June 27

From the experts


The 1918 Influenza and Coronavirus: Social Revolutions, Racism, and Xenophobia Amidst Pandemics

Throughout the era of COVID-19, people have claimed that society would not be able to sustain itself without the modern technology that many of us enjoy today. In adapting to a world of social distancing, we have altered the way in which we communicate, often remotely. There has been an expansion of mental health care to rural areas without licensed counselors through the improvement of telemedicine. World-renowned scientists have collaborated to invent creative strategies to streamline the testing process in labs across the globe. While pandemics have historically provided technological innovation and societal change, they highlight many inequalities in the status quo.

COVID-19 has exposed health and socioeconomic inequities that have always existed but have failed to be addressed. These inequities stem from a long history of injustice and cause an imbalance of power and privilege, or inequality, that systemically disadvantages minority groups while inherently favoring white people. Racial and ethnic minority groups have disproportionately suffered from the complications arising from COVID-19, resulting in a rate of 92.3 deaths per 100,000 Black people in New York City compared to 45.2 deaths per 100,000 white people (“Coronavirus Disease 2019,” 2020). Several social determinants of health — factors that impact health outcomes — including population density, health care coverage and accessibility, occupation, food insecurity, and chronic stress levels can be attributed to this discrepancy. This pandemic is an opportunity to address the systemic racism ingrained in our society that has engendered these disparities, as members of the Black Lives Matter movement have pointed out following the murder of George Floyd and a long list of others. We must look to previous pandemics and social revolutions to learn from our mistakes and ensure this all-important cultural movement is not undermined by the invisible enemy: COVID-19. Using history, we can learn how to better support one another as we combat social injustice during the age of coronavirus.

The 1918 influenza pandemic

Rewind to 1918. As World War I came to its climax, millions of soldiers traveled to and from international bases while those back at home entered the workforce to be confronted by dismal, crowded working conditions (“1918 Pandemic Influenza Historic Timeline,” 2019). Meanwhile, a different, but formidable threat loomed over humankind. Invisible to the naked eye, this enemy — the 1918 influenza, also called the Spanish flu — would take over two times the number of lives lost during the war. The 1918 influenza was caused by a specific strain of the H1N1 virus — different from the strain causing the Swine Flu outbreak of 2009. (“History of 1918 Flu Pandemic,” 2019). Though the exact origin of the virus is still unknown, the first outbreak was detected at a US Army training camp in Fort Riley, Kansas (“1918 Pandemic Influenza: Three Waves,” 2018). This pandemic is still considered the deadliest flu on record and one of the most lethal pandemics yet, with a total of 50 million deaths worldwide and over 500 million infections by 1920 (“History of 1918 Flu Pandemic,” 2019). However, virus particles were not the only things in the air at the time, as protests, social revolutions, and cultural shifts spread across the globe.

One of the many parallels between the 1918 influenza and COVID-19 includes public revolts against social distancing, lockdown efforts, and masking requirements. As the epicenter of anti-lockdown protests and repeated resurgences of the 1918 influenza, San Francisco took extreme measures early on in its handling of COVID-19 (Kane, 2020). The port city now reflects on its complex history with pandemics, particularly drawing attention to the Anti-Mask League formed by business leaders in January of 1919 after the mayor had periodically enacted and lifted orders requiring face masks in public (Bristow, 2020). Four hundred members of the league were arrested by police for refusing to wear masks, with some even being shot by law enforcement (Bristow, 2020; Clark, 2020). Though many factors contributed to this revolt, historians emphasize that the masking effort entirely collapsed after the mayor and a public health leader were spotted without face coverings (Bristow, 2020). Religious groups across the country simultaneously protested restrictions on mass gatherings, facing similar consequences to the Anti-Mask League with arrests and fines (Clark, 2020). Ultimately, cities where these protests took place experienced resurgences similar to San Francisco, where influenza infections increased from 20,000 at the end of October to 45,000 by the end of spring (Bristow, 2020). 

