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How U.S. Cities Tried to Halt the Spread of the 1918 Spanish Flu

How U.S. Cities Tried to Halt the Spread of the 1918 Spanish Flu

In the late summer of 1918, the devastating second wave of the Spanish flu arrived on America’s shores. Carried by World War I doughboys returning home from Europe, the newly virulent virus spread first from Boston to New York and Philadelphia before traveling West to infect panicked populations from St. Louis to San Francisco.

Lacking a vaccine or even a known cause of the outbreak, mayors and city health officials were left to improvise. Should they close schools and ban all public gatherings? Should they require every citizen to wear a gauze face mask? Or would shutting down important financial centers in wartime be unpatriotic?

When it was all over, the Spanish flu killed an estimated 675,000 Americans among a staggering 20 to 50 million people worldwide. Certain U.S. cities fared far worse than others, though, and looking back more than a century later there’s evidence that the earliest and most well-organized responses slowed the spread of the disease—at least temporarily—while cities that dragged their feet or let down their guard paid a heavier price.

Philadelphia Holds a Parade

By mid-September, the Spanish flu was spreading like wildfire through army and naval installations in Philadelphia, but Wilmer Krusen, Philadelphia’s public health director, assured the public that the stricken soldiers were only suffering from the old-fashioned seasonal flu and it would be contained before infecting the civilian population.

When the first few civilian cases were reported on September 21, local physicians worried that this could be the start of an epidemic, but Krusen and his medical board said Philadelphians could lower their risk of catching the flu by staying warm, keeping their feet dry and their “bowels open,” writes John M. Barry in The Great Influenza: The Story of the Deadliest Pandemic in History.

As civilian infection rates climbed day by day, Krusen refused to cancel the upcoming Liberty Loan parade scheduled for September 28. Barry writes that infectious disease experts warned Krusen that the parade, which was expected to attract several hundred thousand Philadelphians, would be “a ready-made inflammable mass for a conflagration.”

Krusen insisted that the parade must go on, since it would raise millions of dollars in war bonds, and he played down the danger of spreading the disease. On September 28, a patriotic procession of soldiers, Boy Scouts, marching bands and local dignitaries stretched two miles through downtown Philadelphia with sidewalks packed with spectators.

Just 72 hours after the parade, all 31 of Philadelphia’s hospitals were full and 2,600 people were dead by the end of the week.

George Dehner, author of Global Flu and You: A History of Influenza, says that while Krusen’s decision to hold the parade was absolutely a “bad idea,” Philadelphia’s infection rate was already accelerating by late September.

“The Liberty Loan parade probably threw gasoline on the fire,” says Dehner, “but it was already cooking along pretty well.”

St. Louis Flattened the Infection Curve

The public health response in St. Louis couldn’t have been more different. Even before the first case of Spanish flu had been reported in the city, health commissioner Dr. Max Starkloff had local physicians on high alert and wrote an editorial in the St. Louis Post-Dispatch about the importance of avoiding crowds.

When a flu outbreak at a nearby military barracks first spread into the St. Louis civilian population, Starkloff wasted no time closing the schools, shuttering movie theaters and pool halls, and banning all public gatherings. There was pushback from business owners, but Starkloff and the mayor held their ground. When infections swelled as expected, thousands of sick residents were treated at home by a network of volunteer nurses.

Dehner says that because of these precautions, St. Louis public health officials were able to “flatten the curve” and keep the flu epidemic from exploding overnight as it did in Philadelphia.

“It’s that crush of new cases in such a short period of time that completely overwhelms a city’s capacity,” says Dehner. “That magnifies whatever problems you’re already having.”

According to a 2007 analysis of Spanish flu death records, the peak mortality rate in St. Louis was only one-eighth of Philadelphia’s death rate at its worst. That’s not to say that St. Louis survived the epidemic unharmed. Dehner says the midwestern city was hit particularly hard by the third wave of the Spanish flu which returned in the late winter and spring of 1919.

San Francisco Enforces Wearing Masks

WATCH: The Spanish Flu Was Deadlier Than WWI

In San Francisco, health officials put their full faith behind gauze masks. California governor William Stephens declared that it was the “patriotic duty of every American citizen” to wear a mask and San Francisco eventually made it the law. Citizens caught in public without a mask or wearing it improperly were arrested, charged with “disturbing the peace” and fined $5.

In his book, Barry says that the gauze masks city officials claimed were “99 percent proof against influenza” were in reality hardly effective at all. San Francisco’s relatively low infection rates in October were probably due to well-organized campaigns to quarantine all naval installations before the flu arrived, plus early efforts to close schools, ban social gatherings and close all places of “public amusement.”

PHOTOS: Innovative Ways People Tried to Protect Themselves From the Flu

On November 21, a whistle blast signaled that San Franciscans could finally take off their masks and the San Francisco Chronicle described “sidewalks and runnels… strewn with the relics of a tortuous month.”

But San Francisco’s luck ran out when the third wave of the Spanish flu struck in January 1919. Believing masks were what saved them the first time, businesses and theater owners fought back against public gathering orders. As a result, San Francisco ended up suffering some of the highest death rates from Spanish flu nationwide. The 2007 analysis found that if San Francisco had kept all of its anti-flu protections in place through the spring of 1919, it could have reduced deaths by 90 percent.

