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Public Health Rep. 2010; 125(Suppl 3): 134–144.
PMCID: PMC2862342

“It's as Bad as Anything Can Be”: Patients, Identity, and the Influenza Pandemic


Americans were stunned when pandemic influenza hit the United States in 1918. Recent advances in bacteriology and public health allowed Americans to imagine a future free of infectious disease, even as their familiarity with influenza tempered their fears of it. They soon realized this influenza was something unprecedented, as it shocked them with its pace, virulence, mortality patterns, and symptoms. Patients endured and frequently succumbed to a miserable illness, their suffering often made worse by the chaotic circumstances the epidemic produced in families and communities and shaped in significant and sometimes discriminatory ways by their gender, class, and race. While the nation's public culture soon forgot the epidemic, it lived on in lives changed irrevocably by its consequences. As they face present and future influenza pandemics, Americans can learn from this earlier experience, guarding against identity-based discrimination and acknowledging and remembering the grief and loss fellow citizens suffered.

In 1939, the writer Katherine Anne Porter published what would become her best known work, the novella Pale Horse, Pale Rider. Her story follows 24-year-old Miranda through her romance with a young soldier named Adam, the narrative soon interrupted by Miranda's struggle with influenza. From the beginning of the novella, Porter alludes to the surrounding epidemic, but only slowly submerges Miranda in the symptoms of the disease, allowing the severity of her situation to dawn on the reader only gradually. Finally, though, Miranda acknowledges she is ill. Though her neighbor's response is initially only a simple exclamation of “Horrors,” and a recommendation that she go to bed “at once!”, her later description of Miranda's influenza as “a plague, a plague, my God” suggests the fear her illness provokes in those around her. As Miranda slowly succumbs, the reader learns of a broader crisis surrounding her, as Adam explains the seriousness of the epidemic unfolding beyond the walls of her room: “It's as bad as anything can be. .. all the theaters and nearly all the shops and restaurants are closed, and the streets have been full of funerals all day and ambulances all night.”1

But Porter does not limit the reader to Miranda's surroundings. Following the conversations of her characters, and later Miranda's internal dialogue, Porter allows her readers to follow Miranda's complex and unfamiliar path through her sickness, beginning with a shadowy sense of foreboding and loss as the illness develops. When Miranda descends into fevered dreams, passing back and forth from consciousness to unconsciousness, Porter lets her readers experience the peace and the terror, the coherence and the confusion, through which her patient passes: “Her mind split in two, acknowledged and denied what she saw in the one instant, for across an abyss of complaining darkness her reasoning coherent self watched the strange frenzy of the other coldly, reluctant to admit the truth of its visions, its tenacious remorses and despairs.” As death approaches, Miranda is briefly freed from her fears and finds comfort, “tranquility,” “an amazement of joy,” and relaxes, “questioning nothing, desiring nothing, in the quietude of her ecstasy.” But death is not to be hers. In the end, Miranda returns from the brink of death, but does not celebrate her recovery, returning to the living, instead, with a sense of distance and of loss.1

Pale Horse, Pale Rider survives as one of the few American literary accounts of the worst influenza pandemic in recorded history, a catastrophe that struck the world in the fall of 1918. When the outbreak began, Porter was a journalist, writing for the Rocky Mountain News in Denver. Porter suffered a very serious case of influenza during the epidemic, and lost her fiancé to the disease during her own illness. Porter was sick enough that the newspaper prepared her obituary, and her recovery was slow and troubled.2 Though fictionalized, her autobiographical novella follows Porter's experiences closely, and reclaims for us the experiences of patients and their loved ones as they faced the traumas of the epidemic. These were stories largely left untold in the annals of this catastrophe.

As historians have explored the epidemic of 1918, the experiences of the patients themselves have remained almost entirely in the background. This is understandable. While influenza that fall was a national, indeed international, phenomenon, and one that carried significant consequences in the public life of the United States, for those who became ill with the disease and for the families and friends who were their most immediate caregivers, influenza was a drama acted out in private. Even for those who suffered in public spaces—in the hallways of city hospitals, in the tents of hastily constructed emergency wards—their travails were intensely private experiences, rarely documented in any public way. Even doctors admitted that the chaos of the epidemic often prevented their maintaining proper records of their patients' illnesses.

And yet the story of the patients who suffered from influenza and the loved ones who tended them must be central to any real understanding of the influenza pandemic. As the historian Roy Porter has suggested, the history of medicine is incomplete without a “patient-oriented history,” a history that documents the patient's experiences as well as the beliefs and behaviors that framed those experiences. Such a history, Porter makes clear, serves to “restore to the history of medicine its human face.”3 This essay seeks to capture the contours of this human face.


For Americans facing influenza, the story of the epidemic was essentially a story of suffering—of patients tormented by an agonizing and often deadly disease, of caregivers frightened and confused by the horror unfolding in their midst, of families fractured by grief and loss, and of communities subjected to the chaos of the epidemic.

It is difficult, perhaps impossible, to comprehend the trauma of the epidemic from the distance of decades. Even at the time, commentators frequently acknowledged that the epidemic strained the imagination, confronting them with scenes so foreign to their experience that words failed them. “You have no idea what havoc this Influenza has wrought every where,” one letter writer explained in mid-October.4 “You cannot imagine how it has scourged the country,” lamented another.5 Or as one Red Cross worker who had seen Camp Dodge, a military post in Des Moines, Iowa, changed in a day, suggested simply, “Words cannot convey the situation.”6

An unexpected scourge

An unimaginably dreadful experience, the ordeal of the epidemic was heightened by the ways in which it surprised its victims. Americans of the early 20th century were not unfamiliar with epidemics, and life-threatening illnesses from tuberculosis to polio remained common features of their lives.710 Health conditions were especially bad in the cities, where more than one in 10 newborns died before the age of one, and poorer urban residents suffered particularly dismal health circumstances. The southern states wrestled with their own health blights, such as malaria and parasitic ailments, and for the most part, did not benefit from promising developments emerging in public health.8,11

