Philadelphia, 1918Philadelphia, 1918

By Paul Rega MD, FACEP

IntroductionIntroduction

The past several years have witnessed intentional and natural The past several years have witnessed intentional and natural infectious disease outbreaks in the United States: Anthrax, infectious disease outbreaks in the United States: Anthrax, SARS, Monkeypox, Norovirus, among others. SARS, Monkeypox, Norovirus, among others.

We have been inundated with new terminology such as “surge We have been inundated with new terminology such as “surge capacity” and “alternative treatment sites” and old capacity” and “alternative treatment sites” and old terminology is being resurrected, namely isolation and terminology is being resurrected, namely isolation and quarantine.quarantine.

The infectious disease outbreaks that are transmissible from The infectious disease outbreaks that are transmissible from person-to-person will be the ones that have the potential to not person-to-person will be the ones that have the potential to not only create the most morbidity and mortality, but will have a only create the most morbidity and mortality, but will have a significant negative impact on a community’s ability to significant negative impact on a community’s ability to respond and rebound. This belief, however, is not well-respond and rebound. This belief, however, is not well-disseminated among the various layers of our social and disseminated among the various layers of our social and infrastructural fabric.infrastructural fabric.

The following resource material will illustrate how one The following resource material will illustrate how one community was confronted with such an outbreak.community was confronted with such an outbreak.

Cast of CharactersCast of Characters

Wilmer Krusen, Department of Public Health Wilmer Krusen, Department of Public Health and Charitiesand Charities Political appointeePolitical appointee GynecologistGynecologist

Lt. Commander RW Plummer, Chief Health Lt. Commander RW Plummer, Chief Health officer for Philadelphia Naval Districtofficer for Philadelphia Naval District

Woodrow Wilson, President of the United Woodrow Wilson, President of the United StatesStates

ProloguePrologue US population, 1870: 40 millionUS population, 1870: 40 million US population, 1917: 105 millionUS population, 1917: 105 million

1916: 140,000 civilian doctors (1/2: incompetent per state 1916: 140,000 civilian doctors (1/2: incompetent per state boards)boards)

Flu origins: Haskell Co., KS (Jan-Feb, 1918)Flu origins: Haskell Co., KS (Jan-Feb, 1918) America on war footingAmerica on war footing

Recruits come togetherRecruits come together Barracks overcrowdedBarracks overcrowded Cold winterCold winter Camp Funston (3/4/18)Camp Funston (3/4/18)

In 3 wk: 1100 hospitalized, thousands more ill, 38 deadIn 3 wk: 1100 hospitalized, thousands more ill, 38 dead From Camp Funston to rest of military in USFrom Camp Funston to rest of military in US

President WilsonPresident Wilson A reluctant warrior who developed a “scorched A reluctant warrior who developed a “scorched

earth” policy to have all America in war effort, earth” policy to have all America in war effort, to make USA one weapon against the Hunto make USA one weapon against the Hun Espionage Act: Post Office censorship, Library of Espionage Act: Post Office censorship, Library of

CongressCongress New “Sedition Act”: Clear and Present DangerNew “Sedition Act”: Clear and Present Danger FBI’s American Protective LeagueFBI’s American Protective League

200,000 spies200,000 spies Committee on Public Information: Propaganda Committee on Public Information: Propaganda

machinemachine Sauerkraut: Liberty CabbageSauerkraut: Liberty Cabbage

The Flu Marches OnThe Flu Marches On

People massed together in cities and camps for People massed together in cities and camps for first timefirst time

Resources to war effortResources to war effort 776 MDs in 1918 to 38,000 in 1921776 MDs in 1918 to 38,000 in 1921 ARC: 107 chapters to 3,800 chaptersARC: 107 chapters to 3,800 chapters

No media informationNo media information April- June: EuropeApril- June: Europe September: New Zealand/AustraliaSeptember: New Zealand/Australia

Flu in Select CitiesFlu in Select Cities

June, Louisville, KYJune, Louisville, KY Flu to “Fulminating Pneumonia”Flu to “Fulminating Pneumonia”

Death in 1-2 daysDeath in 1-2 days 40% mortality in the 20-35 yr. age group40% mortality in the 20-35 yr. age group

More malignant second flu wave beginsMore malignant second flu wave begins September, 1918, Ft. Devens (Boston)September, 1918, Ft. Devens (Boston)

In one day, >1500 ill, 75% hospitalizedIn one day, >1500 ill, 75% hospitalized 100 deaths in one day100 deaths in one day Inadequate care: HCWs fall illInadequate care: HCWs fall ill

