When it came to getting healthcare during the 1918 influenza epidemic, America’s Black communities, hobbled by poverty, Jim Crow segregation and rampant discrimination, were mostly forced to fend for themselves. Opportunities for hospital care proved scarce, leaving many relying on family care and, where available, the small but burgeoning ranks of Black nurses.

When the 1918 influenza epidemic began, African Americans were already beset by a barrage of social, medical and public health problems, asserts Vanessa Northington Gamble, a physician and medical historian at George Washington University. Among the challenges she identified in her 2010 study of the African American experience of the 1918 flu pandemic: “racist theories of black biological inferiority, racial barriers in medicine and public health, and poor health status.”

Some 675,000 people were infected in the United States and 500 million worldwide during the 1918 pandemic, according to estimates from the Centers for Disease Control and Prevention. Accurate numbers showing how many African Americans contracted the disease—or succumbed to it—aren’t available; records remain scarce, since so few of those victims had contact with institutional healthcare providers or agencies.

Some research suggests African Americans may actually have been less susceptible to catching the 1918 influenza virus. “One of the theories we advance is that segregation was functioning somewhat as a quarantine,” says Lakshmi Krishnan, a physician and medical historian at Georgetown University, who co-authored a paper comparing racial disparities in COVID-19 relative to the 1918 flu pandemic. Since pandemics “have always disproportionately affected Black, indigenous and Latinx people,” she says, that made the 1918 influenza “a bit of an anomaly” from an epidemiology perspective.

But while African Americans were less likely than white Americans to contract the disease, they were far more likely to die from it if they did catch it.

The key reason: Black Americans received substandard care in segregated hospitals—if they could even be admitted. “Not many hospitals accepted Black Americans, and those that did sent them to the basement for care,” says Marian Moser Jones, a public health scholar at the University of Maryland. There, they likely languished in rooms unintended for patient treatment, receiving neither the full resources nor timely medical attention white patients received in the main wards.