Besides the astoundingly rapid progress made in describing the nature of SARS-CoV-2 (COVID-19) and the advances in describing the virus and approaches to treatment, another result of the recent pandemic has been resurgent interest in previous epidemics and pandemics, and most notably the Spanish Influenza of 1918-19. The estimated world-wide death toll of that H1N1 illness was probably 50 million, and possibly as high as 100 million. The world population in 1918 was only 28 percent of today’s population, thus a comparable toll today would be 175 to 350 million. It has been estimated that one-third of the world’s population may have been clinically infected during the pandemic, with mortality rates among the infected of more than 2.5%. Up to 50% of deaths were in people 20-40 years of age (see https://www.ncbi.nlm.nih.gov/books/NBK22148/ for a comprehensive review). 

Recently, as I was perusing history of medical websites, I came upon the University of Michigan’s (UM) History of Medicine site (http://chm.med.umich.edu/). I discovered that my undergraduate alma mater, with faculty member Dr. Howard Markel, has developed an extensive resource for the study of that devastating pandemic. As a University of Pittsburgh Medical School graduate, it was not lost on me that the UM and the University of Pittsburgh have strong links in the study of epidemic illness. One only has to look at the work of Dr. Jonas Salk (Pitt researcher but former UM postdoctoral fellow) and his former department chairman, and later director of the Poliomyelitis Vaccine Evaluation Center at the University of Michigan School of Public Health, Dr. Thomas Francis. Together, they announced the successful conclusion of the national polio vaccination trial on April 12, 1955, at Rackham Hall at UM.

It was in reviewing these sites that I learned the well-documented fact that Pittsburgh had the highest death rate of any major city in the United States during the Spanish flu, followed closely by Philadelphia. Pittsburgh was in fact the U.S. epicenter. The average death rate for Eastern cities was 555 per 100,000 people. By contrast, Pittsburgh’s death rate was 807 per 100,000 people, deadlier than that of Philadelphia (748) or Boston (710). The flu killed at least one of every 100 residents: 4,500 deaths. At its peak, in October 1918, daily death rates were in the range of 170, and new cases 1000/day. In parts of the city, 95% of residents were affected by the flu. 

It should not be surprising, then, that Nancy Bristow begins her 2012 book “American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic” with the story of her great grandfather’s becoming an orphan during the Spanish flu, in Pittsburgh. It began her quest to understand history of that time and provides great insight into that period. I have used it as another reference.

I also came across a useful article, “Pittsburgh in the Great Epidemic of 1918” by Kenneth A. White, in the Western Pennsylvania Historical Magazine from 1985. It provides extensive details of the efforts of the general community, as well as the medical community to address the social upheaval (and I have borrowed freely from it): https://journals.psu.edu/wph/article/view/3959/3776.

Themes familiar to us today were seen in that prior era. Its very name, Spanish flu, was a misnomer, as early cases were described in Midwest Army camps in early 1918, and then may have spread to various European cities prior to the outbreak in Boston in the fall of 1918. Soldiers traveling to Europe for WWI engagement may have led to the spread; it may have been American flu. “Social distancing” and the use of face masks were advocated by some. Early on, there was public outrage over the closing of public venues. As is quoted by White, the Pittsburgh Leader commented on the Pennsylvania state health commissioners closing of theaters and public places, stating “…the only thing that will result from it will be that many people will be deprived of what are their rights under ordinary circumstances and no great good will be accomplished.”

Sports events were canceled. Public safety measures were instituted. Police received orders to “arrest all persons expectorating on the sidewalks, in the street cars, incline cars, railroad cars of any other places” with fines of a hefty $100 or a month in jail. As the epidemic widened, schools were closed or, if remaining open, would send home children with a cough or sneezing. The fear of closing of liquor stores led to a rush to stock up. In a recent Time magazine article, Nancy Bristow described the “Anti-Mask League” which swept the country, noting its wide acceptance in San Francisco. Pittsburghers were active participants.

In an interesting example of social distancing, Western Pennsylvania Institution for the Blind (as it was known) was a closed small community which enacted protective sequestration early on of everyone. There were no visitors, and students did not leave. As a result, no cases of influenza appeared in the school during the period it was closed to the outside world.

The medical community stepped up, where possible. There were shortages of physicians due to the War in Europe, leaving some communities with few or no doctors. As a result, the University of Pittsburgh medical students manned the hospital wards as interns. The nursing community stepped up to provide care to the over-taxed healthcare facilities. Hospitals throughout Allegheny County worked together to address the patient needs – Magee, West Penn, Mercy Homeopathic, St. Francis, South Side and St. Joseph’s, to name a few. Local facilities such as the Concordia Club, Kingsley House, and organizations such as the Moose Club and Hunting and Fishing Club provided tents and supplies for overloaded facilities. Sadly, a desperate need was filled when the sisters at St. Vincent’s Hill and St. Mary’s Lyceum offered their buildings as temporary orphanages. The Irene Kaufmann Settlement shouldered responsibility for all nursing service in the Hill District.

