Defense Threat Reduction Agency 8725 John J. Kingman Road, MSC 6201 Fort Belvoir, VA 22060-6201 A Historical Assessment of Nonpharmaceutical Disease Containment Strategies Employed by Selected U.S. Communities During the Second Wave of the 1918-1920 Influenza Pandemic January 31, 2006 Authors: Howard Markel, M.D., Ph.D. Alexandra M. Stern, Ph.D. J. Alexander Navarro, Ph.D. Joseph R. Michalsen, B.S. Prepared by: The University of Michigan Medical School Center for the History of Medicine 100 Simpson Memorial Institute 102 Observatory Ann Arbor, MI 48109-0725 DISTRIBUTION A: Approved for public release; distribution is unlimited. DISCLAIMER: The views expressed herein are solely those of the authors and do not necessarily reflect the official policy or position of the Defense Threat Reduction Agency, the Department of Defense, or the United States Government. Advanced Systems and Concepts Office FINAL REPORT DTRA01-03-D-0017 UNCLASSIFIED TABLE OF CONTENTS Acknowledgements ii I. Executive Summary 1 II. Purpose and Methods A. Specific Aims and Methods of Study 4 B. Caveats of Applying Historical Research to Present-Day Public Health Concerns 11 C. Historiography of Epidemics 15 III. Definitions of Terms 24 IV. The 1918-1920 Influenza Pandemic in the Continental United States A. Historical Overview 27 B. State of Virology 33 C. Influenza Mythologies 35 V. Provisional Influenza Escape Community Case Studies A. Introduction 40 B. Yerba Buena Island, California 42 C. Gunnison, Colorado 56 D. Princeton University, Princeton, New Jersey 74 E. Western Pennsylvania Institution for the Blind, Pittsburgh, Pennsylvania 84 F. Trudeau Tuberculosis Sanatorium, Saranac Lake, New York 92 G. Bryn Mawr College, Bryn Mawr, Pennsylvania 97 H. Fletcher, Vermont 107 VI. Additional Factors Related to the Attempted Containment of the 1918-1920 Influenza Pandemic A. Introduction 114 B. Use of Face Masks in San Francisco, CA, Seattle, WA, and Tucson, AZ 115 C. Public Health Risk Communications/Education 124 D. Military Communal Responses to the 1918-1920 Influenza Pandemic 128 E. Vaccines 131 VII. General Conclusions from the Historical Record 134 with Policy Recommendations VIII. Suggested Future Research 139 Appendix I – References 143 Appendix II – Images and Maps 239 UNCLASSIFIED i UNCLASSIFIED SECTION I – Executive Summary Acknowledgments In the course of conducting the research necessary for this publication, the Center for the History of Medicine Influenza Team spoke with numerous archivists, librarians, and information specialists. We wish to acknowledge their assistance in finding the materials critical to our report. In the Washington, D.C., area, at the National Archives and Records Administration, Washington, D.C., Becky Livingston and Robert Johnson, at the NARA facility in College Park, Maryland, Mitchell Yockelson; Jeff Flannery of the Library of Congress. In California, BCMS Paul Andrieu and Lt. Leanne Bacon of the United States Coast Guard for tours of Yerba Buena Island; Robert Glass of NARA San Bruno, California; Joe Evans of the California Historical Society, San Francisco; Linda Johnson of the California State Archives, Sacramento; Susan Goldstein of the San Francisco Public Library History Center, and Capt. Thomas Snyder M.D. In Colorado, Ann Lockhart and Linda Sherman at the Colorado Department of Public Health; archivists at the Colorado State Archives; librarians at the Stephen H. Hart Library, Colorado Historical Society; David M. Hays and Sarah Johnson at the University of Colorado, Boulder Library; and Janice Praeter at the Denver Public Library. In New York, Michele Tucker, curator of the Adirondack Room of the Saranac Lake Free Library in Saranac Lake; Kelly Stanyon, information specialist at the Trudeau Institute, Saranac Lake; librarian Katie Fuerst at the Hudson Area Association Library, Hudson; Geralynn Demarest, librarian at Columbia Green Community College in Hudson; Melinda Yates at the New York State Library, Albany; archivists at the New York State Archives, Albany; Paul Korotkin at the New York Department of Corrections. In Pennsylvania, Janet Simon, Executive Director of the Western Pennsylvania School for Blind Children; Cindy Ulrich at Pittsburgh’s Carnegie Library, Pennsylvania Department; librarians at the Allentown Public Library; Jill Youngken of the Lehigh County Historical Society; and Richard Baker at the U.S. Army Military History Institute in Carlisle. In Massachusetts, Barbara Maloni of the Harvard University Archives and Jeff Eckert of the Countway Medical Library, Harvard University Medical School. In New Jersey, Jeanette Cafaro of the Princeton Historical Society; Tad Bennicoff of the Seely G. Mudd Archives at Princeton University; and Terri Nelson of the Princeton Public Library. In Vermont, Kathy Watters and Gregory Sanford of the Vermont State Archives in Montpelier; Paul Donovan at the Vermont Department of Libraries, Montpelier; Sylvia Bugbee at the University of Vermont Archives, Burlington; Marjorie Strong at the Vermont Historical Society in Barre; Jack Sumberg of the Orleans County Historical Society, Brownington; Eli Prouty of the Grafton Historical Society, Grafton; Elaine Sweet, Town Clerk, Fletcher; Monica Yeamans, Town Clerk, Holland; Penelope Tice, Holland Historical Society, Holland; Candace Polzella of the Monkton Historical Society, Monkton; Scott Wheeler, independent historian, Derby; and Michael Sherman, historian, Montpelier. We are especially grateful to Dr. Cleto DiGiovanni Jr., Defense Threat Reduction Agency, U.S. Department of Defense, and Dr. Arnold S. Monto, University of Michigan School of Public Health, for their incisive and constructive criticism during the entire process of researching and writing this report UNCLASSIFIED ii UNCLASSIFIED SECTION I – Executive Summary SECTION I – Executive Summary In the absence of adequate stocks of an effective vaccine and/or antiviral drugs, the United States may have to rely on nonpharmaceutical interventions (NPI) to contain the spread of an infectious disease outbreak until pharmacological means become available. Because many of these NPI are costly and socially disruptive, their effectiveness and practicality need to be understood before their implementation or incorporation into a response plan. We undertook a historical evaluation of these NPI as employed by American communities during the second wave (September-December 1918) of the 1918-1920 influenza pandemic. A team of medical historians from the University of Michigan Medical School’s Center for the History of Medicine visited these communities to access and collect available primary source material from libraries, archives, and other private and public holdings. We selected 7 communities that reported relatively few if any cases of influenza, and no more than one influenza-related death while NPI were enforced during the second wave of the 1918-1920 influenza pandemic: San Francisco Naval Training Station, Yerba Buena Island, California; Gunnison, Colorado; Princeton University, Princeton, New Jersey; Western Pennsylvania Institution for the Blind, Pittsburgh, Pennsylvania; Trudeau Tuberculosis Sanatorium, Saranac Lake, New York; Bryn Mawr College, Bryn Mawr, Pennsylvania; and Fletcher, Vermont. Because of the apparently reduced morbidity and low mortality these communities experienced during the second wave of the pandemic, we have labeled them “provisional influenza escape communities.” “Provisional” means that we cannot definitively determine on the basis of the historical evidence available to us if these communities sustained their low morbidity and mortality rates because of policy decisions made by their community leaders and public health officials, because the virus skipped some communities altogether and varied in its behavior in UNCLASSIFIED 1 UNCLASSIFIED SECTION I – Executive Summary other communities (viral normalization patterns), or because of other factors such as population density, geography, and good fortune. Historical research is fraught with all the problems and limitations of retrospective studies. The researcher may be helped or hindered by numerous investigators, recorders, and collectors of information who preceded him or her and generally performed their work without a common reference framework or even sets of uniform definitions and concepts. The historian must also rely upon archivists who may or may not have preserved this material and cataloged it in a way that aids retrieval. These issues are some, but hardly the only, limitations of any historical study, including this one. Nevertheless, history represents an essential arrow in the quiver of human inquiry. One would like to think that the 7 communities we identified fared better than others because of the NPI they enacted. We cannot prove that for any of them, although the case is, perhaps, strongest for the Naval Training Station at Yerba Buena Island and, possibly, Gunnison, Colorado. Further complicating our task, in addition to the quality and quantity of information available for study, is the fact that some of these communities were sparsely populated and geographically isolated, and all of them were subject to the vagaries of how the influenza virus normalized in affected populations. Limited by these factors, we have reached two major conclusions: (1) Protective sequestration (the shielding of a defined and still healthy group of people from the risk of infection from outsiders), if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved without draconian enforcement measures, and continued for the lengthy period of time at which the area is at risk, stands the best chance of protection against infection. When implemented successfully, protective sequestration UNCLASSIFIED 2 UNCLASSIFIED SECTION I – Executive Summary also involves quarantine of any outsider who seeks entry, self-sufficiency in the supplies necessary for daily living, enforcement of regulations when necessary (including fining and jailing), and the ability of those sequestered to entertain themselves and maintain some semblance of a normal life. (2) Available data from the second wave of the 1918-1920 influenza pandemic fail to show that any other NPI (apart from protective sequestration) was, or was not, effective in helping to contain the spread of the virus. American communities engaged in virtually the same menu of measures, including: 1) the isolation of ill persons; 2) the quarantine of those suspected of having direct contact with the ill; 3) social distancing measures, such as the cancellation of schools and mass gatherings; 4) reducing an individual’s risk for infection, (e.g., face masks, hand washing, respiratory etiquette); and 5) public health information campaigns and risk communications to the public. Despite these measures, most communities sustained significant illness and death; whether these NPI lessened what might have been even higher rates had these measures not been in place is impossible to say on the basis of available historical data. Moreover, we could not locate any consistent, reliable data that would support the conclusion that face masks, as available and as worn during the 1918-1920 influenza pandemic, conferred any protection to the populations that wore them. However inconclusive are the data from 1918, the collective experiences of American communities from the pandemic are truly noteworthy, especially in light of the fact that faced with a pandemic today we would likely rely on many of these same NPI to attempt to contain the spread of the infection until pharmacological supplies of vaccine and antivirals were available. UNCLASSIFIED 3 UNCLASSIFIED SECTION II - Purpose and Methods A. Specific Aims and Methods of Study The purpose of this study is to assess historically various NPI implemented to prevent or contain pandemic influenza in the continental United States from 1918 to 1920. These measures included: 1) the isolation of ill persons; 2) the quarantine of those suspected of having direct contact with the ill; 3) social distancing measures, such