Historians' Watch

Mask Ambivalence in the 1918 Influenza Pandemic

The protracted scientific and political debate over the public use of face masks during the COVID-19 pandemic exposed disagreement and discord in many different quarters. For experts, the problem was one of evidence, or its lack, in the question of whether to mask up or not. In our era of evidence-based medicine, an initial dearth of high-quality studies of the benefits and risks of masking created an existential crisis: what to do when the evidence is ambiguous at best or simply missing? The ‘high priestess of the U.K.’s COVID-19 masking campaign’ and Professor of Primary Care at the University of Oxford, Trisha Greenhalgh attacked this line with a vigorous dose of common sense. Likening masks to parachutes, Greenhalgh opined that the obvious low risks posed by masks and their high potential for benefit was enough to introduce a mandate. You don’t, after all, have to wait for a rigorous study of parachutes to know that it’s not a good idea to jump out of a plane without one.

Pockets of deep ambivalence about mask-wearing shot through the public as well. Some were the result of the very public nature of the disagreements between scientists and the uneven policy that resulted. But initially, and especially as mask mandates lifted in early 2022, the decision to wear a mask or not increasingly turned on one’s ideological and political allegiances. As mask-wearing disappeared as a day-to-day reality, receding into more theoretical what-ifs, conversations about masking have increasingly focused on the right of public health and government to mandate such interventions; the trustworthiness of experts and their expertise; and the balance between these and the rights of individuals to make their own choices. In this sense, mask-wearing has – for many – been folded into a larger set of perennially-resonant issues regarding differing conceptions of what good governance looks like amongst the wealthy democracies of the Global North.

Geoffrey Rees for ‘Mask Me Anything’: A Healthy Scepticism Project.

In Britain, the simple gauze mask first became publicly visible and contentious a century ago, during the 1918 influenza pandemic. Though the reasons for promoting or rejecting masks as a sensible public-health measure were not the same, returning to 1918 offers some revealing continuities. But the past, as we know, has no easy or simply continuous relationship with the present. Just so, mask-wearing in the 1910s also bears the unmistakable markers of a single, and singular, moment in time.

The anti-germ mask originated in late-nineteenth century surgical practice and famously used under epidemic conditions on a large scale during the Manchurian plague of 1910. During the 1918 influenza, masks were for the first time outside Asia added to the array of public-health measures that already included border closures, school closures and quarantine. Notably, and exceptionally, the American city of San Francisco and the Australian state of New South Wales enacted and enforced new laws that compelled people to wear masks in public. And while these laws met with some resistance, compliance was generally high.

At no point in the pandemic was mask-wearing made compulsory anywhere in Britain. But masks were much discussed in the national and local newspapers, often with reference to exceptions like San Francisco, or to the British military hospitals that increasingly isolated flu patients and required all medical staff to wear masks (and gowns) as the pandemic wore on.

Britain was still at war when the first civilian cases were reported in Glasgow in May 1918. More than 200,000 would die, mostly during the second, deadlier wave, which crested in November. At the height of the epidemic in London, the Times medical correspondent endorsed mask-wearing as a simple precaution, but one that required ‘courage.’ On 19 December, after the first wave had passed, he reflected in the Times on how it might have been averted. Prevention, he argued in a vein that stands roughly in Greenhalgh’s lineage, ‘merely wanted intelligent anticipation’ and ‘stringent orders.’ British people, ‘had the facts been explained, would not have objected to wearing light gauze masks in the streets and public places.’ Masks, he elaborated, were ‘by no means very inconvenient,’ and they were ‘exceedingly cheap.’ He did not ‘doubt that hundreds, if not thousands of lives might have thus been saved.’

The Times was not alone in mask enthusiasm. ‘Why cannot the people in the towns where influenza is serious wear masks as they do in San Francisco,’ asked a reader of the Birmingham Gazette, ‘and stamp the plague out; it is the only way.’ Captain Thomas Carnwath, a demobilised medical officer, and Sir Arthur Newsholme, the most senior medical adviser in England and Wales, also weighed in. The mask, argued Carnwath at a widely reported lecture in January, was a ‘hopeless innovation without intelligent and educational acquiescence on the part of the public, and unanimity in the medical profession. It lacked public sanction, but deserved a trial.’ But where Greenhalgh and others have seen parachutes, Carnwath saw umbrellas. He ‘did not see why,’ he said, ‘people who had learned to use umbrellas should not wear face masks.’ Newsholme, who chaired the lecture, predicted ‘that in time people would make more use of face masks of a modified kind during epidemics.’

Several commentators suggested repurposing the military gas mask, an innovation of 1915, in defence of the flu. In December, a widely syndicated article pointed out that the Red Cross Society was ‘busy making anti-influenza masks’ for ‘transports taking back troops to the dominions’ and suggested converting ‘the gas masks worn by our soldiers into influenza masks.’ And in January, Albert Leyton, a Leeds pathologist, proposed in the Daily Mail that ‘everybody in public places, except in open air,’ should ‘wear a gas mask’: ‘What will keep out gas will also stop the influenza bacillus’, he reasoned.

John Bell, Hills and Lucas, a London-based company that had produced over 40 million gas masks during the war, saw an opportunity. In January 1919, it launched the ‘Arellano’ influenza mask, a respirator-type mask recently designed and patented by Count Ramírez de Arellano, an enterprising Spanish nobleman. The new mask was widely advertised in medical journals and the general press; a note in the Lancet endorsed it as affordable and medically sound. A firm of chemists in Manchester reportedly ordered ‘some thousands’ and an advertisement in the Chemist and Druggist (hyperbolically) claimed they were selling ‘like hot cakes.’