Read more:

Why the Second Wave of the 1918 Spanish Flu Was So Deadly

Spanish Flu - Symptoms, How It Began & Ended

Amid 1918 Flu Pandemic, America Struggled to Bury the Dead

Why October 1918 Was America's Deadliest Month Ever

Pandemics That Changed History: Timeline

Rapid Response was Crucial to Containing the 1918 Flu Pandemic

One of the persistent riddles of the deadly 1918 Spanish influenza pandemic is why it struck different cities with varying severity. Why were some municipalities such as St. Louis spared the fate of the hard-hit cities like Philadelphia when both implemented similar public health measures? What made the difference, according to two independent studies funded by the National Institutes of Health (NIH), was not only how but also how rapidly different cities responded.

Cities where public health officials imposed multiple social containment measures within a few days after the first local cases were recorded cut peak weekly death rates by up to half compared with cities that waited just a few weeks to respond. Overall mortality was also lower in cities that implemented early interventions, but the effect was smaller. These conclusions — the results of systematic analyses of historical data to determine the effectiveness of public health measures in 1918 — are described in two articles published online this week in the journal Proceedings of the National Academy of Sciences.

“These important papers suggest that a primary lesson of the 1918 influenza pandemic is that it is critical to intervene early,” says Anthony S. Fauci, M.D., director of NIH’s National Institute of Allergy and Infectious Diseases (NIAID), which funded one of the studies. “While researchers are working very hard to develop pandemic influenza vaccines and increase the speed with which they can be made, nonpharmaceutical interventions may buy valuable time at the beginning of a pandemic while a targeted vaccine is being produced.”

The historical analyses are part of an ongoing effort called the Models of Infectious Disease Agent Study (MIDAS), which is supported by NIH’s National Institute of General Medical Sciences (NIGMS). Through MIDAS, researchers have developed computer models to examine how a future pandemic influenza virus might spread and what interventions could minimize the impact.

“Although the MIDAS models can’t predict the exact spread of a potential influenza pandemic, they have all suggested that introducing public health measures soon after the first cases appear could greatly reduce the number of people who get sick,” says NIGMS Director Jeremy M. Berg, Ph.D. “The historical analyses help validate the models’ conclusion and their potential usefulness in preparing for a pandemic.”

The ideal way to contain a potential influenza pandemic would be to vaccinate large numbers of people before they were exposed to an influenza virus strain that is easily transmitted from person to person. Developing such a vaccine in advance, however, is difficult because an influenza virus mutates as it replicates, and over time these mutations can alter the virus enough that older vaccines are no longer effective. With current technologies, it would take months to develop a new vaccine after the first cases of pandemic influenza appear.

Nonpharmaceutical interventions may limit the spread of the virus by imposing restrictions on social gatherings where person-to-person transmission can occur. The first of the two historical studies, conducted by a team of researchers from NIAID, the Department of Veterans Affairs, and the Harvard School of Public Health, looked at 19 different public health measures that were implemented in 17 U.S. cities in the autumn of 1918. The second study, undertaken at Imperial College London, looked at 16 U.S. cities for which both the start and stop dates of interventions were available.

Schools, theaters, churches and dance halls in cities across the country were closed. Kansas City banned weddings and funerals if more than 20 people were to be in attendance. New York mandated staggered shifts at factories to reduce rush hour commuter traffic. Seattle’s mayor ordered his constituents to wear face masks. The first study found a clear correlation between the number of interventions applied and the resulting peak death rate seen. Perhaps more importantly, both studies showed that while interventions effectively mitigated the transmission of influenza virus in 1918, a critical factor in how much death rates were reduced was how soon the measures were put in place.

Officials in St. Louis introduced a broad series of public health measures to contain the flu within two days of the first reported cases. Philadelphia, New Orleans and Boston all used similar interventions, but they took longer to implement them, and as a result, peak mortality rates were higher. In the most extreme disparity, the peak mortality rate in St. Louis was only one-eighth that of Philadelphia, the worst-hit city in the survey. In contrast to St. Louis, Philadelphia imposed bans on public gatherings more than two weeks after the first infections were reported. City officials even allowed a city-wide parade to take place prior to imposing their bans.

If St. Louis had waited another week or two, they might have fared the same as Philadelphia, says the lead author on the first study, Richard Hatchett, M.D., an associate director for emergency preparedness at NIAID. Despite the fact that these cities had dramatically different outcomes early on, all the cities in the survey ultimately experienced significant epidemics because, in the absence of an effective vaccine, the virus continued to spread or recurred as cities relaxed their restrictions.

The second study also shows that the timing of when control measures were lifted played a major part. Cities that relaxed their restrictions after the peak of the pandemic passed often saw the re-emergence of infection and had to reintroduce restrictions, says Neil Ferguson, D.Phil., of Imperial College, London, the senior author on the second study. In their paper, Dr. Ferguson and his coauthor used mathematical models to reproduce the pattern of the 1918 pandemic in different cities. This allowed them to predict what would have happened if cities had changed the timing of interventions. In San Francisco, which they found to have the most effective measures, they estimate that deaths would have been 25 percent higher had city officials not implemented their interventions when they did. But had San Francisco left its controls in place continuously from September 1918 through May 1919, the analysis suggests, the city might have reduced deaths by more than 90 percent.

