The Forgotten American Pandemic: Historian Dr. Nancy K. Bristow on the Influenza Epidemic of 1918

Did your family story about the deaths of your great-grandparents during the influenza epidemic spark your interest in the pandemic?

It did. I had thought about doing my PhD dissertation on the pandemic. It was one of many ideas that floated past me because I was interested in the World War I period. I needed a new project because I was finishing my first book. I was backpacking with my father and during one of those trail conversations it became clear to me that his parents -- my great grandparents -- had died during the pandemic. I knew my grandfather was an orphan and that his parents had died in a short span of time, but I didn’t know why and I’d never asked. And that was all I needed to know. Once I made the connection it was clear this had to be my next project.

From the very beginning, I sought to make sense of what happened to these people -- relatives I had never known. They had been immigrants from Ireland, people without a lot of resources who didn’t leave a record when they died. They just disappeared for us. So this was an effort to build the world in which they lived and died, and in which my grandfather was left an orphan. I literally kept them in my mind through the project. For much of that time I kept a photograph of them on my desk or on the wall.

Didn’t your great-grandparents die within a few days of each other?

We don’t know for sure. The family lore suggests that Elizabeth Bristow died and, immediately following her funeral, indeed on the way home, John Bristow began feeling ill and then passed away in a couple of days. Within a week, according to this narrative, my grandfather lost his mother and his father.

That was a moving opening to your history of the pandemic.

My grandfather was a lovely man and the idea that this had happened to him, especially once I knew that it was the influenza pandemic, felt like a story I needed to understand more fully.

Where did the United States fit into the story of the worldwide pandemic?

It’s an enormous international event. Demographers are still trying to estimate [the casualties] because so many countries then did not have public health recordkeeping. Fifty million [deaths worldwide] is a good guess. For a long time, historians believed something like 20 million people had died, but they were leaving out huge areas of the world, including for instance Africa and India. Now, with updated calculations, the estimates range from 40 to 100 million people dying worldwide.

The United States was very much in the center of the pandemic. The first wave in the spring of 1918 goes largely unnoticed, mistaken for the usual flu coming through. It’s only in retrospect that we see the connection to the major pandemic. It erupts in a second wave in late August in the United States, France and Sierra Leone almost simultaneously. From there it rages around the world.

The United States is usually identified as the site of the index case. Historians and epidemiologists continue to disagree about this, but one theory is that the first wave originated in Kansas in the spring. It then traveled to Europe, where it continued to evolve, and then exploded in its deadly second wave in the fall.

There were two more waves, one in the spring of 1919 and a final one in 1920. It’s probably 1920 when my great-grandparents died. One of the shocks of my research was discovering that they were alive in 1920 and appeared in the census. The particularities of their story are completely confounding to me. A leading scholar of the history of medicine, Howard Markell, suggested to me that they likely died in the fourth wave, and for me, that’s been the resolution to the mystery of their appearance in the 1920 census.

The United States suffered in ways similar to the rest of the world. We had the advantages and disadvantages of being an industrialized nation. Influenza traveled fast for us because the virus could travel at the speed of railroads. But we had some of the advantages of modernized public health and health care as well.

Could it be called the Kansas flu rather than the Spanish flu?

It could, although people aren’t certain yet about Kansas. It’s the theory I like the best, but it’s not unchallenged, even today.

It’s called the Spanish flu because the Spanish didn’t have wartime censorship. It quickly became the Spanish flu because people knew what was happening there and had a sense of the seriousness of the pandemic in Spain. Once that label was used, it stuck, but only because Spain told its story in a more unbridled way than those countries with censorship.

What were the symptoms of the flu?

There was some variation, but the basics are pretty straightforward. Some people had a sore throat and felt crummy as we all do [with] the flu. But for most people, it came without warning, and people were sickened in just a few hours. Some people would go from being perfectly healthy to dead in less than a day. A high fever from 101 to 105 degrees was common. There were terrible headaches and weakness and a feeling of being very sick.

