A deadly strain of the flu that spread across the globe between June 1918 and the end of 1920 killed somewhere between 50 and 100 million people. The following report was presented by the health officer in Asheville, N.C., to his colleagues at the medical society's meeting in Pinehurst in April, 1919.
Influenza Experience Gained from Epidemic in Asheville
Influenza Experience Gained from Epidemic in Asheville
By Dr. C.V. Reynolds, Health Officer, Asheville
In discussing influenza this morning, I am aware that it is retrospective, but in recalling our experiences of a few weeks ago we realize our utter helplessness in combating a disease that was causing such devastation. It would not be amiss to spend a few minutes in reviewing as an example Asheville’s epidemic, and draw conclusions therefrom.
Our knowledge of pandemics of this disease faithfully recorded—one in 1833 to 1835, the second 1836 to 1837, the third 1847 to 1848, a fourth 1889 to 1890—afforded us little help when we were confronted with the recent epidemic.
Notwithstanding the fact that we were forewarned in regard to the fast approaching epidemic and that it was assuming vast proportions, coming to us as fast as travel could bring it, we stood waiting our fate in almost utter helplessness.
On September the 28th the first recognized case of influenza appeared as such in Asheville. A meeting of the Buncombe County Medical Society was immediately called, at which time the situation was thoroughly discussed, and a request was made that all cases with names and addresses should be reported promptly in order that a true census should be at hand, so that we could cope with the situation intelligently.
I am sorry to say, yet I do it unhesitatingly, that very few reports were sent to the health department. This seeming negligence, I will not say indifference, due possibly to stress of time and overwork, necessitated the secretary to telephone each doctor daily for the number of cases on hand and all new cases that had developed during the last 24 hours.
On October the 8th 115 new cases were occurring per day. At this time we began making a graphic chart which was continued throughout the period of the epidemic. By this method and by the information obtained from the school nurses, the district nurse, the metropolitan nurse, and the cooperation of the citizens, we obtained to an accurate degree the number of cases occurring during the entire epidemic.
Precautions taken
Immediately upon the appearance of influenza, handbills were printed setting forth symptoms and stating precautions necessary to be taken. These were distributed to every house and all places of business in the city within 24 hours. Churches, schools, moving pictures and all places of amusement were closed, and all social, business and fraternal gatherings were forbidden. All clinical cases were isolated.
Quarantine
Legal quarantine as an effective measure in the control of the influenza epidemic is impracticable for the following reasons: First, it would have been an overemphasis for minimum good. Second, an attempt at quarantine would have been to place restrictions around certain sickness leaving the ambulatory cases, missed cases, unreported cases, and cases without physicians, all of which constitute the greatest menace, at large.
There were 175,000 reported cases of influenza in New York City, yet in the weekly bulletin of the city of New York it was stated by the health department that at least half a million people had the disease. There were some who thought it was nearer a million than a half million. One case subject to legal quarantine—good. Eight cases running at large and sources of infection.
Second, legal quarantine was a false idea of protection. The general public could be led to believe that a legal system of quarantine would protect them from all sources of danger, and that they could safely go and come and intermingle. This procedure would lead the public to a misconception of the real truth.
Disadvantages arising from attempted quarantine
First, the temptation on the part of the patient and his family to evade being cut off from society and business during the progress of the disease. Second, it is regrettable to say that there would have been a temptation on the part of a few physicians to withhold reports of cases on account of the objection of families to quarantine. Third, there would have been a large number of cases, by reason of failure to consult medical advice, ambulatory cases, missed cases, still remaining as a menace to the public health.
If some wise man had solved this problem and then perfected an organization with which to enforce a legal quarantine, it might have proven effectual.
The ban placed on meetings, social gatherings, etc., could not with safety be removed if a legal quarantine had been established, as it has been shown above that the quarantine could control only a few sources of infection.
From the beginning of the epidemic in the city of Asheville isolation and quarantine were insisted upon, and the hearty cooperation of the physicians, nurses, and families was requested in carrying out this procedure, emphasizing at all times the virulency of the infection.
The height of the wave was reached on October 19th, when 212 cases were reported for the day.
Under the auspices of the American Red Cross, on October 13th there was established in the city hall, headquarters for a relief committee whose duty it was to look after the securing of doctors, nurses and workers, investigating the calls for food and assistance. On October 14th, an emergency kitchen was opened to furnish food for those in distress. On October 19th two emergency hospitals were opened for white and colored. All work except the regular nurses and civilian orderlies was contributed voluntarily, and here I shall pause long enough to pay special tribute to the self-sacrifice and heroic work of those noble women who went in at the risk of their lives and under the guidance of the regular nurses rendered invaluable service in nursing the sick.
With the hearty cooperation of the press and our good citizens, we were able to reduce the number of cases to 77 on October 27th, gradually decreasing until November 11th, when 11 cases were reported for several days.
This time the patriotic enthusiasm over the signing of the armistice caused a most natural desire to celebrate, and plans were made for an elaborate demonstration. A meeting of influential citizens was called and the health department made an appeal which prohibited any authorized demonstration. Nevertheless crowds assembled, resulting in a flare-up which reached its height on November 14th, when there were 55 cases. Again on November 21st we were having 10 cases a day, continuing through a period of incubation when churches, schools and movies were open. Three days thereafter a recrudescence occurred, resulting in 35 cases per day until December 5th.
On December 6th, without the knowledge or consent of the board of health, a mass meeting was held at the auditorium, resulting in an increased number of cases to 30 per day, which was gradually reduced to five per day, when the Christmas crowds caused another increase in the number of cases, 23 per day. The number of cases was then somewhat reduced until New Year’s celebrations again sent the number per day up to 30, gradually reducing again until January 7th, when general unrest and newspaper propaganda caused the citizens to rebel under what they deemed unnecessary sacrifices, causing a general relaxation of precautions, which resulted in a general flare-up, reaching its height of 76 cases on the 21st of January, when restrictions were again enforced, control being secured and the epidemic subsiding until on February 7th normal conditions were restored.
Summarizing, the cases reported were:
Whites, 3,888
Colored, 886
Total number of cases reported, 4,744
Deaths:
Local
Whites, 87
Colored, 14
Total, 101
Imported
Whites, 25
Colored, 2
Total, 27
Grand total number deaths, 127, population 30,000
15.8 per cent of population stricken
3.3 per cent mortality
We realize that influenza per se is not fatal, but the complications, pneumonias, caused the fatalities. We have learned through this epidemic that the pneumonias give us the greatest immediate concern and just ahead we must carefully consider with painstaken individualization the grave possibility of the greatest fear as a result from influenza—the awakening of a latent tuberculosis into an active clinical type.
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From Transactions: Medical Society of the State of North Carolina, April 1919
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