Before World War II there was no permanent program of federal disaster relief in the United States, and private voluntary agencies such as the American National Red Cross and the Salvation Army took primary responsibility for disaster response (Kreps, 1990; Rubin, 2007). The International Committee of the Red Cross was founded in Geneva, Switzerland, in 1863 by Henry Dunant; today, national Red Cross societies exist in nearly every country in the world, with the American National Red Cross, organized in large part by Clara Barton, founded in 1881 (Moorehead, 1998).

During the 1888 yellow fever epidemic in Jacksonville, Florida, the Red Cross recruited nurses to the danger zone. Barton turned to New Orleans for help; there, many people had already had the disease and thus were immune. She recruited 30 nurses, both white and black, to travel with her by train to Jacksonville. On arrival in Jacksonville, however, the train’s engineer refused to stop in the epidemic area. Thus, in the midst of a torrential rain, 10 nurses jumped off the moving train so they could assist the sick. Earning $3.00 a day, they worked 72-hour shifts for 79 days. A scandal developed, however, when several men and women refused to work
for the $3.00 a day wage in hospitals and instead went into private nursing where they could make more money. Other nurses were accused of immoral conduct (Kernodle, 1949). Barton provided an explanation. She admitted that many of the volunteers she recruited were untrained, and clashes developed between them and the local boards of health, which employed federal and municipal health officers who used newer scientific methods. In addition, many adventurers responded and called themselves Red Cross nurses even though they were not. Consequently, the local health board deported them (Barton, 1904; Dock & Pickett, 1922). Barton believed it was unfair to judge the status of Red Cross nurses by these latter individuals (Barton, 1904).

Consequently, the director of Sandhills Fever Hospital did not rely on Red Cross nurses. Rather, he recruited trained nurses and students, a new type of nurse that he had witnessed as an intern at the Bellevue Hospital in New York City. At Sandhills his chief nurse was Jane Delano, a graduate of Bellevue who later became president of the American Nurses Association and director of the Red Cross Nursing Service (D’Antonio & Whelan, 2004; Kernodle, 1949). One of Delano’s classmates, Lavinia Dock, followed her there. As a trained public health nurse, Dock and the other nurses brought improved care to patients through their emphasis on order, cleanliness, ventilation, and nutrition, and they demonstrated the critical importance of what this new nursing profession could offer (D’Antonio & Whelan, 2004; Dock & Pickett, 1922).

A year later, the Red Cross was called on to help at the site of the Johnstown Flood. On the afternoon of May 31, 1889, heavy rains had been pouring down on central Pennsylvania when the decaying South Fork Dam broke. Millions of tons of water and debris came crushing down into the valley in what became the worst flood in the nation’s history. Within 10 minutes, over 2,200 people were killed and tens of thousands more were injured or made homeless. Nurses and physicians from Mercy Hospital in Pittsburgh were among the first to respond, both at the scene and in their hospital (Rafferty, 1974). Clara Barton and her relief team arrived 5 days later, on June 5. They distributed supplies to thousands of survivors and provided warm meals, medical care, and shelter to many in buildings that became known as “Red Cross Hotels” (Kernodle, 1949; National Park Service, 2006). Most of the nursing, however, was handled by a branch of the American Red Cross from Philadelphia not associated with Barton. Led by Lavinia Dock, graduate nurses trained in hospitals and public health worked in tent hospitals set up for the ill and injured. Their nursing proved invaluable as they worked with Barton and other Red Cross relief workers to carry out sanitation measures to prevent disease (Barton, 1904; Dock & Pickett, 1922).

On September 10, 1900, meteorologist and eyewitness John D. Blagden wrote the following to his family (2000):

Two days before, on September 8, a hurricane had hit Galveston, Texas, leaving approximately 8,000 people dead. The image of death pervaded the accounts of the Galveston storm, and by September 12 newspapers were filled with stories about recovering the dead. Eventually,
the bodies had to be burned en masse in bonfires throughout the city. During the storm, both blacks and whites took refuge in two local hospitals, John Sealy and St. Mary’s Infirmary. Both suffered damage but were able to take patients again within a few days (Bixel & Turner, 2000).

