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Public Health Rep. 2010; 125(Suppl 3): 123–133.
PMCID: PMC2862341

Immigration, Ethnicity, and the Pandemic


The influenza pandemic of 1918–1919 coincided with a major wave of immigration to the United States. More than 23.5 million newcomers arrived between 1880 and the 1920s, mostly from Southern and Eastern Europe, Asia, Canada, and Mexico. During earlier epidemics, the foreign-born were often stigmatized as disease carriers whose very presence endangered their hosts. Because this influenza struck individuals of all groups and classes throughout the country, no single immigrant group was blamed, although there were many local cases of medicalized prejudice. The foreign-born needed information and assistance in coping with influenza. Among the two largest immigrant groups, Southern Italians and Eastern European Jews, immigrant physicians, community spokespeople, newspapers, and religious and fraternal groups shouldered the burden. They disseminated public health information to their respective communities in culturally sensitive manners and in the languages the newcomers understood, offering crucial services to immigrants and American public health officials.

La grippe was the foreign-sounding name for a disease that was neither fearful nor a stranger to most Americans at the turn of the last century. This name for the influenza virus that swept through cities and towns, sickening many thousands annually, was familiar. Most of the time victims of la grippe recovered. The United States Public Health Service did not see fit to make it a reportable disease. When many Americans pondered health menaces from abroad, it was not la grippe that sprang to mind, but the millions of immigrants who had been flowing through the nation's ports and across its borders, perhaps bringing with them more serious diseases such as tuberculosis, typhus, cholera, or trachoma. Moreover, Americans feared that newcomers weakened by illness might be unable to support themselves, becoming dependent upon state and local resources or the charity of their new neighbors. All that changed in 1918.

In 1918, the United States was in the midst of the largest wave of immigration in its history. Between 1880 and the 1920s, 23.5 million newcomers arrived in the United States, most of them from Southern and Eastern Europe, but also from China, Japan, Canada, and Mexico.1 (p. 52) The virulent strain of la grippe that was killing millions across the globe, known to many as the Spanish influenza, inspired fear in natives and newcomers alike. The influenza virus responsible for the pandemic of 1918 killed an estimated 20 million and perhaps as many as 100 million people worldwide. In the United States, approximately 550,000 died, an estimate derived from reporting that was incomplete and uneven at best.24 And, unlike other epidemics, this one took the lives of many young adults between 29 and 34 years of age, not the very young and very old who had been typical victims of other epidemics.5,6 In 1918, the United States was also a nation at war. Many of the young men who died were in the armed services. America's armed forces were hit hard: 32,165 died in U.S. military camps and another 18,136 in Europe.7,8

The flu did not respect borders and boundaries. Those felled by the disease in their home countries suffered and often died and so, too, did migrants who had wandered far from home.1,912 However, while the former wrestled with the disease in familiar places, surrounded by family and familiar institutions, migrants sought to regain their health and cope with their mortality among strangers. Some died of influenza among friends who stood powerless to cure the victim and could only show friendship and respect in how they mourned his passing. One such victim of “the cruel disease of influenza” was Frank Potesto, an Italian-born Denver police officer who succumbed in November 1918. His death was reported in Denver's Italian-language newspaper, Il Roma. Potesto was given a big funeral, “a true testament of the love that the colony [Italian community] wished to bestow on the poor deceased.”13 Others died tragically and alone. And still others died of the very fear that the sight of the suffering engendered. A resident of Hamden, Connecticut, 30-year-old Italian immigrant Maria Brava, acted in plays produced by the local Italian theater company. Brava poisoned herself “because of her worry that she would contract it [the flu].. .. Fearful of the suffering the distraught young woman took her own life.”14

How did native-born Americans view newcomers in the midst of this public health debacle? And how did various immigrant communities respond to the 1918 Spanish influenza epidemic? The presence of immigrants certainly complicated public health officials' battle against the epidemic. Government medical personnel needed to communicate advice and regulations to newly arrived, non-English-speaking immigrants. It was difficult, at times, to secure the compliance of the foreign-born with American standards of sanitation and hygiene, and public health regulations that seemed to them alien to their own beliefs about disease, prevention, and therapy. Foreign-born physicians, ethnic community leaders, and the foreign-language press were important mediators between public health officials and immigrants. They labored to diminish fears of the native-born that newcomers might be responsible for the epidemic. Institutions organized by the ethnic groups to which the newcomers belonged provided much-needed assistance to their own and to others during the crisis.


By the turn of the century, many Americans were ambivalent hosts to the scores of immigrants arriving on U.S. shores. They craved an ample supply of foreign-born labor to fuel American industry, but balked at an open-door policy toward immigration. Quarantines and medical inspection had long been the purview of state governments. However, by 1890, Americans' apprehensions about admitting only healthy and robust bodies resulted in the federal government assuming responsibility for enforcing quarantine regulations and for the individual inspection of newcomers. Those who made it to their destinations with diminished physical or mental capacities could be denied admission.