Another important point to know is that the dubbing of the 1918 influenza pandemic as the Spanish flu stems from a misconception. As previously mentioned, the first outbreak was traced back to an Army camp in Kansas. Understandably, many people believed that Spain was the origin of the virus given its nickname (Andrews, 2020). Spain was one of the few neutral countries during World War I and did not experience media blackouts as compared to America, Germany, and the United Kingdom, where much of the news was censored for either propaganda or morale purposes (Andrews, 2020). Virus coverage increased when Spain’s King Alfonso XIII had been infected (Andrews, 2020). Seemingly overnight, the pandemic was dubbed the Spanish flu (Andrews, 2020). This misleading label propagated the illusion that the virus came from a foreign enemy with the intent to sabotage, inciting fear, and facilitating the circulation of xenophobic ideals. The prejudiced name also underscores the false belief that simply closing borders would resolve pandemics and is reflective of countries’ instincts to disregard vulnerable minority communities when developing medical countermeasures (Parmet & Rothstein, 2018). The US government was negligent in its treatment of minority groups, resulting in unfettered spread throughout these densely-populated communities. There was a 35% higher influenza mortality rate in Black populations than in white populations, and further stigmatization and scapegoating minority groups subsequently followed (Hutchins et al., 2009).

A stark, grim contrast

Fast forward to 2020. Once again crowds are protesting the lockdown, gathering without proper personal protective equipment with some defying orders to wear masks in part because some government officials refuse to do so themselves. These parallels between the 1918 influenza and COVID-19 are clear as day but it is equally important to discuss the contrasts between these pandemics, specifically surrounding law enforcement’s responses to public demonstrations. During the 1918 influenza pandemic, police arrested and even fired bullets at protesters for refusing to wear masks or act in accordance with public health measures. Now, for the large part, officers are not arresting anti-lockdown demonstrators but are instead using excessive violence against peaceful protesters demanding racial justice. In the wake of the murder of George Floyd, the Black Lives Matter movement is faced with teargas, rubber bullets, and unwarranted arrests. Attacks on public health are deemed permissible while advocacy for racial equality — a mission that, at its core, is inherently uncontroversial and should not be political — is criminalized.

Lessons to be learned

COVID-19 has disproportionately affected minority groups just as the 1918 influenza impacted Black Americans. In order to reverse this trend, we must first recognize racism as a public health issue. According to a study conducted by the Proceedings of the National Academy of Science, police violence is the sixth leading cause of death for all men in America, and Black men are 2.5 times more likely to be killed by the police than white men (Edwards et al., 2019)  These numbers tie into the fact that average life expectancy was 3.5 years shorter for Black populations than for white populations in 2017 — a record low for this death gap in the US (Arias & Xu, 2019). Police brutality is just one of many ways that institutional racism has directly promoted health inequities and widened the disparity between life expectancy of Black and white Americans. Bottom line, racism is causing a public health crisis.

Racial discrimination is so deeply ingrained in our society that microaggressions — subtle slights or insults that deliver hostile messages to members of marginalized groups — occur far too frequently and often go unchecked. These negative interactions can range from the claim that one “does not see color” — which can be interpreted as ignoring the struggles of Black people — to the act of a business owner following a person of color around their store. Microaggressions are essentially a social determinant of health, as they have lasting impacts on the physical wellbeing of the targeted individual. These slights and insults are stress-inducing and provoke a “fight or flight” response — a physiological reaction to a perceived threat or harmful event (Mays et al., 2007). The neuroendocrine system consequently releases high levels of epinephrine which increases heart rate, causes a spike in blood pressure, and triggers the secretion of cortisol alongside other stress hormones and inflammatory-promoting factors (Ansell, 2017). The cumulative effect of this response is called allostatic load — the weathering of the body due to repeated cycles of stress (Mays et al., 2007). Allostatic load greatly increases the likelihood of developing hypertension, metabolic syndrome, and cardiovascular disease (Mays et al., 2007). These chronic conditions put individuals at higher risk of experiencing severe illness or death from COVID-19 (Schiffrin et al., 2020). As this field of research expands, ongoing studies suggest the relationship between racism and allostatic load contributes to the higher prevalence of life-threatening diseases in Black Americans, and thus, increased vulnerability to diseases like COVID-19 (Mays et al., 2007). Microaggressions are only one example of several stressful circumstances, along with food insecurity and domestic violence, that disproportionately impact members of minority groups on a daily basis. 

Health disparities caused by racism and prejudice do not stop at the US border. The xenophobic rhetoric of 1918 has manifested in intolerant accusations, hysteria, and bigoted conspiracy theories about the coronavirus. It is critical that these attitudes do not result in the exclusion of marginalized groups from medical care, which will require addressing the gap in treatment of COVID-19 between people of developed and developing nations. Poverty, lack of modern sanitation, and lack of access to medical countermeasures were partial reasons for why mortality rates in Asia, Sub-Saharan Africa, and Latin America were significantly higher than those in Europe and North America during the 1918 influenza pandemic (Oshitani et al., 2008). As a leading global power, we cannot repeat our mistakes. Simply closing our borders off and neglecting the rest of the world will not do.

