Medical Examiner

Did We Forget to Memorialize Spanish Flu Because Women Were the Heroes?

Sure, it came on the heels of World War I, but it was way more deadly.

A nurse treating a patient in a sickbed, one in a row of beds stretching into the background, separated by curtains.
Walter Reed Hospital in D.C. during the great influenza pandemic of 1918–19.
Harris & Ewing/Library of Congress

A hundred years ago, in February 1919, the world had made it through two waves of the worst influenza outbreak in history and was suffering the final sporadic throes of the so-called Spanish flu. This flu delivered a gruesome and sudden death: Sickness could come on in the morning and have somebody seriously incapacitated by night, then dead by the next morning. Because of the biological particulars of this virus, half of the victims who died were between 20 and 40 years old. This flu, unlike more common strains that primarily victimize the young and old, killed working people, soldiers, politicians, mothers and fathers of small children—the people most occupied with the labor of society. In all, 675,000 Americans probably died from the flu in 1918 and 1919—far more than the 53,402 who died in combat in World War I.

And yet, for years, Americans didn’t talk about it much in public. Historians of the flu, starting with Alfred Crosby, whose 1976 book America’s Forgotten Pandemic was the first comprehensive account of the outbreak in the United States, have long wondered at the curious fact that this terrible experience left so little mark on the cultural record. Looking at major American newspapers and political discourse in the years after the flu ended, Crosby found that the whole thing seemed to have vanished without a trace. “The flu never inspired awe, not in 1918 and not since,” Crosby wrote. Crosby notes that the major writers of that generation, who were busy memorializing the experience of the Great War and probing the depths of the “modern” soul, didn’t talk much about the flu either. It was left to a few scattered authors less central to the canon—Katherine Anne Porter, William Maxwell, Thomas Wolfe—to write about the epidemic in the ensuing decades. It wasn’t until the end of the 20th century that American historians and documentarians turned their attention to the pandemic.

What was it about the flu that provoked this silent response? Is there something about mainstream American culture, with its optimism and pride, that simply refuses to reckon with the idea of mass death from an unstoppable illness? A close read of recent history suggests that the 20th century silence about the flu epidemic of 1918–19 shows how uneasy many Americans have been with failure, death, and loss, and how strongly most of the nation seems to prefer stories that celebrate heroic achievement to those that memorialize acts of caregiving. Indeed, as the flu came and went, the only people who felt like they’d done anything to help were nurses, who offered palliative care to alleviate symptoms as the sick suffered on. Given America’s somewhat pathological focus on results-oriented medicine, and aversion to the acceptance of death, it’s little wonder that these women’s efforts went unhailed.

Some of the underresponse to the Spanish flu might have been the product of historical circumstance, rather than an artifact of Americans’ particular culture. In 1918, the nation’s attention was directed toward the dénouement of the war in Europe. It’s also worth remembering that 100 years ago, people were much more accustomed to losing family members to infectious disease. For Americans of the early 20th century whose grandparents might have died of diseases like smallpox or yellow fever, the flu may have seemed like too simple a thing to fear. Despite its severity, it didn’t sound scary. “Influenza, flu, grippe, grip—whatever you called it or however you spelled it—was a homey, familiar kind of illness: two or three days in bed feeling downright miserable, a week or so feeling shaky, and then back to normal,” Crosby wrote.

But this “homey, familiar” affliction was singularly murderous. Perhaps it was the contrast between its familiarity and the actuality of its terror that made it difficult to process. Literary scholar Jane Elizabeth Fisher posits that the American failure to respond to the flu’s true threat could have been a matter of overload: “The silence surrounding the 1918 influenza pandemic can also be interpreted as a kind of tribute to its awe-inspiring destructive power, the terrifying number of people it killed, and the inability of human language to adequately represent mortality on such a large scale.”

It is also a story with few visible protagonists. Doctors, the manly conquerors in other American stories about illness in the early 20th century, came up completely short in 1918. “All the physicians of 1918 were participants in the greatest failure of medical science in the twentieth century or, if absolute numbers of dead are the measure, of all time,” Alfred Crosby wrote. Doctors—then almost universally male—remembered the flu as a dire time of self-doubt and anguish. “Give us another war with Germany, Mexico and all the other heathenish countries in preference to another blast of this distressing flu,” a physician from Tennessee wrote. This doctor felt like a “great, merciless juggernaut has rolled over the land and left us weeping and wailing in its path.” Historian Nancy Bristow, in her book American Pandemic, quotes one physician who described the heartbreaking experience: “There wasn’t much a doctor could do. The patient would be dead before you could get back to see him. He could diagnose you and give you some medicine and the next day you’d be dead. … The main thing of visiting every day was to find out who was dead and then bury them.”

This ordeal wasn’t just emotionally upsetting; it was a real blow to doctors’ collective professional ego. During the epidemic, mainstream medicine found itself beset on all sides by doubters. The flu was so impossible to treat that folk remedies filled the gap: People tried powdered lobelia, sagebrush tea, rabbits’ feet, and a laundry list of other home cures. Homeopathic and osteopathic doctors trumpeted their supposed successes with the flu. These doctors leveraged their mainstream colleagues’ failures to criticize them: “Dominant therapy has been ‘weighed in the balance and found wanting,’ ” one homeopath wrote. Bristow quotes a flu-period advertisement for a medicine that questioned the single largest advancement of late-19th-century medical science, germ theory: “Those doctors who believe GERMS the cause of disease and have to give drugs to KILL the GERMS are butting their heads against a stone wall and will have to start a new theory of disease.” Mainstream physicians had little with which to counter these attacks. Historian John M. Barry quotes Victor Vaughan, a former president of the American Medical Association, who said of the flu: “Never again allow me to say that medical science is on the verge of conquering disease.”