as the cancellation of schools and mass gatherings; 4) protective sequestration measures, including the prevention of healthy communities from interacting with anyone from outside that community; 5) reducing an individual’s risk for infection (e.g., face masks, hand washing, respiratory etiquette); and 6) public health information campaigns and risk communications to the public. Our historical research has alerted us to several communities that appeared to have been more successful than others in achieving these goals, with a resulting low morbidity and mortality from pandemic influenza. During the course of our research, we identified and studied 7 provisional influenza escape communities or institutions in the continental United States during the 1918-1920 period. For this historical study, we define a “provisional influenza escape community” as a community or institution where there were relatively few reported cases of influenza (compared to surrounding areas or analogous communities, towns, cities) and zero to one deaths resulting from influenza or pneumonia-related illnesses while NPI were enforced during the second wave of the 1918-1920 influenza pandemic, September-December 1918.1 We use the word provisional 1 Using the World Health Organization’s influenza pandemic phase definitions, the second wave of the 1918 influenza would be considered Phase 6, Pandemic Period – increased and sustained transmission in the general population. It is important to note that there were 4 major waves of pandemic influenza, which notably were described as a demographic event post facto by historians rather than by public health officials at the time. The first wave occurred from February to May 1918. The second and most serious wave, which is the focus of this study, occurred from September to December 1918; the third wave was January to April 1919, which was interesting because communities that seemed to have had success attenuating the second wave seemed to have experienced UNCLASSIFIED 4 UNCLASSIFIED SECTION II – Purpose and Methods decidedly, because on the basis of the historical evidence available to us we cannot definitively determine if these communities sustained their low morbidity and mortality rates because of policy decisions made and NPI enacted by their community leaders and public health officials, because the virus skipped some communities altogether and varied in its behavior in other communities (viral normalization patterns), or because of other factors such as population density, geography, and good fortune. Given the extant historical data, which in many cases are rather sparse, we are unable to rank the importance of these factors in each of the communities we examined. The diagnosis of influenza at this time was largely empirical, without definite culture methodologies or supportive laboratory findings. Mortality statistics of this era were typically derived from reported data of those who died during this period from respiratory symptoms associated with influenza or pneumonia. This suggests that under or over reporting of influenza cases was likely during the 1918-1920 pandemic. Although greater diagnostic precision at the time would have enhanced the use of this historical information in our current pandemic planning, diagnoses made then were based neither on laboratory evidence nor on a standard case reporting definition. These 7 communities differed from one another in location, population density, demographic mix, community or institutional organization (e.g., civilian, military, institutions for the blind and for those with tuberculosis). As a result, they cannot offer a universal or monolithic template for developing public health policy for today. Conversely, one of the great strengths of our study is the diversity of our 7 communities. Consequently, we believe that milder morbidity and mortality during this wave. The fourth wave occurred approximately from December 1919 to March 1920. See World Health Organization. WHO global influenza preparedness plan: the role of WHO and recommendations for national measures before and during pandemics. Switzerland: 2005. UNCLASSIFIED 5 UNCLASSIFIED SECTION II – Purpose and Methods important historical lessons can and should be extracted from a careful and close examination of the communities profiled in this study. The identification of these 7 provisional influenza escape communities was determined by both a review of the contemporary medical literature, circa 1918-1920, and our own review of several national, 40 state, and numerous local public health annual, monthly, or special reports produced during that period. This extensive literature review enabled our research team to identify several provisional influenza escape communities that had not been recognized until now, as well as to disqualify several supposed provisional influenza escape communities discussed in standard references on the pandemic. For example, the New York State Training School for Girls; Lake City, Colorado; and Darien, Connecticut, were identified in standard and respected texts on the influenza pandemic as provisional influenza escape communities, but upon further analysis could not be verified because of contradictory or insufficient historical evidence. Conversely, Fletcher, Vermont, and Bryn Mawr College were not identified in these standard sources, yet additional sources that we uncovered during our archival research suggested they might be provisional influenza escape communities and contained much intriguing information. The historian’s task generally involves the consultation and analysis of hundreds or even thousands of pertinent documents. In ideal situations this work is supported by a foundation of reading and analysis and interpretation of the extant secondary historical literature (e.g., the history of American public health, the history of medicine and epidemics in America and the world, and the history of the American political process especially with respect to acts, statutes, laws, and institutions designed to protect the public health). The lead researchers in this study have extensive knowledge and experience in the fields noted above, and they have published more than one hundred and fifty peer-reviewed articles and books on these topics. UNCLASSIFIED 6 UNCLASSIFIED SECTION II – Purpose and Methods We began our research for this report by reviewing the contemporary medical and historical literature of the 1918-1920 pandemic and the references cited in those papers to compile an exhaustive bibliography of the events. We then proceeded to a systematic review of the annual and monthly reports of virtually all public health agencies in the continental United States during that period. Further, we conducted a combination of searches using 1) electronic databases related to current medical and public health sources (e.g., MEDLINE, PUBMED, and Lexis/Nexis); 2) electronic databases related to historical, medical, and public health sources (e.g., Hist-Med-Sci-Tech, OCLC, WORLDCAT, Library of Congress, CATNYP, National Union Catalog of Manuscript Collections, and ProQuest), and 3) hard copy sources such as card catalogs in medical, state, and local libraries. Card catalog information is typically available only in situ and in the majority of instances is not digitized or freely available on the Internet. This is critical because some of the richest and most informative sources pertaining to NPI taken during the 1918-1920 pandemic reside in these repositories. Shortly after our initial stage of data collection, we conducted archival site visits at more than 30 archives, museums, libraries, town halls, and public health departments. For those materials that we could not locate in the University of Michigan library system, we conducted an extensive inter-library loan search, acquiring books, articles, photographs, reports, maps, and pamphlets. We also made an extensive search and analysis of the newspapers and popular periodicals published during the era under study, using both microfilm and hard copy editions of newspapers. This vast collection of government reports, personal papers such as correspondence and diaries, newspapers and popular periodicals, medical and public health journals, and a host of other materials is detailed in Appendix I: References. UNCLASSIFIED 7 UNCLASSIFIED SECTION II – Purpose and Methods These primary source materials were then read and abstracted by each member of the CHM Influenza Research Team, discussed and analyzed to weigh their historical significance, cross-checked with other sources to determine their veracity, and synthesized into the narratives you are about to read. It is important to note that this interpretation of historical materials involved a great deal of negative research; in other words, we reviewed a large number of materials that were ultimately not included in the text of this report but that were essential to its compilation and our conclusions. A Table of the Negative Research conducted for this study, including both military and civilian sites, is included in Appendix I. Beyond the acquisition of paper documents, our site visits were extremely important in helping us to better understand the topography, geography, and spatial organization of the communities. Of course, we made these observations from a distance of 80-plus years. Nevertheless, the site visits did allow us to better reconstruct what NPI were taken and how they were enacted. For example, the Western Pennsylvania Institution for the Blind still stands in its original location in a residential area of Pittsburgh, with the facilities intact and in use (digital photographs were taken of this location; see Appendix II: Images and Maps). This report systematically discusses the principal measures implemented in the various and distinct provisional influenza escape communities. The 7 provisional influenza escape communities that constitute our case studies are: 1. San Francisco Naval Training Station, Yerba Buena Island, San Francisco Bay, California 2. Gunnison, Colorado 3. Princeton University, Princeton, New Jersey 4. Western Pennsylvania Institution for the Blind, Pittsburgh, Pennsylvania UNCLASSIFIED 8 UNCLASSIFIED SECTION II – Purpose and Methods 5. Trudeau Tuberculosis Sanatorium, Lake Saranac, New York 6. Bryn Mawr College, Bryn Mawr, Pennsylvania 7. Fletcher, Vermont These 7 communities stand out as remarkable exceptions to the devastating impact of the 1918-1920 influenza pandemic in the continental United States. Indeed, virtually every town, city, and state in the United States during this period applied the same menu of NPI. Although these provisional influenza escape communities might have been geographically or socially isolated, they did not exist in a vacuum. As medical historians attuned to the significance of historical context, we examine the larger environment in which each provisional influenza escape community was situated. For example, our discussion of the Yerba Buena Island Naval Training Station places its successful preventive public health measures within the context of the greater San Francisco Bay Area and, furthermore, compares it to the analogous, yet not nearly as effective, NPI implemented at Mare Island Naval Yard, located about 35 miles to the east in Vallejo, California.2 What we do not include in this study, but recommend for future studies, is the analysis of so-called less successful communities. Such communities should be historically evaluated to help us better understand what combination of NPI worked or did not work because of uncontrollable circumstances (see Section VIII: Suggested Future Research). Ultimately, further research in such communities might elucidate a helpful continuum of NPI for policy makers, including their implementation, efficacy, limitations, and salient external factors. 