In the busiest port, New York, a new federal immigration depot was opened in 1892 on Ellis Island. There, officers of the U.S. Immigration Bureau counted and processed immigrants. The United States Marine Hospital Service (later renamed the U.S. Public Health Service) conducted line inspection of all those not traveling first or second class. The latter were inspected in the privacy of their steamship cabins. The medical inspection on Ellis Island was intended to protect the American population from harmful pathogens arriving on the bodies of newcomers and, just as importantly, to exclude immigrants who because of illness or disability would be unable to support themselves. Similar procedures prevailed at Galveston, Texas, Angel Island in San Francisco Bay, New Orleans, and every other U.S. port of entry. Overall rates of rejection were low, rarely greater than 2% to 3%, but improved techniques of diagnosis, including the use of x-ray machines by 1910, increased the likelihood that those rejected would be turned away on medical grounds.1,15 (p. 50–77)

The onset of the influenza pandemic in the fall of 1918 occurred at a time when wartime dangers and dislocations had already slowed immigration to the United States. The total number of immigrants entering the U.S. had dropped to 110,618 in 1918 from 1,218,480 in 1914.16 (p. 105) Immigration depots were not bustling as they had been prior to the war. Indeed, Ellis Island was being used to intern prisoners of war and enemy aliens. The two hospitals on Ellis Island were being used for military personnel and the civilian patients were transferred to medical institutions in New York and New Jersey.17 (p. 795)

While the war slowed the stream of newcomers, the millions of immigrants who had arrived in previous decades were still negotiating their place in American society and culture. Often, they remained in urban enclaves in the port cities where they had first arrived.18,19 However, some moved further inland soon after arrival to locations with occupational opportunities.

At times, native-born Americans' fear of disease from abroad became a rationale for an equally great and preexisting prejudice, fear of the foreign-born, or nativism.1 (p. 9–11, 88–9) Nativists stigmatized particular immigrant groups as the carriers of specific diseases, rationalizing their prejudice with medical and public health arguments. Medicalized prejudice became the foundation for the arguments of immigration restrictionists. Examples of the stigmatization of the foreign-born as disease carriers are ample. In the 1830s, impoverished Irish immigrants were stigmatized as the bearers of cholera.1,20 (p. 32–3; p. 137–8) At the end of the 19th century, tuberculosis was dubbed the “Jewish disease” or the “tailor's disease.”1 (p. 155)

An epidemic or the threat of a potential epidemic enhanced fears of newcomers as carriers of illness from abroad. At times, even public health officers responded with extreme measures. When an autopsy suggested that a deceased Chinese immigrant in San Francisco's Chinatown had died of bubonic plague in 1900, a wave of fear and nativism followed. Chinatown was quarantined, though some San Franciscans wanted to burn it to the ground. Physicians authorized by the Board of Health forcibly inoculated Asians on Chinatown's streets with Haffkine's serum, which at the time was still in the testing stage, to determine its efficacy.1,21 (p. 78–96)

Only two years before the 1918 influenza epidemic, Italian immigrants were blamed for the polio, or infantile paralysis, epidemic that raged through East Coast cities. Children were hit especially hard by the epidemic. In New York, the 1916 polio death rate per 1,000 estimated population of children younger than 10 years of age was 1.63 for Italian children, well below the 3.42 for the native-born or the 3.27 for German children. The reasons remain unknown. However, while the Italian mortality rate for polio was low, the 1,348 polio cases contracted by those of Italian nativity in New York City was the highest for any immigrant group, second only to the 3,825 cases among the native-born. Because there were so many Italian immigrants living in tightly concentrated neighborhoods, and because immigrants were viewed by many as a marginal and potentially subversive influence upon society, the incidence of Italian polio made a dramatic impact upon the imagination of a public already shaken by the virulence of the epidemic and the youth of its victims.

Rumors spread that the epidemic had been brought by immigrants from Italy to the United States rather than contracted here by the newcomers. Some, including visiting nurses participating in New York City's Special Investigation of Infantile Paralysis under the Rockefeller Institute's Dr. Simon Flexner, were angry and impatient with Italian immigrant families. Many Italians did not speak English well and practiced social customs of which the nurses disapproved, such as kissing the dead, part of the Italians' ritualized expression of grief and respect for the departed.1 (p. 108–11) Would the epidemic of Spanish influenza elicit a similar reaction? Would fear of disease and fear of the foreign-born again emerge intertwined?

