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Five years into the First World War, sailors and soldiers started dying en masse in Boston and at Fort Devens, Massachusetts. Initially, the Germans were blamed, since—so the thinking went—if Germans introduced lethal chemicals such as chlorine and phosgene gas into battlefields, they were capable of seeding cities with killer microbes.1 Now they had imported a killer virus in Bayer aspirin bottles. Or perhaps they snuck the pathogens in by sea—commandos swimming ashore with vials of microorganisms for dispersion in theaters and at war rallies.2 But it wasn’t the Germans. And the epidemic wasn’t confined to America’s eastern seaboard. It was part of the worldwide reemergence of an influenza strain— “Spanish flu”—that had run a much milder course the preceding spring. In the fall it got vicious. Unlike ordinary flu, this bug sought out the young and vigorous. Men and women slid in a matter of hours from normalcy to critical illness: burning with fever, gasping for air, coughing blood—and struggling for comprehension. Schools closed to become makeshift morgues. In the worst-hit areas, bodies were stacked like cordwood. In a few months, influenza killed more Americans than heart disease, cancer, strokes, diabetes, emphysema, AIDS, and Alzheimer disease combined now kill in a year.3 Overall, it was the worst human loss of life from any disease over a similar duration in the recorded history of the world,4 killing far more than the combat dead in World War I or even in World War II. In the United States, life expectancy changed in one year as a result of this epidemic, from 51 years to 39 years.5 The public health response to this disastrous epidemic was, at times, coercive. In many instances, quarantines were instituted and people were banned from gatherLegitimacy c h a p t e r t h r e e ing in public places. Ordinances requiring the use of protective masks were widely and quickly passed. In some cases, such ordinances were briskly enforced. But what is perhaps most startling about this worst of all modern mass casualty events is the relative paucity of public solicitude it engendered. People were far more concerned with the war in Europe, and so was the news media. Brutally afflicted Philadelphia, for instance, closed its schools, theaters, pool halls, and churches, but continued to conduct patriotic parades right through the worst of the epidemic.6 On September 20, 1918, Camp Lewis, in the Puget Sound region of Washington state, reported 173 cases of influenza—yet this did not prevent 10,000 civilians from cramming together in the camp three days later to observe a review of the state’s National Guard infantry.7 In San Francisco, there was much initial enthusiasm about the use of surgical masks. Ninety-nine percent of residents used them—even before the enactment of a mandatory mask ordinance.8 Yet when the epidemic started to decline, so did mask use. Dr. William Hassler, chief of San Francisco’s Board of Health, waged an aggressive media campaign emphasizing the continuing importance of masks; police power was appropriated, and hundreds were arrested—all to no avail. Dissenters invoked their civil liberties, and eventually the ordinance suffered what Crosby characterizes as the “worst of possible fates . . . it became funny.” Clever violations of the mask law became as fashionable as sneaking alcohol would be in a future era of Prohibition . Even Hassler was caught without a mask.9 When another wave of in- fluenza broke out at year’s end, efforts to engender mask use failed outright—this time 90 percent of San Franciscans ignored Mayor Rolph’s call for voluntary masking.10 The 1918 influenza epidemic starkly illustrates several sociological barriers to effective public health practice in mass casualty events, including the tendencies of the general public (1) to fear violent or exotic dangers (such as aggression from Germany or biological attacks) over natural or familiar dangers (such as influenza epidemics and motor vehicle accidents),11 (2) to quickly acclimatize to specific dangers with subsequent dissipation of fear or concern, and (3) to prefer liberty and convenience over protection from mundane threats to health. These factors, combined with the tendency of the news media to focus on emerging violent and otherwise sensational threats, beget a skewed perception of risk among citizens at large. Fear of terrorism is a prime example. America could suffer terrorist-related losses of September...

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