0:17, Madeline Laguaite: Hello and welcome to "To Health and Back," a podcast about how health, medicine, and wellness decisions from the past help inform us today. I'm your host, Madeline Laguaite.
Laguaite: In this episode, we're talking about the history of mask wearing, especially during the 1918 influenza pandemic. We'll hear from Dr. Alex Navarro, the assistant director for the Center for the History of Medicine at the University of Michigan.
Laguaite: When Dr. Navarro and his colleagues began studying the 1918 flu pandemic, he didn't really expect the research they did to have an impact on public health policy today. Here to talk about that research, specifically mask wearing in 1918, is Dr. Alex Navarro. Hi, Dr. Navarro and welcome to the show.
1:06, J. Alexander Navarro: Hi, Madeline.
1:08, Laguaite: As I mentioned in a previous episode, experts have made lots of comparisons between COVID-19 and earlier pandemics like the 1918 influenza pandemic. Luckily for me, Dr. Navarro has spent more than a decade studying the 1918 flu pandemic.
1:24, Navarro: Yeah, my name is J. Alex Navarro, and I'm the associate director at the Center for the History of Medicine at the University of Michigan. I have spent the past 15-16 years now studying influenza and not that entire time. But we started at the Center about 15 years ago, studying the 1918 influenza pandemic. We were asked by first the Defense Department, of all places, to look at what we ended up labeling provisional escape communities. And these are small, typically small, communities in the United States... A few of them are sub-communities, so like college campuses, for example, in the United States that in the fall of 1918—which was the deadliest wave of that pandemic—managed to more or less escape influenza, meaning that they had zero or one perhaps death, and generally very few cases, although there were some places that had large case counts, but managed to not have any deaths.
Navarro: And the Defense Department was interested in finding out why and they wanted to know, with the possibility of another influenza epidemic. This was 2005. So the threat at the time was thought to be H5N1, avian influenza, a very deadly form of the disease that was lurking around in Southeast Asia. They thought, well, the military thought, could we load people up in the event of an outbreak somewhere in the globe, before it became an epidemic and a pandemic? Could we load up military assets on ships and send them out to sea, for example, and can we sort of emulate what these escaped communities did? That kicked off the work.
Navarro: But you know, what Gunnison, Colorado, for example—a town of 1,300 people in a county of about 5,000 people—did in 1918 very different than what we could do today with a pandemic of a respiratory disease, such as we found out with COVID. You know, those are two very different populations. You can potentially isolate a small community that's already isolated. It's much more difficult to do an entire city, entire state. We have a lot more interest, e-commerce now, etc.
Navarro: And so building on that work, the CDC then asked us to look at the 1918 pandemic, from the perspective of what American cities did. What they did was social distancing, mask wearing, etc. We did that work we showed that it did... that went into the pandemic guidance provisions that the CDC put out back in 2007 and the Department of Health and Human Services.
3:39, Laguaite: All the work and research that Dr. Navarro put in these last 15 or so years came in handy when more and more COVID cases started to pop up around the world in early 2020.
3:50, Navarro: Fast forward to today, really this time last year with the spread of COVID, and those plans were dusted off. And that's one of the reasons why we had the social distancing and mask recommendations rolled out is largely because of the work that we did and some other groups did, looking at that data from 1918. Yeah, I mean, it's not every day that historians get to have an impact on public policy, particularly public health policy. We really never imagined that would be the case. We hoped that it wouldn't. In fact, we would have been happier leaving those plans gathering dust on the shelf rather than dust them off and have to use them. But you know, here we are. We always knew it was a matter of "when" not "if," but you never think that "when" is going to happen during your lifetime.
4:36, Laguaite: At this point, we're all too familiar with mask wearing and mask ordinances. If I remember correctly, our local mask ordinance began sometime in July of 2020. And these local mask ordinances varied across the nation, though they had one main goal: to help slow the spread of COVID-19. And as it turns out, there were mass ordinances back during the 1918 pandemic.
