Among the worst moments of the 1918 influenza pandemic were Philadelphia’s overwhelmed morgue stacking unembalmed bodies without ice on multiple floors until storage was found, or the city resorting to steam shovels for digging mass graves.
The 1918 Spanish influenza – a vicious disease, some historians call it – emerged as World War I was ending. It killed an estimated 50 million or more people worldwide, 675,000 in the USA alone.
It attacked the lungs, making breathing difficult. But influenza alone did not kill all those people. Most of the victims died of bacterial pneumonia, a secondary infection that closely followed the flu.
Some patients exhibited a condition called cyanosis; their lungs filled with fluid and bodies starved of oxygen, they would change color from red to blue to nearly black before dying.
The virus of a century ago infected approximately 500 million people, or one-third of the world’s population, according to the Centers for Disease Control and Prevention. What people did then is familiar to what we’re doing today, including self-isolation, guarding against coughing and sneezing, and limiting public gatherings.
While the diseases aren’t exactly the same, what happened in 1918 may tell us what’s ahead in 2020 and beyond.
Success in St. Louis, failure in Philadelphia
Even though they didn’t have the highest or lowest death rates in the country, two major U.S. cities emerged as examples of government response in what to do and what not to do: St. Louis, which recognized the viral danger and took immediate steps to contain it, and Philadelphia, which did not.
“They make a good foil for one another,” says J. Alexander Navarro, assistant director for the Center for the History of Medicine at the University of Michigan.
The East Coast and Philadelphia “were hit at a much earlier stage of the pandemic,” says David McKinsey, an infectious disease physician at the Research Medical Center in Kansas City, Missouri. “St. Louis had the advantage of being able to watch and learn from others’ mistakes.”
As the coronavirus escalates around the globe, researchers are reexamining the 1918 pandemic, how it spread and how people responded.
States and cities devised their own strategies because “the federal government really didn’t do a lot,” McKinsey says. “It issued some guidelines but had its hands full with World War I and preventing disease among the troops.”
How Philadelphia, St. Louis deaths compare
Peak death rate, the day with the highest number of cases, per 100,000 population for 1918 flu:
NOTE Excess pneumonia and influenza mortality rate, Sept. 8-Dec. 18, 1918, from 1913-17 baseline; SOURCE Proceedings of the National Academy of Sciences
The 1918 influenza did not come from Spain. It was named the Spanish flu when Spanish newspapers reported its presence on World War I battlefields and after Spanish King Alfonso XIII was reported as recovering after contracting the flu in May 1918.
It came in three waves, “the first in the spring of 1918; the second, more deadly, in the fall of 1918; and the third in February-March in 1919,” Navarro says.
There are multiple theories about where the virus originated, including France, China and Haskell County, Kansas, about 200 miles west of Wichita. The U.S. military’s first recorded case was at Camp Funston, part of the Army base at Fort Riley, Kansas, on March 4, 1918.
The war and massive troop movements spread the virus to all points of the globe.
The United States entered the war April 6, 1917. By May 1918, a million U.S. soldiers were fighting in Europe, according to the Smithsonian, and ships of troops were crossing the Atlantic both ways, often carrying the virus with them. The war didn’t end until Nov. 11, 1918.
Away from the front, the military plays a significant part in the two-city comparison. St. Louis is about 17 miles north of Jefferson Barracks, at that time a large Army mobilization point, and Philadelphia was home to the U.S. Navy’s busy Philadelphia Naval Shipyard, which housed about 45,000 sailors. St. Louis had far fewer fatalities than Philadelphia.
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, who either believed it was true or wanted to avoid hurting public morale, 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.
As deaths mounted, Philadelphia went ahead with parade
As flu advanced, cities were hounded to buy war bonds
The flu was in the shadow of World War I, in which the United States had been fighting for nearly 18 months. The conflict was costly, about $32 billion, or about half of that era’s gross national product, according to the National Bureau of Economic Research.
The war was funded by a combination of higher taxes and the sale of Liberty Bonds, which were securities issued by the Treasury Department to raise money.
In 1918, Philadelphia was the third-largest city in the USA. It had a population of about 1.7 million and an additional 300,000 people there for the war effort. It was naturally a target for war bond sales, and organizers hoped its fourth bond parade would raise millions.
Parade spread virus like wildfire
Relentless patriotism was used to sell bonds to the public, and loan drives were “the subject of the greatest advertising effort ever conducted,” according to Federal Reserve historians. Under intense pressure, cities competed to raise the most money. Parades were part of it.
Like today’s coronavirus, the 1918 virus spread primarily by person-to-person contact. Philadelphia’s Liberty Loans Parade – its fourth and most financially successful – which drew about 200,000 onlookers, provided the perfect path to unleash infection.
“That parade gave the epidemic a shot of adrenaline,” Navarro says. “Cases surged after that.”
Infections were spreading before the parade. “On Sept. 27, the city’s University Hospital had received so many cases of the flu that it was virtually under quarantine,” Anderson wrote.
Several physicians urged Wilmer Krusen, the city’s public health director, to cancel the parade. He didn’t. “The political machine was too powerful,” Anderson says.
