In 1918, in the midst of a massive mobilization of troops in World War I, an epidemic of influenza AH1N1 began to spread and led to a brief but lethal pandemic. It was also known as “the violet death,” the “flu,” and, in some European and American countries, the “Spanish flu.”
After reviewing its worldwide impact, it is estimated that about 50 million or more people died from the disease. It is speculated that some 100,000 people died in the Caribbean and 675,000 in the United States. It has been alleged that the pandemic could have begun in China, France or in the state of Kansas and by June of 1918 countries such as Indonesia, Australia, New Zealand, Puerto Rico and parts of the coast of Brazil began to be impacted, though at the time it was not clear that the cause was influenza.
Its worldwide course has been divided into three “waves” or stages, and it was the second, which affected the most countries between September of 1918 and January of 1919, that was most devastating, in terms of mortality, among the historical epidemics. Three stages of its spread through Puerto Rico can be identified.
The first local stage of the flu is placed from the middle of June to the end of September in 1918. It was categorized as a “benign type,” and there were various versions of when it began and how it spread. It was reported on June 20, 1918, that an “alarming epidemic” attacked the Puerta de Tierra neighborhood and put many entire families in bed with illness. There were more than 1,000 victims in just four days among a population of 18,000.
A large part of this population were workers at “La Colectiva” tobacco factory, also known as Porto Rican American Tobacco Company. The situation there was difficult as around 200 workers were absent due to the illness. The fear and concern led many families to leave the area immediately to other parts of the island. To make the situation worse, there was a strike by street sweepers that lasted six days and contributed to the spread of the epidemic due to poor hygiene.
Naturally, there was a lot of “uneasiness and worry.” The health commissioner, Dr. Eliseo Font y Guillot, declared that the epidemic was dengue. The condition was also known as “trancazo.” The confusion over the diagnosis continued through June, July, August, September and part of October, which is one of the reasons the deaths due to the flu were not accurately counted. Some cases “of the illness were incorrectly called dengue.” Later, other medical professionals considered that both illnesses could have occurred simultaneously.
This lack of understanding was not unique to Puerto Rico. In Spain, where there were approximately 250,000 deaths, as well as in other parts of the world, it was established that “the waves of flu” demonstrated “the lack of medical understanding of etiology and the epidemic behavior” of the illness. It still had not been discovered that a virus was the cause, no specific treatment was known, and there were no effective antiviral drugs to combat it, much less vaccinations.
The second worldwide wave took place in the fall of 1918 (September 23) and extended into January of 1919. The most devastating months, in terms of mortality, were October, November and part of December. Contrary to other flu epidemics, half of the deaths registered were among adults between 20 and 40 years of age. These had been considered a low-risk group.
During those months, the arrival of ships with ill people was a key factor in spreading the disease. Also, as World War I ended on November 11, 1918, many of the 18,000 veterans began to return and there were celebrations, assemblies, gatherings and many contacts that passed on the flu. The spread increased that month and the effects of the San Fermín earthquake of October 11, which left 116 dead and caused an estimated $4 million in property damage were also felt. That doesn’t include the generalized fear caused by the subsequent tsunami, especially in the northeastern part of the island. It caused waves 18 feet tall and left more than 600 people homeless.
In addition to a lack of economic resources, there was a scarcity of medical personnel and infrastructure on the island to control the epidemic. Governor Arthur Yager, along with the Health Department, turned to religious and charitable groups for help with both materials and aid.
“Emergency plans” were implemented to avoid the spread of the disease and health measures were recommended, such as dividing spaces to control the movement of residents. Among the measures were: cleaning balconies and sidewalks, avoiding large gatherings, no spitting on the ground, covering the mouth when coughing or sneezing, and more. On November 30, 1918, the Governor ordered the closure of public and private schools, cinemas, churches and meeting sites, except for factories, shops and the University of Puerto Rico. Unlike other epidemics, such as bubonic plague, measles, leprosy or cholera of 1855, the flu, in its second stage, was not stigmatized as a divine punishment, nor was its transmission blamed on the poor because both the rich and the poor got sick and died.
The third worldwide stage, classified as a “benign” stage like the first, fluctuated in Puerto Rico between the middle of January with sporadic cases until May of 1919. Public school buildings used as temporary hospitals had been disinfected and closed since late December of 2018, due to the decline in the number of infected people and the beginning of classes in January. In February of 1919, the Senate passed a measure extending by one month the classes in the schools that had been used as hospitals.
It is calculated that through the first weeks of February, 1919, 10,888 people died and 261,828 fell sick in a nation of 1,258,970 residents, and that’s considering that there was no obligation to report the illness locally until the middle of November.
The pandemic caused a severe impact on the health and stability of the residents of Puerto Rico, as well as the physical, sanitary and health systems. It also brought to light the impoverished conditions in which a large part of the population lived, especially in the rural areas, as well as the inability of the government to confront the magnitude of the epidemic without help. While its passage through the island was devastating, it brought about solidarity among various social sectors. Beds, cots, food, milk, blankets and money were donated and temporary spaces were opened to attend to the needy.
After the epidemic of 1918, the Department of Health continued taking steps to avoid the accumulation of trash and to try to prevent the spread of other epidemics. In May of 1919, cleanup days were proclaimed to collect “all useless junk” from homes in San Juan and remove it from the city. That month, there were not many cases of flu in San Juan and many wondered if it was possible to be at ease. Then there was the season for typhus and meningitis. It was better not to give a name to the “big epidemic” of 1918 and thus avoid remembering its effects. As one Japanese doctor said, “There is no way to stop it.”
Hundreds of years later, Puerto Rico faced a new pandemic with attitudes of uncertainty, health measures, and political and economic concerns similar to the flu pandemic of 1918. That is the coronavirus, or Covid19. It is believed to have begun in December of 2019 in Wuhan, China. Its worldwide spread was declared a pandemic in March of 2020 in countries such as the United States and Puerto Rico. Despite taking place in a historical setting very different from 1918, there are certain similarities in terms of the state and medical response to the flu epidemic.
Physical distancing and controlling movements of people, quarantines, the use of masks, vigilance by the State, lack of medical understanding, widespread fear and sometimes contradictory analysis of the disease and its symptoms without the immediate availability of a vaccine are some of the main aspects that are similar between the past pandemic and the one of 2020.
The current pandemic occurs in an interesting cybernetic context that opens the possibility of many historical investigations that will arise over the years. Among them are the constant civil disobedience in terms of violations of distancing regulations and gatherings, the questioning of authority figures for the control they exercised and the emotional need to escape confinement.
History will also have to consider the impact of emotional depression, not only among health professionals but also among people tired of being closed up or unable to meet with friends and family. Others are the changes of lifestyle and ways of working, the economic impact on many families and the additional demands, as well as domestic violence that has happened in some households. Both pandemics open new ways of thinking about the changes that occur during times of world crisis due to disease.
Pérez, Ibrahim. “Cada país construye su propia historia sobre COVID-19”, El doctor Ibrahim Pérez analiza la estrategia salubrista de China, Corea del Sur, Estados Unidos y Puerto Rico para atender la pandemia. 20/4/2020, https://www.noticel.com/opiniones/20200420/cada-pais-construye-su-propia-historia-sobre-covid-19/. Consulted 8/11/2020.
Rosario Urrutia, Mayra. “La epidemia reinante: llegada, difusión e impacto de la influenza en Puerto Rico, 1918-1919”. San Juan: Ediciones Laberinto, 2018.
Author: Dr. Mayra Rosario Urrutia, November 20, 2020
Published: February 12, 2021
Revision: Dr. Lizette Cabrera Salcedo, February 23, 2021