While the disease was widely called Spanish influenza because the earliest cases were identified in Spain, some blamed the Germans for intentionally spreading flu as a weapon of war. Lieutenant Colonel Philip S. Doane, the head of the Health and Sanitation Section of the Emergency Fleet Corporation who was responsible for the health of the nation's shipyards, raised the possibility that the presence of influenza in the United States was a direct result of covert German submarine landings. “It's very possible that the epidemic began when the commanders of the submarines that approached our coasts had their men make landfall by night. We know they really landed on our coasts because they have been seen in New York and in other places. It would have been very easy for some of them to spread the germs of the illness either in a theater or in another public place.”2 (p. 47) Such theories were discarded. German soldiers, who called the disease “Flanders fever,” were perishing, too, as were French, Belgian, and English soldiers.

If citizens of various nations squabbled over the flu's origins and name, there was only modest backlash in the United States against immigrants, usually highly localized. Many initially thought the influenza treatable, as had been earlier strains of la grippe. Also, newcomers and the native-born seemed equally vulnerable to the disease, and the prevalence of influenza among young, strong men of the American military curbed the tendency of even virulent nativists to brand a particular group of newcomers as responsible because of inferior bodies. In communities throughout the United States, most of the victims were among the native-born majority, while tens of thousands of American soldiers and sailors were losing their lives to influenza rather than enemy bullets. Also, with immigration slowed because of the war, as well as increasingly restrictive immigration laws including a literacy requirement passed over President Woodrow Wilson's veto in 1917, immigrants seemed less menacing. And, nearly 500,000 foreign-born soldiers of 46 different nationalities served in the wartime army.22,23 With so many newcomers or their children in military service, nativism was directed primarily against those of German heritage. Sauerkraut was renamed “Liberty Cabbage,” and German-language classes were dropped from school curricula. Some fearful immigrants anglicized German-sounding names. One hundred percent Americanism was the goal. Stigmatizing the foreign-born as disease carriers, then, was a genre of nativist rhetoric largely, albeit not completely, supplanted by wartime jingoism.

The Spanish influenza crossed class lines. Rich and prominent individuals got the disease. While they often were able to more readily cease work, rest, and seek treatment, death came to them as well as to impoverished members of immigrant groups. In most cities, even despised minorities were not specifically blamed for bringing the flu. In San Francisco, where nativists had stigmatized the Chinese at various times for leprosy, venereal disease, and bubonic plague, there seemed no inclination to blame the Chinese for influenza in 1918.1,2 (p. 78–96; p.96), 21

There were exceptions. In Denver, where policeman Frank Potesto had succumbed to the flu and been honored by his fellow Italians, there was a great deal of anti-Italian feeling. Denver, the home of many tuberculosis sanatoria, had a large number of immigrant patients in its institutions. Only 2,872 of Denver's 250,000 residents were Italian. Still, there was anti-Italian sentiment. Some of it was generated by the nativist American Protective Association and the Ku Klux Klan. As in other cities, Italians in Denver were stereotyped as poor, slovenly, violent, and given to heavy drinking. Their Catholicism and inability to speak English well were marks against them in a city that was predominantly white Anglo-Saxon Protestant. The Dillingham Commission's 1911 report to Congress, a 42-volume study of every aspect of immigrant life in the United States, had described Southern Italians generally as “slow to learn English” and “clannish.” In Denver, the commission observed, “as the number of Italians increases the standards of living are gradually lowered, the good influence of the higher types of races being absent.”24,25 (p. 553–4; p. 18)

The epidemic seemed to hang on longest in Little Italy and Globeville, where many non-Jewish Eastern Europeans lived. Why? An unnamed municipal health department official quoted in the Denver Post cited the newcomers' social customs as the root cause. “When an Italian or Austrian [anyone from the nations included in the Austro-Hungarian Empire] is taken sick, a physician is seldom called, but all the relatives and friends immediately flock into the house to call on the sick person.”26 Poverty, cultural preferences for folk healers, and the desire to be close, not distant, from sick friends and relatives may have been the basis of immigrant behavior, but to the health official this was clear evidence that these newcomers suffered and spread disease because of behavior he regarded as primitive and willfully noncompliant with health authorities' efforts to isolate the sick from the well. The victims were contributing to the spread of the disease. Another public health official was even more explicit: “The foreign element gives us much trouble when an epidemic occurs. They pay no attention to the rules or orders issued by the health department in its efforts to check the disease.” He, too, saw visits to influenza patients as detrimental to confining the pandemic. How many visitors swirled around a victim's bed? Perhaps exaggerating, he reported it was “two or three dozen or more,” thus disrupting any effort to isolate the patient.

