Some places isolated themselves during Spanish flu. Could we do the same?
of the new coronavirus has health officials using an ominous vocabulary — social distancing, isolation, quarantine — practices that have not been in widespread use since the 1918-19 Spanish flu.
It was a time when some communities took extreme measures, seeking to make themselves islands of the uninfected. Their actions, though extreme, may preview debates we will be forced to have in this country if coronavirus becomes widespread.
The U.S. military appeared to recognize this possibility in 2005 when it commissioned researchers at the University of Michigan to study a largely-forgotten chapter of Spanish flu history, involving seven comFear munities that closed off their populations to keep out the virus.
The communities were: Gunnison, Colorado; Yerba
Buena Island in San Francisco Bay; Princeton University in New Jersey; Fletcher, Vermont; Trudeau Tuberculosis Sanatorium, in Saranac Lake, New York; Western Pennsylvania Institution for the Blind in Pittsburgh; and Bryn Mawr College in Pennsylvania.
The military had the researchers study the responses of these communities to answer a question that anticipated our current predicament: Could any of these measures be used to safeguard U.S. servicemen in the event of a novel influenza pandemic?
Coronavirus is a different microbe than influenza, but this virus appears similar to seasonal flu.
Researchers found the seven closedoff communities experienced few infections or deaths — as long they imposed the restrictions. They did run into opposition in a country where freedom of movement is among the most cherished liberties.
Some are hard to imagine in modern America.
“There was a period when Gunnison let no one in for several months,” said Michael Osterholm, who directs the Center for Infectious Disease Research and Policy at the University of Minnesota. “I don’t think any community can do that now. We’re dependent on the rest of the world for our food and life-saving drugs.”
Yet the actions taken by the seven communities under the threat of Spanish flu resemble in some ways the extraordinary measures China has used to slow the coronavirus. Whole villages and cities essentially closed themselves off. Checkpoints appeared outside numerous communities. In Wuhan, the outbreak’s epicenter, authorities halted all transportation by train, plane, ferry and bus.
The same researchers who examined the seven communities were later asked by the U.S. Centers for Disease Control and Prevention to conduct a broader study examining the responses to Spanish flu by 43 cities, including Milwaukee. The cities did not resort to closing themselves off but used a host of other methods of reducing crowds such as closing schools, banning public gatherings and quarantining those exposed to the flu.
Quarantining and isolation are often used interchangeably but are not the same. Quarantine is imposed on people believed to have come in contact with the sick; isolation is used to separate people who are actually sick.
Milwaukee employed its restrictions — known as social distancing measures — for 132 days. One example: Asking factories to stagger their hours to avoid overcrowding streetcars. Although some cities sustained their approaches even longer, more than half kept their rules in place for less than 100 days.
“If the measures were in place for a long time people really started to bristle,” said J. Alexander Navarro, who coauthored both studies and works as assistant director of the Center for the History of Medicine at the University of Michigan. “Schools were closed, football games canceled, saloons closed, no church gatherings.”
Writing in 2007 in the Journal of The American Medical Association, the authors concluded that cities that responded early to the threat and sustained their responses for longer periods saw lower death rates from Spanish flu.
John Barry, a Tulane University scholar and author of “The Great Influenza: The Story of the Deadliest Pandemic in History,” said he supports social distancing but is not as big a believer in it as computer modelers.
“The real question is how complete can you make it and how well can you enforce it?” Barry said. “Now the Chinese have done it. And they’ve used a lot of force to do it.”
So what did the seven communities do to keep out Spanish flu and how did they fare?
Gunnison County, Colorado
In early October 1918, officials in Gunnison County, Colorado, sensed Spanish flu closing in. Surrounding communities were reporting dozens of cases.
On Oct. 8, leaders of the sparsely populated mountain community (5,590 residents, less than 2 per square miles) immediately closed all schools. On Oct. 31, the county closed itself off to visitors, except those willing to undergo a twoday quarantine. The quarantine was expanded to five days in mid-November.