The fact that the early, nonpharmaceutical interventions were effective at the height of the pandemic can inform pandemic planners today, the authors of both studies say. In particular, the two studies lend weight to guidance that the Centers for Disease Control and Prevention recently released on the use of nonpharmaceutical interventions during a pandemic (http://www.pandemicflu.gov/plan/community/mitigation.html), which recommends precisely such a rapid early response.

NIAID is a component of the National Institutes of Health. NIAID supports basic and applied research to prevent, diagnose and treat infectious diseases such as HIV/AIDS and other sexually transmitted infections, influenza, tuberculosis, malaria and illness from potential agents of bioterrorism. NIAID also supports research on basic immunology, transplantation and immune-related disorders, including autoimmune diseases, asthma and allergies. News releases, fact sheets and other NIAID-related materials are available on the NIAID website at http://www.niaid.nih.gov.

NIGMS supports basic biomedical research that is the foundation for advances in disease diagnosis, treatment, and prevention. For more information about the Models of Infectious Disease Agent Study, visit http://www.nigms.nih.gov/Initiatives/MIDAS/.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

NIH&hellipTurning Discovery Into Health ®


R Hatchett et al. Public health interventions and epidemic intensity during the 1918 influenza pandemic. PNAS DOI: 10.1073/pnas.0610941104 (2007)

M Bootsma and N Ferguson. The effect of public health measures on the 1918 influenza pandemic in US cities. PNAS DOI: 10.1073/pnas.0611071104 (2007)

What worked against the Spanish flu

Plasma transfusions

A plasma bag. Plasma transfusions were used successfully with some patients. (Photo: Jeremy-Gunther-Heinz Jahnick/CCBYSA3.0)

Among the medical treatments, the only one that had some effect was the plasma transfusion.

When a virus infects a person, their body fights off the intruder by creating specific antibodies against that virus.

After the virus is beaten, the antibodies remain in the blood. In that way, if the body gets reinfected, the antibodies are ready to fight the intruder again.

But the body takes a while to react to an unknown virus it does not make the antibodies immediately. It may take a week, two, or more. And in that time, the virus may have already wreaked havoc in the body.

Enter the plasma transfusions. Someone who had recovered from the Spanish flu donated their antibody-rich blood. Their plasma was injected into someone that was sick with the flu. And the ready-made antibodies helped them fight off the virus.

It did not work in all cases, but the treatment did have moderate success. Furthermore, it was the only medical treatment that worked at all against the Spanish flu.

Social distancing and lockdowns

A driver in Seattle, U.S., telling an unmasked man that he cannot enter the trolley. Seattle applied several measures like social distancing and had a low death rate. (Photo: Wikimedia/Public domain)

Social distancing rules and lockdowns were the best tools against the pandemic.

The towns that shut themselves up and prohibited or quarantined incoming visitors, banned gatherings, and closed schools and the like, were the ones that weathered the storm with few casualties.

Or in the case of Gunnison, Colorado, with zero casualties. That is quite impressive since all the towns surrounding Gunnison reported flu-deaths.

Shishmaref, Alaska, and American Samoa also went for a total lockdown and escaped the plague. They did not have one single sick person.

For comparison, other villages in Alaska that did not go into a lockdown lost up to 90% of their population. And unlocked Western Samoa, American Samoa’s neighbor, lost 22% of its population.

In the U.S., each town and city chose how to fight -or not fight- the flu.

San Francisco acted swiftly. Before the second wave of the flu arrived, the authorities quarantined visitors and closed schools, theaters, and bars. When the plague hit them, they had social distancing rules in place, and the use of masks was mandatory in public.

San Francisco had relatively few deaths during that second wave (1,800 in a population of 500,000).

But then the flu subsided, and the third wave hit them.

This time local business owners refused to comply with the mayor and close their stores, thinking that the masks – and not the lockdown- had saved them the first time. Sadly, they were wrong.

In the first days of January 1919, an average of 20 San Franciscans were dying with the flu every day.

And the mild third wave that elsewhere killed few, in San Francisco killed twice as many as the locked-down second wave.

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.

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 358 people per 100,000 in St Louis, compared to 748 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, a study in the Journal of the American Medial Association analyzed health data from the U.S. census that experienced the 1918 pandemic, and charted the death rates of 43 U.S. cities. That same year, 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 would allow time for vaccine development (though a flu vaccine was not used until the 1940s) 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 U.S. Cities Tried to Halt the Spread of the 1918 Spanish Flu - HISTORY

In the fall of 1918, as cases of Spanish Influenza started to rise across the country and in Humboldt County, health officials recognized the virulence of the disease and how gatherings of even a few people could feed an exponential spread. In mid-October, the U.S. Public Health Service cautioned:

It is now believed that influenza Is always spread from person to person, the germs being carried with the air along with the very small droplets of mucus, expelled by coughing or sneezing, forceful talking, and the like by one who already has the germs of the disease. They may also he carried about in the air in the form of dust coming from dried mucus, from coughing and sneezing, or from careless people who spit on the floor or on the sidewalk.

