What effects can a virus have on society? A virus is more than a biological organism. It's a social organism. Historian Nancy Bristow shares the lessons about human behavior that we can take away from a century-old pandemic.

An Unfinished Lesson

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From NPR, this is HIDDEN BRAIN. I'm Shankar Vedantam. For months, people were afraid. The virus outbreak started out small but then grew exponentially. Within days, every part of the country, every part of the world, was affected. Uncertainty and confusion abounded. Misjudgments about how to fight the pandemic proved catastrophic. All this rings true today, but it was also true a century ago. Almost exactly 100 years ago, a new infectious disease swept the world. My guest this week says the lessons from that outbreak are instructive if we only stop to listen.


VEDANTAM: Nancy Bristow is a historian at the University of Puget Sound. She's the author of "American Pandemic: The Lost Worlds Of The 1918 Influenza Epidemic." Nancy, thank you for joining me today on HIDDEN BRAIN.

NANCY BRISTOW: Thank you so much.

VEDANTAM: Give me a sense of the scale of the 1918 pandemic, Nancy.

BRISTOW: This was a massive event. Inside the United States, more than a quarter of Americans were sickened. By the time the pandemic was through, 675,000 Americans would die, and the estimates vary for the world for somewhere between 50 and 100 million people, and a third of people on the globe were likely infected.

VEDANTAM: So this was not the first time the country had been affected by an influenza outbreak. What is it that made this strain so dangerous, Nancy?

BRISTOW: The influenza virus is a very clever virus. It's constantly changing, drifting through limited but frequent changes in its genetic makeup during the reproduction process. But sometimes, there's a thing called antigenic shift. It's a much more dramatic transformation when a single cell hosts two separate and distinct strains of influenza and during the reproduction process recombines those two parental strains into a new hybrid virus, a virus for which no one is prepared. No one has immunity.

VEDANTAM: So, of course, because the virus sort of strikes with some regularity every year, people have developed some immunity, your point is that when the virus mutates in this fashion, it essentially is striking a naive population.

BRISTOW: Exactly.

VEDANTAM: So many people believe the 1918 outbreak in the United States first began at an army camp in Kansas. Tell me about Camp Funston.

BRISTOW: Well, Camp Funston was one of many places in the United States where American soldiers were training for the First World War. And that spring, they experienced a somewhat unusual example of influenza. And as it traveled through the army camps, a few pathologists noticed that there was something unusual. The postmortem exams of the victims showed a kind of soggy lung, but in general, most Americans didn't notice it. And this first wave, with its origins in Kansas, would pass the United States almost entirely unnoticed except by a few military epidemiologists.

VEDANTAM: And so once it strikes in Camp Funston, soldiers presumably are moving about the country. They're moving from camp to camp. What happens to the virus?

BRISTOW: Well, the virus, of course, is continuing to do its work of infecting American soldiers and traveling with them, first all over the country and then, of course, it will become more noticeable because it will travel with those American troops over to the European battlefields. By April, it spread to the British and German forces. By May, the French troops are infected. And then, of course, by that summer, Italy and Spain will also be infected. By June, it would infect Britain, and in July, citizens all over the continent of Europe would be infected with this first wave.


VEDANTAM: So you mentioned a second ago, of course, that this pandemic is unfolding at a time when the world is engulfed in war. And the virus travels from the United States to Europe, to the countries of Europe, but it's also traveling to the theaters of war in Europe. Tell me what was happening on the Western Front, Nancy.

BRISTOW: Well, of course, the Western Front is deep in the throes of this war. American troops are just beginning to arrive in large numbers in the spring of 1918. The nation had joined the war in April of 1917. So the war is ongoing. It is deep. Millions of people have already died in trench warfare. And by the spring of 1918, the United States has entered, and we're beginning to see a new round of assaults, a new round of battles. And so the opportunity for the virus, in a sense, is unlimited. You have a virus ready to attack the very people who are in those trenches, the target audience for the virus - young people.

VEDANTAM: So across the Western Front, which is essentially the dividing line between the German forces and the Allied forces, you have these trenches and you have this very lengthy period of trench warfare unfolding in World War I. Conditions are pretty dismal. Health conditions, of course, are terrible. From the virus' perspective, of course, this is actually ideal conditions to spread and grow and mutate.

BRISTOW: Exactly. Not only do you have a number of people far too many close together - we know now that social distancing is the best thing we can do to prevent the virus' spread. But in 1918, you have large numbers of people both in training camps and then on the battlefields themselves. And these are often people with compromised health already. They're living in horrible conditions. They may be undernourished. They're certainly not sleeping well. And so you have a large population that is simply an easy field, in a sense, for this virus.

