Health Reports that discussed the nineteen eighteen response in Minneapolis and St. Paul. Quote, because clear orders were not being given to public health officials, the public in turn was not receiving transparent and consistent advice and information. Should the public wear masks? Why was it allowable to be next to someone in a street car and not in an elevator? Why were church services closed while Red Cross workers gathered in crowded conditions in those very same churches? Was influenza a life threatening condition? Or was the panic the most dangerous element of the influenza pandemic? And Minneapolis and St. Paul, there was no single message on any of these issues. In many cases, the public had to decide for itself, in which case the effect of the messages that were communicated only serves to contradict each other. I read that and was like, is this about today? So we have talked mainly about cities here, but in nineteen eighteen, almost half of the U. S population was living in more rural areas, and the pandemic was devastating in those areas as well. Smaller communities were taking many of the same non pharmaceutical steps that big cities were, but in rural areas, people in general had even less access to medical care and fewer resources. It was particularly bad in places that were outside of cities but also densely populated, like in coal mines. So we have spent this episode mostly talking about masks and the generally scattered, chaotic response to the nineteen eighteen pandemic in the United States. Now next time we were going to dive into some more focused topics, which is honestly what I thought this episode was going to be like when I started on it, Like, for example, was anything happening with vaccines in nineteen eighteen, were there the kinds of food and supply shortages that we have seen through some of this pandemic, and were there any places that managed to actually get things under control? Uh? While we ruminate on all of this, Tracy D of listener Mail, how do I have listener mail that has a connection in that it discusses some of the medical stuff that we have talked about lately, but it's not about the pandemic. This is from Megan. Uh. Megan says, Hi, Holly and Tracy, I hope that this email finds you well. First of all, I want to thank you for all the great work you do. You definitely make my car drives, housework, and projects that I've been doing during the pandemic more interesting. I'm writing to you as I've just finished your most recent podcasts on the Mississippi Freedom Summer and w Montague Cobb. When listening to your episode on Freedom Summer, you mentioned the Mississippi Burning case. I immediately thought to myself, why do I feel like I know much more about this case than I would have learned in school. When you mentioned the other bodies found, it clicked for me. Another podcast that I've discovered during the pandemic is called Someone Knows Something That takes a hard look at unsolved crimes. The third season of that show was on the murder of two of the bodies that were discovered when trying to find Cheney, Goodman and Schwerner. What struck me most about this podcast was that it made me realize that for some people, this is not history. One of the victims, brother, who the show followed, was still very frightened to look into this case and even returned to that part of Mississippi as he felt it was still unsafe for racial minorities. It was definitely a check your privilege moment for myself. I would recommend it to any of your listeners who enjoy true crime. The second reason I am writing to you is that I am a nursing student, so I highly enjoy any of your podcasts about medical history. This latest podcast about Dr Cobb was not any differ rent. As you mentioned in your podcast, he focused a lot on the disparities and healthcare for non whites. I've come across a book and my attempt to better serve my patients that I think any of your listeners and health care might be interested in, called Mind the Gap, a handbook of clinical signs in black and brown skin. It was written by a black medical student in London that realized that he was only learning the white symptoms in school and wanted to better educate his spellow students as well as better serve his community. I hope that your listeners will look into this and we can continue to correct the disparities and our healthcare system. Again, thank you for all that you do bringing the more obscure and less talked about parts of history to light. Megan uh Megan also sent dog pictures. Thank you so much for the dog pictures and for this email. I spent a moment looking at this UM at the Mind the Gap handbook. UM. There's a whole website for it online and some of it has uh like photographs of things like skin conditions that look very different depending on the coloring of a person's skin. UM. One of the ways that I know this has come up with the COVID nineteen pandemic is the oxygen monitors that go on your fingers, reading people's oxygen saturation very differently if they are black or brown. UM. So it's a there's a whole, huge and immediate relevance to this, So thank you again for this email. If you would like to write to us about this or anither podcast, we're at history Podcasts that I heart radio dot com. And we're also all over social media at miss in History. So you'll find our Facebook, Twitter, Pinterest, and Instagram, and you can subscribe to our show on the I heart radio app and Apple podcasts and anywhere else to get your podcasts. Stuff you missed in History Class is a production of I heart Radio. For more podcasts from I heart Radio, visit the iHeart Radio app, Apple podcasts, or wherever you listen to your favorite shows.

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