Influenza Encyclopedia

On the other side of the state, influenza was already causing a great deal of alarm. On the same day that Pittsburgh reported its case, the Philadelphia Health Department reported a staggering 635 civilian cases in 24 hours.² In Harrisburg, Pennsylvania’s Acting Commissioner of Health, Dr. Benjamin Franklin Royer, scrambled to organize the state’s efforts to combat influenza. On October 3, he issued a statewide closure order for saloons, theaters, movie houses, and other places of amusement, and a ban on all public meetings and other gatherings. Public funerals, parades, and visits to the sick were included in the order, but Royer left the issue of closing schools and churches up to local authorities.³

Two hundred miles west, Pittsburghers had a difficult time accepting Royer’s orders given that there were so few cases of influenza in the city. Nevertheless, officials acted. Faced thus far with only news reports of Royer’s order, Pittsburgh’s Mayor Edward Vose Babcock, Director of the Department of Health Dr. W. H. Davis, and Superintendent of Schools William M. Davidson hurriedly met to discuss what to do. The men quickly decided that, as the official order likely would be received in the morning, the city would begin carrying out Royer’s directive immediately, though they the issue of closing schools and churches for the time being.⁴ Davis reminded physicians that influenza became a reportable disease in Pennsylvania on September 21.⁵

The next day, Friday, October 4, health and other city officials gathered again for a full day meeting to discuss further Pittsburgh’s response to influenza. Health Director Davis ordered hospitals to end all unnecessary visitations, and requested that they provide a report on available beds in their wards. Churches, while not closed, were asked to limit attendance, to exclude parishioners exhibiting symptoms of illness, and to keep services as brief as possible. Doctors were instructed to report all cases of influenza to the city’s health department. Schools were kept open for the time being, but night school enrollment and classes were halted because they did not have medical inspectors; some 15,000 night school students were affected. Mayor Babcock thought that the measures went too far. “Personally, it appears to me,” he told reporters, “in view of local conditions and in the absence of any epidemic of influenza, that the orders of the [state] Department are too drastic.”⁶ Nonetheless, there was little Pittsburgh could do other than to follow Royer’s directives.

Within a few days, Pittsburgh had hundreds of cases of influenza. Suddenly in the midst of a rapidly growing epidemic, Director Davis met with the superintendents of all city hospitals to appoint a special Emergency Committee to plan for the creation of temporary hospitals to handle the volume of influenza patients. Davis buttressed his decision to keep schools open by fortifying medical staff in the public school system with 32 new doctors to monitor students closely for symptoms of influenza.⁷ Churches were not so lucky. Initially allowed to remain open, Davis now ordered churches closed for regular service, although they could remain open during the week for private worship. Jury trials were suspended. Elevator capacity was limited to six passengers. These measures were met with nary a word of grumbling. Such was not the case when Royer banned the sale of liquor by any outlet other than a drug store, and then only with a doctor’s prescription. Liquor associations immediately complained to Davis, who simply read Royer’s order to them and demanded their compliance.⁸

By Thursday, October 10, when more than 1,300 Pittsburghers had the flu, the Emergency Committee proposed devoting Pittsburgh’s hospitals to the care of the poor as well as any stricken industrial workers or miners living in the city’s over-crowded boarding houses and private homes. To further take the strain off hospitals, the Committee asked all those capable of caring for the sick at home do so. The next day, the Emergency Committee started gathering resources for the first of several temporary hospitals, identifying Kingsley Settlement House at 1707 Penn Avenue as the site of a 130-bed emergency facility.⁹ Next, the Committee readied a building on the Washington Park playground for a 200-bed hospital and made contingency plans for a canvas hospital close by with another 300 beds.¹⁰

Numerous military cases exacerbated the problem of hospital space. To help alleviate the problem, officials at the Elizabeth Steel Magee Memorial Hospital temporarily donated their facility for the care of sick soldiers and student cadets. Quickly, the hospital filled with 260 military cases, with an additional 160 sick soldiers sent to several other area hospitals. Major W. E. Day, a United States Army Medical Corps officer in charge of the quarantines of student cadets at the University of Pittsburgh and the Carnegie Institute of Technology, arranged for 80 more beds at West Penn Hospital, despite being ill himself. He also ordered tents from Harrisburg to be used as a temporary convalescent hospital.¹¹ One physician later reported that Day’s unflagging work during the epidemic resulted in keeping influenza among Pittsburgh’s military personnel within reasonable bounds.¹²

