On January 1, 1919, the six-member Washington State Board of Health delivers to Governor Ernest Lister (1870-1919) its Twelfth Biennial Report, three months later than normal. The delay is due to the flu pandemic, which is killing people in unprecedented numbers around the world and has become epidemic throughout Washington. The disease, commonly if inaccurately referred to as "Spanish influenza" or "Spanish flu," first appeared in the state in late September and early October of 1918, spread rapidly, was exceptionally lethal, and seemed unstoppable. Baffled by a medical catastrophe like no other, the board has little good news for the governor or the public. The Spanish flu in Washington has taken 4,879 lives in the last three months of 1918, of whom more than half were adults between the ages of 20 and 39. Even so, Washington's death rate is substantially lower than in most other states. Worldwide the pandemic is believed to have killed at least 50 million people before tapering off and disappearing entirely in late 1919 or early 1920.
The Washington State Board of Health
The Washington State Board of Health was established in 1891 to provide "general supervision of the interests of the health and life of the citizens of the state" and to establish and supervise a system for the registration of births and deaths (1891 Wash. Laws, Ch. 98, Sec. 1). It was required to meet twice annually, in January and June, but routinely held interim sessions to discuss matters within its purview. In 1901 the legislature gave the board more specific responsibilities, including "promulgating orders or regulations for the prevention of the spread of contagious or infectious diseases" and "supreme authority in matters of quarantine" (1901 Wash. Laws, Ch. 116, Sec. 1). Every two years a report to the governor would summarize its activities.
In 1916 the board reported that "During the two years under consideration we have had no serious outbreaks of communicable diseases, but we have had more or less of those diseases present all the time, and it is against this endemic form of disease that our fight must be concentrated ... " (Eleventh Biennial Report, 12). Seven "principal diseases" were identified: "typhoid fever, scarlet fever, measles, whooping cough, diphtheria, and diarrhea and enteritis in children under 2 years of age" (Eleventh Biennial Report, 13). No mention was made in the report of influenza, which was considered an annual wintertime nuisance rather than an epidemic or endemic disease. This view would have to be revised two years later when the pandemic labeled Spanish influenza scoured the earth, killing more people in less time than any other disease in recorded history.
Bad News and Worse News
In 1918 the board of health had six members, of whom four were doctors. Dr. J. R. Brown of Tacoma served as president and was joined by Dr. Fred H. Hedges of Everett; Dr. H. H. McCarthy of Spokane; Mrs. R. C. McCredie of Sunnyside; E. F. Benson, the state's commissioner of agriculture; and Dr. Thomas D. Tuttle, the state's health commissioner, who as board secretary kept the minutes of meetings and was primary author of the group's 1918 biennial report to the governor. In normal times these reports were delivered in October. However, in 1918 the board held a special meeting on September 28 in Spokane to address, among other things, the flu pandemic that had already afflicted much of the country but as yet seemed absent in the civilian population of the state. It was decided to delay the issuance of the report until a more detailed investigation of the flu's impact was possible.
The board's Twelfth Biennial Report was released on January 1, 1919, and summarized its concerns and activities since October 1916. Among the more-or-less routine matters addressed was the need to hire a new state bacteriologist -- the previous one, a native-born Austrian, was fired in 1917 when America joined the war against Germany and her allies, including Austria. There also was an extended account of efforts to control venereal diseases, including the full text of a recent King County Superior Court opinion upholding the coercive quarantine of infected persons.
It was not until page 22 of the report that Dr. Tuttle turned his attention to the Spanish flu, noting "While this report nominally covers the biennial period ending September 30, 1918, the fact that the influenza epidemic has delayed its preparation justifies a brief statement relative to the influenza epidemic" (Twelfth Biennial Report, 22). He opened with an account of an opportunity missed:
"This epidemic was very prevalent in the Eastern states during the month of September, and, realizing that in all human probability it would rapidly spread over the entire country, your commissioner of health took up with the United States Public Health Service the question of the advisability of quarantining individual cases. Accordingly, the following telegram was sent and answer received:
Seattle, Wash. Sept. 25th, 1918
Blue: [Rupert Blue, U.S. Surgeon General]
Intrastate quarantine Spanish influenza under consideration. What period of quarantine if any do you recommend?
Washington, D.C. Sept. 25th, 1918
Tuttle, Seattle, Wash.:
Service does not recommend quarantine against influenza.