Authorities placed barricades with lanterns and warning signs on major highways, warning drivers to pass through the county without stopping or submit to quarantine. Residents could leave the county but were required to enter quarantine if they re-entered Gunnison.
Two Nebraskans were arrested and jailed after they tried to drive around a barricade and enter the county.
The Town of Gunnison required anyone who exited a train at the station to submit to a mandatory quarantine. Those entering the town by rail or other means were brought to the Town Hall, which was pressed into service as a 48hour detention center.
For the three months, the county cut itself off, no one got the flu in the Town of Gunnison. Only two people in the entire county got the infection, one of whom died.
“By late December Gunnison County residents had started to become restless,” the University of Michigan researchers wrote in their report. The county reopened schools on Jan. 20 but maintained the quarantine order until the morning of Feb. 5.
In mid-March 1919, the pandemic’s third wave hit Gunnison. The county reported at least 140 influenza cases, most of them mild, and at least five deaths from pneumonia.
Yerba Buena Island
For two months, Yerba Buena Island, a naval training station that housed about 6,000 people on less than 2 square miles in San Francisco Bay required all staff to remain on the island.
The island allowed no visitors. Tugboats bringing in food and supplies were ordered to come no closer than 20 feet to any of the sailors on the dock.
Some recruits were sent to Yerba Buena, but they were not allowed onto the island ferry until a topical anti-infective solution had been sprayed into the upper part of the throat behind the nose. They were also required to wear gauze masks. As soon as they arrived on the island they were placed in quarantine camp for several days.
The naval training station also isolated anyone who was sick, placed muslin screens between bunks or hammocks and heated the spigots of all drinking fountains with a gas torch twice a day.
On Nov. 21, 1918, the island lifted restrictions and reopened contact with the outside world. On Dec. 6, Yerba Buena saw its first case of influenza. Over the next month or so, the island reported 28 influenza cases and 21 pneumonia cases, resulting in at least five deaths.
Princeton University
In 1918, Princeton University had a population of 1,142 men, most of them enrolled in either the student Army Training Corps or the Naval Training Corps. The university was surrounded by the much larger Town of Princeton (population 5,700).
On Oct, 1, the Town of Princeton’s Board of Health closed all places that housed public gatherings: schools, churches, movie theaters and pool halls. The Board also advised the public to avoid travel and discouraged visits to Camp Dix a half-hour drive away.
Despite these actions, influenza reached epidemic proportions in the town by Oct. 18, when newspaper accounts reported more than 300 cases. The influenza hospital was full.
The university, which had been transformed into a military mobilization and training camp, recorded its first influenza case on Sept. 5 and immediately began isolating anyone with symptoms of an upper respiratory infection.
Men arriving at the university from the naval training camp in Pelham Bay Park, New York, were examined for influenza symptoms and treated with nasopharyngeal spray; anyone with symptoms was isolated in sick quarters.
In October, all student trainees brought to the university were disinfected at a special plant. Inspections were carried out every day. For several weeks, students at the university were not allowed to cross Nassau Street or enter any building outside the campus. Dormitories were later closed in the evenings; students could not leave their dorms without a special pass.
Researchers reported they found no evidence that faculty were restricted to the campus, and at least a few parents visited students. Nonetheless, during a period when the Town of Princeton sustained 32 influenza deaths, the university reported the deaths of no students and just one professor.
All military corps were ordered to stand down on Dec. 21, 1918.
Western Pennsylvania Institution for the Blind
The Western Pennsylvania Institution for the Blind in Pittsburgh had 179 students as well as faculty and staff living on-site. They lived in the midst of a city of 580,000, the nation’s ninth-largest at the time.
Although the institution allowed no visitors and kept all children on the premises, it is not clear that all faculty and staff remained at the institution. It may also be that discrimination against people with disabilities helped to isolate the students and staff.
