How two US cities responded to the 1918 flu pandemic very differently - and what we can learn from those mistakes

How two US cities responded to the 1918 flu pandemic very differently - and what we can learn from those mistakes
Spanish Flu, St. Louis

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St. Louis was fast to act against the 1918 flu pandemic but lifted its social distancing measures too soon and suffered a second wave of death.

  • Philadelphia and St. Louis were both hit by the flu outbreak of 1918-19, but one city suffered a death rate of approximately 358 per 100,000 people, whereas the other suffered 748 deaths per 100,000.
  • 1918 was a very different time from today, but there are still lessons that we can draw from how Philadelphia's slow action to respond to the pandemic left its citizens dangerously vulnerable.
  • We spoke with a social epidemiologist who said that policymakers should prolong social distancing measures or else suffer St. Louis's mistake of lifting them too early and enduring a second wave of infection and death.
  • Visit Business Insider's homepage for more stories.

On September 28, the city of Philadelphia hosted its "Liberty Loan" parade in the midst of the flu outbreak of 1918-19 - sometimes referred to as the Spanish flu. Shortly thereafter, hospitals were at capacity and 2,600 people had died.

Around the same time, the city of St. Louis was closing schools, libraries, courthouses, churches, playgrounds as well as limiting the number of people on streetcars and staggering work shifts to minimize contact.

Eventually, Philadelphia followed suit. But according to a study published in the Proceedings of the National Academy of Sciences, it was just two days - from October 5 to October 7 - between when the first cases showed up in St. Louis to closures being enacted. In Philadelphia, it was over two weeks.


These very different actions against the flu pandemic in 1918-19 led to very different outcomes for the two cities. At its height, the death rate in St. Louis was one-eighth what it was in Philadelphia. In fact, from September through February of that winter, the flu death rate was approximately 358 per 100,000 people in St. Louis and 748 per 100,000 in Philadelphia, according to a study in JAMA.

While we live in different times compared to 1918, there are lessons we can learn from this history to advise how we deal with the current coronavirus pandemic.

"Closing schools, theaters, and other locations where a lot of people come together is essential, as respiratory viruses, including both the 1918 pandemic flu and SARS-CoV-2 are easily spread when people are in close proximity to each other and when they touch the same surfaces, even hours apart," said Jennifer Toller Erausquin, a social epidemiologist and assistant professor in the department of health education at UNC Greensboro.

"The goal of social distancing and isolation is to lower the peak mortality rate. A secondary goal is to lower cumulative excess mortality. Taken together, this is what epidemiologists mean when we talk about 'flattening the curve.'" St Louis was able to do both of these things, she said.

It's important for leadership to be on the same page

When it comes to St. Louis, the fact that many places closed at the same time was important. "Having multiple institutions involved also underscored for the public that the flu outbreak was something to take seriously - that it was important to take these actions for the collective good," said Erausquin.


Another advantage that St. Louis had was that their cases "started a few weeks after Philadelphia's, so they had additional lead time to plan and to have at least some communication between public health authorities and physicians."

In Philadelphia, the fact that leaders weren't on the same page didn't help matters. "Philadelphia's response was also impacted by challenges of leadership," says Erausquin. "The mayors of Philadelphia and Pittsburgh disagreed with the governor of Pennsylvania on the appropriate pandemic response." Neither of the mayors were on board with social distancing-and ultimately, though the measures were put in place (and Philadelphia's mayor did allocate money to help fight the pandemic), the mayors likely contributed to the fact that it happened later and didn't last long enough, she said.

Social distancing shouldn't end too soon

Right now, many are probably wondering when social distancing measures will be lifted and we can return to our normal lives.

"Interestingly, if you look at the data from St. Louis, you notice that their epidemic curve shows two peaks in the fall and early winter of 1918-19," said Erausquin. "Once the pandemic seemed to be declining, the city rolled back its social distancing measures. It did this too early, and flu deaths went up again. Health officials then put the measures back in place."

And this can provide some insight as cities and states struggle to figure out when to lift social-distancing measures. "I think this is a key lesson for us with the current pandemic: We need to keep social distancing measures in place long enough. How long will it take? That's going to be hard to judge," she said.


Erausquin also said that social distancing can "create some major challenges," particularly for those whose income depends on their ability to leave home and go to work, such as service workers.

Do you lift social distancing sooner so that they can go to work sooner and make the money they need to survive, or do you prolong social distancing as an extra precaution to prevent spread? "These are difficult decisions for policymakers, as either choice has potentially serious negative consequences."

We can adapt

"The lessons from these two cities is that early, multi-sector, and sustained social distancing measures can dramatically reduce deaths in a viral pandemic," said Erausquin. "Leadership is critical, and the public benefits from clear messaging."

Also important? We can adapt. "We also learn that the public is willing and able to dramatically alter their daily lives in order to protect the most vulnerable. Collective action for the common good is absolutely possible."

After all, what we have going for us that our 1918 counterparts did not is technology. "Make use of technology and social media to stay connected to your friends, family, and community and contribute your ideas and talents to combating both this pandemic and the inequities it exposes."


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