Higher Education Institutions Respond to Epidemics

Figure 1. Iowa State University's Gymnasium was transformed into a hospital during the 1918 influenza pandemic (courtesy of the University Photograph Collection, Department of Military Science, Iowa State University Special Collections).

As colleges and universities respond to the COVID-19 outbreak, many in the media call it unprecedented. This is not the first time that institutions of higher education have had to respond to an epidemic, however. A historical review of college and university reactions to illnesses such as yellow fever and the 1918 influenza pandemic provides prior examples of institutional responses to epidemic diseases.

Yellow Fever and Early Southern College Responses

Yellow fever outbreaks in the United States go back to the late seventeenth century. Deanne Nuwer's focus in Plague Among the Magnolias is how officials in the South addressed yellow fever concerns through quarantine procedures over a century, including the creation of the first state board of health in the country, in Louisiana in 1855.¹ Her coverage of the disease's impact on academic institutions is limited, focusing exclusively on those in Mississippi and Louisiana in 1878. Nonetheless, her account provides important context for understanding the disease's broad impact both on campus and throughout the South.

One of the first signs of the epidemic involved a high visibility death. Prior to the surge of cases in the late summer of 1878, yellow fever claimed the life of John Edward Leonard, a Louisiana congressman, in March.² In this early case, warnings of the future were apparent. Leonard had recently returned from Washington, DC, indicating the disease's ability to spread quickly. This public attention perhaps solidified the need for public institutions to respond.

Newspapers across the nation carried stories of illness and death, the struggles to stop it, and fund-raising efforts to help those infected and contain its spread. Some early reports, however, treated outbreaks less seriously. On June 21, 1878, a Memphis, Tennessee, newspaper covered a cholera report from New Orleans and Pensacola as part of its “Ledger Lines” column, hidden among reports of travel, visitation, and the increased consumption of lager in New York. The column states, “It is rumored that yellow fever prevails in New Orleans and Pensacola, the latter city being under quarantine.”³ By August, prior to most educational institutions opening, there was no more need for rumors as the illness had spread throughout the South. Deaths escalated in many areas, but there was some inconsistency in reporting. While the August 28^th Denver Daily Tribune noted forty-nine deaths in New Orleans and thirty-three in Memphis on August 27^th, other reports showed a much higher daily average.⁴ For example a The Inter Ocean, Chicago newspaper, reported at that “The mortuary report for the week ending Sunday evening at 6 p.m. shows death from all causes 493, of which 308 were of yellow fever.”⁵ The illness continued to spread through September, when northern newspapers started reporting the outbreaks by town. A section of daily reports compiled stated that on September 18, 1878, New Orleans had sixty-seven deaths with fifty-five more occurring the next day, while Baton Rouge reported forty-three deaths for September 19^th, including former Governor Samuel Bard, and Memphis lost ninety-one people in a 24 hour period.⁶

Articles seeking to allay fears also became more prevalent, as one article attributed to the Atlanta Constitution indicated that cities such as Atlanta were safe. Yellow fever was described as a “creeping plague” that advanced “about forty feet per day,” with the “infected atmosphere [lying] close to the ground, a high wall often arresting its progress.”⁷ Despite dubious theories such as these, some cities such as Natchez, Mississippi, implemented quarantines:

There is a rigidly enforced quarentine [sic], and the wharfboat has been moved one and a half miles below the city. Person or persons coming from any part where any infections or contagious disease exists or may have existed within twenty days from their departure, such person or persons if landed, shall be detained at the quarantine station for a period of not less than ten days.⁸

September, however, continued to be threatening, with reports breaking down the number of deaths by the hour; the Leavenworth (Kansas) Times reported that on September 9 alone, “from noon to six o'clock in the evening, thirty-three deaths were reported to the Board of Health” in New Orleans.⁹

The response by institutions of higher education to these stories in the press was isolation, and many institutions remained closed for most of the fall:

The Mississippi Military Institute in Pass Christian announced that its next session would begin on the first Monday in November instead of its usual September opening. In Jackson County, officials canceled the school session in Scranton until November 1. Further inland, Meridian Female College delayed its opening until October 1, and local newspapers announced that “Oxford University [the University of Mississippi] will open on the 31st of October. This postponement has been made on account of the epidemic prevailing through out the land.” The epidemic proved to be more virulent than first anticipated by the University of Mississippi's board of trustees; as a result, the school session was again delayed until November 21. Because of this lengthy postponement, the trustees in 1878 canceled all Christmas holidays except December 25.¹⁰

