The American Influenza Epidemic of 1918-1919: A Digital Encyclopedia (2.0)

A Conversation with Howard Markel and J. Alexander Navarro

influenza awareness poster

Howard Markel and J. Alexander Navarro, director and assistant director of the Center for the History of Medicine at the University of Michigan, respectively, talk to Choice about the American Influenza Epidemic of 1918-1919: A Digital Encyclopedia (2.0), produced by the University of Michigan Center for the History of Medicine and Michigan Publishing.

influenza archive
The Influenza Archive homepage.

How would you describe the project to a perfect stranger?

The American Influenza Epidemic of 1918–1919: A Digital Encyclopedia 2.0 grew out of a huge national study we conducted for the U.S. federal government on the use of non-pharmaceutical interventions (such as school closures, public gathering bans, quarantine and isolation, etc.) in American cities during the 1918–19 epidemic. This period was one in which vaccines and anti-viral drugs were not available and mirrored the earliest phases of a pandemic in the early 21st century, when vaccine and anti-viral drug supplies may not yet be ready for the nation at large.

The Influenza Encyclopedia consists of two broad parts: a set of essays detailing the experience of fifty American cities with their influenza epidemics, and a vast digital archive of the materials we collected in the course of our research. These materials include newspaper articles; federal, state, and local municipal health reports; contemporary medical journal articles; manuscript collections from repositories across the United States; archival materials from the U.S. Navy and Army and their various divisions; and miscellaneous documents gleaned along the way.

Can you construct a brief time line of the influenza epidemic of 1918–1919 in the US?

The 1918 influenza epidemic began with an initial wave in the late winter through the early spring. That wave did not affect all communities in the United States, nor did it produce sufficient mortality or morbidity to prompt a significant public health response. In mid-August, a second, more virulent wave of influenza struck simultaneously at Freeport, Sierra Leone, and Brest, France. Other locations were also reported as being struck by “the flu.” From these ports the disease likely spread to the United States, striking the Boston area by late August. By mid to late September, influenza had spread across the United States, aided by the massive military mobilization being undertaken as part of the war effort. This second wave, which was the deadliest one, peaked in late October before subsiding slowly throughout the rest of the fall. It was during this period that many American cities enacted social distancing measures in an attempt to slow the spread of the disease. In addition to the age-old methods of isolation and quarantine, state and local public health officers ordered schools closed, sporting events cancelled, theaters, saloons, and dance halls shuttered, and large gatherings—including, in some cities, weddings and funerals—prohibited.

Many cities, particularly those in the Midwest and the South, experienced a third wave of cases and deaths beginning in late-December 1918 and January 1919, and lasting through the spring. A fourth and final wave struck at the end of that year and lasted until approximately March 1920. Altogether, the epidemic killed approximately 550,000 Americans.

ambulance during influenza epidemic
The Motor Corps of the St. Louis chapter of the American Red Cross on ambulance duty during the influenza epidemic, October 1918. From the Still Picture Unit, National Archives and Records Administration, 165-WW-269B-3.

What is the intended audience of the Influenza Encyclopedia? How do you envision undergraduates using the archive?

We created the Influenza Encyclopedia with historians, journalists, public health officers, students, and the general lay public in mind. For the general public, we envision users being most interested in the city essays, perhaps focusing on their own city as they learn about their community’s experience with the deadly influenza epidemic. For others, such as students and scholars, we envision people utilizing the vast archival component of the site, where they can access thousands of pages of primary source materials for use in their own research projects.

How did the archive come to be? Was there one overarching question or goal that catalyzed its creation?

The Influenza Encyclopedia grew out of a series of research projects we were commissioned to conduct by two federal agencies, the first the Defense Threat Reduction Agency (DTRA) and the second the Centers for Disease Control and Prevention (CDC). In 2005, with the potential threat of H5N1 “avian” influenza looming, the Department of Defense became interested in US communities that managed to escape the ravages of the 1918 influenza pandemic. We discovered eight such “escape communities”—several of which were actually sub-communities such as college campuses or military installations—and detailed the methods they used to keep themselves disease-free.

Immediately following this work, we were contracted by the CDC to conduct another research project. Knowing that it would take many months before a vaccine could be produced and distributed in the event of another epidemic, CDC was interested in knowing what lessons could be gleaned from the use of non-pharmaceutical interventions in American urban centers in 1918. How did American cities respond to the epidemic? Were those efforts successful? Could those methods be used effectively today to mitigate the mortality and morbidity of an influenza epidemic, at least until an effective vaccine could be produced and distributed?

