How some cities flattened the curve during the 1918 flu pandemic
Social distancing isn’t a new idea—it saved thousands of American lives during the last great pandemic. Here’s how it worked.
New update: The Spanish Influenza Pandemic: a lesson from history 100 years after 1918. Past Mistakes: The Spanish Flu that started on March 1918 was almost eradicated by December of the same year thanks to global lockdowns; But impatient countries lifted their lockdowns too soon, which resulted in a 3rd wave of the virus to hit, infected & killed thousands more and lasted until 1920. Link: PMC
Source: National Geographic
PHILADELPHIA DETECTED ITS first case of a deadly, fast-spreading strain of influenza on September 17, 1918. The next day, in an attempt to halt the virus’ spread, city officials launched a campaign against coughing, spitting, and sneezing in public. Yet 10 days later—despite the prospect of an epidemic at its doorstep—the city hosted a parade that 200,000 people attended.
Flu cases continued to mount until finally, on October 3, schools, churches, theaters, and public gathering spaces were shut down. Just two weeks after the first reported case, there were at least 20,000 more.
The 1918 flu, also known as the Spanish Flu, lasted until 1920 and is considered the deadliest pandemic in modern history. Today, as the world grinds to a halt in response to the coronavirus, scientists and historians are studying the 1918 outbreak for clues to the most effective way to stop a global pandemic. The efforts implemented then to stem the flu’s spread in cities across America—and the outcomes—may offer lessons for battling today’s crisis. (Get the latest facts and information about COVID-19.)
From its first known U.S. case, at a Kansas military base in March 1918, the flu spread across the country. Shortly after health measures were put in place in Philadelphia, a case popped up in St. Louis. Two days later, the city shut down most public gatherings and quarantined victims in their homes. The cases slowed. By the end of the pandemic, between 50 and 100 million people were dead worldwide, including more than 500,000 Americans—but the death rate in St. Louis was less than half of the rate in Philadelphia. The deaths due to the virus were estimated to be about 385 people per 100,000 in St Louis, compared to 807 per 100,000 in Philadelphia during the first six months—the deadliest period—of the pandemic.
Dramatic demographic shifts in the past century have made containing a pandemic increasingly hard. The rise of globalization, urbanization, and larger, more densely populated cities can facilitate a virus’ spread across a continent in a few hours—while the tools available to respond have remained nearly the same. Now as then, public health interventions are the first line of defense against an epidemic in the absence of a vaccine. These measures include closing schools, shops, and restaurants; placing restrictions on transportation; mandating social distancing, and banning public gatherings. (This is how small groups can save lives during a pandemic.)
Of course, getting citizens to comply with such orders is another story: In 1918, a San Francisco health officer shot three people when one refused to wear a mandatory face mask. In Arizona, police handed out $10 fines for those caught without the protective gear. But eventually, the most drastic and sweeping measures paid off. After implementing a multitude of strict closures and controls on public gatherings, St. Louis, San Francisco, Milwaukee, and Kansas City responded fastest and most effectively: Interventions there were credited with cutting transmission rates by 30 to 50 percent. New York City, which reacted earliest to the crisis with mandatory quarantines and staggered business hours, experienced the lowest death rate on the Eastern seaboard.
In 2007, two studies published in the Proceedings of the National Academy of Sciences sought to understand how responses influenced the disease’s spread in different cities. By comparing fatality rates, timing, and public health interventions, they found death rates were around 50 percent lower in cities that implemented preventative measures early on, versus those that did so late or not at all. The most effective efforts had simultaneously closed schools, churches, and theaters, and banned public gatherings. This allowed time for vaccine development and lessened the strain on health care systems.
The studies reached another important conclusion: That relaxing intervention measures too early could cause an otherwise stabilized city to relapse. St. Louis, for example, was so emboldened by its low death rate that the city lifted restrictions on public gatherings less than two months after the outbreak began. A rash of new cases soon followed. Of the cities that kept interventions in place, none experienced a second wave of high death rates. (See photos that capture a world paused by coronavirus.)