By the early 20th century, these promising developments were many, and were not limited to the arena of public health. In the late 19th century, the new field of bacteriology had verified germ theory and in succeeding decades, discoveries of the causal relationship between specific microorganisms and particular diseases seemed to promise the elimination of several illnesses that had long plagued American health. Public health measures evolved alongside these scientific gains and contributed in significant ways to the efforts to identify, track, and eliminate particular disease agents and to educate the public on measures to aid in their control. By 1918, life expectancy was on the rise as Americans employed a vast arsenal of vaccines, anti-toxins, and public health measures such as quarantines, mosquito control, and the regulation of water and milk supplies against several major afflictions.8 Taken together, these successes encouraged at least some Americans to imagine infectious disease might soon be a thing of the past.1113 The New York Health Department declared in its popular maxim, “Public health is purchasable. Within natural limitations a community can determine its own death-rate.”11

Not every disease, however, was so easily controlled, and influenza was one of those that continued to torment Americans. Despite reports in 1892 that the influenza microbe had been discovered by Dr. Friedrich Johann Pfeiffer in Berlin, influenza remained a mystery to scientists and a common plight for Americans. Indeed, influenza was a disease whose visitations, even deadly ones, were assumed. The nation, along with much of the world, had faced a significant epidemic in 1890 and another more limited epidemic outbreak in the winter of 1915–1916. Even in non-epidemic years, Americans expected influenza to bring significant sickness to their communities. And yet despite this familiarity, or perhaps precisely because of it, influenza did not generate fear or garner much public attention, a reality that many physicians and public health officials lamented.1417 As The New York Times reported in 1901, “Influenza has apparently become domesticated with us.”18 As a result of this complacent attitude, when the first wave of the epidemic swept through the United States in the spring of 1918, it went almost entirely unnoticed and unheralded.

But when influenza struck the nation in its second wave in the late summer of 1918, it was quickly obvious that nothing had prepared Americans for the scourge they now found in their midst. This disease was different, first of all, in the efficiency and pace of its spread. Arriving in the United States in Boston on August 27, within a few weeks influenza had spread to neighboring communities, and by the end of October American cities from Buffalo to Birmingham and from Pittsburgh to Portland were drowning in a sea of disease.19 In turn, this new incarnation of influenza was shockingly infectious, recording a morbidity rate of roughly 28%.2 Gone, too, was the annual visitor that sickened many but killed few and picked its fatalities from among the elderly and the very young. This influenza brought death to an estimated 550,000 Americans and perhaps 50 million people worldwide, and struck with sufficient ferocity among young adults to lower life expectancy in the United States by 12 years.2,20,21 Such a disease soon created a profound sense of disturbance, disorder, and chaos in the lives of Americans. As one correspondent described the situation, “The whole world seems up-side-down. So many people around here have died, and so many are sick.”22

“The worst sickness I ever had”

It was not just the numbers or patterns of infection that shocked Americans, though. This influenza was unfamiliar, and often horrifying, in its symptoms as well. While a small percentage of sufferers escaped with mild cases, enduring only the usual aches, fever, and cold-like symptoms of the more familiar influenza, the remaining victims endured illnesses that bore only scant resemblance to a normal case of the flu. For some the problem was Spanish influenza itself, a disease that, in its worst cases, advanced with shocking rapidity and brought very high fevers, head and body aches, prostration, edema in the lungs, and belabored breathing.

Though for some these initial symptoms passed without complications in a week or so, for others the suffering grew worse. Delirium and unconsciousness often followed, and as the lungs filled, a blue or purple coloring overcame the extremities and the face. For some, too, bloody fluids drained from the nose, creating a grisly scene for families and caregivers. Death soon followed. Some patients died in a day, though most endured a longer illness—perhaps three or four days, a week, or 10 days of crisis. Others suffered what at first appeared to be a standard influenza infection, but an infection that soon paved the way for pneumonia, which ravaged the lungs and again brought death to many. Even for those lucky enough to recover, the illness might last several weeks and leave long-term health problems in its wake.

Occasionally patients documented their encounters with influenza, providing a window into the world of distress the epidemic's victims suffered. Franklin Martin kept a diary for his wife, Isabelle, during a postwar tour of Europe, and when he sickened during the third wave of the epidemic, managed to continue recording his experiences.23 On January 12, 1919, on board a ship headed home, he noted that he had “felt chilly all day and after noon went regularly to bed.” Though he went to lunch the next day, he was still cold, and returned to bed that afternoon, and despite “all the blankets I could get was still cold.” With a fever of 105, his condition soon worsened. “About 12 o'clock I began to feel hot. I was so feverish I was afraid I would ignite the clothing. I had a cough that tore my very innards out when I could not suppress it. It was dark; I surely had pneumonia and I never was so forlorn and uncomfortable in my life.” Fearing the worst, Martin planned his own funeral. “Then I found that I was breaking into a deluge of perspiration and while I should have been more comfortable I was more miserable than ever.” Daybreak found him in a wretched state: “When the light did finally come I was some specimen of misery—couldn't breathe without an excruciating cough and there was no hope in me.” Others shared Martin's perspective that Spanish influenza had been a terrible experience. One soldier, who claimed he had suffered only “a slight touch of it,” nevertheless maintained, “It certainly is the worst sickness I ever had.”24 Or as another victim, Clifford Adams, stated succinctly, “I got to the point where I didn't care whether I died or not.”25


The effects of the epidemic were heightened exponentially by the ripple effects of scarce medical resources and lack of social services to support families battling with the illness or the deaths of primary breadwinners. Deaths from influenza also taxed communities' abilities to bury the dead, heightening the stress of grieving families.