That project resulted in a major publication in the journal of the American Medical Association (August 8, 2007; Volume 298, No. 6, pp. 644–54), along with a very large compendium of documents collected over the course of our research. Along the way, we decided that the fruits of this labor should be made available to the public, and that digitizing them would be the only viable way of sharing our research. We also realized, however, that in order to make our digital archive more useful, we needed to add a layer of contextualization to it, providing historical essays on the epidemic experiences of major American cities. Our CDC study included forty-three cities for which we could obtain reliable mortality and morbidity data. To this list, we added an additional seven cities and continue to identify other American municipalities to be documented in successive editions of the encyclopedia. With the hard work of a small but dedicated team of historians, research assistants, and information technologists, along with a web designer to create the graphical interface to tie the two halves of the project together, the Influenza Encyclopedia was born.

soldiers in flu masks
The 39th Regiment marches down 2nd Avenue in Seattle with their flu masks on, passing Cheasty’s Haberdashery, ca. October/November 1918. From the Still Picture Unit, National Archives and Records Administration, 165-WW-269B-8.

What was the process of acquiring and selecting materials like? Are there any future developments planned for the online exhibit?

The process by which we acquired and selected material for our site was, by and large, the same process all historians use when conducting research: good, old-fashioned library and archive work. For our initial CDC project, we relied heavily on the day-by-day newspaper accounts of the influenza epidemic in each city. Because newspapers can be biased in both tone and coverage, and because not all newspapers report on the same topics in the same manner or with the same depth, we examined the two largest circulating newspapers for each of the cities in our study. We painstakingly went through reel upon reel of microfilm, looking at each page of each of those newspapers for every city from late August 1918 through the end of March 1919, capturing every article that mentioned influenza or related topics. These newspaper accounts formed the bulk of our research and provided a rich narrative of the epidemic in each of the cities we studied.

We then supplemented this material with the next most important set of documents: state and municipal annual health reports and monthly bulletins. Unfortunately, we discovered that few libraries had retained these documents. Those we could locate frequently had large gaps in the years we required. Through exhaustive searching, we found a large number of municipal health reports for the epidemic years in the storage annex of the New York Academy of Medicine. We paid to have the pertinent documents located, retrieved, and sent to us. Similarly, we located one of the few (and perhaps the only) extant sets of the Census Bureau’s Weekly Health Index reports for the epidemic period in the Science, Industry, and Business Library branch of the New York Public Library. These short, typewritten reports are the “gold standard” for epidemiological data on the epidemic, as they contain the weekly influenza and pneumonia mortality figures for all major U.S. cities. It was a critically important discovery for us and for our work. Other materials, such as mayors’ papers, military records and reports, and even photographs, were painstakingly gathered by visiting archives, libraries, historical societies, and special collections across the country. Contemporary medical journal articles and other scholarly publications were located through exhaustive bibliographic searches. We are fortunate to have a world-class library system here at the University of Michigan, which, together with interlibrary loan, provided us with access to a trove of old journals and other medical publications.

The beauty of a digital archive is that it is easily expandable. Since the initial launch of the site, we have located and gathered additional documents and other resources related to the epidemic, including more contemporary medical journal articles and several lengthy, seminal reports drafted in the immediate post-epidemic period. We have added these sources to the site in the currently updated “second edition,” The American Influenza Epidemic of 1918–1919: A Digital Encyclopedia (2.0), and are continuing our research, document gathering, and contextualizing work for future, successor editions that will contain even more historical materials on the influenza pandemic of 1918–1919.

Tell me more about the process of organizing the online exhibit. Why did you choose to primarily organize the exhibit by location?

There were a number of ways an online archive such as ours could have been organized: thematically, geographically, chronologically, etc. Ultimately, we chose to organize the Influenza Encyclopedia geographically by city because we felt it was the way most lay users would approach the materials. Also, it is important to remember that while the epidemic had an overarching national (and international) narrative, each city had its own unique experience with it. This fact is reinforced through the organizational structure of the site. However, for those users who wish to delve right into the archival materials, we offer full Boolean search capabilities, along with browsing by people, places, organization, subject, and publication.

typist wearing flu mask
A New York City typist wears a flu mask while at her desk, October 16, 1918. From the Still Picture Unit, National Archives and Records Administration, 165-WW-269B-16.

Why did you choose to research this epidemic?