VEDANTAM: So the chronology here is that early in 1918, perhaps with the epicenter at Camp Funston, the virus starts to spread in the United States, primarily following the paths of soldiers. It goes to Europe. It mutates. It changes. It becomes more deadly. And then something really dramatic happens that August and in the fall of 1918. What happens, Nancy?

BRISTOW: Well, it's really an explosive moment. The virus emerges in this new form on three continents almost simultaneously in Freetown, Sierra Leone, in Brest, France, and in Boston here in the United States where it arrives on August 27. And then over the course of just two months, by the end of October, the entire United States will be awash in disease, from Buffalo to Birmingham, from Pittsburgh to Portland. No one will be able to hide from this illness. And the same thing is happening worldwide.

VEDANTAM: And, of course, the picture you've painted is that the virus, having mutated and become in some ways more deadly in Europe, when it returns to the United States, presumably it's much more dangerous now.

BRISTOW: That's exactly right. At this point, it is both very, very contagious and also deadly. Probably about 28% of Americans will be sickened by the virus. And in the end, as I mentioned, 675,000 people in the United States will die. The morbidity rates in the United States will range in different communities, sometimes as high as 40%. The mortality rate is also very high, somewhere between 2 and 2 1/2%. To put that in perspective, seasonal influenza is at .1%. So this is something like 25 times as lethal as regular seasonal influenza.


VEDANTAM: So the second wave of the influenza epidemic runs through the fall of 1918. And as you've described, it's truly devastating. And then almost incredibly there is a third wave of the epidemic that strikes early in 1919. What happens here, Nancy?

BRISTOW: It's horrific for communities in many cases that are just coming off the second wave. Perhaps they've just reopened their schools. Stores are open again. Perhaps movie theaters and saloons are up and running once again. And then people begin to sicken all over again, and they suffer through a third wave, again, this time quite noticeable because Americans are on high alert having just recovered from or, in some cases, still in the throes of the second wave. So, again, people are just beginning to breathe again, just beginning to relax and, suddenly, the disease is back.

VEDANTAM: Deaths from influenza outbreaks tend to have what you call a U-shaped curve when it comes to the age of its victims. Most victims are very young children, very old people. Was that the case with the 1918-1919 epidemic?

BRISTOW: This was something else that made this particularly horrific. In 1918, the mortality chart had a W shape. In other words, those between the ages of 20 and 40 were particularly susceptible. And so in fact almost 50% of the epidemic deaths in the United States were 20 to 40-year-olds, the very people who are the mothers and fathers of young children. They may be the teachers in schools. They're the firefighters and the police officers. They're the people who are, in a sense, the guts of a society, the people who are keeping a place up and running. And that population was struck desperately by this particular virus.

VEDANTAM: I'm wondering if this might be partly connected to the chronology that you unfolded a few moments ago. When the virus essentially traveled from the United States to Europe and spread in the theater of World War One, its primary victims were people, again, in the prime of their lives, young men in their 20s and 30s and obviously for the virus to essentially acquire a foothold in the trenches required the virus to mutate so that it would be effective among people in their 20s and 30s, which might explain why, when it returned to the United States, the victims were not just the very young and the very old but people in - working age people, often in the prime of their lives.

BRISTOW: That's a really interesting theory. Not being an epidemiologist, I won't go too far on this, but certainly the war played a fundamental role in furthering the virus, in facilitating its mutation, and the opportunity provided by all of those soldiers, again, really was the groundwork laid out there for the virus.

VEDANTAM: So some of the best accounts of the outbreak come to us not from doctors and scientists but from writers. Tell me the story of Katherine Porter and the novella she wrote about the 1918 influenza epidemic.

BRISTOW: This is really a remarkable novel, one of the best sources we have on the influenza pandemic because it's told from the perspective of a patient rather than the perspective of a physician. Katherine Anne Porter was a journalist living in Denver at the time, and she wrote a novella later, years later in the 1930s, recounting her own experience with the influenza pandemic. She had sickened, and while she was sick, her dearly beloved, a young soldier named Adam, also sickened and he died. And when she woke up, she came back to a world that was not the one she had left. And she was really quite tortured, in a sense, by the loss that she suffered during the pandemic. And she gives us a full account, almost a blow by blow, of what it was like to go through this illness. At the very beginning, she's not quite clear on what's happening because, again, the pandemic was new. And so she talks at first about not being able to smell or see or hear. She says I must have a fearful cold. And then she begins to talk about something much more fearful, much more frightening.