The corner of Broad and Chestnut Streets, Philadelphia, during the 1918 parade and today.
The Sept. 28 parade started at Diamond Street, moved south on Broad and ended at Mifflin Street, according to the Evening Public Ledger, a city newspaper. That’s about 4 miles. Participants, including bands, troops, Boy Scouts and women’s auxiliary organizations, took up 23 city blocks.
Parade marchers mingled with crowds, and “in the week following the parade, physicians and nurses reported 4,541 new cases of influenza, nearly nine times the number reported for the week prior to the Liberty Loan march,” Anderson wrote. Many sick people, who couldn’t get into a hospital, simply stayed home.
St. Louis took action early
St. Louis was the sixth-largest city in the USA with a population of about 756,000. News of the flu spreading through Boston, Philadelphia and other cities provided early warnings, and officials took notice.
“St. Louis had an energetic and visionary health official in Dr. Max Starkloff,” Navarro says. The city’s health commissioner “immediately started warning the public and told physicians to report influenza cases.”
Starkloff, fully supported by the city’s mayor, “was very quick to implement city closures,” Navarro says. He closed public places such as schools, theaters, playgrounds, city courts and churches and banned gatherings of more than 20 people.
He canceled the city’s Liberty Bonds parade. “They recognized that crowds were a danger,” McKinsey says.
Businesses protested closings. “They were upset because they were losing revenue,” McKinsey says. “It was a constant conflict between them and the city.”
How many more deaths did Philadelphia have?
Estimated total deaths from influenza and pneumonia, September-December 1918:
SOURCE University Archives and Records Center, University of Pennsylvania; Research Medical Center, Kansas City, Missouri
Though “Starkloff listened to business pleas to reopen, he didn’t reopen the city all at once,” Navarro said. “He did it in a step-wise fashion.”
Starkloff reimposed restrictions as infection cases rose again in November 1918. Infections subsided, and restrictions ended in December. St. Louis fared better than other cities.
Which cities had highest peak death rates?
Estimated peak death rate per 100,000 population in 16 weeks for 1918 flu:
NOTE Excess pneumonia and influenza mortality rate, Sept. 14-Dec. 14, 1918, from 1913-17 baseline; peak is the day with the highest number of cases; SOURCE Proceedings of the National Academy of Sciences
Post-pandemic analyses revealed “social distancing was highly effective against virus transmission,” McKinsey says.
“We also found volunteers had a great impact in dealing with the epidemic, especially the Red Cross, which did an excellent job in making masks, training nurse assistants and distributing medical information pamphlets to the public. It really made a difference,” McKinsey says.
Total death rates of cities compared
Estimated overall death rate per 100,000 population for 1918 flu:
NOTE Excess pneumonia and influenza mortality rate, Sept. 14, 1918-May 31, 1919, from 1913-17 baseline; SOURCE Proceedings of the National Academy of Sciences
Except for a minor fourth wave early in 1920, U.S. pandemic fatalities dwindled and virtually ended in the summer of 1919.
In the pandemic’s aftermath, “we see a change in efforts for better public health,” says Deanne Stephens, professor of history at the University of Southern Mississippi.
“It ranged from a greater emphasis on clean drinking water to the recognition that nursing was a critical service,” Stephens says. “There was also the realization that government could take a stronger role in disease prevention.”
Beyond that, Americans turned their attention elsewhere. Perhaps that was to be expected.
“There was a different mentality then,” Stephens says. “The U.S. was used to epidemics. So in urban areas, there was an attitude of ‘we’re going to plow through this.'”
And finally, there was the shadow of World War I itself. Americans “may have thought of the flu as simply a subdivision of the war,” historian Alfred Crosby wrote in “The Forgotten Pandemic.”
Horror of 1918 flu faded
Subjects of stories in American periodicals after the flu (in inches of column space):
NOTE Prohibition was the ban on sale of alcoholic beverages in the U.S.; Bolsheviks were far-left Marxist revolutionaries who killed the czar in 1917 and started a communist regime in Russia; SOURCE The Readers Guide to Periodical Literature, 1919-1921, as cited in “America’s Forgotten Pandemic: The Influenza of 1918“ by Alfred Crosby.
SOURCES Centers for Disease Control and Prevention; University of Pennsylvania, Archives and Records Center; National Institutes of Health; National Endowment for the Humanities; Library of Congress; Federal Reserve History; Museum of American Finance; National Bureau of Economic Research; “When We Have a Few More Epidemics, the City Officials Will Awake,” published master’s thesis of historian Jeffery Anderson, Rutgers, 1997; “The Great Influenza: The Story of the Deadliest Pandemic in History“ by John M. Barry, 2004; “Pale Rider: The Spanish Flu of 1918 and How It Changed the World“ by Laura Spinney, 2017; “America’s Forgotten Pandemic: The Influenza of 1918“ by Alfred W. Crosby, 1989; “Pandemic 1918: Eyewitness Accounts from the Greatest Medical Holocaust in Modern History” by Catherine Arnold, 2018; “Influenza: The Hundred-Year Hunt to Cure the Deadliest Disease in History” by Dr. Jeremy Brown, 2018
USA TODAY research by George Petras; illustrations and graphics by Karl Gelles