Pandemic | Library | Royal College of Nursing

Disease is powerful.

It devastates communities and challenges modern health care. Florence Nightingale was the first nurse to link poor hygiene and sanitation to the spread of infectious disease. Cholera and typhoid were rife during the nineteenth century, when living conditions of the poor were overcrowded and squalid. When influenza struck in 1918, the impact on front line nurses and other clinicians was devastating.

Just over 100 years since the so called ‘Spanish flu’, every one of us living through 2020 has felt that impact for ourselves. The world we live in and the technology we use now looks very different. But throughout centuries of disease, it is the front line staff, who stand in the face of it.

With the help of vaccines many diseases are now rare. Smallpox for example, once rife, is now a fear of the past. Yet microbes that cause disease are adaptable, constantly modifying to be one step ahead of us. The more we fight them the stronger they become. Influenza has been visiting our homes for centuries, each time a different strain to the last. Nursing skills in this unpredictable environment become ever more vital, keeping infections at bay in our homes, clinics and hospitals.

Black and white postcard image of the interior of a diptheria ward at Leeds City Hospital, Seacroft. The portrait contains nurses, doctors and two child patients.

Image: Interior of a diphtheria ward at Leeds City Hospital, Seacroft, c.1920. RCN Archive.

Text saying: 'On the frontline' in blue on a white background with a patterned blue border

In the late nineteenth and early twentieth centuries, infected patients, particularly those with tuberculosis, would be admitted to a sanatorium. Often these institutions had large open air balconies and porches, where patients could get plenty of fresh air.

Around this time nurses began taking an active role in caring for infectious patients. Fever nurses washed and fed the sick, applied poultices and lotions, and monitored the patient’s temperature and breathing.

Nurses with experience of TB nursing would have used similar skills when caring for patients with influenza. Maintaining well ventilated wards and high hygiene standards were key to the nursing role, as they are today.

One of the first wards to experience the effects of the so-called Spanish Flu was St Marylebone Infirmary, London, in October 1918. The Sisters tirelessly cared for the weakened North Kensington community, as well as for their own colleagues. The effect on nursing staff was devastating. Through history, when a new disease strikes, it is often the nursing staff who are hit by it first.

"Temporary wood partitions have been put up between each bed…on each partition is hung a sheet wrung out in Lysol and kept wet…Every nurse, doctor, ward-maid, char-woman who enters the epidemic block must wear the mask and overall.”

-Nursing Times, 1918.

Sanatorium at Withernsea, 1906 shows patients and nurses sitting outside on porches and balconies.

Image: Sanatorium at Withernsea, 1906. RCN Archive.

Postcard of a 'Queen's' nurse walking through the snow to a cottage, 1926. RCN Archive.

Postcard of an illustration of a nurse reading from the bible to a uniformed soldier with his arm in a sling, 1914-1918. RCN Archive.

Title saying: 'Preventative measures' in blue with a mottled blue background artwork

Personal protective equipment, or PPE, has become a household term in 2020. Images of masked medics and robed nurses have been made all too familiar by the media in recent years. News reporting on the Ebola outbreak in 2014 is a key example of this. The Lassa Fever hospital in Kenema, Sierra Leone, was one of the first in the country hit by the Ebola virus. In just a few short months, the clinic lost 15 nurses to the disease.

To those outside Ebola affected countries, the current climate makes it easy to forget that Ebola outbreaks are still happening. More recent cases in the Democratic Republic of Congo’s Equateur province continue to be a concern. Responding to Ebola within the COVID-19 context is a huge challenge. UK nurses and health care teams continue to support local communities in Ebola prevention and health care maintenance.

"Today I woke up with a cold, a surprising thing given how many hundreds of times a day I wash my hands with chlorine to kill Ebola. Chlorine is the bullet that kills the enemy we can’t see."

-Nurse Gillian Mckay

Image: Ebola Survivors and Champions campaign poster, Social Mobilisation Action Consortium, 2015.

