May 3, 2020

“I must confess that I found myself almost hopeless in the wake of the storm.”

So wrote Dr. J.C. Taylor, the health officer of Rogers County, Oklahoma, of his feelings after the 1918 flu pandemic. What lessons can we learn from that H1N1 viral outbreak, which was commonly called the “Spanish Flu”?

Few elders have useful memories dating back over 100 years, but written history has helped prompt a more vigorous and coordinated response to the 2020 pandemic. The so-called “Spanish Flu” of 1918 got its name from when it spread from France, where news of it was suppressed by wartime censorship, into neutral Spain. The press coverage in Spain helped spread word of its devastating impact. No one is sure where that particular strain of the H1N1 influenza virus originated, with hypotheses including Haskell County, Kansas and a hospital camp in France.

But the importance of social distancing and closures was made perfectly clear in comparisons of how a parade in Philadelphia helped overwhelm its health care system to how closures in St. Louis “flattened the curve” and helped suppress its death rate to a fraction of that observed in the City of Brotherly Love.

Those examples and a far better understanding of viral transmission have led to a massive response over a century later, which has, as of early May 2020, avoided overwhelming Oklahoma’s hospitals.

Due in part to outbreaks in multiple local nursing homes, I am unlucky enough to live in the zip code with the highest rate of infections in the state as of May 3, 2020.

As of this writing, Bartlesville has a reported infection rate of 224/36,423, which is over six times higher than Tulsa’s (405/400,669) or Oklahoma City’s (627/649,021), and our death rate is 11 and 13 times higher, respectively.

So, as closures ease after this first wave, I wondered how both Oklahoma in general and Bartlesville in particular fared in the 1918 pandemic. I used a variety of internet sources, but the most comprehensive was in print: the Spring 2001 edition of The Chronicles of Oklahoma with an article by Dr. Nigel Anthony Sellars: Almost Hopeless in the Wake of the Storm: The 1918 Spanish Flu Epidemic in Oklahoma. I have included highlights from it below, but you must order your own print copy to see his complete overview.

Dr. Sellars documented how 7,350 Oklahomans died of the influenza and related secondary infections in the second and third waves of the epidemic between October 1, 1918 and April 1, 1919. Health officials were overwhelmed by the second wave, and few back in 1918 suspected that the culprit was a virus. Many incorrectly blamed Pfeiffer’s bacillus, a bacterium.

Emergency hospital at Camp Funston, Kansas in 1918

The first reported human case was in early March 1918 at Camp Funston near Fort Riley, Kansas. The first wave of outbreaks was carried to Europe, where the virus spread in the trenches of World War I. Thankfully, it retreated in the summer.

But it mutated in Europe into a more deadly form, leading to a devastating second wave in the fall, which peaked in October. Entire units fighting in Europe were disabled in the late summer, and returning naval and merchant vessels brought the mutated influenza back to America.

Typhoid inoculation lineup at Camp Doniphan, Oklahoma, circa 1917-1918

Camp Doniphan near Fort Sill in southwestern Oklahoma had only 8 deaths from flu among 25,000 men in the winter and spring of 1918. But as Dr. Sellars noted, “…from September to December, with just 3,964 troops, the camp suffered 2,856 flu cases, eighty-three flu deaths, and eight pneumonia deaths.” The Spanish Flu attacked adults in their twenties and thirties rather than children or the elderly, with those between twenty and forty accounting for half of the epidemic’s deaths.

Prevention strategies were haphazard. Articles recommended that folks quit smoking, drinking, and overeating. They were told to steer clear of people who sneezed or coughed, to avoid using public drinking cups, and to gargle with various concoctions.

The deadly second wave in Oklahoma

In October, the flu exploded in Oklahoma City (OKC), with the first reported case on September 28. By October 1 there were 1,000 cases, and that would double within two days.  Much of the nursing staff at St. Anthony Hospital fell ill. Dr. Sellars notes, “The flu practically collapsed all city and commercial operations, a pattern duplicated in nearly every state town.”

Daily Oklahoman editorial on October 4, 1918

Dr. LeRoy Long, the dean of the University of Oklahoma’s Medical School, recommended correctly that people avoid crowds to check the disease’s spread. At first, OKC failed to organize a coordinated response. The Daily Oklahoman newspaper editorialized that the city should close all schools, churches, theaters, and other public spaces. But the county physician considered those actions premature, with many city doctors believing the crisis would pass after the weekend. A lack of new cases for two days provided false hope, followed by fourteen deaths over the next three days. That finally prompted the City Commission to issue a sweeping closure order on October 9. By October 12, 70 citizens had died from the flu, including attorney Norman R. Haskell, the son of Oklahoma’s first governor. Hospitals were overcrowded, and pneumonia spread.

