FARGO — The coronavirus pandemic that has burned through North Dakota with ruthless efficiency now has claimed more lives than the official death toll of the Spanish influenza pandemic more than a century ago.

So far 1,435 lives have been lost to COVID-19 and deaths continue, though at a more gradual rate than during the pandemic’s peak last fall.

That number, current as of Friday, Feb. 19, exceeds the 1,378 deaths officially recorded in North Dakota from the Spanish flu in 1918-19 — but the actual death toll almost certainly greatly surpassed the official number in an era before death certificates became standard and before vital statistics reporting.

The actual number of lives lost to the influenza pandemic a century ago might have been closer to 3,235, the estimated toll from applying the national death rate.

Red Cross volunteer nurses making gauze masks, which were worn to try to prevent infection during the 1918 Spanish influenza pandemic. Centers for Disease Control and Prevention photo
Red Cross volunteer nurses making gauze masks, which were worn to try to prevent infection during the 1918 Spanish influenza pandemic. Centers for Disease Control and Prevention photo

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Still, the coronavirus pandemic has served as a lethal reminder of how serious infectious diseases can be — a painful awakening for a population that has grown complacent because of the largely invisible protections provided by modern sanitation and vaccinations.

A striking feature of North Dakota public health reports from 1918 to 1920, which encompassed the influenza pandemic, was just how common deadly infectious diseases were at a time when raw sewage was discharged into rivers, garbage was dumped in the open and not all milk was pasteurized.

Largely forgotten communicable diseases including diphtheria, scarlet fever, smallpox, tuberculosis and typhoid were routine scourges when the killer flu struck and spread like wildfire, fueled by the massive troop movements during World War I.

“There was a lot of infectious disease,” said Dr. Stephen McDonough, a retired Bismarck pediatrician and former senior state health official who wrote “The Golden Ounce: A Century of Public Health in North Dakota” in 1989.

Until antibiotics became widely available after World War II, and vaccines subdued many deadly communicable diseases, “They dealt with infectious diseases on a regular basis,” McDonough said.

The disruptive and deadly coronavirus pandemic, however, has reacquainted people with the dangers of infectious disease and the need to be vigilant, he said.

“This has been an awakening for the importance of public health,” McDonough said, adding experts warned for decades that another deadly pandemic was inevitable, but people shrugged it off — at great cost.

Failure to prepare for the inevitable pandemic was part of a broader complacency that settled in as the threat of infectious diseases became less prevalent, he said. In recent years, vaccine skepticism has increased, weakening public health protections.

“It was much easier to do immunizations” in the 1980s, when McDonough started practicing medicine in North Dakota. “The public easily accepted them,” he said.

During the time of the influenza pandemic a century ago, however, infectious disease was a grim fact of life.

Bismarck, for example, recorded 92 cases of scarlet fever, 76 measles cases, 17 typhoid cases, eight cases of smallpox and five cases of tuberculosis during 1918-20.

But those other diseases scarcely warranted mention in the report of the North Dakota State Board of Health. “During this period we have been visited by the worst epidemic, perhaps, the world has ever known,” the report said. Influenza overshadowed all other infectious diseases, “its appearance in a community brought with it almost a state of hysteria.”

Bismarck treated its drinking water with lime, iron sulphate and liquid chlorine, but dumped raw sewage into the Missouri River, its drinking water source, a common practice at the time.

Indoor toilets weren’t yet universal, and outhouses were present even in cities. “All outside toilets are inspected and cleaned at night,” the public health officer in Devils Lake wrote.

The crude sanitation practices at the time created breeding grounds for pathogens. Mayville passed an ordinance in the spring of 1919 requiring all people selling cows within city limits to be tested for tuberculosis.

The city’s public health board recommended that Mayville “take action at once to comply” with state law on garbage disposal, “but as yet little has been done by the city for garbage disposal,” the city’s health officer reported for 1918-20.

Mayville’s septic basin was cleaned by draining the contents into the Goose River. “The only means of garbage disposal we have at present is by emptying in sewer or burning in furnaces,” the health officer wrote.

Some cities were moving aggressively to improve sanitation. In April 1920, Minot was spending $280,000 for a new sewage treatment plan to replace the old disposal system, which discharged raw sewage into the Souris River.