Artistic intervention

In 2015, artist Mary Beth Heffernan created an art intervention to humanise the alienating appearance of the Ebola “hazmat” suits. By taking headshot portraits of the health care workers and securing them to the outside of the suits, Mary Beth gave a face to the staff behind the masks. She says:

“The otherworldly appearance of the personal protective equipment (PPE) exacerbates patients’ isolation and fear of Ebola Virus Disease (EVD). The frightening effect diminishes clinicians’ ability to establish trust and emotionally connect with patients.”

Her PPE portraits are were used in Liberia at the ELWA II Ebola Treatment Unit in Paynesville, and the Tubmanburg Ebola Treatment Unit in Bomi County. Mary Beth's portrait project is now supporting COVID-19 patients and caregivers at Stanford University Medical School, among others.

Image: Melissa Kemokai, RN. Liberia 2015. Photo credit: Marc Campos.

Nursing staff at Hampstead Military Hospital, pictured with and without their influenza masks, 1918. Nursing Times article.

Tyvek PPE suit hoods with staff photographs by artist Mary Beth Heffernan, 2015. Pictured: Marthalyne Freeman RN, Rosaline D. Biago RN. Photo credit: Justine Desmond.

Different viruses are spread in many different ways.

In the early 1980s, hundreds of men were becoming sick and dying from an unknown illness spreading through the gay communities. Misunderstandings about how the disease spread led to fear, stigma and public anxiety. In 1983, Human Immunodeficiency Virus (HIV) was discovered and recognised as the virus that causes Acquired Immune Deficiency Syndrome (AIDS).

The face of HIV changed overnight when Princess Diana visited the Middlesex Hospital, in 1987. She sat and held the hands of men dying from AIDS without wearing gloves. That same year, the world’s first government sponsored national AIDS Awareness campaign was launched: Don’t Die of Ignorance.

At the start of the epidemic nurses were at the forefront of breaking down myths about how HIV was transmitted and developing standards of care. Today we still have no cure for HIV. But a person living with HIV who is accessing care and treatment now has a normal life expectancy.

Sunday Times cover article, 1987 Saying 'this issue is about AIDS, it also about you' in black text on a white background.

Title saying: 'Wash your hands' on a blue and white background with stylised graphics of ebola and flu viruses.

We have all become more familiar with the importance of handwashing regularly throughout the day. For nurses this has always been part of the daily routine. Whether working in Ebola-struck countries, or in UK hospitals today, how to correctly wash hands is fundamental to nursing training.

It was in the mid-nineteenth century in Vienna, that a connection was made between dirty hands and disease. Physician Ignaz Semmelweiss was noticing a trend in the death rates caused by infection among women following childbirth. The rate was much lower in clinics where midwives delivered babies than in another, where babies were delivered by physicians and medical students.

Semmelweiss concluded that the higher death rates were due to the physicians and students handling corpses during autopsies, before attending to the pregnant women. So called “cadaverous particles” were being transmitted on the physicians’ hands. After he introduced mandatory hand washing with a chlorine solution for all staff, death rates began to fall.

Today, nurses use alcohol-based sanitisers to clean their hands up to 50 times a day and chlorine remains a common disinfectant.

A stylised pair of hands being washed under a stream of water on a green, blue and white background.

Image: Stamp commemorating Ignaz Phillip Semmelweiss. Credit: Wellcome Collection.

We now face new challenges.

Through history, nurses continue to be the main source of care throughout a pandemic. Whilst the context has changed, the fundamentals of nursing care remain, such as hygiene, hydration, physical handling and bladder and bowel care. Today, these same essential procedures are aided by technologies and advanced procedures.

ICNs or Infection Prevention and Control nurses provide advice in all care settings, from health protection to commissioning of services and research. During 1918 influenza pandemic, many nurses had to live and work away from loved ones, just as they have been in 2020.

Pre antibiotics, we feared infection. Upon the discovery of antibiotics and the revolutionary results of vaccines, society entered a period of optimism. Cures had seemingly been found and people were surviving diseases that would have once killed them. This led society into complacency and a false sense of security.

We now find ourselves at the start of the cycle once more. COVID-19 has presented a new challenge as researchers and scientists work tirelessly to find a vaccine. Hygiene standards, especially hand-washing, still remain as the most important action we can all take to prevent the spread of disease. In these times of fear and uncertainty, it is the skill, knowledge and support of nursing that guides us through.

Don't let the bugs win!