Not all the foreign-born in Denver were regarded as irresponsible. The Jewish quarter of the city, the West Colfax neighborhood, was described in the press as having the epidemic under control.26 However, many members of Denver's Jewish community were native-born and of German Jewish ancestry. They were assimilated members of the city's middle class and were considered no threat to public well-being in general. Many of the more recently arrived Eastern European Jews in the community were patients in the various sanatoria and already under medical supervision.1,27,28 (p. 156–70)

Influenza was not classified as a reportable disease by the U.S. Public Health Service in 1918. Thus, most states and cities struck by the epidemic did not accumulate precise data on how it affected ethnic communities. Morbidity data were usually sketchy and incomplete. Connecticut, a state particularly hard hit by the epidemic, managed to compile more data than most other states, data suggesting that new immigrants to the United States had notably higher death rates than the native-born.2931 A post-epidemic study concluded that, “The mortality was relatively low among persons of native Irish, English, and German mother nativity. It was relatively high among persons of Canadian, Russian, Austrian and Polish mother nativity, and exceedingly high among persons of Italian mother nativity. The Italian race stock contributed nearly double its normal proportion to the state death roll during the epidemic period.”29 (p. 215) In a 1921 profile of the pandemic, physician Warren T. Vaughan agreed with the Connecticut study that Italy had suffered greatly from the 1918 epidemic in Europe, and added that “the normal pneumonia rate of the [Italian] race is a very high one.”32 (p. 174)

A later study of Hartford, Connecticut, where ample data were available, concluded that Southern and Eastern European immigrants were major carriers of the disease, and people who came in contact with them were “most likely to contact the flu and die from it.” Newcomers of these groups who lived outside immigrant enclaves still suffered from an “abnormally high number of casualties and died at an accelerated rate.” Available data allow no more than speculation. Perhaps work and social contacts brought sick and well Southern and Eastern Europeans together although they lived apart. Native-born individuals or immigrants not of Southern or Eastern European origin who resided in areas with high concentrations of Southern and Eastern Europeans also had a higher probability of contracting the disease. However, native-born individuals or other immigrants who lived in surrounding neighborhoods without a dense concentration of Southern and Eastern immigrants “were the least likely to contract the disease and, in the aggregate, took the longest to die.”6 (p. 191)

Why were immigrants from Southern and Eastern Europe so vulnerable to the Spanish influenza virus? One hypothesis suggests that many of those arriving from Southern and Eastern Europe were young workers who had come from agricultural communities where the chances of exposure to influenza earlier in their lives would have been small. They had not acquired immunity. Italians, for example, came in particular from southern Italy and Sicily, agricultural regions of low population density. Similarly, many Russian and Polish immigrants were born and raised in small farming villages before moving to cities.30 (p. 420–2) Certainly the poverty of urban immigrant life among new arrivals, and congested living conditions, facilitated the transfer of the virus from one victim to another. Long hours of work and malnourishment left immigrant bodies vulnerable to a variety of illnesses.


Leaders of the various immigrant communities well understood that they had a special obligation to assist public health authorities even as they strove to bring comfort and comprehension to those in their own ethnic communities. The task was to diminish fear of the epidemic among their own even as they diminished the native-born's fear of newcomers as public health menaces.

Prominent physicians, especially those highly respected by native-born Americans as well as their own ethnic groups, were key figures in battling the epidemic. One such leader was Dr. Antonio Stella, a prominent figure in New York City's medical community. Born to wealth and privilege in the southern Italian province of Lucania, Stella was educated in Naples, where he attended the Royal Lyceum. He received his medical degree from the Royal University in 1893. After graduation he immigrated to the United States and was naturalized in 1909.1,33 (p. 20, 80–1; p. 123)

Stella, who specialized in internal medicine, often asserted that whatever health problems Italians in the United States might suffer were acquired on this side of the Atlantic. Speaking of the Italians in their homeland, he described them as “one of the healthiest in the world on account of [their] proverbial sobriety and frugality, also perhaps on account of the fact that natural selection has had there [in Italy] freer play than elsewhere.”34 (p. 66)

Stella's patients were among the 4.5 million from the southern provinces of Italy, the Mezzogiorno, who traveled to the United States at the turn of the century, the most numerous group to arrive in that era. Competition for land and grinding poverty at home increasingly drove young men into seasonal labor migration to the United States and elsewhere. During the summer, they sent back remittances crucial to their families' welfare and the stability of their homeland. In the winter, when excavation and construction work ground to a halt, they returned home, though ultimately many of these workers came to stay and brought their families or married here.