Treatments of the day were limited primarily to supportive care with a variety of recommendations including saltwater gargling and purgatives. Among the more interesting recommendations was quinine. (Hydroxychloroquine not being available!)

The UM site provides extensive information (http://www.influenzaarchive.org/cities/city-pittsburgh.html#) and links to contemporaneous news articles: (https://quod.lib.umich.edu/cgi/t/text/idx/f/flu?type=simple&q1=Pittsburgh,%20Pennsylvania&rgn=subject).

To give some idea of the nearly 150 headlines (which could be just as well from our recent papers), I note for example:

  • In early fall of 1918, the Pittsburgh Sun’s headlines read: “Situation here does not alarm.”
  • By October, the Gazette-Times noted: “Lists of Grip Victims Shows Big Increase,” and within days: “Rapid Spread of Influenza in Pittsburgh,” and soon: “Influenza Sweeping Nation; Pittsburgh under Quarantine.”
  • The fallout spread; The Sun Times noted: “Pittsburgh For the First Time Sees All Sports Events Suspended,” and “Churches And Bars Closed,” but then again “Whisky Praised as Influenza Medicine.”
  • There were calls for help as noted in the Pittsburgh Times: “Red Cross Needs 300 Nurses To Fight Spanish Influenza,” and “Officials Plan Hospitals for Grip Patients.”
  • But not everyone followed the rules, said the Pittsburgh Sun: “Fight Begins on Influenza Ban Violators.”
  • And not everyone agreed with recommendations over time, as the Sun Reported: “Fight on Lifting Influenza Ban is Expected.”
  • But finally: The Sun reported: “Influenza Hold on Pittsburgh is Weakening,” and about five weeks into the epidemic, the Pittsburgh Gazette Times reported: “Influenza Ban To Be Lifted Next Saturday.”

Little did they know then that another wave would hit the following year, and in fact, Bristow’s ancestors died in a later wave of the disease in 1920.

The severity of the 1918 pandemic led to finger pointing, including to certain ethnic and religious groups. As Bristow noted, “Forgotten was the failure of public health leaders to mobilize the nation in advance of the approaching scourge. Ignored was the inability of modern medicine to protect Americans from influenza, pneumonia and death.” Implementation of nonpharmaceutical interventions was eventually instituted in most cities, but the time of activation, duration and choice or combination of these nonpharmaceutical interventions appear to have been key factors in their success or failure. In Pittsburgh, some of the blame may be related to a decision to keep schools open initially. Pittsburgh waited three weeks after implementing other closure orders to extend those closures to schools as well. The Pittsburgh Sun noted in late October, well into the epidemic, that “City Schools Not Closed by Grip Epidemic” and “Children Best in Schools, Says Burns” (Dr. Burns was Director of School Hygiene). Others speculate that Pittsburgh’s “bad air” at the time was an important factor. 

I am struck by today’s relative ignorance in the population, and the medical community, of this devastating event. (I personally remember during my medical training in the 1970s hearing from patients who told of siblings and parents who had died from “the 1918 flu,” but I neither appreciated nor explored the issue.) This well explains the relative astonishment that such an event could occur today (at least to others besides Bill Gates). But as Bristow explains, our universal blindness to this disaster: “To remember the pandemic would have required Americans to accept a narrative of vulnerability and weakness that contradicted their fundamental understanding of themselves and their country’s history … The return to pandemic conditions was a terrible surprise, a shocking descent into a past from which Americans hoped they had escaped.” A prophetic statement made almost a decade ago.

It is a cliché to note that those who forget history are apt to repeat the mistakes. We may be once again proving that statement. Also, I wish I’d known this story back in the 1970s when I might have been more insightful in reviewing the “Family and Social History” of patients from that era.

 

References

  1. Nancy Bristow, Time magazine: https://quod.lib.umich.edu/cgi/t/text/idx/f/flu?type=simple&q1=Pittsburgh,%20Pennsylvania&rgn=subject
  2. Nancy Bristow; American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic 2012
  3. University of Michigan The American Influenza Epidemic of 1918–1919: A Digital Encyclopedia,
  4. White, Kenneth A; Pittsburgh in the Great Epidemic of 1918” The Western Pennsylvania Historical Magazine (Volume 68, Number 3, July 1985)
Author profile
Thaddeus Osial, MD

Dr. Osial is a practicing rheumatologist with Margolis Rheumatology Associates, UPMC. He attended the University of Pittsburgh School of Medicine, where he also completed his internal medicine and rheumatology training.