Tulsa was more organized, with its leaders meeting on October 2 on a response plan and working with the Red Cross to open an emergency hospital at “The Ark”, a former women’s detention clinic to combat venereal disease. It was fumigated for 18 hours, and trustees from the county jail carried out old beds (which were burned), whitewashed the walls, and installed new cots. But while the virus did not discriminate, Tulsa did, with racially segregated wards at The Ark. The Tulsa Race Massacre would occur less than three years later.

Its efforts did not prevent Tulsa from being overcome with 3,000 cases by October 5. The Tulsa Red Cross ordered its members to make 5,000 gauze masks, obtain clothes and bedding for victims, and drive nurses to see patients. Local school children and the Red Cross folded newspapers to make sputum cups to collect and dispose of nasal and oral discharges. Nurses went out into Tulsa schools to give nasal douches, a questionable preventative.

Tulsa finally shut down all schools, churches, and public meetings on October 8. Later soda fountains, cold drink bars, bowling alleys, and pool halls were also closed. The mayor ordered morticians to provide their ambulances to the city and notified car dealerships, taxi companies, and private citizens that their vehicles should be made available to transport nurses free of charge. Restaurants were closed between midnight and 5 a.m. for nightly fumigations.

On October 10 the state health commissioner prohibited all public gatherings of more than twelve people, including funerals, and forbade even small prayer meetings at churches. Police in Tulsa and OKC jailed persons found spitting or coughing without a handkerchief. In Oilton, after a local Baptist minister prayed over one young prostitute whose fever then broke, the local prostitutes turned their brothel into a treatment center and worked as nursing volunteers.

By October 11, every member of the Stroud High School football team was “ill in bed with Spanish influenza” and the school’s game with Drumright was canceled. OU’s game against Phillips University in Enid was called off due to both schools being in quarantine, and the OU-Texas game was postponed. 

Formaldehyde became the disinfectant of choice, with Tulsa city workers flushing the streets twice daily with water before sprinkling the chemical. It was used to fumigate hotel rooms, victim’s homes, and even local libraries in both major cities. Oklahoma County officials used so much of it on the jail floors that newly released inmates reeked of it as they walked the city streets.

Clean-up campaigns and fumigation did not prevent the state from reaching over 70,000 reported cases by October 21. Tulsa added 400 cases in one day. Muskogee had 14 deaths in a single day and converted schools into hospitals. Obituaries filled the front pages of local rural newspapers.

Dr. Sellars noted, “The worst struck was Bartlesville, where the flu wreaked havoc, especially among smelter workers. The city had suffered fifty-six deaths by October 22, which gave it the second highest ratio of flu deaths to population in the nation, trailing only Philadelphia. Federal officials sent a doctor and two nurses to aid city officials. The city set up an emergency hospital at the local Elks Lodge, but as the number of victims grew, officials had to create a second one at the city’s First Baptist Church.” Late in the epidemic, Bartlesville closed all stores, except drugstores, at 5 p.m. each day.

Medical and prevention measures

Doctors and nurses were in short supply statewide since about 1/3 of the doctors had joined the military alongside about 1/2 of the nurses. What doctors and nurses there were relied on aspirin to treat fever and reduce pain and epinephrine to battle pneumonia victims’ congestion. There were experiments with cinnamon in milk, quinine, and intravenous delivery of digitalis.

General prevention recommendations included avoiding crowds, getting plenty of sleep and fresh air, and washing hands with antiseptic soap. Some advised gargling with chlorinated soda or a mixture of sodium bicarbonate and boric acid.

The public was urged to wear six-by-four-inch gauze surgical masks, but only Muskogee and Clinton mandated their widespread use. Those without surgical masks could use an 18-by-18-inch piece of gauze folded diagonally three times or a cotton handkerchief worn like a bandit’s bandana. But gauze was scarce, so health officials recommended changing masks every two hours and boiling contaminated masks for 30 minutes before reuse.

Red Cross nurse with gauze mask from October 1918

A doctor at the Mayo Clinic claimed bacteria caused the flu and promoted a serum for it, but some Oklahoma doctors correctly believed that was incorrect and that any existing vaccines lacked value. Labs in both Tulsa and OKC produced the useless serum in bulk and thousands received injections, including public officials. Sellars recounts, “Oklahoma City mayor Ed Overholser had himself inoculated with an earlier ‘vaccine’ on October 7. He came down with the flu the same day, eventually growing so ill he resigned his office under doctor’s orders.”

Patent medicines were ineffective treatments, while pharamacists could prescribe whiskey as a “remedy” during Prohibition

The public turned to dubious over-the-counter patent medicines such as Dr. Kilmer’s Swamp Root, Dr. Pierce’s Pleasant Pellets, and Eatonic. Vicks VapoRub did relieve congestion, and customers cleaned out the drugstores of it, with the manufacturer placing ads in major newspapers promising to supply more.

Folk remedies were utilized, with one farmer attributing his own resistance to “quinine and lots of coffee” while whiskey was the most popular remedy, which was issued by pharmacists for medical purposes under Oklahoma’s prohibition laws.

