Masks on Campus
Masks on Campus: Historical Lessons from 1918 for 2020
by E. Thomas Ewing, Jessica Brabble, and Ariel Ludwig
Authors’ Note: This essay builds upon research conducted in spring and summer 2020 in response to the Covid-19 crisis. A complete list of peer reviewed publications is available from the project website. We are posting this essay on our website, as a non-peer reviewed post, because of the urgency of bringing these lessons to public attention as American higher education resumes operations in late August and early September. This essay may be updated as events continue to evolve. This essay was first posted on August 21, 2020.
A photograph of masked students in a large classroom at Brigham Young University during the 1918-1919 influenza epidemic should prove familiar yet alarming to college students, faculty, parents, and administrators thinking about resuming instruction in fall 2020. The use of face masks to prevent the spread of infectious disease has quickly become an expected and even required practice in 2020, more than a century after masks were last used as a widespread public health measure. In this photograph, however, all the masked students are sitting in close proximity to each other, thus violating the effectiveness of social distancing as a complementary measure to prevent the spread of disease from person to person. Sitting for a lengthy period of time shoulder to shoulder, as is being done by these men and women, is likely to undermine the effectiveness of masks in preventing the spread of disease. This photograph raises the question of what historical lessons the 1918 influenza can teach us about masks on campus during an epidemic.
Woman wearing Mask, Indianapolis, 1918
Masks during Epidemics
As American universities resume and plan to resume classes in a few weeks, the use of masks is widely recommended and even required in combination with a menu of other public health measures, including social distancing, testing, contact tracing, self-quarantines, and good personal hygiene. A face mask requirement is one of the most important, yet also most challenging, of these measures, as it requires individuals to constantly adjust their own behavior to promote the public good. In this essay, we review the historical evidence from mask wearing during the 1918-1919 epidemic as a way to inform current discussions about resuming instruction on college and university campuses in the fall semester.
Our research on the 1918 epidemic has explored how the use of masks began as a universal recommendation for nurses, physicians, and family members caring for influenza patients and at home, building upon accepted practices in surgical wards. As the influenza spread across the country, and the number of deaths escalated quickly, public health officials began to discuss and even adopt mask requirements for certain occupations, in designated locations, or, in the most extreme cases, by all citizens in public spaces. Although mask ordinances in certain cities, particularly San Francisco, have attracted considerable attention recently, it is important to recognize that relatively few cities, making up a very small percentage of the total population, were governed by any kind of requirement to wear masks in public. In fact, many public health officials argued against mask requirements during and especially after the epidemic, with the claim that masks were not effective in preventing the spread of infection. Even cities that imposed some kind of mask requirement ended the regulations relatively quickly, usually in a matter of weeks. In Provo, Utah, the home of Brigham Young University, the mask ordinance lasted just under a month, from November 22 to December 17. As influenza cases rose again in early 1919, health officers considered, and then rejected, the possibility of extending this order. San Francisco’s flu mask ordinance lasted just over a month in October and November, and a second ordinance lasted less than two weeks in January and February 1919. Even Stockton, California, where residents lived under three mask ordinances for more than seventy days in late 1918 and early 1919, this historical experience was shorter than the length of mask ordinances imposed in 2020.
Comparing Epidemics 1919 and 2020
As this historical review suggests, the epidemics of 1918 and 2020 exhibit certain similarities yet also significant differences. The most important similarity, of course, was the sudden and urgent request or requirement to wear a face covering to prevent the spread of infection. In 1918 as in 2020, this specific recommendation built upon certain kinds of public health guidance, but the sudden appearance of masks in public marked a dramatic change in individual and collective behavior. The response to recommendations and regulations to wear masks in 1918 and 2020 also shows similarities across a spectrum from enthusiastic willingness to grudging acceptance to partial implementation to open rebellion. Given the absence of any effective treatment or preventive, physicians in 1918, much like their contemporaries in 2020, had limited capacity to cure those who fell ill with this disease. Finally, explanations for the medical value of masks in 1918 and 2020 have demonstrated similar variation, inconsistency, and disagreement, compounded by jurisdictional tensions between city, county, and state health authorities.