A crisis of medical and social resources

The misery of patients was often worsened by the shortage of available medical care. When the epidemic struck, it assaulted a nation strained by the demands of war, including the scarcity of medical help caused by the military service of doctors and nurses. In Philadelphia, for instance, 26% of the city's doctors were in the ranks of the military; an even higher percentage of nurses was absent. At one of the city's hospitals, three-quarters of the medical and surgical staff were unavailable due to military service.2 The shortages were often made more serious by rural circumstances, leading the Red Cross to call special attention to the difficulties in Kentucky where “the unbeatable combination” of isolation, “bad roads,” limited railroad links, and a shortage of nurses created an especially dire situation.26 In cities and rural hamlets alike, wartime shortages made certain that countless families in desperate need found themselves unable to acquire the aid of any health-care professional.

Within families, too, the already difficult situation of an influenza illness was often worsened by epidemic conditions as multiple family members sickened simultaneously, creating chaos in the home. Reports during the epidemic repeatedly cited cases of entire families stricken by the disease. As one nurse in New Jersey described her experience during the epidemic, “I had whole families down with it at once.” Detailing one such case, she continued, “The father and eight children in one home and then the [pregnant] mother came down with it, and labor came on ahead of time. The man got up and staggered round the house, just keeping up the fire and giving milk and medicine.”27 With entire families bedridden, disorder often followed. “Many distressing scenes were witnessed by the nurses,” explained a report on the Emergency Nursing Service in New York City during the epidemic. “In one family two children were found dead, and the father and mother and three other children so ill that they were unconscious of the fact.”28 A report from the Red Cross in Baltimore acknowledged that such circumstances were not uncommon: “Conditions were found by the nurses in most cases visited to be of most serious nature, requiring immediate attention. Several cases reported revealed the fact that there were not only two and three sick patients in one bed at a time but a dead body as well.”29 As families faced multiple illnesses, the ability to take care of one another was often severely compromised.

Struggling against a terrible sickness in the context of the epidemic, families suffered the “torments of Hell” as they agonized over the condition of their loved ones or suffered the grief of a family member's death.5 In the epidemic's aftermath, the Reverend Francis J. Grimke, a leading advocate for African American rights and the minister of the Fifteenth Street Presbyterian Church in Washington, D.C., worried about “the large numbers that have been sick—the large numbers that have died, the many, many homes that have been made desolate—the many, many bleeding, sorrowing hearts that have been left behind.”30 As Grimke suggested, for many Americans the trauma of the epidemic only grew as families mourned members lost to influenza.

Communities and families in disarray

The pain of loss was often exacerbated by the realities of community and familial disarray survivors confronted. At the height of the epidemic, for instance, many communities were overwhelmed by the sheer quantity of dead bodies, and struggled to handle them in accordance with popular custom. “I can to this day see the ‘cords' of bodies stacked in the Base Hospital. They were dying faster than the bodies could be taken care of,” one soldier remembered years later.31 Again and again, accounts of the epidemic described bodies “piled up like cords of wood,” awaiting the respectful treatment normally accorded the dead.32 In some cases, shortages of caskets, undertakers, morgue space, or gravediggers led to ghoulish scenes, while in others bodies sat unclaimed by families so stricken by the flu themselves that they could not shoulder the responsibility for their dead.3335

All of these problems came together in Philadelphia, perhaps the city hardest hit by the epidemic. As the Pennsylvania Council of National Defense reported, “It is doubtful whether the city of Philadelphia, at any time in its history, has been confronted with a more serious situation than that presented in connection with the care and burial of its dead during the recent epidemic.”36 Early in the epidemic, the result was a horrific situation in which “decomposing human bodies rotted in crowded mortuaries” and in the city's morgues.37

In turn, restrictions on public gatherings in many cities and towns meant families were not able to give their loved ones what they considered a proper funeral, and were left to grieve entirely in private. Again, Philadelphia was an especially exaggerated example. Because the epidemic was so serious in that city, the restrictions covering funerals were particularly prohibitive. Orders required that services for anyone dying of influenza be private, that “only the immediate adult relatives of the deceased who may not at the time be sick with epidemic influenza” might attend, and that no church or public building could be used if the body was to be included in the service.38 Similar rules applied in other cities and towns throughout the country. For many families, then, the pain of their losses was coupled with an inability to fulfill their full responsibilities to their loved ones or to grieve with the support of their community.

In addition to public chaos, many survivors suffered the disruption or complete destruction of their family unit. Children left without parents, for instance, presented both a pressing problem for communities and an unspeakable tragedy for the orphans. In some cases, if the children were old enough, they faced early adulthood, taking charge of their own lives and those of their siblings in the wake of the epidemic. In most cases, though, orphans became the responsibility of extended families or faced institutionalized care.39 As the writer Mary McCarthy recounted of her experiences as an orphan, even those children taken in by relatives sometimes suffered from the rejection of unfeeling families and a sense of being abandoned, unwanted, and helpless.40


Though the influenza virus did not discriminate among its victims, in a country in which identity mattered, Americans' suffering was often shaped not only by the disease, but also by their “place” in the society: by their gender, class, and race. Even in the private suffering of patients and their families, the power of social identity shaped the vastly varied experiences of the epidemic.

