The Pandemic of 1918: The Tale of Two Cities

The Pandemic of 1918: The Tale of Two Cities

Frederick W. Nolting, D.D.S.*:

I am fortunate to have been acquainted with a Mayo Clinic physician who was alive during the influenza pandemic of 1918. He related that his parents and he did not come down with the disease, but his younger sister did. She died within a few days. As it was February, his parents kept her body in her upstairs bedroom with the window open. A number of days passed before the undertakers could come by to take her. The morticians were very busy that winter. My friend told me that he was not allowed to go in his sister’s room after she died, but, as his parents went out to the barn to do chores, he sneaked in anyway. He touched her arm, and it was very cold. Her face was relaxed and without any expression. Although he was only five years old at the time, he said that those memories have never gone away.

Many people died from influenza during that time. Philadelphia in particular had many more excess deaths than other cities. Speculation was that Philadelphia was a major crossroad of rail traffic from the Midwest, especially Kansas, where some feel the pandemic began, spread by the soldiers being deployed to Europe during World War I. St. Louis, at that time, was as large as Philadelphia. It had both rail traffic and riverboat traffic. The results of a study of the timeline of the death rates of both cities coupled with the timing and quality of the public health response is depicted in Figure 1.**

In Philadelphia, the first cases of influenza in civilians were reported on September 17, 1918. Officials regarded this as having little significance, allowing public gatherings, most notably a large parade on September 28th.  This crowd of about 200,000 people allowed the rapid spread of the virus. The first social distancing measures were taken on October 3rd, at which time local medical and public health resources were overwhelmed. The excess deaths caused by influenza hit a high midway through October (257 per 100,000).

In St. Louis, the first case of influenza was reported on October 5, 1918. There the officials moved very rapidly to institute social distancing measures. The peak number of excess deaths in St. Louis reached 31 per 100,000 when these measures were in place. St. Louis officials discontinued the social distancing measures in mid November, and the death rate climbed. The measures were reinstated, and the excess death number again decreased.

The total number of excess deaths in St. Louis was 347 per 100,000 from September 8-December 28, 1918. The total number of excess deaths in Philadelphia during the same time period was 719 per 100,000.  The pattern of these deaths is also significant. There was a huge surge in Philadelphia during the month of October to where all health care and public health resources were overwhelmed. By November, the number of excess deaths decreased very markedly.  In St. Louis, by contrast, the excess death rate was fairly steady and only increased when the social distancing measures were relaxed.

Today, with the presence of the H5N1 virus in the avian population in Asia and Europe, the very real possibility of a pendemic looms. Vaccine production takes about six months and will yield enough vaccine for about 14% of the world’s population. Other measures must be taken. The effectiveness of anti-viral drugs and Avian vaccine is unknown. Social distancing measures such as closure of all public gathering places, quarantine, isolation, and wearing of N-95 masks are about the best defenses we have. To ignore these measures would be very costly in human life. A pandemic will happen; just like earthquakes, tornados, and hurricanes. Do you have your N-95 mask?

*Dr Nolting is chair of the Disaster Preparedness Subcommittee of the MDA’s Environment & Safety Committee. He is a general dentist in private practice in Byron, Minnesota. E-mail is

**Reprinted with permission from “Public Health Interventions and Epidemic Intensity During the 1918 Influenza Pandemic” by Richard J. Hatchet, Carter E. Mecher, and Marc Lipsitch, Journal of the National Academy of Sciences, Volume 104, Number 18, May 1, 2007.