“Despite its location in the heart of a residential neighborhood of Pittsburgh, where influenza was raging during this period, the ... students and staff already constituted a socially segregated community,” authors of the study wrote. “During the Progressive Era, the physically and mentally handicapped, people with contagious diseases, the mentally ill, and those considered to be of inferior moral stock (e.g. wayward girls) were often shunned... Social interaction with the outside world was, as a result, minimal for these groups.”
While the city of Pittsburgh reported almost 15,000 cases of influenza, the institution experienced just 12 cases and no deaths.
Trudeau Tuberculosis Sanatorium
In 1918, Trudeau Tuberculosis Sanatorium in Saranac Lake, New York, admitted 356 patients and discharged 259. The sanatorium had no influenza cases at all.
Tuberculosis patients were isolated and a large percentage received a vaccine that contained what turned out to be the wrong microbial agent.
Like the Institution for the Blind in Pittsburgh, the sanatorium did not require extensive measures to sequester its population. In 1918, most tuberculosis facilities were isolated geographically, researchers wrote, “deliberately removed from society ... traffic in and out was strictly regulated.” They also had developed longstanding sanitary practices ideal for keeping out influenza.
During the third wave of the Spanish flu, between January and April 1919, the sanatorium’s luck ran out. The sanatorium had 27 cases, including some nurses and an orderly who died.
Bryn Mawr
Bryn Mawr women’s college outside Philadelphia recorded its first influenza case in late September 1918. By October, the college had begun a strict quarantine. Students were forbidden from entering theaters and other public gathering spots and were not allowed to cross Montgomery Avenue, the main street separating the college from the town.
While students were not allowed to ride public transportation, college staff were only advised to stay off trains.
On Oct. 5, off-campus visitors, including mothers of the students, were not allowed to enter residence halls. They could only see their daughters if the daughters were ill and being cared for in the infirmary. Students were ordered not to visit private homes without permission of the dean.
The college president also ordered widespread vaccination of those on campus, though the vaccine was the same one that contained the wrong microbial agent. The president would go on to order that students be fined $5 if they were caught not using a handkerchief when coughing or sneezing.
Students were told to avoid crowds but still were expected to attend chapel and association meetings. Students ill at home were not allowed on campus until after Nov. 7, 1918, when the pandemic’s second wave had ended.
Although the college reported 110 cases of influenza, not a single person died.
Fletcher, Vermont
Fletcher, Vermont, was a small rural town with a population of 737 people spread out over 38 square miles.
Vermont jumped out ahead of most other states in responding to influenza. Health officers were empowered to place placards on the homes of any patients and the state advised home isolation of all the ill.
Nonetheless, by late September several areas of the state were experiencing an influenza epidemic. In October, the governor enacted statewide bans on public gatherings. Schools, churches and movie theaters were all closed.
However, researchers found few details of Fletcher’s response. Unlike residents elsewhere, those in Fletcher engaged in some public gatherings (a Red Cross dance, and a county fair in the neighboring and larger town of Essex).
On Sept. 18, a soldier from Camp Devens, Massachusetts, arrived in town for his wedding, which included a 120guest reception. At the time, Camp Devens was in the midst of a major epidemic that would result in more than 14,000 cases and 757 deaths — just in September.
Yet Fletcher experienced two cases of influenza and no deaths.
The study authors concluded that while Fletcher’s experience with influenza may have been helped by social distancing measures, it was “more likely shaped” by good fortune, the remote location and a weakening of the virus over time.
How would we do today?
Graham Mooney, an associate professor at the Institute of the History of Medicine at Johns Hopkins University, said that communities in 1918 had one advantage in confronting Spanish flu.
Having dealt with previous outbreaks of scarlet fever and diphtheria, cities had a network of hospitals with a capacity for dealing with a major infectious disease. Today, we don’t have that firsthand, even frequent, experience.
Depending on what happens with the new coronavirus, Mooney said, health officials may find themselves having to consider options they have not employed in a long time.