BLUE" (Twelfth Biennial Report, 22-23).
When Tuttle telegraphed Surgeon General Blue on September 25, three days before the Spokane meeting, there were no confirmed civilian cases of Spanish influenza in Washington, although the virus was lurking in one or more military cantonments in the state's western half. Two days later the Seattle Post-Intelligencer reported that the board of health had decided to not impose mandatory quarantines, asking only that those infected quarantine themselves. It is interesting to note that the only organized society on earth that completely blocked the Spanish flu virus was American Samoa, where the governor imposed an early, rigorous, and lengthy quarantine. Western Samoa, only 50 miles distant, did not follow suit, and lost fully 20 percent of its population to the disease. Washington is not an island, however, and even mandatory quarantines could not have totally blocked the virus from the state. However, strictly enforced quarantines may have hindered its rapid dispersal through nearly every community across Washington, and even into remote lumber and mining camps deep in the hills.
By the time Tuttle wrote his report in late December 1918 things had changed dramatically. By then state health authorities had been battling the outbreak for nearly three months, and weren't done yet. Tuttle reported the board's belief that the disease had gained its first foothold in and around Seattle, but he gave the city some absolution, noting that it "was evident that the disease was brought into many localities from other sources" and "not directly traceable to the infection at or near Seattle" (Twelfth Biennial Report, 23).
However, Seattle may well have had somewhat greater responsibility for a resurgence of the epidemic after it seemed to have run its course by early November. Tuttle reported that strict limitations on public gatherings had apparently slowed the flu's progress and that "after about six weeks it appeared that the disease was so on the decline that these stringent measures were relinquished" (Twelfth Biennial Report, 23). What he had the good grace not to point out was that this relinquishment started when Seattle was unable to control crowds taking to the streets to celebrate the end of World War I on November 11, 1918. Even Mayor Ole Hansen (1874-1940) was swept away with enthusiasm, quoted in The Seattle Times as proclaiming, "The lid is off: Everybody get out today and celebrate in the open air! Give me my coat! I'm going to get in it myself!" ("Seattle in Ecstasy of Joy ... ").
The next day, November 12, the city lifted nearly all its restrictions on public assemblies, although not the largely useless requirement that face masks be worn at such gatherings. Wisely, Seattle schools refused to reopen, but many other towns around the state followed the city's lead and, as Tuttle reported, "In from two to three weeks the disease again made rapid progress" (Twelfth Biennial Report, 23).
Given the speedy spread of the disease and its unprecedented lethality, particularly to young adults, a fitting emotion for those battling the pandemic was despair. After attending a December gathering in Chicago of about 950 state and federal health authorities, Tuttle's own despair was apparent:
"The outstanding feature of the discussion of the subject at this conference was the evidence that whatever efforts were made the spread of the disease was only retarded and not prevented. As one health officer very aptly expressed the situation: 'One can avoid contracting the disease if he will go into a hole and stay there, but the question is how long he would he have to stay there? The indications are that it would be at least for a year or longer'" (Twelfth Biennial Report, 23).
A variety of responses were discussed at the Chicago meeting, but for every city that believed it had achieved some success with one method or another, there were several other cities in which identical measures had been entirely futile. Tuttle had to concede:
"The character of this disease is such that we are in the dark, to a large extent, as to a means to prevent its spread ... . We know of no way at present whereby we can detect a 'carrier' of influenza germs. In fact, we are in extreme doubt as to what germ is responsible for this disease" (Twelfth Biennial Report, 23-24).
One reason even the best medical minds in the country were in the dark was the universal but mistaken belief that influenza was caused by bacteria. One particular "germ," called Bacillus influenzae (or Pfeiffer's bacillus), was frequently found in flu sufferers, believed by many to be the causative agent, and named accordingly. It was not until the 1930s that scientists figured out that influenza was a viral disease, and that measures that might provide some protection against bacteria, such as gauze masks, were entirely useless against the much smaller viruses of the world.
Trying to Save Lives
The influenza caused death in two primary ways, either through acute respiratory distress (a direct effect of the flu virus) or from opportunistic bacterial pneumonias. Given the belief that flu was a bacterial disease, it was thought by some that vaccines against specific bacterial strains could be useful. In fact they were, but for the wrong reasons.