By the end of October, the State Board of Health would warn that simply by talking, an infected person spread invisible droplets that could give the virus to anyone located within four feet. Coughing increased that radius to 10 feet. Wearing a mask, advice often repeated in the months to come, offered the “greatest service in preventing the spread of the disease.” Those who fell ill were urged to isolate themselves immediately to avoid dangerous complications. Perhaps most importantly, the agency warned that “As in most other catching diseases, a person who has only a mild attack of the disease himself may give a very severe attack to others.”

As local case counts continued to rise in Eureka and the surrounding communities, local medical providers voiced concern about their ability to adequately respond to the crisis. On October 19, Humboldt had its first flu-related fatality, reported on page 12 of the Humboldt Times. Victor Tonini, a longshoreman and member of the Italian Order of Druids, left a wife and five children, the oldest 11 years “and the youngest but three months of age.” The same day, the Eureka Board of Health closed all public meeting places, including theaters, fraternal orders, clubs, and dances, prohibiting public meetings and other “assemblages of people.”

Three days later, after over 150 people were diagnosed with the “flu” in Eureka alone, including many nurses and two physicians. Eureka’s officials heeded the State Board of Heath’s advice and ordered “all persons serving the public” to wear influenza masks to slow the spread of the virus. Humboldt County’s Board of Health followed suite, ordering that every person employed in a store, hotel, restaurant, hospital, streetcar, saloon or “in any way waiting upon or serving the public” wear a mask. The order added, “If in doubt as to whether this means you, wear one.” The mask could be simple folds of gauze or cheese cloth. and tied to cover the month and nose completely. Initially people were advised to keep the mask damp with a disinfectant, but that recommendation did not last.

The downtown streets were washed down to dispel any dust that might carry the disease. Many lumber camps, like that owned by William Carson, where men shared close quarters, were closed and fumigated though at least one camp manager took a different approach. According to Matina Kilkenny in her story “Missing Faces,” Carl Munther, superintendent of the California Barrel Company’s McKinleyville camp, kept his camp running and workers healthy by quarantining each employee as they returned from town. Upon arriving back to camp, workers were required to stay for four days in a tent set up away from the workers’ cabins. This policy discouraged workers from leaving in the first place and it kept the disease at bay, with not a single case recorded at the camp during the epidemic.

On October 23, Dr. Wing, Eureka’s Health Official, reported 182 new influenza cases in a single day, up from 125 new cases the day before but still insisted the illness could “soon run its way out” IF [emphasis added] all directions and precautions of the Board of Health were followed. Volunteers set about making anti-flu masks “as rapidly as scissors, fingers and sewing machines could be made to operate” but many still refused to use them, asserting that they had no fear of the disease.

Local businessmen did, if only for the impact on their bottom line. In desperation, they paid for a full-page newspaper ad and made posters imploring the community to wear masks to keep the city’s business interests from being “paralyzed.” The ad seemed to work, as the next day the Humboldt Times reported a “veritable bread line” for masks. Streets, alleyways, homes and businesses were also ordered to be cleaned regularly to stop the spread of germs.

Ad in The Humboldt Times, October 24, 1918.

Despite increasing case counts, at least ten deaths and drastic closures in the community, the editor of the Humboldt Times encouraged the community to “keep smiling”, reassuring readers that the world would not “be turned into a howling wilderness” because of the epidemic, as long as people avoided crowds and wore masks. Even if they thought it unnecessary, the editor admonished, they should wear them “to set an example for others whose lives may be saved by It.” The editorial also prescribed “copious doses of common sense… well digested.” After all, he observed, common sense never did any harm.

On October 25, the County Council of Defense issued “drastic orders”, enforced by the police, that closed non-essential businesses in Eureka and required residents and visitors to wear masks. Smokers, who were used to pulling masks aside to enjoy their habit, would not be excused.

Unfortunately, the country was now fighting two wars, one against the virus and the other against the “Huns”. The new demand for masks diverted 500 yards of gauze marked for surgical dressings for the war front in a single day and to save the precious material, citizens were encouraged to boil and reuse their masks or make them at home using handkerchiefs or other “sanitary” material. Instructions on mask making “so easy, even a child could do it” were included in multiple papers.

The Humboldt Times, Blue Lake Advocate and others now regularly reminded readers that masks were “the best preventative in other cities” and within days of the orders, Dr. Wing proclaimed that the worst of the disease was over, thanks in large part by wide use of masks.

“Coughs and Sneezes Spread Diseases.” Blue Lake Advocate, October 19, 1918.

But compliance was far from universal. Non-masked arrivals to Eureka, many from the mills and shipyards across the bay and accustomed to dropping into a saloon on their way from the boat for a drink or two before going home, were escorted by officers to the nearest drug store to purchase masks. Others received warnings. On October 28, 1918, Ole Olsen was arrested for refusing to pull the mask under his chin up over his nose and mouth and Jesus Lopez was booked for refusing to wear one at all. Lopez was the first “mask slacker” to be fined, and his $5 was forwarded to the Red Cross. Other “mask slackers” were required to “buy themselves a mask”, the price/fine varying depending on the amount they had in their possession.

At the end of October, Arcata followed Eureka’s lead by closing public places and required masks in public and on November 5, at a special meeting, the County Board of Supervisors passed a new ordinance requiring masks and authorizing a maximum penalty of $25 and up to 10 days in the county jail for violators. The city of Eureka passed a similar ordinance shortly thereafter.

