A century ago – during World War I, as it turned out, when so many were already dying of their wounds – a global pandemic killed millions more.

It was the Spanish flu.

There was no treatment, no vaccine, no antibiotics. Health officials estimate that 500 million people worldwide – a third of the planet's population – became infected. About 50 million people died.

This fall, the School of Science and representatives from other schools at the College of New Jersey in Ewing hosted numerous events to commemorate the centenary, including lectures, discussions, displays, a flu-themed Escape the Room tent, and a flu-vaccination clinic so students could get their annual shots.

Carole Kenner, a registered nurse with a doctorate in nursing who also is dean of the TCNJ School of Nursing, Health, and Exercise Science, recently spoke with us about the Spanish flu and how it led to sweeping changes in nursing and the health-care industry.

Carole Kenner, a registered nurse with a doctorate in nursing.
Courtesy of Carole Kenner
Carole Kenner, a registered nurse with a doctorate in nursing.
What was the Spanish flu? What happened?

It was a virus that we knew very little about at the time.  The first wave – there were three — started in spring 1918 and began really hitting military bases, where people lived in close quarters. The usual pattern occurs in the fall, so in this case, the fall of 1918 began the second wave. The third wave was in the spring of 1919. The reason it became called the Spanish flu is because Spain was more or less neutral and was not under the same constraints as far as talking about things that were going on. There was influenza in other countries, but you couldn't say much about what was going on in a war zone or military camp.

Again, because of the wartime conditions, more people were exposed. Normally, when you have a flu epidemic or a seasonal flu, two populations are extremely vulnerable: the very young and the very old. Also, people who have compromised immune systems. But with the Spanish flu, it was the 20-, 30-, 40-year-olds that were affected.

We knew very little about it. We just knew that we had an infection that was killing people, and people that you would expect to be healthy.  As it spread — it did come to the U.S. — everyone lived in fear.  Someone might be fine one day, and dead the next evening.

Here in the New Jersey and Philadelphia area, nurses were being deployed to work in the military. A school was started primarily to train nurses for military service overseas. That meant that a lot of nurses weren't around to care for the people that got sick here. Also, the nurses that were here were getting sick and dying. Six student nurses from one school who volunteered to stay and help died.  So, often, family members had to care for the sick.

Health officials were looking for any solution. They decided they could do a short training course for what they termed in those days a practical nurse.

How did the nursing profession change as a result?

This was the beginning of the division of the practical nurse, as we know it today, and the registered nurse. The hospitals were overwhelmed. We realized that everyone couldn't be trained at the same level. The practical nurse was given maybe three to six months of training and was geared toward being in the communities.

At the same time, it opened doors for the nursing profession. There was a lot of need for people to have special skills. That wasn't recognized prior to the pandemic.

The flu also increased the visibility of what nurses could do under these kinds of circumstances. It brought to the international forefront the realization that nurses were the front-line medical professionals. There were more of them than physicians. The status of nursing was raised, and … their role in health, in community and public health, was also more visible.

It also attracted more people to the profession. Over and over in our history, that has happened in times of disaster, and it was the same during the Spanish flu. People said, "If nurses can save lives, I want to do that."

The health-care industry overall changed, as well?

Public-health nursing was through the American Red Cross at that time. It wasn't public-health nursing as we know it today. They were having to beef up their responses to such an overwhelming number of people who were sick. Out of that grew the recognition that you needed to have a stronger public-health system to respond to these disasters. It scared people enough to make them realize they needed to have trained people in communities who could respond to situations like this. The community had to respond to the local problem, even if it was a national disaster.

So the public-health network was strengthened and solidified. Over time, that grew into a public-health network and alert system. The buzzwords we now use are population-focused health and disaster preparedness.

So the Spanish flu led to changes in how we respond to disasters?

Now, when we have disasters like floods, tornadoes, hurricanes, it's not just the first responders who come. It's health-care workers from the Red Cross, from public-health services, from the Centers for Disease Control and Prevention. They respond in a more organized fashion. They talk to each other. They know where the trained people are and how to deploy them, much like a military operation.

We use social media to get information out there quickly. For example, I was living in Boston during the bombing at the Boston Marathon. We had students at the marathon, thinking they were going to help with sprains and strains. After the bombing, we had no way of getting in touch with them because the cell phone networks were jammed.

Now, we have these alert networks. Just like we get notices about power outages on our cell phones, we send out alerts that say, "We need people to go to X."  We have surveillance systems and quarantine plans. We have a reporting network. Cases go into a database, so you can begin to track where pockets of outbreaks are and you can see where you need to deploy your workforce.

All that grew out of the times, like the era of the Spanish flu, where we were totally overwhelmed.

Even with all these advances, what more needs to be done?

My concern now is that we're cutting back on the funding for our public-health programs and public-health departments. Those areas have been underfunded for a while and, in some instances, are in danger of being cut. There is always the danger of outbreaks, whether we're talking about infectious disease or natural disasters.  We need to have more professional training. We need to strengthen the team approach, knowing what each of us brings to the table.

I've been on several planes in the past few years where there's been a medical emergency. They'll call over the intercom for anyone who has health-care experience. Several times, two or three of us will respond. The first thing we do is say, "I'm a nurse, my background is …" "I'm a doctor, my background is…" So we know how to respond as a team.

One time, an older person was feeling faint and was sweating. Three of us responded. My specialty is neonatal care. The other two were an oncologist and a thoracic surgeon. We said, "OK, it's a health assessment. We can do this."  It turned out he had diabetes. His planes had been delayed. He had not had enough to eat. He had become dehydrated. We figured that out in a few minutes. We checked his glucose. We got him some orange juice, and he did just fine.

It's just those kinds of situations that you have in disasters, where you've got to assemble the team that is there, know whom to deploy, know what the skill sets are, and know how to work together as a team.