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In her excellent article, An Epidemic Checked: A Chronicle of the 1918 Influenza Pandemic in Dayton, Ohio , author Jackie Frederick relates the striking story of how the people of Dayton, Ohio, led by one doctor, effectively stemmed the Pandemic Influenza of 1918 in their city. The following summary of her article illustrates how one city devised, managed and responded to a public health crisis of epic proportions.
In the late summer of 1918, as World War I was approaching its conclusion, the people of Dayton were transfixed to the newsreels from the European front. In September 1918, at a military camp near Chillicothe, Ohio, eighteen men fell ill from violent, flu-like symptoms and died shortly thereafter. Red Cross nurses responded immediately. There was no known drug regimen or procedure for treating what became known as the “Spanish Flu,†except “warm food, warm blankets, fresh air, and ...TLC—Tender Loving Care.â€
By October, the disease had spread outside the military camps. As the pandemic widened, the government and local authorities took all possible measures to stop its spread The Navy’s Department of Sanitation delivered the following set of warnings:
• Protect yourself from infection, keep well, and do not get hysterical over the epidemic.
• Beware of those who are coughing and sneezing.
• Avoid crowded streetcars—walk to the office if possible.
• Keep out of crowds—avoid theaters, moving picture shows, and other places of public assembly.
• Do not travel by railroad unless absolutely necessary.
• Do not drink from glasses or cups which have been used by others.
• Avoid close, stuffy, and poorly ventilated rooms.
• Stay at home and not try to go to work if sick.
• Boil handkerchiefs and keep away from others.
The influenza pandemic quickly gained daily front page coverage in the Dayton Daily News, along with news of the war. Articles about the number of current and new cases, deaths, and recommended methods people could employ to limit the spread of the influenza were commonplace. The newspapers also included ads for products to treat flu symptoms.
One man at the front lines in battling the pandemic was Dr. A. O. Peters—Dayton’s Health Commissioner. He saw the first signs of the influenza pandemic and immediately began his own personal crusade to calm Dayton’s populace. At the outset, Peters began organizing the city to combat the spread of the virus. His information campaign was a plea to the people of Dayton for a measured, deliberate response. His message contained two warnings: the first warned about the danger in becoming complacent; while the second urged people not to become panicked. He spoke in clear, easily understood terms, seeking more to educate than to warn. There were simple steps every family could take, he argued—the most important step was to follow the basic tenets of personal hygiene:
- He warned the public that most of the cases in Dayton were due to the negligence of people that, when they or another family member were ill, did not take the proper precautions to keep the disease from spreading. He claimed that the deaths so far were caused by pneumonia, which developed because the patient returned to normal activities too soon. He recommended that anyone suspected of contracting the disease should be isolated from the rest of the family. Only one other person, who should wear a gown and mask when entering the room, should attend to the patient, and this person should wash his/her hands after leaving the room. He indicated that people were becoming unnecessarily frightened. He wanted them to understand that some simple precautions and sanitary measures could protect them from the disease.
With the realization that the epidemic was still spreading in Dayton, Dr. Peters ordered all public gathering spots—schools, theaters, churches, saloons, soda fountains, and poolrooms—closed. The order was extended “to all places where non-essential activities [were] carried on, and where a considerable number of persons [was] congregating.†He later permitted some establishments to reopen with the sole purpose “to sell goods but require[d] that there shall be no congregating of the individuals.†Dr. Peters issued a warning for all establishments that their patrons must “keep moving.†Saloons could only sell bottled drinks, but even those had to be consumed elsewhere. Ice cream could not be sold in cones, and nothing could be eaten on the premises. Free-standing drinking fountains that allowed water to fall back into its source were also closed. Those shops that did not conform to Dr. Peters’ directives were cited and closed. Restrictions even applied to those who died from the illness. All funerals of influenza victims could only be attended by immediate relatives. All caskets had to remain closed unless they were covered by a glass shield.
In addition to these restrictive measures, some targeted permissive measures were also implemented. In the widespread belief that fresh air “was one of the best preventives of the disease,†the longstanding wartime ban that prohibited the use of gasoline on Sundays was withdrawn in order to encourage people to go for drives on Sunday.
Influenza cases continued to increase to the point where hospitals had become overwhelmed. On January 1, 1919, Dayton health officials reported 572 deaths from influenza since October with 40,000 to 50,000 cases still present in the city.
The ban on congregating in public places continued in Dayton until November 2, 1918 when ‘â€the situation in the city…[was] sufficiently improved to warrant a partial lifting of the ban.†All public places with the exception of schools reopened. Adults, now free from any restrictions on their whereabouts, came and went as they pleased. The schools remained closed due to reports of an increase in cases and severity among children.