On November 2, officials in San Francisco were declaring the epidemic under control and some county officials proclaimed the same, explaining that deaths were still increasing only because the epidemic was running “the end of its course”. Local physicians, like Dr. C. Mercer, then bedridden with the disease, disagreed, blaming the “stubbornness of the epidemic” on the “laxity prevailing among many citizens with respect to the wearing of anti-flu masks.”

Unfortunately, Mercer was right. On November 7, San Francisco reported seventy-three new cases, up 23 from the day before and 48 deaths. Local reports included 78 new cases in two days and one fatality. The Board of Health again emphasized the necessity of “taking every precaution possible, especially the wearing of masks, and the avoidance of crowds, whether indoors or out.” Violators risked arrest and fines, but some, like Gunder Christiansen, arrested twice for wearing his mask under his chin, still stubbornly resisted the order. On November 9, at least 22 people were arrested and fined for similar offenses in Eureka and on November 11, following celebrations dedicated to the end of the war, another 40 were arrested, most of the them drunk. Another arrested was Florence Ottmer, a well-respected local doctor, who apparently wore a mask in public from then on.

Sheriff Redmon and his deputies toured the county’s smaller communities to answer questions and encourage compliance, but some, including residents of Alderpoint, disputed their authority. In response, the local District Attorney assured them that “the quickest and surest way of ascertaining the validity of the ordinance is to appear without a mask, be placed under arrest by the constable, hire an attorney and plead the case.”

In Eureka, though, things were shifting, likely in part from pressure from businesses feeling the economic impact of reduced hours and/or shuttered doors. On November 16, the city of Eureka’s Board of Health pulled the trigger, allowing businesses to resume as normal, as long as people did not congregate and masks were consistently worn. On November 17, with no deaths reported in two days and a continued decline in new cases, the Humboldt Times happily reported that Eureka was “taking on a more lifelike and uplifted air” with more people on the streets and increased traffic in the business district. Perhaps, the editor surmised, the epidemic was at last controlled, and soon the city would return to “a normal condition of life and pleasure.”

While schools remained closed, starting November 19, saloons that prevented crowds could again extend their hours a and ice cream parlors and theaters could open the following Saturday. Dances were allowed to resume on November 24 but permission was rescinded on November 28 after the health board warned that, ” that in a crowded dance hall, in a hot and perspiring condition, the danger of contagion would be at its height, and probably result in another outbreak.”

Dr. Wing continued to reassure the community that the epidemic was played out and the current fatalities were a “normal condition” after such a crisis. He suggested that mask restrictions be discarded within a five-block radius of Eureka’s business district (perhaps as Eureka’s health official he was responding to political pressure?). At the stroke of midnight on November 28, the mask order was rescinded. Fortuna also proclaimed the flu bug “captured” and celebrated with a large gathering in front of the Star Hotel but other communities continued to battle the virus and as residents would soon discover, the crisis was not over….

The medical response to the Spanish Flu, including a plea for volunteers, setting up satellite hospitals, the death of healthcare workers and more.

Lynette Mullen writes about Humboldt County history at Lynette’s NorCal History Blog.

  • During the 1918 pandemic known as the 'Spanish flu,' two American cities - Philadelphia and St. Louis - had vastly different approaches to the disease
  • Philadelphia held a parade, which drew 200,000 people, to disastrous results: the city's hospitals were full in 72 hours and it would soon see 2,600 deaths
  • St. Louis banned gatherings, closed businesses, and treated the sick at home. It was able to 'flatten the curve' and had a lower death rate than Philadelphia
  • The pandemic, which had 3 waves, killed at least 50 million people worldwide

Published: 16:56 BST, 27 March 2020 | Updated: 00:43 BST, 28 March 2020

Businesses and schools shuttered. Uncertainty unspooled and panic was palpable. Social distancing rules doled out differently depending on the local government.

America has been here before: in 1918.

Over 100 years ago, what was called the 'Spanish flu' killed the young and old alike. While some things still remain unclear about the deadly pandemic, the toll it took is not: at least 50 million people died and nearly a third of the world's population was infected. In the United States, an estimated 675,000 perished from the virus, which was more than the country lost fighting in World War I. The Great War, which started in July 1914 and ended on November 11, 1918, was one of the factors in the disease spreading.

And, just like now, with no cure or vaccine in sight, the measures implemented to combat the virus varied from city to city.

In Philadelphia, a parade was thrown in support of the war effort to disastrous results: the city's hospitals were full 72 hours later and it would soon see 2,600 deaths. Meanwhile, after the virus moved from the military to the civilian population, health officials in St. Louis immediately ordered closings and banned public gatherings, which kept the disease 'from exploding overnight as it did in Philadelphia,' according to History.com.