2 We looked closely at several other communities or military sites that instituted many of the same NPI but did not achieve the same level of success. These include Fort Custer in Battle Creek, Michigan; Camp Crane in Allentown, Pennsylvania; Camp Kearney in San Diego, California; and certain naval ships in the 11th District of the Pacific Fleet, based in San Diego, California, under the command of Rear Admiral William F. Fullam. These sources are cited in the Bibliography section of the report. (See Appendix II.) UNCLASSIFIED 9 UNCLASSIFIED SECTION II – Purpose and Methods Our study considers a set of 5 major questions about the 1918-20 influenza pandemic and the 7 provisional influenza escape communities. We developed these questions based upon the framework of existing scholarship and public health challenges likely to arise in a potential future pandemic. Central Study Questions: 1. How did these communities attempt to limit the spread of a highly virulent virus easily transmitted from person to person via droplet and/or aerosol in order to protect their human, social, and economic assets from the impending pandemic? 2. What methods of public health preparedness, prevention, and administration (i.e., NPI) were successful in these provisional influenza escape communities? How were they executed? What applications from these examples might be of use in contemporary planning? 3. What lessons might be learned from communities that implemented more restrictive NPI early in the proceeding pandemic, and how did public health and local officials recruit their populations to comply with what might be interpreted as draconian measures? Did these NPI work to contain the spread? What political, economic, and social costs came with these NPI? 4. How does one ratchet up measures of pandemic prevention and containment? How and when do you ratchet them down? What was the tolerable time period for a population to be ordered into protective sequestration, isolation, and/or quarantine? What social measures were taken to facilitate cooperation among the quarantined and isolated people? Were there rebound cases of influenza because of an early lifting of the preventive measures? 5. To what extent did mitigating, uncontrollable, or immutable forces contribute to a particular community’s either escaping or succumbing to the influenza pandemic (e.g., geography, viral normalization patterns, population density, transportation access, politics, social structure, weather, and even luck or fortunate circumstances beyond human control)? UNCLASSIFIED 10 UNCLASSIFIED SECTION II – Purpose and Methods B. Caveats of Applying Historical Research to Present-Day Public Health Concerns When asked to explain the power of historical research for contemporary policy making, we are decidedly enthusiastic but are obligated to begin with some caveats. To be sure, there are many themes and continuities that the study of pandemics in the past can offer to those of us concerned about their containment and prevention in the present and the future. Nevertheless, this approach can be carried only so far. It would be wonderful if every past event adhered to the oft-quoted axiom of George Santayana (“those who cannot remember the past are condemned to repeat it”), in point of fact, history does not serve as an exact roadmap of what is to come or even what necessarily happened in the past.3 Much of our knowledge of the past depends on the supporting archival materials that were actually saved; other archival materials may not be entirely reliable; and some lacunae are so great that we can only hypothesize or speculate about what may actually have occurred. A good way to think about archival research in general is to imagine that your life was being recorded by a historian. Every day, the scholar would file a report and store that document in a bank of file cabinets that, by the end of your life, would presumably amount to many reams of paper. Then imagine that a fire destroyed most of that room, with only occasional file folders from discrete periods of your life surviving. With few exceptions, especially when it comes to the history of ordinary, everyday people, such spotty records are what the historian deals with in his or her inquiry. Moreover, because the sites analyzed in our study are far from identical, varying in size, location, social organization, and a host of other factors, we need to be cautious in offering universal precautions that might be more widely applied under the potentially misapplied banner 3 Santayana G. The life of reason or the phases of human progress. (One volume edition revised by the author in collaboration with Daniel Cory). New York: Charles Scribner’s Sons; 1954. p. 82. UNCLASSIFIED 11 UNCLASSIFIED SECTION II – Purpose and Methods of “historical precedent.” It is also critical to note how epidemiological data, surveillance, microbiological knowledge (specifically the etiology of influenza), and vital statistics were recorded in 1918. Frequently, critical numerical population data were not recorded or were recorded in a less than consistent manner during this period of American history; such gaps constitute significant roadblocks in the present historical report. The continental United States of 1918 contained many features of the modern era we currently enjoy, such as rapid transportation in the form of trains and, on a much more limited basis when compared to today, automobiles; rapid means of communication in the form of telegraph and telephone; large, heterogeneous populations with substantial urban concentrations (although many more Americans lived in rural environments in 1918 when compared to the present); a widely circulated distribution of news and information on the pandemic in the media, and the existence, in many cases, of public health agencies at various levels of government. Yet there are many striking contrasts between this era and our own. For example, legal understandings of privacy and civil and constitutional rights as related to public health and governmentally directed measures (such as mass vaccination programs or medications) have changed markedly over the past eight decades. In addition, public support or trust of these measures, and of the medical profession in general, has changed significantly, especially with regard to vaccines and medications. Consider the recent spate of lawsuits tied to vaccine failures or perceptions that vaccines may have significant and dangerous side effects. The speed and mode of travel, principally the development of high-volume commercial aviation; immediate access to information via the Internet and personal computers, and a base-line understanding among the general educated population that the etiological agents of infectious diseases are microbial — not to mention advances in medical technology and therapeutics that have vastly UNCLASSIFIED 12 UNCLASSIFIED SECTION II – Purpose and Methods changed the landscape of how to approach a pandemic in the 21st century – are all formidable changes that need to be considered when applying historical research to contemporary policymaking. Another important feature of American society circa 1918 that was markedly different from the present has to do with daily commerce and commercial transactions. In 1918 there were no supermarkets, refrigeration was primitive (e.g., ice boxes), and a limited variety of preserved foods were available for purchase. Consequently, daily marketing at multiple locations (e.g., grocers, produce vendors, bakeries, butchers) was often a facet of daily life. Moreover, there were no credit cards, and personal checking accounts were typically employed only by the affluent, so frequent visits to banks for cash were not uncommon. Indeed, for ordinary citizens in 1918 the United States was almost entirely a cash economy. Moreover, during an epidemic the closure of a bank might be explained as a public health measure, but for many Americans in 1918 who had lived through the Depression of 1893, as well as other boom and bust cycles, such an action might be misconstrued as a failure of the bank itself, and had the potential to create civil unrest. As a result, often the last public spaces (after theaters, schools, churches, restaurants, and saloons) to close would be banks and similar financial institutions. This historical difference between 1918 and today reveals a striking change over time. At present, a number of daily functions of life can be accomplished with little or no human interaction. For example, banking and credit transactions, the ordering and delivery of food via the Internet, as well as entertainment and personal or business communication, to name but a few, can all be realized by large numbers of people in a manner that might minimize the degree of human contact and thus the potential spread of contagious disease.4 Nevertheless, as recent 4 Germain RN. Dollars through the doors: a pre-1930 history of bank marketing in America. Westport, Conn.: Greenwood Press; 1996; Chandler AD. The visible hand: the managerial revolution in American business. UNCLASSIFIED 13 UNCLASSIFIED SECTION II – Purpose and Methods disasters have shown, the tenuous economic safety net that many Americans encounter today suggests that crises related to access to financial resources and even basic needs of living can have a deleterious affect on pandemic containment. As Alfred Crosby has wisely noted in his classic book, America’s Forgotten Pandemic: The Influenza of 1918, in human terms pandemic was not one over-arching story but, instead, “thousands of separate stories” with different origins and outcomes for the influenza victims, their families, and their communities.5 Our research strongly confirms that observation. Moreover, it is not surprising that none of our provisional influenza escape communities were large cities. As Crosby and many others have noted, “prospective flu victims were packed much more closely together in the cities than in the countryside: they transmitted the disease to one another much more rapidly.”6 Or to re-state the obvious: sparse populations and infrequent human contact are among the best defenses against influenza. Our historical analysis reinforces Crosby’s findings and suggests that it is very difficult to completely characterize, let alone apply, the lessons gleaned from the provisional influenza escape communities to U.S. cities, where the vast majority of Americans now live. Cambridge, Mass.: Belknap Press; 1980; Blackford MG. A history of small business in America. Chapel Hill: University of North Carolina Press; 2003; Rothbard MN. A history of money and banking in the United States: the colonial era to World War II. Auburn, Ala.: Ludwig von Mises Institute; 2002. 5 Crosby AW. America’s forgotten pandemic: the influenza of 1918. Cambridge: Cambridge University Press; 1989. p. 66. 