Clara Barton and her staff arrived on September 17 and found an impromptu local relief committee that was tending to disaster recovery needs and collecting supplies. Barton was 78 years old at the time, and this would be her last trip to the scene of a disaster. She had presided over many disasters, and with each one her fame grew (Barton, 1900; Moorehead, 1998). Her arrival in Galveston was met with great fanfare, as one assistant recalled, “When Miss Barton’s train got in the guards were ready, soldiers at present arms, everything in very martial style, in fact it was the only spice of the theatrical that there was in the whole business” (Fayling, 2000, p. 91).

Although the Red Cross had recruited nurses during the yellow fever epidemic and the Johnstown Flood in the 1880s, in Galveston it was primarily responsible for obtaining supplies. Rather than assuming total control, Barton and her staff worked with the local relief committee, supplying food, clothing, and shelter. Galveston women had formed a new Red Cross Auxiliary, and Barton ensured they would provide greater leadership at the distribution stations. The Red Cross also worked with volunteers from various charitable and patriotic societies, including the Women’s Relief Corps, the Women’s Christian Temperance Union, and the Grand Army of the Republic. Blacks had formed their own relief committees, and Barton also set up a special fund for them (Barton, 1900). Barton stayed in Texas for 2 months. In addition to providing help in Galveston, she and her staff distributed supplies to people in towns and villages over a thousand-square-mile area that had suffered severe damage. Barton had a policy of restarting local work. When the hurricane washed away strawberry plants of farmers in six storm-swept counties and no money was available to buy more, she helped secure over a million plants.

After Barton’s retirement, the Red Cross reorganized in 1905 and created state and territorial branches. One of the organization’s newly assigned responsibilities included nursing during peacetime emergencies such as fire, floods, pestilence, and other national disasters. The state and local committees of enrolled Red Cross nurses served as volunteer recruiters of other nurses when the need arose. The new structure would be critical to the nursing response to the influenza pandemic when it hit the United States in the autumn of 1918.

The influenza epidemic of 1918, killing over 40 million people worldwide and causing over 675,000 deaths in the United States (Hilleman, 2002; Johnson & Mueller, 2002), challenged the nation’s public health service, the American Red Cross, the medical and nursing professions, and the U.S. federal government in much the same way it challenged other nations around the world. In 1918, the extremely high death rate—particularly among young adults—from a rare and highly contagious form of influenza was mysterious and frightening. According to one historian (Byerly, 2005):

The influenza and pneumonia of 1918 shocked medical officers and soldiers alike. It rendered strong, healthy men powerless and struggling for breath; it distorted and saturated the lungs of those it killed; it rendered helpless professional physicians of great skill and knowledge; it consumed an enormous amount of army resources; and it killed in such great numbers that images
of sick and dead bodies and coffins stayed with the survivors for the rest of their lives. (p. 87)

When the flu hit the cities of the United States and killed citizens, not soldiers, the country was unprepared for the magnitude of the crisis. Reflecting on the events of that year, nurse leader Janet Geister (1957) later wrote: “We weren’t ready in plans and resources, nor were we ready in our thinking. A country-wide epidemic was utterly inconceivable” (p. 583). To complicate the situation, the United States had only recently entered the war in Europe and thousands of physicians and nurses had just been deployed. Few were left to cope with a major epidemic at home.

In the United States, influenza first broke out in Kansas at a crowded military recruit camp. It then traveled with the soldiers to the cities of the East Coast, notably Boston, Philadelphia, and New York, where it also arrived on ships from Europe. Within a matter of days it raced south and westward across the country along transportation lines (Crosby, 2003; Markel et al., 2007).