5:01, Navarro: Yeah, there were. So mask use was still—certainly for the general public—it was pretty novel. There had been some mask use in 1911 in Manchuria. There was an outbreak of pneumonic plague and there was a physician, a Chinese mentoring physician who had been trained in Cambridge, who advocated the use of face masks for the public, realizing this was a respiratory disease, highly deadly, near 100% fatality. Despite pneumonic plague, there were people, including some American physicians, who went over to monitor who refused to wear a mask and died as the result.
5:41, Laguaite: Medical professionals have used face masks in surgical settings for over 100 years and the first documented instance was in 1897. The mask used was a single layer of gauze covering the mouth, and it was meant to protect the patient from infection at the surgical site. It wasn't until the 1940s and 1950s that antibiotics and septic techniques were used as major players of infection control methods within a surgical setting. So what did that look like in 1918?
6:14, Navarro: By 1918, the use of face masks in the surgical theater was fairly widespread, but still not universal. That really didn't come out for another maybe two decades. But I would say about two-thirds of physicians use face masks when performing surgeries or other procedures, building on the work of Semmelweis, and Pasteur and Lister and Koch etc, and realizing, 'Oh, now we're several decades into modern germ theory.'
6:44, Laguaite: The influenza pandemic of 1918 happened during the same time period as World War 1. Thanks to the overcrowding and global troop movement during the war, the 1918 flu was able to spread pretty extensively. Both the lack of treatments and vaccines and the vulnerabilities of healthy young adults spawned this major public health crisis reminiscent of the one we're in today. The flu pandemic of 1918 was responsible for at least 50 million deaths globally. Dr. Navarro said that back then, there were facemask recommendations and mandates coming from experts. Still, that doesn't mean every city or every region was adhering to these ordinances.
7:25, Navarro: In terms of the general public using face masks, there were plenty of recommendations nationwide to use masks and when locally and regionally to use face masks. But the mandates typically with the exception of Indianapolis, for example, typically tended to be done in western states and communities. So Los Angeles toyed around with the idea of issuing a mandatory facemask ordinance. They ultimately did not. Denver did, Seattle, Sacramento, Oakland. In Utah, they considered a statewide mask mandate but they ultimately did not. And it tended to be out west and it had to do with several factors. One was, there were a few influential and one, in particular, a physician named Woods Hutchinson, who was from the East Coast but traveled around and California sort of going up and down the coast, telling local communities to wear face masks and to issue these ordinances. And so he had some impact on the local decisions to do that. And also it was a little bit having to do with the timing. Although the influence of the second wave of the influenza pandemic hits pretty rapidly, it spreads from epicenters in Boston and New York almost simultaneously in late August, early September. And then it spreads within a matter of about 3 or 4 weeks across the nation. The exact shape of those epidemic curves is slightly different as you go across the nation. So it looks different in the East than it does in the Midwest. And it looks different in the West, and it does it in the Midwest or, or the east. And so partly because of the timing. It's a little bit more dragged out in the West. Those a lot of those communities resorted to mandatory facemask ordinances as a way of controlling the spread of the disease.
9:09, Laguaite: We know that the first known depiction of medical personnel wearing a face mask and surgery during the late 19th century was a single sheet of gauze. What about the types of masks worn in 1918?
9:21, Navarro: They were all types of masks. Not all that uncommon from what we're used to today, with the difference being that they did not have any N95 respirators back then, although the general public doesn't generally have those today either. But the types of surgical masks that are fairly common now you can find on online etc, that a lot of people are using... they didn't have those either. That sort of electrostatically charged, the Tyvek plastic material. The most typical mask in 1918, at least in the beginning of the fall would have been made of several plies of surgical gauze. So people think of surgical gauze and they think of cheesecloth, but it was actually much more densely woven than that. It's a pretty densely woven cloth. And two plies that would probably—I'm not an expert in this—but probably would be fairly similar to some of the better-made cloth face masks that most of us are using today when we go out and about.
10:14, Laguaite: So were these effective?