Gender and social roles

In an age of strict adherence to gender roles, the loss of even one parent could plunge families into disarray as survivors were left to handle not only their own responsibilities but also those of their spouses. Men who lost wives sometimes found themselves responsible for children, a role for which many were not prepared or socially sanctioned. For Lillian Kancianich, who was born just a few months before the epidemic in 1918, her mother's death meant the break-up of her home. Because local custom discouraged older men from living alone in a household with children, her older sister Christine was sent first to boarding school, and later to live with her mother's relatives in Minnesota. Lillian would not find a stable home for two years. “No one adopted me,” she recalls. “I just went from home to home … I had six different homes.” Kancianich eventually settled in to live with relatives, and was able to see her father every day. Even so, the loss of her mother had an enormous impact on her life. As she explained decades later, the flu epidemic and her mother's death “changed my life completely… . It had to.”41

The story of Kancianich demonstrates not only the familial dislocation caused by the epidemic, but also the powerful impact social identity sometimes played in shaping individuals' experiences of the scourge. At first glance the epidemic would seem to have challenged social norms. Morbidity and mortality rates make clear that influenza was not selective in its victims. Social identity—a person's gender, class, or racial status, for instance—affected neither the likelihood of infection nor one's chances of surviving the attack. In the end, though, social identity did matter. Though the virus struck indiscriminately and the entire nation suffered, the experience of the disease and the epidemic was often shaped by a person's perceived “place” in the society.

As Kancianich discovered, gender often played a substantial role in shaping Americans' experiences with the epidemic. In this case, the meaning of her mother's death was shaped by the assumptions of her community that without her mother in the home, it was inappropriate for her father to raise his daughters, a common view that left countless children without homes. The loss of a father often led to different costs, leaving the remaining family members scrambling to make a living. As one Red Cross worker in Kentucky explained, “A large number of cases were reported where the mother was left with a large family of children without any means of support: left really to the mercy of the meager assistance that sympathetic neighbors might give.42 In some cases, the problem was solved by a woman's transition from the home to the workplace. With a common refrain, a woman widowed in Vermont during the epidemic explained years later, “My husband die [sic] from pneumonia at the time of the influenza… . It was hard for me to get along after he die [sic].” As was common for working-class families, this woman soon went to work, in this case crocheting altar linens. She recognized her good fortune in having this skill: “I always say it is lucky for me that I learn to do this work. How else then could I support myself and three children, except that I scrub floors and do hard work all the time?”43 For many others, such work was all that kept them from complete destitution.

Other families solved this crisis by sending children to work. For Melvin Frank, for instance, life was irrevocably altered by his father's bout and eventual death from influenza. “By whatever name, the disease was a killer and scarcely any household in our north side neighborhood was unaffected,” he explained. “It brought eventual tradegy [sic] to our house.” Frank recounted his father's cardiac asthma, a condition aggravated by his influenza in 1918. Eventually his father became a “bed patient,” and the entire family suffered over his condition, and when he was finally hospitalized, the family became still more depressed. “Gloom descended,” Frank remembered. “A sob was close to the surface.” Though his death came in June 1920, long after his exposure to influenza, Frank's father was nevertheless a victim of the epidemic, and his passing no less tragic for its delay. Upon learning of his father's death, Frank found himself “reeling” from the news, “for my world had tumbled in.” Like many other young people in that time, Frank found himself prematurely grown, told that he was now “the man of the family” at the tender age of 12. A week after the funeral, Frank went to work, his childhood over as he assumed the role of breadwinner.44

The epidemic and the crisis of poverty

As these stories make clear, in addition to gender, class also had a profound impact on Americans' experiences during the epidemic. For the poorest families, the basic problems of the epidemic were worsened by material need. With no financial cushion, lost wages, even for a short time, might mean hunger, cold, or even homelessness. The story of the [D] family in Minneapolis reflected how easily the epidemic could derail the fortunes of a family already living in poverty.

This family first appeared in the records of the Associated Charities of Minneapolis in 1916, when the family sought help with their rent and furniture payments. Though they had left Georgia for Minnesota in 1915 in hopes of both a better climate and employment, by March of 1916 Mr. [D] had yet to find a steady job, and records suggest the family rarely experienced financial stability. In December 1918 influenza struck, infecting first the father and later the remaining family members—his wife and five children. By December 28, the father had “been out of work for three weeks” due to his own illness and then that of his relatives, and the family was in need of groceries. For the first two weeks the family had managed on their meager savings and on money sent from a relative. After that, though, the family became frantic, and approached the Society of the Friendless for aid. Soon the Associated Charities of Minneapolis would resume their responsibility for the family.

By December 30, though Mr. [D] had assured case workers that he would return to work, relapses in the family had made such a return impossible. “He had dared not go to work that morning and leave the six of them sick,” the report explained. At this point, the situation became desperate: “They were absolutely without coal and he had borrowed a pailful from the woman downstairs. The groceries were also gone. He had tried his best to get credit at the grocery but had been unable.” Calling his workplace that day, Mr. [D] discovered he had lost his position. At that point, “Mr. [D] broke down and cried, saying everything was against him, just when he was trying to get back on his feet, everything went wrong.”45 Though the [D] family's problems did not originate with the epidemic, it was clear that their already insecure situation was worsened by their bout with influenza, a consequence suffered by many poorer Americans.46

As working-class families faced desperate conditions brought on by the epidemic, charities recognized an ideal opportunity to intervene in working-class homes. Targeting the poor as a particularly problematic population, middle-class distributors of charity regularly distinguished between the “deserving” and “undeserving” poor and attempted to use the distribution of aid as a mechanism for shaping the behavior of their clients.47 At its best, this effort might take the form of education on “the value of cleanliness, of sanitation, of ventilation, of isolation” in fighting illness.48

