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“Afraid to Breathe”: Understanding North Carolina’S Experience of the 1918-1919 Influenza Pandemic at the State, Local, and Individual Levels

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“Afraid to Breathe”: Understanding North Carolina’S Experience of the 1918-1919 Influenza Pandemic at the State, Local, and Individual Levels “AFRAID TO BREATHE”: UNDERSTANDING NORTH CAROLINA’S EXPERIENCE OF THE 1918-1919 INFLUENZA PANDEMIC AT THE STATE, LOCAL, AND INDIVIDUAL LEVELS by Lauren Amanda Austin A dissertation submitted to the faculty of The University of North Carolina at Charlotte in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Policy Charlotte 2018 Approved by: ______________________________ Dr. William P. Brandon ______________________________ Dr. Mark R. Wilson ______________________________ Dr. Steven O. Sabol ______________________________ Dr. James N. Laditka ProQuest Number:10830755 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. ProQuest 10830755 Published by ProQuest LLC ( 2018). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106 - 1346 ii ©2018 Lauren Amanda Austin ALL RIGHTS RESERVED iii ABSTRACT LAUREN AMANDA AUSTIN. “Afraid to Breathe”: Understanding North Carolina’s Experience of the 1918-1919 Influenza Pandemic at the State, Local, and Individual Levels. (Under the direction of DR. WILLIAM P. BRANDON) This dissertation is the first comprehensive, detailed study of a single state’s experience of the 1918-1919 influenza pandemic at state, local and county, and individual levels. Its two articles provide quantitative analyses of a unique new statewide database and traditional historical narrative integrating institutional action and individual experience. Article 1, a quantitative examination of all death certificates (N=11,836) for October 1918 and March 1919 and the 1920 Census (N=2,561,959), employed multinomial logistic regressions, OLS regressions, and ArcGIS mapping. Results (p≤ 0.05): Singles were less likely to die of flu than marrieds but more likely to die of all other causes; blacks were more likely to die from flu than whites; black subgroups received less treatment than whites; children received less treatment than other age groups; Tidewater and Coastal Plain regions had greater standardized mortality while the Mountains, less than other regions. Findings confirmed literature reporting lower death rates among elderly, but not lower black mortality nor higher rates in manufacturing centers. Epidemiological evidence suggested flu virus mutations by March 1919. Article 2, a qualitative account of people’s experience, used government archives, newspapers, and letters. Results: A growing desensitization — or “inurement” — to the epidemic as early as October 1918, due to government downplaying its seriousness and emphasizing the war effort, officials instructing the public to remain calm and maintain normality, businessmen wanting to restore sales, and boredom with quarantine measures. iv DEDICATION To those whom I love – Because you have supported, guided, encouraged, and believed in me… For you I persevere. v ACKNOWLEDGMENTS The first and foremost position of thanks for anything that I achieve always belongs to my parents. Thank you for supporting me in my decision to go back to school yet again and for pushing me to follow through the adventure that it became. When most people would have given up, your lessons of persistence, determination, strength, and outright stubbornness helped me overcome every obstacle and reach my goal. Extra thanks goes to my mama for relieving me of some of my quantitative coding burden. Immense appreciation also goes to my committee members. Each of you agreed to come aboard this dissertation when the odds were stacked against the completion of my degree and your dedication to my success helped keep me on track of what was a difficult timeline. For all of the time, effort, advice, and encouragement that they have given me, Dr. Bill Brandon, Dr. Mark Wilson, Dr. Steve Sabol, and Dr. Jim Laditka have my deepest appreciation. My gratitude especially goes out to Dr. Brandon for taking on one last dissertation, helping me carve a new path through the program, providing countless hours of brainstorming, editing, and revisions, and showing me how a true dissertation chair interacts with their student. I would also like to extend my thanks to Dr. Martha Kropf for standing up for me and being my champion when so many others expected me to quit. Last, but certainly not least, thank you to my friends for putting up with me through this overly long, dramatic, and often ridiculous process. You know who you are so thank you for the phone calls, venting sessions, coffee dates, pep talks, and words of encouragement. Each of you make my life brighter and my dark days fewer. Special thanks goes to my fish for your endless support, loyalty, and fierce protection. vi TABLE OF CONTENTS LIST OF TABLES