Colleges seemed ill-suited to responding to epidemic diseases. For some, going to college meant traveling, including crossing lines of quarantine. Further, college life was inherently modeled on gatherings in locales such as lecture halls, chapels, dining halls, and residences, which only furthered the spread of disease. Student travel and the expectations of social contact affected how a college could respond, and most colleges had no protocol in place. While some institutions made initial moves in considering student health and wellness, most colleges had no system or staff in place for caring or monitoring student health. Thus, during the 1878 outbreak of yellow fever, the institutions relegated control to local responses and “shotgun” quarantines to ensure their safety.

Even with delaying the start of the fall term, some institutions did not recover. The Chalmers Institute in Holly Springs, Mississippi, closed in 1878, an educational casualty of the virus. By the end of the outbreak, the institutions of learning had lost time, students, facilities, and some credibility among the population by acting as a bystander. When the 1918 influenza pandemic occurred, however, the response was different.

The Influenza Outbreak of 1918

Often called the “Spanish Flu,” the 1918 pandemic flu had more of an impact on colleges and universities, forcing them to respond more comprehensively. One reason for this increased response was that this flu did not follow the normal influenza mortality rate, as Nancy Bristow explains in her study of the 1918 pandemic, American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic:

High rates of infection and death were made all the more startling, and ultimately more disruptive, as Americans recognized just who it was who was sickening and dying. Influenza is traditionally associated with an age-specific mortality chart shaped like a “U,” the result of high death rates among infants and the elderly. Infection rates during the 1918 pandemic remained consistent with this model as children evidenced the high rate of illness. Mortality rates, though, defied previous patterns associated with influenza as 99 percent of excess influenza deaths occurred among Americans younger than 65. The result was a W-shaped mortality chart that reflected the surprisingly high death rates for adults between 20 and 40, a population that suffered almost half of the pandemic deaths in the United States.¹¹

This was important for colleges and universities, which during this time were home to students between 18 of 22 as well as hosts for soldiers training for military services on campus during WWI. This additional impact on college-age populations forced schools to be more responsive to the threat.

A 1918 timeline published by the Philadelphia Board of Health provides insight into how the first wave of the pandemic began. On July 22, 1918, the Department of Public Health issued its first bulletin regarding the influenza and the possibility of it spreading. Despite this early bulletin, Kenneth C. Davis’ More Deadly Than War demonstrates that Philadelphia followed an example set by Boston which held a parade in early September, holding one of its own on September 28^th – and both cities saw rapid increases in outbreaks after their events.¹² By September 30, the problem was more serious, with notices that “schools may be kept open for the present in order that the children may be kept under observation of the medical inspectors,” a precedent that lasted only until October 3, when churches, schools, theaters, and other public places were closed, and all funeral services had to be private.¹³

Responses varied in other places. The health commissioner in Roanoke, Virginia, W. Brownley Foster, originally had the support of the media with his initiatives to close schools, churches, and places of entertainment in late September. When the first outbreak seemingly passed in early October, he recommended only slowly opening those facilities. By the middle of October, the World News was assuring readers that the virus was under control in a front page story.¹⁴ By the end of the month, the editors of the World News turned on him, decrying that slow openings would only make larger crowds.¹⁵ The virus then returned for its second wave, creating a sense that the illness was everywhere and spreading, yet the newspaper and magazines of the time did not always support closure. The perceived need to return to normal did not always align with the concerns of individual health boards.

Beyond the impact of the various health boards, other governmental entities influenced how institutions addressed the 1918 flu pandemic. In the context of the First World War, the federal government took a role in responding to this flu outbreak even as the war neared its end. Secretary of State William Gibbs McAdoo initiated policies to minimize the spread to government officials and those near Washington offices by modifying the working hours for some government employees, thus leaving fewer cars on the roads and fewer people in the streets.¹⁶ Further, colleges were turned into military training centers, with most state schools converted into Student Army Training Corps (SATC) bases. ¹⁷

Figure 2. Cots for use by ill students lined the halls of a campus building at the Colorado Agricultural College (courtesy of the University Historic Photograph Collection, CSU Morgan Library Archives & Special Collections, Colorado State University).