Influenza continued to tighten its grip on Pittsburgh. On October 16, more than 800 new cases appeared, bringing the total in the city to 4,445.¹³ A few days later, that total jumped to nearly 7,500. Davis believed that official reports were only capturing about half of the true number of cases. As the situation grew worse, Pittsburgh’s civic and charitable organizations further stepped up their efforts. The local chapter of the Red Cross renewed its efforts to recruit nurses, sending a total of 70 graduate nurses, 40 practical nurses, and 172 aides and helpers to emergency hospitals throughout the county, where they cared for close to 3,000 patients. At the same time, these workers managed more than 12,000 homebound influenza cases.¹⁴ To help staff hospitals and help the sick at home, more than 600 members of the Mothers of Democracy organized themselves into volunteer brigades.¹⁵ Davis asked city churches to help the Mothers of Democracy by organizing parishioners to engage in home service to aid stricken families.¹⁶ On October 26, Roman Catholic Bishop Regis Canevin placed all local resources of the church at the disposal of the health department. At his direction, the Catholic Conference of Charities established relief stations on church property in all 27 of the city’s wards, staffed by teaching nuns who also visited parishioners’ homes to provide home nursing services.¹⁷ The sisters at St. Vincent’s Hill and St. Mary’s Lyceum offered their buildings as temporary orphanages.¹⁸ The Beechview Moose Lodge donated its clubhouse, and the Twelfth Ward Hunting and Fishing Club volunteered its tents to the Department of Health to use as emergency hospitals.¹⁹ The Irene Kaufmann Settlement shouldered responsibility for all nursing service in the Hill District, home to most of Pittsburgh’s Easter European Jews. The Free Burial Association provided poor Jews with burial according to Jewish rites, with shrouds, coffins, hearses, and burial plots free of charge.²⁰ All across the city, volunteers did their best to keep up with the rising tide of cases and the growing cries for help.

Meanwhile, school illness and absenteeism had become a problem, at least as anecdotally recounted by teachers and principals. Superintendent William Davidson estimated that attendance was at 75 percent of normal levels, while Director of School Hygiene Dr. H. B. Burns said that as many as 1,000 students were sick with influenza. To determine the true extent of the illness in Pittsburgh’s schools, City Council member Enoch Rauh pushed through a resolution on October 21 requesting a tally of attendance at the city’s public, parochial, and private schools. The next day, Davidson and Davis presented their findings to the Board of Public Education. Attendance, they found, was down thirty percent from normal levels, meaning some students were 27,000 absent. Of this number, 6,070 – only eight percent of the total student population – had influenza, while the others were absent for other illnesses or because their parents were worried. Fifty-three students and two teachers had died from influenza or pneumonia. Burns informed the Board that, “school, for the five hours that children spend there, is the best possible places for them in the course of this epidemic. He added that medical inspection in Pittsburgh’s schools was amongst the best in the nation. Based on the data and Burns’ opinion, the school board voted to make no move to close public schools.²¹

On October 23, Davis met with Davidson, Burns, and his bureau heads to discuss the school situation further. The data clearly indicated that the vast majority of student absences were not due to influenza, at least directly. Still, it was abundantly clear that absenteeism had become a significant problem. With nearly forty percent of children out of the classroom (ten percent absenteeism was within normal limits), the chief reason for keeping schools open – medical inspection – was no longer relevant. Davis expected absenteeism due to fear to increase in the coming days. “Under these circumstances,” he announced, “it is not possible to maintain through the schools the medical supervision that would have been possible had the attendance remained standard.” The next day, October 24, Davis ordered Pittsburgh’s public, private, and parochial schools closed, and instructed parents to keep their children at home and off of the city’s streetcars, streets, and playgrounds.²²

City Versus State

By late-October, Pittsburgh residents were starting to get anxious over when the closure orders and gathering ban might be lifted. Saloon owners and wholesale liquor distributors were particularly eager to have state Health Commissioner Royer rescind his orders. On several occasions, Pittsburgh’s liquor concerns sent delegations to Harrisburg to take the matter up with Royer. In each instance they met without success.²³ Mayor Babcock then took up the cause. His first tactic involved asking Commissioner Royer to give local health boards autonomy as local conditions warranted, or to at least set a date for when bans might be lifted. Royer tersely responded that removing bans at this time would be criminal. He softened the harsh terms of his telegram, however, by inviting Babcock to Harrisburg for a face-to-face meeting.²⁴

The meeting was productive. Although Babcock failed in his attempt to have the bans lifted immediately, Royer offered hope they would be lifted in Allegheny County shortly so long as the infection rate continued to decline. Furthermore, Royer dispatched Dr. Wilmer R. Batt, the state’s vital statistics registrar, to assess Pittsburgh’s epidemic situation. A few days later, Batt reported that Pittsburgh’s influenza epidemic was indeed on the decline.²⁵ Taking Batt’s report into consideration, on November 1 Royer announced that Pittsburgh might be allowed to reopen its places of amusement as early as November 4.²⁶ Residents, and especially affected business owners, sighed in collective relief.