The FluThe Flu

Severe headaches, extreme arthralgias, fever, chills, Severe headaches, extreme arthralgias, fever, chills, malaise, anorexia, intense cough, nausea, vomitingmalaise, anorexia, intense cough, nausea, vomiting

Nasal congestion, oropharyngeal, tracheal, pulmonary Nasal congestion, oropharyngeal, tracheal, pulmonary congestion, severe earachescongestion, severe earaches

Intense cyanosis (blue-black)Intense cyanosis (blue-black) Gasping for breathGasping for breath Blood from mouth, nose, GI tract, conjunctivaBlood from mouth, nose, GI tract, conjunctiva DeliriumDelirium

Autopsy ReportsAutopsy Reports

No organ untouchedNo organ untouched Kidneys, liver, adrenals, testesKidneys, liver, adrenals, testes

Marked hyperemia of the brainMarked hyperemia of the brain Pericarditis, myocarditisPericarditis, myocarditis Lungs: Plague lungs or lungs exposed to toxic Lungs: Plague lungs or lungs exposed to toxic

gasgas

US Flu StatsUS Flu Stats

47% of all US deaths from flu47% of all US deaths from flu 1918-1919: 675,000 dead1918-1919: 675,000 dead

Equivalent to 1,750,000 nowEquivalent to 1,750,000 now 15 times as many civilians died as military15 times as many civilians died as military Most vulnerable: Pregnant femalesMost vulnerable: Pregnant females

Anywhere from 23-71% depending on areaAnywhere from 23-71% depending on area

Young Old

TYPICAL INFLUENZAM

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Young Young Adult Old

1918 INFLUENZA

Philadelphia in 1917Philadelphia in 1917

1.75 million1.75 million Slums worse than in NYCSlums worse than in NYC Housing scarceHousing scarce

4 families/apartment sleeping in shifts4 families/apartment sleeping in shifts “…“…the worst-governed city in America.” L Steffensthe worst-governed city in America.” L Steffens Political machinePolitical machine

Graft, corruptionGraft, corruption Social services sufferedSocial services suffered

City government power split among political boss, City government power split among political boss, precinct captains, and mayorprecinct captains, and mayor

September 7September 7

Sailors arriving in Philadelphia Navy YardSailors arriving in Philadelphia Navy Yard

September 11September 11

Flu settles on sailorsFlu settles on sailors

September 15September 15

600 sailors hospitalized at Navy Hospital600 sailors hospitalized at Navy Hospital More sent to civilian Pennsylvania Hospital in More sent to civilian Pennsylvania Hospital in

citycity 5 doctors and 14 nurses collapse 2 days later5 doctors and 14 nurses collapse 2 days later

Krusen denies threatKrusen denies threat 1000 die in Boston1000 die in Boston Has meeting with local medical experts and agree Has meeting with local medical experts and agree

to monitor eventsto monitor events

Between September 15 and 20Between September 15 and 20

Plummer and KrusenPlummer and Krusen Have handle on situationHave handle on situation Municipal Hospital for Municipal Hospital for

Contagious Diseases Contagious Diseases opened to Navy illopened to Navy ill

Civilians begin dying Civilians begin dying with regularitywith regularity

September 21September 21

Board of Health announces “flu” to be a Board of Health announces “flu” to be a reportable diseasereportable disease To public: To public:

Stay warmStay warm Keep feet dryKeep feet dry Keep the bowels openKeep the bowels open Avoid crowdsAvoid crowds

Avoid Crowds??Avoid Crowds??

9/28: Great Liberty Loan Parade scheduled9/28: Great Liberty Loan Parade scheduled US on war footingUS on war footing Keep morale highKeep morale high Keep free speech to minimumKeep free speech to minimum

Union halls raidedUnion halls raided 1200 union workers locked in boxcars1200 union workers locked in boxcars Eugene V. Debs jailed 10 yrs for opposing warEugene V. Debs jailed 10 yrs for opposing war

Meanwhile local ID experts and doctors wanted to cancel Meanwhile local ID experts and doctors wanted to cancel ParadeParade

Concerns never published in newspapersConcerns never published in newspapers

September 26September 26

1400 sailors 1400 sailors hospitalized so hospitalized so farfar

Local Red Cross Local Red Cross opens first opens first alternative care alternative care site in citysite in city 500 bed United 500 bed United

