In 1918 and 1919, a new strain of influenza virus swept the world in a pandemic that killed an estimated 21 million people, including at least 675,000 Americans. How the virus mutated is unknown, but certainly the vast movement of people set off by the First World War contributed to its spread. Normally, children and the elderly are the most vulnerable to influenza, but this virus was dramatically lethal among otherwise healthy young adults. In American cities the mortality rate varied, depending, in part, on how individual cities responded to the epidemic.
Spread in droplets of mucous expelled by sneezing, coughing, and exhaling, the influenza virus that caused the 1918 epidemic was easily spread by direct contact, particularly in close quarters. The symptoms, which began with a hacking cough, fever, body aches, and exhaustion, were brought on by the body's struggle against the virus's inroads. Within a week, many victims of the virus began to develop bacterial pneumonia. In some cases, particularly among those between 20 and 40, the virus provoked a drastic immune response that quickly filled the lungs with fluid and caused lesions. The victims' skin turned blue from lack of oxygen. In those instances, death usually followed, often within days of the onset of symptoms.
During the war years, people flooded into cities, especially in the Northeast and Midwest, seeking high-paying war-industry jobs. Thousands lived in temporary, inadequate barracks-style housing, while others poured into already crowded slums. Meanwhile, the federal government hastily threw together scores of equally overcrowded military training camps with inadequate sanitation and pressed into service thousands of doctors and nurses for the war effort.
In July 1918, doctors at the Philadelphia Navy Yard reported an outbreak of respiratory illness among sailors returning from Europe. In late August, sailors and soldiers in the Boston area complained of flu symptoms, and within days, large numbers began to die. The disease spread rapidly and steadily across the county. It was readily obvious the disease was highly contagious, although, since the entire concept of a virus was unknown at the time, no one knew how it spread or how to treat it. While little could be done for patients suffering through the agonies of acute respiratory distress, for the population as a whole, a great deal could have been accomplished by aggressive public health measures. Closing schools, canceling unnecessary public gatherings, demanding that people wear face masks in public, and enforcing no-spitting ordinances could have slowed the disease and reduced the number of fatalities. But some cities, out of ignorance, ineptitude, or civic pride, rejected effective preventative measures and suffered badly.
A comparison of five major cities reveals the stark difference that effective and good local public health measures good make. With its notoriously overcrowded tenements, New York might be expected to have the highest mortality rate. But for two decades the city had invested heavily in its public health infrastructure, and its mortality rate was far lower than that of other large cities. But in both Philadelphia and Pittsburgh local authorities were hesitant to take effective action. Philadelphia's mayor was under arrest for corruption during part of the epidemic, and the head of the city health department was a political hack. In September the city held a Liberty Loan parade that drew hundreds of thousands, despite pleading from doctors to cancel it. Within 3 days (the precise incubation period), the disease broke out all over the city. For more than 3 weeks, Philadelphia suffered hundreds of deaths daily. In a scene reminiscent of the Black Death, in the immigrant district of South Philadelphia a parish priest rode a wagon through the streets calling on families to bring out their dead. Hundreds were hastily buried in a mass grave; altogether, 14,000 died. Philadelphia had one third the population of New York, but suffered almost half as many deaths.
Pittsburgh suffered the highest death rate of any American city, with about a quarter of all its reported flu cases resulting in death. Mayor E. B. Babcock and his health department failed to cooperate with state and federal authorities even when they directly ordered him to close certain public places and enact quarantine measures. Even though they were desperately needed in the city, Babcock dispatched dozens of local nurses and doctors to eastern Pennsylvania coal towns, which were also struggling with insufficient medical staff. The virus, combined with the inept local government, resulted in at least 4,000 deaths. A similar mentality affected Atlanta, which took little effective action—there were no emergency hospitals or collections of bodies. The black community, in particular, was ignored and suffered badly.
In contrast, San Francisco took aggressive action, including quarantining all its military bases and staffing a telephone line to report new cases so nurses could be quickly dispatched. Consequently, its case rate in the fall of 1918 was remarkably low. However, in December, when the threat appeared to have passed, the city lifted its restrictions and then suffered a serious epidemic, inadvertently demonstrating the effectiveness of its initial measures.
Every possible medical remedy was tried, including onion baths, herbal amulets, and vaccines made from the secretions of influenza sufferers. Some surgeons tried open thorax surgery to relieve fluid and pressure, with limited success. While most remedies did nothing more than soothe aching muscles and make sleeping easier, clean bedding and general nursing cannot be undervalued as means that moderated the severity of the disease in many instances.
Although the flu returned for at least the next couple of years, the greatest mortality occurred in 1918-1919. On the whole, the fatality rate for most American cities fluctuated between 10 percent and 20 percent of all reported cases. The worst-hit cities had death rates that approached those of the yellow fever and cholera epidemics of the previous century. African Americans suffered in disproportionately large numbers, particularly in the South, where local authorities and hospitals overlooked them entirely. Some Native American communities lost fully 80 percent or more of their pre-epidemic populations.
It was not until the 1990s that scientists unraveled some of the mysteries of the disease, collecting samples from the organs of victims buried in permafrost. The outbreaks of Sudden Acute Respiratory Disorder (SARS) in 2002 and the appearance of incredibly lethal avian flu strains in Asia in 2004-2005 accelerated research on influenza viruses and their mutation to head off another possible pandemic.
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