Racial Disparities in Mortality During the 1918 Influenza Pandemic in United States Cities

Abstract

The 1918 influenza pandemic stands out because of the unusual age pattern of high mortality. In the United States, another feature merits scientific scrutiny: against a historical backdrop of extreme racial health inequality, the pandemic produced strikingly small ratios of nonwhite to white influenza and pneumonia mortality. We provide the most complete account to date of these racial disparities in 1918, showing that, across U.S. cities, they were almost uniformly small. We examine four potential explanations for this unexpected result, including [1] socio-demographic factors like segregation, [2] city-level implementation of non-pharmaceutical interventions (NPIs), [3] exposure to the milder spring 1918 “herald wave,” and [4] early-life exposures to other influenza strains resulting in differential immunological vulnerability to the 1918 flu. While we find little evidence for 1-3, we offer suggestive evidence that racial variation in early-life exposure to the 1889-1892 influenza pandemic shrunk racial disparities during the 1918 pandemic. We also raise the possibility that differential behavioral responses to the herald wave may have protected nonwhite urban populations. By providing a comprehensive description and careful examination of the potential drivers of racial inequality in mortality during the 1918 pandemic, our study provides a framework to consider interactions between the natural history of particular microbial agents and the social histories of the populations they infect.

Urbanization and the Future of Population Health

“…Concerns about infectious diseases are once again resurgent because of the COVID‐19 pandemic, with far‐ranging implications for changes to urban infrastructure (e.g., improved ventilation) and to the reorganization of public health resources within a city. Notably, research indicates that the health of cities during pandemics past and present is characterized by stark intraurban inequities, with the variation in mortality across racial groups during infectious disease outbreaks attributed in part to how health resources are allocated within cities 25–27 …”

“…Notably, research indicates that the health of cities during pandemics past and present is characterized by stark intraurban inequities, with the variation in mortality across racial groups during infectious disease outbreaks attributed in part to how health resources are allocated within cities. [25][26][27] Looking beyond the pandemic, the epidemiological transition of the modern era will require a new paradigm for cities and population health, with a particular focus on improving chronic disease prevention and management. For example, policy interventions such as smoking bans or taxes on sugary beverages can align health promotion activities with the experience of city living.…”

Pandemics, past and present: The role of biological anthropology in interdisciplinary pandemic studies

“…Research on other racial and ethnic groups has focused on Black Americans. In a working paper, Eiermann et al ( 2021 ) report strikingly small differences in White versus non‐White mortality. However, other research has found that in the autumn of 1918, Black Americans had lower morbidity and mortality but higher case fatality than the White population (Crosby, 1976 , 2003 ; Økland & Mamelund, 2019 ).…”

1918 Every Year: Racial Inequality in Infectious Mortality, 1906–1942

“…Flu, another airborne disease, was the other most prevalent cause of infectious mortality during this period (Armstrong, Conn, and Pinner 1999). While recent research has begun to systematically explore racial inequality in flu mortality during the 1918 pandemic (Eiermann et al 2021), less is known about racial inequality in flu mortality generally.…”