Nurses and Essential Workers: The “Sacrificial Lambs” of US Pandemics in 1918 and 2020

The COVID-19 pandemic has taken the lives of more than 6.5 million people around the world. Despite containing only 4.25% of the global population, the United States has accounted for 16% of those deaths—more than 1 million. There was significantly higher mortality among younger Americans than in comparable nations. But it's not as if this country hadn’t been warned. A century ago, the U.S. saw about 675,000 deaths due to the “Spanish Flu.” So why weren’t we more prepared this time around?

Beatrix Hoffman, PhD, professor of history at Northern Illinois University, examined this question in her recent lecture at Yale School of Medicine, “The Necropolitics of U.S. Pandemic Responses: Expendable Workers in 1918 and 2020.” Necropolitics is the power to determine who lives and who dies. In her talk, she explored how America's willingness to sacrifice its “essential workers” both in 1918 and 2020—especially nurses and low wage workers—contributed to mass deaths. “I can’t find a better word [necropolitics] to capture what was happening and what is still happening in the politics of COVID,” she said.

“The research and analysis presented in Professor Hoffman’s talk is a cautionary tale,” says John Warner, PhD, Avalon Professor in the History of Medicine and professor of American studies and of history. “By weaving together labor history with the history of medicine, public health, and policy history, it is in part a statement about lessons that could have been learned from the 1918 pandemic but—like the pandemic itself—were largely, quickly forgotten as Americans put the influenza pandemic and World War I behind them.”

The Spanish flu killed more soldiers during and following World War I than died on the battlefield. With no effective testing, treatment, or vaccine, doctors watched powerlessly as patients turned blue, suffocating on the fluid buildup in their lungs, and died.

The U.S. government quickly realized that the role of nurses was critical. As these nurses worked tirelessly to provide hydration, nutrition, fever control, rest, ventilation, emotional support, and more, they became patients’ main hope for survival. Within weeks, the Red Cross mobilized 21,000 nurses to various domestic army camps, and as many as half would fall ill themselves. While the organization advised the public against sleeping in the same room as an individual with influenza, nurses were frequently in overcrowded, poorly ventilated rooms with highly infectious patients. They were 50% more likely to die than doctors were.

Witnessing the devastation of the pandemic at the frontlines, nurses were also at the forefront of calling for relief efforts and preparedness for future respiratory disease outbreaks. After families lost caregivers and many children were left orphaned, the Visiting Nurses Association in Philadelphia—one of the hardest hit cities—argued for continuing social support measures. The head of the Chicago Visiting Nurse Association called for better ventilation systems to protect nurses in the event of another outbreak.

During the summer of 2020, Hoffman participated in an oral history project in which she talked to Latinx health care workers about their experiences during the first wave of the COVID pandemic. Their complaints echoed many of the experiences nurses faced in 1918. Many were forced to expose themselves without proper protective gear like n95 masks. Hospitals expected nurses to be in the rooms with COVID patients, while physicians waited outside. One nurse told her that “it felt like we were a little bit of a sacrificial lamb.”

Their perception was not far from reality, said Hoffman. Over 3,600 health care workers lost their lives in the first year of the pandemic alone, with nurses and support staff being at significantly greater risk. Health care workers in nursing homes, who are often paid less and are more likely to be immigrants or people of color, were twice as likely to die as someone who worked in a hospital. Once again, the expectation of nurses and low-income health care workers to place themselves heroically at the frontline led to disproportionate amounts of illness and death among these groups.

A common myth surrounding the Spanish flu was that it was so deadly that it killed the rich and poor alike. This was not so—workers of lower socioeconomic status were at greater risk of dying. Coal miners, for example, experienced especially high mortality due to the inhalation of airborne particles and overcrowded conditions. Manufacturing was another high-risk occupation. To supply the military during World War I, factories remained open as many other businesses shut down. When one did close, it was because too many employees were ill. “Only the inability to produce, not the endangerment of workers, led to factories closing,” said Hoffman. The pandemic was also especially dangerous for Mexican migrant workers in the sugar beet industry, who lived in overcrowded company housing.

These disparities shed light on the need for policy changes and the better treatment of low wage workers. “Just like today, the 1918 pandemic was a moment of possibility for worker protections, health insurance, and sick pay,” said Hoffman. In 1919, compulsory health insurance actually passed in the New York state senate but was ultimately struck down by the speaker of the state assembly as “foreign” and “socialist.”

In 2020, while stay-at-home orders emptied many offices, in industries deemed “essential,” many employees once again were not afforded the luxury of being able to work safely from their houses. These workers were nearly twice as likely to die of COVID than others in their age group, with those in the lowest income groups at the greatest risk.

One of the most hazardous occupations was food production. Farm workers, for instance, were four times more likely to come down with COVID. Like nurses, they lacked adequate protective gear and the ability to social distance. And the Trump administration’s response to a COVID outbreak in a meatpacking plant in South Dakota, Hoffman said, highlights the U.S.’ prioritization of industry over the well-being of its workers.

In early April of 2020, just weeks into the pandemic, county health officials planned to close the Smithfield Park processing plant in Sioux Falls as many of its employees fell ill, but then-U.S. Secretary of Agriculture Sonny Perdue pressured authorities to reopen the plants. Two weeks later, the administration declared meatpacking plants “critical infrastructure.” The plant reopened May 7. Following its opening, more than 1,200 workers got sick and at least four died. “We see from this example how highly infectious industries can be designated essential and exempt from public health protections like shutdowns, no matter the cost to workers,” Hoffman said. The meatpacking industry employs about a half million workers nationwide, and most of these employees are people of color.

Throughout the 20th century, Hoffman reminded her Yale audience, government leaders in Washington refused to adopt universal health care, opting instead in mid-century for a system of private insurance in which Americans mostly receive coverage through their employment. The COVID pandemic, she said, offered yet another opportunity for workplace and health care reform. But while the health care safety net is more comprehensive than what Americans had a century ago, Hoffman noted that in 2020, almost 28 million people, or 11% of the U.S. population, were still uninsured, and many were low wage essential workers. Fewer than half of employees in the agriculture industry, for example, had medical coverage. And many insured Americans faced the choice between going to an unsafe workplace or losing both their job and insurance coverage. And mass layoffs left three million without access to employer-provided care in the first few months of a deadly viral outbreak.

Hoffman argued that the U.S. has also failed to provide other needed workplace protections. In January 2022, for example, the Supreme Court struck down President Biden’s vaccine-or-test mandate, ruling that the Occupational Safety and Health Administration (OSHA) did not have the power to set broad public health regulations. And as emergency protections expire, uninsured Americans may struggle for access to testing and vaccines.

The talk concluded with Hoffman calling for Americans to follow the lead of the new labor movement. Amazon workers in Staten Island, New York, for example, participated in a walkout led by former employee Christian Smalls in 2020 demanding paid sick leave. And nurses across the country, she noted, are once again calling for permanently improved workplace safety standards.

“So much of the 1918 pandemic was forgotten, and it’s just starting to be rediscovered now,” said Hoffman. “We’re starting to forget 2020 now. How can we commit to ending the systemic inequalities that have led to so many deaths in these pandemics?”