CAT SCHUKNECHT, BYLINE: (As Katherine Anne Porter) This is the beginning of the end of something. Something terrible is going to happen to me. I shan't need bread and butter where I'm going. I'll will it to Chuck. He has a venerable father to buy hooch for. I hope they let him have it. Oh, Adam, I hope I see you once more before I go under with whatever is the matter with me.

BRISTOW: And she can't control going in and out. She keeps wishing that she can come out of her dream so that she can talk to him.

SCHUKNECHT: (As Katherine Anne Porter) I have pains in my chest and my head and my heart, and they're real. I'm in pain all over, and you are in such danger as I can't bear to think about. And why can we not save each other.

BRISTOW: And at this point, she's not actually able to see Adam. He's been called back to camp, and by the time he tries to return to her in the novella, they will not allow him to see her, and so they never see each other again. And she goes off then into the delirium that was common with those who suffered deeply from this pandemic. At one point beforehand, she talks about loving to be alive. She says to Adam...

SCHUKNECHT: (As Katherine Anne Porter) Don't you love weather and the colors at different times of the day and all the sounds and noises, like children screaming in the next lot and automobile horns and little bands playing in the street and the smell of food cooking?

BRISTOW: She seems to want to be alive. And then once she's really sick and goes into this very high fever and a delirium, a kind of dreamlike unconscious state, she doesn't so much give up as embrace what's coming, which for her appears to be the beauty of what comes after life, what death looks like to her when she is on the very cusp of it.


VEDANTAM: So one reason that you've looked at novels and other cultural artifacts is that historians have noted that the great pandemic of 1918, even though it cost so many lives, was sort of quickly forgotten after the fact. Talk to me about this idea, that in many ways even though the effects of the pandemic were really horrific, it faded from public view, at least, relatively quickly.

BRISTOW: It did, and it's one of the things that I think historians have kind of puzzled over and even marveled about. Some people will simply dismiss it and say, well, this is what people do. H.L. Mencken wrote that the human mind always tries to expunge the intolerable from memory, just as it tries to conceal it while current. In fact, it seems to have been subsumed very easily under the memory of the war. It did happen concurrently initially, and the war was a much better story for the American people at this time. To remember the flu would be to admit to the lack of control that people had had over their own health. It would be to admit that the United States was not necessarily all powerful but was, like everywhere else in the world, subject as victims to something beyond their control.

VEDANTAM: You describe songs that have been sung about the flu, especially in the tradition of the blues.

BRISTOW: Yes. One of the rare places that we do see the story of the flu told are in blues lyrics. And I think it's because this was actually a genre that had space in it for the kind of message that this was a horrific event through which people had suffered and which left in its aftermath people lost, confused and very frightened. Essie Jenkins had a remarkable song called "The 1919 Influenza Blues."


ESSIE JENKINS: (Singing) It was in 1919, yes, men and women were dying with that stuff which the doctors call the flu.

BRISTOW: And another good one is Blind Willie Johnson's "Jesus Is Coming Soon."


BLIND WILLIE JOHNSON: (Singing) In the year of 19 and 18, God sent a mighty disease. It killed many a-thousand, on land and on the seas.

BRISTOW: And both of these tell the story of people suffering and dying and that this was really all part of God's plan, that this was God's way of speaking to the people about their having drifted from their faith or having acted in some ways that were either shameful or simply incongruous with their Christianity.


JOHNSON: (Singing) Jesus coming soon. The doctors, they got troubled, and they didn't know what to do. They gathered themselves together, they called it the Spanishin flu.

VEDANTAM: When we come back - what the 1918 influenza pandemic and the coronavirus pandemic of 2020 reveal about human nature. You're listening to HIDDEN BRAIN, and I'm Shankar Vedantam. This is NPR.


JOHNSON: (Singing) Soldiers died on the battlefield, died in the counts, too. Well, the captain said, lieutenant, we don't know what to do.

VEDANTAM: Historian Nancy Bristow says the ferocity and virulence of the 1918 influenza pandemic caught the world by surprise. But in many ways, it shouldn't have been a surprise. The pandemic hit a world engulfed in war. We've seen how the movement of soldiers were a powerful vector for the virus, but it went deeper than that. Nancy, how did the conflict between nations change how they responded, especially when it came to taking steps to limit the spread of the virus?

