Masked sanitation worker and elevator operator during the 1918 Great Pandemic in New York City.

Just over a century ago, New York City tackled the “greatest pandemic in history” also known as the Spanish Flu, that infected a third of the world’s population killing nearly 50 million people and forcing New Yorkers to self-quarantine and wear masks in public. The City’s response, similar to the measures currently being undertaken today with COVID-19, is credited with slowing the spread of the Great Influenza of 1918. From fights over keeping schools open to temporary hospital construction and home-quarantining, the battle to curb the spread of influenza in 1918 is suddenly very familiar to New Yorkers in 2020. COVID-19 has impacted our lives in a way this generation has never experienced. But while exploring the Great Influenza, we see that New York City has an established public health history known for successfully slowing the spread of infectious pandemics, from yellow fever to cholera, typhoid, and polio.

New York City skyline in 1918. Click here to purchase a fine-art print.

In 1918, while much of America’s focus was on World War I, the world was hit with the most severe pandemic in modern times. The 1918 Influenza Epidemic (also known as the Spanish Flu) spread globally from 1918-1919 infecting about one-third of the world’s population (about 50 million people).

New York City was hit hardest by the epidemic in the fall of 1918 and with no known vaccine or treatment the City’s approach was to rely on its well established public health infrastructure. Using what the City had learned from previous cholera and tuberculosis outbreaks, NYC adopted a containment strategy. The city’s proactive approach had three main goals; slow the spread by distancing the healthy from the sick, start a large-scale education campaign teaching people how the virus spreads and best practices to avoid it, and disease surveillance capacities.

The Spanish Flu was caused by the H1N1 virus, which contained genes with avian origin, however, there is no conclusive evidence as to the geographic location where the outbreak started. Despite popular belief, the flu did not originate in Spain. When the outbreak began in Europe, wartime censorship minimized accounts of the epidemic in order to keep morale high. Because Spain was one of the only major European countries to remain neutral in World War I, they were not censored and freely reported on the rise of this illness. As a result it appeared that Spain was hit harder and earlier, leading people to believe it originated there.

Containment consisted of an isolated quarantine for anyone already infected in their private home. Those who lived in boarding houses or other non-private residences ( largely lower class in more dense living conditions) were moved to hospitals or makeshift quarantine wards. These temporary units were set up in gymnasiums, armories and even the City’s first homeless shelter at the Municipal Lodging House on 1st Ave and 25th was turned into a temporary influenza quarantine ward.

One of the largest concerns for New York City was public transit. The Health Department Commissioner Royal S. Copeland set up a program mandating business to stagger their work hours in an attempt to spread out rush hour traffic and avoid large crowds. Schools were mostly left open but each student had a health check every morning, with symptomatic students being immediately sent home. This decision was extremely controversial, Commissioner Copeland felt that school was a more sanitary environment than most children’s homes and by conducting daily observations, they could help slow the spread of the virus by keeping these children in a safe and hygienic location every day. They also used schools as a major distribution point for educational flyers about the virus and the steps needed to protect against it. Many theaters were also closed, except the larger, well-ventilated ones that followed strict health guidelines. On top of the increased health regulations, theaters had to decrease overcrowding, ban smoking and were not allowed to admit children under twelve. Any theaters that did not meet the increased regulations were ordered closed. Copeland felt that keeping theaters open would not only afford them another avenue to spread information but would also keep the public from panicking.

The city put together a huge educational campaign, giving schools over 1,000,000 million pamphlets so that each student could help spread the information. Police rounded up and in some cases fined anyone who was caught spitting in public. New York relied on a mix of mandatory as well as voluntary measures to keep people distanced and curb the spread.

Health center locations around the city. Credit: National Archives.

Daily death rate, 1918. Credit: National Archives.

Because there was no vaccine or known medical treatment that would cure the H1N1 virus there was little that doctors could do for patients. Nurses emerged as the true heroes of this epidemic as they would spend time treating the patients, providing them warm baths, soup, blankets and fresh air. The Department of Health set up a group of 150 emergency health centers in neighborhoods all over the city. Their chief function was to coordinate nurses making home visits and to report on the numbers of cases in each area. This system was successful in getting sick patients the help they needed and tracking the spread of the virus.

The 1918 influenza pandemic was the largest public health crisis in modern times. Globally it is estimated that about 50 million people lost their lives with 675,000 of them in the United States. New York lost roughly 30,000 of its 5.6 million residents throughout the three waves of the virus. Although this was a devastating epidemic, New York could have fared much worse if it wasn’t for their pro-active approach in decreasing the spread. New York City’s death rate was 4.7 per 1000 residents while both Boston and Philadelphia had higher rates (6.5 per 1000 and 7.3 per 1000, respectively). New York has a long history of public health work and the city government was able to draw on this long-established network to organize and fight the spread of the virus. Their methods proved to be successful, the daily health checks at the schools helped to prevent the spread among children and the overall approach of containment, education and the reporting of cases helped New York City have one of the lowest death rates in the region.

After the epidemic had subsided, Health Commissioner Copeland credited the city’s ability to escape with such a low death rate on the city’s public health efforts over the previous 20 years trying to control tuberculosis and improve sanitary conditions in New York. When New York was faced with the 1918 Pandemic they relied on their well-established public health structure and the time-tested methods of isolation, education, and data reporting to slow the spread of the virus.

The Great Pandemic of 1918