10:18, Navarro: So certainly not 100% effective. But probably roughly analogous to what we're using today. So maybe 70%-80%, depending on how they're used. The problem was, of course, that this is the time of World War I, and so surgical gauze is in high demand, but short supply. And so you have organizations like the Red Cross, and volunteers stitching masks for sale. Those, in some communities, run out pretty quickly. And so in places where they pass these mask ordinances, the ordinance is not all that dissimilar from today saying, basically, 'Cover your face with something.' And so to entice people, they even tell fashion-conscious women that they can wear a chiffon veil if they want. So some of the face coverings were probably not effective at all. And we don't really know in terms of compliance, how many people wore them regularly, what type they were, etc. But, roughly speaking, I'd say that generally, most people, you know, would have been wearing some fairly effective, certainly not 100%, but some fairly effective face covering
11:32, Laguaite: During the COVID-19 pandemic, adherence to mask ordinances and social distancing guidelines have been a key issue. What did mass compliance look like back then in 1918?
11:43, Navarro: That being said, there were plenty of communities where we have lots of data that there were very high levels, relatively high levels of noncompliance, or at least very high levels of vocal noncompliance. So, you know, we may have seen 70%-80% people wearing masks. I'm not sure if it was that high. But that 20%-30% that weren't were really vocal about not wearing them. And so places like San Francisco, you may have heard of the Anti-Mask League is formed in San Francisco and Denver had a really hard time getting people to wear masks and they had to keep watering down the mask ordinance because essentially, no one was wearing them. In fact, the mayor at one point in Denver says you'd have to have half the city forcing the other half to wear them, just to get any sort of compliance. So they were like today, uncomfortable to wear. And like today, we live in a nation, the United States and I think a lot of Western democracies, where we hold our individual freedoms and liberties very dearly, and to have the quote, unquote, "the government" tell us that we have to wear a face mask flies in the face of that and we don't like that. And so a lot of people said the same types of arguments back then that they have been saying today.
13:02, Laguaite: Given his extensive background in the 1918 flu pandemic, I asked Dr. Navarro if he expected so much resistance to mask wearing today.
13:11, Navarro: Yes and no. So I'll say yes, we certainly saw lots of... In fact, I just wrote an article about this for the American Journal of Public Health. We saw lots of evidence of some forms of noncompliance with pushback in 1918. So typically, the types of social distancing orders, we call them nonpharmaceutical interventions. Those types of interventions that were issued in 1918, mostly centered around things like isolation and quarantine, which we know work. In fact, New York City only resorted to isolation and quarantine and did a very good job of it and could have done better had they implemented more social distancing measures, but actually did fairly well for it considering a densely populated urban area, in the midst of the epicenter of the epidemic. They did very well just, robust isolation and quarantine and contact tracing.
Navarro: But most communities that issued closure orders, they closed places of public amusement, so pool halls, bowling alleys, movie theaters, performance theaters, cabarets—those were the places that were closed. Now, of course, if you're an effective business owner, and of course, you're being told initially by public health officials that this epidemic will burn through pretty quickly, you're thinking you might only be closed for a few weeks. And so initially, and also it's wartime. So there's a high sense of civic duty and patriotism. So you go ahead, and if you're a theater owner or manager, you realize that people aren't going to come to a theater during a pandemic anyway, so let's do our part and get through this very quickly. Well, when it starts to roll on, you know, 3, 4 or 5 weeks in some places, and these orders are still in place, then people start to balk. And they say, "Well, you know, we've lost 10s of $1,000s of dollars on lost revenues, and we have employees who we can't pay." And this is before welfare and workman's compensation and unemployment and all this and the social safety net that we have today. And so you have a lot of people relying on charity.
Navarro: You have churches that are closed, either because they were recommended to close their following, or in some places, depending on the laws, they were ordered to close. They comply, they start to push back. They're pushing back in places where saloons may not be closed, for political reasons and social reasons. They're places where workmen who didn't have access to a kitchen, or the ability to cook their own food, could get a meal, as well as lots of drinks. And they tend to be very crowded places. And so you have clergy saying, "Why can you have people go after work, belly up to a bar crowded with people, but they can't come once a week on Sunday, to hear a sermon for their spiritual needs?" So we do see lots of those types of pushback in 1918 and of course, with facemasks.