BRISTOW: The war again really facilitated the virus' work. In the United States, for instance, President Woodrow Wilson would never - and I say never - speak publicly about the pandemic. Even as more than half a million Americans are dying of influenza, the president of the United States refused to speak of the crisis that was underway precisely because he was worried about the war effort. He was so preoccupied with the prosecution of the war that he feared that people would lose sight of the most important business at hand, which was, for the United States, to win the war.

VEDANTAM: I understand that this was not limited to the United States. The same thing was happening in Germany where people didn't want to communicate the idea that the epidemic was basically going to harm Germany or undermine the war effort.

BRISTOW: That's exactly right. And, of course, what we need most in the midst of a pandemic is good, sound, direct information from public health experts. And that's what many governments were fearing to share with their people. And in fact, that's how we end up with the misnomer Spanish influenza. Spain was not participating in the First World War, and so they were actually willing to share the reality of what was going on in their country quite publicly. And so there was this assumption that Spain was sick when no one else was. And people came to call it the Spanish Flu, quite unfairly, in fact. It may well have been an American flu.


VEDANTAM: So I want to better understand the connections between the epidemic and human behavior by zooming in on what happened in one place - Kansas City. You write that when the second wave of the epidemic hit in the fall of 1918, this was the deadliest wave. How did the leaders of Kansas City respond?

BRISTOW: In fact, Kansas City had a relatively common response. Public health experts asked for there to be social distancing measures and the city followed through, closing public amusements and prohibiting large public gatherings - again, that social distancing that now is a term that's become so familiar to all of us. But as happened in many, many cities, as the numbers of people being infected would begin to slow a bit, people would relax. Eventually, they would overturn those requirements or those restrictions.

But, of course, there's another wave coming, and with the arrival of another wave, the government wants to put back in place the same kinds of public health restrictions. And the people are much less compliant, much less interested in following the rules. They figure if it didn't stop it when we tried it last time, why should we bother to try it again? So there is a kind of turning away from the public health expertise precisely because the virus came back. But, again, that's what viruses do. It was no failure on the part of public health that the virus could return.

VEDANTAM: But it's so understandable, isn't it, which is that, you know, you're trying to follow the public health guidelines, and then the virus comes back and you start to question how good are these guidelines. And then perhaps you follow some of the social distancing requirements that are put in place, and you do that for a couple of months, and it's difficult because schools are closed and businesses are closed and everyone's itching to get back to normal. And then the third wave hits. And at this point, when people say let's go back to social distancing, it's not surprising that people would say absolutely not.

BRISTOW: It's not surprising at all, and I think it's a really important idea to put out in our minds that even if we follow the social distancing practices, people will continue to sicken and people will continue to die. That doesn't mean that it's not working because those figures are going to be substantially lower than if we move forward without social distancing. But people get frustrated, again partly because it's really inconvenient. It is not that fun to be quarantined. It's not that fun to not be able to leave your homes. So people are anxious to get back to regular life. And there is this suspicion that somehow, well, none of this is really working because people are still getting sick and dying. But that's not how we measure the success when we're in the midst of a deadly pandemic.

VEDANTAM: So it's a really tricky thing, isn't it, because the counterfactual, which is the number of people who might have died otherwise, that's something that a model is telling you. You have to sort of in some ways trust the math over how you're feeling at that point.

BRISTOW: That's right. And in 1918, they didn't have that mapping available to them. They couldn't look at models that would tell them how many would have died. In fact, our assumption that the social distancing worked is based on really careful research that has been done by epidemiologists and social historians who've looked at what took place in different communities and have been able to realize that places like Milwaukee, Wis., or St. Louis, Mo., that followed the rules and really maintained their restrictions for the longer period of time just were more successful in keeping the death rates down.

VEDANTAM: You talk about the distinction between the city of Philadelphia and you just mentioned Milwaukee. These cities had a very different response to the outbreak. Tell me what happened in those cities and then what the outcome was in terms of mortality as a result of the epidemic.

BRISTOW: In Philadelphia, they had a somewhat corrupt political situation at the time. Philadelphia's health commissioner Wilmer Krusen, decides that even though the disease was spreading that the war was important, and he'd allow the Fourth Liberty Loan Parade and event to take place on September 28. At this point, we're already a month into its having arrived in the United States. Some 200,000 people showed up for that march, and by the end of the flu season, in fact, some 12,000 residents in Philadelphia had died. Now, in some other cities, they moved much more quickly. They prohibited those parades, and they were in fact able to cut the death rate in some cases by half.

VEDANTAM: Was it partly because the residents in places like Milwaukee were much more cooperative, much more likely to listen to public health officials?