The influenza pandemic of 1918 came in three waves. The first phase hit America that March when there were cases at a military base in Kansas. The pandemic's second phase, which started that fall, was its most deadly. Public health officials in Philadelphia were aware that the disease was spreading. Nonetheless, the city decided to move forward with the Liberty Loan Parade on September 28, 1918, seen above. Seventy-two hours later, all of the city's 31 hospitals were full, and soon 2,600 people died, according to History.com

St. Louis took a different tactic when it came to the pandemic. First, city officials warned the public to avoid crowds. Once the disease spread to the general population, schools and businesses, such as pool halls and theaters, were closed and public gatherings banned, according to History.com. Volunteer nurses also treated the infected at their homes. Above, women, who were part of the St. Louis Red Cross Motor Corps, wear masks and hold stretchers at the back of ambulances in October 1918. George Dehner, author of Global Flu and You: A History of Influenza, told History.com that St. Louis was able 'to flatten the curve.' The city had a lower date rate than Philadelphia, according to History.com

Above, a chart that shows the death rate between the two cities during the pandemic from mid-September until December 28. Philadelphia held its Liberty Loan Parade on September 28, 1918. 'The difference in response times between the two cities. represents approximately three to five doubling times for an influenza epidemic. The costs of this delay appear to have been significant by the time Philadelphia responded, it faced an epidemic considerably larger than the epidemic St. Louis faced, according to a 2007 research article titled Public health interventions and epidemic intensity during the 1918 influenza pandemic in the Proceedings of the National Academy of Sciences

The United States entered World War I in April 1917 and troops were deployed to Europe. There is still no consensus about where or which country this particular strain of influenza originated. Spain, which was neutral during the conflict, did not have wartime press restrictions and after reporting about the virus, the disease was then mislabeled the 'Spanish flu.'

The first wave of the pandemic hit in the United States in March 1918, showing up at Camp Funston in Fort Riley, Kansas. It was 'generally mild' with those infected experiencing 'typical flu symptoms as chills, fever and fatigue' and they usually recovered. 'The number of reported deaths was low,' according to the Centers for Disease Control and Prevention, known as the CDC.

No one wants that!

I feel like heɽ be more likely to try to explain why the virus is a "hoax" just to irritate people.

If he is talking to people who do not wear masks then they would just agree with him on it being a hoax.

it def depends on his “audience.”

That would definitely suck the life right out of me.

The influenza pandemic of 1918 and 1919 was the most deadly flu outbreak in history, killing up to 50 million people worldwide. In the United States, where it ultimately killed around 675,000 people, local governments rolled out initiatives to try to stop its spread. These varied by region, and included closing schools and places of public amusement, enforcing “no-spitting” ordinances, encouraging people to use handkerchiefs or disposable tissues and requiring people to wear masks in public. Mask-wearing ordinances mainly popped up in the western states, and it appears most people complied with them. The nation was still fighting in World War I, and officials framed anti-flu measures as a way to protect the troops from the deadly outbreak.

WATCH: The Spanish Flu Was Deadlier Than WWI The first recorded infection was in a U.S. Army private stationed at Fort Riley, Kansas on March 4, 1918. Although the United States and the other nations at war initially suppressed news of the flu (neutral Spain freely reported it, hence the misnomer “Spanish flu”), there was a sense that following these new health precautions was patriotic.

As one Red Cross PSA put it, “the man or woman or child who will not wear a mask now is a dangerous slacker.” This sense of wartime duty—and the fear of being seen as a “slacker”—may have motivated those who complied with mask orders in cities like San Francisco, Seattle, Denver and Phoenix. Yet even though compliance was high, some complained that the masks were uncomfortable, ineffective or bad for business. Officials were caught in public without masks. And after the war ended, and there was no longer a sense that people should wear masks to keep the troops safe, some dissenters even formed an “Anti-Mask League” in San Francisco. WATCH: World War I Documentaries on HISTORY Vault

Masks Were Made of Gauze or Even More Porous Material

Women working for the Red Cross make masks during the pandemic flu in 1918. Bettmann Archive/Getty Images

In 1918, advanced masks like the N95s that healthcare workers use today were a long way off. Surgical masks were made of gauze, and many people’s flu masks were made of gauze too. Red Cross volunteers made and distributed many of these, and newspapers carried instructions for those who may want to make a mask for themselves or donate some to the troops. Still, not everyone used the standard surgical design or material. “To entice people to get them to wear them, [cities] were pretty lax in terms of what people could wear,” says J. Alex Navarro, assistant director of the Center for the History of Medicine at the University of Michigan and one of the editors-in-chief of The American Influenza Epidemic of 1918-1919: A Digital Encyclopedia.

In October 1918, the Seattle Daily Times carried the headline “Influenza Veils Set New Fashion: Seattle Women Wearing Fine Mesh With Chiffon Border to Ward Off Malady.” These “fashionable” masks and others made from dubious material probably weren’t helping much. Yet there was also debate within the medical and scientific community about whether multiple-ply gauze masks were effective either. For instance, Detroit health commissioner J.W. Inches said gauze masks were too porous to prevent the spread of the flu among the public. Also, masks are most effective when worn properly, which wasn’t always what happened. In Phoenix, where most people apparently complied with the city’s mask order, some nonetheless poked holes in their masks to smoke—which greatly reduced their effectiveness. SEE PHOTOS: The 1918 Flu Campaigns to Shame People Into Following New Rules

'Mask Slackers' Faced Enforcement, Punishment

Still, for the small percentage of people who went without a mask entirely, reports suggest their issue had less to do with the science behind them, and more to do with personal comfort. “You read routinely about people not wanting to wear them because they’re hot and stuffy,” says Nancy Bristow, chair of the history department at the University of Puget Sound and author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic. “Some people argue against them because they say that they create fear in the public, and that we want to keep people calm which I think is really an excuse to critique them because someone doesn’t want to wear them.”

