Philadelphia, 1918

1. Philadelphia, 1918 The Great Influenza By Paul Rega MD, FACEP

2. Introduction The past several years have witnessed intentional and natural infectious disease outbreaks in the United States: Anthrax, SARS, Monkeypox, Norovirus, among others. We have been inundated with new terminology such as “surge capacity” and “alternative treatment sites” and old terminology is being resurrected, namely isolation and quarantine. The infectious disease outbreaks that are transmissible from person-to-person will be the ones that have the potential to not only create the most morbidity and mortality, but will have a significant negative impact on a community’s ability to respond and rebound. This belief, however, is not well-disseminated among the various layers of our social and infrastructural fabric. The following resource material will illustrate how one community was confronted with such an outbreak.

3. Cast of Characters • Wilmer Krusen, Department of Public Health and Charities • Political appointee • Gynecologist • Lt. Commander RW Plummer, Chief Health officer for Philadelphia Naval District • Woodrow Wilson, President of the United States

4. Prologue • US population, 1870: 40 million • US population, 1917: 105 million • 1916: 140,000 civilian doctors (1/2: incompetent per state boards) • Flu origins: Haskell Co., KS (Jan-Feb, 1918) • America on war footing • Recruits come together • Barracks overcrowded • Cold winter • Camp Funston (3/4/18) • In 3 wk: 1100 hospitalized, thousands more ill, 38 dead • From Camp Funston to rest of military in US

5. President Wilson • A reluctant warrior who developed a “scorched earth” policy to have all America in war effort, to make USA one weapon against the Hun • Espionage Act: Post Office censorship, Library of Congress • New “Sedition Act”: Clear and Present Danger • FBI’s American Protective League • 200,000 spies • Committee on Public Information: Propaganda machine • Sauerkraut: Liberty Cabbage

6. The Flu Marches On • People massed together in cities and camps for first time • Resources to war effort • 776 MDs in 1918 to 38,000 in 1921 • ARC: 107 chapters to 3,800 chapters • No media information • April- June: Europe • September: New Zealand/Australia

7. Flu in Select Cities • June, Louisville, KY • Flu to “Fulminating Pneumonia” • Death in 1-2 days • 40% mortality in the 20-35 yr. age group • More malignant second flu wave begins • September, 1918, Ft. Devens (Boston) • In one day, >1500 ill, 75% hospitalized • 100 deaths in one day • Inadequate care: HCWs fall ill

8. The Flu • Severe headaches, extreme arthralgias, fever, chills, malaise, anorexia, intense cough, nausea, vomiting • Nasal congestion, oropharyngeal, tracheal, pulmonary congestion, severe earaches • Intense cyanosis (blue-black) • Gasping for breath • Blood from mouth, nose, GI tract, conjunctiva • Delirium

9. Autopsy Reports • No organ untouched • Kidneys, liver, adrenals, testes • Marked hyperemia of the brain • Pericarditis, myocarditis • Lungs: Plague lungs or lungs exposed to toxic gas

10. US Flu Stats • 47% of all US deaths from flu • 1918-1919: 675,000 dead • Equivalent to 1,750,000 now • 15 times as many civilians died as military • Most vulnerable: Pregnant females • Anywhere from 23-71% depending on area

11. TYPICAL INFLUENZA Mortality Incidence Young Old

12. 1918 INFLUENZA Mortality Incidence Young Young Adult Old

13. Philadelphia in 1917 • 1.75 million • Slums worse than in NYC • Housing scarce • 4 families/apartment sleeping in shifts • “…the worst-governed city in America.” L Steffens • Political machine • Graft, corruption • Social services suffered • City government power split among political boss, precinct captains, and mayor

14. September 7 • Sailors arriving in Philadelphia Navy Yard

15. September 11 • Flu settles on sailors

16. September 15 • 600 sailors hospitalized at Navy Hospital • More sent to civilian Pennsylvania Hospital in city • 5 doctors and 14 nurses collapse 2 days later • Krusen denies threat • 1000 die in Boston • Has meeting with local medical experts and agree to monitor events

17. Between September 15 and 20 • Plummer and Krusen • Have handle on situation • Municipal Hospital for Contagious Diseases opened to Navy ill • Civilians begin dying with regularity

18. September 21 • Board of Health announces “flu” to be a reportable disease • To public: • Stay warm • Keep feet dry • Keep the bowels open • Avoid crowds

19. Avoid Crowds?? • 9/28: Great Liberty Loan Parade scheduled • US on war footing • Keep morale high • Keep free speech to minimum • Union halls raided • 1200 union workers locked in boxcars • Eugene V. Debs jailed 10 yrs for opposing war • Meanwhile local ID experts and doctors wanted to cancel Parade • Concerns never published in newspapers

20. September 26 • 1400 sailors hospitalized so far • Local Red Cross opens first alternative care site in city • 500 bed United Service Center