The city of Grand Forks had a modern water filtration system by the time of the influenza epidemic — thanks to a deadly typhoid outbreak in 1893-94.

The outbreak resulted from a backflow of sewage in Crookston, Minn., in the fall of 1893 that filled a coulee until it broke out and entered the Red Lake River, which flowed downstream to Grand Forks, where the first wave of illness struck in December.

By January it became clear the outbreak was caused by typhoid fever and people began to clamor for a safe water supply. Ultimately, 40% of residents got sick. By the time the outbreak subsided in April 1894, 194 succumbed to typhoid fever, accounting for 13% of all deaths reported in the state, McDonough wrote.

“It was one of the biggest typhoid fever outbreaks in the history of the country, per capita,” McDonough said in an interview.

When Grand Forks built its new water treatment system later in 1894, it became the nation’s first fully enclosed sand filtration system — a progressive step at a time when many mistakenly believed that lakes and rivers could “self-purify.”

Diphtheria was another common killer infectious disease, and was especially lethal among children. An outbreak in 1890 in McIntosh County started in a family after a relative visited from Russia.

The contagion quickly hopscotched around the county, sparing some and sickening others in a puzzling pattern. “I attribute the rapid spreading and malignancy of this epidemic to the want of ordinary sanitary precautions and the total lack of provision for ventilation in the houses,” a doctor who investigated the outbreak wrote.

Many of the houses were made from sod and had sealed windows, and doors were kept shut to keep out farm animals, inhibiting ventilation. Thirteen died in the outbreak.

Smallpox was epidemic in North Dakota at the turn of the 20th century, McDonough wrote. In the first six months of 1902, 808 cases were reported with six deaths, although many mild cases never were recorded.

Then as now, quarantines were difficult to enforce. “Almost no locality has been free from the disease,” a doctor wrote of efforts to contain smallpox. “It has, however, been more prevalent in some counties than others, partly on carelessness in enforcing quarantine.”

As drinking water and sanitary sewer systems began to improve, tuberculosis emerged in the early 1900s as North Dakota’s biggest infectious disease killer, claiming more lives in 1906 than typhoid, smallpox, diphtheria, measles, scarlet fever, whooping cough and influenza combined, according to McDonough.

San Haven Sanitorium, a state hospital for those battling tuberculosis, an infectious disease that killed hundreds in the state for decades, opened in 1912. The main buildings are shown in this photograph from the 1920s. Special to The Forum / NDSU Archives
San Haven Sanitorium, a state hospital for those battling tuberculosis, an infectious disease that killed hundreds in the state for decades, opened in 1912. The main buildings are shown in this photograph from the 1920s. Special to The Forum / NDSU Archives

Tuberculosis is a bacterial infection that usually affects the lungs but can progress to the kidneys, bones and lining of the brain and can kill within months. The public health threat from tuberculosis was so great that the state opened the San Haven Sanatorium near Dunseith in 1912.

Even with a place to isolate the infected, tuberculosis killed 309 in 1925, a number that fell to 143 by 1939 and continued to dwindle. San Haven closed in 1987.

Spanish influenza surfaced in North Dakota when a Marine on leave visited New Rockford in September 1918. By Oct. 6, more than 100 flu cases were reported in New Rockford and 125 in Fargo.

A researcher later estimated that one in three Fargo residents became ill from influenza. By comparison, 11.4% of Cass County residents have tested positive for COVID-19, according to state health figures, although Columbia University researchers believe the actual number could exceed 50%.

Polio, a viral infection that causes paralysis in severe cases, emerged as a major public scare in the late 1940s and early 1950s, when smallpox and diphtheria were rapidly disappearing, though had been a top 10 communicable disease in North Dakota in the late 1920s.

In 1946, 492 cases of polio were reported in the state, including 28 deaths, and 150 cases treated in Fargo hospitals. But a vaccine became available in the 1950s and 520,875 residents were vaccinated between 1956 and 1958.

Penicillin, the first antibiotic, went into mass production following World War II, delivering a potent weapon against bacterial infections. A Golden Age in combating communicable disease — the result of antibiotics, vaccinations and modern sanitation — had arrived by the 1940s, McDonough wrote.