PHOTOS: Innovative Ways People Tried to Protect Themselves From the Flu Some businesses worried customers would shop less if they had to wear a mask when they went outside, and some people claimed mask ordinances were an infringement upon civil liberties. Yet “more important in terms of critiques,” Bristow says, “is this idea that we’ve heard today as well that they give people a false sense of security.” As she points out, wearing a mask is less effective when people don’t follow other health guidelines too (and especially if some are poking holes in their masks to smoke). Cities that passed masking ordinances in the fall of 1918 struggled to enforce them among the small portion of people who rebelled. Common punishments were fines, prison sentences and having your name printed in the paper. In one horrific incident in San Francisco, a special officer for the board of health shot a man who refused to wear a mask as well as two bystanders. This was far different from the treatment San Francisco’s leaders received when they didn’t comply. At a boxing match, a police photographer captured images of several supervisors, a congressman, a justice, a Navy rear-admiral, the city’s health officer and even the mayor, all without masks. The health officer paid a $5 fine and the mayor later paid a $50 fine, but unlike other “mask slackers,” they received no prison time (not to mention no one shot at them).

Mask-Wearing Declines After the War

A man receives a shave from a barber who wears a mask during the ongoing pandemic in Chicago, Illinois, circa 1918. Chicago Sun-Times/Chicago Daily News Collection/Chicago History Museum/Getty Images

San Francisco’s first masking order began in October and ended in November after the World War I armistice. In January, when flu cases began to surge again in San Francisco, the city implemented a second mask order. This time, the resistance was much more intense. A group of dissenters that included a few physicians and one member of the Board of Supervisors formed the “Anti-Mask League,” which held a public meeting with over 2,000 attendees. Navarro speculates the resistance to San Francisco’s second mask order may have been more intense because the country was no longer at war, and some residents didn’t feel the same sense of patriotic duty they had before. In any case, the city was an outlier. It doesn’t appear that there were similar leagues or protests in other cities. Nancy Tomes, a distinguished professor of history at Stony Brook University who has written about public health measures during the 1918-1919 flu pandemic says while there were pockets of resistance to mask-wearing in 1918 and 1919, it was not widespread. And, unlike handkerchiefs and paper tissues, which Tomes says people began to use more regularly because of the pandemic, mask-wearing did not catch on in the United States after the ordinances ended. It’s still difficult to say how effective mask-wearing on its own was in 1918 and 1919. What is clear is that communities that implemented stronger health measures overall fared better than those that didn’t.

“Today we can look back and see that they flattened the curve and the communities that did enforce much stricter regulations and for a longer period of time and began earlier had lower death rates,” Bristow says. “But they didn’t have that data tabulated yet, so I think in the aftermath it wasn’t as clear that what they had done had been effective.”

How U.S. Cities Tried to Halt the Spread of the 1918 Spanish Flu

Why the 1918 Flu Became ɺmerica's Forgotten Pandemic'

Why the Second Wave of the 1918 Spanish Flu Was So Deadly

How America Struggled to Bury Its Dead During the 1918 Flu Pandemic

'Mask Slackers' and �ly' Spit: The 1918 Flu Campaigns to Shame People Into Following New Rules

What did cities do differently?

The first flu deaths were reported in Boston on Sept. 8, 1918, the day before 300 sailors from the city arrived in Philadelphia. On Sept. 11, 19 sailors at Philadelphia's Navy Yard were sick. The numbers kept climbing, spilling over from sailors to workers to citizens.

Philadelphia officials knew about the flu in Boston and at the Navy Yard. The city's bureau of health issued flu warnings and upgraded it to a reportable disease. Health officials said there was little chance it would spread among the public.

This doubt was embraced by many Philadelphians who "saw the war as the real priority and even characterized the hype of the flu as a 'German ploy,' " historian Jeffery Anderson, who published his master's thesis on the pandemic at Rutgers, told USA TODAY.

Case Study: 1918 Influenza Pandemic

Prior to COVID-19, the 1918 influenza pandemic was the most severe pandemic in recent history. First identified in military personnel in the spring of 1918, the influenza was an H1N1 virus of avian origin. It is commonly referred to by scientists and historians as “the Mother of all Pandemics.” This pandemic is often referred to as the “Spanish Flu” in the lay press, though this name is a misnomer, and the virus likely originated elsewhere. Contemporary reporting focused heavily on Spain, as it was one of few places at the time that did not have restrictions on the press during World War I.

Infectivity: 500 million people, or ⅓ of the world’s population. Note that this is smaller than estimates for SARS-CoV-2, as the population had some pre-existing immunity from prior influenza exposure.

Death rates: at least 50 million people worldwide, with 675,000 deaths in the United States.

Mortality: highest in people age <5, 20-40, and 65+ years. It is thought that this unusual age-distribution of cases may be due to differences in prior influenza exposure across different age groups.

More soldiers died from the 1918 flu pandemic than were killed in battle during World War I in 1918.

In 1918, there were no flu vaccines, antiviral drugs, antibiotics, or mechanical ventilators. Treatment options were limited to supportive care and unproven remedies.