In a way, we didn’t choose influenza; influenza chose us. Our work grew out of a concern in 2005 that H5N1 avian influenza in Southeast Asia might mutate into a human transmissible form that would spark a global pandemic. The 1918–1919 pandemic was one of the world’s deadliest and also one of the world’s best-recorded public health events, and came at a time when physicians and medical researchers understood at least the fundamentals of germ theory. As a result, the historical record for the epidemic constitutes the greatest “database” of epidemiological data we have for a large-scale public health crisis. For these reasons, studying the 1918–1919 epidemic was a natural choice. In the spring of 2009, in the midst of our work on the Influenza Encyclopedia, the United States was struck by the H1N1 “swine” influenza epidemic, which quickly spread around the globe. Although it fortunately proved to be far less deadly than initially anticipated, the event reinforced the importance of our work and the need to create a database of historical information that could be drawn on to help inform current and future pandemic preparedness and response guidelines.

What importance does an understanding of this epidemic hold for current medical research/practices?

The world is vastly different today than it was in 1918. Air travel, mass media, and the internet mean people—and thus microbial threats—and information can travel across the globe much faster than they could a century ago. Today, we understand that a virus causes influenza. We have the capacity to isolate circulating strains of influenza and develop vaccines against them. We also have antiviral medications that can lessen symptoms, shorten the duration of illness, and help prevent complications such as pneumonia. In 1918, medical researches believed influenza was caused by a bacterial infection, and knowledge of viruses was still in its infancy. Yet, there are many ways in which 1918 is similar to today. Beginning in the late nineteenth century, the United States underwent a massive demographic shift from a predominantly Anglo-Saxon Protestant country of rural farmers to a polyglot nation of people working and living in industrial urban centers. Population densities increased. Mass transportation systems were widely used. People gathered for large sporting events, or in department stores and other shops. Mass media (in the form of daily newspapers) kept residents informed of local as well as national and international news. So, in some important ways, the America of 1918 was not all that different from the America of today. For these reasons, studying the response of American cities to the deadly influenza epidemic can help inform best public health practices today. Indeed, our research into the use of non-pharmaceutical interventions during the 1918–19 epidemic demonstrated that cities that implemented social distancing measures in an early, layered, and sustained manner had better outcomes than those cities that did not. This finding has formed the basis for the CDC’s and the Department of Health and Human Services’ pandemic preparedness guidelines, and was the rationale used for recommending school closures under certain conditions during the 2009 A/H1N1 epidemic.

We have already developed a second edition of the encyclopedia, or as it is now known, Digital 1918 Influenza Encyclopedia 2.0, and are at work on future editions of the collection of materials and historiography on these events. One unfortunate gap in our digital archive is the stories of the countless individuals and families impacted by the deadly 1918–1919 epidemic. Nearly every American was touched by the epidemic in some way, whether through direct illness or the illness or death of a friend or family member. Unfortunately, extant sources of these day-to-day experiences with the epidemic are few and far between. As a result, our Influenza Encyclopedia focuses mostly on the local, state, and national epidemic narratives, and contains very few personal stories. We hope that our future research and composition of the 3.0 and successor editions will uncover more personal narratives and similar sources that can help round out our collection.

Visit the American Influenza Epidemic of 1918-1919: A Digital Encyclopedia 2.0 database to learn more:

howard markel headshot

Howard Markel, M.D., PhD., is the George E. Wantz Distinguished Professor of the History of Medicine and director of the Center for the History of Medicine at the University of Michigan. His books include Quarantine!, When Germs Travel, and An Anatomy of Addiction. His articles have appeared in The New York Times, Journal of the American Medical Association, and The New England Journal of Medicine. He is a Guggenheim fellow, and he is a monthly contributor to PBS NewsHour. Markel is a member of the National Academy of Medicine, and lives in Ann Arbor, Michigan.

j. alexander navarro headshot

J. Alexander Navarro, PhD., received his doctorate in history from the University of Michigan. A diplomatic, political, and intellectual historian by training, Dr. Navarro has taught and conducted research on a wide range of topics, including U.S.-Latin American history and U.S.-Southeast Asian relations, Western labor history, 20th-century urban history, race and racism, and issues of national identity. Since joining the Center for the History of Medicine, Dr. Navarro has focused his research on the historical, social, economic, and political ramifications of the 1918 and 2009 influenza pandemics. In addition to supervising the Center’s large research projects, Dr. Navarro assists in the management of the Center’s operations.