If Stella knew that many Italian laborers found their bodies sickened by hard work and cramped living conditions in the United States, he also knew that physicians such as he were the last place they sought therapy. As is common in many peasant cultures, Southern Italians attributed illness to the influence of one who practiced jettatura (sorcery), through use of the mal'occhio (evil eye), a belief that had no basis in Roman Catholic theology and that the church never succeeded in eradicating. Misfortune was blamed on the influence of “an ever-present menace, the power of envy.”35 (p. 130–42) Witches and wizards who offered folk remedies were the de facto health-care system among the peasantry. Affordable physicians were rare and often were regarded with the same suspicion as priests and landowners. Such fear and loathing of the physician as intruder, common in rural southern towns, was not the case in larger cities such as Naples and Palermo, where a more cosmopolitan view of medicine and its practitioners prevailed.1 (p. 11–119), 36

The ailments that both folk healers and physicians confronted in southern Italy at the end of the 19th century were endemic to poor rural populations. Respiratory diseases such as tuberculosis, influenza, and pneumonia were relatively rare. Still, peasants so feared tuberculosis and its stigma as a certain death sentence that those infected would refuse to use a receptacle for sputum, preferring to spit on the dirt floor of the house as did healthy people.37 This habit of spitting spread not only tuberculosis but other diseases as well, and in 1918 lent wings to the Spanish influenza. How could one improve living conditions and educate the new arrivals?

Stella and other physicians hoped that rational social planning would improve health and hygiene in Italian immigrant communities generally. In an essay on “The Effects of Urban Congestion on Italian Women and Children,” Stella advocated the building of model tenements and distributing job opportunities to various cities to redistribute population. He wrote, “When we shall have given the people clean, healthy homes, full of light and sunshine, we shall have accomplished the physical and moral regeneration of the masses; we shall have given them that to which every human being is entitled, health and happiness.”38 (p. 732)


If individual physicians such as Stella were crucial in mediating between their groups and American society during the 1918 Spanish influenza epidemic, so too were medical institutions organized and supported by religious and ethnic groups to serve their poor, especially newcomers. In the United States, the tradition of such hospitals began with the first Roman Catholic and Jewish hospitals organized in the antebellum period. Roman Catholic hospitals were founded in St. Louis and New York in the 1840s to protect the flock, especially Irish Catholic and German Catholic immigrants, from deathbed conversions by Protestant clergy and to offer the sick the spiritual comfort of mass, sacraments administered by priests, and observance of dietary restrictions. Often nuns served as nurses in such hospitals. German Jews in Cincinnati and New York also sought to provide for their poor and for all Jews seeking medical care in a culturally sensitive environment that included kosher food, religious services, and the ministrations of rabbinical chaplains. As the immigrant communities swelled in the late 19th and early 20th centuries, the number of such hospitals increased, especially in areas of high immigrant residential concentration. Always, admission policies were nondenominational, and such hospitals added badly needed hospital beds to the number available to the entire community.1,39 (p. 44–9; p. 2–6)

During epidemics, ethnic and religiously supported hospitals were on the front lines. At Boston's Beth Israel Hospital, 250 patients with influenza were admitted in the fall of 1918. The mortality rate was 25%, similar to other hospitals across the city. Several of the nurses contracted influenza and one died. After the epidemic ended, Boston's Mayor Andrew J. Peters wrote, “I write to thank you and to convey to the Superintendent my gratitude for the services the hospital has rendered to the city during the influenza epidemic. I assure you that this is no small measure appreciated by all of us.”40 (p. 137–8) At Mount Sinai Hospital in New York, 85 nurses contracted influenza, 18 of whom developed pneumonia, but the hospital took great pride that all the nurses stayed at their posts as long as they could be of service. When the student nurses at Mount Sinai's Training School were instructed by the superintendent of nurses to disband and return home until the epidemic ended, the class voted unanimously to stay and serve.41 (p. 178–9) The physicians and nurses of Baltimore's Hebrew Hospital made home visits in the surrounding neighborhood to treat flu victims, and one nurse/social worker even borrowed an automobile to go beyond the vicinity to see patients.25 (p. 9)

Other immigrant groups were not so fortunate. Chinese people were often criticized by the native-born for being unhealthy, but the native-born did not wish to pay for newcomers' care. Chinese preference for traditional therapies, including herbal remedies, further dissuaded native-born Caucasians from providing medical care to these immigrants.42 (p. 212) In 1900, Chinese merchants in San Francisco financed the Tung Wah Dispensary, which initially offered Western therapies administered by three white physicians. Traditional therapies were later made available to patients at the dispensary. It was at Tung Wah that Chinese victims of the 1918 influenza epidemic could seek treatment. Not until 1925 was the five-story, 55-bed Chinese Hospital constructed in San Francisco. During the pandemic, San Francisco Commissioner of Health William Hassler suggested that Caucasian San Franciscans keep their house servants in their homes and not let them return to Chinatown, lest they bring infection.2 (p. 96)43,44

