Pandemics: Avoiding the Mistakes of 1918 As Bodies Piled Up, the United States’ Response to the ‘Spanish Flu’ Was to Tell the Public That There Was No Cause for Alarm
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OPINION NATURE|Vol 459|21 May 2009 ESSAY Pandemics: avoiding the mistakes of 1918 As bodies piled up, the United States’ response to the ‘Spanish flu’ was to tell the public that there was no cause for alarm. The authority figures who glossed over the truth lost their credibility, says John M. Barry. In the next influenza pandemic, be it now or in saying that most citizens were “mentally The press never questioned him. the future, be the virus mild or virulent, the sin- children” and advising that “self-determina- Meanwhile, the bodies piled up. In many gle most important weapon against the disease tion” had to be subordinated to “order” and cities, they lay uncollected in homes for days. In will be a vaccine. The second most important “prosperity”. In 1917, the day after receiving some places, including Philadelphia, they were will be communication. History has shown Lippman’s memo, Wilson issued an executive buried in mass graves dug by steam shovels. that to cut vaccine production time, minimize order to control all government communica- economic and social disruption, deliver health tion strategy during the war that was premised Same old fever? care and even food, governments need to on keeping up morale. Unfortunately, Philadelphia’s communication communicate well — both between themselves As a result, when the full-blown and lethal strategy was the rule, not the exception. Local and with the public. pandemic wave arrived in the United States in officials and newspapers across the country The US response to the 1918 flu offers a case September 1918, Wilson never made a single were either deceptive or said nothing. Many study of a communication strategy to avoid. statement about it, and lesser public figures papers did not print lists of the dead. Even as The world response to the threat of an emerging provided only reassurance. US surgeon gen- 8,000 soldiers were hospitalized in Camp Pike, flu in recent weeks shows that we have learned eral Rupert Blue declared: “There is no cause Arkansas, over four days, the Arkansas Gazette from the past. And there is much to learn. for alarm if proper precautions are observed.” in Little Rock, just a few miles away, main- The pandemic that began in January 1918 Local health officials echoed this message. tained, “Spanish influenza is plain la grippe — and ended in June 1920 killed an estimated Chicago’s director of public health, for instance, same old fever and chills.” This communication 35 million–100 million people worldwide, or decided not to “interfere with the morale of the strategy of either reassurance or silence had its 1.9–5.5% of the entire population1. Although community”, explaining: “It is our job to keep effect. Its effect was terror. an estimated 2% of people people from fear. Worry kills Lies and silence cost authority figures credi- died in Western countries, “The communication more than the disease.” bility and trust. With no public official to believe some large subgroups were That last phrase became a in, people believed rumours and their most affected disproportionately. strategy of either mantra repeated in hundreds horrific imaginings. A man living in Washing- The Metropolitan Life Insur- reassurance or silence of newspapers. Paid adver- ton described the result: “People were afraid to ance Company, based in New had its effect. Its effect tising carried a comparable kiss one another, people were afraid to eat with York, found that the disease message: every day, press one another … It destroyed those contacts and killed 3.26% of its insured was terror.” advertisements for Vicks destroyed the intimacy that existed amongst US industrial workers aged VapoRub appeared with the people … there was an aura of a constant fear 25–45. Given that 25–40% of the population line: “Simply the Old-Fashioned grip masquer- that you lived through from getting up in the contracted the disease, case mortality would ading under A New Name.” morning to going to bed at night.” have been 8–13% in that population2. Yet it was not ordinary influenza by another Under that pressure, society first drifted, The flu started slowly. In the United States, a name. The disease was unusual enough to be then threatened to fall apart. The health-care small wave of the disease sputtered across the misdiagnosed initially as cholera, typhoid and system, already drained of physicians and country in the spring of 1918, but went largely dengue. Some people died within 24 hours of nurses by the military, collapsed first. Else- unnoticed except in military training camps. the first symptom. The most horrific feature where, fear, not illness, kept people at home. The effects were more noticeable in Europe, was bleeding, not just from the