Many times, there was serious pain in the joints or in the back and muscles. One report said, “The patient felt as though he’d been beaten all over by a club.” And there was the prostration and chilliness we associate with influenza. Frequently people would become very drowsy and they’d move in and out of consciousness. Those who got really sick would pass into delirium and unconsciousness.

The most unusual symptom of this influenza, though, was intense congestion when the lungs would hemorrhage and fill. That would lead to breathing difficulty, nosebleeds and coughing of blood and sputum. Sometimes the extremities would turn blue because the sick were literally drowning from fluid in the lungs. On autopsy they’d [describe} the “lungs of the drowned.”

Others would die not of the flu, but of pneumonia. The sequelae of this flu were very bad. Huge numbers of people died of bacterial pneumonia in this period before antibiotics.

Seeing friends and relatives go through the flu had to be a horrifying experience, and you include some vivid descriptions.

A few things made this disease and this pandemic especially hard. One was the pace with which people sickened and died. Another was the horrifying appearance of it. And then it was the wrong people who were sick and dying.

A strange feature of this disease was that the young and healthy died in the largest numbers. The very young and very old also died, but there was [a higher toll] among young adults, which is very uncommon for influenza. Historians and scientists are still trying to figure this out, but one theory is that for those who were young and healthy, their strong immune response [caused] what happened in the lungs as the body tried to fight the influenza but instead fought itself.

Didn’t more American soldiers die of the flu than died in combat in World War I?

Yes, and that story wasn’t really told. One of the consequences of the way Americans remembered the pandemic was that there was a real tendency not to talk about all of the deaths. That was true of the military as well, and it allowed the military to talk about low war death figures. The pandemic again was a terrible catastrophe for the military, both for soldiers abroad and for soldiers in the training camps here in the States.

Carol Byerly wrote a tremendous book Fever of War: The Influenza Epidemic in the U. S. Army during World War I. According to War Department figures she cites, 50,280 soldiers died of combat wounds and 57,460 soldiers died of influenza.

It seems that the flu was a mystery that confounded medical professionals who, before this epidemic, were confident about addressing any infectious illness with new treatments.

That’s right. There were real triumphs in the development of medicine in the late nineteenth century. They had figured out germs, which wasn’t an entirely new theory, but they now had the science to prove it, thanks to a real revolution in bacteriology. They were able to cure some diseases and, more important, they were successful in preventing serious infectious diseases. They expected they had cracked the nut of infectious disease.

The epidemic came as a terrible shock, then, because the medical profession hoped it was past the point when something this horrific could occur. That was very difficult for medical practitioners during the pandemic. They worked very hard, but had an awareness that there was little they could do, and that nursing was the most important ingredient in patient care during the pandemic.

And did they understand the cause of the flu then?

No. They understood germ theory and they were fairly certain they were dealing with an infectious disease. Scientists also had a theory about infective agents smaller than bacteria, but they didn’t have the technology to see viruses yet. There was a lot of experimentation during the pandemic seeking to identify the causal feature and understand the etiology, but it was unsuccessful. It wasn’t until the 1930s that the flu virus was first seen.

It was surprising to me that President Woodrow Wilson was virtually absent from this story and he wasn’t using the “bully pulpit” to address the pandemic.

You’re right. It’s a very interesting public health moment because they need to avoid a nationwide panic. They need people to care for patients and marshal the forces to deal with this emergency. On the other hand, they need to educate the public about the situation.

Public health forces were walking a very fine line between education and avoiding panic and, in a number of cases, they err on the side of being overly cautious in what they tell the public. They rarely describe the seriousness of the epidemic itself, but use other methods to mobilize citizens. They talk about the need for patriotism, about being a nation at war and this is part of the war effort, about being an American and about contributing to your community. But they don’t talk about the numbers of people who are sick and dying.

And Wilson is in the midst of the end of the war. Some people believe he had the flu when he was in Paris.

