Two women wear masks during an influenza epidemic in 1929, 10 years after the deadly 1918-1919 flu pandemic that took the world by storm.

Life after the 1918 flu has lessons for our post-pandemic world

Updated 9:40 AM ET, Mon June 28, 2021

(CNN)A widespread sense that time has split into two -- or pandemics creating a "before" and "after" -- is an experience that's associated with many traumatic events.

That's the reflection of Elizabeth Outka, a professor of English at the University of Richmond and author of "Viral Modernism: The Influenza Pandemic and Interwar Literature."
This social phenomenon is both psychologically and practically relevant, in that pandemics -- including the 1918 influenza and Covid-19 pandemics -- significantly affect how we assess and act on risk, or stay resilient, but also how we work, play and socialize.
The startling and harrowing nature of the 1918 flu and its fatal consequences induced a sense of caution that, in some places, had permanent implications for how people would respond to disease outbreaks in later decades -- such as using isolation and quarantine, according to a 2010 paper by Nancy Tomes, a distinguished professor of history at Stony Brook University.
Similarly, as the Covid-19 pandemic fades, "some existing trends will remain," said Jacqueline Gollan, a professor of psychiatry and behavioral sciences at Northwestern University's Feinberg School of Medicine in Chicago.
For example, the recent expansion and use of online shopping, telehealth services, hybrid work models and technology that allows virtual gatherings will endure, Gollan said. And "given our recognition that global crises occur," she added, "we're likely to retain an inventory of cleaning supplies and personal protection materials. We are also likely to adopt habits that improve cleanliness to promote personal or group hygiene."
As the world gradually reopens in a patchwork of ways amid other crises -- much like how states' reopenings varied after the 1918 flu and World War I -- we'll be evaluating many of the lifestyle habits we've engaged in before and during the pandemic, said CNN Medical Analyst Dr. Leana Wen, an emergency physician and visiting professor of health policy and management at the George Washington University Milken Institute School of Public Health.
These are the changes that might stick around post-pandemic.

How we greet people

While public health officials discouraged people from unnecessary contact with others during the 1918 flu, some people broke the rules at the height of that pandemic -- which meant that, afterward, continued compliance with safety precautions to prevent another outbreak didn't last for everyone, according to Tomes' research.
As Covid-19 restrictions ease, some people, including infectious disease experts, have felt OK shaking hands again if others are cautious or fully vaccinated. But others didn't like this social custom even before the pandemic, Wen said. Those who have been wanting to change things up may see now as the opportunity to do so.
"I also hope there will be alternatives to handshakes as in, maybe instead of doing handshakes, we have the elbow bump or the namaste greeting as the baseline of a greeting, especially between strangers," Wen said. Simply waving is another option that's taken hold.

Thinking twice about travel

The aftermath of the 1918 flu didn't keep everyone off of public transportation, but it did create some level of caution about how the virus could spread in such places.
As late Canadian physician William Osler observed, the flu traveled only as fast as modern transportation, meaning "it was human bodies and not some ethereal atmospheric force that spread it," Tomes wrote.
Getting the masses to be safe after the 1918 flu was difficult, but minimizing contact via isolations and quarantines seemed "to offer the best chance we have of controlling the ravages of influenza," wrote late bacteriologist Edwin O. Jordan in 1925.
Depending on future rates of cases of coronavirus, flu or other viruses, when choosing travel destinations, people might have considerations they may not have contemplated in the past, Wen said.
People ride the subway in New York City on May 26.
Travelers' recent decisions to drive to destinations close to home, rather than fly to faraway places, could indicate there are remaining concerns about Covid-19 risk, experts have said. "In the next few years," Wen added, "we are going to see coronavirus rage in parts of the world that don't have it well controlled."

Mask-wearing and other precautions

"The influenza pandemic heightened a contrast between the safe home and the dangerous public space that had already become a familiar theme in the late 19th century," Tomes wrote.
The adoption of safety precautions such as coughing into handkerchiefs or avoiding crowds to try to manage the 1918 flu didn't have a ubiquitously positive impact on individuals' safety habits over the next decade, since some people abandoned such practices. However, some behaviors did influence how people and institutions responded to later disease outbreaks.
An influenza warning notice by the Anti-Tuberculosis League, displays inside public transportation sometime between 1918 and 1920.
When influenza broke out in 1928, for example, some colleges and universities immediately isolated people sick with flu, Tomes wrote. "By acting quickly, college authorities at the University of Oregon limited the spread of influenza to less than 15% of the student body."
Interwar educators, advertisers and public health officials "embraced the gospel of germs with great enthusiasm," Tomes wrote. New health curricula in the 1920s introduced kindergarteners to handkerchiefs, while elementary school children learned versions of the "'handkerchief drill,' in which they sneezed into their hankies with military-style precision."
Promoting hygiene by invoking flu fears, some ads for mouthwash, cough drops and tonics reminded readers that "'a cold may be something far more dangerous,'" Tomes wrote. Women were encouraged to learn the early signs of contagious diseases so they could remind their children and husbands about careful coughing