An older man in a bowler hat labeled "The Public" points to a hankerchief as a young boy prepares to sneeze.

Droplet Infection Explained in Pictures

Circulating Now welcomes guest bloggers Katherine Randall, Linsey C. Marr, PhD, and E. Thomas Ewing, PhD to explore the history of public health messaging during the 1918 influenza epidemic.

An older man in a bowler hat labeled "The Public" points to a hankerchief as a young boy prepares to sneeze.
Poster, United States Public Health Service, ca. 1918
National Library of Medicine #101453084

In November 1918, at the height of the influenza epidemic, the United States Public Health Service released a poster providing guidance on how to prevent the spread of infectious disease. An elderly man, wearing a hat labelled, “The Public,” instructs a young boy, about to sneeze: “Use the handkerchief and do your bit to protect me!” The man points to a partially unfolded handkerchief. The caption emphasizes the health message: “Colds, influenza, pneumonia, and tuberculosis are spread this way.”

More information about this poster appeared in an article, “Droplet Infection Explained in Pictures,” published in Public Health Reports, November 15, 1918. The article praised the “striking poster” by “well-known Washington cartoonist” Clifford Berryman, as proof of a shift in public health messaging. While the poster was described as accessible and relatable, “[showing] at a glance and in language understood by everybody just how influenza and other respiratory diseases may be guarded against,” this apparently had not always been the case:

Not so many years ago, under similar circumstances, the health authorities would have issued an official, dry, but scientifically accurate, bulletin teaching the role of droplet infection in the spread of respiratory diseases. The only ones who would have understood the bulletin would have been those who already knew all about the subject; the man in the street, the plain citizen, and the many millions who toil for their living, would have had no time and no desire to wade through the technical phraseology.

Berryman’s poster had captured not only the scientific urgency of preventing infection, but also the appropriate method by which to communicate expert knowledge and practical advice.

In the weeks that followed, the poster appeared in newspapers across the United States, including more than one hundred newspapers on just one day, December 5, 1918. Each article began with a frank statement from US Surgeon General Rupert Blue: “The present epidemic has taught by bitter experience how readily a condition beginning apparently as a slight cold may go on to pneumonia and death.” One result of the epidemic, Blue declared, was that “people are beginning to learn that ordinary coughs and colds are highly catching and are spread from person to person by means of droplets of germ laden mucus. Such droplets are sprayed into the air when careless or ignorant people cough or sneeze without covering their mouth and nose.” This clear explanation of disease transmission, followed by the text of the Public Health Reports article and the poster, combined assertions of scientific authority with public health language “understood by everybody.”

The public health warning appeared at an important moment in the 1918 epidemic. The initial surge in cases and deaths, mostly in October, was followed by significant decreases, leading many to believe that the danger had passed. As temperatures cooled and people remained inside, however, health officials warned against another wave of deadly disease. Statistics from the ten largest cities indicate that the poster, Public Health Reports issue, and newspaper articles appeared as influenza and pneumonia deaths had decreased substantially, yet still remained higher than pre-epidemic levels.

A bar chart indicates the frequency of the term "Droplet Infection Explained" over time from November 1918 to January 1919 after an October spike in deaths.
Statistics from Public Health Reports, February 7, 1919, Vol. 34, No. 6, pp. 225-229 National Library of Medicine PMC 1996906
A line drawing of a man with a pen and ink bottle and a toy bear.
Berryman and His Bear, Evening Star, November 25, 1918
Courtesy Library of Congress

Berryman was indeed “well-known” in 1918, almost twenty years after his cartoon launched the “Teddy Bear” craze. Berryman’s cartoons appeared regularly on the front page of the Evening Star, yet only two cartoons during the epidemic make any connection to the disease: a warning on October 11 that the epidemic might interfere with the war effort and an appeal on December 28 for ventilation in street cars. The latter cartoon remains relevant, as a new epidemic has resurrected earlier assertions that ventilating closed spaces helps to prevent spread of disease.

A century later, we have seen that scientific knowledge about infection—and the public communication of that knowledge—evolves quickly under the glare of an epidemic spotlight. And while forms of communication are more rapid in 2020 than they were in 1918, the accessibility, authority, and timing of public health messaging are still crucial.

A huge figure in a tricorn hat that reads D.C. speaks to a crowded trolly car.
Evening Star, December 28, 1918
Courtesy Library of Congress

Early in the COVID-19 epidemic, public health officials asserted that the virus traveled in large droplets. This widespread belief led to recommendations to keep six feet apart, avoid crowds, wash hands, and use face coverings. Today, research is ongoing around aerosol transmission of COVID-19, involving smaller particles of fluid traveling further and remaining in the air longer. This information, transmitted though web and social media, creates a complex, diverse, and ever-expanding record of current experience which will become the future historical record.

The historic public health poster discussed here helps to confirm lessons from 1918. First, messages must be understandable to the public—and it helps if the graphics are engaging and memorable. Second, public health guidance must be based on scientific research—yet these warnings must also adapt or evolve if this research changes. Finally, health warnings must provide specific guidance on preventing infection. The primary message from 1918 remains highly relevant as we wear masks, avoid crowds, improve ventilation, wash our hands, and remain socially distant: “do your bit to protect me!”

A woman wearing a cloth facemask in an interior room.Katherine Randall is a doctoral candidate in the Rhetoric and Writing program at Virginia Tech. Her research focuses on medical rhetoric and health communication. In 2018, she and Dr. Ewing co-edited Viral Networks: Connecting Digital Humanities and Medical History, which grew out of an interdisciplinary workshop hosted by the History of Medicine Division of the National Library of Medicine. @katierandall

A woman wearing a cloth facemask stands outdoors.Linsey C. Marr is the Charles P. Lunsford Professor of civil and environmental engineering at Virginia Tech. She studies the airborne transmission of viruses and applies interdisciplinary approaches to study pollutants in indoor and outdoor air. She received an NIH New Innovator Award in 2013. @linseymarr

A man in a bandana stands outdoors in front of a moument.E. Thomas Ewing is a professor of history at Virginia Tech, with research interests in the history of influenza epidemics. In 2018, he directed a summer workshop on the 1918 influenza epidemic funded by the National Endowment for the Humanities in partnership with the History of Medicine Division, National Library of Medicine. @ethomasewing

One comment

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.