Public health officials, medical authorities, and research scientists have reached a consensus that masks are an effective and essential measure in controlling the spread of COVID-19. Unfortunately, some elected officials, state and local governments, and members of the public have resisted policy recommendations and scientific evidence supporting the use of masks. This opposition has resulted in delays in implementing public health measures, verbal and even physical confrontations with those enforcing regulations, and widespread evidence of non-compliance with mask regulations.
A century ago, Americans encountered similar recommendations, as well as debates and disagreements, regarding masks during the “Spanish Flu” epidemic. Photographs of nurses wearing masks, instructions for making masks, regulations on wearing masks in public spaces, and arrests of individuals for defying mask ordinances confirm that “flu masks” were part of the American experience of the 1918 epidemic.
This article explores a dimension of “flu masks” that has acquired greater significance in 2020: efforts by public health experts to explain the value of wearing masks to the public. During the 1918 epidemic, Roanoke, like most cities in Virginia and across the United States, never required masks to be worn in public. In late September, as the epidemic began, the city health department endorsed recommendations from the United States Public Health Service that anyone attending influenza patients wear a mask. These recommendations were endorsed by Dr. Brownley Foster, city health officer, on October 5, as the number of cases suddenly spiked, and again on November 27, as the number of cases increased again. On October 19, the World News published a photograph of Marguerite Inman Davis, First Lady of Virginia, wearing a gauze mask while volunteering as an emergency influenza nurse in Richmond. One week later, a photograph of a Red Cross nurse wearing a mask appeared under the headline: “‘Flu’ Masks Ready to Check Epidemic.” Throughout the epidemic, health officials in Roanoke and elsewhere consistently recommended the use of masks when caring for influenza patients.
By contrast, requirements for masks in public were more controversial in 1918, and thus public health officials faced pressure to explain these policies to the public. On Dec. 20, the World News provided an extended statement of Foster’s views on “the wisdom of the use of face masks.” Under the heading, “The Task of the Mask,” Foster explained that germs “almost infinitely smaller than the openings of the mask” travel in much larger “droplets of mucus” which are trapped by the absorbent threads of a gauze mask. Foster’s technical explanation thus anticipates similar efforts in 2020 by health departments to explain how the masks prevent the spread of the coronavirus. Foster’s December 20 statement drew upon lessons learned during the epidemic to repeat that claim that it was “wise for masks to be worn by doctors, nurses, and all other persons who are in intimate association with the sick.”
Foster’s final conclusion, “Not Feasible for General Use,” is most directly relevant to our current situation: “Unfortunately, masks are not always properly worn and handled and this is likely to be the case frequently when efforts are being made to enforce the use of masks by the general public.” Given the “confusing” and “contradictory” outcomes of mask ordinances, Foster declared that “general use by populations in their daily lives is not practicable.” In reaching this conclusion, Foster apparently drew upon the emerging consensus among public health officials that mask requirements had generally failed to control the epidemic.
While we respect Foster’s explanation, our research leads to a different recommendation about mask requirements in 2020. As we now know, the primary protective value of masks is preventing infected people from transmitting the virus. Even if masks are not worn properly or all the time, requiring everyone to wear masks in public is an effective way to reduce the potential for infection. Wearing a mask also communicates a message that the individual is taking appropriate measures to contain the disease. Seeing others wearing masks may serve as a reminder to maintain appropriate distance in public spaces, wash hands frequently, and watch for symptoms of illness. Given the political polarization characteristic of 2020, wearing a mask signals that the individual understands the reasons for public health policies, listens to the advice of experts, and makes a conscientious decision to put the public welfare ahead of individual conveniences. Masks for all in 2020 is thus an approach consistent with the historical experience of the 1918 epidemic and the best guidance from public health experts.