6 Crosby. America’s forgotten pandemic. p. 66. UNCLASSIFIED 14 UNCLASSIFIED SECTION II – Purpose and Methods C. Historiography of Epidemics The scholarship on epidemics and society that the lead researchers of this study have generated over the past decade and a half is based on the conceptual framework that epidemics have distinct social, cultural, economic, and political contours and patterns of progression that can be traced over time.7 To identify which mix of social and biological factors dominates in a particular instance, we seek to study societal power relations, aspects of everyday life, class, gender, ethnicity, and the global impact of health problems that neither respect nor are limited to national boundaries. This mode of historical analysis is termed the social construction of disease and is based on the theory that disease is as much shaped by social factors (such as national context, politics, economics, race and gender relations) as it is by biological or physical components. A central aim of this mode of research is to uncover how the interests of particular groups and competing social values are often culturally embedded in the resulting policies developed to address social or public health problems. The historian Charles Rosenberg has identified four principal phases of an epidemic. He refers to the unfolding of an epidemic as a dramaturgic event, usually in four acts, that has a rather predictable narrative plot line. 7 Rosenberg C, Golden J, editors. Framing disease: studies in cultural history. New Brunswick, N.J.: Rutgers University Press; 1992; Aronowitz RA. Making sense of illness: science, society, and disease. Cambridge: Cambridge University Press; 1998; Brieger G. The historiography of medicine. In: Bynum WF, Porter R, editors. Companion encyclopedia of the history of medicine Vol 1. London: Routledge; 1993. p. 24-44; Bynum WF. Health disease and medical care. In: Rosenau GS, Porter R, editors. The ferment of knowledge: studies of the historiography of eighteenth-century science. Cambridge: Cambridge University Press; 1980. p. 211-53; Pelling M. Medicine since 1500. In: Corsi P, Weindling P, editors. Information sources in the history of science and medicine. London: Butterworth Scientific; 1983. p. 379-407; Brieger G. History of medicine. In: Durbin P, editor. A guide to the culture of science, technology, and medicine. New York: Free Press; 1984. p. 121-194; Rosen G. People, disease and emotion: some newer problems for research in medical history. Bull Hist Med. 1967;4:5-23; Porter R. The patient’s view: doing medical history from below. Theory Soc. 1985;14:167-74; Porter R, Porter D. In sickness and in health: the British experience 1650-1850. London: Fourth Estate; 1988; Porter D, Porter R. Patient’s progress: doctors and doctoring in eighteenth-century England. Cambridge: Polity Press; 1989. UNCLASSIFIED 15 UNCLASSIFIED SECTION II – Purpose and Methods 1) The first act is one of “Progressive Revelation.”8 Specifically, in this period members of a community begin to acknowledge an increasing number of cases and/or deaths resulting from the spread of a particular contagious disease. 2) Act two, “Managing Randomness,” is “the creation of a framework within which [the epidemic’s] dismaying arbitrariness can be managed.”9 It includes social, political, medical, and economic responses to the epidemic, which are typically framed by how a particular society understands disease, science, and medicine, as well as its social and cultural values. 3) The third act is referred to as “Negotiating Public Response.” Once an epidemic is recognized, collective action of some kind soon follows. Yet as Rosenberg notes, “one of the defining characteristics of an epidemic is in fact the pressure it generates for decisive and visible community response.”10 How these events are understood and how counter- measures are negotiated by all of the stakeholders involved is intimately related to a host of cultural values and attitudes, such as how the poor and socially marginal are considered at a particular time, social hierarchies, the roles science and religion play in a particular society, and so on. 4) Act 4, “Subsidence and Retrospection,” is often the most vexing phase of an epidemic for public health management and epidemic preparedness planning. As Rosenberg notes, epidemics often end as ambiguously as they appear. This trend is perhaps most eloquently described in the closing passages of Albert Camus’s novel The Plague.11 8 Rosenberg C. What is an epidemic? AIDS in historical perspective. In: Rosenberg C, editor. Explaining epidemics and other studies in the history of medicine. New York: Cambridge University Press; 1992. p. 278-292. Quote is p. 281. 9 Ibid. p. 285. 10 Ibid. p. 285. 11 Ibid. p. 286. Camus A. The plague. Trans. S Gilbert. New York: Modern Library; 1948 UNCLASSIFIED 16 UNCLASSIFIED SECTION II – Purpose and Methods Specifically, once an epidemic peters out and susceptible individuals die, recuperate, or escape, and life begins to return to its normal patterns, people begin to place the epidemic in the past. What is most troubling about this phase is that although it can lead to retrospection and action in terms of preparedness for subsequent epidemic events, all too often it leads to complacency or even outright amnesia about the event. This characteristic is of particular importance when planning for emerging pandemics. A critical question, therefore, is how does a community or government maintain credibility in its warning systems, maintain public support for costly preparedness planning, and keep the public on alert but not alarmed? Howard Markel has articulated 7 leitmotivs that appear in most epidemics and pandemics. This construct is based on analysis of numerous pandemics including the Black (bubonic) Plague of the Middle Ages, the cholera pandemics of the 19th century (1832, 1845, 1866, 1892), and the influenza pandemics of 1880, 1918, 1957, and 1968, as well as contemporary pandemics including HIV/AIDS, tuberculosis, SARS, and other newly emerging infectious diseases. To be sure, not all of these themes appear in every epidemic or pandemic.12 Instead, they should be viewed as essential ingredients to an epidemic, but from era to era and disease to disease, the precise mix of the themes can change. The 7 leitmotivs are: 1) Epidemics are almost always framed and shaped, sometimes advanced, and sometimes hindered by how a given society understands a particular microbe to travel and infect others. Consequently, people living in an era when microbes were not considered part of the etiology of a particular epidemic disease responded to that threat differently from those living in eras that do. For example, in the cholera epidemics of 1832, 1845, and 12 Markel H. Quarantine! East European Jewish immigrants and the New York City epidemics of 1892. Baltimore: Johns Hopkins University Press; 1997; Markel H. When germs travel: six major epidemics that have invaded America since 1900 and the fears they have unleashed. New York: Pantheon Books; 2004. UNCLASSIFIED 17 UNCLASSIFIED SECTION II – Purpose and Methods 1866 cholera was thought to spread through polluted air, or miasma (from the Greek for defilement or pollution). The term refers to the now outdated theory that toxic emanations come from the soil, earth, or rotting organic material, and cause specific epidemic diseases such as cholera, typhus, and malaria. When this theory was in vogue, public health efforts were often different from those taken today; they were typically centered on the sanitarian pursuits of cleaning up the environment (e.g., streets, sewers, and privies). This trend changed markedly in the late 19th century with the advent of the germ theory of disease. By the 1890s, when cholera was understood to be a water-borne disease, caused by the microbe Vibrio cholerae that attacked the gastrointestinal system, public health efforts were more often tied to methods of purifying the food and water chain.13 2) The economic devastation typically associated with epidemics frequently shapes the public’s response to a contagious crisis. The order of quarantine, when one closes a port or a city to foreign travelers or goods, costs communities a great deal of money and creates great hardships for individuals. It is not surprising that during the international sanitary conferences in the mid-19th century, merchants were vocal participants who often opposed the implementation of preventive and containment efforts that might have impeded commercial enterprises and the flow of capital. This concern is particularly salient in today’s globalized marketplace.14 3) The movements of people and goods and the speed of travel are essential factors in the spread of pandemic disease. For example, during the cholera pandemics of the 19th century, the main mode of transoceanic travel was steamship. Journeys from Europe or 13 Duffy J. The Sanitarians: a history of American public health. Urbana: University of Illinois Press; 1992. 14 Stern AM, Markel H. International efforts to control infectious diseases, 1851 to the present. JAMA 2004;292:1474-1479. UNCLASSIFIED 18 UNCLASSIFIED SECTION II – Purpose and Methods Asia to North America required a travel time of 7 to 21 days, giving most infectious diseases ample incubation periods, thus facilitating their recognition by health officers at the point of disembarkation. Contrast this scenario to today’s main mode of international travel, commercial jet planes: anyone can travel to anywhere in the world in a matter of several hours to just under a day. 4) Our fascination with the suddenly appearing microbe that kills relatively few in spectacular fashion too often trumps our approach to infectious scourges that patiently kill millions every year. Compare, for example, social response to SARS in 2003, which affected approximately 8,000 people and killed 800, and tuberculosis, which infected 8,000,000 and killed 3,000,000 that year. Similar comparisons could be made for anthrax in 2001 to the ongoing global pandemic of HIV/AIDS, which kills 2,000,000 people a year. The lack of widespread attention to the common scourges of lower respiratory tract infections and diarrheal diseases which kill millions on an annual basis is an even more egregious example of what can only be called a contagious cognitive dissonance.15 5) Widespread media coverage of epidemics is hardly new and is an essential part of any epidemic. It has the power to both inform and misinform. Therefore, the ways popular communication is framed are of utmost importance. One new wrinkle in the media’s coverage of pandemic events today is the technology, speed, and variety with which reports are generated. Compare New York City circa 1918, when consumers relied heavily on an extensive print media, to our current era with its panoply of newspapers, magazines, radio, cable, Internet Web sites, Web logs, and discussion groups. The 15 Markel H, Doyle S. The epidemic scorecard. The New York Times. 2003 Apr 30; A31; Achenbach J. Can we stop the next killer flu? Washington Post. 2005 Dec 7; W10. UNCLASSIFIED 19 UNCLASSIFIED SECTION II – Purpose and Methods problem is not new, but the breadth of media genres is logarithmically greater and has a far greater potential to provide both useful information and misinformation. 6) A dangerous theme of epidemics past is the concealment of the problem from the world at large. Too often, these efforts have been generated by a nation or a state in order to protect economic assets and trade (e.g., the German government’s initial response to the 1892 cholera pandemic). At other times, they have been motivated by nationalistic bias, as with HIV in South Africa in the 1990s. Ironically, one of the potential public health benefits of a global marketplace is a greater transparency of the dissemination of information on brewing or developing epidemics. For example, in the post-SARS era, China (which initially concealed its SARS cases) appears to have subsequently been much more open in its influenza surveillance; in contrast, Indonesia has not. Regardless of the reasons for concealment of a public health crisis, secrecy almost always contributes to the further spread of an epidemic and hinders public health management. 7) Perhaps the saddest theme of epidemics throughout history has been the tendency to blame or scapegoat particular groups. Frequently these groups have already been deemed “socially undesirable” by the population at large. The result has usually been the development of harsh policies aimed at the scapegoats rather than those specifically exposed to a particular infectious microbe. These lead to a wide menu of oppositional responses by those targeted, which in turn can hinder the prevention or containment of an epidemic. There are many examples of scapegoating; two of the most frequently discussed in the historical literature are 1) the demonization of the Chinese in the 1900 bubonic plague outbreak in San Francisco, and 2) the stigmatization of gay men during UNCLASSIFIED 20 UNCLASSIFIED SECTION II – Purpose and Methods the early years of the AIDS epidemic in the 1980s.16 To make this point more relevant to policy today, we have included the table below, which highlights many problems associated with scapegoating, social unrest, and what are perceived to be unfair public health practices.17 16 Kraut AM. Silent travelers: germs, genes, and the “immigrant menace”. New York: Basic Books; 1994; Grmek MD. History of AIDS: emergence and origin of a modern pandemic. Trans RC Maulitz, J Duffin. Princeton, N.J.: Princeton University Press; 1990. 