As reports of a new influenza epidemic sweeping the nation alarmed residents, Dallas’ chief doctor offered reassurances.
“The general health situation in Dallas is good,” he told a reporter for The Dallas Morning News. The disease wasn’t much worse than the common flu, he claimed.
It was 1918, and the new disease was the Spanish flu. Within two weeks, Dallas’ hospitals were overflowing with patients and the city was in lockdown. By the time the pandemic had run its course, millions of people were dead worldwide and, according to some estimates, around 500 in Dallas.
The outbreak of the novel coronavirus — a highly infectious disease similar to SARS that emerged in Wuhan, Hubei Province, China, last year and has now been declared a pandemic by the World Health Organization — has drawn comparisons to the Spanish flu.
“I spend a lot of time thinking about whether I’m being too alarmist or whether I’m being not alarmist enough,” said Donald McNeil Jr., a health and science reporter for The New York Times, in an interview aired late last month. “And this is alarmist, but I think right now, it’s justified. This one reminds me of what I have read about the 1918 Spanish influenza.”
By Wednesday, there were more than 1,000 confirmed cases of coronavirus in the United States and 37 deaths, with thousands of more deaths worldwide. Still, experts caution, it’s far too early to say whether the coronavirus will prove as devastating as the Spanish flu.
“Compare it to Spanish flu, SARS, MERS and our current H1N1 influenza — all of those are models. This one could go toward any one of them,” said Dr. Robert Haley, director of epidemiology at UT Southwestern in an interview last Friday. He spoke to the Observer on behalf of the Dallas County Medical Society.
And, as many commentators and public health experts have pointed out, while Spanish flu and the coronavirus share many similarities, the responses by public health officials do not. We’ve learned a few things about handling epidemics in the intervening century.
“The Spanish flu taught us great lessons about distancing,” Haley said.
Historians have documented in detail the missteps taken by city officials across the country, but particularly in places like Philadelphia, where thousands of the pandemic’s victims were buried in mass graves. Less well known — similar, if not in magnitude, then in the lessons it has to tell — is the story of the Spanish flu in Dallas.
The city’s chief physician during the 1918 outbreak was Dr. A.W. Carnes. He was old school, a member of a generation of clinicians who believed sanatoriums and fresh air could cure tuberculosis. Viruses were still a new discovery, and doctors had little understanding of how they spread.
For weeks, Carnes hesitated to take drastic action and told residents to focus on keeping the city clean. It was wartime, and Carnes allowed the "Liberty Loan" parade to go on. Thousands gathered in the streets while the virus raged. Eventually, Carnes agreed to close the city’s theaters but objected to closing schools, which he argued were safer for children because they were "well ventilated." They remained open for weeks until the mayor ordered them closed in response to public outrage, overriding the recommendation of his own Board of Health.
This reaction came too late, said Alex Navarro, assistant director of the University of Michigan’s Center for the History of Medicine. His team, in collaboration with the Centers for Disease Control and Prevention, analyzed the efforts made by dozens of cities across the country to stop the virus. This story leans heavily on that historical research, which found that by the time Dallas officials issued a sweeping closure order, there were close to 3,000 cases in the city.
“All these things have to be balanced. How deadly is the disease, what's the impact on healthcare infrastructure if we don't do this, versus what's the social and economic cost?” — Alex Navarro
“That's pretty late to do something,” Navarro said.
Navarro would know. The 2007 paper that came out of his team’s analysis was hugely influential and helped the CDC define its current strategy to fight pandemics.
“Public health officers had, for generations, relied on things like quarantine and isolation, but there really hadn’t been a study to see how effective they work,” he said.
This study did. It relied on a database of Spanish flu deaths in 43 cities and compared the death toll with the speed and magnitude of each city’s response. The results were both clear and intuitive: “nonpharmaceutical interventions” like quarantines and school closures saved lives.
But that doesn’t mean they’re easy to implement, as Dallas officials found out in 1918. After Carnes ordered theaters and places of “public amusement” shut down, business leaders pushed back. The directors of the city’s Chamber of Commerce and members of the Manufacturers’ Association met with the mayor and the Board of Health. “They were unanimous that the schools should not be closed,” reported The Dallas Morning News at the time. Carnes too wanted to keep them open, arguing that “schools, to my mind, are far less dangerous than other things.”
In fact, according to Navarro’s research, cities that closed schools were more effective in reducing deaths. But all of these interventions have a social cost. Businesses that are forced to close will lose income, and sending kids home requires parents to find child care.
“All these things have to be balanced,” Navarro said. “How deadly is the disease, what's the impact on healthcare infrastructure if we don't do this, versus what's the social and economic cost?”
“There's this tension in Dallas and in other cities: You have people saying that we need to close schools, we need to close theaters, we need to stop church gathers,” said Navarro. “And then you have the other side saying, 'No, no, this is overreacting. We don’t see the number of cases. We don’t see the number of deaths that would warrant that.' You see that today — when do you pull the trigger?”
In 1918, public pressure eventually forced officials to act. “I am taking this action not because the situation in our city is alarming, but as a measure of safety and precaution and because it seems to be the desire of our citizenship,” the mayor reportedly said after announcing school closures the day after the meeting with business leaders. That same day, the city reported 659 new cases of the disease. At one orphanage, teachers became health workers after both nurses fell ill, along with 200 kids.
The impacts of the outbreak were not felt equally across the city. On one day, the paper reported, a third of reported cases were in Oak Cliff and another third in South Dallas.
“Health conditions among the poor are most deplorable … extreme cases are among the Mexicans where they are entirely without beds or bedding,” reported The Dallas Morning News. Health officials blamed “miserable housing conditions,” as well as the impact of institutional racism: Treating the Mexican victims was difficult because few nurses spoke Spanish, and a black nurse had to be appointed to treat the city’s black patients because few others would.
By the end of October, several weeks into the lockdown, the city was getting restless and confusion reigned. Carnes proposed lifting it but recanted as cases continued to roll in. Church leaders petitioned the mayor to reopen places of worship. He refused, although the city did end an emergency order requiring doctors to report new cases. It was reinstated a month later when the flu briefly reemerged, before quickly dying out for good.
In the end, Navarro said, the city fared better than most. Schools and theaters were closed for only a few weeks and the death rate was less than half of that in some other cities. According to a report from an annual health conference, about one in 400 people died in Dallas from the flu that year. It was one in 136 in New Orleans.
“Dallas seemed to fare OK — they got a little bit lucky — and that’s just the facts of the 1918, or any, pandemic: They spread unevenly,” Navarro said.
In the weeks ahead, Dallas officials will be judged on their ability to weigh all of the fears and risks brought on by a fast-changing pandemic. They'll face tough decisions, and Haley, the UT Southwestern epidemiologist, is optimistic that they’ll do better than their predecessors.
“Our health department is excellent," he said. "Dallas is fortunate to have a great team.”
Already, it's evident that they've learned from past mistakes. On Wednesday, the city announced that the annual St. Patrick's Day parade, expected to draw 125,000 people, was canceled.