On September 6, 1918, The Boston Globe reported an outbreak of “old fashioned grippe” among the sailors on the Commonwealth Pier (Fayling, 2000). By September 17, influenza reports were front page news. Within the next 24 hours health authorities recorded 41 more deaths, and the Boston health commissioner issued a warning against public hysteria. On September 18, only 12 days after the explosion of the epidemic in Boston, the flu spread through Philadelphia, the center of the war industry. Within days hundreds of sailors were ill; civilians were also succumbing to flu. Almost simultaneously, the epidemic erupted in New York City.

Meanwhile, in Boston, where they had been dealing with the flu for over 2 weeks, health officials were alarmed enough to send a telegram to the American Red Cross headquarters in Washington, DC, to ask for nurses. In Washington, it was becoming increasingly clear that this was no ordinary flu epidemic. Reports were coming to the Red Cross from cities up and down the East Coast. The new strain had devastated Boston and was now sweeping through New York, Philadelphia, and Washington. It was also racing south and west. The Red Cross had to take action. As a result, on September 24 members of the American Red Cross National Committee assembled in Washington to discuss the federal response. Their plan was to implement the decentralized response they had adopted for home defense a year earlier. The U.S. Public Health Service would manage the medical response and distribute posters and pamphlets educating the public about the illness. The Red Cross National Committee would communicate with its local organizations and direct the nursing response. The major response would have to be done at the local level (Fieser, 1941). Thus, immediately after the meeting, Director of the Red Cross Bureau of Nursing Services Clara Noyes telegraphed all Red Cross Divisions with a directive: “Suggest you organize Home Defense nurses … to meet present epidemic … Provide nurses with masks” (Noyes, 1918, p. 2).

In New York City, Lillian Wald, director of the Henry Street Settlement, did not need to be told to organize the nurses. In fact, she was all too aware of the alarming rapidity with which the flu was affecting the city’s residents; her staff had already been working around the clock. In the slums of the Lower East Side, epidemics of infectious diseases were commonplace, and in September 1918 it seemed this was just another bad flu epidemic—only this time the intensity of the disease and the devastation it caused were remarkable. Finally, on October 10, the Atlantic Division of the Red Cross assembled New York
City nursing leaders to plan their response. At that meeting the nurses created the Nurses’ Emergency Council to organize a city-wide response. The Red Cross also inserted a “quarter page advertisement in all the Sunday papers, calling for service from the women of the city” (Doty, 1919, p. 951).

In Philadelphia the situation was becoming increasingly serious, in part because on September 28, despite the fact that 123 civilians had been admitted to hospitals with flu just the day before, the city proceeded with its scheduled Liberty Loan parade to raise money for the war effort. Pandemic then exploded. By October 3, a doctor estimated that the city had seen 75,000 cases since September 11. Finally, the city government allocated $100,000 from its emergency war defense fund “to combat the disease” (Visiting Nurse Society, 1918, n.p.). It also coordinated all relief organizations under the direction of a central office and notified citizens struck with flu to call “Filbert 100” to obtain “a nurse, a doctor, an ambulance or an automobile” (Visiting Nurse Society, 1918, n.p.).

Under the direction of Katherine Tucker, RN, the Philadelphia Visiting Nurse Society handled thousands of influenza cases. In many of the families more than one member was ill; when both parents succumbed, the nurses had to supply food for the entire family. Soup kitchens were set up where the nurses could obtain soup, bread, and milk for such cases. And, as family after family was affected, the city’s social infrastructure crumbled. Thousands of city workers were out sick, including streetcar drivers, telephone receptionists, shopkeepers, and garbage collectors. When the few nurses there also became sick, the situation became critical. There were simply not enough nurses. According to Health Director Kreusen (Visiting Nurse Society, 1918), “If you would ask me the three things Philadelphia most needs to conquer the epidemic, I would tell you “Nurses, more nurses, and yet more nurses.” (n.p.)