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Cold Comfort

that protective sequestration and other nonpharmaceutical interventions were the best way to prevent or delay the onset of influenza. They found no consistent data to suggest that facemasks conferred any protection.

The question DiGiovanni is now asking is how do we structure disease-containment strategies in a way that fosters public compliance. He's looking for answers to communities spared in 1918: Princeton University in New Jersey; Bryn Mawr College outside Philadelphia; San Francisco Naval Training Station on Yerba Buena Island; Western Pennsylvania School for Blind Children in Pittsburgh; Trudeau [Tuberculosis] Sanatorium in Saranac Lake, N.Y.; and the towns of Fletcher, Vt., and Gunnison, Colo.

As a Dartmouth alumnus, DiGiovanni was also "curious about how Hanover fared." So when he was meeting with the Michigan scholars at Saranac Lake, he drove over to Hanover to look at the College's records. He confirmed that "Dartmouth was not one of the escaped communities—they had their share of illness and death."

Princeton, however, did escape. There, as at Dartmouth and other colleges, most of the students were enrolled in military training outfits. The reason Princeton had so few cases of flu and no student deaths was because officials enacted protective sequestration—the shielding of healthy people from contact with outsiders who might be infected with the flu. Students were forbidden to enter offcampus buildings. Anyone coming onto the campus was treated at a disinfecting

Harris Hatch, the father of Dartmouth freshman Tracy Hatch, wrote President Hopkins during the influenza epidemic.

"We hope that there are no more fatal cases, although any of the convalescents appear to be inexplicably subject to pneumonia up to the moment of complete recovery. The training detachment proposition has been so bad as to be almost tragic."
—President Hopkins

plant. A medical officer performed careful inspections every morning. The barracks were well ventilated. And all suspected cases of the flu were isolated. The other spared communities had instituted similar procedures.

For all the advances in medicine since 1918, these nonpharmaceutical interventions—protective sequestration and the closing of schools and other gathering places—"remain the only tools we have in our bag" today, DiGiovanni says. "The lessons of 1918 really do describe techniques, and ways of implementing [them], which may have applicability now."

DiGiovanni has also been working on quarantine strategies and is helping to shape new federal guidelines designed to help communities prepare for a possible influenza pandemic. It's "incumbent upon everyone in public health to realize that these are not guidelines to be put on a shelf and brushed off when needed," he cautions. "Work needs to start now to prepare."

Dartmouth and DHMC are already working with government agencies and other organizations to prepare for the possibility of pandemic flu, as well as for other emergencies—such as power outages, earthquakes, or terrorist activity.

For the flu, "we'll be relying on the same types of interventions that people had to rely on in 1918," DiGiovanni emphasizes. "So a careful reading of history is useful."

Maybe one day children will chant: "I had a little bird and its name was Enza. I opened the window and out-flew-enza."

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Laura Carter is the associate editor of Dartmouth Medicine magazine. For ease of comprehension, some punctuation, spelling, and abbreviations in the historical quotations have been standardized; the wording, however, has not been altered at all.

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