viii LIST OF FIGURES x CHAPTER 1: INTRODUCTION 1 Background of 1918-1919 Influenza Pandemic Research 1 Recent Trends of 1918-1919 Influenza Pandemic Research 5 Purpose and Aims of the Current Study 6 CHAPTER 2: “FALLING AROUND US ‘AS THICK AS LEAVES IN 8 VALLOMBROSA’”: A TRI-LEVEL QUANTITATIVE ANALYSIS OF NORTH CAROLINA’S EXPERIENCE OF THE 1918-1919 INFLUENZA PANDEMIC Introduction 8 Literature Review 12 Research Questions 25 Methodology 26 Results 41 Discussion 78 Conclusion 89 References 91 Appendices 97 CHAPTER 3: “WE HEAR OF SO MANY DEATHS THAT WE HARDLY TAKE 113 NOTICE THESE DAYS”: A TRI-LEVEL QUALITATIVE ANALYSIS OF NORTH CAROLINA’S RESPONSE TO THE 1918-1919 INFLUENZA PANDEMIC Introduction 113 The Responses of State Level Officials and Departments 121 The Response of Local and Community-Level Officials and Departments 147 vii The Response of North Carolina’s Citizens 215 Conclusion 252 References 258 CHAPTER 4: CONCLUSION 266 A Continuing National and International Threat 266 Policy Recommendations 275 REFERENCES 282 APPENDIX E: DETAILED MAP OF NORTH CAROLINA WITH COUNTY 285 NAMES viii LIST OF TABLES TABLE 1: Quintile Rankings of County Standardized Flu Mortality by 46 Geographical Region, October 1918 & March 1919 TABLE 2: Model Summary of County-Level October 1918 OLS Regression 50 TABLE 3: Model Significance of County-Level October 1918 OLS Regression 51 TABLE 4: Coefficient and Collinearity Results of County-Level October 1918 52 OLS Regression TABLE 5: Model Summary of County-Level March 1919 OLS Regression 53 TABLE 6: Model Significance of County-Level March 1919 OLS Regression 53 TABLE 7: Coefficient and Collinearity Results of County-Level March 1919 54 OLS Regression TABLE 8: North Carolina Crude Mortality Rates by Age, October 1918 and 56 March 1919 TABLE 9: Model Significance of October 1918 Individual-Analysis Model 59 TABLE 10: Goodness of Fit of October 1918 Individual-Analysis Model 59 TABLE 11: Explained Variance Statistics of October 1918 Individual-Analysis 59 Model TABLE 12: Likelihood Ratio Tests of October 1918 Individual-Analysis Model 60 TABLE 13: Coefficient Estimates of October 1918 Individual-Analysis Model 60 TABLE 14: Model Significance of March 1919 Individual-Analysis Model 65 TABLE 15: Goodness of Fit of March 1919 Individual-Analysis Model 65 TABLE 16: Explained Variance Statistics of March 1919 Individual-Analysis 66 Model TABLE 17: Likelihood Ratio Tests of March 1919 Individual-Analysis Model 66 TABLE 18: Coefficient Estimates of March 1919 Individual-Analysis Model 66 ix TABLE 19: Crosstabulation of Birthplace_Recoded, All Deaths (October 1918 69 and March 1919), and 1920 Living Population TABLE 20: OLS Regression Model for Days of Treatment Received 72 TABLE 21: Multicollinearity Check of Days of Treatment OLS Regression Model 72 TABLE 22: OLS Regression Model for Number of Days Between Last Visit 75 and Death TABLE 23: Multicollinearity Check of Last Visit to Death OLS Regression Model 76 TABLE 24: Population Frequencies 97 TABLE 25: Model Fit of Sensitivity Analysis 99 TABLE 26: Overall Model Significance of Sensitivity Analysis 100 TABLE 27: Explained Variance Statistics for Sensitivity Analysis 100 TABLE 28: Likelihood Ratios of Sensitivity Analysis 100 TABLE 29: Coefficient Estimates of Sensitivity Analysis 101 TABLE 30: Missing Data Frequencies 103 TABLE 31: Age-Specific Analysis of those aged 10-19 and marital status/flu death 104 TABLE 32: Age-Specific Analysis of those aged 20-29 and marital status/flu death 105 TABLE 33: Age-Specific Analysis of those aged 30-39 and marital status/flu death 108 TABLE 34: Age-Specific Analysis of those aged 40-49 and marital status/flu death 107 TABLE 35: Age-Specific Analysis of those aged 50-59 and marital status/flu death 108 TABLE 36: Age-Specific Analysis of those aged 60-69 and marital status/flu death 109 TABLE 37: Age-Specific Analysis of those aged 70-79 and marital status/flu death 110 TABLE 38: Age-Specific Analysis of those aged 80-89 and marital status/flu death 111 TABLE 39: Age-Specific Analysis of those aged 90+ and marital status/flu death 112 x LIST OF FIGURES FIGURE 1: October 1918 Flu Dispersion Map: County Standardized Mortality 42 Rates by Quintiles FIGURE 2: March 1919 Flu Dispersion Map: County Standardized Mortality 43 Rates by Quintiles FIGURE 3: Epidemiological Curve for North Carolina, October 1918 57 FIGURE 4: Epidemiological Curve for North Carolina, March 1919 58 FIGURE 5: ‘Board of Health’ Illustration, February 19, 1919 250 FIGURE 6: Map of North Carolina with Labeled Counties 285 CHAPTER 1: INTRODUCTION It is not uncommon that bodies should be piled from floor to ceiling, morgues should be overflowing, and streets should be filled with corpses when a country is in the midst of fighting a world war. However, it is uncommon to see bodies spread everywhere when the country in question is thousands of miles away from the nearest battleground.
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