You’re right that the president was not obviously involved in this story at all. It was the U.S. Public Health Service that provided the leadership during the epidemic, not the politicians or the political sphere. It’s really a public health situation, and you can imagine this is a disaster for them, but they never framed it that way. In the aftermath, they were aware that people sickened and died, but they were also pleased with how they got information out, with how they organized their forces, and with how they responded to the crisis. For them, they’re quick to understand the pandemic as a public health success in terms of their profession. In some ways, I suppose they’re right.

What does the experience with the pandemic say about progressivism at this time?

Progressivism is in its heyday when the war begins. Historians used to argue that “war is the nemesis of reform,” but in fact World War I was nothing if not the Progressive war. It’s a war led by the forces of the Progressive movement -- people who finally have state power in a way they had never had it before. We see this phenomenon during the pandemic as well. The Public Health Service benefits from the fact that the nation is at war and that Americans are ready to accept state control that had been unheard of prior to the war and even more so prior to the Progressive era.

The Public Health Service mobilizes the public through a Progressive effort. Progressivism was always about identifying a problem, doing research to understand the issue, publicizing the findings and then mobilizing the public to act through the government to make change to solve the problem. You see that again and again during the pandemic, and especially in the way the public health leaders consider the problem and try to deal with it. That’s why they can imagine [their work] as a success, because they were very effective in spreading education and getting people to understand what they needed to do to prevent the flu, and making this an issue people thought about through a public health lens.

And yet, don’t these public health efforts in part lead to a rejection of progressivism?

People are pretty weary of it by the end. It’s true not only in the response to the public health leaders, but it’s a problem for progressivism across the board. This is one example of a massive backlash against government intervention that we see by the end of the pandemic.

During the pandemic, people are anxious to do what they’re told because they hope that will protect them. There’s a sense of optimism and belief in the power of the expert to protect you.

Of course, with the evidence that comes in day after day, especially during the third wave when influenza returns to so many communities, people are no longer convinced that the experts know what will happen or that government intervention will protect them. They become much less compliant with the various restrictions that governments are trying to put in place. This is acted out at the local level, whether it’s wearing masks in San Francisco or agreeing to cancel church services or agreeing to close schools or not go to the movies.

By the end of the pandemic, Americans are ready to return to their regular habits whether or not the pandemic continues. We see a backlash against progressivism, government intervention, and even the authority of experts. It’s not only true of the epidemic, but we see it in many places.

You focus on how the epidemic affected the poor and women and minorities. You write that “the economic circumstances framed the impact of the disease.” Can you talk about that idea?

The primary problem is that, if you’re poor, you’re already living on the edge of catastrophe because you might already be a paycheck away from being very hungry or being homeless. That’s true across the country whether in rural Kentucky, New York City, or the farms of the West.

If you’re living on the edge and poverty is a short step away, the pandemic is enough to throw you into really serious deprivation, and this is an era before any meaningful social safety net, and so people are reliant on whatever local charity they may have access to, or with luck the local Red Cross. And if you’re poor, you have this serious problem of hunger, of cold, of homelessness and potentially of children being placed in orphanages, even if one of the parents is still alive.

The poor also suffered from a lack of access to the resources of nursing and medicine, which are both already very thinly spread because of the war. If you’re wealthy, you may be able to buy health care, but if you’re poor, you’re at the back of the line and you’re less likely to get what health care was available. What is really important in this crisis is good nursing care. And if you were poor, you might get placed in one of the public clinics that opened, but a spot in a hospital bed was challenging if you were a poor American.

If you add into that the huge number of immigrants at that time who didn’t speak English and the serious problems with racism and ethnic discrimination, opportunities then were even fewer. If you’re an African American and live in the South, you can only go to a segregated hospital. As emergency hospitals we created by the white community, African Americans were left to look after their own, despite their more limited resources. Similarly, there was no consideration of the needs of Mexican Americans living in Texas or of the special needs of people living on reservations.