The number of cases among children dwindled, and they returned to school on Monday, November 11, 1918; however, the schools dismissed the students within an hour because of the celebrations taking place as word of the signing of the armistice ending World War I began to spread. Officials ordered the closing of saloons again, not as a precaution against the disease, but as a preventative against drunken celebrations. As news of the war’s end spread, parades formed spontaneously, and people began plans for more formal celebrations.
In early December, Dr. Peters issued an order closing the grade schools again because of an increase in the number of cases in grade school children. He also declared children under fourteen to be forbidden from any public place. While the children enjoyed an extended holiday vacation, they could not spend their time paying a visit to Santa because of the ban and a decree that no department store, church, or school Santas would be allowed that year. A notable development, perhaps as a result of the measures taken, was that no influenza deaths were reported on Christmas Day.
New Year’s Eve brought the removal of all restrictions except the one on the use of confetti during the holiday celebrations. Children under fourteen could now go to public places again, and school recommenced on January 6, effectively ending all bans on school attendance.
With the official reopening of all the schools and all the restrictions lifted on gathering in public places, Dr. Peters proclaimed a victory in checking the epidemic in the city. While there would still be some lingering cases and deaths, there would be no further need for any bans or limitations.
If the estimated influenza cases in Dayton are correct, it is probable that an estimated one-third of the population contracted the disease. The national impact is put into modern context when we consider that the influenza pandemic of 1918 killed about 500,000 Americans — more than all of the 20th century wars combined. Its three deadliest months were September, October and November of that year. During October alone, nearly 200,000 people died in this country.
Despite the terrible impact of the pandemic on Dayton, Dr. Peters nonetheless recognized an “indirect benefit†from the experience, noting “the fact that the epidemic ha[d] resulted in a campaign of education intended to teach the people the need of ventilation, better sanitary conditions and the fearful results of overcrowding†in addition to the “responsibility for one’s health.†In fact, the efforts of Dr. Peters and the Dayton health officials not only contributed to the halt of the disease, but it also lead to a new awareness of the importance of hygiene as a method of prevention. As an end result, Daytonians overcame the problems caused by epidemic through a combination of education, commitment, and cooperation.
Public warning for the Influenza Pandemic of 1918 was achieved primarily through public bulletins, city newspapers and word of mouth. Enforcement was also instrumental in spreading awareness of the protective measures implemented. Dayton’s public warning strategy was largely effective because it relied on centralized control and decentralized execution, as well as a close linkage between the city government, state and federal governments, local businesses, and the media. As Dayton’s “Flu Czar,†Dr. A.O. Peters was remarkably effective in stemming the pandemic through a strategy of public awareness, positive control, quarantine and cooperation with public and private entities.
The primary challenge that Dr. Peters faced in warning the public of the threat posed by the spread of influenza in Dayton was the rapid dissemination of information to a city that was not immediately willing to adapt to a threat it couldn’t see and couldn’t fully understand. Voluntary methods of population control, Peters realized, would not be effective. And yet, Peters also seemed to understand that compliance required a concerted effort at educating the public on the influenza virus and how to limit its spread. Many of the measures Dr. Peters employed are what today are called “nonpharmaceutical interventions (NPIs),†social-distancing protective measures such as school closures, business telecommuting and cancellations of mass gatherings to mitigate the impact of influenza pandemics. Dr. Martin Cetron, director for global migration and quarantine at the federal Centers for Disease Control and Prevention in Atlanta, was encouraged by the success of the employment of NPIs to combat the spread of the pandemic:
- …when you look back to 1918, you find that those who used nonpharmaceutical measures effectively were able to mitigate the impact of the severe pandemics, and this is consistent with some of the 21st-century simulation models.
The consistency of the information conveyed in Dayton’s public warnings, the credibility of the official announcing the warnings, and the rapid adaptation of officials to developments in the virus’ spread were decisive factors in the success of the Dayton warning system. Even in the face of mass fatalities and casualties, and unable to control the behavior of the pandemic’s virus, the Dayton Warning System worked ceaselessly to stop its spread by controlling the behavior of the threat’s potential victims—the city’s populace.
In summary, the Dayton Warning System was largely successful because it established a strategy of public warning aimed at mitigating the effects and spread of the influenza. Several characteristics of the system were instrumental to the success of the Dayton public warning system:
• Open communication between local, state and federal officials.
• Ability to quickly adapt local health policies and warnings to the virus’ behavior.
• Centralized control and consistency of city-wide warnings.
• Cooperation of the local media.
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