With soldiers mobilized for World War I, the virus spread as soldiers traveled to and from bases and went abroad. Unlike yellow fever, the flu did not depend on mosquitos and the climate to ensure spreading, but rather was passed person to person. In 1918, the northern states were in as much danger as the southern states, and overcrowding in cities made the spread more of an issue. The “Spanish flu” was met with a significantly more advanced scientific understanding of how diseases spread than was yellow fever. In 1878, newspapers carried such incorrect scientific theories as yellow fever lying only close to the ground and being able to be stopped by walls that would stop low lying fogs.¹⁸ By 1918, medical science had advanced to a greater degree and the spread of illnesses was better understood.

Still, the willingness of the population to respond to the outbreak seemed remarkably high. Ogden, Utah, passed an ordinance that required all sales clerks to wear a mask to prevent the spread of disease, with violators subject to a fine.¹⁹ Michigan passed ordinances designed to limit the spread of the illness by halting the admission of new soldiers into military camps, the only exception being military training at “college training schools.”²⁰ As businesses, community centers, and the military all began to respond to the epidemic, institutions of higher learning also established varied responses, some more effective than others.

Higher education did not respond universally or with any consensus. For a brief time, universities and colleges in small, rural towns far from major urban centers hoped to avoid the outbreak.²¹ One such institution was the State College of Washington in Pullman, Washington, which dedicated an entire section of its biennial report to the topic of the “Spanish Influenza,” including this excerpt:

While it was known by the college authorities that the epidemic of Spanish influenza was sweeping the country, was world-wide in fact, it was believed that the State College in its position of comparative isolation from the centers of population and traffic might escape a serious attack of the malady.

These hopes were justified until the arrival of the October fifteenth detachment of six hundred student-soldiers who, by the War Department, had been assigned to this institution for vocational training in military trades. In spite of all that could be done by the college authorities and the officers in command of the detachment, Spanish influenza assumed a very serious aspect, and a number of fatalities occurred.²²

Colleges and universities in some locales responded quickly by closing, others were more hesitant. The various responses were not always the decision of the institutions as they responded to health boards, government policies, and a host of other factors. Institutional responses, therefore, were not universal as institutions weighed student needs with state, county, and city responses. There was no national or regional coordination; each institution responded in its own time and context, according to the dictates of state, county, or city health boards. For example, Indiana University, the University of Illinois, and the University of Colorado all followed different response paths. Indiana University closed on October 10, 1918, for ten days in compliance with the state board of health.²³ Meanwhile, Thomas Arkle Clark, dean of men at the University of Illinois, reported in the Daily Illini that the institution could not notify faculty in the crisis, saying, “It is impossible in the present crisis to notify instructors of the illness of students. … We will report to the military office daily, but that is all that is feasible for us to do at present.”²⁴ In the same issue of this student newspaper, physician J. Howard Beard also posted a small notice: “Influenza cases among students not in the S.A.T.C. must be reported at 200 Men's Gymnasium.”²⁵

Oddly enough, despite such conditions and a seemingly disconnected communication, Beard and Clark managed to keep the University of Illinois open throughout the length of the pandemic from 1918 through 1920. Beard accomplished this, for better or worse, by extending the number of hospital beds from thirty to four hundred, while Arkle “corresponded with the parents of infected students, notified them of medical changes, and, too often during this epidemic, expressed condolences and coordinated financial and material transactions after a student's death.”²⁶

Other institutions, like the University of Colorado, seemingly held out until the last wave of the illness in 1920. A simple headline, “State University Closes Due to Flu,” was followed by a single sentence, “The state University, the public schools, churches, and theatres have been closed by the city health board as a result of the influenza.”²⁷ However, a society announcement in the same paper provided more information: “According to reports from the state university at Boulder the school has been closed due to the number of cases of influenza there. 100 cases are reported among the students, many of whom will probably return home while the university is closed.”²⁸ These institutions encapsulate the varied responses—early closures during the initial outbreak, refusal to close, and, finally, closing during the final wave of the epidemic.