Tulsa had a burial casket shortage by October 15, with the county making them for sale at seven dollars each. Gravediggers were in short supply, with Bartlesville asking for volunteers but eventually pressing county jail inmates into service.

Another echo of our current times was documented by Dr. Sellars. “But as the epidemic wore on, many Oklahomans started to chafe under the local and statewide restrictions. Although the bans initially helped create a sense of community action and solidarity, they soon became an inconvenience to some groups, especially merchants who feared the bans posed a threat to business and who claimed the state order was an improper intrusion on local authority.”

The state health commissioner, himself ill at the time, finally suspended the quarantine on November 9. For the first time in almost a month, schools, churches, theaters, and other public places opened. By then the disease had killed over 5,000 Oklahomans.

The third wave

Rumors of an armistice in the world war and then the actual end of the war on November 11 led to crowded city streets in both major cities, despite a cold drizzle, with many people drunk.

Armistice Day Parade in Lawton in November 1918

The epidemic returned by November 25 with outbreaks in Tulsa, Oklahoma City, Drumright, Sapulpa, Bristow, Chickasha, and many rural communities.

That wave was slightly less virulent than the October outbreak but lasted into late spring. By December 15 there were 10,245 cases in 45 counties, but that dropped the following week to 4,640 cases in 38 counties. Some doctors yielded to local pressure and suppressed information to avoid affecting Christmas business. Tulsa police arrested several doctors who failed to report cases for up to two weeks.

In the later wave, some cities abandoned public closures as ineffective. Tulsa relied on home quarantines. Lawton tried closing schools again, but children congregated on city streets and the city instead relied on limiting attendance at public places, restaurants, hotel lobbies, pool halls, cigar stores, and soda fountains. OKC required all public places to have at least 200 cubic feet of air space per person, so movie houses left every second or third row vacant.

But some members of the public and local businesses often disregarded or opposed preventative measures in the third wave. OKC restaurants resisted orders to boil dishes. People were reported to have openly sneezed in others’ faces, and streetcar riders frequently ignored a regulation that every third window be open for ventilation.

Aftermath

The flu eventually burned out in the cities but lingered in rural areas. Once again the front pages of small town newspapers carried almost nothing but obituaries. The flu finally ended in the late spring, with smaller outbreaks in the fall and winter for three more years.

In late January 1919, the state health department figures showed 125,000 to 150,000 flu cases with at least 7,500 deaths. The actual toll was higher due to under-reporting, particularly in African-American and rural communities. Native Americans suffered the most, with 861 deaths out of 15,227 cases, for a death rate of 5.7%, which was twice the national average. 1918 was the first year Tulsa ever had more deaths than births.

The effects were long-lasting, but thankfully so was charity. In February 1919, a destitute 35-year-old father arrived in Enid with two boys, 8 and 6, and a 4-year-old girl, all thinly clad and barefoot. Their mother had died from the flu and the father had lost his job while battling the sickness. He traveled by train from Oklahoma City to Enid, looking for work. En route, passengers collected $15 for the family while local residents purchased clothes for the children and helped get the man a job.

Dr. Taylor of Rogers County, who had weathered the storm, continued to advocate reasonable measures in the fall of 1919. He suggested avoiding contact with those who were sick, not sharing eating or drinking utensils, and washing “the hands and face several times a day.” He also shared, “plenty of soap and water and fresh air are the best means of prevention.”

Dr. Richard Shope was instrumental in identifying influenza as being caused by viruses

Health departments were eventually beefed up even as public attention to pandemics waned. Research continued, with American virologist Richard Shope noting in 1928 that a swine flu virus resembled the Spanish flu. Shope’s techniques led to the first human flu virus being isolated by British scientists in the early 1930s, finally ending the misconception that influenza was caused by bacteria.

1945 flu vaccine

The first effective flu vaccine did not come for another decade, in 1943. But the constant mutations of the virus means influenza vaccines must be reformulated annually and thus influenza, unlike smallpox and polio, has not been effectively wiped out. In recent years, misinformation has led many to refuse vaccinations, leading to unnecessary outbreaks of measles in 2019.

The current pandemic promises to linger through the summer of 2021 as we hopefully await an effective vaccine that might help us eventually achieve herd immunity. But even that is being quite optimistic, given that we’ve never had an effective vaccine widely deployed in less than five years.

So we must continue to wear masks and practice social distancing for the foreseeable future, with public gatherings carrying significant health risks. If the easing of restrictions across the nation in May 2020 leads to an unacceptable rise in infections and death rates, we can expect fresh closures that attempt to avoid overwhelming hospitals in second and later waves of infection.

So far we have handled the 2020 pandemic far better than our predecessors handled the one of 1918. For us to remain hopeful in the wake of this first wave, we must continue to heed the lessons of history and apply scientific advancements to weather this latest storm.