Some Mexicans living in Texas were immigrants in 1918, but others' families had been living there or elsewhere in the Southwest in 1848, when the United States and Mexico negotiated the Treaty of Guadalupe Hidalgo following the Mexican War. In El Paso, Texas, influenza hit the barrios hard. U.S. soldiers in the area were restricted from entering the barrios and the community's meager resources were overwhelmed. Twenty-two Mexicans infected with flu were discovered in a single room. There was a lack of physicians and nurses who could speak Spanish and there was no hospital in the vicinity. Aoy School became a temporary hospital operated by the Red Cross. As in the case of the Chinese on the West Coast, the native-born Caucasian community was unwilling to spend money on health-care facilities to serve the Mexican community.4548 (p. 146)


While immigrant physicians and hospitals constructed by immigrants to care for their own battled the epidemic, foreign-language newspapers educated and encouraged newcomers in ways to survive the epidemic, by exchanging unhealthy habits for healthier ones. Italian-language newspapers performed an important educational function during the Spanish influenza epidemic. New York's Il Progresso Italo Americano was one of the largest-selling dailies in New York, and sold in other cities as well. It explained to readers that they must pay attention to the Board of Health and follow its advice as articulated by Commissioner Royal Copeland. In September 1918, the paper described the Spanish influenza's symptoms to readers. “Ordinarily. .. the illness begins with a chill that is immediately followed by fever. The fever can oscillate between a minimum of 101 to a maximum of 103 [degrees], the eyes redden, and the patient is taken by violent and spasmodic fits of coughing.” The course of action: “One must immediately go to bed and call the doctor.”49 As for young people who might feel the onset of illness in class, “In school, children who suddenly feel a chill must immediately be sent home and put to bed.” However influenza arrived, Il Progresso wanted its readers to know that there was no serum to stop the infection. It advised, “One must isolate the patient immediately upon diagnosis and keep him in a well-ventilated but also warm room,” administering water and quinine.50

Throughout the epidemic, Il Progresso and other newspapers sought to persuade Southern Italian readers to abandon traditional practices that might in time of epidemic prove harmful. One of these concerned the routine expression of affection through kissing on the lips, especially with respect to the young. In January 1919, Il Progresso reminded readers, “One should never kiss children on the mouth and should avoid kissing them as much as possible.”51

As the fall of 1918 wore on, the Italian community received reports in Il Progresso of what New York was doing as compared with other communities to curb the number of cases. Il Progresso also reported expressions of support for Copeland's approach. For example, while Massachusetts and New Jersey had closed all public schools, New York kept its schools open. Copeland was influenced by the advice of the prominent physician and public health officer, S. Josephine Baker. Baker founded and headed the Division (later Bureau) of Child Hygiene within the New York City Health Department, the first government agency devoted to the medical problems of infancy and childhood. In her autobiography, Baker recalled how and why she had objected to Copeland's plan to close the schools. She asked him, “If you could have a system where you could examine one fifth of the population of this city every morning and controlled every person who showed any symptom of influenza, what would it be worth to you?” When Copeland answered “almost priceless,” Baker explained, “I want to see if I can't keep the six- to-fifteen -year age group in this city away from danger of the ‘flu'. I don't know that I can do it, but I would awfully well like to have a chance.” Copeland gave it to her and she succeeded: “The number of cases of influenza among children of school age was so small as to be negligible. There was no evidence at all, in this age group, that there had been any epidemic of influenza in the city. The number of children absent from school because of illness was lower than it had been for the same period the previous year.”52,53 (p. 155–6; p. 330–1)

While Italians tended to hold their children close, even preferring that they eat lunch at home with family rather than with strangers in school, they supported Copeland's decision to keep the schools open as a measure that would be safer for children than closing them. At home, the young children might be playing out of sight in the streets, while in school, “a sick child cannot escape the teacher's watchful eye. Moreover, in the schools hygiene and ventilation are better cared for than in many houses,” the paper reminded readers.51 Edicts of the Board of Health must be obeyed or the violators would be punished, Il Progresso admonished readers. “Very strict orders have been issued against those who do not scrupulously follow hygienic measures or don't use a handkerchief when they expectorate. These infractions will be punished with both fines and jail time.”54 Yet, even as the newspaper tried to frighten those inclined not to obey the Board of Health, Il Progresso also sought to replace rumors with truth, such as the one that “nurses and doctors, guilty of spreading the flu and pneumonia germs among the soldiers, have been shot to death at dawn.” The newspaper told readers, “No rumor is more insidiously false than this.”55

The Italian newspapers were not alone in their desire to educate and thereby protect their group from both the epidemic and nativist charges of inferiority. Yiddish-language newspapers served a similar function.