17 Mullet CF. A century of English quarantine, 1709-1825. Bull Hist Med. 1949;23:527-45; McDonald JC. The history of quarantine in Britain during the 19th century. Bull Hist Med. 1951;25:22-44; Hardy A. Cholera, quarantine and the English preventive system, 1850-1895. Med Hist. 1993;37:250-60; Rosen G. A history of public health. New York: MD Publications; 1958; Humphreys M. Yellow fever and the South. New Brunswick, N.J.: Rutgers University Press; 1992; Ellis JH. Yellow fever and public health in the New South. Lexington: University Press of Kentucky; 1992; Duffy J. The Sanitarians; Schepin OP, Yermakov WV, editors. International quarantine. Madison, Conn.: International Universities Press; 1991. p. 125-58; Risse, G. Epidemics and history: ecological perspectives and social responses. In: Fee E, Fox D. AIDS: The burdens of history. Berkeley: University of California Press; 1988. p. 33-66; Powell JH. Bring out your dead: the great plague of yellow fever in Philadelphia in 1793. Philadelphia: University of Pennsylvania Press; 1949; Winslow C-EA. The conquest of epidemic disease: A chapter in the history of ideas. New York: Hafner; 1967. For more literary versions of the drama of epidemic disease and quarantine, Boccaccio G. The Decameron, trans. John Payne. New York: Modern Library; 1931; Defoe D. A journal of the plague year. New York: Modern Library; 1948; Camus A. The Plague; Ibsen H. An enemy of the people, trans. James McFarlane. Oxford: Oxford University Press; 1988; Lewis S. Arrowsmith. New York: Harcourt Brace; 1925; Dworet L, Pool RR. Outbreak. Warner Brothers Pictures; 1995. For recent journalistic accounts of contemporary epidemic diseases, Garrett L. The coming plague: newly emerging diseases in a world out of balance. New York: Farrar, Straus, and Giroux; 1994; Preston R. The hot zone. New York: Random House; 1994; Shilts R. And the band played on: politics, people and the AIDS epidemic. New York: St. Martin's; 1987; Shah N. Contagious divides: epidemics and race in San Francisco’s Chinatown. Berkeley: University of California Press; 2001; Craddock S. City of plagues: disease, poverty, and deviance in San Francisco. Minneapolis: University of Minnesota Press; 2000. UNCLASSIFIED 21 UNCLASSIFIED SECTION II – Purpose and Methods Social scapegoating If one social group has a high percentage of quarantined individuals compared to others, there is a risk that the rest of society will designate the quarantined social group as scapegoats, with a wide range of negative effects for both the scapegoated group and society at large. Misdiagnosis of healthy Diagnosing healthy people as infected and treating them as such may erode the public health authority’s legitimacy. Mixing ill people with healthy If healthy people are quarantined with ill persons, the number of cases to be observed may increase. Business closure If businesses are closed for extended periods of time, not only will people have difficulty acquiring supplies, the businesses may eventually be forced to fold, seriously hampering post-pandemic recovery efforts. Moreover, individual workers, especially those without large monetary reserves, will likely experience economic hardship. Such a scenario has the potential to create social unrest and non-cooperation in public health efforts. Infringement of liberties Quarantine and other NPI can infringe on people’s basic freedoms and civil liberties, leading to ostracism, anger, fear, and panic. Counterproductive Behavior Pandemics are highly stressful, and they are likely to introduce counterproductive behaviors in a society that may lead to the further spread of disease. The term “panic” can be used to describe behavior that may turn out not to be helpful, yet which many believe is based on rational decisions informed by the knowledge available at the time. Potential Riots If the pandemic or the management of pandemic inflames a particular group enough, violence may occur and can even result in riots and/or casualties and injuries. Legal Entanglements Unfair public health ordinances can be contested in the courts, typically during the height of a pandemic, often distracting from other public health matters. Knowledge of past pandemics has informed our study of the 1918 influenza pandemic. In particular, Rosenberg’s four phases are relevant for understanding the second wave of the pandemic (September to December 1918). His rise and fall model does not work as well for a multi-phasic pandemic as seen with influenza, however, given that the third and fourth waves appeared from 1919 to 1920. Similarly, Markel’s theme of scapegoating does not apply to 1918, because the pandemic spread so rapidly among all sectors of American society (especially among those 20-45 years of age). To date, there has not been a systematic study of the extent to UNCLASSIFIED 22 UNCLASSIFIED SECTION II – Purpose and Methods which specific social groups were affected by the 1918-1920 influenza pandemic. Nevertheless, all of the remaining leitmotivs articulated by Markel were present in the 1918 influenza pandemic. For example, during the 1918 pandemic it was very common for local business owners to oppose NPI that seriously affected their economic health. Similarly, the mass media (primarily in the form of newspapers) played an enormous role in delivering accurate and sometimes erroneous information to the population at large. In order to produce this report, we have carefully operationalized the methods of the social historian of medicine and public health and heeded the guiding principles articulated above. We have done so with the specific aim of elucidating the history and potential lessons that can be extracted from an analysis of the NPI taken by the 7 provisional influenza escape communities profiled in this study. We aim to illuminate, through fine-grained analysis, the dynamics of these 7 provisional influenza escape communities, while not losing sight of the larger social, national, and international context. UNCLASSIFIED 23 UNCLASSIFIED SECTION III - Definition of Terms These definitions were formulated by the CHM research team in consultation with Dr. Cleto DiGiovanni, of the U.S. Department of Defense, and Dr. Arnold S. Monto, of the University of Michigan School of Public Health. The definition of Nonpharamaceutical Interventions (NPI) is derived from the World Health Organization Writing Group of the WHO Global Influenza Programme.18 The final three definitions that we employ in this report are taken from, HHS Pandemic Influenza Plan of November, 2005. The definitions are taken from Part II, Supplement 8, page 14, Box 1. Containment Measures: Terms and Definitions.19 Nonpharmaceutical Interventions (NPI) NPI include measures that focus on: 1) limiting international spread of the virus (e.g. travel screening and restrictions); 2) reducing spread within national and local populations (e.g., isolation and treatment of ill persons; monitoring and possible quarantine of exposed persons; protective sequestration of healthy communities; and social distancing measures, such as cancellation of mass gatherings and closures of schools); 3) reducing an individual person’s risk for infection (e.g., hand hygiene, face masks, self-monitoring, voluntary quarantine, etc.); and 4) communicating risk and educating the public. Provisional influenza escape community A community or institution where there were relatively few reported cases of influenza (compared to surrounding areas or analogous communities, towns, cities) and zero to one deaths resulting from influenza or pneumonia-related illnesses while NPI were enforced during the second wave of the 1918-1920 influenza pandemic, September-December 1918. We use the word provisional decidedly, because on the basis of the historical evidence available to us we cannot definitively determine if these communities sustained their low morbidity and mortality rates because of policy decisions made and NPI enacted by their community leaders and public health officials, because the virus skipped some communities altogether and varied in its behavior in other communities (viral normalization patterns), or because of other factors such as population density, geography, and good fortune. Given the extant historical data, which in many cases 18 World Health Organization Writing Group. Nonpharmaceutical Interventions for Pandemic Influenza, International Measures. Emerg Infect Dis. 2006;12(1):81-87; World Health Organization Writing Group. Nonpharmaceutical interventions for Pandemic Influenza, National and Community Measures. Emerg Infect Dis. 2006;12(1):88-94. 19 United States Department of Health and Human Services. HHS pandemic influenza plan. November 2005. Definitions from pages S8-14. UNCLASSIFIED 24 UNCLASSIFIED SECTION III - Definitions Provisional Influenza Escape Community (cont’d) are rather sparse, we are unable to rank the importance of these factors in each of the communities we examined. The diagnosis of influenza at this time was largely empirical, without definite culture methodologies or supportive laboratory findings. Mortality statistics of this era were typically derived from reported data of those who died during this period from respiratory symptoms associated with influenza or pneumonia. This suggests that under or over reporting of influenza cases was likely during the 1918-1920 pandemic. Although greater diagnostic precision in 1918 would have enhanced the use of this historical information in our current pandemic planning, diagnoses made then were based neither on laboratory evidence nor on a standard case reporting definition. Protective Sequestration Measures taken by local authorities to protect a defined and still healthy population from infection. This term applies to both institutions (e.g., prisons, schools) and communities (e.g., towns, military bases). Measures taken usually include prohibitions on members of the institution or community from leaving the site and prohibitions on outside visitors from entering the site or circumscribed perimeter; when visitors do seek admission, they may be placed in quarantine for a period of time prior to their admission into the community or institution. In the case of communities, protective sequestration measures may take advantage of geographical barriers (e.g., an island community surrounded by water). (N.B., Protective Sequestration is explicitly different from quarantine.) Quarantine Separation and restriction placed on the movement of persons who, although not showing signs or symptoms of illness, may have acquired, or are believed to have acquired, an infectious agent through contact with known carriers of the agent. The duration of separation and restriction depends on the incubation period of the agent. Quarantine is typically mandatory. Isolation Separation and/or restricted movement of persons who manifest signs and/or symptoms of a contagious disease from the larger population. Isolation may occur anywhere, but it generally occurs at home or in a health care treatment facility. Isolation may also entail a set of procedures that health care providers must follow in their contact with that patient; these procedures vary and depend on the route of transmission of the infective agent, (e.g., respiratory precautions, gowns, face masks, gloves, etc.) Social Distancing NPI implemented to discourage or prohibit close social contact between individuals in schools, sports facilities, churches, and other places of public gathering. These measures may be advertised to the public as voluntary, or they may involve the actual closing of places of public gathering or prohibitions of public events and gatherings. UNCLASSIFIED 25 UNCLASSIFIED SECTION III - Definitions Community-wide Quarantine, including cordon sanitaire The closing of community borders or the erection of a real or virtual barrier around an area that has experienced contact or suspected