At times, though, the relationship could prove considerably less friendly, as appeals to the charity system could involve working-class families in extensive dealings with charity organizations and even the local justice system, as evidenced in the case of a poor immigrant family in Minneapolis. In this case, initiated by the illness of the mother, the male member of an unmarried couple appealed to the Children's Protective Society (CPS) in late November 1918 for help during the woman's bout with influenza, seeking in particular boarding for their one-year-old child. In mid-December, a social worker discovered on a visit to the home that the couple was not married, and from here the case record discusses repeatedly the couple's unmarried status. Later entries in the record develop further the theme of immorality in the home. On January 20, for instance, the social worker noted that the man's “breath smelt strong of liquor.” The woman of the household, by this point, had recovered from influenza, but the caseworker noted on January 23 the “very dirty condition” of the room, and the “very careless” appearance of the woman, whom she described further as “dirty” with her “hair uncombed.” Four days later the case appeared in Juvenile Court, where the woman was described as “totally ignorant of any moral laws, altho [sic] not what you could term a common prostitute.” With the interpreter unable to attend the hearing, the clients' ability to defend themselves was surely compromised, and on February 3 the court ruled that the man would be required to pay the board for the couple's child, and that the woman's two older children would be temporarily removed to an orphanage. As the case record explained, the woman “would be expected to show improvement and desire to live more cleanly.” Later that month, the woman announced that she was now married, and began the lengthy process of reclaiming her children. It was June before she succeeded. The children remained in temporary custody of the CPS for six months, and the case did not close permanently until June 1925, six and a half years after the first contact between the family and the CPS.49 As this case illustrates, poor families often could not weather the epidemic without aid, but sometimes discovered this aid came with a price.

Enforcing and resisting Jim Crow

Just as gender and class assumptions framed some Americans' behaviors and experiences during the epidemic, race, too, often came into play. White Americans, for instance, maintained segregation during the epidemic with the same insistence they had prior to the crisis, leading to particularly inadequate resources for fighting the disease in African American communities. In Baltimore, the leading black newspaper, the Afro-American, told the story of the struggle to get one unidentified local resident, discovered “unconscious,” into the “overcrowded Provident Hospital,” an effort that proved unsuccessful. The meaning of this story, and others like it, was clear to the paper. “This is one of the extremely sad cases that are the pitiable result of the jim crow [sic] policy practiced in white hospitals of the city, and the woeful lack of larger quarters in Provident,” it argued, and concluded, “The need for a colored hospital large enough to supply the needs of the city and well equipped for all emergencies has never before been felt so keenly.”50

Other commentators focused on the persistence of white supremacist attitudes in the midst of the crisis. An opinion piece in the same newspaper pointed out the tendency of some white people to view the epidemic through a racist lens. When African Americans were rumored to be suffering less seriously from influenza, one writer argued, some white people found a way to translate this strength into a racial weakness. “But when a lady on the Eastern Shore of Maryland heard that influenza germs were having relatively little effect on colored people, she is reported to have said, ‘Well, that proves that they are not human like the rest of us,’” the report concluded.51

Though the influenza virus did not discriminate among its victims, the same, it seems, could not be said for all Americans. As people reacted to the emergency of the epidemic and the disorder and chaos it created, they often did so on the basis of existing beliefs about differences among and between Americans. When this happened, they often shaped not only their own experiences, but those of others as well, too often making more difficult the already demanding circumstances of the epidemic.

It is important to note that some Americans refused to accept this double-victimization, choosing to battle discrimination alongside the epidemic. Poor families, for instance, sometimes resisted the interventions of the courts and charity organizations.52,53 In turn, African Americans often offered a critique of the racism they encountered, both in the pages of their newspapers and on their pulpits. In an especially powerful challenge to the ideology of white supremacy, the Reverend Grimke of Washington, D.C., found in the epidemic God's effort to awaken the white community to their sins against their fellow black Americans, in obvious violation of His laws. “During these terrible weeks, while the epidemic raged,” Grimke argued, “God has been trying in a very pronouncedly conspicuously and vigorous way, to beat a little sense into the white man's head.” Stating his case more bluntly, Grimke continued:

“In this terrible epidemic, which has afflicted not only this city but the whole country, there is a great lesson for the white man to learn. It is the folly of his stupid color prejudice. It calls attention to the fact that he is acting on a principle that God utterly repudiates, as He has shown during the epidemic scourge; and as He will show him when He comes to deal with him in the judgment of the great day of solemn account.”30

Unwilling to accept a world, or a God, that accepted white supremacy, Grimke offered his parishioners an explanation of the influenza epidemic that resisted subjugation and granted them a meaningful role in God's plan for the nation.


Grimke was not alone in his efforts to make sense of the epidemic. As Americans suffered through the worst epidemic in their history, they sought to explain it in ways that made the unknown knowable and that granted some sense of meaning to the personal and national tragedy. Like Grimke, many Christians turned to religion and found meaning for their suffering in their beliefs. If some, like the Reverend Grimke and the evangelist Billy Sunday, saw in the epidemic evidence of God's punishment for the nation's evil ways, others found solace in the notion of Christian salvation.2,30,54,55 For others, the epidemic was described as a “plague,” offering a subtle critique of the narrative of medicine's triumphs.56,57 For still others, only comparisons to a range of natural disasters seemed to do justice to both the horror and the power of the epidemic. Some believed it was like a storm, that “struck like a cyclone,”58 while others described it as a “conflagration” or a terrible tide that had “suddenly swept the country and prostrated communities in its destructive course.”39,59 For many, though, the epidemic was too unfamiliar to suggest a likeness to any known disaster. Instead, “It was like a horrible nightmare,” something so awful only the imagination could have conjured it, or even something “more terrible than I could have imagined.”27,60

It was the war, though, that for many Americans provided the most fitting cues for interpreting the epidemic. Occasionally the link between the epidemic and the war was a direct one, as some Americans were quick to connect the growing epidemic with the ongoing struggle in Europe and to blame the Germans for the health crisis.61 Such an association made the inexplicable comprehensible, casting influenza as nothing more than another weapon of the enemy, another battle in the ongoing war.62

Even when Americans did not assume a literal connection between the war and the epidemic, the war often continued to serve as an important rhetorical device, as Americans relied heavily on military metaphor as they sorted out the meaning of the epidemic. From the beginning of the epidemic, Americans employed the language of the military contest as a means to voice their control and power over the epidemic. Describing the onset of influenza as an “attack” and an “invasion,” and influenza as “the enemy” and “as dangerous as poison gas shells,” Americans again and again characterized their responses in the language of a military mobilization, language that was active and that implied the nation was on the move against the scourge.6265 Nurses became an “army in nurses' blue,” and “led a fight against the dread disease until it was routed,”66,67 while physicians became soldiers, “the line of first defense,” ready to protect Americans and defeat the epidemic.68 As Susan Sontag suggested about the function of military metaphors used to describe disease, during the influenza epidemic Americans employed the imagery of a military struggle to explain and familiarize the crisis, and to suggest their own control over it.69