Some 2.25 million Eastern European Jews arrived in the late 19th and early 20th-century era of mass migration, the second largest group after the Italians. Anti-Semitism and charges that the Jewish body was inherently inferior to the Christian body were ubiquitous in Europe. In the United States, immigrant physicians such as Dr. Maurice Fishberg, a Russian-born physician and amateur anthropologist, collected data to refute allegations that Eastern European Jewish immigrants were inherently sicker than the general population.56 (p. 41) Instead, Fishberg and others argued that Eastern European Jewish immigrants often arrived in ill health because they had lived impoverished lives, with inadequate nutritious food, poor sewage, and contaminated drinking water. Their pre-departure environment was typically a frigid breeding ground for disease. And conditions after arrival were usually not much better: long days in filthy sweatshops, nights in congested, ill-ventilated tenements, and wages too low to afford a well-balanced diet. Although physicians held a place of great admiration and respect among Eastern European Jews, physician care was a luxury that few could afford. Not surprisingly, the Spanish influenza epidemic of 1918 aroused fears of anti-Semitism within the Jewish immigrant community. History had taught Jewish spokespeople that they must at all costs deflect blame for the pandemic away from Jewish immigrants less they trigger the sort of medicalized anti-Semitism they had left Eastern Europe to escape. At the same time, the health and safety of the people had to be protected by discussing disease prevention in every available public forum. In Denver, public health officers praised the Jewish community for its compliance. What would happen in communities with even higher concentrations of Eastern European Jewish immigrants?

The Forverts (also known as the Jewish Daily Forward and hereafter Forward) was New York's Yiddish-language daily newspaper, launched in 1897 by the Forward Association, dedicated to the cause of democratic socialism. At its zenith, it was one of the most widely read newspapers in the country, with a circulation of 200,000 in 1924. Many people who were illiterate, including many Eastern European immigrant women, had Forward articles read and explained to them by those who could read. Under the editorship of Abraham Cahan from 1911 to 1953, the paper became an essential element in the life of the Jewish immigrant community and Cahan labored not only on behalf of trade unionism and socialism, but on behalf of his community's health, well-being, and integration into the broader life of American society and culture. If Jewish immigrants were to tread the road to assimilation and acceptance, they must be healthy and robust.

In the fall of 1918, the Forward's first task was to explain the illness to the Jewish immigrant community and explain why cases must be reported. The paper warned, “Influenza is often the prelude to pneumonia, which ends very often with death.” Noting that previously flu need not be reported, the article emphasized, “The Health Commissioner has ordered that from now on, doctors should report on every case of influenza and pneumonia, exactly as they do for [other] contagious illnesses.”57 Likewise, the Forward kept its readers apprised of the epidemic's spread.58,59 (p. 20, 47–8; p. 288) On September 21, the paper informed readers that 47 new cases had been reported to the New York Board of Health, but that the Commissioner had been reassuring nevertheless and explained that meetings were being held to prevent the flu's transmission. Meanwhile, the Forward advised readers to “be cautious; if anyone should sneeze, he should not sneeze into someone's face, but into a handkerchief.” Such advice did not consider the obvious. For impoverished immigrants, many from rural villages, standards of etiquette and urban hygiene were still lessons to be learned. Not everyone owned a handkerchief.

Throughout September, the number of newly reported cases mounted. On September 25, a Forward headline warned, “Influenza Spreads: 150 New Cases; Doctors Warn.”60 Now almost every issue included “new rules” on flu prevention.61 The Forward advised readers to not use hand towels in public places and not to drink from cups that others had used. Knowing the popularity of candy stores and soda fountains in immigrant neighborhoods, Yiddish-speaking Jews were reminded, “Above all you should in particular be careful in ice-cream soda places: do not drink if the glass has not been completely and appropriately cleaned.” There were warnings against public spitting and using “any napkins, handkerchiefs, clothes or bedding that an ill person has used.” In a community where many smoked, pipe smokers were reminded, “Do not smoke from a pipe that has been in another's mouth.” While few Jewish immigrant households in this era had their own telephones, many used public phones and were reminded, “When you speak on the telephone, keep your mouth farther from the receiver.” These were familiar words of advice, not unlike reminders designed to avoid transmission of tuberculosis, the bane of impoverished immigrants. Children were of special concern and readers were cautioned, “Do not let your child play with things that belong to other children.”62

Who was the authority? To whom ought immigrants pay attention? The Forward's readers, like those of the Italian newspapers, were told to heed the directives of Health Commissioner Copeland. When in October 1918 Copeland ordered all stores except food stores to close no later than 4 p.m., readers were told that he had “consulted with [other] doctors and superiors.”

