On September 28, 1918, the Liberty Loans Parade was held in Philadelphia to help finance America’s participation in the First World War, which cost the United States roughly $32 billion. Even though local doctors had clearly warned about the dangerous flu strain that existed in the city, more than 200,000 people turned out shoulder-to-shoulder cheering on the marching soldiers, bands and floats. Within 72 hours, all of Philadelphia’s hospital beds were filled. The morgues ran out of space, the coffins ran out, and the bodies stayed in people’s houses while waiting for burial. Over 17,500 Philadelphians eventually died of the influenza virus.
In 1918, although our republic’s economy grew at an extremely fast pace, the country still did not have a modernized public health care system. The duty of preventing and controlling infectious diseases was the sole responsibility of local governments, who often lacked funds and well-trained health experts. Although municipalities had their own health departments to fight diseases such as cholera, yellow fever, and smallpox, they were mostly local in nature. There was no coordinated effort on the part of the federal government through its Public Health Service, which was still quite small in size.
These vulnerabilities were particularly harmful during the First World War. Troops were living in overcrowded army camps prior to their deployment overseas, providing a perfect breeding ground for communicable diseases. The movement of troops helped spread influenza throughout the US and Europe, and the overcrowded trains, factories, and cities hastened the infection process within civilian populations. Influenza was a well-known seasonal disease, but the specific virus that surfaced in 1918 was very deadly, even for otherwise healthy young adults.
As infections continued to increase during the fall of 1918, local authorities struggled to keep up. While some towns like St. Louis and Los Angeles reacted immediately by closing down schools, churches, theatres and other crowded places, and recommending the use of face masks by citizens, others such as Philadelphia were hesitant to act due to the negative impact for the war effort and the economy. The outcome was clear: towns and cities that acted immediately to introduce restrictions had lower mortality rates than those where such interventions were introduced after hospitals became overcrowded. St. Louis closed its schools, churches, and theaters within days and ended the pandemic with one of the lowest death rates among American cities. Philadelphia, which hesitated, finished with one of the highest.
An estimated 675,000 Americans died during the 1918 influenza pandemic, while worldwide the deaths exceeded 50 million. It became evident that the responsibilities of public health cannot be solely left to local governments.
All these fatalities forced the federal government and medical workers to think anew about dealing with epidemics. While several targeted emergency bills were introduced, Congress itself became too sick to function. The bills would have funded epidemic preparedness and built a stronger federal role in public health. The flu, war-weariness, and a Congress too depleted to push them through killed the effort. so momentum quickly evaporated for the failed flu bills of 1919. Even the backing of a future president, Ohio Senator Warren G. Harding, could not save them.
Western Europe began building universal healthcare and expanded access to state-funded medicine. The Soviet Union built the first fully centralized, state-run system. The United States rejected universal coverage, and employer-based insurance would not take hold until the wage controls of the 1940s. Washington did react, but differently — expanding data tracking, building private hospital capacity, and legally cementing local emergency powers.
The aftermath of the 1918 influenza pandemic left its trace far beyond the tragedy. The systems used today to track infectious diseases, to gather information on epidemics, to prepare hospitals for future pandemics were built on lessons learned from the deadliest pandemic in history. Although there have been significant advances in medicine since those times, the main lesson of 1918 has nothing to do with medical breakthroughs. It’s that the protection of public health is impossible without coordinated efforts of both governance and science.