Perhaps because the nation was literally at war in 1918, the military metaphors seem to have functioned in some other ways as well during the epidemic. Even as the connection to martial language gave Americans a mechanism for articulating their power in relation to the disease, it also allowed them to acknowledge the unique and awful character of both Spanish influenza and the epidemic. Often it was through a direct comparison to the war that Americans articulated the shock and horror that accompanied the epidemic, a comparison in which the epidemic was judged the more severe of the two catastrophes.7072 Using the familiarity of the war, as well as the unprecedented scale of its ghastliness, provided Americans with a mechanism for communicating just how significant the epidemic had been.

In doing so, Americans may have found in this rhetorical device one other function, charging the epidemic not only with importance, but also with meaning and value.2 Coupling influenza with the war in this metaphoric relationship, Americans drew upon the contemporary idiom of wartime culture in an attempt to imbue the seemingly meaningless losses from the epidemic with value. Again and again Americans celebrated the memory of those who died, and sought through the use of the martial comparison to make those deaths heroic rather than tragic, meaningful rather than empty. This was perhaps most common in descriptions of the deaths of nurses and doctors who died while serving others. Noteworthy, though, is how commonly the language of martyrdom was applied to those who had simply died in the epidemic. As an editorial in a training camp newspaper illustrated as it suggested the importance of the deaths recorded in the epidemic, “Who shall say that those in the service of the army who were felled by the disease are not just as much entitled to a place on the nation's honor roll as those who fell in battle?”73 Or as a chaplain suggested at the funeral of soldiers who died in the epidemic at Camp Sherman in Ohio, “It is sweet to die for one's country. These men are as true martyrs as those who have died in the trenches.”74 Even as Americans embraced military rhetoric in the most traditional manner, using it as a means to depict their energetic response and their ultimate control over influenza, this language also allowed them to voice the enormity and severity of the epidemic, to acknowledge its nearly overwhelming horror, and to imbue their experiences and their losses in the epidemic with valor and meaning.


As the epidemic eased in 1919, the nation soon turned its attention to other business. With a war just ending and a postwar world to navigate, most Americans had little interest in memorializing or even remembering the epidemic. As the years passed, World War I gained a prominent place in Americans' cultural memory as cities and towns memorialized its victims in public monuments and writers of the Lost Generation used the war as foreground for their fiction. No similar phenomenon preserved a public memory of the epidemic, however. As the historian Alfred Crosby has suggested, this was truly “America's forgotten pandemic.”2

And yet for those whose lives were irrevocably changed by the epidemic, its consequences lived on in lives permanently shaped by that event. It is perhaps Katherine Anne Porter's account that best captures the difficult aftermath of the epidemic for many patients and their families. She concludes Pale Horse, Pale Rider with a vivid portrayal of the malaise, indeed depression, from which influenza victims often suffered in its aftermath.1 As Miranda returns to consciousness, she formulates an ironic declaration of the promise of the future: “No more war, no more plague, only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with the shades drawn, empty streets, the dead cold light of tomorrow. Now there would be time for everything.” Though there would be “time for everything,” a profound sense of loss pervades Porter's words, as Miranda discovers that Adam has died of influenza, and his passing seems a particularly cruel trick. “I wish you had come back,” she beseeches him. “What do you think I came back for, Adam, to be deceived like this?”1 Though life would go on, for Miranda and for countless Americans like her, those lives would be forever changed by their experiences in the epidemic. As the writer Thomas Wolfe suggested in the autobiographical novel Look Homeward, Angel, referring to his own family's situation in the aftermath of his brother's passing, “It was not, could never be, all right.”75

Though the country moved on, and expected the epidemic's victims to move on as well, countless Americans continued to suffer their losses and their grief in the decades that followed, a reality likely made worse by their culture's failure to acknowledge it. As we face the possibilities of a new pandemic, and seek to learn lessons from the experiences of 1918–1919, we would do well to remember the grief, dislocation, and loss such a catastrophe leaves in its wake, and attend with special care to those who might suffer in our midst, even as we guard against the injustices that lurk in the imposition of social hierarchies.


The author is grateful to the University of Puget Sound and the National Endowment for the Humanities for their financial support of this project. She also wishes to thank Alexandra Minna Stern and Howard Markel of the University of Michigan Center for the History of Medicine and the participants in “The 1918-1919 Influenza Pandemic in the United States: Historical Experiences and Lessons for Contemporary Public Health” workshop they organized and hosted. Finally, the author thanks her colleagues and students at the University of Puget Sound, especially Douglas Sackman, who generously provided comments on the broader project from which this essay is drawn.