In the end, colleges and universities responded in their own ways, depending on their location, the stakeholders, and the impact on college life from the social to intercollegiate activities. Early in the first wave, Arthur Twining Hadley, president of Yale University, postponed a late October faculty reception to limit the risk of faculty exposure.²⁹ Citing war issues and the increase in flu outbreaks, most college football games were canceled. This left the University of Michigan and University of Illinois football teams as “co-champions”, with the University of Michigan lamenting, “Illinois was more fortunate in not having the influenza situation cancel some of her games.”³⁰ Throughout 1918, Michigan limited travel and points of contact, interrupting the operations of the extension offices and related community-focused courses such as beekeeping until the outbreak ended.³¹ Eventually, the institution canceled convocation and graduation ceremonies.³²

Other residential educational institutions also experienced flu outbreaks. Native American schools such as Chemawa Indian School in Salem, Oregon lost students to the illness. The administrator was quick to point out that the influenza “was no worse here than elsewhere,” but that proved little comfort to one mother, unable to attend the immediate funeral or reclaim an already buried body.³³ The losses seemed insurmountable in some ways—educational institutions were losing students, administrators, faculty, and community connectivity, while often having to address the removal and burial of bodies.

One significant example of the flu's devastation occurred at the University of North Carolina (UNC). In the spring of 1915, Edward Kidder Graham became the new president of UNC.³⁴ Graham was well respected and considered socially oriented, capable, and a step in the right direction in modernizing the university. A believer in social responsibility, he was elected president of the North Carolina Conference for Social Service in 1916.³⁵ Graham's wife would succumb to an illness in late 1916, but he proceeded in his work at the University of North Carolina. When influenza struck campus in 1918, he worked tirelessly to ensure the safety of students, often responding directly to parents:

On Oct. 7, 1918, the concerned father of a UNC student wrote a letter to University President Edward Kidder Graham. He wanted Graham to notify him if his son got infected by a strain of influenza—the Spanish flu. “Should our son John come down with influenza,” wrote the parent, “and his condition in any sense be serious, please notify of same (sic) by wire at my expense.” … “There are thirty cases in the hospital,” Graham wrote back to the parent on Oct. 19. “This shows a steady decrease from the maximum of about one hundred and thirty. There are twenty in the convalescent building. These men are virtually well; they are simply being detained there as a precaution.³⁶

Within two days of that response, however, Graham himself fell ill and ultimately died from influenza on October 26, 1918.³⁷ Newspapers in the state and throughout the country took notice. One paper lamented, “He had become one of the foremost educators of the United States, and under his leadership our University was pulsating with marvelous energy. A marvelous mind had he.”³⁸ UNC quickly appointed Marvin Hendrix Stacy as acting president.³⁹ However, within two months of assuming the role, he too succumbed to the flu. While less covered in the media, the university definitely felt the uncertainty the death caused, with one faculty member lamenting:

This winter will go down in University tradition as one of heavy loss and mourning. Three of the University's most noted figures and leaders have been taken by death. Two of them were just attaining the zenith of their powers and usefulness, men of rare gifts, of splendid qualities of mind and heart, who had won an assured place in the esteem and affections of the community and the state, of whom we were justly proud and in whose care and guidance we had fondly hoped the University would be safe for years to come.⁴⁰

UNC stands as a noteworthy example of an institution that lost multiple upper level administrators and thus faced a crisis in leadership.

Still, during these losses, there were signs that colleges and universities were taking an active role despite shutdowns and orders against large gatherings. Some campuses engaged home economics staff and extension offices with kitchens in supporting hospitals in dire need of food (“vast quantities of broth, egg lemonades, custards and other good things”), while in North Carolina, emergency wards at the state college of agriculture and engineering benefited from these same services and from having an extension agent serve as a nurse.⁴¹ Likewise, the University of Michigan documented the outreach of what would now be considered student affairs divisions, documenting that “During the epidemic of the Spanish influenza, the various sororities, dormitories, and house club organizations have been giving their services in providing meals served from their own kitchens to the convalescent members of the S.A.T.C. The girls have carried on this work under the direction of the Dean of Women. They have provided, in many cases, not only the meals, but also the magazines, fruit and flowers.”⁴²

