Why Gauze Masks ‘Failed’ in 1918 — And What We Can Do Better

A look at the mistakes Americans made while wearing homemade cloth masks to protect against the Spanish flu, according to the secretary of the California State Board of Health in 1918

An American Red Cross worker wears a gauze mask during the Spanish flu pandemic in 1918. Photo: Paul Thompson/FPG/Stringer/Getty Images

The Centers for Disease Control and Prevention has now recommended that all Americans wear masks as we live through this pandemic. And so, like our relatives who faced the influenza pandemic 102 years ago, we are now covering our noses and mouths in public with cloth masks — because that’s what’s available. Except this time, our masks will be better (we hope) and definitely more colorful.

Although there is evidence to show that surgical masks and N95 respirators offered significant protection of medical workers against contracting SARS (a closely related coronavirus), we are now moving into uncharted territory by using homemade cloth face masks to protect against Covid-19. So why not turn back the clock and learn what we can about a time when cloth masks were the gold standard?

Most of us have seen photos of nurses, workers, children, and possibly even cats wearing masks during the Spanish flu pandemic. But despite the widespread use of masks in 1918, some experts at the time concluded that masks made from gauze “failed” to help slow infections on a citywide scale in San Francisco. The main reason for this failure, they decided, was that gauze is a terrible material for filtering respiratory droplets. But they also noticed some other problems.

Now that we’re wearing cloth masks again, we should consider why the gauze mask supposedly fell short of protecting the public a century ago. Because, as we all know, history sometimes repeats itself.

To combat the Spanish flu, Americans were told to make face masks with four to six layers of fine mesh gauze — which is what was used in hospitals.

The challenges we can expect from homemade masks

Gauze masks were fairly common in hospitals by the time the great influenza pandemic arrived in the United States in 1918. Two decades of prior research demonstrated that masks could work in both directions: preventing doctors and nurses from spreading germs to their patients — and also protecting doctors and nurses from getting sick.

Because medical professionals realized in 1918 that the flu was passed through respiratory droplets, there was a nationwide call for Americans to make and wear masks. And like most of today’s guidelines, masks were encouraged but not mandatory, except for in a few cities — like San Francisco — which made masks mandatory by penalty of fine or imprisonment.

Unfortunately, despite this law, San Francisco’s infection and death rates were pretty much identical to those of Boston, Buffalo, and Washington, where masks were optional.

W. H. Kellogg, the secretary of the California State Board of Health at the time, identified five key reasons he thought mandatory gauze masks didn’t help lower the infection rate. He mostly blamed the citizens who made them but also found fault in the instructions they were given. What follows are his century-old criticisms, along with notes on why we will do better this time around.

1. The homemade masks were shoddy

To combat the Spanish flu, Americans were told to make face masks with four to six layers of fine mesh gauze — which is what was used in hospitals. The finer the mesh, the better the gauze would be at filtering out respiratory droplets, or so the thinking went. Unfortunately, Kellogg observed that many civilians’ masks were only made from one or two layers of a very coarse gauze similar to cheesecloth.

This criticism was echoed by others, including the Detroit health commissioner, Dr. J. W. Inches. When he saw the skimpy masks that people were making and wearing, he called them “worthless,” with weaves so loose that “a mosquito could jump through them.”

Why we’ll do better 102 years later: All of us have access to cheaper, higher-quality fabrics than our ancestors did. We can also watch countless instructional YouTube videos and ask our social networks to double-check our work.

Sometimes they only covered their mouth but left their nose exposed. Others constantly touched and moved their masks around, especially while smoking.

2. Shoddy masks gave people a false sense of security

To his horror, Kellogg saw that people who wore poorly constructed masks took more risks than they would have if they weren’t wearing masks. Even though their skimpy masks offered no protection, they felt comfortable and safe — and acted that way.

Why we’ll do better 102 years later: Although most of us will craft higher-quality masks today, we do need to take the social distancing warnings seriously. Taking extra risks will cancel out any positive benefits we reap from wearing a mask.

3. People wore their masks incorrectly

Although the board of health posted fliers instructing people how to wear a mask, Kellogg noticed that people often wore their masks incorrectly. Sometimes they only covered their mouth but left their nose exposed. Others constantly touched and moved their masks around, especially while smoking.

Why we’ll do better 102 years later: Luckily, we have the benefit of a vast media culture that is prepared to show us the do’s and don’ts of mask etiquette.

4. People wore their masks at the wrong times

Because the San Francisco police were enforcing the mandatory face mask law, most people wore their masks outdoors and in public. However, Kellogg noticed that many people took off their masks “in private offices, and among gatherings of friends.” These places were, of course, where they were most likely to be exposed to infectious droplets.

Why we’ll do better 102 years later: For those of us using face masks today, it is essential to learn which situations are the riskiest and prioritize wearing a mask during those times. For instance, public indoor locations, like the grocery store or a bus, will be riskier than the outdoors.

5. The material they were told to use didn’t work very well against the flu

At first, Kellogg thought gauze masks failed because most people were idiots but that masks could still protect the “intelligent individual.” However, during the 1918 pandemic, 78% of San Francisco nurses contracted the flu even while wearing proper gauze face masks. After a series of experiments, Kellogg concluded that gauze was not a very effective barrier against respiratory droplets. And in order to make gauze a better barrier, so many layers of fabric were required that it became unbreathable.

Why we’ll do better 102 years later: It’s 2020. We don’t have to wait until after the fact to learn what fabric works best. Laboratories are actively testing the filtration efficiency of different fabrics right now and sharing their results with the world.

So, it turns out we got a few things wrong 102 years ago, but history doesn’t have to repeat itself (at least not in these ways). We are going to battle a pandemic in cloth masks again and hopefully, we are going to do it right this time.

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