contact with infected persons, with prohibition of travel into or out of the area. Snow Days Days on which offices, schools, transportation systems are closed or cancelled, as if there were a major snowstorm, in an effort to minimize or eliminate a wide array of public assemblies. UNCLASSIFIED 26 UNCLASSIFIED SECTION IV - The 1918-1920 Influenza Pandemic in the Continental United States A. Historical Overview The influenza pandemic of 1918-1920 resulted from the confluence of myriad factors. It was in many ways a “perfect storm” of viral contagion brought about by the convergence of a mutated strain of influenza, the social and geographic disruption of the mass mobilization and movement of millions of troops because of World War I. Although this confluence of factors was specific to the fall of 1918, the kind of mass movement of people associated with the spread of that pandemic is certainly not exclusive to that era and has continued to this day, through human migration, social disruption, and extensive travel and tourism. Because of its harrowing impact on the United States and the world, the 1918 pandemic is a common reference point for contemporary discussions about a potential pandemic and how to respond to such a threat. Carol Byerly observes in The Fever of War, “war created the influenza epidemic by producing an ecological environment in the trenches in which the flu virus could thrive and mutate to unprecedented virulence.” In turn, the epidemic “impacted the war by striking down millions of soldiers.”20 The processes associated with military preparedness and conducting trench warfare that enveloped much of the globe in 1918 helped to turn the influenza outbreak into a pandemic that, according to several estimates, killed approximately 50 million people worldwide and 675,000 in the United States. There were four waves of the pandemic between 1918 and 1920. In the United States, the first wave appeared concurrently in Kansas, California, Michigan, New York, and other locations from February until May 1918, sending many able-bodied workers and soldiers to their beds or to the infirmary. This wave did not produce sufficient mortality or morbidity to prompt 20 Byerly CR. Fever of war: the influenza epidemic in the U.S. Army during World War I. New York: New York University Press; 2005. p. 8. UNCLASSIFIED 27 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 health officials to take action beyond the status quo employed for annual bouts of influenza and other acute upper respiratory infections.21 For reasons that are still not completely understood by scientists, from June to August the initial strain likely underwent a mutation and/or reassortment that increased its virulence, making it especially destructive not only to the upper respiratory tract but also to the linings and tissues of the lungs. Contrary to the long-sustained hypothesis that this mutated strain of H1N1 jumped from birds to swine to humans or combined with another human influenza strain, Taubenberger et al. have recently demonstrated that it jumped directly from birds to humans: “it is the most bird-like of all mammalian flu viruses.”22 This biological event was propelled and accompanied by the mass movement of millions of American troops around the country and the globe and their close quarters confinement in barracks and camps for weeks or months – not to mention the millions more European soldiers engaged in the war. As Alfred Crosby writes in America’s Forgotten Pandemic, So at the end of the last summer of World War I some 1.5 million American adults who were most perfectly qualified to cultivate the most dangerously virulent strain of influenza virus in history and its jackal bacteria were living cheek-by-jowl in a small number of military camps all over the nation, and large numbers of them were constantly traveling back and forth between these camps. All that was needed was the proper germ.23 The second and deadliest wave began in the middle of August 1918, erupting simultaneously in Freetown, Sierra Leone, and Brest, France, and reaching Commonwealth Pier in Boston on August 27, when two soldiers reported sick. Within several days, dozens more men 21 Olson DR, Simonsen L, Edelson PJ, Morse SS. Epidemiological evidence of an early wave of the 1918 influenza pandemic in New York City. Proc Natl Acad Sci USA. 2005;102(31):11059-63. 22 Von Bubnoff A. The 1918 flu virus resurrected. Nature 2005;437:794-5; Tumpey TM, Basler CF, Aguilar PV, Zeng H, Solorzano A, Swayne DE, Cox NJ, Katz JM, Taubenberger JK, Palese P, Garcia-Sastre, A. Characterization of the reconstructed 1918 Spanish influenza pandemic virus. Science. 2005;310:77-80; Taubenberger JK, Reid AH, Lourens RM, Wang R, Jin G, Fanning TG. Characterization of the 1918 influenza virus polymerase genes. Nature 2005;437:899-93; Belshe RB. The origins of pandemic influenza – lessons from the 1918 virus. N Engl J Med. 2005;353:2209-11. 23 Crosby. America’s forgotten pandemic, p. 32. UNCLASSIFIED 28 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 were falling sick in and around Boston. Camp Devens, 35 miles northwest of Boston, was one of the primary epicenters of the second wave, and its cases revealed the virulence of the mutated strain. Opened in August with 15,000 men, Camp Devens experienced its initial cases in early September, and by September 22, 19.6% of the camp was sick. These young men soon began to die at striking rates. The second wave hit young healthy Americans in the between the ages of 20 to 39 with particular vengeance, to the extent that the overall U.S. life expectancy rate dropped 12 years for men and women between the 1910 and 1920 censuses. By late September 1918, influenza had spread across the United States, often through military mobilization routes, appearing in Illinois, California, and Texas. Typically, the epidemic began with the town or city newspaper reporting a few cases at the nearest army or naval base; several days or a week later civilian cases began to appear, and the epidemic would begin to spike, peaking two to three weeks later. Traveling in human vectors, its spread tended to follow the transportation arteries of the day – railroads – moving from the northeast to the west and south. Influenza, however, did not spread in a simple linear fashion from east to west but zigzagged across the country in staggered waves that hit communities in a geographically and temporally uneven fashion. For example, influenza struck Camp Dix, New Jersey, on September 18; Camp Funston, Kansas, on September 20; Camp Kearney, California, on September 27; and Camp Dodge, Iowa, on September 29; but it did not arrive at Camp Wheeler in Georgia until October 11.24 (For maps showing the time frame of influenza in the continental United States, see Appendix II: Images and Maps). How a given community responded to the influenza pandemic was determined by many geographical, biological, economic, social, cultural, and medical factors. In 1918 an irregular 24 Byerly. Fever of war. p. 75. UNCLASSIFIED 29 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 and in many locations underdeveloped, public health landscape in the United States was becoming increasingly centralized and nationalized. In some locations, such as New York, both state and city agencies were sophisticated and well-developed; in others, such as New Mexico, a state public health department did not exist and in fact would be established in 1919 to rectify the lack of services and coordination revealed during the pandemic.25 The United States of America is a nation guided by the Constitution, a remarkably prescient document that was nevertheless conceived almost a century before the articulation of the germ theory. Written in an era when contagious diseases were believed to be spread by miasma or local pollution, the founders deemed public health to be a state (or they hoped, local) function and prerogative. In the following decades, the federal government’s forays into the field were often tentative if at all existent. Indeed, the United States Public Health Service (USPHS) was not officially so designated by Congress until 1912. This federal entity was actually an outgrowth of the U.S. Marine Hospital Service, the nation’s oldest federal health agency, founded in 1798 to provide medical care for seamen. During the 20th century, however, along with the Department of Health and Human Services, U.S. Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention, and a host of other federal agencies and departments, federal public health officers have played a heroic role in protecting and monitoring the nation’s health. Although by law these federal agencies do not hold absolute control over the nation’s public health, they have long worked to standardize and connect the country’s varied and far-flung public health infrastructure and personnel.26 25 Luckingham B. Epidemic in the southwest, 1918-1919. El Paso: Texas Western Press; 1984. Southwestern Studies, Monograph No. 72. 26 Marcus AI. Disease prevention in America: from a local to a national outlook, 1880-1910. Bull Hist Med 1979;53(2):184-203. UNCLASSIFIED 30 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 The USPHS issued its first circular about the pandemic on August 16, followed by a request on September 18 that its officers report cases of influenza via telegram. Later that month it issued a circular, “Surgeon General’s Advice to Avoid Influenza.”27 Many city, county, and state health departments incorporated the contents from this circular into the posters, broadsheets, and educational pamphlets they distributed to their communities. Americans in the military followed the orders regarding influenza dictated by the superiors in their particular units, whether in the Army, Navy, Student Army Training Corps, or Student Navy Training Corps. Civilians in the general population were influenced broadly by the federal and military responses to influenza and much more directly by the strategies implemented by city, county, and state health entities. Close examination of responses to the pandemic on the local level demonstrates again and again that tensions over authority and jurisdiction were common during this transitional period in American public health. For example, in California’s capital, Sacramento, a city-mandated face mask ordinance rankled state leaders, including senators who were arrested in the capitol rotunda for appearing in legislative sessions without donning their masks. The second wave took the heaviest toll, peaking in the last week in October, when nearly 21,000 Americans died from influenza or pneumonia in the country’s 45 biggest cities.28 The pandemic subsided in most parts of the country starting in mid-November, and although deaths never again reached the heights of fall 1918, influenza spiked again in many regions in late December and early January. In the week ending January 25, 1919, for example, 4,199 Americans died of influenza in the country’s 45 biggest cities. Even though the stories of horror and death of the second wave have overshadowed our memory of the third wave, this subsequent 27 United States Public Health Service. Annual report of the Surgeon General of the Public Health Service of the United States for July 1, 1918, to June 30, 1919. Washington, D.C.: Government Printing Office; 1919. 