BRISTOW: That's part of it. In Milwaukee, they have a very well-established health board and health commission. They're very familiar. This is a city that has during the Progressive Era really embraced the idea of experts and the possibilities of reforming our communities and moving towards healthier, cleaner, safer lives by way of following sort of what science can teach us. And so Milwaukee had a very robust public health system. People were familiar with it. And in turn, because they had a good health board in place, they were able I think politically to do the work that needed to be done to get those restrictions in place, to keep them in place for the longer period and, in fact, do more things. In Milwaukee, for instance, they used quarantining as well as closing spaces, prohibiting meetings and asking about the possibilities of public masking. They went all the way to enforcing quarantine as well.

VEDANTAM: It really speaks to the importance of public institutions and the trust that people have in those institutions when catastrophe strikes, doesn't it?

BRISTOW: Absolutely. And that's one of the things I worry about right now is the faith in government is a little bit shakier in 2020. And it's going to be very important as we go forward to listen carefully to those public health leaders and particularly the experts who really know what they're talking about. And in 1918, in those communities where people did that, it really did make a difference.

VEDANTAM: You describe how in Roanoke, Va., people with mild cases of the flu or people who had had the flu and recovered decided that quarantines really weren't for them anymore. And this is, again, totally understandable. People were starting to chafe after a few days or a few weeks of enforced, you know, restrictions. And they said, all right, I've sort of come out the other side. I'm fine. I can go about my daily business - again, completely human but potentially really dangerous.

BRISTOW: Very dangerous not only for the individual who may have a relapse, may not in fact be fully healthy yet, but also for those around them - their families would become ill or those whose shops they went to, the people who might sit next to them in a movie theater. So extraordinarily dangerous to assume that one is healthy before one is verifiably over these illnesses because you can continue to shed the virus even after you begin to feel healthy.

VEDANTAM: I want to be cautious about one point. You know, when we hear about Roanoke or the difference between Philadelphia and Milwaukee, you know, we know the people in Roanoke who were breaking quarantine were making a mistake. We know that Milwaukee got it right and Philadelphia got it wrong. But in some ways, Nancy, I'm wondering if we know this because we know now how the pandemic turned out. We have the advantage of hindsight. There have probably been dozens of other disease outbreaks where the Philadelphia response might have been just fine. What I'm trying to get at is that there are huge social and economic consequences from shutting down schools and businesses, and those can harm people's lives, too. And I guess what I'm trying to say is that policymakers, when something is unfolding, when an epidemic is unfolding, it's really difficult to actually know exactly what the right thing is to do because there are potentially devastating consequences regardless of which choice you pursue.

BRISTOW: That's so true. And it's one of the things I was worrying about on my way into work this very morning as we're closing schools, those hundreds of thousands of children who rely on school breakfast, lunch and in some cases even dinner. So policymakers in 1918 did not have the benefit of hindsight that we have as we look back at them. So you're right that in some ways the critique of the policymakers really does have to be softened a bit. In many cases, they really were doing the best they could. Now, in some cases, I think we have corrupt politicians in some communities that are really thinking more about their political futures than the health of their communities. And in those cases, I think it is a little easier to point a finger. But again and again and again, we have to remember how difficult this is when you don't know where the pandemic is going. And that is something that I think I've never understood as well as I have in the last week.

VEDANTAM: I'm wondering if one of the deeper lessons here is not so much that some people were right and some people were wrong but that, you know, as the catastrophe was unfolding, many people really didn't change their behavior. It's really difficult to get people to change their behavior for any length of time.

BRISTOW: That's right. And in 1918, we have to remember that the notion of germ theory had certainly caught on and was certainly fully embraced by the vast majority of health providers. But for the general public, there were still a lot of questions out there about how disease was transmitted. So the idea that washing your hands was important or that you wouldn't all drink out of the same drinking cup was relatively foreign for some people. In fact, it's during this pandemic that most American cities finally banned the common drinking cup at places where people would gather to get water. So, again, it was hard for people because, on the one hand, it's inconvenient and, on the other, they were asking for new habits, things that they had always been allowed to do before and suddenly you're not allowed, for instance, to spit on the street or to share a drinking cup. That you had to cover your cough and sneeze in your elbow, these were new things people were being asked to do in 1918.

VEDANTAM: One of the things I found really interesting is that you cite a number of letters in your book. These were letters written during the time of the 1918 pandemic. One of them was written by the aviatrix Amelia Earhart; others were written by men. What did these letters say, and what do they reveal?

