How racism shaped the public health response to the 1918 Spanish Flu Pandemic

It was October 15, 1918 and Los Angeles was in the thick of the fight against the Spanish flu. Patients were dying at numbers much higher than earlier that spring. At the Los Angeles County hospital, wards were crowded with the sick, 20 of them nurses that had served in the same halls.

Despite these conditions, 126 student nurses sent in resignation notices that day. Why? Four black students made it on a waiting list for admission into the hospital’s training school. The white nurses did not want to share the same living and eating quarters with black nurses, or have white students to treat them as superiors as they progressed through the curriculum.

Days later, the Los Angeles Times reported that the resignations would come at at a hefty price for the county: Professional nurses would need to be paid $80 per month, compared to the $15 dollars a month the student nurses were paid. That’s a difference of around $1,100 in today’s money.

Even as pressure mounted, training school administrators refused to strike the four names from the list. However, by October 19, the 126 retracted their threat to resign as the virus continued to claim more lives.

While the only information about the strike can be found in the pages of old Los Angeles Times newspapers, it hints towards how racism deeply influenced the public health response to the 1918 ‘Spanish flu.’

The rise of eugenics in public health

Let’s take a closer look at the public health environment before that day in October 1918.

At the turn of the century, the public health structure in the United States prioritized eugenics, or ideas and practices that focus on improving a population by either lifting up groups deemed superior, or excluding those deemed inferior. The United States government funded sterilization programs in 32 states throughout the 20th century. Many of these sterilization programs were forced, or performed without the informed consent of patients.

Without basis, public health specialists targeted African-Americans, along with immigrants, Native Americans, and other groups with these eugenicist theories, often blaming them for their own health problems. For example, in 1915, some doctors claimed that black people were susceptible to tuberculosis because they were “structurally maladapted” to live in northern cities.

Frederick L. Hoffman, a statistician at the Prudential Life Insurance Company, claimed that African Americans were healthier during enslavement, and only now were “shown to be on a downward grade” towards the “gradual extinction of the race.”

Even when public health experts of the period advocated for more inclusive health regulations, they opted to focus on the capability of African-Americans to spread diseases to wealthier, white employers. Since black Americans worked in homes as maids, cooks, butlers, and laundresses and comprised the majority of cheap agricultural labor in the south, they referred to these inequities as a “white man’s burden” to correct.

One Georgia doctor, at a 1914 Public Health Association annual meeting proclaimed, without evidence, that “disease among the negroes [sic] is a danger to the whole entire community.”

Black leaders and physicians fought against these stereotypes, urging the medical community to consider the realities of economic and health disparities. Many insurance providers refused to cover African-Americans, and discriminatory laws forced them to receive care in separate, black-only hospitals, many of which were poorly funded.

Racist practices and beliefs were actually accelerated by the ‘Spanish flu’ outbreak, writes historian Elizabeth Schlabach.

“Even though African Americans were not carrying the deadly influenza virus, their bodies became the metaphorical vessels of transmission, and, therefore, in the eyes of whites, African Americans were worthy of punishment and physical acts of violence and unworthy of adequate medical treatment.”

Fighting the virus

Los Angeles wasn’t the only city to be hit hard in the fall of 1918. The Spanish Flu roared through communities in every state. More than 500,000 Americans died from the virus.

Facing dire conditions and limited resources, black communties banded together to fight the virus in whatever way they could. In Philadelphia, black teachers volunteered to cook at food centers, schools, hospitals and nurseries. In Chicago, the National Urban League organized groups of volunteers to distribute food and visit the homes of the sick. Black newspapers such as The Chicago Defender and the Baltimore Afro-American featured health columns, that urged readers to wear masks and stay home if they were. sick.

Some black hospitals turned away patients because of overcrowding. The 40-bed Provident Hospital in Baltimore, asked patients to seek care elsewhere in October. Black soldiers stationed at a nearby fort were ordered to bury bodies that had been left “exposed to the elements” for three weeks when a local black cemetery was overwhelmed, the Baltimore Sun reported.

Frederick Douglass Memorial Hospital, one of Philadelphia’s two black hospitals, constructed an “emergency annex” in a nearby school to add more beds.

“The colored woman wanted to go but we wouldn’t let her”

Black doctors and nurses continued to care for the sick despite racist policies. Even as hospitals faced nursing shortages, many black nurses were denied employment. However, this had been an issue for many black nurses before the onset of the virus. Towards the end of World War I that November, the lack of black nurses in the war effort was a point of contention for many black Americans.

“Don’t let it be said by the great American historians in the coming years that only the American white women served as nurses in the great conflict…put in a paragraph that the colored woman wanted to go but we wouldn’t let her,” wrote an anonymous commenter in The Baltimore Afro-American.

Faced with a shortage of nurses, the United States army, which had denied black nurses just months before, permitted 18 black nurses to serve in domestic army bases iafter the Armistice was signed. However, black nurses were not sent overseas to care for black soldiers in Europe, and since they technically did not serve during wartime, they were not eligible for the same educational and post-war benefits extended to those who had served.

The pandemic also changed opportunities for black nurses in the private sector: Carnegie Steel in Pittsburgh, Pennsylvania, hired 16 black nurses to care for sick employees.

The extent of the outbreak on black communities

Paging through newspapers, the exact impact on the 1918 flu epidemic on African American communities across the United States is difficult to piece together.

In October, the Philadelphia Tribune described “hundreds” that lay in West Philadelphia, “at the point of death, colored and white.” The Baltimore Afro-American reported that “while the death rate from the epidemic of influenza is not as high as the white death rate, colored people are far from being immune of the disease.”

“Although the newspapers provide a useful lens to examine the impact of influenza on African Americans, it is an incomplete one,” wrote Vanessa Northington Gamble, a medical doctor and professor of medical history at George Washington University, in a study of African Americans and public health during the 1918 outbreak.

On one hand, some medical doctors reported that African American communities were left unscathed by the virus prompting headlines like “Flu Shuns Us, Says Health Doctor” in the Cleveland Advocate, while a lack of detailed data remains to paint a complete picture.

On the other, the lower number of cases could be explained by the fact that a lot of cases went unreported in the chaos of the outbreak. For instance, researchers Helene Økland and Svenn-Erik Mamelund explained that the “only year in the 20th century when black people in the USA had lower influenza mortality than white people was 1918,” in a report in the International Journal of Environmental Research and Public Health.

Death rates and health disparities today

Today, we have a clearer picture of how the COVID-19 coronavirus pandemic is affecting communities of color than public health experts did in 1918. Data shows that Black and Latino Americans are dying from the virus at disproportionately high rates in communities across the United States.

In Louisiana, African-Americans accounted for more than a half of deaths, while they amount to only a third of that state’s population. In San Francisco, California, where Latinos make up a quarter of confirmed cases, they make up only 15% of the city’s population.

On April 30, Senator Kamala Harris (D-CA) announced plans to introduce the COVID-19 Racial and Ethnic Disparities Task Force Act, which would help tackle the healthcare disparities many communities of color face.

“It is critical that the federal government proactively work to right historical wrongs that have led to racial inequities for generations,” Harris said in a statement. “The COVID-19 Racial and Ethnic Disparities Task Force Act is a necessary step to fully understand the impact of this virus in the hardest hit communities, and make targeted investments that correspond with their unique needs.”