For those Americans in the most fragile circumstances in terms of socioeconomic dynamics of the country, the pandemic only made everything worse.

It seems a time of triumph for some women, especially in terms of the successes of the nursing profession as traditional medicine failed in the face of the epidemic.

Absolutely. Even many doctors acknowledged that the only thing you could do for patients was provide nursing care, keeping them warm and as comfortable as possible. The nurses didn’t have the responsibility to cure or to save the sick; their responsibility was care giving, which they were very able to do during the pandemic.

Nurses had to witness the same horror that confronted physicians, but they didn’t feel responsible for the deaths in the same way so they could celebrate their accomplishments during the pandemic in a way that no one else could.

Because nursing was primarily female, it’s one of the great opportunities in terms of a profession for women at the time. They celebrate themselves and they’re celebrated as well by their communities and medical practitioners because they do tremendous service during the pandemic. It’s a moment, of course, when many women are looking for those opportunities. We have the first [large] generation of women who went to college in the 1890s who are able to capitalize on that and imagine a future in which those accomplishments will give them access to greater control and prestige and greater economic remuneration.

Did the Northwest deal with the epidemic differently than other regions of the U.S.?

The Northwest conformed in many ways to the story of the country as a whole. The Northwest had a little bit more time to prepare because it hit Boston then the rest of the East Coast first.

One aspect of the local epidemic is the presence of Fort Lewis, or Camp Lewis during the First World War, and it was quite hard hit. But you hear the same complaints by the end of the pandemic. The soldiers are frustrated at Camp Lewis because they can’t go into Tacoma to have some fun.

The Northwest is also illustrative of the power of social identity in shaping experience. I write about the Chemawa Indian School [in Salem, Oregon], for instance, where the experience of the victims of the pandemic is very much shaped by who they are, what their origins are, and what their role in their society is. And here we see Indian children who were sent off to Indian schools where they faced a circumstance framed entirely around national assumptions about who they are as a people. They sicken and die in a context shaped by their identities as Native people and the historical dynamics of American oppression.

In that sense the Northwest has its own story, but it’s a story again in which the social identity of the actors is very much a part of how they experience the cataclysm.

A theme of the book is our national amnesia. You note that 675,000 Americans died and a quarter of the population was infected with the flu. It’s remarkable that this major calamity was forgotten so soon.

Yes. It’s increasingly remembered by historians. There’s been an upsurge in writing on the pandemic, which I think is important. But there’s nothing we can do for all those people who lived their lives with private pain and no public memory of what caused it. It’s a real tragedy not only with the deaths themselves but with people who were left to live with losses in their lives -- spouses, children, parents, best friends -- without public acknowledgment of what happened to them.

There was a drive in the country, a common American reaction to disaster, to put the epidemic behind them and move on to what they believed should be the brighter future ahead. That’s a tendency encouraged by a number of things. We see again and again, in the aftermath of catastrophe, how quickly Americans want to look to their future and forget about their past. And that’s not a very healthy way to live. The reality is that you have to contend with tragedy, with losses, and with the nation’s past to build the brilliant future that we all want.

Is this tendency toward national amnesia uniquely American?

I don’t know if it’s distinctly American. I know less about the rest of the world than I know about the United States, but it’s profoundly common in the United States. You can take it all the way back to John Winthrop in 1630 who talked about establishing “a city on a hill,” and this belief that we are on the road to perfection in this country has persisted. That brings with it a sense of optimism and possibility, potentially great characteristics that allow us to do remarkable things as a country, but it also brings with it a great cost when we allow another side to it: a refusal to look at our past.

I worry about this a lot, and it’s why I became a professor of American history, because there’s so much we need to know and acknowledge and recognize so that we can understand the world we live in now and try to make the future better than the past was. The pandemic is a classic example [of forgetting] because the narratives that are silenced are the narratives from which we would have learned a great deal if we had been willing to listen.