In late September and early October of 1918, a total of 4,212 U.S. Navy personnel dispersed among six camps in Seattle and Bremerton received a vaccine developed by navy doctors and a U.S. Public Health Service doctor, made from killed cultures of the streptococcus bacteria. It did nothing to prevent influenza infections (considerably more of those vaccinated came down with the flu than those who were not), but not a single person from the vaccinated group died, while 96 of the unvaccinated did. This was no doubt due to the vaccine preventing (or at least weakening) secondary bacterial infections, but in a report published in the Journal of the American Medical Association on January 4, 1919, the doctors made broader claims: "We believe that the disease called influenza at the Puget Sound Navy Yard was due to the [streptococcus] organism described above" and that "the use of killed cultures as described prevented the development of the disease in many of our personnel and modified its course favorably in others" ("Influenza As Seen ... ," p. 28). They were at best half right.
The state's board of health supervised a similar effort with some beneficial results, but in his report Dr. Tuttle adopted a much more cautious tone:
"[T]here was prepared and distributed, so far as our funds would permit, a vaccine that we felt would have certain preventive influence, especially with regard to the pneumonia that proved so fatal in this disease. Reports received by us indicate that this vaccine did have a very marked influence in preventing pneumonia among those to whom it was administered. Whether due to early action or whether due to the influence of the vaccine used in this State, I am not prepared to state, but evidence indicates that in proportion to the population the death rate in the State of Washington from influenza and pneumonia incident to influenza, is as low as any State in the United States, if not lower than any other State. In fact, up to date I have not received figures that indicate that any State will show a lower or as low a death rate per 1000 population from influenza as will the State of Washington" (Twelfth Biennial Report, 24).
How Much Worse Could It Have Been?
It could have been much, much worse, and Tuttle's tiny glimmer of optimism proved to be almost justified. Among the 30 states that the U.S. Census Bureau canvassed for its Mortality Statistics 1918, only Oregon reported fewer influenza deaths per 1,000 people than its neighbor to the north. This was no small achievement given the heavy military presence in Washington and the strong connection that had been noted between the military and the disease's spread. Even so, the statistics are sobering enough. In 1918 alone, there were 4,879 deaths attributed to Spanish influenza in the state, of which 2,461, or slightly more than half, were men and women between the ages of 20 and 49, a demographic slice that normally was among the healthiest. In Seattle 708 of 1,441 flu deaths recorded between October 12, 1918, and March 15, 1919, fell into that age range, while in Spokane the count was 252 of the 428 flu deaths. Why this disease killed young adults so disproportionately has never been fully resolved, but the leading theory is that the 1918 virus triggered catastrophic reactions in those with the most robust immune systems.
Although the numbers were not available to Dr. Tuttle, later statistics illustrate just how fortunate Washington was, at least comparatively. Based on population counts from the 1920 census (the count closest in time to the pandemic) and the government's 1918 mortality statistics, it is clear just how bad things might have been. Connecticut, which in 1920 had a population of approximately 1.38 million compared to Washington's 1.36 million, recorded nearly 10,200 deaths from Spanish influenza in 1918, considerably more than twice the Washington count of 4,879. Similarly, Maryland, with a population of 1.45 million, lost 10,163 souls to the disease. Even Colorado, with a population of only 940,000, endured the loss of 6,938 lives, 30 percent more than had died in Washington, with a population more than one-third greater. In most cases, though, the more populous the state, the greater the loss of life. In New York, with a population exceeding 10 million, nearly 60,000 were killed in the pandemic. In the U.S. overall the Spanish flu is estimated to have killed more than 650,000, and while estimates for the worldwide toll vary widely, most authorities believe it to have been well in excess of 50 million.
Washington's epidemiologist, J. E. Henry, wrote a separate section of the board's Twelfth Biennial Report in which he gave some concise context for the threat posed to the state by the pandemic:
"In the history of the State Board of Health no such calamity has afflicted the State nor has so serious an emergency ever arisen. In the five years 1913-1917 inclusive, from the five most common contagious diseases, viz.: typhoid fever, scarlet fever, diphtheria, measles and whooping cough, there have been 1768 deaths. From influenza alone we have had to date well over 2000 deaths and the end is not yet. The toll will probably be double or treble 1768" (Twelfth Biennial Report, 34).
Henry was not being alarmist; by the time the epidemic finally petered out, his most pessimistic estimate proved less than 10 percent too high.