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Meanwhile in St Louis once public health officials realised that the disease had crossed over from the military to the general population, they immediately employed strict lockdown conditions. St Louis immediately ordered crowd control and banned public gatherings, and volunteer nurses treated the sick in their homes. Crowd control in 1918 included restricting business hours and the closing down of schools, theatres, churches, playgrounds and dance halls, and this kept the disease from exploding, as it did in Philadelphia.

The result is clearly visible in the diagram below.

Data sourced from: Public Health Reports, Vol 45, No 39, September 26, 1930

Interestingly, when you look at the St Louis curve, you will see two peaks in the Fall and early Winter. Once the pandemic seemed to be declining, the city rolled down its lockdown measures. It did this too early, and flu deaths increased again, and health officials locked the city down again. The third wave returned that Winter and last showed up in early 1920.

The virus likely lurked around for years thereafter, not causing pandemics (global breakouts), but seasonal epidemics (national breakouts), because more people had been exposed and had developed antibodies.

Implementing an early and effective restriction on social activities is a critical action that officials need to have the courage to take when a pandemic infiltrates.

Spanish Flu in Other US Cities

Across the cities in the United States there were a range of responses to the Spanish Flu, with Philadelphia and St Louis representing the two ends of the spectrum.

In a study on the Spanish Flu, conducted in 2007, every city amongst the forty-three US cities that were analysed adopted at least one of the following three social restrictions, or lockdown measures: school closures, cancellation of public gatherings, and isolation and quarantine.

The cities that implemented all three lock down measures early and rigidly not only delayed the peak in the number of deaths, but also reduced size of the peak and the total number of deaths. There was also a direct association between increasing the number of days for which lockdown measures were implemented and reducing the total number of deaths. Meaning the longer the lockdown, the fewer people died from the Spanish Flu.

Looking in more detail at New York City, Pittsburgh, and Denver, we need to understand what is meant by total excess death rate, and public health response time.

Total mortality is expressed as total excess death rate (EDR) per 100 000 population, which means the smaller the number per 100 000 population, the fewer people that died.