BRISTOW: It's very interesting the ways in which the reactions to the pandemic were actually somewhat gendered. We find that in the midst of this catastrophe, as people are wrestling with something so new to them, that there's a great deal of sort of looking for security in how things are commonly done and grabbing hold of our traditional patterns and behaviors. And so for women, it was much more common for them in their letters to talk about what they were seeing, how frightened they were, giving detailed outlines of who in the family or who in the friend groups were ill and what was going on and really admitting upfront how frightening it all was.

VEDANTAM: And, again, it feels so typical because you sort of see some of the same things happening today. I feel like you have people reacting in fairly predictable ways, some people saying we really have to be anxious and other people saying, no, it's going to blow over in a couple of weeks.

BRISTOW: I think that's right. What's interesting is the ways in which in 1918 it is so profoundly about being male and female so that someone as well known as Amelia Earhart - as she will become known - right? - as a great aviatrix - said of the flu, I hate and fear it somehow more than a little. Having seen so much of it, I suppose, has prejudiced me with the very uncertainty of treatment adding to the prejudice. She was working in an influenza ward, knew what it looked like and was sharing this with one of her dear friends. And, meanwhile, men are worrying about not getting into the office and sending notes to one another apologizing for missing another day of work in the midst of the war.


VEDANTAM: You also note how gender in the form of social norms played a very powerful role. You interviewed a survivor of the 1918 epidemic when she was 85 years old. Can you tell me the story of Lillian Kancianich?

BRISTOW: I can. This is a lovely woman, lived in Tacoma when I interviewed her several years ago. And she had lost her mother when she was only 3 months old. And in her community, it was felt that men shouldn't live alone with daughters, that they could not adequately raise children on their own. And so she and her sister were sent away, her sister to live some ways away with family, and Lillian was actually traded between members of the family for a couple of years before she finally was able to move in to a permanent situation with relatives in the same town as her father. But she remembered for the rest of her life that this had cost her something. She didn't remember her mother, but she remembered that she was somehow different from others. She knew that she and her sister had lost valuable years together during their youth, and she felt that her life had been changed. She said that it had changed my life completely. It had to.


VEDANTAM: At one level, a virus is a biological organism. It's a creature of natural selection. It follows rules that have been studied for decades by epidemiologists. But at another level, a virus is a social organism. It detects fissures in societies and exposes fault lines between communities. That's when we come back. I'm Shankar Vedantam, and you're listening to HIDDEN BRAIN. This is NPR.


VEDANTAM: Nancy Bristow is the author of "American Pandemic: The Lost Worlds Of The 1918 Influenza Epidemic." She has studied the lessons of the deadly outbreak a century ago, and she sees historical parallels with our own battle against the coronavirus. Nancy, you describe how the Red Cross once went into a rural and disadvantaged part of Kentucky to help residents affected by the 1918 epidemic. How did volunteers relate to the patients?

BRISTOW: Well, in the case of Kentucky, not very well. As was common often with visiting nurses as they would enter homes or communities that were not like their own middle-class upbringing, they would look down their noses somewhat disparagingly at the conditions that they found and in the case of Kentucky would say terrible things, in fact. They talked about them being desperately poor, but they would also go on to say things like they were ignorant of the simplest principles of sanitation and hygiene, that they were living in crowded quarters, and they would almost make it seem as if the poor were responsible, in fact, for their own situation and that they were, in fact, causing the very epidemic conditions from which they were reeling.

VEDANTAM: You would imagine it would be difficult for the volunteers to truly play a helping role when they had such attitudes about the people they were trying to help.

BRISTOW: I think that's right. In some cases, they could be useful and it was usually I think especially those who had a much more compassionate and empathetic approach to those who were not just like them who could enter a home and recognize that the reason it was dirty was because both parents were working. The reason that there wasn't as much clothing or as clean of clothing was because the family was strapped. The reason it was cold was because perhaps they couldn't afford to buy coal. And so, again, those who could recognize difference as coming not from innate human lacking but rather from circumstance, from actual social conditions, those were the people I think who had the most opportunity to facilitate good health and to actually help people move forward out of this pandemic towards health.

VEDANTAM: How did these class divisions and class attitudes shape the way people reached out to others in terms of charitable donations, in terms of being willing to extend a helping hand? Did people in general in the public see the poor as essentially being somehow responsible for their illnesses?

BRISTOW: At this time, there really was a lot of distinguishing by those in the middle and upper classes that among the poor there were those who were worthy and those who were not. And to be worthy meant a few very particular things. One, it meant that everyone in the household was working. In other words, if you're going to pull yourself up by your bootstraps, everybody better be helping with the pull. In other cases, if families didn't adhere to certain American traditions - they might have a different spiritual system, they may have come from a different part of the world and not speak English yet. Anything that made them seem somehow different would also sometimes categorize people as the other in a sense and make them somehow more suspicious not quite as, quote, "worthy" of the kind of care that charitable organizations were happy to give to some people.

