The 1918 flu pandemic and Covid-19: Has mask-wearing culture changed?

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

However, in the West, the adoption of masks has been much slower, and British Chief Medical Officer Chris Whitty has even declared that wearing masks is unnecessary.

However, wearing masks wasn't always a trend in Asia.

At least, that certainly wasn't the case during the 1918 influenza pandemic, which lasted from January 1918 to December 1920 and infected one-third of the world's population, or about 500 million people, and killed 50 million, including half a million American citizens.

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

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

Although many theories remain about the origin 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 across the globe.

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

But there was one clear difference: at that time, the United States was a world leader in mask-wearing.

In October 1918, as San Francisco experienced its second wave of the pandemic, hospitals began reporting a surge in the number of infected patients.

On October 24, 1918, the city's democratically elected legislature, the San Francisco Board of Supervisors, recognizing the need for drastic action against over 4,000 cases of the flu, unanimously passed the Flu Mask Ordinance.

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

Widespread use of face masks.

After San Francisco mandated mask-wearing in public, an awareness campaign was launched.

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

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

The warehouse was converted to house patients in isolation. Photo: Getty

Anyone found out in public without a mask could face a fine or even imprisonment.

The campaign proved effective, and other California cities followed suit, including Santa Cruz and Los Angeles, and then many other states across the United States.

And not only in America, but on the other side of the Atlantic, similar measures were being taken. The Academie de Médicine of Paris recommended wearing masks in the French capital in early November 1918. Dr. Niven, head of the Manchester health authority in northern England, did the same.

History seems to be repeating itself; this week, the mayor of Los Angeles has requested that people wear masks when shopping in public places.

Going back to the 1918 influenza pandemic, as face masks became increasingly common in Europe and North America, the supply issue became critical. Only a small number of factories specialized in producing face masks, such as the Prophylacto Manufacturing Company in Chicago, and they were unable to meet the sudden surge in demand.

The solution was to produce at home. In many areas of the U.S., churches, community groups, and Red Cross chapters joined forces, seeking to obtain as many masks as possible and organizing mass mask-making sessions.

American police officers wore "flu masks" to protect themselves during the Spanish flu pandemic following World War I. Photo: Getty

Many newspapers, along with state governments in the US, linked face masks to the ongoing war 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, promising to provide 45,000 masks to American soldiers to protect against “Spanish flu”.

When World War I ended on November 11th, manufacturers of respirators had completed government orders and switched to producing flu masks.

Mask wearing policy

The regulations on wearing masks generally received public support at the time and were largely accepted and implemented.

Tucson, Arizona, issued a mask mandate on November 14, 1918, with the exception of preachers, singers and actors in theaters, and teachers in schools—all of whom were required to maintain sufficient distance from their audience.

Shortly afterward, Police Chief Bailey told Tucson citizens that he wasn't threatening to arrest those breaking the law, but that, in his view, no gathering was appropriate unless attendees wore masks.

Seattle police officers wear masks during the 1918 influenza pandemic, which claimed the lives of millions of people. Photo: Getty

Back on the West Coast, San Francisco remained a pioneer in promoting the use of masks. On October 25, 1918, the front page of the San Francisco Chronicle featured a series of photographs of the city's senior judges and leading politicians all wearing masks.

At that point, avoiding wearing masks was no longer an option. Every train arriving at West Coast stations was subject to mask-wearing checks by committees. This is a group of female volunteers who distributed masks to those who couldn't buy them outside the state.

Of course, there are still some who don't comply with the rules. At a boxing match in California, a flash photograph showed that 50% of the male audience were not wearing masks. The police enlarged the photo and used it to identify those individuals.

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

Is wearing a mask effective?

During the 1918 influenza pandemic, scientific research surrounding the use of masks was generally unreliable, and a fascinating story about a ship captured everyone's attention.

In early December 1918, the Times in London reported that doctors in America had determined that influenza was "transmitted through contact and therefore preventable."

The Times noted that at a London hospital, all doctors, nurses, and patients were given and continuously instructed to wear face masks. The newspaper also cited the success of face masks on a ship.

This ship traveled back and forth between the US and the UK, and experienced a terrible surge in infections in New York. Upon returning to the US, the captain issued a mask mandate for the crew and passengers after reading about their use in San Francisco.

No infections were detected on the return journey, even though both Manhattan and Southampton, where the ship departed, were recording high infection rates. It is impossible to know whether the mask mandates on the return journey helped reduce infections, or whether that was how the media interpreted them.

There have been a few precedents behind the guidelines on wearing face masks.

During the 1910-1911 Manchurian plague, which prompted scientists from China, Russia, Mongolia, and Japan to collaborate in combating the spreading disease in northern China, face masks were believed to be effective.

Science journalist Laura Spinney, author of a 2017 book about the 1918 Spanish flu, noted that following the experience in Manchuria, the Japanese quickly adopted the practice of wearing masks in public in 1918.

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

And wearing masks also appears to help limit the increase in infection rates.

By the end of December that year, cities and states across the US felt confident enough to lift mask mandates, as new infections had dropped to single digits in most places.

Sanitation workers in New York City wore masks to curb the spread of the flu. "Better to look ridiculous than to die" was the prevailing sentiment of an official at the time. Photo: Getty

A century later

In 1918, the United States began imposing penalties for wearing masks.

But a century later, it is the Asian nations that will most clearly remember the lessons the U.S. learned about the benefits of wearing masks in slowing the spread of infections.

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

Those epidemics helped maintain the culture of wearing masks.

The US and Europe do not experience similar outbreaks with such frequency.

Therefore, it seems that the concept of masks as a preventative measure has been absent from the consciousness of several generations. But the coronavirus pandemic may change that.