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18 Working Nurse l WorkingNurse.com March 23–April 27, 2020 Nursing During the Spanish Influenza Pandemic of 1918 Some cities, like Chicago, responded to the shortage by developing a two-track scheme to supplement registered nurses with practical nurses, who received a shorter, six-month course of training. This move was popular with hospitals and the public because it made more nurses available more quickly and for less money, but registered nurses, who had fought so long for formal recog- nition and decent pay, opposed what they saw as a dilution of their professional status. Clara D. Noyes, RN, head of the American Red Cross Nursing Service, expressed dismay at the proliferation of short-term "nursing" courses then cropping up left and right. "There are moments when I wonder whether we can stem the tide and control the hysterical desire on the part of thousands, literally thousands, to get into nursing," she declared. "[T]he most vital thing in the life of our profession is the protection of the use of the word nurse." While the nursing shortages were primarily due to the war, the profession itself was partly to blame. During this period, nursing remained a predominantly white, almost exclusively female occupation. Black candidates still had only limit- ed access to nursing education and employment, even in the face of strong wartime demand. Such prejudices limited the supply of skilled nurses at a time when they were needed the most. A GRUELING BATTLE D uring the pandemic, professional dis- cipline proved to be every bit as important for nurses as skill and train- ing. Nurses' exposure was great and they were just as vulnerable as were patients — especially with the added dangers posed by exhaustion. With so many afflicted and such rapid onset of symptoms, the work was hard, intense and seemingly endless. In Chicago, the American Red Cross publicized the story of a nurse out on a house call who expected to find a sick mother, but instead found an entire family stricken, a 10- month-old baby in desperate need of food and a delirious father roaming the streets in frantic search of a doctor. As one another nurse put it, "You start out to see 15 patients, but instead see 50 to 60 extreme- ly ill people before day's end." Untrained volunteers sometimes pitched in, although what they could do was limited. "We tried to be as nice to them [patients] as we could and just be with them when they died," said one volunteer. Such Good Samaritans were rare. Neighbors and even family members were often reluctant to help, fearing that they too might become infected. Ultimately, it was the trained nurses, even the beginners, who stuck with the job until the end. At Philadelphia General Hospital, Head Nurse S. Lillian Clayton offered to allow the hospital's freshman nursing students to return home rather than remaining to help fight the out- break. All of them volunteered to stay. In the end, six died during the epidemic. ✜ FOR DECADES, the exact nature of the 1918 pandemic puzzled researchers and public health experts. That's no longer true: Over the past 15 years, many of the outbreak's mysteries have been unlocked. Back in 2005, researchers from the CDC succeeded in actually reconstructing the specific H1N1 influenza A virus that caused the outbreak. The goal was to better understand the secrets of a virus whose genetic descendants have been responsible for most subsequent influenza epidemics. (You can read the results of this project in the Oct. 7, 2005, issue of Science.) Nine years later, researchers at the University of Arizona, Tucson took the next step: determining why the virus killed so many healthy, young adults. The study team's theory, reported in the Proceedings of the National Academy of Sciences (PNAS) for June 3, 2014, is that the pandemic virus was a hybrid of an avian N1 strain and a human H1 virus that had appeared about a decade earlier. Like most influenza strains, the earlier human virus had mainly killed young chil- dren and the elderly. However, it left survivors with protective antibodies that made them less susceptible to the 1918 strain, which caught the immune systems of healthier adults completely off-guard. "[I]t may be the missing piece of the puzzle," explains Michael Worobey, Ph.D., lead author of the PNAS paper. "Once you have that clue, many other lines of evidence that have been around since 1918 fall into place." Solving Medical Mysteries