15:52, Laguaite: Even with these parallels between the COVID-19 pandemic today and the 1918 pandemic, there was one huge difference that Dr. Navarro mentioned: the nature of the pushback.
16:03, Navarro: The big difference between 1918 and 2019, 2020 and 21 is that the political nature, the ideological nature, and the partisanship of that push back is drastically different today. There really... we don't have the evidence that in 1918, in the fall wave, that push back to the public health measures was politicized in any way. So these orders were issued in Democratic states and cities and in Republican states and cities. And it didn't take... there may have been a slight ideological hue to, for example, refusing to wear face masks on supposed constitutional grounds. But that ideology did not necessarily correlate with politics and political party affiliation the way it has today. And certainly, you know, we've seen with former President Trump and some of his statements and actions. If you compare that to 1918, Woodrow Wilson, who was president then, was essentially silent on the issue of the influenza pandemic. A lot has been made about that. Some people have claimed that that was all part of this sort of conspiracy, see, to cover up the pandemic, or to censor it. That wasn't really the case. It was just that like today, public health was in 1918, the domain of state and local governments. The difference is that now we live in a post-Great Depression, post-New Deal era, where we have now a more robust federal government, and we have come many of us have come to expect and more robust federal response to whatever the national crisis may be, whether it's public health, natural disaster, etc. That didn't exist in 1818. So it wasn't odd that Wilson, as president, didn't really come out and say much to control or do anything about the pandemic. People look to their local leaders. A difference today, we look to local and state leaders as well as to the federal government, and then to have somebody like Donald Trump, and lots of other Republicans in office or in media pushing misinformation, disinformation, and in some cases, saying that the virus was a hoax, etc—that was drastically different than 1918.
18:27, Laguaite: With regard to what we can learn from the prevention methods used in 1918, Dr. Navarro said, we have to look at the data that we do have.
18:37, Navarro: So, I will say this. In our study in 2007, looking at these nonpharmaceutical interventions, because of the way that they were overlapped with one another, it was very difficult—basically impossible—for us to say with any confidence in any one of those nonpharmaceutical interventions, isolation, quarantine, school closures, closing of businesses, public gathering brands, or face masks, that any single one of those contributed X percent to the reduction in cases and deaths. What we do know is that taken together, those cities that implemented those measures earlier, that layer them so it wasn't just school closures... Several of those types of interventions layered on top and kept them in place for as long as possible—those cities fared better. So what I would say is that we have much better data today that face masks do indeed work, that they are very effective, although not 100%, in reducing transmission when worn properly.
19:40, Laguaite: Complacency is a dangerous trap to fall in, especially during a pandemic.
19:45, Navarro: We don't want to have a face mask on and give ourselves a false sense of security that we can have just a simple face covering, not an N95, and we can be face-to-face with strangers or with family members who don't live in our house. For example, if you're in an area where there's a hotspot and think that you're safe... The way this was explained to me and the way I've been explaining it to people—I think this is perfect—is that if you imagine each of these interventions as a piece of Swiss cheese, they all have holes in them. But if you layer several of those pieces together, hopefully, the hole doesn't go through the entire stack. And so, face masks are an incredibly important part. But so is hand washing, social distancing, staying out of congregated areas until we get this under control.
Navarro: Vaccines are a much more important part of today than they were in 1918. We didn't really have effective vaccines in 1918. And there were some vaccines that were developed. They thought they were dealing with a bacterial infection, not not not a viral one. They didn't have that technology until the early '30s. And so they weren't really effective. Today, we have vaccines—that will increase. But we also have these other variants that are circulating that could be very dangerous. They're much more transmissible, it seems. We could have another one pop up. And so we have to get it under control. Face masks are an important part of that. If we allow the pandemic... it's starting to come down now. But if it flares up again, these viruses always mutate. And there's always a chance for one of those mutations to be a more dangerous one. And so we want to control as much as possible transmission. Face masks are definitely an important part of that. We have better data today. We know that they worked in 1918. We don't know how well they worked because we have different technology for the construction today. We don't really have data about compliance back then. We know that they were an essential part, then we know that they are definitely an essential part of the plan today.
