What convinced Americans during the 1918 Flu Pandemic to wear masks
The Covid-19 pandemic is not the first time in the United States that public health officials encouraged people to wear masks to limit the spread of a deadly virus. In the United States, a surprising number of Americans have been angered by this simple request. This reaction should not be unexpected. Similarly, during the 1918 Spanish Flu pandemic, mask-wearing was also politicized. In desperation, public health officials then turned to various tactics to convince Americans to wear masks.
During the Flu Pandemic were people punished if they did not wear masks?
By the autumn of 1918 in the United States, it was clear the flu pandemic was out of control. Surging cases across the country required public health officials to issue direct guidance for people to wear masks. For some states, masks were part of a broader set of social distancing, washing hands, and general cleanliness to avoid spreading the virus. Some cities in the Western United States, including some towns now where we see hostility to wearing masks, passed laws that required masks to be worn at all times by the autumn of 1918. These laws were implemented in places all over the United States, including Phoenix, San Francisco, and even Juneau, Alaska (Figure 1).
Punishments ranged from fines to imprisonment in cities. While most punishments for not wearing a mask were fines, prison sentences did occur. One infamous incident in San Francisco, where a special officer hired by the Board of Health to enforce mask-wearing, shot a man who had earlier refused to wear a mask; two bystanders even were hit during the shooting.
In another case in San Francisco, at a boxing match attended by many dignitaries from the city and government, a photographer shot a photo of that night and the well-known individuals present. That photograph led to many officials being shamed for not wearing masks. People who were caught not wearing masks included a congressman, a court justice, a Navy rear-admiral, a health officer, and the mayor. These violations led to fines for these officials and public shaming. Still, none of these individuals were imprisoned as others had been.
Did medical professionals support wearing masks?
Nevertheless, most people or places that had rules requiring masks generally had no major issues or incidents. Only after substantial declines in deaths and infections did most of these cities gradually removed the requirement about masks.
Masks in 1918, however, were criticized for both being ineffective and having a limited value in slowing the spread of the 1918 virus. The American Public Health Association in December 1918 concluded that wearing masks should be compulsory for medical staff, barbers, dentists, and other occupations that come into close contact with other individuals. Even though it was found that masks were not always effective, most of their concerns were a result of masks made from inappropriate materials or the incorrect usage of these masks. In essence, they supported masks' use, but only if they were used properly and created with the correct materials.
Thus, the board recommended that only workers in close contact wear them, and others who wish to do so should be instructed on the proper way of making and wearing masks. However, a later study in 1927 showed that those who wore masks generally did help limit the spread of the 1918 virus. The study also determined many misconceptions of what masks were for, which was part of the problem.
Masks should be presented to the public as devices that help infected people spread their infection, whereas many people saw them differently and took them even to be a stigma. The study also recognized there is likely hostility in wearing masks in countries emphasizing individual freedom. The study made clear that masks should be presented as something that should be worn because it reflects the presence of a serious disease where public and community health is more important than individual rights at a given time.
Other Efforts Related to Masks
Not all cities passed such laws requiring masks in 1918, but there were still efforts to get people to wear masks. One action attempted to get people to wear masks by stating that the effort was patriotic since it helped prevent the spread of the virus to US soldiers. The pandemic severely impacted the United States troops both in the US and Europe. This effort worked because it appealed to people's patriotism and gave them a tangible way to support the war effort.
There were still some dissenters, and even an Anti-Mask League was formed in San Francisco. Other cities, such as Seattle, tried appealing to people's fashion sense to get people to wear masks. One newspaper, Seattle Daily Times, even created headlines titled: "Influenza Veils Set New Fashion: Seattle Women Wearing Fine Mesh With Chiffon Border to Ward Off Malady."
The idea of calling them veils, rather than masks, was intended to get people to feel they were more of a fashion item, perhaps similar to how some masks today are relatively decorative (Figure 1). Perhaps also the newspaper took liberty with interpreting them as a new fashionable trend. However, some ways suggested by newspapers made masks useless, despite any positive intentions these newspapers had (Figure 2). Finally, embarrassing people were also tried by the authorities. In some places, the local newspaper printed the names of people who were caught not wearing masks. 
Why did people refuse to wear masks?
The standard complaints people did give in 1918 on why they did not wear masks did vary, besides the main reason being that some saw them as impinging on their personal freedom. One of the most common complaints was they were hot and stuffy. Some businesses worried masks would limit sales, as people would not want to wear them, so they would not go outside and shop. Others pointed out that masks were ineffective. Many of these complaints had some merit, although they could have been remedied or at least minimized, such as wearing masks properly to make them more comfortable and effective and providing information as to why they were being used for public health.
For instance, people were caught making holes in their masks to smoke, negating the utility of a mask. Protests did spring up, including those organized by anti-mask groups such as the Anti-Mask League. Still, generally, people complied with the laws requiring masks to be worn or followed due to public pressure and a sense of duty.
The 1918-1920 flu pandemic offers us valuable insights into getting people to wear masks and common complaints against them. Similar to today, American society debated its utility and looked at issues of personal freedom and comfort. While many concerns and issues are familiar to us, people were also creative in attempting to get people to follow community health practices. These efforts included punishment, embarrassment, appealing to patriotism, or creating more fashionable masks. While these tactics were not always effective, they also generally convinced people to wear masks in the United States.
- For more on laws and ways cities got people to wear masks in the 1918 flu pandemic, see: Crosby, Alfred W. America's Forgotten Pandemic: The Influenza of 1918. 2nd ed. Cambridge ; New York: Cambridge University Press, 2003.
- For more on this study looking at the effectiveness of masks in 1918, see: Jordan, Edwin. Epidemic Influenza: A Survey. Chicago: University of Chicago, 1927.
- For more direct and indirect methods used to get people to wear masks, see: Bristow, Nancy K. American Pandemic the Lost Worlds of the 1918 Influenza Epidemic. Oxford: Oxford University Press, 2017.
- For more on complaints and concerns about masks in 1918/1919, see: Phillips. H, and David Killingray, eds. The Spanish Influenza Pandemic of 1918-19: New Perspectives. Routledge Studies in the Social History of Medicine 12. London ; New York: Routledge, 2003.