nose and mouth Absenteeism reached extraordinary levels. where many soldiers in the armies of the First but also from the ears and eyes. Shipyard workers were told that their duties World War fell ill. By the end of summer, a Nonetheless, the government and news- were as important as a soldier’s; they were paid more lethal wave had surfaced in Switzerland. papers continued to reassure. Although only if they worked; and, unlike elsewhere, On 3 August, the US military received an intel- physicians fully understood the explosive physicians were available to them on site. Yet ligence report comparing the Swiss epidemic nature of the pandemic, they routinely misled absentee rates in the shipyards — one of the few to the Black Death. people, covered up the truth and lied. In Phil- industries for which there are good data — still The US government used the same strategy adelphia, for example, public-health director ranged from 45% to 58% (ref. 3). Absenteeism for communicating about the disease that it Wilmer Krusen promised — before a single crippled the railroad system, which trans- had developed to disseminate war news. The civilian had died — to “confine this disease to ported nearly all freight, bringing it to the point essence of that strategy was described by its its present limits. In this we are sure to be suc- of collapse. It shut down telephone exchanges, main architect, writer Arthur Bullard: “Truth cessful.” As the death toll grew, he repeatedly closing off communication, and further isolat- and falsehood are arbitrary terms … There is reassured the public that “the disease has about ing and alienating people. Grocers refused to nothing in experience to tell us one is always reached its crest. The situation is well in hand.” open. Coal sellers closed. In cities and rural preferable to the other … The force of an idea When the number of daily deaths broke 200, communities, the Red Cross reported that peo- lies in its inspirational value. It matters very he again promised: “The peak of the epidemic ple “were starving to death not for lack of food little if is true or false.” Fellow adviser Walter has been reached.” When 300 died in a day, but because the well were too panic stricken to Lippman, another architect of this strategy, he said: “These deaths mark the high-water bring food to the sick”. sent President Woodrow Wilson a memo mark.” Ultimately, daily deaths reached 759. Victor Vaughan, a sober, serious scientist, 324 © 2009 Macmillan Publishers Limited. All rights reserved NATURE|Vol 459|21 May 2009 OPINION Telling the public the truth is also paramount. Before a vaccine becomes available during a severe pandemic, at some point the government will ask citizens to adhere to a series of public-health guide- lines for non-pharmaceutical interventions, such as staying at home if they become ill. Large-scale, sustained compliance will be CHRONICLE THE SAN FRANCISCO essential if those measures are to succeed. Compliance requires trust, and that depends on truth-telling. In the United States, former health and human services secretaries Tommy Thomp- BETTMANN/CORBIS; son and Michael Leavitt deserve credit for institutionalizing real transparency in the current US pandemic plan. And the admin- istration of President Barack Obama has performed admirably so far. Obama himself has addressed the issue several times, making perhaps only one mistake, when he said the threat was “cause for concern, but not alarm”. Had things deteriorated quickly, he ran the risk of suddenly having to reverse his position. In Mexico, the problem was not reticence but candour, releasing inaccurate informa- tion that overstated the problem. Mexico should be congratulated for this, not condemned. Although a false alarm can be damaging, it is not nearly as Bold declarations like this one from San Francisco were rare in 1918. damaging as silence — the type of silence that makes people believe for years dean of the medical school at the against all influenza the truth is being withheld. That University of Michigan in Ann Arbor, worried viruses and available is how trust disintegrates and how that if this trend accelerated “for a few more globally, the world will rumours — passed in the streets in weeks … civilization could easily disappear be vulnerable to influ- 1918, today passed over Internet from the face of the Earth”. enza pandemics. H1N1 blogs — take hold and grow. Better communication led to better results. In is the most immediate I don’t much care for the term San Francisco, for example, despite a slow reac- danger, including the ‘risk communication’. It implies tion to the initial onslaught of flu, in October possibility that a more that the truth is being managed. 1918 the mayor, health officials and business and deadly wave will strike later this year, but H5N1 The truth should not be managed, it should be union leaders all signed a full-page newspaper and other viruses remain pandemic threats.