VEDANTAM: I'm thinking of some of the fissures that are already emerging in the present day in the United States in the context of the coronavirus. You know, if you're a white-collar worker who can work from home on your computer, it's an inconvenience to stay home, but it's not really devastating to you. You're still getting paid. You still have your health benefits. But if you're an hourly worker, a gig economy worker, a contractor without health insurance, this can actually be a disaster.

BRISTOW: That's exactly right, and it was true in 1918 as well. The Associated Charities of Minneapolis worked with a family listed only as the, quote, "D family" but they tell this story of a man who had done everything right, had been working hard and then was stricken by the pandemic. By the time they reported in for charitable aid, they already needed groceries. They'd used all of the money that they had saved. He was trying to return but was too sick. His children were getting ill. And by the time they visited his home, they were absolutely without coal. He borrowed a pailful from a woman downstairs from his apartment. The groceries were completely gone, and he could not get any credit at the grocery store. At this point, Mr. D, as they refer to him, simply broke down and cried, saying everything was against him. It wasn't his fault. His problems didn't originate, in fact, with the epidemic but in his insecure situation, which was then made much worse by the bout with influenza. And I fear we're going to be seeing the exact same thing right now.


VEDANTAM: I'm wondering, you know, when I'm thinking about the present moment how this might play out here where people - you know, you talk about sort of the mortality rate of the coronavirus, but that mortality rate is likely to be very different in different places, is it not? I mean, if you're wealthy, if you're living in a part of the country that has excellent medical care, if you have access to health insurance, your mortality rate is likely to look very different than somebody who is poor or living in a rural part of the country or living in a part of the country where they don't have access to health care.

BRISTOW: I think that's right. And, again, I'm not an epidemiologist nor am I a physician, but it seems that this particular crisis with COVID-19, it is going to matter who has access to health care. For instance, the availability of a ventilator is going to be really crucial for those in really critical condition so that there's going to be a really inequitable landing of this virus and of this illness depending on one's social position, one's economic position, one's place in the racial hierarchy of the country. All of these things will be playing out, I fear, as people have inequitable access to health care.

VEDANTAM: You mentioned the racial hierarchy a second ago and, of course, this was true in 1918 as well. You tell the story of how, in Richmond, African Americans were allowed access to a hospital where whites were being treated, but there was a catch.

BRISTOW: Yes. They could certainly visit this new emergency hospital at John Marshall High School. The problem is that they were only allowed to be treated in the basement where a separate space had been opened up.

VEDANTAM: And was the treatment quality different in the basement than it was in the main hospital?

BRISTOW: One has only to imagine. I have no way of knowing for certain, but, again, we know that segregation had made two very distinct health systems, and African Americans were routinely undertreated. In 1915, the life expectancy for white Americans was 55.1 while for African Americans it was only 38.9 years - so a huge differential in life expectancy prior to the pandemic. So we certainly have to assume that in the midst of the pandemic, the kind of care that was creating that differential was also happening. What's odd in 1918 is that there's no evidence necessarily that access to health care changed the death rate particularly. It certainly changed how comfortable people were however.

VEDANTAM: I understand that some black pastors offered sermons that used the 1918 outbreak as a way to argue for social justice and social change.

BRISTOW: That's right. There were those who resisted this clinging to the status quo who saw in the epidemic actually an opportunity to shake up the hierarchies, to call out that which was unjust. My favorite example of this was the Reverend Francis Grimke. He was an important advocate for African American rights and worked at the 15th Street Presbyterian Church in Washington, D.C., his church. And he really believed that God was trying to awaken Americans to the sacrilege of the caste system. He said, what ought it to mean to us, this pandemic? Every part of the land has felt its deadly touch - north, south, east and west, in the Army and the Navy, among civilians, among all classes and conditions, rich and poor, high and low, white and black. And he concluded, God has been trying in a very pronouncedly, conspicuously and vigorous way to beat a little sense into the white man's head, has been trying to show him the folly of the empty conceit of his vaunted race superiority by dealing with him just as he dealt with the people of darker hue. He was convinced that the epidemic scourge was actually God's work, and he was trying, in a sense, as he said it, to teach the white man the, quote, "folly of his stupid color prejudice" - end quote.

