We all have heard warnings about the flu season. It seems to be following a typical pattern as occurs almost every decade—1947, 1957, 1968, 1977…But there is an outlier in the routine: the flu pandemic of 1918 which killed 55 million people around the world and is considered the deadliest health crisis in modern history and perhaps, ever.

1918 began in a regular manner. New Yorkers were focused on the Great War that raged overseas, food rationing and other mundane issues. The Weekly Bulletin of the Department of Health reflects the concerns of public health experts: contaminated milk, sanitary issues in commercial laundries and deaths caused by automobiles. The rate of marriage was up compared to prior years; the rate of suicides was down and the rate of deaths from pneumonia was unfortunately stable and described as “one of the most important problems facing health authorities throughout the world.” Tuberculosis death rates were falling, as were those from typhoid fever. And in the most auspicious news, deaths from poliomyelitis the previous year dropped to 51 from the high of 2,248 in 1916. About influenza? Nary a word in the Bulletin.

The Health Department statisticians produced weekly reports showing the rates of infectious disease, birth and death rates, by borough, and the causes of death by age and gender. The mortality report in an early January 1918 circular showed that 11 people died from influenza, favorably compared to 49 in the corresponding week in 1917. Four of the deceased were male, 7 were female, and 5 were over 65. It was just a regular flu year. That’s not to say that there was a callous attitude about these deaths. Rather the Health Department tried to determine what factors contributed to the spread of infectious disease and where to focus resources to reduce infection and mortality.

Deaths from influenza continued to drop. By June 7 only two people died from this illness in the preceding week. Typically, influenza, or “the flu” strikes during the cold weather months when people are more likely to be in closer contact, inside apartments, offices and subways. The winter season actually was less severe than in the prior years and by the spring of 1918, officials were turning their attention elsewhere.

In May, 1918 Mayor John Hylan appointed the former Ann Arbor, Michigan, Mayor, Royal S. Copeland, as the Health Commissioner. Little did he know that the public health crisis he would soon face. Instead, the monthly bulletin described efforts to combat venereal disease (on the increase due to the soldiers passing through the City), and the Children’s Year designated by President Woodrow Wilson to reduce child mortality nationally and by 4,700 in New York City. The July 6 bulletin urged vaccination against typhoid fever, noting, “Many times the healthfulness of a place is judged by its typhoid death rate. Can you afford to give New York City a bad name?”

The first mention of the “Spanish Influenza” in the bulletin was the front page article on August 17. Ironically, there were zero deaths attributed to the flu reported in this edition. The article reported that nearly one-third of Spain’s population had experienced the flu, which illustrates how the misnomer, “Spanish Influenza,” came about. The flu did not originate in Spain. It was no more severe there than in other European nations, but because news reports in that country were not constrained by wartime censorship the extent of the epidemic was reported publicly. The Bulletin stated that a Norwegian steamer had arrived bearing a dozen passengers with the flu who had been quarantined. Nevertheless, “The public has no reason for alarm since through the protection afforded by our most efficient quarantine station, and the constant vigilance of the city’s health authorities, all the protection that sanitary science can give is assured. The very mildness of the disease, as reported in Europe, is, in itself, assurance against anxiety on this side of the water.”

That was not the case. The flu hit in two waves, the first during the regular winter season. The second wave, the direst threat to public health, emerged that summer. On the Eastern Seaboard, Boston and Philadelphia were particularly hard hit. New York City, proportionately, experienced fewer deaths. Why? In large part, by doubling down on the public health systems that the Health Department had deployed to fight another highly contagious disease: tuberculosis. Principally these were public education, quarantine, and decentralized medical care, including visiting nurses.

At this time, medical researchers did not know exactly what caused the flu. Some “experts” hypothesized that the germs came from Germans, part of the war effort. While debunked as a German plot, historians have agreed that there is a close correlation between the Great War and the flu. Whether the movement of the armed forces dispersed the virus or the deployment of medical personnel into the theater of war left civilians with reduced medical care. Another query was whether the Bayer aspirin was the cause. The rumor was that “the aspirin tablets contain influenza germs and some slow poison,” according to the Bulletin. This caused the Health Department to conduct laboratory tests of aspirin purchased randomly from locations throughout the City. “Nothing irregular was found in the composition of the tablets,” they reported.

Clearly, educating the public about how the flu was spread was key. The Health Department developed leaflets that were distributed widely, including 900,000 to every public and private school student. They urged people to use handkerchiefs to cover up each cough and sneeze, and to stay out of crowds. This advice was heeded by the medical professionals themselves as the convention of the American Public Health Association was postponed from October to December, at the request of the United States Surgeon General.

By September 28, when cases of the flu were doubling in the City, Copeland acknowledged the seriousness of the disease and possibility of an epidemic but refused to order that schools and theaters be closed. He rationalized that the schools had healthier environments than many homes. His reasoning proved wise, although highly controversial. After the epidemic ended, he was quoted in the New York Times saying, “My purpose in doing it all in this way, without issuing general closing orders and making a public flurry over the situation, was to keep down the danger of panic… I wanted people to go about their business without constant fear and hysterical sense of calamity.”

The Board of Estimate (the government entity that made budget decisions at that time) made a special allocation of $25,000 to fight the flu. It was largely used to hire nurses and nurses’ aides and sanitary inspectors who collaborated on identifying flu cases and providing care. Copeland set up a system of emergency health districts from which localized care was provided. If cases of the flu were detected in apartments or private homes, care was provided on site and the ill person quarantined. Tenement house or boarding house residents who contracted the flu were taken to municipal hospitals. Copeland explained the plan to doctors in an October 10 letter, “In the future, the Department of Health will largely center the efforts of its nurses and medical inspectors in the field, within the congested sections of the city and will make home visits to all cases of influenza and pneumonia in which the practicing physicians fail to state that they will assume entire responsibility for proper isolation in the patients’ homes.”

