In the autumn of 1918, as the First World War was nearing its end, a far deadlier enemy was moving through the United States. The influenza pandemic of 1918–1919 killed an estimated 50 million people or more worldwide, and about 675,000 in the United States. Its impact varied sharply from city to city. Some places saw death rates climb so steeply that hospitals, morgues and cemeteries were overwhelmed within days. Others, while still suffering heavy losses, kept their peak deaths far lower. The contrast between Philadelphia and St. Louis has become one of the most cited case studies in public health history.
A Virus in Wartime
The 1918 virus arrived in waves. A milder first wave appeared in the spring of 1918. The second, which began in late August and spread across the country in September and October, was much more lethal. Unusually, it killed many healthy young adults, people between about 20 and 40, who normally survive influenza. Many died of secondary bacterial pneumonia, for which there were no antibiotics.
The war shaped the outbreak at every turn. Troops packed into training camps and transport ships spread the virus. Many doctors and nurses were serving overseas, leaving civilian hospitals short-staffed. Wartime censorship and a political climate that discouraged bad news made officials reluctant to admit how dangerous the situation was. The popular name “Spanish flu” came from the fact that neutral Spain’s press reported freely on the disease, not because it began there. Where it really originated is still debated.
Philadelphia: The Parade
Philadelphia’s first civilian cases were reported around September 17, 1918, after sailors at the Philadelphia Navy Yard had fallen ill. City health officials played down the danger. On September 28 the city went ahead with a large parade to promote the Fourth Liberty Loan, a government bond drive to pay for the war. Roughly 200,000 people crowded along the route on Broad Street to watch bands, soldiers and floats.
Within about 72 hours, every bed in the city’s 31 hospitals was reportedly full. On October 3 the city closed schools, churches, theaters and other public gathering places, but by then the epidemic was spreading explosively. Within a few weeks thousands were dying. Philadelphia ran short of coffins and gravediggers. Bodies stayed in homes for days. Priests drove carts through neighborhoods to collect the dead, and some victims were buried in mass trenches. In about six weeks roughly 12,000 Philadelphians died.
The public health director, Wilmer Krusen, made a famous plea: “Nurses, more nurses, and yet more nurses.” Volunteers, including Catholic nuns and medical students, filled in where they could. Many of them died too.
St. Louis: Acting Early
St. Louis had a different experience. Its first civilian cases were reported in early October, about two weeks after Philadelphia’s. The city’s health commissioner, Max Starkloff, had been watching the spread elsewhere and had support from the mayor. Within about two days of the first local cases, St. Louis closed schools, theaters, churches and other public gathering places and banned large public gatherings.
The measures were unpopular with many businesses. They were not perfect, and they were not kept in place for the entire pandemic. When restrictions were lifted, cases rose again. But the city’s early action kept its peak death rate far lower than Philadelphia’s, and hospitals were not completely overwhelmed.
What the Numbers Show
In 2007 researchers published two major studies of 1918 city data in the Proceedings of the National Academy of Sciences. One, by Richard Hatchett, Carter Mecher and Marc Lipsitch, analyzed 17 U.S. cities. It found that Philadelphia’s peak weekly excess death rate from pneumonia and influenza reached about 257 per 100,000 people. St. Louis’s peak, while its measures were in effect, was about 31 per 100,000, roughly one-eighth as high. Over the whole autumn period, Philadelphia’s cumulative excess death rate was about twice St. Louis’s.
Across the cities studied, those that brought in several measures early, such as closing schools and banning public gatherings, had peak death rates about 50 percent lower than cities that acted late or not at all. The effect on total deaths over the whole period was smaller and less certain, around 20 percent. A second study, by Martin Bootsma and Neil Ferguson, reached similar conclusions. A separate analysis led by Howard Markel of the University of Michigan looked at 43 cities and also found that early, layered and sustained measures were associated with lower death rates.
Important Caveats
Historians and epidemiologists warn against turning this into a simple morality tale. Cities differed in population density, housing, age structure, health infrastructure and how much exposure they had had during the spring wave. Some researchers argue that earlier, milder outbreaks gave some cities partial immunity. Data from 1918 is also patchy, and death certificates often recorded pneumonia rather than influenza. The general pattern of earlier action and lower peaks is well supported, but the exact size of the effect in any one city remains debated.
The studies also show a hard trade-off. Measures worked while they were in place, but when they were lifted the virus often returned. Several cities, including St. Louis, saw later surges after reopening.
Daily Life in an Epidemic City
For ordinary Americans, the autumn of 1918 meant shuttered schools, closed saloons, and church services held outdoors or cancelled. In some cities, including San Francisco, gauze masks became mandatory in public, and people who refused could be fined or arrested. Telephone companies asked customers to make only urgent calls because so many operators were sick. Children’s rhymes and newspaper cartoons captured the fear. Families lost parents within days of each other, and many children were orphaned.
The pandemic also exposed inequality. Crowded tenements, poor sanitation, and lack of access to nursing care made outcomes worse in poorer neighborhoods. Black Americans, who faced segregated and underfunded health care, often had to rely on their own community hospitals and nurses.
A Long Shadow
After the war ended in November 1918, the pandemic faded from public memory surprisingly fast, perhaps because it came at the same time as the joy of the Armistice and was too painful to dwell on. For decades it received little attention from historians. Interest revived in the late twentieth century as scientists worried about new pandemic influenza strains. Researchers recovered and sequenced the 1918 virus from preserved tissue samples, including from a victim buried in the Alaskan permafrost.
The Philadelphia and St. Louis studies directly shaped U.S. pandemic planning guidance in the 2000s and were widely cited during the COVID-19 pandemic. Whatever lessons people draw from them today, the experience of 1918 shows how a city’s decisions during the first two weeks of an outbreak can matter for thousands of lives.
Sources
- Hatchett, Mecher and Lipsitch, PNAS (2007): Public health interventions and epidemic intensity during the 1918 influenza pandemic
- JSTOR Daily: The 1918 Parade That Spread Death in Philadelphia
- CDC: History of the 1918 Flu Pandemic
Featured image: Unknown authorUnknown author or not provided / Wikimedia Commons, Public domain
