The Flu of 1918: Lessons for 2020

Any person who has a running nose, headache, slight cough, feeling of illness or other symptom indicative of sickness should see a physician at once. If it is determined that he has influenza that person should immediately go home and shut himself off from his family and the community until it has been determined definitely that he has influenza.

—From The Weekly Bulletin for the NYC Department of Health, December 1918 

NYC Municipal Library

As of Tuesday, March 17, 2020, New York City had 814 known cases of COVID-19 and seven people had died. By Wednesday, March 18, cases spiked to 923 during a 24-hour span. By March 21, the number of cases had jumped to 6,200 cases with more than 43 fatalities. “I wouldn’t be surprised if we get to a day when we have double digits with new people dying every day,” said Dr. Oxiris Barbot, city health commissioner at a Friday afternoon press conference.

In an extraordinary step, President Donald J. Trump ordered the USNS Comfort, a floating hospital ship with a 1,000-bed capacity, to set sail from the west coast to New York Harbor. As of March 21, New York City accounts for approximately 42 percent of total U.S. confirmed cases of COVID-19.

Though all if this feels unprecedented, in fact the city has been here before. New York City experienced a pandemic more than 100 years ago and learned some valuable lessons from that experience.


The Spanish Flu of 1918-1919 was the deadliest six-month period in human history. Global fatality estimates from September 1918 to February 1919 range from 50 to 100 million people killed, eclipsing the estimated 20 million total casualties suffered during the Great War.

The war, meanwhile, was a contributing factor to the spread of the disease, according to experts. “A severe seasonal flu became more virulent when it reached the front,” said Francesco Aimone, a former influenza researcher who earned a Thesis Excellence Award for Mailman School at Columbia University. “Whether this was due to co-infections, or mutated on its own, is unclear but it became much worse,” he said.

However, despite the staggering global death totals, New York City suffered a comparably low 33,000 fatalities from the flu—a remarkable number given a city population estimated to be approximately 5 million in 1918. In comparison to Boston and Philadelphia, New York City fared reasonably well in its overall mortality rate at 4.7 per 1,000 while Boston’s rate was 6.6 and Philadelphia’s 7.3.

This outcome can be attributed to the city’s prior experience with tuberculosis clusters and the establishment of a robust public health infrastructure. “The city had launched TB awareness campaigns, and began to identify the causes. Tenements and TB went hand in hand,” said Aimone. “The big difference was that in 1918 no one knew how influenza was spread and the concept of a virus was not yet discovered.”           


Typist wearing mask, New York City, October 16, 1918.

In January of 1918, 11 New Yorkers died of influenza, and by June 7 of that year just two more people expired, according the weekly Bulletin of the Department of Health for New York City. Influenza typically strikes in cold weather when people are in closer contact in subways, offices, and apartments.

By the late spring, city health officials had shifted their attention to the significant increase in venereal disease cases that was widely attributed to American soldiers transiting through New York, the main port of entry to Europe, according to the Weekly Health Bulletin of May 1918.

Soon that focus changed. The first reference to the Spanish Flu was in the August 17 edition of the Weekly Health Bulletin. By September 17, the Board of Health required healthcare workers to report all cases of influenza.  

The disease began to spread throughout the five boroughs. Officials weighed the implementation of some of the preventive measures that are now being considered during the 2020 COVID-19 emergency: Staggering work hours, limited quarantine, and a robust awareness campaign that enlisted unconventional allies like Tammany Hall ward bosses and the Boy Scouts of America.

By September 18, cases of the flu continued to rise, prompting Health Commissioner Royal S. Copeland to establish a system of emergency health districts comprised of doctors and nurses charged with treating patients while also compiling data. Copeland directed medical personnel to provide care on site and to quarantine the patient.

The Survey, February 14, 1920. NYC Municipal Library.

Where they would be quarantined depended on the dwelling. He explained this two-tiered approach to isolating influenza to The New York Times on September 19: “When cases develop in private homes, they will be kept in strict quarantine there. When they develop in tenements, the patient will be removed to city hospitals and held under strict observation.”

City officials believed that conditions present in poor neighborhoods exacerbated the spread of influenza. “Reformers acknowledged that the housing stock in immigrant communities was substandard and this method would limit community transmission,” said Aimone.

Though this plan was reasonably well received, Copeland faced criticism for keeping schools and movie theatres open during the crisis. He believed that sanitary conditions in public schools were preferable to many homes and that theaters the primary source of information for many illiterate New Yorkers.

On October 4, city officials recognized that an epidemic existed and by October 21, 450 influenza deaths had been recorded in New York City.  

A New York City police officer, October 7, 1918. The National Archives and Records Administration

Plans to shut down the port were briefly introduced by city leaders but dismissed as impractical. “It was wartime. This was an overriding factor guiding the municipal response. The port of New York was the main nexus for troops, and sealing the port was not a realistic option from a national defense perspective,” said Aimone.

In general, New Yorkers complied with mandated safety measures and very few cases of civil unrest were recorded. “The relationship with government has changed in 100 years but in 1918 people understood the strong sense of police powers,” said Aimone.

“These directives were not voluntary and shaped by wartime environment,” he said.

Here in 2020, since no effective treatment for COVID-19 has yet been developed, prevention practices based on lessons learned, some of them in 1918, will be instrumental in navigating through this crisis.

“City officials used a combination of traditional public health practices, such as quarantine, isolation, and the regulation of public spaces to mitigate the spread of influenza,” said Amione.

“The quantitative data supports the premise that social distancing does lower mortality rates,” he added.

Influenza death rates of the six largest cities, from the Weekly Bulletin of the Department of Health, December 1918. NYC Municipal Library.