Student records like yearbooks and newspapers began to serve as catalogs of those lost. Some 1919 yearbooks, such as the Kentuckian at the University of Kentucky, opened with words of loss: “We have been hampered by one of the most unfortunate years any University has ever weathered.” The yearbook included a Dedication and an Appreciation to those in the military killed in action, as well listing those in each class who died of the influenza.⁴³ The Kentuckian went on to document the role that the illness played in furloughs and delays, as barracks were erected near the football field for their SATC:

Hardly had the men become established in their new quarters, however, when the influenza germ invaded their ranks. So quickly did it proceed that on October 11, a furlough was granted section ‘A’ men. … The Lexington Red Cross established hospitals on campus, and with volunteer trained and untrained nurses successfully combatted the disease.⁴⁴

Despite that, the flu returned to the campus, prompting more furloughs and delays until December, when the SATC was disbanded due to the end of the war.

There were also new educational opportunities—sometimes brief, sometimes sustained—for institutions of higher learning in addressing the crisis. One was the expansion of nursing courses for African American women. The Red Cross began offering training in “practical elementary nursing,” noting that “many of the women took the work to fit themselves to care for the sick in their own homes more efficiently,” and that “there has been a great demand for practical colored nurses during the present influenza epidemic.”⁴⁵ Bristow cites an article describing “a makeshift hospital that operated in the early days of the epidemic and heralded the social diversity of the staff, which included ‘army doctors,’ ‘army medical students,’ ‘trained nurses, and ‘college professors, teachers, Red Cross aids, volunteers from offices after office hours…’”⁴⁶ As the military effort also drew away males, universities began to offer more trainings for women. At the Medical College of Michigan, Dr. F. G. Novy arranged courses in “Hygiene and Bacteriology” to address “the increased demand for trained women assistants for the work in the laboratories in the army and in public health service.”⁴⁷

Some colleges and universities saw their faculty and students elevated to esteemed levels for a host of reasons. Victor C. Vaughan, dean of the medical school at the University of Michigan, was awarded the Distinguished Service Medal by the War Department for services “rendered in connection with communicable diseases, and especially in checking the spread of the influenza epidemic.”⁴⁸ University faculty who worked to save students found themselves honored not only within their program or school but by the entire institution, as was the case with engineering professor William Muir Edwards at the University of Alberta. Edwards, already hailed as a hero for saving students during a 1910 typhoid outbreak by repairing a faulty water treatment plant, succumbed to the flu in November 1918 while caring for students. Dying on his thirty-ninth birthday, he was immortalized with an institutional plaque and a fund that still bears his name.⁴⁹ Milton Joseph Rosenau, professor of preventive medicine at Harvard was “voluntarily offered $50,000 to carry on” his work addressing the outbreak, even after it was over, with ongoing research funded by an anonymous corporation that had endured severe employee losses during the epidemic.⁵⁰ While a teenager in Australia, future professor of experimental medicine and Nobel Prize winner for immunology, Frank Macfarlane Burnet, found that the illness “burned itself into his consciousness.” He was so affected by what he saw globally that when he isolated a flu strain in 1935, he used it as a way to look back at the 1918 Spanish flu.⁵¹

Thus, educational institutions and their people responded to concerns and patients beyond their own campuses; yet even as they suffered losses and the death tolls outpaced those of previous wars, universities carried on. Classes may have been shuttered, but students were often cared for—and sometimes mourned—on college campuses. The yellow fever epidemic of 1878 had generally only delayed the opening of universities, but during the influenza pandemic, the dialogue shifted. Colleges protected their students but also responded to their communities, applying what expertise they could while honoring health board and governmental orders beyond their direct control. Schools and administrators tried to maintain their town-and-gown relationships, with faculty, deans, and presidents all engaging students, families, and townspeople in dialogues regarding the outbreak.