Our research on masking has also illuminated important differences between 1918 and 2020 that relate directly to current discussions about wearing masks on campus. When the influenza epidemic began in late September, the United States was at war, and many male students were being trained in Student Army Training Corps (SATC) units (which were quickly disbanded following the Armistice on November 11). Requiring masks for men already in uniform was probably easier to mandate and enforce than a similar expectation for civilians. The impact of the disease was also different, as the 1918 influenza caused an unusually high proportion of deaths among younger populations, including college-aged men and women. Whereas the concentration of deaths among elderly populations in 2020 could reinforce a sense of safety among younger populations, the widespread reports of young men dying from influenza in army camps clearly documented the danger to younger populations. Finally, influenza cases were diagnosed by symptoms, which generally resembled seasonal influenza and other common forms of respiratory disease, whereas Covid cases are confirmed by tests. The current faith expressed by university officials in testing and tracing to contain Covid clusters was not a viable option in 1918, as cases were only identified as people fell ill and sought medical treatment.
Lessons from 1918
Taking into consideration these similarities as well as differences, our historical analysis suggests the following lessons for students, faculty, staff, family, and administrators as American higher education responds to Covid in fall 2020.
First, we can anticipate early enthusiasm for wearing masks, as people embrace the possibility of taking actions to protect themselves and members of their community from a dangerous infection. In 1918, when health officials first recommended or required masks in public, newspaper reports highlighted the sudden appearance on masked faces on streets, in trolleys, and in stories. In preparation for resuming the fall semester, American universities have used a variety of tools to exhort students to wear masks in response to this health emergency. The evidence from 1918 suggests that this message will inspire many people to wear masks because they understand how their own behavior can affect the whole community.
Second, masks must be part of a combined campaign for disease control that includes social distancing, monitoring individual health, practicing good personal hygiene, and intensified disinfection of contaminated spaces. In 1918, masks were initially recommended in combination with other measures, such as prohibitions on meetings, closing schools, theaters, and churches, restricting hours on public transportation, and recommendations to stay home when sick. Over time, however, masks came to be seen as an alternative to sustaining these other measures that impeded business activities and compromised personal choice. In 2020, universities seeking to resume instruction safely must integrate masks with other regulations and requirements on public health.
Third, we must expect widespread non-compliance with mask recommendations, regulations, and even requirements. Our research on masks in 1918 has revealed a spectrum of reasons for non-compliance, ranging from principled opposition to government mandates to a belief that masks were ineffective to objections that masks were not convenient or comfortable. Based on our review of enforcement practices, we believe the most common reasons people didn’t wear masks in 1918 was a combination of ignorance and indifference, as they either didn’t know or didn’t care that masks were an effective way to prevent the spread of infection. Recent reports of college students socializing without masks confirms that these same patterns will present a major challenge to universities seeking to maintain the health of campuses and communities in the weeks and months to come.
Fourth, American students, faculty, staff, and community members must prepare for the challenges of sustaining mask wearing over the long term. Most Americans in 2020 have already lived under some kind of mask requirement longer than any city required masks during the 1918-1919 epidemic. Masks may be a recommended, expected, or even required personal action for months or even years to come on campus and elsewhere in communities. We are moving into a phase with few historical precedents to guide our actions and attitudes.
Two photographs from California universities further illustrate the challenges facing campuses during an epidemic. A photograph from the San Jose Normal School Yearbook (1919) shows twelve young women, all wearing masks, kneeling or standing in close proximity to each other. A photograph from the Stanford University Archives shows seven men, one in uniform, wearing masks covering their entire faces below their eyes. Yet the fact that both photographs depict individuals standing so close to each other also calls into question the effectiveness of the mask in preventing the spread of infection. These two photograph suggest that wearing masks allowed for other forms of “normal” interaction, when the lessons of 1918 as well as our collective experience in 2020 remind us that masks must be accompanied with other health interventions, including maintaining social distancing. Protecting public health on campuses will require judicial balancing between "normal" forms of sociability and the "abnormal" requirement to wear a mask in almost any kind of social setting.
Photo sources: Brigham Young University Special Collections; Indiana Historical Society; San Jose State University Special Collections; Standford University Special Collections