New story in Health from Time: COVID-19 Isn’t the First Pandemic to Affect Minority Populations Differently. Here’s What We Can Learn From the 1918 Flu

On a Monday afternoon in early October about 100 years ago, a special meeting of the Baltimore school board was held to decide whether schools should close. Some 30,000 children—more than 60% of the city’s students—had reported absent that day, along with 219 teachers.

It’s unknown how many students stayed home because they were already sick or because they feared getting sick. Either way, the 1918 influenza known as the “Spanish Flu” was to blame. Baltimore, like other cities and towns across the country, was grappling with overwhelmed hospitals and crippled industries. The city had something else in common with much of the rest of the U.S. at that time, too: it was racially segregated.

The school board ultimately decided to close the schools, but the decision wasn’t unanimous. Some members agreed with John D. Blake, the city health commissioner, who wanted schools to remain open. Blake—who was accused by some at the time of downplaying the pandemic in order to keep public spaces open and businesses operating—pointed out that, at one school for Black students, there was a 94% attendance rate. He used this statistic and other similar data to claim that “colored people are not, as a rule, subject to the flu,” according to an account of the meeting published by the Baltimore American.

This statement was a careless over-generalization, but it reflected a common perception of the time. White health experts of the era, as well as Black doctors and Black journalists who served their communities, generally believed that white people were more susceptible to the virus. They were working with real observations, but their suppositions about the reasons for those numbers were often misguided and in some cases based on racist pseudoscience. (It was a common belief of scientific experts at the time—and particularly white experts—that health disparities between the races stemmed from biological differences, even though such ideas are scientifically baseless.) As the world grapples with the coronavirus pandemic, which has had a particularly devastating impact on communities of color in the U.S. and abroad, that history stands out as particularly surprising. But those who have studied the 1918 flu say it still offers a lesson for today.

“It’s counterintuitive,” says Vanessa Northington Gamble, a history professor at George Washington University, of the idea that a pandemic wouldn’t affect Black Americans. Gamble has scoured historical documents to understand why Black people seemed to be less affected by the 1918 outbreak. “I might not believe it, but it was believed at that particular time,” she says.

Indeed, observational accounts of lower death rates among Black people are supported by the available data: one 1919 analysis of mortality statistics by race and sex from the Metropolitan Life Insurance Company found that Black influenza death rates exceeded white influenza death rates in the years prior to the pandemic, but the opposite was true during peak pandemic months:

Other historical statistics paint a similar picture. In November of 1918, an official from the U.S. Public Health Service reported that flu incidences were lower among Black populations in seven predominantly Black localities. Meanwhile, military records from World War I show that, among troops stationed in the U.S., white soldiers had higher incidences of influenza and other respiratory diseases like pneumonia in the fall of 1918 compared to black soldiers.

Gamble cautions that historical data have flaws. Public health agencies and insurance companies were operating under racist systems; statistics such as mortality rates are based on unreliable population estimates; and the pandemic struck so furiously that health agencies, hospitals and physicians could barely keep up with the stream of patients, let alone find time to compile thorough records.

Race data may be especially incomplete. Medical facilities were segregated, and the few Black-only hospitals that existed at the time were operating at capacity. Patients who couldn’t secure a place in the hospital and who subsequently died at home may not have been recorded, potentially resulting in under-reported fatalities—a phenomenon that’s sadly repeating itself with COVID-19.

Still, Gamble thinks that the historical numbers have some merit. “We have to use them,” she says, “But not in absolute terms. We need to put them in the context of the time.”

One way to consider the historical context is by looking at how people of different races fared in 1918 relative to a non-pandemic time period. A 2007 study of 14 cities from the Federal Reserve Bank of St. Louis, for example, shows that for the full 1918 year, Black populations’ influenza death rates were higher than that of white populations in all but one city. However, the uptick in deaths that year wasn’t as dramatic as it was with their white neighbors, because Black communities already had such a high influenza death rate prior to the pandemic. In other words, there were more excess deaths among white people than black people.

Take Louisville, Ky., where the overall Black influenza mortality rate in 1918 was slightly higher than the white rate. But while the Black mortality rate had increased 175% compared to pre-pandemic levels, the white rate soared 810%:

Statistics and anecdotal accounts suggesting that Black communities weren’t as pummeled by the 1918 influenza outbreak as white areas leave historians and health experts with a paradox: how is it possible that people who were forced by discriminatory housing practices to live in crowded and unsanitary conditions, whose medical facilities and doctors were barred from collaborating with white hospitals, and who, as a result of these racist policies, were more prone to underlying health conditions would fare better, relatively speaking, in a pandemic?

The question is especially puzzling in light of COVID-19’s disproportionate effect on racial minorities who are still dealing with inequities in the modern-day health care system—in today’s pandemic, over a century later, Black people are dying at more than twice the rate of white people in the U.S.

Theories explaining this phenomenon have evolved over time. During the pandemic, according to Gamble’s research, some white experts blamed scientifically baseless “biological” differences between the races. For example, some claimed that Black people were less susceptible to respiratory viruses because the lining of their noses were more resistant to microorganisms. This type of shoddy reasoning wasn’t unusual for the era; myths about physical differences were frequently peddled as fact to justify discrimination.

“Some data seems to suggest lower death rates in the Black community,” says Nancy Bristow, author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic. “But that was not because of biological differences, but because of how they lived in the society. Race doesn’t exist biologically. It is a socially constructed concept.”

Modern theories are more firmly based in science and consider the socio-economic factors of the time. One hypothesis is that an initial milder strain of the influenza virus, which hit the U.S. in the spring of 1918, affected communities of color harder than white communities, allowing Black people to build up an immunity to the more virulent strain that swept the country in the fall. But some researchers say there’s little evidence that a spring flu hit the southern states, where most Black people lived at the time.

Another theory is that racial segregation may have limited Black people’s exposure to the 1918 virus. The military, which played a critical role in the transmission of the disease around the world, was entirely segregated at the time. Private establishments held a firm color line, as did public transit. In rare cases when Black people were admitted to white-only hospitals, they were treated in separate wards, often in the most undesirable areas of the building, like attics and basements. But this explanation has been questioned by researchers who note that discrimination didn’t shield Black communities from other infectious respiratory diseases like lobar pneumonia and tuberculosis, which were more prevalent in Black communities than in white communities.

Despite holes in all these theories, at least one fact about the 1918 pandemic is certain: Black communities were left to fend for themselves to get through the crisis.

Unfortunately, this situation is still all too common today, and the outcomes are painfully apparent in the COVID-19 era. Today, as the country is grappling with another pandemic, the human toll is higher among Black and brown people. Disparities in health outcomes between races—both today and a century ago—are indisputably tied to systemic discrimination and oppression of those communities.

“Germs know no color line,” says Gamble. “The 1918 influenza revealed racial inequities—where people lived, where they got their health care, what jobs they had. It’s parallel to what we’re seeing now.”