Service CenterService Center

September 27September 27

Out of 200 hospitalized that day, 123 were Out of 200 hospitalized that day, 123 were civilianscivilians

September 28September 28

The Great Liberty Loan Parade takes placeThe Great Liberty Loan Parade takes place Several hundred thousand attendSeveral hundred thousand attend Incubation period was less than 48 hoursIncubation period was less than 48 hours

September 30September 30

Krusen announces an epidemic is occurring in Krusen announces an epidemic is occurring in PhiladelphiaPhiladelphia

October 1October 1

All beds in all 31 hospitals filledAll beds in all 31 hospitals filled Hospitals refuse admission unless patient had a Hospitals refuse admission unless patient had a

doctor or police orderdoctor or police order Nurses refuse $100 bribesNurses refuse $100 bribes Lines of people waiting to get into Lines of people waiting to get into

Pennsylvania HospitalPennsylvania Hospital No doctors, no medicinesNo doctors, no medicines

117 die that day117 die that day

October 3: Krusen ActsOctober 3: Krusen Acts

All public meetings bannedAll public meetings banned All churches, schools, theaters, courts closedAll churches, schools, theaters, courts closed No public funeralsNo public funerals Saloons stay openSaloons stay open

Key voting bloc for political machineKey voting bloc for political machine Closed next day by State Health CommissionerClosed next day by State Health Commissioner

Another alternative care site open in City Poorhouse Another alternative care site open in City Poorhouse (Emergency Hospital #1)(Emergency Hospital #1) 500 beds filled in single day500 beds filled in single day Eventually 12 such sites openEventually 12 such sites open

In 10 DaysIn 10 Days

From a few hundred ill From a few hundred ill civilian cases and 1-2 civilian cases and 1-2 deaths per day to deaths per day to hundreds of thousands hundreds of thousands ill and hundreds of dead ill and hundreds of dead per dayper day

Newspapers stay mute!Newspapers stay mute!

Placards DisseminatedPlacards Disseminated

““Avoid Crowds”Avoid Crowds” ““Use Handkerchiefs”Use Handkerchiefs” ““Spitting Equals Death”Spitting Equals Death”

Arrested if caught spittingArrested if caught spitting 60 arrested in 1 day60 arrested in 1 day

October 5October 5

254 deaths that day254 deaths that day Announcement: Peak has been Announcement: Peak has been

reachedreached

October 6October 6

289 dead that day289 dead that day >300 on October 7>300 on October 7 >300 on October 8>300 on October 8

October 9October 9

428 deaths428 deaths Would approach double Would approach double

that figure in the next that figure in the next few weeksfew weeks

2/3 of the dead were 2/3 of the dead were under 40 years of ageunder 40 years of age

The DeadThe Dead

Pile upPile up Gravediggers refuse to bury themGravediggers refuse to bury them Caskets pile up in funeral homesCaskets pile up in funeral homes Coffin shortageCoffin shortage Guards posted by unused coffinsGuards posted by unused coffins Dead bodies lying next to the illDead bodies lying next to the ill At home families pack their dead in iceAt home families pack their dead in ice

StenchStench Bodies on porches to be picked up, wrapped in sheets, by Bodies on porches to be picked up, wrapped in sheets, by

“dead wagons” (1 atop another)“dead wagons” (1 atop another) Mom wanted to place her dead child in a macaroni boxMom wanted to place her dead child in a macaroni box

City MorgueCity Morgue

Capacity: 36Capacity: 36 Jammed with 200 bodiesJammed with 200 bodies Stench!Stench!

Mental StressMental Stress

People increasingly isolatedPeople increasingly isolated Avoid each otherAvoid each other No social activitiesNo social activities Phone company allowed only emergency callsPhone company allowed only emergency calls

Philadelphia General HospitalPhiladelphia General Hospital

8 doctors & 54 nurses hospitalized (43%)8 doctors & 54 nurses hospitalized (43%) 10 nurses die10 nurses die Board of Health appeals for retired nurses and Board of Health appeals for retired nurses and

doctorsdoctors One old doctor treating patients with purging and One old doctor treating patients with purging and

venesection!venesection!

Medical/Pharmaceutical Medical/Pharmaceutical StudentsStudents

5 medical schools and 1 5 medical schools and 1 pharmaceutical schoolpharmaceutical school

Dispatch their students Dispatch their students to assistto assist

1 medical student in 1 medical student in charge of an entire floor charge of an entire floor at one of the Emergency at one of the Emergency HospitalsHospitals ¼ of his patients die each ¼ of his patients die each

dayday

More Help?More Help?