There will never be a clear, singular solution to institutional racism, especially as a public health issue, but there are steps that we can take now. It is essential that the Black Lives Matter movement continues to receive the public attention that it rightfully deserves. Looking forward, however, we must keep in mind that we are still in the midst of a pandemic despite states reopening and media coverage shifting its focus. Do not give in to the illusion that coronavirus is no longer among us, as we have learned that prematurely letting our guard down only leads to resurgences. Hold your community accountable to ensure we do not make the same mistakes as the Anti-Mask League in San Francisco. Most importantly, educate yourself on racism as a public health issue, seek concrete solutions from trusted sources, and adamantly commit to protecting the health of yourself and others. Public health is more than a mechanism to mitigate the spread of coronavirus. It is a tool to learn about and navigate the multitude of disparities caused by institutional racism. It is a reminder of how your interactions with marginalized groups may cause a cascade of physiological events that lead to increments of change in health inequities. Public health, if used in its full capacity, can be a driving force behind the fight against racial discrimination. 


1918 Pandemic Influenza Historic Timeline | Pandemic Influenza (Flu) | CDC. (2019, April 18). Retrieved June 18, 2020, from https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/pandemic-timeline-1918.htm

1918 Pandemic Influenza: Three Waves | Pandemic Influenza (Flu) | CDC. (2018, November 29). Retrieved June 18, 2020, from https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/three-waves.htm

Andrews, E. (n.d.). Why Was It Called the “Spanish Flu?” Retrieved June 18, 2020, from https://www.history.com/news/why-was-it-called-the-spanish-flu

Ansell, D. A. (2017). The death gap: how inequality kills. Chicago ; London: The University of Chicago Press.

Arias, E., & Xu J. (2019). United States life tables, 2017. National Vital Statistics Reports, 68(7), https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_07-508.pdf 

Bristow, N. (2020, May 1). Loosening Public-Health Restrictions Too Early Can Cost Lives. Just Look What Happened During the 1918 Flu Pandemic. (n.d.). Retrieved June 18, 2020, from https://time.com/5830265/1918-flu-reopening-coronavirus/

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Clark, D. (2020, May 11). “A breaking point”: Anti-lockdown efforts during Spanish flu offer a cautionary tale for coronavirus. (n.d.). Retrieved June 18, 2020, from https://www.nbcnews.com/politics/politics-news/breaking-point-anti-lockdown-efforts-during-spanish-flu-offer-cautionary-n1202111

Edwards, F., Lee, H., & Esposito, M. (2019). Risk of being killed by police use of force in the United States by age, race–ethnicity, and sex. Proceedings of the National Academy of Sciences, 116(34), 16793–16798. https://doi.org/10.1073/pnas.1821204116

History of 1918 Flu Pandemic | Pandemic Influenza (Flu) | CDC. (2019, January 22). Retrieved June 18, 2020, from https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918-pandemic-history.htm

Hutchins, S. S., Fiscella, K., Levine, R. S., Ompad, D. C., & McDonald, M. (2009). Protection of Racial/Ethnic Minority Populations During an Influenza Pandemic. American Journal of Public Health, 99(S2), S261–S270. https://doi.org/10.2105/AJPH.2009.161505

Kane, P. L. (2020, April 29). The Anti-Mask League: lockdown protests draw parallels to 1918 pandemic. The Guardian. Retrieved from https://www.theguardian.com/world/2020/apr/29/coronavirus-pandemic-1918-protests-california

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Oshitani, H., Kamigaki, T., & Suzuki, A. (2008). Major Issues and Challenges of Influenza Pandemic Preparedness in Developing Countries. Emerging Infectious Diseases, 14(6), 875–880. https://doi.org/10.3201/eid1406.070839

Parmet, W. E., & Rothstein, M. A. (2018). The 1918 Influenza Pandemic: Lessons Learned and Not—Introduction to the Special Section. American Journal of Public Health, 108(11), 1435–1436. https://doi.org/10.2105/AJPH.2018.304695

Schiffrin, E. L., Flack, J. M., Ito, S., Muntner, P., & Webb, R. C. (2020). Hypertension and COVID-19. American Journal of Hypertension, 33(5), 373–374. https://doi.org/10.1093/ajh/hpaa057

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