Nursing During the Deadliest Influenza Pandemic of 1918

A century before COVID-19, the 1918 Spanish influenza became the deadliest pandemic in human history, and it reshaped what nursing was understood to be. The parallels are hard to miss: no effective treatment, blunt public health measures, and crushing demand on nurses.

The Spanish influenza pandemic

The Spanish flu struck in 1918 as World War I was ending. The world's attention was on the war, so little was recorded at the time, and historians have only reconstructed the story over the past few decades.

Estimates put infection at around 500 million people, between a quarter and a third of the world's population, with roughly 50 to 100 million deaths. That exceeded the combined death toll of both World Wars, the medieval bubonic plague, and HIV/AIDS to date.

The name was a misnomer. The disease most likely originated in the US, not Spain. It got tagged "Spanish" because King Alfonso XIII of Spain was an early, widely reported victim, while wartime censorship kept other countries from reporting their own outbreaks, which had started among soldiers.

A first wave hit army camps in spring 1918 and faded quickly. That fall a far more virulent strain took hold. Overcrowded, unsanitary camps fueled the spread, and returning soldiers carried it to nearly every corner of the world.

What was the Spanish Flu?

Doctors barely understood it and were baffled that it killed young, healthy adults rather than the usual victims, children and the elderly. Germ theory was accepted, but no one yet knew viruses could cause human disease. Analysis of a preserved sample from a soldier who died confirmed it was an H1N1 strain, the same virus behind the 2009 swine flu.

Patients started with ordinary flu symptoms, then deteriorated fast with high fever and fluid in the lungs. A distinctive sign was heliotrope cyanosis, a dark blue or purple coloring spreading across the body. Once acute respiratory distress set in, death was usually inevitable. "It is simply a struggle for air until they suffocate," one doctor wrote.

Public health measures to control the spread

Distancing measures dated back to the Middle Ages, and local authorities applied their own versions, so responses varied widely. Cities banned large gatherings and shut schools, cinemas, saloons, dance halls, and streetcars. People were urged to stay home, and the sick were placed under quarantine.

The public was taught to avoid crowds, cover coughs and sneezes, and wash their hands. Some authorities pushed rest, fresh air, and good nutrition to build resistance. In Minnesota, volunteer teachers, Boy Scouts, and postal workers put up posters and handed out pamphlets. San Francisco required gauze masks outdoors, which tracked with a sharp drop in cases, and reminded people with a rhyme:

Obey the laws

And wear the gauze

Protect your jaws

From Septic Paws.

Reactions split, as they always do. Some complied, some demanded stricter rules, and some protested the restrictions as unfair. Speed mattered. In Philadelphia, the public health director insisted there was nothing to worry about and let a mass Liberty Bond parade go ahead. Tens of thousands flooded the streets, cases spiked within days, and Philadelphia became one of the hardest hit cities in the country. Where measures came early and stayed in place, death rates were lower.

Treatment for Spanish influenza

There was no effective treatment or vaccine. Doctors reached for old respiratory remedies: quinine, camphor, whiskey, creosote, even strychnine, plus aspirin, calomel, and castor oil for symptoms. The public used folk remedies, and con men sold worthless "cures."

Hospitals and improvised facilities were overwhelmed, so only the sickest were admitted and the rest were cared for at home by visiting nurses and volunteers. Inside hospitals, infection control meant good ventilation, spaced beds, fewer beds per ward, head-to-foot bed arrangement, sheets hung between beds, disinfected bedding and rooms, antiseptic handwashing, and gauze masks.

The Camp Brooks tent hospital stood out for its low fatality rate among both patients and staff. It admitted 351 sailors, many already pneumonic. Patients were nursed outside in fresh air and sunshine by day, and at night the tent flaps stayed open with extra blankets and hot water bottles for warmth. Patients used their own dishes, washed in boiling water. Staff disinfected their hands after every patient contact, shared nothing, and wore gowns, gloves, head coverings, and masks. The masks were improvised from gravy strainers fitted to each face so the gauze never touched the mouth or nose, and staff replaced and re-sterilized them every two hours.

Medicine had spent the previous decades building a reputation for curing disease. Against this flu, doctors had to admit they could do nothing. What became clear was that nurses were the ones who could make a difference at the bedside.

Nursing during the Spanish Influenza

With no effective medical intervention, nursing was the care that mattered: monitoring vital signs, ensuring ventilation, disinfecting, bathing, changing linen, feeding, emotional support, and teaching, until the patient recovered or died.

Nursing education was already established, with 1,129 training schools in the US by 1910, yet there was an acute shortage of trained nurses. Many were still serving in the military, and large numbers of health workers got sick or died. The centralized response came not from the federal government but from the American Red Cross, which formed a National Committee on Influenza to distribute nurses, volunteers, and supplies. Requests still went unfilled. One telegram read, "Can send all the Doctors you want but not one nurse."

Beyond hospitals, thousands of nurses worked as health visitors in cities and remote areas, often the only providers available. They reported working up to 18 hours a day, or until they could no longer stand. Visiting nurses found whole families critically ill, some already dead. "The people watch at their doors and windows, beckoning for the nurse to come in. One day a nurse who started out with fifteen patients to see, saw nearly fifty before night," one wrote.

The Red Cross recruited volunteers to fill the gap, sometimes with minimal training, but the public quickly grasped the value of trained nurses even when care was only symptomatic. "One trained nurse is worth a score of untrained volunteers," reported one newspaper. Access to skilled nursing care was the best predictor of survival.

How the nursing profession changed

Before the epidemic, the nurse's role was mostly seen as carrying out doctor's orders. During the flu, doctors had no effective treatment and often could not even reach patients. Nurses exercised independent judgment and acted on it, keeping watch and responding when a patient's condition turned, "with knowledge, with control, and with authority."

Nurses found new meaning and pride in the work. "Terrible as was the influenza epidemic, with its frightful toll, there was a certain tremendous exhilaration to be felt as well as many lessons to be learned from such a terrific test," one wrote. The heavy use of volunteers also helped introduce a second category of nurse, the licensed practical nurse as we know it today. Health authorities worldwide accepted the need for stronger public health systems, and several countries passed central public health laws soon after, expanding community health nursing.

Lessons from the Spanish Flu and COVID-19

The 1918 pandemic raised the status of nursing and became a route to greater professional recognition in the early 20th century. The irony of a new pandemic landing in 2020, the Year of the Nurse and Midwife, was not lost on anyone, and COVID-19 made the case for recognizing nurses and fixing shortages better than any argument could. The open question is whether governments will hold onto these lessons longer this time than they did after 1918.