1. Porter KA. Pale horse, pale rider: three short novels. New York: Harcourt, Brace, Jovanovich; 1939. pp. 177–264.
2. Crosby A. America's forgotten pandemic: the influenza of 1918. 2nd ed. Cambridge (MA): Cambridge University Press; 2003.
3. Porter R. The patient's view: doing medical history from below. Theory and Society. 1985;14:175–98. [PubMed]
4. Letter from Katherine to Jamie, 1918 Oct 13. Ella Katherine Fife Letters, Box 1, Folder: 1918 Oct 13 Katherine Mae Reynolds Fife to JDF. Special Collections Department, University of Virginia Library, Charlottesville, VA.
5. Letter from Will to “Squeechy,” 1918 Oct 26. Ella Katherine Fife Letters, Box 1, Folder: 1918 Oct 26 WOF to EKF w/env. (Charlottesville). Special Collections Department, University of Virginia Library, Charlottesville, VA.
6. Steward JR. Field director's report—Camp Dodge, Iowa—period covering influenza epidemic, dated 1918 Oct 17. File 803.11, Folder Epidemic, Influenza, Iowa, Record Group 689, National Archives and Records Administration, College Park, MD.
7. Ott K. Fevered lives: tuberculosis in American culture since 1870. Cambridge (MA): Harvard University Press; 1999.
8. Duffy J. The sanitarians: a history of American public health. Urbana (IL): University of Illinois Press; 1990. [PubMed]
9. Rogers N. Dirt and disease: polio before FDR. New Brunswick (NJ): Rutgers University Press; 1992.
10. Oshinsky DM. Polio: an American story. New York: Oxford University Press; 2006.
11. Leavitt JW. Typhoid Mary: captive to the public's health. Boston: Beacon Press; 1996.
12. Karlen A. Man and microbes: disease and plagues in history and modern times. New York: Touchstone; 1996.
13. Rothman SM. Living in the shadow of death: tuberculosis and the social experience of illness in American history. Baltimore: Johns Hopkins University Press; 1995.
14. Anderson E. Epidemic influenza; commonly called “the grip.” JAMA. 1894;22:749–50.
15. The grippe. Los Angeles Times. 1894 Apr 3;4
16. Murphy M. Grip don'ts. JAMA. 1916;66:449.
17. Moseley JM. Complications and sequellae of influenza. New Orleans Med Surg J. 1917;70:68–9.
18. Mortality from influenza—Chicago Health Department wants the disease more actively fought. New York Times. 1901 Apr 28;3
19. Influenza studies—1.On certain statistical aspects of the 1918 epidemic in American cities. Public Health Rep. 1919;34:1746–50.
20. Johnson NPAS, Mueller J. Updating the accounts: global mortality of the 1918–1920 “Spanish” influenza pandemic. Bull Hist Med. 2002;76:105–15. [PubMed]
21. Noymer A, Garenne M. Long-term effects of the 1918 “Spanish” influenza epidemic on sex differentials of mortality in the USA: exploratory findings from historical data. In: Killingray D, Phillips H, editors. The Spanish influenza pandemic of 1918–1919: new perspectives. London: Routledge; 2003. pp. 202–17.
22. Letter from Sam to Clara [no date]. Army Experiences Questionnaire Collection, World War One Research Project, Herbert Greenfelder Collection, 84th Division, 325th Field Artillery, HQ Company, U.S. Army Military History Institute, Carlisle Barracks, Carlisle, Pennsylvania [hereafter USAMHI].
23. National Library of Medicine. Bethesda, MD: Diary of Martin Franklin, 1914–1919. History of Medicine Division.
24. Barr HS. 1918 Nov 17. Box 2, Folder 7: November–December 1918, Harold S. Barr Manuscript Collection, Manuscripts Section, Indiana State Library. Indianapolis, IN: Letter to darling mother.
25. Hardy C., III . Talking history. Albany (NY): State University of New York; [cited 2010 Apr 8]. I remember when: what became of the influenza pandemic of 1918 [Internet] producer. Available from:
26. Report of the influenza epidemic—Lake Division. Box 688, File 803.08, Folder, Epidemics, Influenza—Reports and Statistics, Lake Division. National Archives and Records Administration, College Park, MD.
27. War-reports from the influenza front. Literary Digest. 1919 Feb 20;69:62–7.
28. Gregg E. Emergency nursing service during the epidemic: care given to patients during the epidemic of influenza by the nurses of the Bureau of Preventable Diseases. Monthly Bulletin of the Department of Health, City of New York. 1918;8:289–90.
29. Edwards M. American Red Cross—Baltimore Chapter—Report of the Red Cross Nursing Center during epidemic of Spanish influenza Oct. 1918. Box 689, File 803.11, Folder Epidemic, Influenza, Maryland, Record Group 220. National Archives and Records Administration, College Park, MD.
30. Grimke Rev FJ. Some reflections, growing out of the recent epidemic of influenza that afflicted our city, 1918 Nov 3. Manuscript Department, Moorland-Spingarn Research Center, Howard University, Washington.
31. Questionnaire of Mark E. Swanger. Army Experiences Questionnaire Collection, World War One Research Project, 9th Division, 18th Infantry Brigade, 68th Infantry, USAMHI.
32. Dochez AR. The reminiscences of A.R. Dochez. Oral History Research Office, Columbia University, New York.
33. Questionnaire of George C. Dobbs. Army Experiences Questionnaire Collection, World War One Research Project, 17th Division, 33rd Infantry Brigade, 50th MG Bn., USAMHI.
34. Death grip of epidemic broken, following toll of 483 dead and 1438 serious. Camp Sherman News 1918 Oct 9:1.
35. The burial situation during the epidemic and what the health department has done to curb the epidemic of influenza. Monthly Bulletin of the Department of Public Health and Charities of the City of Philadelphia October–November 1918. :16–9.
36. Dripps RD. Philadelphia County report in: The emergency service of the Pennsylvania Council of National Defense in the influenza crisis—report of the Vice-Director, Department of Medicine, Sanitation and Hospitals. College of Physicians, Philadelphia; Pamphlet 173.