In 1918, the studies found, the key to flattening the curve was social distancing. And that likely remains true a century later, in the current battle against coronavirus. “[T]here is an invaluable treasure trove of useful historical data that has only just begun to be used to inform our actions,” Columbia University epidemiologist Stephen S. Morse wrote in an analysis of the data. “The lessons of 1918, if well heeded, might help us to avoid repeating the same history today.”
How a Fragmented Country Fights a Pandemic
During the 1918 influenza crisis, public officials faced similar challenges to the ones American government is confronted with today.
Over the past week, Americans have seen a sudden, dizzying variety of social-distancing measures ordered by mayors, county officials, and state governors. For better or worse, the nation’s defense against pandemics depends on such local decision making. This is because the unique system of federalism in the U.S. makes it one of the most decentralized public-health systems in the world.
he U.S. legal system has been here before—just over a century ago, during the pandemic influenza of 1918–1919, the most severe pandemic in recent history. Then, too, public officials faced constraints on their knowledge, authority, and capacity to deal with the crisis. The result was a patchwork approach that radically, if temporarily, changed American life.
Were they still with us, that generation could tell us much about what we face now—what it was like to go on with daily life in the midst of travel shutdowns, school and business closings, and bans on public gatherings of any size. State and local governments imposed a variety of restrictions on daily life that constitute “social distancing” measures in modern terminology. They had little choice: There was no cure and no vaccine for this particularly deadly strain of flu that spread easily from person to person. For COVID-19, health officials emphasize that similar measures are “the only viable strategy at the current time.”
The nation’s expectations about what the federal government could do to help were very different in 1918 than they are today. On September 28 of that year, Surgeon General Rupert Blue, in the crisp blue military uniform of the U.S. Public Health Service, testified before the Senate Appropriations Committee that the nation needed federal help: “Until we get a vaccine we have to rely upon careful treatment of the sick, keep away from crowds, and cover up the mouth and nose so that they will not spread the disease.”
Even with the $1 million Congress agreed to that fall, Blue could do little more than try to coordinate the distribution of doctors, nurses, and supplies from richer states to poorer ones. He also provided advice and information to local health authorities, including urging bans on public gatherings anywhere the flu was present. Eventually, the Public Health Service published 6 million bulletins, posters, and newspaper articles and distributed them throughout the country.
Meanwhile, city and county officials made their own decisions about when to close schools, stop travel, and prevent public gatherings. Examples abound of the variation in decision-making abilities among local leaders. The City of St. Louis took the surgeon general’s advice to close schools, churches, and places of entertainment, and to cancel public events. Philadelphia did not.
The result, as The New York Times recently reported, was a dramatic difference in death rates between the two cities. In Philadelphia, health officials suggested to the mayor that a parade in support of the sale of war bonds should be canceled in light of the epidemic, but the mayor refused. Huge crowds showed up, and flu cases spiked afterward. By contrast, St. Louis more quickly and promptly shut down public gatherings and had one-eighth as many flu-related fatalities at the end.
The influenza pandemic hit the country unevenly in three waves over the course of two years. The greatest hardship for families and individuals was economic: restaurants, bars, and other businesses were ordered to close. Such measures took away livelihoods and caused widespread unemployment with no social-safety net to fall back on—this was, of course, before the advent of the country’s major welfare programs during the New Deal. Local welfare barely existed, and private charities, often the only option, were overwhelmed just like everybody else. Prohibitions on church services and funerals pained people emotionally and spiritually.
A resigned and terrified population mostly complied with the orders of mayors, town councils, health officers, and school boards. (Those ordered into complete isolation were too sick to be out anyway.) But residents sometimes turned to the courts to challenge these measures—not surprising, perhaps, given American legal traditions and strong notions of individual liberties in the U.S.
State and local judges, in response, routinely upheld the measures. For example, residents of Globe, Arizona, objected to their local health board’s order closing “all theaters, motion picture shows, banks, business houses, pool halls, shooting galleries, lodges, schools, and churches,” throwing in for good measure “any other place people are congregated.” The Supreme Court of Arizona was unsympathetic to the complaining residents and upheld local authority: “Necessity is the law of time and place, and the emergency calls into life the necessity … to exercise the power to protect the public health.”