VEDANTAM: One of the things that strikes me as you're describing these various responses is how little people actually changed from what they believed or thought before the outbreak began. And what I mean by that is if you're a black pastor and you're advocating against white supremacy, the outbreak becomes a mechanism for you to argue against white supremacy. If you're fairly high up in the class hierarchy and you look down on poor people, the outbreak becomes a vehicle for you to express your class prejudice. If you're interested in prosecuting a war, then the virus becomes a way for you to say, you know, fighting the virus is a way to win the war.

And I'm seeing actually some curious parallels with the present moment as well, which is as soon as the coronavirus outbreak began, you saw people from different parts of the political spectrum, different interest groups, all sort of essentially using the outbreak to basically say, look, the point of view that I had before this actually happened, all this does is confirm everything that I believe to be true.

BRISTOW: I'm afraid that's what I'm seeing as well. Whether it's the xenophobia that we saw expressed against people who appeared to be of Asian descent or this willingness to say that actually we have everything in hand because our government knows what it's doing, these kinds of tendencies to simply rely on what we already believe is not actually going to help us effectively manage what is not just a national crisis but an international crisis. For Americans, many of whom I fear think of us as somehow exceptional, this is a moment to step away from that kind of belief and to recognize ourselves as citizens, in fact, of a world that is wrestling with this pandemic. And my hope is that maybe this time around, we can be a bit more sensitive, a bit more culturally aware and perhaps embrace that sort of world citizenship because that's the route I think to handling this scourge in the most effective way.

VEDANTAM: You're speaking to me from the campus of your university, which is in Tacoma, Wash. And as we record this interview, the state of Washington has been especially hard hit by the coronavirus outbreak. What have you seen yourself these last few days, Nancy, and what parallels are you seeing with the 1918 outbreak?

BRISTOW: Well, as you mentioned a little bit ago, one thing we've seen right away is the differential in who's able to stay home, who can do this remote work and who is being forced to continue to go to their job. So at my university, of course, faculty were encouraged to, you know, teach remotely. We will be encouraging our young people to stay home after spring break for an undetermined length of time. So those of us with privilege have been able to do social distancing somewhat easily. And I will continue to be paid, and they will continue to learn. At the very same moment, as I arrived on campus this morning, of course, custodial staff are here. Those who work in our lunchroom are here.

So those who are working blue-collar jobs, let's say, have less opportunity to practice social distancing because they may be required by their employers to go to work. Or alternatively, many workers are going to be simply forced not to go to work, in which case the Uber driver and the waiter are going to be losing the money on which they rely day by day by day. So those of us with salaries, those of us who can work remotely, we are going to be much safer, in a sense. And we're also going to continue to make a living while those who are in more precarious financial contexts and situations will be, in fact, facing the greatest danger - more exposure to the virus or alternatively not exposure but simply the loss of their living.


VEDANTAM: Nancy Bristow is a historian at the University of Puget Sound. She's the author of "American Pandemic: The Lost Worlds Of The 1918 Influenza Epidemic." Nancy, thank you for joining me today on HIDDEN BRAIN.

BRISTOW: It's been an honor and a pleasure. Thank you so much.


VEDANTAM: This week's show was produced by Rhaina Cohen. It was edited by Tara Boyle and Jenny Schmidt. Our team includes Parth Shah, Laura Kwerel, Thomas Lu and Lushik Wahba. Special thanks to Eilis O'Neill for production support, James Willetts for engineering help and to Cat Schuknecht for her voice acting work. Our unsung hero this week is Derek Adams (ph). Derek and other custodial staff at NPR make it possible for us to do our jobs. Derek is helpful and solicitous and someone who takes genuine pride in his work. In recent weeks, as NPR has had to cope with the coronavirus outbreak, Derek and others have sanitized surfaces and ensured the building is equipped with soap, disinfectant and hand sanitizer. He's the very definition of an unsung hero. Thank you, Derek. For more HIDDEN BRAIN, you can find us on Facebook and Twitter. If you liked today's show, please remember to share it with one friend.

One last thing - this is a time of great upheaval. We want to hear the surprising, unexpected and profound ways your life has changed since the coronavirus outbreak began. What have you noticed about your friends and family, about yourself, that revealed something about human nature? If you have a personal story you would be willing to share with the HIDDEN BRAIN audience, please find a very quiet room or a coat closet and record a voice memo on your phone. Email it to us at hiddenbrain@npr.org using the subject line human nature. Be sure to include a phone number. Again, find a quiet room and record a personal experience and send it to us at hiddenbrain@npr.org. I'm Shankar Vedantam, and this is NPR.


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