The health district plan was announced on October 4 and implementation began immediately. A call went out for nurses and by October 13, the health centers were staffed. The nursing personnel worked in the emergency clinics but also in people’s homes, caring for the sick. In a post-outbreak summary, Mildred Lum, the nurse in charge of emergency nurses wrote: “Three classes of women rendered efficient service in this crisis, and made the opening and maintenance of these emergency hospitals a possibility. Women who in previous years had had hospital training, women who were recent graduates of emergency war time courses and women who were without hospital training but who were willing to serve in any capacity to fight the fight against this dread disease.”

The Henry Street Settlement House founder, Lillian Wald, already directed a visiting nurse service providing in-home care throughout Manhattan. In October, she assisted in creating the Nurses Emergency Council that brought together all of the private nursing agencies and City inspectors. In a post-flu summary titled “Influenza: When the City is a Great Field Hospital” she claimed, “These forces, municipal and private, Catholic Jewish and Protestant, were mobilized and ready for action in less than twenty-four hours after the forming of the Council.” In Wald’s view, the City should remain on constant readiness to provide this level of service because severe outbreaks of “epidemics” weren’t extraordinary. Rather, “their occurrences are frequent enough to be anticipated and are not inherently incapable of administrative control.”

October 4, 1918 was a busy day for the flu fighters. In addition to announcing the clinic plan, the Board of Health declared a flu epidemic existed and also adopted a resolution to regulate the hours of operation for businesses, entertainment venues and other entities.

Copeland reported on this development in the November 1918 edition of The American City, after the height of the epidemic had passed. Published by the Civic Press, this monthly publication was meant for municipalities of 5,000 or more people and reported on innovations ranging from a Snow Scratcher in Ottawa that roughed up snow to make it passable and not slippery, to Bathing Suit Regulations (no white or flesh colored suits) to “The Patriotic Unification of Your Town Thru Drama.”

His article “Fighting Influenza with Transit Systems” described how the Board of Health “called into play some of its vast powers” adopting a resolution that set schedules for the opening and closing of most places of business, thus spreading out the transit window and reducing congestion. Reduced congestion = Reduced Flu. For example, retail dry goods stores were scheduled to open from 9:45 – 6:15 P.M. whereas other retail stores were scheduled to open at 8:00 a.m. and close at 4:00 pm. Some entities were not affected—banks and offices of the U.S. Government, for example. Theaters and places of amusement were permitted to maintain afternoon hours as normal but evening performances at movie theaters and two-a-day vaudeville houses were regulated. Copeland noted that this emergency measure had faults because it was “conceived and executed in less than four hours.” Never-the-less, he concluded that the scheme effectively reduced the number of people packed into various locales, including subways and buses, and reduced the spread of the deadly flu.

Throughout September and October, New Yorkers weighed in on how to resolve the epidemic. One can imagine the reaction provoked by the letters sent to the Health Commissioner about how to fight the flu. One, proposing that all telephones be supplied with individual mouthpieces would seem impossible to implement. Unfortunately, the suggestion seemed compelling to Mayor John Hylan who sent along his own letter of support, suggesting daily replacement and disinfectant of telephone receivers along with cleaning subway restrooms. Another suggesting saturating all public places with camphor to prevent the flu must have been met with eye rolls and guffaws. And some must just have provoked frustration, as when the Staten Island Borough President insisted in a letter that places of assembly be closed during the epidemic, the exact opposite approach that Copeland was implementing.

When the flu was in check, Copeland responded with his own missive stating in which he wrote:

In responding to a brief note by one R. J. Caldwell claiming that Copeland didn’t take the quantity of flu cases seriously, Copeland penned a letter directly to Mayor John Hylan claiming that not only did he take the matter seriously but devoted 21 hours daily to handling the epidemic.

Copeland and his Department had a good deal to be proud of. By November, when the worst of the epidemic had passed, New York City had experienced 20,403 deaths from influenza and pneumonia (the first frequently resulted in the second so both were deemed influenza-related deaths). However proportionate to the population, the City fared much better than most counterparts with a rate of 3.9 deaths per thousand residents. Of the twenty large cities, only Chicago and Cincinnati had lower mortality rates, with 3.3 and 2.6 deaths per 1,000 residents.

In the Sunday New York Times published on November 17, 1918, Copeland took a verbal victory lap in an article titled “EPIDEMIC LESSONS AGAINST NEXT TIME.”

In meeting the situation when it got here we did a number of unconventional things and we did not do several conventional things that were done elsewhere.... The first thing that was done almost everywhere but New York was to close the schools…and the theatres and all places of public assemblage.... They may have been just the right things to do in those places; I don’t know their conditions. But I do know the conditions of New York and I know that in our city one of the most important methods of disease-control is the public school system.

An ad in that edition praised Copeland with a headline: “This Man Guards the Health of Five Million People.” Paid for by the National Association of the Motion Picture Industry, the ad praised him for not closing the theatres despite the “hullabaloo and panic of other cities” and claimed “An Ounce of Courage is Worth a Ton of Fear.”

The lead article in the penultimate edition of the Bulletin in December 2018 was headlined, “Control of Influenza Must Be Continued,” and cited the practices that Copeland implemented: reporting illnesses, public health education and requiring sick people to stay home.

Any person who has a running nose, headache, slight cough, feeling of illness, or other symptom indicative of sickness should see a physician at once, and if it is determined that he has influenza or there is any doubt as to whether or not it may be influenza, that person should immediately go home and go to bed, or at least shut himself off from his family and the community until it has been determined definitely that he has not influenza.

Oh, so wise.