Full-page advertisement for Count Arellano’s patented flu mask in Chemist and Druggist, 18 January 1919, p.2.

In the absence of sales figures, possibly lost to time and certainly subject to the murkiness of corporate archives, it is difficult to recover demand. Evidence in newspapers is circumstantial, but suggestive of an uneven uptake. The Daily Mail reported on 19 February that masks had so far ‘not been much seen in London, though a few people at the West End are wearing them.’ On the other hand, the Press Association confirmed on the same day that Selfridge’s were preparing for ‘brisk’ sales and there was already ‘big demand’ at Harrod’s. The Yorkshire Telegraph reported that the ‘surgical department’ of a ‘well-known store in London’ was ‘making up the masks as fast as they could, and that the demand over the counter was continuous.’ A few customers ‘put on the masks and continued their shopping in them.’

Gauze masks were also endorsed by central government. In February 1919, at the start of the third and final wave, the Local Government Board, antecedent to the Ministry of Health, published a memorandum that advocated – alongside other measures – ‘wearing a mask and glasses when nursing or in attendance on a person suffering from influenza.’ The indefatigable Times medical correspondent endorsed the advice and went further, reiterating his view that masks should also be worn in public. Municipal health authorities followed suit, many going beyond what the board recommended. Medical officers in Birmingham, Bradford, Edinburgh, Liverpool, Manchester, and Newcastle all recommended the preventive use of masks, especially for people attending influenza sufferers, but also in public spaces and on public transportation.

Mask-wearing was described as a ‘common sight’ by the London News Agency in February 1919. And in March, a Nottingham newspaper claimed that influenza masks were being worn in Sheffield. But other reports – of a masked man in Northampton who ‘attracted much attention’, or a masked woman in Tooting who was ‘followed by curious children for over a mile’ – suggest that the practice was, at least in some areas, uncommon enough to be newsworthy. One journalist who walked back to Fleet Street in a mask he had purchased at a West End store confessed to ‘embarrassment.’ Masks, he surmised in the Daily Chronicle, would ‘have to become much more popular’ before they attracted ‘no more attention than an eye-glass.’ Newspapers also printed photographs—of masked pedestrians in London, masked office clerks in Birmingham. But most people who purchased a mask or made their own probably did so for private, indoor use.

The Leeds Mercury, 22 February 1919, p.12

Compared to our recent experience, the debate over masks during the 1918 influenza was muted. But there were dissenting voices. Several critics likened compulsory mask-wearing to the highly controversial muzzling orders introduced in the 1890s to control rabies and which were opposed by many as ineffective and an affront to civil liberties. Others raised aesthetic objections; women, it was often repeated, would reject masks as unsightly. And though their rubric for determining effectiveness was not ours, scepticism increasingly attached to the effectiveness of gauze or muslin to protect against influenza following laboratory demonstrations that the infectious agent could pass through filters like flies through a barbed wire fence.

One of the more vociferous critics of masking within scientific circles was Leonard Hill, a London physiologist whose studies catalysed the widespread belief that it was not air’s molecular content, but its temperature, humidity and movement that mattered for health. And it was on these grounds that he condemned masks for the quality of the air they produced. Hill’s influential work, which spanned in application from open-air disease cures to the total rethinking of ventilation in industrial design, suggested that masks made air too humid and too hot, impairing the ability of the mucus membranes to ensnare microbes in the first place. Instead of masks, he urged the ‘breathing of cool air,’ ‘sleeping in open air,’ and ‘any spray, gargle, or snuff which enhances the outflow of secretion from the respiratory nose and throat.’

Sales of commercial prophylactics such as those recommended by Hill surged during the pandemic, especially in the third, milder wave. John Bell, purveyors of the Arellano mask, also marketed a range of influenza medications. A pharmacy in Sheffield had only ‘one or two inquiries’ about masks but was doing a ‘brisk’ sale in ‘all forms of “flu” medicines and preventives.’ And some products even traded on mask aversion. Advertisements for at least one germicidal salve boasted that it obviated the need for masks. And the perceived ‘antipathy of Britons to wear anything in the nature of a mask that would make them conspicuous’ was mobilised to promote a more discrete ‘nasal attachment’ imbued with antiseptic drugs.

Then as now, Britons were ambivalent about masks. In 1918, they preferred to put their faith in more familiar products. Happily, the influenza receded in the spring of 1919. No sooner had John Bell commercialised the anti-flu mask than the need for it dissipated.

The history of masking is instructive. Certain themes have remained resonant, though differently articulated: worries that masks violated civil liberties, for example, seem a constant, even if these worries were differently configured and weighted in 1918. Though the terms of debate today are not equivalent to those articulated a century ago, worries about how to establish effectiveness for masks percolated then as now. But differences are also apparent: not only have parachutes replaced umbrellas as the metaphor du jour, but also our modes of knowledge production have dramatically shifted. It is no longer to the laboratory but to the large-scale, big data study that we turn to evidence our ideas. And it is no longer just scientists who are privy to these discussions but diverse publics, who have watched with bated breath, and ample commentary, decisions being made and unmade and then made again concerning the obligation to mask or not.

What is certainly true is that mask ambivalence hasn’t gone away, at least in the Global North. Rather, it has been restructured by and expressed through our contemporary scientific, political, and public cultures. So what is the source of the remarkable, recurring ambivalence about what are, at their simplest, just bits of material stretched over nose and mouth? Why do they, more than other disruptive public health measures (of which many are invisible or enacted privately) raise such ire? Simultaneously incredibly banal and exceedingly visible and public, masks became the embattled technologies upon which we could heap the emotional labour of coping with a pandemic.

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