While medical experts could not always agree on the steps local governments should take to prevent the spread of the flu, the most widely recommended were strict quarantines of towns and the mandatory use of face masks in public, although, as The New York Times reported on December 13, 1918, health officials in some of America’s larger cities “opposed both these measures and placed great reliance on [the development of a] vaccine.”
When local governments ordered residents to wear face masks when outside their homes, they often had to make their own because face masks were not available for purchase. The Red Cross organized volunteers to make masks and distributed them free throughout the nation, but more were needed. On September 28, 1918, The Boston Daily Globe instructed readers how to make a gauze mask; the Boston commissioner of health urged his constituents to “make any kind of a mask, any kind of a covering for the nose and mouth and use it immediately and at all times. Even a handkerchief held in place over the face is better than nothing.”
As one can well imagine, compulsory face-mask laws were hugely unpopular. News reports noted resistance in many towns across the nation. The local health officer might order it; whether the police chief would enforce it was another matter. Usually arrests were made without violence, but in one notable instance a San Francisco health officer shot three people, two of them innocent bystanders. Under the alarming headline “Refuses to Don Influenza Mask; Shot by Officer,” a reporter for The Bellingham Herald described how the attempted arrest for refusal to wear a face mask led to the shooting:
On October 27, 1918, a special officer for the board of health named Henry D. Miller shot and severely wounded James Wisser in front of a downtown drug store at Powell and Market street, following Wisser’s refusal to don an influenza mask. According to the police, Miller shot in the air when Wisser first refused his request. Wisser closed in on him and in the succeeding affray, Miller shot him in the leg and right hand. Wisser was taken to the central emergency hospital, where he was placed under arrest for failure to comply with Miller’s order.
Tucson, Arizona, even featured what a local reporter called “influenza court,” to handle the cases of citizens who had been issued citations for not wearing face masks, or not wearing them properly (including cutting holes in masks to smoke). The police chief declared, “We are going to enforce this ordinance or close up the town entirely.” Fines were generally $10. Judges would listen to excuses, although they were rarely countenanced.
One day in the court, 28 people appeared to appeal for relief from the $10 fine. None were excused, although some were creative. The judge noted that “when one’s mask is in the wash, it is no exemption from wearing it.” (Presumably one should stay home on wash day.) One resident wanted only “a brief privilege of fresh air”; he hated that the privilege cost him a week’s wages. The judge also held that “a pink muffler is not a legal substitute for a mask.”
A study in 2007 asked what pandemic planners could learn from the social-distancing measures imposed during the 1918–19 pandemic. The authors concluded that school closure, public-gathering bans, transportation restrictions, limited closure of businesses, and even face-mask ordinances almost certainly mitigated the consequences of what they termed “the most deadly contagious calamity in human history.”
The 1918 experience, they wrote, teaches that sustained social-distancing measures are beneficial, and need to be “on” throughout the particular peak of a local experience. Despite no effective vaccine, U.S. cities that “were able to organize and execute a suite of classic public health interventions before the pandemic swept fully through the city” appeared to do better than those that did not. Judges routinely upheld the emergency measures identified in the study, recognizing the need to defer to health authorities in the face of the unknown.
The homemade face mask probably did some good as well, or at least was better than nothing, especially when caring for patients at home—akin to current advice to cough into your elbow (or a pink muffler, so long as you throw it away afterward).
Hardship, fear, and dejection undoubtedly accompanied the nearly complete shutdown of social life in many cities. Yet it also brought out a remarkable spirit of charity. For those who lived through it, the lifting of bans on public gatherings brought immediate celebration. The Los Angeles Times noted the “fiesta spirit” that pervaded that city, bringing to an end the city’s “longest funless” season.
On December 3, 1918, the paper reported, “From the depression of closed theaters and other places of amusement, closed churches and assembly halls, the city reacted yesterday to the spirit of gladness.” People who had been “staying closely at home for weeks” joined the throngs downtown to celebrate, shop, attend a movie. Stores were filled with shoppers, and “long lines of people reached even out into the corridors at the Public Library.”
A return to normalcy occurred throughout the nation as public-gathering bans were gradually lifted. They celebrated when the worst was past—not even knowing the Roaring Twenties were right around the corner.