A photograph of a nurse wearing a surgical mask and a list of tips "to prevent influenza"

Influenza Precautions, Then and Now

Circulating Now welcomes guest blogger Tom Ewing, Professor of History and Associate Dean in the College of Liberal Arts and Human Sciences at Virginia Polytechnic Institute and State University.  Professor Ewing offers a comparison of health recommendations during the Spanish Influenza epidemic of 1918 and today. 

On October 18, 1918, the Illustrated Current News in New Haven, Connecticut, published a list of steps “To Prevent Influenza!” with a full page photograph of a Red Cross nurse wearing an influenza mask. These recommendations echoed numerous statements from federal, state, and local public health officials urging the population to take specific measures to prevent the further spread of so-called Spanish Influenza. In late September 1918, as this particularly deadly form of influenza spread throughout military camps and then into civilian populations, the United States Public Health Service issued a bulletin urging citizens to take precautionary steps to contain the disease.

A photograph of a nurse wearing a surgical mask and a list of tips "to prevent influenza"
To Prevent Influenza, Illustrated Current News, October 18, 1918
National Library of Medicine #A108877

In the weeks that followed, as the epidemic worsened and deaths rose dramatically, these recommendations were distributed as pamphlets, republished in newspapers and journals, and displayed as placards in train stations, store windows, and movie theaters.

At the start of 2015, as flu cases remain widespread and health officials recommend steps to contain the disease, the historical record is a useful way to gauge how much has changed, but also how much remains the same, in experts’ responses to disease outbreaks. A comparison of answers to the question, “How can one guard against influenza?” in 1918 and the steps urged by today’s Centers for Disease Control demonstrates that public health responses to disease outbreaks are shaped by both advances in medical knowledge and the context in which epidemics occur.

Remember to Take 3 actions to fight flu this season. 1. Get a Vaccine in shot or mist form. 2. Wash your hands. 3. Take antivirals if prescribed by your doctor if you get the flu.

The most significant change is the availability now of vaccines to prevent disease transmission and antiviral drugs medications to treat illness, as neither of these medical options were available a century ago. In 1918, the Public Health Service could only recommend measures to make patients feel better, such as offering fluids and cold compresses to feverish patients. Despite the obvious ineffectiveness of limited medical options in 1918, the Public Health Service issued a seemingly pointless warning that patients only take medicine prescribed by a doctor, as it was “foolish” to follow druggists’ advice to try “the so-called ‘safe, sure, and harmless’ remedies advertised by patent-medicine manufacturers.”

Ad reading: "To Regain health and strength after Spanish Influenza or Pneumonia...Gude's Pepto-Mangan"
Gude’s Pepto-Mangan Ad, Lynchburg News, November 5, 1918.
Courtesy University of Virgina

If the level of medical understanding has changed significantly over a century, “everyday preventive actions that can help stop germs, like flu,” to use the current terminology from the Centers for Disease Control, are remarkably similar to measures in 1918 to keep the body strong and “able to fight off disease germs.” These measures included maintaining “a proper proportion of work, play, and rest,” wearing warm clothes, spending time in fresh air, avoiding crowds, and eating “sufficient, wholesome, and properly selected food.” Just as the Centers for Disease Control now recommends that healthy individuals avoid contact with the sick, the Public Health Service in 1918 instructed sick citizens to remain home to avoid infecting others. In both 1918 and now, avoiding contaminated surfaces was recommended as a preventive measure, although the suggestion a century ago that attendants of patients wear gauze masks has been discarded as medically ineffective. The couplet that ended the 1918 pamphlet, “Cover up each cough and sneeze / If you don’t you’ll spread disease,” is reproduced almost verbatim, but without the mnemonic device of a rhyme, on websites and in tweets.

Newspaper column with headline "Uncle Sam's Advice on Flu."
Graham Guardian, October 25, 1918
Library of Congress

The pace and scope of information dissemination has obviously changed significantly since 1918. Whereas websites, social media, and live interviews now allow officials to respond to changing conditions or address public concerns within days or even hours and publish data on a weekly basis, the 1918 publication cycle was slower and more distributed. Some newspapers delayed publication of “the latest word” on the Spanish Flu for as much as a month, even as cases and deaths mounted. Yet public health officials in 1918 actively pursued media strategies appropriate to the context, including collaborating with theater owners to post placards in lobbies.

The Spanish influenza occurred in a wartime context, when public health organizations, like all branches of the government, were fully mobilized to support this national priority. The close connection between the war and influenza was evident when newspapers illustrated “Uncle Sam’s Advice on Flu” with a graphic showing a sick man standing in front of a crowd that included civilians and soldiers, with this caption: “Coughs and Sneezes Spread Diseases / As Dangerous as Poison Gas Shells.”

As is now well-known, the death toll from Spanish influenza in the United States, estimated at more than 600,000, was at least five times the number of American soldier deaths in World War One. Public health officials in 1918 certainly underestimated the danger of Spanish influenza, with a confident prediction that “ordinarily” patients recovered after three days of illness and the “proportion of deaths in the present outbreak has generally been low.” Yet even at this early stage, the Public Health Service warned that “in some places the outbreak has been severe and deaths have been numerous.” Epidemiologists and historians continue to seek explanations for the very high morbidity rates in 1918 and ask whether any preventive measures could have been mitigated this toll. A comparison of health recommendations then and now demonstrates both significant advances in proven medical responses, such as vaccines and antiviral medications, and important continuities in information about the flu and everyday preventive measures that may contribute to the overall health of the population.

Portrait of Tom Ewing outside. Professor Ewing’s recent research in the historical collections of the National Library of Medicine includes using new methods of analyzing textual information to discover information about public health communication. In July 2015, Dr. Ewing will lead a summer seminar for schoolteachers, funded by the National Endowment for the Humanities, on the Spanish Flu, with a site visit for research at the National Library of Medicine, Library of Congress, and National Archives and Record Administration. Follow him on Twitter at @EThomasEwing.



  1. we have to sit still to avoid influenza.. thanks for sharing the information

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