That seems to tie in with the idea of American exceptionalism, yet we weren’t exempt from the flu.

We weren’t exempted from the flu. And one of the notions of exceptionalism is that we were a nation born in democracy and the reality of the flu pandemic is that we are nothing if not a nation in which your class, racial, and gender identity defined the experience you had and yet that’s not a story that is told. We celebrate it as a moment of brotherhood and democracy, and that’s not what the pandemic was.

There were ways in which communities pulled together but the reality is, if you were poor or a person of color, you suffered worse than most. The nation refused to acknowledge those real stories that happened on the ground. Again, that’s not surprising. We don’t like to look at the more troubling side of who we are as a people or of our history, but for me, that’s an important part of the story. There’s great heroism in the story, but there’s great tragedy beyond the deaths.

Even as a theme in the arts, the pandemic is virtually ignored except for some blues songs and some notable writing by Katherine Anne Porter, Mary McCarthy, Thomas Wolfe, and a few others.

That’s why the first important book about the flu pandemic by Alfred Crosby was titled The Forgotten Pandemic when a new edition was issued. It was absent in the cultural flowering in the 1920s. We have the Harlem Renaissance and the Lost Generation writers, and very few touch on the pandemic.

There seemed to be profound social pressure to forget and get over this widespread catastrophe.

And you see that today with tragedies. Who’s thinking about Hurricane Katrina now? Obviously, we’re opening a 9/11 memorial, but are we really acknowledging the costs those tragedies had for the people who experienced them? I think not. If we refuse to acknowledge those experiences in any public way, we are saying to people, you’re supposed to be over it. You’re supposed to get on with your life. And that’s a profoundly powerful inclination in our culture.

I think knowing our history is absolutely vital not only to being good members of our community and good democratic citizens, but to being good human beings.

One of the things that I have learned in spending my life doing history is there are so many stories that are not our own. Even as an American historian, all I do is study the world and lives of people who are not just like me and it has shaped how I approach my community today and how I approach the people around me in my day-to-day life.

Trying to understand the world of someone other than yourself helps you not only understand the world from which other people come, but helps you get more agile on your feet in working with people who may be living lives very different from one’s own.

Thanks you for those moving comments on your work as a historian. Your book has been praised for your vivid writing and storytelling. Who are some of influences you admire as a historian and a writer?

The most obvious person I admire is my editor Susan Ferber at Oxford University Press. I had read a number of books that she had edited and I was aware of her, and when I learned that she would edit this book, I knew I was extraordinarily fortunate. She did virtually line-by-line editing for me. Some of the quality of the writing is due to my editor rather than anything I brought to the page.

The other influence, and this is where being a teacher at a small liberal arts college comes through, is my experience of teaching writing. I teach a history methods course every year, and working with my students to help them solve the puzzles of their writing has helped with my own thinking about writing. The work of Joseph Williams, a scholar of writing and a co-author of The Craft of Research, has been very influential.

I also have two colleagues at the University of Puget Sound, William Breitenbach and Douglas Sackman, who are two of the best writers I’ve ever read, and so the opportunity to work with them has been really important. I could mention several other colleagues, but I’ll stop with those two.

Also, another important influence is Edward Linenthal, who has written about how we memorialize American history, and who pushed me to think about the pandemic as a chapter in that story.

Is there anything else you’d like to add on the lessons from the American pandemic?

I suppose the most important lesson for me is to be aware that everyday we are living with people who have endured a private tragedy, if not a public catastrophe like the pandemic. We should be attentive to that and recognize that our tendency to want to move on and have people “get over it” is not very helpful. In fact, sensitivity to the aftermath of loss and of tragedy is an important part of being a member of a community, whether it’s the tornadoes that hit Joplin or the flooding in New Orleans or families in our communities who have lost loved ones in the wars that we’re fighting. That’s important to remember, I think, if we want to try to make a real difference in the world.