National Red Cross: NothingNational Red Cross: Nothing PHS: NothingPHS: Nothing City: NothingCity: Nothing

““..death toll for 1 day in Philadelphia alone ..death toll for 1 day in Philadelphia alone was more than the death toll from France for was more than the death toll from France for the whole American army for one day.”the whole American army for one day.”

Real action begins October 7Real action begins October 7

The Women Take ChargeThe Women Take Charge

Oldest, wealthiest familiesOldest, wealthiest families Council of National Defense Council of National Defense Emergency Aid SocietyEmergency Aid Society Provide organization and leadershipProvide organization and leadership Had moneyHad money

Emergency Aid SocietyEmergency Aid Society

Used existing system to distribute anything from Used existing system to distribute anything from medical care to foodmedical care to food Divided city into 7 districtsDivided city into 7 districts Dispatched doctors according to geographyDispatched doctors according to geography

Developed list of physiciansDeveloped list of physicians 24 hour phone bank for info and referrals24 hour phone bank for info and referrals Soup kitchens in public schools for the illSoup kitchens in public schools for the ill Volunteers (thousands)Volunteers (thousands)

Private cars as ambulancesPrivate cars as ambulances Drove physicians on roundsDrove physicians on rounds

Krusen Wakes UpKrusen Wakes Up

Gives women control of nursesGives women control of nurses Seizes $100,000 in the emergency fund and $25,000 Seizes $100,000 in the emergency fund and $25,000

in the war emergency fundin the war emergency fund Supplies hospitalsSupplies hospitals Hires doctors (twice what PHS paid)Hires doctors (twice what PHS paid) Sends doctors to police stationsSends doctors to police stations Cleans streetsCleans streets Requests Feds not to draft Philly’s doctorsRequests Feds not to draft Philly’s doctors

ApprovedApproved

Krusen, The Women, The Krusen, The Women, The Catholic Church, & The DeadCatholic Church, & The Dead

Police & priests clear bodies (wore Police & priests clear bodies (wore masks)masks) 33 cops die by mid-October33 cops die by mid-October

6 alternative morgues6 alternative morgues Streetcar company builds coffinsStreetcar company builds coffins Enlist embalming students and Enlist embalming students and

morticians from 150 miles awaymorticians from 150 miles away Seminary students dig gravesSeminary students dig graves Heavy equipment to dig mass Heavy equipment to dig mass

gravesgraves

October 10October 10

759 dead759 dead Before the flu, death from all causes averaged Before the flu, death from all causes averaged

485 per week in Philadelphia485 per week in Philadelphia Orphans aboundOrphans abound

The Unsung HeroesThe Unsung Heroes

Attrition rate for volunteers highAttrition rate for volunteers high Medical profession continuedMedical profession continued

Few fledFew fled Police continuedPolice continued

Request for 4 volunteers to remove decomposed Request for 4 volunteers to remove decomposed bodiesbodies

118 responded118 responded

Week of October 16Week of October 16

4,597 deaths4,597 deaths Worst week of the epidemicWorst week of the epidemic

Then…the numbers began Then…the numbers began droppingdropping

10/26: Ban on public gatherings lifted10/26: Ban on public gatherings lifted 11/11: The flu officially gone from 11/11: The flu officially gone from

PhiladelphiaPhiladelphia

EpilogueEpilogue

The 1918 influenza epidemic in Philadelphia The 1918 influenza epidemic in Philadelphia illustrates the good, bad, and ugly of American illustrates the good, bad, and ugly of American responses to a galloping infectious disease responses to a galloping infectious disease outbreak. There were heroes and there were outbreak. There were heroes and there were “goats”. Both personal courage and political “goats”. Both personal courage and political ineptitude were on display. Altruism played a ineptitude were on display. Altruism played a “tug-of war” with profit.“tug-of war” with profit.

As George Santayana said, “Those who do not As George Santayana said, “Those who do not know history are condemned to repeat it.”know history are condemned to repeat it.”

BibliographyBibliography

Barry JM. The Great Influenza- The Epic Barry JM. The Great Influenza- The Epic Story of the Deadliest Plague in History. Story of the Deadliest Plague in History. Viking Press, New York. 2004.Viking Press, New York. 2004.

Influenza 1918. A Robert Kenner Films Influenza 1918. A Robert Kenner Films Production for The American Experience. Production for The American Experience. 1998.1998.