COVID-19 Goes to College: Historical Perspectives on the Current Crisis

Historical comparisons of the effects of epidemics on higher education past and present demonstrate a number of differences and a few similarities. One difference is the legal context of institutional authority. Institutions of higher education have historically had an ambiguous legal relationship with students. During the 1918 influenza outbreak, universities were covered by legal ideas such as in loco parentis, but current legal reasoning looks for elements of a special relationship. As institutions have advisory information from national health boards and state actors, processes that invite students to document existing health conditions, and on-campus clinics, these elements could meet the threshold of a “special relationship” where students should expect protection from foreseeable eventualities. Moreover, many state universities, as state actors, once relied on the concept of “sovereign immunity,” but concerns about the realm of discretionary functions may open universities up to more legal suits. Discretionary functions--being those where the institution's actors choose courses of action not dictated as ministerial duties--can open up liability concerns. Court cases such as Kleinknecht v. Gettysburg College, 989 F.2d 1360 (3d Cir. 1993), have been noted for defining special relationship duty wherein “a court will consider whether what the individual befell was foreseeable.”⁵² These shifts in the legal relationship between universities and students mean that that the potential impacts on universities of the current pandemic may differ from those of the past.

There are also implications for different student populations. The Los Angeles Times responded to the decision by some private colleges to close their student housing and other operations, by pointing out that it was “creating hardships for students who are homeless, don't have safe places to shelter or have immunocompromised relatives at home.”⁵³ Concerns also exist around providing reasonable accommodations to students in need under the Americans with Disabilities Act and Section 504.⁵⁴ Housing and food insecurity have faced increased scrutiny. Previous studies have found that “nearly 90 percent [of students] indicated that they were upset or worried about not having enough money to pay for the things they needed in order to attend college; 78 percent stated that they were having difficulty paying their bills.”⁵⁵ Presumably, these circumstances are more acute under current conditions. Students may also need the mental health, counseling, and health services universities provide, which can cause complications if students are taken out the college environment.

Issues of access extend not only to support networks, but technologies, with some administrators and students pointing to the “digital divide” between those who have access to the internet and computer technologies and those who don't, and between those who learn well on-line and those who do not, which can lead some students to drop out.⁵⁶

The larger role of the university in society has also changed since the yellow fever epidemic and the 1918 flu pandemic. Some universities are home to the best hospitals in a region or state, serving as “Trauma 1” centers that can handle severe medical conditions and provide care “from prevention through rehabilitation.”⁵⁷ During times of illness, these campus-based medical institutions may need to deal with a higher number of infected individuals. These universities must address the student population while providing medical services to patients.

Even with the variations in institutional context and dynamics, however, historical and present effects of epidemics on higher education institutions demonstrate some similarities. Just as some schools and institutes did not successfully weather yellow fever or influenza, alarms are being raised today about the financial health and survival of colleges and universities facing the COVID-19 outbreak. Some question if the residential nature of college is still necessary, saying, “Just how safe is it to have students on campus at all?”⁵⁸ As Andrew Pavia, chief of pediatric infectious diseases at the University of Utah, states, “They can act as tremendous amplifiers of the epidemic. And the behaviors that young people have in college: spending a lot of time close together, intimate contact, sharing food and drink, make the spread of viruses in that setting a pretty high likelihood.”⁵⁹ The concerns amplified by a residential college are present, then, in all times of outbreak of infectious disease.

If some question the wisdom of such residential communities, others worry that the already beleaguered budgets of colleges and universities will be unable to handle the fiscal strain of effectively responding to this pandemic. Concerns vary, but include both financial value and stability: “Parents and students are demanding refunds for shortened semesters in the dorm. The value and quality of an elite college education is under scrutiny as universities pivot to makeshift online classes.”⁶⁰ Moody's, the financial services company, downgraded its outlook for higher education in 2020 from “stable” to “negative,” with Moody vice president Michael Osborn indicating that “just over 30% of public universities and nearly 30% of private universities were already running operating deficits.”⁶¹ These points suggest that the cost of the coronavirus for institutions may not only be in dollars but also in perceived trust and dependability.

Finding Cures Among the Maladies

Comparing responses to the illnesses that confronted institutions of higher education in 1878, 1918, and 2020 involves complex issues. Legal definitions, campus expectations, medical commitments, and a host of other factors have shifted throughout time, yet the financial challenges and survival concerns of institutions are similar. In the diseases discussed here, however, distinctive social aspects of college life—graduations, public forums, athletic competitions, and social groups—were canceled, their loss leaving questions about how communities and leaders viewed the campus and its role as town and gown relations shifted. Yet these historical records also contained hope—while a few institutions suffered dire losses due to the diseases of 1878 and 1918, the records also noted increased connection to institutions. As universities and colleges serve various research, social, and community needs, what will be the long-term impact of this new pandemic on higher education?