37. Meeker GH. Descriptive in Southeastern Pennsylvania Chapter of the American Red Cross in the influenza epidemic, September–October, 1918. Box 689, File 803.11. Folder Epidemic, Influenza, Pennsylvania; Record Group 200, National Archives and Records Administration, College Park, MD.
38. The closing order—3 October 1918 in resolutions of the Board of Health in what the Health Department has done to curb the epidemic of influenza. Monthly Bulletin of the Department of Public Health and Charities of the City of Philadelphia November–December 1918. 3:6–7.
39. Moses G. Report of the activities of the chapters and branches of the Atlantic Division of the American Red Cross during the epidemic of Spanish influenza, 20 December 1918. Box 688, File 803.08, Folder Epidemics, Influenza-Reports and Statistics—Atlantic Division; Record Group 200. National Archives and Records Administration, College Park, MD.
40. McCarthy M. New York: Harcourt, Brace, Jovanovich; 1957. Memories of a Catholic girlhood.
41. Kancianich L. Interview with the author. 2003 Aug 8.
42. Watts SD. Memorandum to Fieser JL. Subject: aftermath of the influenza epidemic in Kentucky mountains, 1919 Feb 12. Box 689, File 803.11, Folder Epidemics, Influenza, Kentucky; Record Group 200. National Archives and Records Administration, College Park, MD.
43. A Spanish stonecutter's widow. WPA Federal Writers' Project Collection, Manuscript Division, Library of Congress 1936–1940. [cited 2010 Mar 18]. Available from: URL:
44. Frank ML. Minneapolis: Minnesota Historical Society; Reminiscences: sawmill city boyhood (unpublished)
45. Case #13906, Reel #197—Family Welfare, Minneapolis Family and Children's Service Case Records 1895–1945. Social Welfare History Archives, University of Minnesota, Minneapolis.
46. 50,000 children examined. New York Times. 1919 Feb 24;5
47. New York's 100 neediest cases. New York Times. 1918 Dec 15;:73–6.
48. What the visiting nurse does in the house on Henry Street. Publication of the Visiting Nurse Service 1921 Dec;1(1). Henry Street Visiting Nurse Service, Box 1, Folder 4:1:1 Publicity, flyers 1918, 1920–1927. Social Welfare History Archives, University of Minnesota, Minneapolis.
49. Case #3126, Reel #16, Children's Protective Society, Minneapolis Family and Children's Service Case Records 1895–1945. Social Welfare History Archives, University of Minnesota, Minneapolis.
50. Influenza and pneumonia claims many victims. Afro-American (Baltimore) 1918 Oct 18;1
51. Pickens W. God's a nigger. Afro-American (Baltimore) 1918 Dec 20;4
52. Case #3126, Reel #16, Children's Protective Society, Minneapolis Family and Children's Service Case Records 1895–1945. Social Welfare History Archives, University of Minnesota, Minneapolis.
53. Case #13786, Reel #196—Family Welfare, Minneapolis Family and Children's Service Case Records 1895–1945. Social Welfare History Archive, University of Minnesota, Minneapolis.
54. Collier R. Plague of the Spanish lady. McMillan: New York; 1974.
55. Letter from unidentified author to Urban C. Stover, 1918 Sep 29. Folder: Urban C. Stover—Letters, August–September, 1918, Urban C. Stover Manuscript Collections, Manuscript Section, Indiana State Library, Indianapolis.
56. Letter from Madge to Ella, 1918 Nov 7. Box 1, File: November 1918, Folder: 1918 November 7—MWF to EKF w/env. (Charlottesville), Ella Katherine Fife Letters (5943-e), Special Collections Department, University of Virginia Library, Charlottesville, VA.
57. Editorial: Don't help the plague. News Tribune. 1918 Oct 11;14
58. Letter to “My precious daughter,” 1918 Oct 29. Box 1, Folder 1918 October 29 SAGSF to EKF (Charlottesville). Ella Katherine Fife Letters (5943-e), Special Collections Department, University of Virginia Library, Charlottesville, VA.
59. Copeland RS. General survey of the influenza epidemic (reprinted from the New York Medical Journal 1918 Oct 26). NYC Vertical Files, City of New York Municipal Reference and Research Center, New York.
60. de Forest J. First woman searcher for the Red Cross. New York Times. 1919 Mar 16;76
61. Connecticut State Council of Defense. Broadside 1918 H44. Charlottesville, VA: Special Collections Department, University of Virginia Library; Poster: Help fight the grippe—Kaiser Wilhelm's ally.
62. Wallace youth dies suddenly—Harry R. Kinkead victim of pneumonia which follows influenza attack. Wallace (ID) Press-Times. 1918 Oct 29;1
63. Harvey OJ. The influenza pandemic of 1918: an account of its ravages in Luzerne County, Pennsylvania, and the efforts made to combat and subdue it. [publisher unknown]; 1920.
64. Will the ‘flu' return? Literary Digest. 1919 Oct 11;63:26.
65. Uncle Sam's advice on flu. Shenandoah Valley (New Market, VA) 1918 Oct 17:1.
66. Wald LD. Influenza: when the city is a great field hospital. Survey. 1920;43:579–81.
67. Jones CC. Report of the Bureau of Civilian Relief, Pennsylvania-Delaware Division, American Red Cross, for the month of October 1918. In: American Red Cross Report of the Division Directors of Civilian Relief for the month of October 1918. Box 201, Record Group 200, Entry 27130D. File 149.18--Civilian Relief Reports—All Divisions—September–October, 1918, National Archives and Records Administration, College Park, MD.
68. Spanish influenza—a circular to the medical profession. Weekly Bulletin of the Department of Health of the City of New York. 1918 Oct 26;7:335.
69. Sontag S. Illness as metaphor and AIDS and its metaphors. New York: Anchor Books; 1989.
70. How influenza got in. Literary Digest. 1918 Nov 30;59:23.
71. Influenza deaths far exceed war losses—fatalities in 46 cities total 82,306—toll in camps may equal deaths in battle. New York Times. 1918 Nov 18;8
72. Editorial. The World News (Roanoke, VA) 1918 Dec 3;6
73. Flu. Trench and Camp (Camp Greene) 1918 Nov 13;6
74. Epidemic claims 926 here. Camp Sherman News. 1918 Oct 15;1
75. Wolfe T. Look homeward, angel: a story of the buried life. New York: Charles Scribner's Sons; 1929.

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