With the outbreak of COVID-19 in Philadelphia on March 10th, 2020, local institutions were quick to respond (6). On March 16th, both Temple University and the School District of Philadelphia closed their doors to students—Temple had then made the commitment to end for the rest of the semester; it took until Gov. Tom Wolf declared all Pennsylvania schools closed for the rest of the academic year on April 9th that Philadelphia committed to do so (1, 3, 5). By then, Philadelphia had issued a Stay at Home Order effective March 23rd restricting social gatherings and non-essential business activity until further notice (2).
These steps were taken to flatten the curve, a now ubiquitous phrase, repeated by many to encourage us to minimize physical interaction so that we may slow the spread of the virus to avoid overburdening our medical system.
Flattening the curve is not a new idea.
Excess P&I mortality over 1913-1917 baseline in Philadelphia and St. Louis.
From Public health interventions and epidemic intensity during the 1918 influenza epidemic, PNAS, 2007
In 1918, Philadelphia was the hardest hit city in America during the world's deadliest pandemic: Spanish influenza.
St. Louis, on the other hand, fared the best of the largest American cities at the time. They had effectively flattened the curve (12).
In 1918, the nation was engaged in the First World War. The city of 1.7 million was vulnerable: twenty-six percent of Philadelphia's physicians were away with the military. Philadelphia's naval shipyards were fully engaged in the war effort when a draft of sailors from Boston brought the pandemic to Philadelphia.
Still, weeks later, with ever-surmounting cases, the city held the Fourth Liberty Loan Parade to raise funds for the military. This proved disastrous (10).
"The one morgue in the city with a maximum capacity for the care of thirty-six bodies, contained several hundred... Some of the bodies were mortifying and the stench was nauseating... the doors were open and bodies laying all over floor, a spectacle for gaping curiosity seekers, including young children."
Emergency Service of the Pennsylvania Council of National Defense in the Influenza Crisis (4)
How did St. Louis avoid the same death toll as Philadelphia in 1918?
RESTRICTIONS by City
Philadelphia waited until there were over 600 sailors and civilians in city hospitals with flu before the disease was made reportable to the Bureau of Health (10).
St. Louis had only 44 reported cases of flu and no deaths when the disease was made reportable (13).
Philadelphia closed all schools, churches, and places of public amusement 17 days after the first reported civilian case. The estimated number of cases doubled 3-5 times during that period (12).
St. Louis closed all schools, churches, and places of public amusement 2 days after the first reported civilian case (13).
Philadelphia did not strictly mandate positive cases to isolate at home (10).
St. Louis cooperated with the city police to enforce quarantining
positive cases in their homes for up to 14 days (13).
Philadelphia, despite having thousands of cases, saw 200,000 people attend the Fourth Liberty Loan Parade to raise funds for the war effort (10).
St. Louis had no reported cases when the Fourth Liberty Loan Parade went on (12).
Fourth Liberty Loan Parade
The outbreak is often hardest for those who stay.
In 1793, Philadelphia was the temporary capital of the fledgling United States. Spurred by its strong Quaker tradition, Philadelphia raised funds, established charities, and accepted over 2,000 French refugees from the island of Saint-Domingue where the Haitian Revolution raged.
Aided by city's ravenous mosquitoes, the yellow fever virus brought by the French circulated through Philadelphia (9, 15).
Of the 55,000 Philadelphians at the time,
over 5,000 died
20,000 had fled
With the same ratios in today's Philadelphia,
over 140,000 would die
575,000 would flee
In the coronavirus pandemic, those too poor to flee bear the brunt of hardship. Many have questioned if the government is doing enough for the starving and the jobless.
How are the experiences below similar to our experiences with COVID-19?
Click on the stories below to learn more
Fever at Home
Fever at Home
Those unfortunate enough to have had to remain in the city were often the hardest hit.
"A woman, whose husband and two children lay dead in the room with her, was in the same situation, without a midwife, or any other person to aid her. Her cries at the window brought up one of the carters employed by the committee for the relief of the sick. With his assistance, she was delivered of a child, which died in a few minutes, as did the mother, who was utterly exhausted by her labour, by the disorder, and by the dreadful spectacle before her. And thus lay in one room, no less that five dead bodies, an entire family, carried off in an hour or two.”
A Short Account of the Malignant Fever, Lately Prevalent in Philadelphia (1793) (9)
Wellcome Images via Wikimedia Commons
In the first cholera pandemic of the 1830's, the poor were most highly affected and stigmatized. Transmissible by drinking water contaminated with the bacteria Vibrio cholerae, even early 19th century scientists with no knowledge of the pathogen noticed that the disease especially struck neighborhoods with poor sanitation (although they attributed it to bad odor or miasma) (16).