28 Great Britain, Ministry of Health. Reports on public health and medical subjects number 4, report on the pandemic of influenza, 1918-19. London: His Majesty’s Stationery Office; 1920. p. 319-320. Crosby calculated the overall figure of 675,000 in America, in Part VI of America’s forgotten pandemic. UNCLASSIFIED 31 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 phase of the 1918-1920 influenza pandemic holds important clues for understanding the challenges faced by health authorities as they sought to sustain and/or re-implement NPI when their communities were suffering from what might be termed pandemic fatigue. For instance, many citizens who willingly cooperated with public health orders in October were much less enthusiastic about repeating the same efforts in January and publicly doubted their efficacy. The third wave spanned early January to April 1919; its unfolding illustrates the multi- phasic nature of the 1918-1920 pandemic. In fact, some communities were hit harder by the third or even the fourth wave, which spanned December 1919 to approximately March 1920. Notably, our study suggests that communities that enacted effective and early protective sequestration may have delayed the entry of the disease for a significant period of time. Moreover, epidemiological data suggest that when influenza did strike Yerba Buena Island, California and Gunnison, Colorado, in a subsequent wave the observed morbidity and mortality rates were lower.29 Although well-trained medical professionals, well-intentioned community leaders, compliant soldiers, and ordinary citizens developed a wide variety of NPI against influenza, they were often both insufficient in their practical enforcement and lacking in scientific understanding of virology and influenza etiology. Ideally, sophisticated global epidemiological surveillance and communication systems, knowledge about the genetic structure of influenza viruses, and the development of antivirals and vaccines will enable us to handle a potential pandemic with much greater foresight and preparedness today. 29 Additional data from Australia’s protective sequestration and quarantine measures suggest a similar experience there. Crosby A. The forgotten pandemic. P. 64, 234; Cumpston JHL. Influenza and maritime quarantine in Australia. Report no. 18. Melbourne: Commonwealth of Australia, Quarantine Service; 1919; McQueen H. “Spanish ‘flu” – 1919: political, medical and social aspects. Med J Aust. 1975;1:565–70; New South Wales Department of Public Health. Report on the influenza epidemic in New South Wales in 1919. Report on the influenza epidemic in New South Wales, for the year 1919, including a report on the influenza epidemic, 1919, Section V. Sydney: William Applegate Gullick; 1920. p. 139–272. UNCLASSIFIED 32 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 B. State of Virology The influenza pandemic occurred during an era in which bacteriology was the dominant scientific framework for identifying and treating diseases. With the discoveries of Louis Pasteur and Robert Koch in the 1870s and 1880s, which demonstrated that the etiologic agents of diseases such as anthrax, tuberculosis, cholera, and typhoid were bacilli, visible under a light microscope, the bacteriological method and mindset became a cornerstone of public health in the United States.30 Nevertheless, scientists had not yet identified viruses or clarified the distinction between viruses and bacteria. Unlike the long list of bacteria identified by scientists around the globe in the early 20th century, viral structure and analysis would have to await electron microscopes to be visible to the human eye. In addition, as Walter Reed demonstrated with yellow fever in 1900 and Thomas Rivers of New York’s Rockefeller Hospital with influenza and polio viruses in the 1920s, viruses were so small that they could not be retained by the filters of the day.31 Viruses are difficult to culture, especially when compared to many of the pathogenic bacteria that were being studied during the period; it was not until 1949 that John Enders, Thomas Weller, and Frederick Robbins, working on poliomyelitis, developed the pioneering technique of culturing cells on glass surfaces, which then allowed for greater understanding of 30 Markel H. When germs travel. 31 Benison S. Tom Rivers: reflections on a life in medicine and science; an oral history memoir. Cambridge, Mass.: MIT Press; 1967; Rivers TM, Stanley WM, Sawyer WA. Problems and trends in virus research. Philadelphia: University of Pennsylvania Press; 1941; Opie EL, Blake FG, Small JC, Rivers TM. Epidemic respiratory disease: the pneumonias and other infections of the respiratory tract accompanying influenza and measles. St. Louis: C.V. Mosby Company; 1921; Rivers TM, editor. Filterable viruses. London: Baillere, Tindall & Cox; 1928; Reed W, Carroll J, Agramonte A, Lazear J. The etiology of yellow fever – A preliminary note. Proceedings of the twenty- eighth annual meeting of the American public health association in Indianapolis; 1900 Oct 22-26; Reed W, Carroll J, Agramonte A. The etiology of yellow fever: an additional note. Proceedings of the Pan-American Medical Congress in Havana, February 4-7, 1901; Reed W, Carroll J, Agramonte A. Experimental yellow fever. American Medicine. 1901 Jul 6:15-23; Reed W, Carroll J. The etiology of yellow fever: A supplemental note. American Medicine. 1902 Feb 22:301-5. UNCLASSIFIED 33 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 the cytopathogenic effects of viruses, the identification of antibodies in the blood, and the development of effective polio vaccines.32 Today, we recognize hundreds of strains of both DNA and RNA viruses that affect plants, bacteria, and humans. The influenza virus (types A, B, C) is a RNA virus of the family Orthomyxoviridae arranged in a helical nucleocapsid that includes 8 segments and whose lipoprotein envelope contains 2 glycoproteins, hemagglutinin (H) and neuraminidase (N). Only subtype A is thought capable of causing pandemics. The arrangement and structure of H and N determine the molecular and cytopathogenic features of the influenza virus and can indicate its actual or potential level of virulence in animals. Experts now believe that the 1918 pandemic was caused by a Type A influenza virus, H1N1 denoting its molecular structure. 32 Enders JF, Weller TH, Robbins FC. Cultivation of the Lansing strain of poliomyelitis virus in cultures of various human embryonic tissue. Science 1949;109:85. UNCLASSIFIED 34 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 C. Influenza Mythologies The 1918 influenza pandemic may well be the best studied pandemic in history. Scientists and medical historians can benefit greatly from the many books and articles that focus on it. These publications, however, have also helped to promote several “influenza mythologies” that can obfuscate our overall understanding of the pandemic and, more important for this study, the particular character of provisional influenza escape communities. One of the most valuable historical sources is Edwin O. Jordan’s Epidemic Influenza, published in 1927.33 This book is essentially an epidemiological survey and literature review replete with quantitative and qualitative data. Written almost one decade after the pandemic, this text possesses an immediacy of perspective that lends it a great deal of historical relevance. Yet Jordan made his conclusions about the efficacy of NPI unaware that a specific virus is the causative agent of influenza. Despite its limitations, Epidemic Influenza holds up under scrutiny. In fact, Jordan’s list and discussion of NPI provided a useful foundation for this study. In Jordan’s order of importance and using his terminology, these NPI were: 1. Isolation and Quarantine 2. Closures of Schools and Prohibition of Public Gatherings 3. Face Masks 4. Preventive influence of certain gases (germicidal chemicals) 5. Prophylactic inoculation or vaccination 6. General measures of Hygiene and Sanitation (including crowd control, ventilation, hand-washing, sterile drinking receptacles, and good nutrition). 33 Jordan EO. Epidemic influenza: a survey. Chicago: American Medical Association; 1927. UNCLASSIFIED 35 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 All of these NPI, except Item #4, are addressed in this report, although they have been regrouped and redefined in accordance with the development of current public health interventions, priorities, and terminology. Since 1918, methods involving the application of germicidal chemicals, such as fumigation with sulfur or other chemical agents or gases, have largely been abandoned in the United States because of their inefficacy and/or their toxicity to organisms and the environment. Jordan’s treatise was also instrumental in helping to determine our list of provisional influenza escape communities, notably Yerba Buena Island, California; Gunnison, Colorado; the Western Pennsylvania Institution for the Blind; and the Trudeau Tuberculosis Sanatorium. Yet we discovered through our research that several of the communities that Jordan defined as provisional influenza escape communities, upon further investigation do not qualify, either because more than 1 death occurred while NPI were enforced during the second wave of the pandemic or insufficient data exist to incontrovertibly prove their status. The most significant of these are Lake City and Hindsdale County, Colorado (for which practically no information could be found), and Camp Custer, Michigan (which reported, from September 16 to November 15, 1918, alone, 7,686 total cases of influenza, 2,365 of pneumonia, and 672 deaths from pneumonia).34 Furthermore, our fine-grained historical research revealed three additional provisional influenza escape communities: Princeton University, Bryn Mawr College, and Fletcher, Vermont, which Jordan does not discuss in any depth. After Jordan’s survey, three decades elapsed before the publication of a historical study of the 1918 pandemic, A. A. Hoehling’s The Great Epidemic: When the Spanish Influenza 34 Base Hospital, Camp Custer, Michigan. Admissions at Camp for influenza and pneumonia, Sept. 16th to Nov. 15, 1918. [undated; no cover letter]; Folder 710 “Influenza, Camp Custer, Mich.”; Entry 31-C; D (Cantonments); Surgeon General’s Office, 1917-1927 (SGO 1917-1927); Records of the Office of the Army Surgeon General Record Group 112 (RG 112); National Archives College Park, Maryland (NACP). UNCLASSIFIED 36 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 Struck.35 With this book, the influenza pandemic in the United States acquired a book-length historical narrative, told with the melodramatic journalistic flair that continues to underpin (and potentially undermine) the catastrophic story of this disease to the present. Yet as the pandemic became an epic, influenza mythologies began to emerge, like a game of Telephone, where pieces of information become distorted as they move along the lines of communication from source to source. As just one of many examples, Hoehling claimed that on Yerba Buena Island, a total quarantine was imposed and “guards were placed at the docks with orders to shoot to kill anyone embarking or disembarking without authorization,” and that all ferries, tugs, and supplies were kept at bay at gunpoint. After careful analysis of the historical record, it is impossible to confirm Hoehling’s claims of armed sentries; indeed, we have concluded that this was an animated exaggeration of the facts.36 In the retelling of the pandemic, influenza mythologies mutated or re-assorted slightly, usually from one book to next, so that in the next major work on the topic, America’s Forgotten Pandemic (which most historians of medicine and public health still consider the best book on the topic), Crosby echoes misconceptions about Yerba Buena Island. He reports that San Francisco’s health officer, Dr. William Hassler, persuaded the island’s naval commander to enact a quarantine, despite the fact there is no direct or circumstantial evidence to support this specific claim. In addition, Crosby manufactures a mythology of his own, namely that the towns of Darien and Milford, Connecticut, escaped the influenza pandemic with no deaths, an assertion we easily refuted by reviewing that state’s annual board of health reports for 1918 and 1919 as well as the local newspapers.37 35 Hoehling AA. The great epidemic: when the Spanish influenza struck. Boston: Little, Brown; 1961. 36 Hoehling. The great epidemic. p. 35 and 186. 37 Black JT. State of Connecticut thirty-sixth report (42d and 43d years) of the state department of health for two years ending January 30, 1920. 