1918 Flu and Covid-19: Has Mask Culture Changed?

Red Cross volunteers wearing masks during the 1918 flu pandemic. Photo: Getty

But in the West, the use of masks has been much slower, and UK Chief Medical Officer Chris Whitty has now declared that wearing masks is unnecessary.

But wearing masks is not always an Asian trend.

At least certainly not what happened during the 1918 flu pandemic, which lasted from January 1918 to December 1920, and infected a third of the world's population, or about 500 million people, and killed 50 million, half a million of whom were American citizens.

There are many similarities between the two pandemics: the 1918 flu pandemic and the Covid-19 pandemic.

San Francisco issued an order requiring residents to wear masks during the 1918 flu pandemic. Photo: CNN

While there are many theories about the origins of the 1918 virus, it has been attributed to a specific country: the Spanish Flu. Globalization facilitated the spread of the virus as soldiers fighting in World War I carried the flu around the world.

Then as now, the warehouse was converted into a quarantine hospital. And a ship carrying many infected patients became a subject of controversy.

But there was one obvious difference: America was the world leader in wearing masks.

In October 1918, as San Francisco was hit by the second wave of the pandemic, hospitals began reporting a surge in infected patients.

On October 24, 1918, the city's elected legislature, the San Francisco Board of Supervisors, recognizing the need for drastic action in the face of more than 4,000 cases, unanimously passed the Influenza Mask Ordinance.

Wearing masks in public has become mandatory for the first time in the United States.

“Popularize” masks

After San Francisco made masks mandatory in public, an awareness campaign was launched.

The mayor of the city, along with members of the Board of Health, authorized the Red Cross to use a slogan to appeal to the public's awareness: "Wear a mask and save your life! Masks are 99% effective against influenza."

Many songs have been written about wearing masks, including the line: “Obey the law, and wear a mask. Protect your jaw from infected fingers.”

Warehouse converted to house quarantined patients. Photo: Getty

Anyone caught out without a mask could be fined or even jailed.

The campaign worked, and other California cities followed suit, including Santa Cruz and Los Angeles, and then many other states across the country.

And it wasn’t just America that took similar measures on the other side of the Atlantic. The Paris Academie de Médicine recommended wearing masks in the French capital as early as November 1918. So did Dr. Niven, the chief medical officer of Manchester, in northern England.

History seems to be repeating itself, this week the mayor of Los Angeles asked people to wear masks when going out shopping in public.

Back in the 1918 flu pandemic, when masks became widely available in Europe and North America, supply issues became acute. There were only a handful of specialized mask factories, such as the Prophylacto Manufacturing Company in Chicago, and they were unable to meet the surge in demand.

The solution is home production. In many parts of the United States, churches, community groups, and Red Cross chapters are banding together to secure as many masks as possible and organizing mass mask-making events.

US police wore "flu masks" to protect themselves during the Spanish flu epidemic after World War I. Photo: Getty

Many newspapers, along with many state governments in the US, linked masks to the war that was taking place on the European battlefields in October 1918 - "Gas masks in trenches; flu masks at home" was the information published in the Washington Times on September 26, 1918, which promised to provide 45,000 masks to American soldiers to prevent "Spanish flu".

When World War I ended on November 11, gas mask manufacturers filled government orders and switched to making flu masks.

Mask policy

Mask-wearing regulations at that time were generally supported by the public and were almost universally approved.

Tucson, Arizona, enacted a mask ordinance on November 14, 1918, with exceptions for preachers, singers and actors in theaters, and teachers in schools—all of whom were deemed to be kept at a sufficient distance from their listeners.

Shortly afterward, Sheriff Bailey told Tucson citizens that he was not threatening to arrest lawbreakers, but that in his view, no gathering was appropriate unless attendees were fully masked.

Seattle police officers wear masks during the 1918 flu pandemic, which killed millions. Photo: Getty

Back on the West Coast, San Francisco was still at the forefront of promoting the use of masks. On October 25, 1918, the front page of the San Francisco Chronicle featured photos of the city’s top judges and leading politicians wearing masks.

There was no escaping the mask-wearing. Every train arriving at West Coast stations was inspected by mask-encouraging committees, groups of female volunteers who distributed masks to those who couldn’t get them out of state.

Of course, there are still some who don’t follow the rules. At a boxing match in California, a flash photo showed that 50% of the male audience was not wearing masks. Police enlarged the photo and used it to identify the men.

Each offender must make a “voluntary contribution” to a charity supporting those fighting abroad, or face prosecution.

Are masks effective?

During the 1918 flu pandemic, the science surrounding the use of face masks was still largely unreliable, and the intriguing story of a ship caught people's attention.

In early December 1918, the Times of London reported that doctors in the United States had determined that influenza was “transmitted by contact and therefore preventable.”

The Times notes that at a London hospital, all staff and patients were given and instructed to wear masks at all times. The paper also cites the success of masks on a ship.

The ship, which was traveling between the US and the UK, was hit by a devastating outbreak in New York. Upon returning to the US, the captain ordered masks for crew and passengers, after reading about their use in San Francisco.

No cases were detected on the return journey, despite high infection rates in both Manhattan and Southampton, where the ship departed. It is unclear whether mask-wearing on the return voyage helped reduce cases, or whether that was how the press interpreted it.

There has been some precedent behind mask-wearing guidance.

During the Manchurian plague of 1910-1911, which brought together Chinese, Russian, Mongolian and Japanese scientists to fight the spread of the disease in northern China, masks were found to be effective.

Science journalist Laura Spinney, author of the 2017 book Spanish Flu of 1918, noted that after their experience in Manchuria, the Japanese quickly adopted mask-wearing in public in 1918.

Japanese officials argue that masks are a polite gesture to protect others from germs and have been effective in previous outbreaks in Japan.

And wearing masks also appears to have a role in limiting the rate of infection.

By late December, cities and states across the US felt confident enough to lift mask mandates, as new cases dropped to single digits in most places.

Sanitation workers in New York wear masks to help control the spread of influenza. “It’s better to look ridiculous than die,” was the view of one official at the time. Photo: Getty

A century later

In 1918, the United States began to enforce mask wearing as punishment.

But a century later, it is Asian countries that remember the lessons America learned about the benefits of mask-wearing in slowing the spread of infections.

Perhaps that's because Asia has had to deal with cholera, typhoid and other infectious diseases in recent years, followed by SARS in 2003 and the recent avian flu outbreak.

Those epidemics have helped maintain a culture of mask wearing.

The US and Europe do not see similar epidemics with such regularity.

So it seems like the concept of masks as a preventive measure has been absent from the consciousness of several generations. But the Corona epidemic may change that.