There were 3 waves of the epidemic, which lasted from January 1918 - December 1920 ( CDC ):

First wave: March 1918 - Summer 1918

Second wave: Fall 1918 (peak of epidemic)

Third wave: Winter 1918 - Spring 1919

According to a 2007 study in the Internal Journal of Epidemiology ( Vynnycky et al. ), the Re for the 1918 influenza virus was in the range of 1.2-3.0 for community-based settings.

The study estimates that, in a totally susceptible population, a single infectious case could have led to 2.4-4.3 cases in a community-based setting.

By mid-September 1918, the second wave of the flu epidemic was in full effect, spreading from Boston to New York and Philadelphia before traveling west to St. Louis and San Francisco. Without a vaccine or known cause for the outbreak, mayors and city health officials were grappling with how to implement social distancing and reduce community transmission . They asked themselves the following questions:

Should they close schools and ban all public gatherings?

Should they require all citizens to wear a gauze face mask?

Would shutting down financial centers during a time of war be unpatriotic?

Wilmer Krusen, Philadelphia’s public health director, advised citizens they could lower their risk for flu by: staying warm, keeping their feet dry, and “loosening their bowels.” Krusen refused to cancel the Liberty Loan parade on September 28, 1918, even as cases steadily increased up to this point. Infectious disease experts warned Krusen that the parade (likely to attract several hundred thousand people) would be a “ready-made inflammable mass for a conflagration.” Krusen kept the parade on because it would raise millions of dollars in war bonds. The parade took place: soldiers, Boy Scouts, marching bands, and local dignitaries processed two miles through downtown Philadelphia past sidewalks teeming with spectators. Just 72 hours after the parade, all 31 of Philadelphia’s hospitals were full. By the end of the week, 2,600 people were dead.

Before the first case of 1918 flu appeared in the city, health commissioner Dr. Max Starkloff wrote an editorial about the importance of avoiding crowds in the St. Louis Post-Dispatch , putting local physicians on high alert. When a flu outbreak from nearby military barracks spread to St. Louis, Starkloff closed schools, movie theaters, and pool halls, and banned public gatherings. When infections surged, thousands of sick residents were treated at home by a network of volunteer nurses. George Dehner, author of Global Flu and You: A History of Influenza , writes that because of these precautions, St. Louis public officials flattened the curve and prevented the flu epidemic from exploding overnight like in Philadelphia. According to a 2007 NIH analysis in PNAS of 1918 flu death records ( Hatchett et al. ), the peak mortality rate in St. Louis was only ⅛ of Philadelphia’s death rate at its worst.

California governor William Stephens declared it the “patriotic duty of every American citizen” to wear a gauze face mask and eventually made it the law. Citizens found in public without a face mask or wearing it improperly were arrested, charged with disturbing the peace, and fined $5. San Francisco’s low infection rates were likely not due to the face masks, but instead due to:

Well-organized campaigns to quarantine all naval institutions before the flu arrived

Early efforts to close schools

Bans on social gatherings

Closing all places of “public amusement”

San Francisco did well in the second wave of the epidemic through the fall of 1918. When the third wave struck in January 1919, businesses and theater owners fought back against closings, as they believed masks were what saved them the first time. The 2007 NIH analysis found that if San Francisco had kept up the same flu protections in the third wave as it did in the second wave, it could have reduced deaths by 90%.

CORE TEXT: Barry, J. The Single Most Important Lesson From the 1918 Influenza . New York Times, (March 17, 2020).

The Great Influenza: The Story of the Deadliest Pandemic in History , John Barry (2004).

Global Flu and You: A History of Influenza , George Dehner (2012).

If you were a public health official in the early 1900s trying to determine the cause of the outbreak, what methods would you use to find the answer? (Assume you can only use resources available from the early 1900s.)

How could public health officials in San Francisco have probed deeper into whether it was gauze face masks that reduced transmission or closing of public spaces?

What are the challenges for trying to determine R0 and Re values for the 1918 flu epidemic? What assumptions can be made in modeling? What challenges do these assumptions bring?

How the U.S. Dealt with the Spanish Flu of 1918

Patent medicines aimed at the flu appeared around the world, but did little to ease the crisis. Wikimedia

15. The Armistice exposed the crisis in Europe

Following the Armistice on November 11, 1918, censorship of newspapers did not immediately cease. It did ease however, and reporters who had written of the flu in Spain learned of its extent in France, Great Britain, and throughout the British Empire. Its extent in the German sides of the trenches exposed itself, from German prisoners and civilians. In the first and second waves the flu ravaged the troops on the front lines, in the support trenches, and throughout the logistics trails. Railroads and other supply systems, disrupted by absences caused by the flu could no longer support the German Army in the last few weeks of the war.

The widespread nature of the disease in Europe was reported in America, though few Americans paid much attention, too concerned with their own plight to worry about the recently defeated enemy. In Great Britain and Canada the disease spread faster than attempts to contain it could be established. Throughout the European continent, hunger and malnutrition made the survivors of the war more susceptible to the illness, and more likely to die from its symptoms. No person was immune. At the Versailles Conference, in addition to American President Woodrow Wilson, the British Prime Minister, David Lloyd George, contracted the flu. So did Georges Clemenceau of France, and Johannes Ball, who represented Germany.

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