The most common treatment for a flu patient was bed rest, pain relief, isolation, and plenty of warmth. Beyond that, a “prescription” was anyone’s guess, and the remedies that doctors prescribed make for quite a list. All kinds of useless “vaccines” were developed. Patients might be prescribed castor oil to purge the bowels, turpentine enemas for the same purpose, bloodletting, quinine (because it worked for malaria, so … try it?), camphor injections, typhoid vaccines (to stimulate the immune system), alcohol “in heroic doses,” narcotics, linseed poultices, or (a treatment documented in Willa Cather’s novel One of Ours) an egg in a cup of orange juice, given every two hours. In such a varied list, you can see how frantic doctors must have felt to make a difference—any kind of difference.

While male doctors flailed, women took charge of the day-to-day care for flu sufferers. Perhaps this is another reason why the flu epidemic faded in memory: It was the women who did most of the work, and that work was dangerous drudgery. In the United States, home-based care for sickness was de rigueur in the 19th century, and “it was still customary in the second decade of the twentieth century for serious illnesses to be treated at home,” historian Emily Abel writes. Care for the flu was an hour-by-hour labor of love—or duty. The nurse would keep the patient hydrated and nourished, ventilate the room and make sure it was warm enough, and administer whatever remedies the doctor had recommended. Along the way, of course, the nurse risked being infected herself.

Some people had no female relative to care for them, or the women in their families were sick too. These patients looked to professional nurses—privately engaged in their homes, visiting under the auspices of the government, or working in hospitals—to fill the gap. For these professionals, the epidemic was the ultimate test. Professional nurses, who were already in high demand because of the war, actually seem to have found the epidemic—despite its dangers—a time of great professional fulfillment. Nancy Bristow found, through reading their memoirs and writings, that such nurses remembered the epidemic period with something you could even call fondness. She quotes Mabel Chilson, a student nurse who recalled how it felt to start to work in 1918: “The nurses soon became the happiest family and when off duty we had jolly good times. The greatest comfort we possessed was the knowledge that each girl was doing her best and making good as a nurse.”

Bristow found similar responses in diaries and letters written by nurses across the country. Their cheerfulness is jarring. “The happy memories of the epidemic are many. … The list of treasured experiences is long,” wrote one. “Terrible as was the influenza epidemic, with its frightful toll, there was a certain tremendous exhilaration to be felt as well as many lessons to be learned from such a terrific test,” wrote another. Nurses at the time insisted that their job, which some saw as simply the natural work of women, should be respected as a legitimate career, and they saw their record during the epidemic as a way to claim professional recognition. One nurse wrote: “It was a most horrible and yet most beautiful experience. … The nurses rendered as noble service as any soldiers in battle.” In 1918, Bristow points out, male physicians believed that doctors should be heroes, a perspective the flu compromised: “They embraced an understanding of their profession as one that healed patients and cured disease, standards difficult to meet during the pandemic.” The nurses, on the other hand, needed simply to administer care—not to fix the disease. They could not only do this, but be proud of having done it.

Some nurses understood this noble service as socially significant, not just personally virtuous—a gesture of inclusion, proving that the United States had the heart to comfort all sufferers. Writing in the Survey, a progressive magazine, in November 1918, Frances Hayward recounted the story of her experience nursing indigent and immigrant men in New York during the pandemic. “I cannot help feeling that in the old building on the river, something more than a fight against influenza had taken place,” Hayward wrote. “Another disease was being fought, a disease from which the nurses were suffering as well as the patients—the disease, the plague of class feeling. Amidst the inconveniences and discomforts of the Lodging House hospital, the kind of democracy toward which we are all working showed a sign of health.”

And it’s these reactions—somehow cheerful in the face of great tragedy—that feel the most characteristically American. In Katherine Anne Porter’s novella Pale Horse, Pale Rider, the main character Miranda and her lover Adam, before they get the flu, chat while they’re walking down the street during Adam’s leave from the military: “Did you ever see so many funerals, ever?” Miranda asks. “Never did. Well, let’s be strong minded and not have any of it,” Adam says, shifting the conversation to their plans for that night. Miranda makes it through the flu, though she’s forever changed; when she’s returned to the living, she finds out that Adam has died. Porter, who tapped her own experience as a flu sufferer to write the novella, critiques American optimism, what she saw as our singular tendency to look forward instead of backward—a tendency that also blunted the memory of the flu, with its shame and confusion and sadness.

Perhaps mainstream culture in the United States and other Western countries is still too optimistic to reckon with this kind of threat. We’ve made progress in preparedness for another such epidemic, but not nearly enough. In a paper published in 2015, summarizing findings from interviews about the 2009/2010 H1N1 pandemic with people in Australia and Scotland, Mark D.M. Davis and a team of researchers wondered what might be causing apparent resistance to public health advice about the possibility of a flu pandemic. Was it something the researchers termed “health threat fatigue”? But complacency and resistance were not the major responses they found; rather, “health individualism” determined people’s responses to the prospect of pandemic flu. Respondents didn’t think a pandemic was preventable; they just believed that they could boost their own immunity as a defense. People who were by and large in good health believed that they could “push through” any influenza.

There’s something about the idea of a flu pandemic that would kill you and your loved ones—whether or not you eat your vegetables and exercise regularly—that is difficult to imagine. This is why most of our pandemic-oriented fantasy in culture and public life (Contagion aside) tends to personalize the threat of disease by making it a bioweapon wielded by a terrorist, turning the afflicted into zombies that can be fought, or attaching the threat to the specter of “invading” immigrants. We like a war so much more than a flu. But it might be the flu that gets us.