21. September 27 • Out of 200 hospitalized that day, 123 were civilians

22. September 28 • The Great Liberty Loan Parade takes place • Several hundred thousand attend • Incubation period was less than 48 hours

23. September 30 • Krusen announces an epidemic is occurring in Philadelphia

24. October 1 • All beds in all 31 hospitals filled • Hospitals refuse admission unless patient had a doctor or police order • Nurses refuse $100 bribes • Lines of people waiting to get into Pennsylvania Hospital • No doctors, no medicines • 117 die that day

25. October 3: Krusen Acts • All public meetings banned • All churches, schools, theaters, courts closed • No public funerals • Saloons stay open • Key voting bloc for political machine • Closed next day by State Health Commissioner • Another alternative care site open in City Poorhouse (Emergency Hospital #1) • 500 beds filled in single day • Eventually 12 such sites open

26. In 10 Days • From a few hundred ill civilian cases and 1-2 deaths per day to hundreds of thousands ill and hundreds of dead per day • Newspapers stay mute!

27. Placards Disseminated • “Avoid Crowds” • “Use Handkerchiefs” • “Spitting Equals Death” • Arrested if caught spitting • 60 arrested in 1 day

28. October 5 • 254 deaths that day • Announcement: Peak has been reached

29. October 6 • 289 dead that day • >300 on October 7 • >300 on October 8

30. October 9 • 428 deaths • Would approach double that figure in the next few weeks • 2/3 of the dead were under 40 years of age

31. The Dead • Pile up • Gravediggers refuse to bury them • Caskets pile up in funeral homes • Coffin shortage • Guards posted by unused coffins • Dead bodies lying next to the ill • At home families pack their dead in ice • Stench • Bodies on porches to be picked up, wrapped in sheets, by “dead wagons” (1 atop another) • Mom wanted to place her dead child in a macaroni box

32. City Morgue • Capacity: 36 • Jammed with 200 bodies • Stench!

33. Mental Stress • People increasingly isolated • Avoid each other • No social activities • Phone company allowed only emergency calls

34. Philadelphia General Hospital • 8 doctors & 54 nurses hospitalized (43%) • 10 nurses die • Board of Health appeals for retired nurses and doctors • One old doctor treating patients with purging and venesection!

35. Medical/Pharmaceutical Students • 5 medical schools and 1 pharmaceutical school • Dispatch their students to assist • 1 medical student in charge of an entire floor at one of the Emergency Hospitals • ¼ of his patients die each day

36. More Help? • National Red Cross: Nothing • PHS: Nothing • City: Nothing • “..death toll for 1 day in Philadelphia alone was more than the death toll from France for the whole American army for one day.” • Real action begins October 7

37. The Women Take Charge • Oldest, wealthiest families • Council of National Defense • Emergency Aid Society • Provide organization and leadership • Had money

38. Emergency Aid Society • Used existing system to distribute anything from medical care to food • Divided city into 7 districts • Dispatched doctors according to geography • Developed list of physicians • 24 hour phone bank for info and referrals • Soup kitchens in public schools for the ill • Volunteers (thousands) • Private cars as ambulances • Drove physicians on rounds

39. Krusen Wakes Up • Gives women control of nurses • Seizes $100,000 in the emergency fund and $25,000 in the war emergency fund • Supplies hospitals • Hires doctors (twice what PHS paid) • Sends doctors to police stations • Cleans streets • Requests Feds not to draft Philly’s doctors • Approved

40. Krusen, The Women, The Catholic Church, & The Dead • Police & priests clear bodies (wore masks) • 33 cops die by mid-October • 6 alternative morgues • Streetcar company builds coffins • Enlist embalming students and morticians from 150 miles away • Seminary students dig graves • Heavy equipment to dig mass graves

41. October 10 • 759 dead • Before the flu, death from all causes averaged 485 per week in Philadelphia • Orphans abound

42. The Unsung Heroes • Attrition rate for volunteers high • Medical profession continued • Few fled • Police continued • Request for 4 volunteers to remove decomposed bodies • 118 responded

43. Week of October 16 • 4,597 deaths • Worst week of the epidemic

44. Then…the numbers began dropping • 10/26: Ban on public gatherings lifted • 11/11: The flu officially gone from Philadelphia

45. Epilogue The 1918 influenza epidemic in Philadelphia illustrates the good, bad, and ugly of American responses to a galloping infectious disease outbreak. There were heroes and there were “goats”. Both personal courage and political ineptitude were on display. Altruism played a “tug-of war” with profit. As George Santayana said, “Those who do not know history are condemned to repeat it.”

46. Bibliography • Barry JM. The Great Influenza- The Epic Story of the Deadliest Plague in History. Viking Press, New York. 2004. • Influenza 1918. A Robert Kenner Films Production for The American Experience. 1998.