1920. p. 272-311. UNCLASSIFIED 37 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 The myth that Yerba Buena Island’s quarantine was ordered by Dr. Hassler is repeated in John Barry’s recent popular history, The Great Influenza.38 Given his interest in telling a gripping story of disease, death, and its consequences in America, Barry provides very little information about provisional influenza escape communities that experienced the pandemic with no deaths and markedly less fanfare. Furthermore, two recent studies challenge a pair of long- standing assumptions, repeated by Barry and reiterated more generally in the scholarship on the 1918-1920 influenza pandemic, that strong circumstantial evidence exists to support the theory that the first wave of H1N1 emerged in or near Camp Funston, Kansas, and that pigs served as the intermediary “mixing bowl” for H1N1 to skip from birds to humans and attain extreme virulence.39 First, an analysis of epidemiological data from New York City in 1918 by Olson et al. shows that morbidity and mortality rates for pneumonia and related respiratory conditions are statistically significant enough to suggest that the first wave struck that city as early as February 1918, before the much-noted and historically heralded Kansas outbreak.40 Second, over the past decade, the attempts to tell the biological story of influenza through gene sequencing have resulted in a recent demonstration by Taubenberger et al. (mentioned above) that H1N1, unlike the influenza viruses that caused epidemics in 1957 and 1968, did not rely on pigs as an intermediary. This is a powerful revelation that represents the culmination of a quest undertaken by a handful of dedicated scientists hoping to reconstruct the biological and molecular history of the 1918 influenza pandemic, a journey documented by the journalist Gina Kolata.41 38 Barry, JM. The great influenza: the epic story of the deadliest plague in history. New York: Viking; 2004. 39 Barry. The great influenza. p. 107-15, 162-66, 176-84. 40 Olson DR, Simonsen L, Edelson PJ, Morse SS. Epidemiological evidence of an early wave of the 1918 influenza pandemic in New York City. Proc Natl Acad Sci USA. 2005;102(31):11059-63. 41 Kolata G. Flu: the story of the great influenza pandemic of 1918 and the search for the virus that caused it. New York: Farrar, Straus and Giroux; 1999; Taubenberger JK, Reid AH, Janczewski TA, Fanning TG. Integrating historical, clinical and molecular genetic data in order to explain the origin and virulence of the 1918 Spanish influenza virus. Philosophical Transactions of the Royal Society of London. 2001; 356: 1829-1839. UNCLASSIFIED 38 UNCLASSIFIED SECTION IV – Influenza in the U.S. 1918-19 All of these widely circulated influenza mythologies point to the importance of seeking out and identifying as many primary source documents (as opposed to secondary source accounts) as possible when attempting to historicize the NPI implemented during the 1918-1920 influenza pandemic. Influenza mythologies are easily repeated when researchers rely heavily on secondary source articles or books and fail to consult primary sources of the era, such as archival materials, public health reports, or newspapers, or simply by over or under interpreting the extant historical record. Our study is the first to systematically examine provisional influenza escape communities in the continental United States preponderantly based on primary source materials. UNCLASSIFIED 39 UNCLASSIFIED SECTION V – Provisional Influenza Escape Community Case Studies A. Introduction: During the course of our historical research and review of the primary and secondary medical, public health, and popular literature on the 1918-20 influenza pandemic, we identified 7 provisional influenza escape communities, which we define as: a community or institution where there were relatively few reported cases of influenza (compared to surrounding areas or analogous communities, towns, cities) and zero to one deaths resulting from influenza or pneumonia-related illnesses while NPI were enacted during the second wave of the 1918-1920 influenza pandemic, September-December 1918. We use the word provisional decidedly, because on the basis of the historical evidence available to us we cannot definitively determine if these communities sustained their low morbidity and mortality rates because of policy decisions made and NPI enacted by their community leaders and public health officials, because the virus skipped some communities altogether and varied in its behavior in other communities (viral normalization patterns), or because of other factors such as population density, geography, and good fortune. Given the extant historical data, which in many cases are rather sparse, we are unable to rank the importance of these factors in each of the communities we examined. The diagnosis of influenza at this time was largely empirical, without definite culture methodologies or supportive laboratory findings. Mortality statistics of this era were typically derived from reported data of those who died during this pandemic period from respiratory symptoms associated with influenza or pneumonia. This suggests that under or over reporting of influenza cases was likely during the 1918 pandemic. Although greater diagnostic precision in 1918 would have enhanced the use of this historical information in our current pandemic planning, diagnoses made then were based neither on laboratory evidence nor on a standard case reporting definition. The 7 communities are: 1. San Francisco Naval Training Station, Yerba Buena Island, San Francisco Bay, California 2. Gunnison, Colorado 3. Princeton University, Princeton, New Jersey 4. Western Pennsylvania Institution for the Blind, Pittsburgh, Pennsylvania 5. Trudeau Tuberculosis Sanatorium, Saranac Lake, New York 6. Bryn Mawr College, Bryn Mawr, Pennsylvania 7. Fletcher, Vermont UNCLASSIFIED 40 UNCLASSIFIED SECTION V – Case Studies Each case study is prefaced by a data summary sheet that presents this information in a concise and standardized format. Each summary sheet is then followed by a narrative account of the proceedings of each location during the pandemic, with particular emphasis on the second wave, September to December 1918. Images of each location are included in Appendix II: Images and Maps. Although we believe that important lessons about NPI can be abstracted from these case studies, it is important to stress that the implementation and execution of protective sequestration was the exception rather than the rule. In each of the cases we studied, the outcome was typically the result of multiple factors, not the least of which included good fortune and geographical separation. We should not be seduced into thinking that we can easily translate these examples into contemporary public health policymaking. Sadly, our conclusions – and for that matter, any historical analysis of the 1918 pandemic – cannot be used as a precise blueprint for future pandemic preparedness planning. That said, we argue that numerous salient lessons can and should inform the present. These lessons, grouped into four categories - Epidemic Preparedness, Benefits and Liabilities of Protective Sequestration, Nonpharmaceutical Interventions During a Pandemic, and Power and Limits of Historical Research - are enumerated in our Section VII: General Conclusions from the Historical Record with Policy Recommendations. UNCLASSIFIED 41 UNCLASSIFIED YERBA BUENA ISLAND, CALIFORNIA Location San Francisco Bay Type of Site Naval Base Population Approximately 6,000 (including approximately 1,000 family members) Population Density 33,103 persons/sq. mi Geographical Considerations Yerba Buena is an island in San Francisco Bay. In 1918 no bridges connected it to land; boat travel was the only means of ingress/egress. Influenza Cases 0 cases during period of protective sequestration; 25 cases after these NPI were lifted on Nov. 21, 1918 to Dec. 31, 1918. Influenza Deaths 0 during protective sequestration; 3 deaths from influenza and 2 deaths from pneumonia after lifting the NPI (Nov. 21, 1918- Dec. 31, 1918). First Reported Case Dec. 6, 1918 Protective Sequestration Sep. 23, 1918 – Nov. 21, 1918 Stringent travel restrictions between island and mainland. Quarantine Rigid inspection of all members of the community and immediate removal of those suspected of being sick into an isolation facility with stringent sterilization measures in place. Isolation Early transfer of the sick to base hospital, where they were isolated in small groups. Medical personnel wore face masks and used aseptic techniques. Cordon Sanitaire Not applicable to Yerba Buena Island Social Distancing N/A Face Mask Use Face masks were used by medical personnel Vaccines Prophylactic (Pfeiffer’s Bacillus) vaccine Complementary NPI Daily inspection of personnel. Taking of temperatures. No overcrowding, good ventilation, and muslin screens in wards. Application of nose and throat sprays (containing argyrol). Educational measures. Strict enforcement of all existing sanitary rules and regulations. Acquisition of Supplies Tugboats brought supplies from the mainland – strict restrictions on interaction between crew members and YBI sailors. They could not come closer than 20 ft. to one another. Family members Several hundred family members of officers lived on the island. Public Coping with NPI All indications point to the YBI population coping very well with their protective sequestration. Disease Reporting Influenza was reportable in the Navy effective Sep. 20, 1918. Inter-authority relationships, cooperation The single authority on the island, the United States Navy, did not show external signs of dissent or contradictory orders. Public Health Education and Risk Communications Naval commanders frequently enacted orders regarding face masks, ventilation, floor space, and other issues that directly concerned the health of sailors facing influenza. In addition, circulars were distributed among the sailors. Economic Impact Little to none Undocumented Factors The availability of mail or telecommunications to those on Yerba Buena Island. Impact of Subsequent Waves YBI recorded 3 cases of influenza and 4 of pneumonia in Jan. 1919. No data for Feb.-Apr. 1919 is available. UNCLASSIFIED 42 UNCLASSIFIED SECTION V – Case Studies Yerba Buena Case Study Yerba Buena Island Naval Training Station, San Francisco, CA [with comparisons to Mare Island Naval Yard, Vallejo, CA ] Historical Background Yerba Buena, a small island (116 acres) located approximately one mile on either side from the closest points in present-day San Francisco and Oakland, was discovered in 1775 by Spanish explorers entering San Francisco Bay. Finding an abundance of wild mint growing on the island, they named the land Yerba Buena, or “Good Herb.” The island has at various times also been called Wood Island, Bird Island, and Goat Island (its official name from 1895 to 1931). Use of the island by the U.S. military dates back to 1852, when the government proposed building a line of fortifications in San Francisco Bay to protect northern California and the valuable gold recently discovered there. In 1866, in a preemptory move to prevent the Central Pacific Railroad from gaining possession of the island to use as a terminus, the government ordered the occupation of Yerba Buena Island. From 1871 to 1892, Yerba Buena Island was used as a quartermaster depot for the Army before it was transferred to the U.S. Engineer Department. In 1898, a naval training station was erected on the island. During World War I, Admiral Dewey’s old flagship, the USS Boston (which had aided in the American overthrow of the Hawaiian monarchy in 1893 and later served in the Spanish-American War), was moored at Yerba Buena Island as the receiving ship for the facility. When the Bay Bridge was constructed in 1936, engineers designed it as two bridges, with a tunnel through Yerba Buena Island connecting the sections. Shortly after, an artificial island, Treasure Island, was constructed adjacent to Yerba Buena Island and connected by a small isthmus; this artificial island was the UNCLASSIFIED 43