What Happened When Americans Had to Wear Masks During the 1918 Flu Pandemic

Med­ical pro­fes­sion­als have had a par­tic­u­lar­ly dif­fi­cult time get­ting peo­ple in the Unit­ed States to act in uni­son for the pub­lic good dur­ing the pan­dem­ic. This has been the case with every step that experts urge to curb the spread of COVID-19, from clos­ing schools, church­es, and oth­er meet­ing places, to enforc­ing social dis­tanc­ing and wear­ing masks over the nose and mouth in pub­lic spaces.

The resis­tance may seem symp­to­matic of the con­tem­po­rary polit­i­cal cli­mate, but there is ample prece­dent for it dur­ing the spread of so-called Span­ish Flu, which took the lives of 675,000 Amer­i­cans a lit­tle over a hun­dred years ago. Even when forced to wear masks by law or face jail time, many Amer­i­cans absolute­ly refused to do so.

“In 1918,” writes E. Thomas Ewing at Health Affairs, “US pub­lic health author­i­ties rec­om­mend­ed masks for doc­tors, nurs­es, and any­one tak­ing care of influen­za patients.” The advi­so­ry “grad­u­al­ly and incon­sis­tent­ly” spread to the gen­er­al pub­lic, in a dif­fer­ent cul­tur­al cli­mate, in some impor­tant respects, than our own, as Uni­ver­si­ty of Michi­gan med­ical his­to­ri­an J. Alexan­der Navar­ro explains.

Nation­wide, posters pre­sent­ed mask-wear­ing as a civic duty – social respon­si­bil­i­ty had been embed­ded into the social fab­ric by a mas­sive wartime fed­er­al pro­pa­gan­da cam­paign launched in ear­ly 1917 when the U.S. entered the Great War. San Fran­cis­co May­or James Rolph announced that “con­science, patri­o­tism and self-pro­tec­tion demand imme­di­ate and rigid com­pli­ance” with mask wear­ing. In near­by Oak­land, May­or John Davie stat­ed that “it is sen­si­ble and patri­ot­ic, no mat­ter what our per­son­al beliefs may be, to safe­guard our fel­low cit­i­zens by join­ing in this prac­tice” of wear­ing a mask.

Despite the civic spir­it and gen­er­al­ized pub­lic sup­port for mask wear­ing, pass­ing local mask ordi­nances was “fre­quent­ly a con­tentious affair.” Debates that sound famil­iar raged in city coun­cils in Los Ange­les and Port­land, both of which reject­ed mask orders. (One offi­cial declar­ing them “auto­crat­ic and uncon­sti­tu­tion­al.”) San Fran­cis­co, on the oth­er hand, brought the police down on any­one who refused to wear a mask, impos­ing fines and jail time.

These mea­sures were adopt­ed by oth­er cities, as well as abroad in Paris and Man­ches­ter. “Fines ranged,” Navar­ro writes, “from US$5 to $200,” a huge amount of mon­ey in 1918, and a good amount for many peo­ple out of work today. Even in cities that did not impose harsh penal­ties, “non­com­pli­ance and out­right defi­ance quick­ly became a prob­lem.” Much of the resis­tance to wear­ing masks, how­ev­er, came lat­er, after a first wave of flu infec­tions sub­sided. When pre­cau­tions were relaxed, cas­es rose once again, and new mask man­dates went into effect in 1919.

San Francisco’s Anti-Mask League formed in protest, attract­ing some­where between 4,000 and 5,000 unmasked atten­dees to a Jan­u­ary meet­ing. Some of their objec­tions rest­ed on an ear­ly study that found scant evi­dence for the effi­ca­cy of com­pul­so­ry mask-wear­ing. How­ev­er, a lat­er com­pre­hen­sive 1921 study by War­ren T. Vaughn, notes Ewing, found that the data was too sketchy to draw con­clu­sions: “The prob­lem was human behav­ior: Masks were used until they were filthy, worn in ways that offered lit­tle or no pro­tec­tion, and com­pul­so­ry laws did not over­come the ‘fail­ure of coop­er­a­tion on the part of the pub­lic.’”

Vaughn con­clud­ed, “It is safe to say that the face mask as used was a fail­ure.” Many behav­iors con­tributed to this out­come. As we see in the pho­to­graph at the top of anony­mous Cal­i­for­ni­ans wear­ing masks and hold­ing a sign that reads, “Wear a mask or go to jail,” many did not wear masks prop­er­ly, leav­ing their nose exposed, for exam­ple, like the woman in the cen­ter of the group. Notably, instead of social dis­tanc­ing, the group stands shoul­der to shoul­der, ren­der­ing their masks most­ly inef­fec­tive.

The kind of masks most peo­ple wore were made of thin gauze. (“Obey the laws and wear the gauze. Pro­tect your jaws from sep­tic paws,” went a jin­gle at the time.) The mate­r­i­al was­n’t at all effec­tive at clos­er dis­tances, where today’s quilt­ed cot­ton masks, on the oth­er hand, have been shown to stop the virus a few inch­es from the wearer’s face. Still, masks, when com­bined with oth­er mea­sures, were shown to be effec­tive when com­pli­ance was high, though much of the evi­dence is anec­do­tal.

What can we learn from this his­to­ry? Does it under­mine the case for masks today? “We need to learn the right lessons from the fail­ure of flu masks in 1918,” Ewing argues. The over­whelm­ing sci­en­tif­ic con­sen­sus is that masks are some of the most effec­tive tools for slow­ing the spread of the coro­n­avirus, and that, unlike in 1918, “Masks can work if we wear them cor­rect­ly, mod­i­fy behav­ior appro­pri­ate­ly, and apply all avail­able tools to con­trol the spread of infec­tious dis­ease.”

Relat­ed Con­tent: 

Japan­ese Health Man­u­al Cre­at­ed Dur­ing the 1918 Span­ish Flu Pan­dem­ic Offers Time­less Wis­dom: Stay Away from Oth­ers, Cov­er Your Mouth & Nose, and More

What Hap­pened to U.S. Cities That Practiced–and Didn’t Practice–Social Dis­tanc­ing Dur­ing 1918’s “Span­ish Flu”

The His­to­ry of the 1918 Flu Pan­dem­ic, “The Dead­liest Epi­dem­ic of All Time”: Three Free Lec­tures from The Great Cours­es

Josh Jones is a writer and musi­cian based in Durham, NC. Fol­low him at @jdmagness