21:34, Laguaite: So what will future historians say about the current pandemic we're living through?
21:39, Navarro: You know, I sadly, think that we are going to be talking about... future historians are going to be talking about this pandemic, and all of the lessons that were not learned over the 102-year intervening years between 1918 and 2020, 2021. And that's really the sad part. We have a much better understandings of the science and medicine behind viruses today that simply didn't exist in 1918. They knew that viruses existed, but they didn't really know what viruses were. And we didn't really know that influenza virus existed until 1933 in pigs and 1935 in humans.
Navarro: We have much better technology today. We were able to produce these vaccines. A 95% effective vaccine for a virus is incredible. And we did that so quickly. I mean, that's the beauty of science and really dedicated, hard-working scientists. But we knew when we were working back in 2007, when we were contacted by the CDC, that whatever the new virus, whether it was a new strain of influenza, or coronavirus, that was going to emerge. It was going to be a novel strain. It was going to take time to isolate it, to genotype it, and to develop effective therapies and vaccines against it. And what do you do in that intervening time? Well, you resort to the old standbys: contact tracing, isolation and quarantine, social distancing, mask wearing for respiratory diseases. And some places did very well. Other places did not do very well. But unfortunately, I really don't think that any place in the United States did very well for as long as we needed to.
Navarro: When these measures were implemented back in the spring, we really needed to keep them in place in some form, until we have herd immunity from vaccine rollouts. And we haven't done that. And if you look at the three spikes—the three surges of the disease—they correlate with people getting together for the summer holidays than the winter holidays, along possibly with more contagious variants spreading and colder weather where people naturally congregate more indoors. 1918 showed us that it's very difficult to get people to follow these orders for a long time. Some cities did it for about 5-6 weeks in 1918. I was surprised that we actually did longer than that in the spring, but I knew that we needed to do longer still.
Navarro: One of the big differences between COVID or the SARS-CoV-2 virus and influenza virus. They're different viruses. COVID is a much more contagious disease and as a result, without getting into the math of it, basically the more contagious diseases, the more transmissible it is, the higher that threshold for herd immunity is. So we always knew going in that we were going to have a much higher threshold for herd immunity from COVID than we would for influenza, which was about 30%-35%. About 70%, it might be 80% or higher now with these new, more transmissible strains circulating. And so that means that we have to do even better keeping these social distancing measures in place and really strictly following them.
Navarro: And I think what we've seen is that anytime those social distance measures were peeled back just a little bit by authorities, it, unfortunately, gives the idea to the population that well, maybe it's OK to get together. So, "I haven't seen my friends, my family in a while. Things are getting better. The officials said indoor dining is allowed, so maybe let's go and do that, or we can get together in bars." And it just gives— and then people get whiplash back and forth, because they're constantly being told, "No, you shouldn't. But yes, it's OK. You can get together in small groups. Now, we have to peel that back." Now, some of that is naturally ebb and flow. We want to keep our economy functioning, etc. This is a very difficult thing to do for public policymakers. But from a public health standpoint, I think it's a really bad idea to give people that false hope that it's okay to get back together. And then they are going to do it and then you get mad at them for getting back together.
25:57, Laguaite: Well, thank you so much for taking the time to talk with me today, Dr. Navarro. It was so good to hear from you.
Laguaite: In the United States, the COVID pandemic continues between emerging variants and restrictions easing up, it can be hard to keep track of all the information. For now, the Centers for Disease Control and Prevention recommend everyone aged two and older wear a mask to protect themselves and others. Still, a mask isn't meant as a substitute for social distancing. So these masks should be worn in addition to stay at least six feet apart. The CDC also recommends that face masks be worn completely over the nose and mouth fitting snugly without any gaps.
Laguaite: This has been "To Health and Back." Thanks again for joining me on this health history journey. Tune in next time for a discussion on xenophobia. Until then, don't forget to rate the podcast and subscribe. Feel free to shoot me an email at [email protected] and I'm also on Twitter, Instagram and Facebook as @healthandback. Thanks. See you next time.