Overnight, Pittsburgh’s great expectations were dashed when Royer abruptly announced that Pittsburgh would not be allowed to reopen until November 9. Mayor Babcock was furious. He called the city solicitor and the rest of his cabinet into conference to discuss the city’s options. Emerging from the meeting, Babcock announced that Pittsburgh hereby would return to normal business. Although technically the Mayor did not have the power to rescind the state’s closure order, Babcock knew that Harrisburg relied on local authorities to enforce it. “While the state is, of course, supreme in this respect, the city will refuse to act as its police agent,” Babcock told the public. “If Dr. Royer wants to quarantine the city in punishment, he may try to do so, provided government needs do not interpose a higher power.” For all intents and purposes, Pittsburgh’s closure orders and gathering ban were over. Church and school closures were a local matter; Davis said that churches could resume services on November 3.²⁷

There was little Royer could do. The beleaguered health commissioner was dealing with defiance in other sections of Pennsylvania as well, most notably in Lancaster. There, city officials refused to abide by Royer’s influenza bans. As a result, Royer forbade all trains from entering Lancaster, symbolically quarantining it from the rest of the nation. Pittsburgh, however, was not Lancaster. An industrial powerhouse with a large population, Royer dared not try to isolate the Steel City, especially during wartime. Instead, he issued a statement condemning the city’s actions as an invitation to lawlessness and disorder.²⁸ Many businesses were unfazed and continued with their plans to reopen. Churches were split on whether or not to do so; Catholic clergy prepared their churches to reopen, set to open while many Protestant ministers called for harmony between state and local authorities. While the city and state fought, Davis devised a plan to reopen schools in a week, giving them time to recall teachers and prepare the buildings. It also gave parents time to obtain certificates of health for their children from physicians, as now required by Davis for readmission to school.²⁹

Babcock did not stop there. The spirited mayor accused Royer of being drunk with power, perhaps taking a poke at the health commissioner’s concerns voiced statewide about alcohol consumption during the epidemic. Royer ignored the accusation and instructed Nelson McVicar, the state health department’s legal representative in Pittsburgh, to prosecute all defiant business owners. This legal war only lasted a day, as most theaters, movie houses, and saloons decided to remain closed while the political and legal battle was being fought between the city and the state. The few that opted to tempt fate and open were issued warrants, although a wise McVicar subsequently dropped the cases in order to reward compliance.³⁰

Ultimately, Royer held true to his promise to lift the state-ordered bans on November 9. In Pittsburgh, Davis announced that schools could reopen on Monday, November 18 so long as students were inspected and medically cleared to return to their classrooms. Movie houses and theaters could reopen immediately provided they were clean, well ventilated, and sold only as many tickets as there were seats. Other entertainment venues, such as poolrooms, dance halls, and cabarets, could open but could not allow large crowds to gather for extended periods.³¹ Other than these restrictions, Pittsburgh was once again free to return to life as usual.

Conclusion

Pittsburgh continued to experience cases of influenza and pneumonia throughout the rest of the winter, with a small spike in late-January 1919 that briefly concerned health officials. By the start of February, more than 25,000 Pittsburghers had contracted influenza.³² It was not until April 21, 1919 that the city celebrated its first flu-free 48-hours since the epidemic started, some seven months earlier.³³

Overall, Pittsburgh experienced the worst epidemic of any major city in the United States. The average death rate for Eastern cities was 555 per 100,000. By contrast, Pittsburgh’s excess death rate was a whopping 807 per 100,000 people. The Steel City’s ordeal with influenza was even deadlier than that of Philadelphia (748) or Boston (710), two communities where influenza ran rampant in the fall of 1918. Despite advance warning and preparation, organized local leadership, and efficient allocation of resources, Pittsburgh fared horribly during the crisis.

While we know with certainty that Pittsburgh had a very poor outcome, it is difficult to explain why. Despite some grumbling, Pittsburgh officials acted on Royer’s statewide closure order very quickly, even before receiving official word. In fact, Pittsburgh’s closures came even sooner in its epidemic than did Boston’s. At the other end of the epidemic, the few days’ worth of preemptive re-openings that Mayor Babcock unilaterally implemented likely would not account for the severity of the city’s excess death rate. In addition, there is little evidence that many businesses were willing to incur the wrath of state officials by following Babcock’s lead.

There are several significant differences between Pittsburgh and either Philadelphia or Boston, however, that may account for the more severe epidemic in the Steel City. Both Philadelphia and Boston closed schools earlier in their epidemics. Pittsburgh, on the other hand, waited three weeks after implementing other closure orders to extend those closures to schools as well. As a result, Pittsburgh’s various social distancing measures were staggered, and only overlapped by two weeks. Modern epidemiological studies of the 1918 epidemic show that the early, sustained, and layered implementation of such social distancing measures had an impact on the severity of a city’s peak and overall influenza and pneumonia mortality.³⁴ That is, it is not enough to simply utilize multiple measures; those measures should be implemented at the same time so as to create the maximum social distancing possible in a community.

It is also possible that Pittsburgh’s high death rate was in part due to the city’s notoriously poor air quality during the time. A lifetime of exposure to heavy smoke pollution from the city’s coal-fed steel mills may have left many residents more susceptible to respiratory complications from influenza. Several studies over the decades since the 1918 epidemic have shown that historically, Pittsburgh suffered from higher rates of pneumonia than did other areas of the state, especially in the fall and winter months when the weather kept pollution trapped over the city. Other, more recent studies have concluded that high pneumonia mortality is frequently observed in communities with heavy air pollution.³⁵ Combined with the delay in closing schools, Pittsburgh’s pollution may have contributed to the severity of its bout with influenza in 1918.