"... the paper declared that '[cholera's] greatest ravages have been among those whose constitutions had become impaired by poverty and wretchedness, or ruined by intemperance and vice.' ...
... The Friend reported on June 30:
'The appearance of this fatal malady in our favoured country is calculated to awaken the most serious reflection, and to excite the mind to close self-examination. That is a dispensation permitted to a wise and gracious Providence as a chastisement for the sins of the people, and as a solemn warning to repent and amend their ways, I have not the smallest doubt.' ”
The Sisters of Charity and the 1832 Cholera Epidemic in Philadelphia (2009) (16)
What more can be done to protect our most vulnerable communities?
1. “All School District of Philadelphia Schools Will Be Closed Through Friday, March 27, 2020.” School District of Philadelphia Office of Communications and External Relations, March 13, 2020. https://www.philasd.org/communications/2020/03/13/all-school-district-of-philadelphia-schools-will-be-closed-through-friday-march-27-2020/
2. “City Issues Stay at Home Order Clarifying Restrictions on Business Activity in Philadelphia.” Board of Health, Managing Director’s Office, Department of Public Health, Department of Commerce, Office of the Mayor, Office of Emergency Management, March 22, 2020. https://www.phila.gov/2020-03-22-city-issues-stay-at-home-order-clarifying-restrictions-on-business-activity-in-philadelphia/
3. “Coronavirus.” School District of Philadelphia, updated May 27, 2020. https://www.philasd.org/coronavirus/
4. “Emergency Service of the Pennsylvania Council of National Defense in the Influenza Crisis, Report of the Vice-Director, Department of Medicine, Sanitation and Hospitals.” Accessed by University of Michigan Center for the History of Medicine and Michigan Publishing, University of Michigan Library. https://quod.lib.umich.edu/f/flu/1770flu.0015.771/2/--emergency-service-of-the-pennsylvania-council-of-national?page=root;rgn=full+text;size=100;view=image
5. “Main Campus buildings close as students, faculty stay at home.” The Temple News, March 19, 2020. https://temple-news.com/main-campus-buildings-close-as-students-faculty-stay-at-home/
6. “Philadelphia Reports First Case of New Coronavirus.” NBC10, March 10, 2020. https://www.nbcphiladelphia.com/news/coronavirus/philadelphia-reports-first-case-of-new-coronavirus/2319796/
7. Baker, Sam and Alison Snyder. “Coronavirus hits poor, minority communities harder.” Axios, April 4, 2020. https://www.axios.com/coronavirus-cases-deaths-race-income-disparities-unequal-f6fb6977-56a1-4be9-8fdd-844604c677ec.html
8. Bootsma, Martin C. J. and Neil M. Ferguson. “The effect of public health measures on the 1918 influenza pandemic in U.S. cities.” PNAS, May 1, 2007. https://doi.org/10.1073/pnas.0611071104
9. Carey, Mathew. A short account of the malignant fever, lately prevalent in Philadelphia: with a statement of the proceedings that took place on the subject in different parts of the United States. Philadelphia: Printed by author, November 14, 1793.
10. Crosby, Alfred W. America’s Forgotten Pandemic: The Influenza of 1918, Second Edition. Cambridge University Press, 2003
11. Gammage, Jeff, Elizabeth Robertson, Mike Newall and Tom Avril. “Hospital delivers bodies to Philly medical examiner in the open back of a pickup truck.” The Philadelphia Inquirer, April 20, 2020. https://www.inquirer.com/health/coronavirus/bodies-pick-up-truck-medical-examiner-ford-overflow-storage-20200420.html
12. Hatchett, Richard J., Carter E. Mecher and Marc Lipsitch. “Public health interventions and epidemic intensity during the 1918 influenza pandemic.” PNAS, April 6, 2007. https://doi.org/10.1073/pnas.0611071104
13. Kalnins, Irene. “The Spanish Influenza of 1918 in St. Louis, Missouri.” Public Health Nursing, September 7, 2006. https://doi.org/10.1111/j.1525-1446.2006.00586.x
14. Paybarah, Azi, Matthew Bloch and Scott Reinhard. “Where New Yorkers Moved to Escape Coronavirus.” The New York Times, May 16, 2020. https://www.nytimes.com/interactive/2020/05/16/nyregion/nyc-coronavirus-moving-leaving.html
15. Powell, J.H. Bring Out Your Dead: The Great Plague of Yellow Fever in Philadelphia in 1793. University of Pennsylvania Press, 1993.
16. Watson, William. “The Sisters of Charity, the 1832 Cholera Epidemic in Philadelphia and Duffy’s Cut.” U.S. Catholic Historian 27:4 (Fall, 2009): 1-16.