Still, because of its ideological commitment to socialism and to the Socialist Party, the Forward was critical of Copeland, whom they regarded as a pawn of New York's Democratic machine, Tammany Hall. They blamed any inadequacies of New York's response to the epidemic squarely on the very economic system upon which American politics, including Tammany Hall, was constructed—capitalism. Hardly shy in proclaiming its own party preferences, the Forward observed, “The only political party that puts in its platform the requirement that the Board of Health should improve its activity, spread to every resident's house, in every shop in every factory, in every school, everywhere where people live, work, and gather; the only party which has always known how necessary it is that the city government should watch over the health of the residents and especially the health of the worker—was and is the Socialist Party.”62

Among rich capitalists, landlords had long been favorite targets of Forward socialists and now Forward arguments were fueled by the Board of Health's order that landlords not wait until November 1, the date when they were legally required to begin giving tenants heat. The article quoted the order, “Each home in the city must now be heated. It is a danger for people who are recovering from influenza and pneumonia to be in cold houses. Cold residences also encourage the development of the sickness.” The paper indignantly demanded compliance, asking rhetorically, “They [landlords] know that for every dollar that they save on coal, a father of children, a mother of babies might pay with (his or her) life. But what sort are they?”63


If newspapers such as Il Progresso and the Forward mediated between the public health establishment and their respective non-English-reading communities, there was also an opportunity for the ethnic communities to act directly on behalf of their members' health. Jews, especially, had a long history of fending off anti-Semitism by being self-sufficient. They could not then be accused of burdening the communities where they resided. At the time of the influenza epidemic, New York's Jewish community had formed a kehillah, a communal organization to govern itself. The purpose was not to resist assimilation, but to promote ethnic pluralism, whereby the group could aid and support individuals making the transition to life in the United States. Communalism could allow newcomers to share burdens of their existence in a way that American individualism did not. The intent was never anti-Americanism. As historian Arthur Goren observes, “even as immigrants built institutions to preserve the solidarity of their particular group and to provide a measure of personal security, they endeavored to fit these institutions into the American social landscape.”64 (p. 2)

Although it only lasted from 1908 to 1922, the New York Kehillah published the names of 65 Jewish organizations in New York where help and information were available during the influenza epidemic.65 One such organization, the Workmen's Circle or Arbeiter Ring, offered medical assistance to its members and their families. Funerals were an equally important matter. Observant Jews must be buried in sacred ground separate from non-Jews. In the fall of 1918, the Workmen's Circle appointed its first funeral director to watch over the growing number of funerals of flu-stricken members in the Greater New York area wanting to be buried in Workmen Circle cemeteries. During the height of the epidemic, there were 14 to 16 funerals a day among Circle members, an unprecedented daily toll.66 (p. 2)

Religious organizations in the immigrant communities also sought to protect their communities. Many churches agreed to remain closed during the epidemic or increased the number of masses to spread out the congregation and prevent opportunities for infection. In the Jewish community, the head of the rabbinic court or Beis Din of New York announced that Jews in mourning who must sit shiva “can and must be lenient with regard to the laws of mourning.” Mourners were required by Jewish law to stay at home, do no work or domestic tasks, or even change clothes or bathe. However, because of the flu, mourners were told, “He who lives in narrow rooms or such a one who must have fresh air may go around outside for a few hours each day on account of health.” The bereaved were told they could buy food and need not go barefoot, “even at home, but wear shoes in order not to catch a cold. God forbid.”67


When the influenza pandemic of 1918–1919 passed into history, it left behind a storehouse of memories, personal and public.68 (p. x–xi) Medical personnel and public servants who performed heroically were memorialized. And in most communities there was no need to express regrets about outbreaks of nativism occasioned by the epidemic. The preexisting patterns of nativism that existed before 1918 did not vanish, but neither were they fueled by this public health crisis.

As historian of medicine Charles Rosenberg has observed, the defining aspects of an epidemic are “fear and widespread death,” but also “their episodic quality.” An epidemic, he reminds us, is “an event, not a trend.”69 The Spanish influenza pandemic was an event that struck fear in the hearts of millions of Americans as they watched beloved friends and relatives die. Not all reacted as did Italian immigrant Maria Brava, who committed suicide rather than experience the suffering that preceded death from influenza, but the epidemic left a lasting imprint upon the collective memory of those who watched it progress in 1918 and 1919, including the newest Americans, immigrants.

Significantly, the epidemic does not appear to have triggered a wave of medicalized prejudice. However, the fear of such a nativist reaction, as well as the impulse to assist their own, energized spokespeople and institutions in the various ethnic communities. Physicians such as Antonio Stella and institutions such as hospitals operated under ethnic and religious auspices, and voluntary and religious organizations all offered care and comfort to newcomers. They sought to alleviate the complexities and tensions of an ethnically plural population facing a terrifying public health crisis. Foreign-language newspapers educated their readers and, at times, mediated between public health authorities and the immigrant community. All sought to untangle the double helix of health and fear created by an episode and a trend, the intersection of the Spanish influenza pandemic that would last for months and the wave of immigration that had been in progress for decades.1 (p. 1–9)


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