Loosening Public-Health Restrictions Too Early Can Cost Lives. Just Look What Happened During the 1918 Flu Pandemic

On Jan. 25, 1919, nearly 2,000 San Franciscans showed up at Dreamland Rink for a public meeting of the Anti-Mask League. In the midst of a renewed wave of pandemic influenza that was washing over the city, the Board of Supervisors had imposed, once more, a regulation requiring citizens to wear masks in public. This crowd, though, was tired of the pandemic and especially of wearing masks.

The directive requiring masks had not been imposed hastily or arbitrarily. During the fall and winter of 1918-1919, influenza raged around the globe in one of the worst disease outbreaks in human history. By pandemic’s end, roughly a third of the world’s population had been infected. Of the startling 50-100 million people who had died, some 675,000 were American.

The pandemic had first struck in Boston in late August, and gradually made its ways across the country, infecting the entire nation in a matter of weeks. San Francisco, like many West Coast cities, had hoped to be immune to the pandemic’s reach, but that dream was shattered when, by mid-October, the city was awash in illness and local leadership imposed its first round of public health measures to protect the citizenry. By late January, many San Franciscans had grown weary of the impositions and turned out to the Anti-Mask League meeting to make that fact clear. They passed resolutions disparaging the ordinance and declaring it “contrary to the desires of a majority of the people.”

Though it took place more than a century ago, this scene is highly resonant with events around the United States in recent days. Last Friday, some 2,000 people turned out at the Wisconsin State Capitol to demand that the Governor end the state’s stay-at-home order, which he recently extended to May 26. Protestors, many without masks, condemned the public health measures designed to save their lives. The beliefs that brought them there varied. Some, already facing layoffs, were legitimately worried about their economic wellbeing. Others claimed the orders were the result of an “evil cabal” or a ruse by the government to take away their freedoms. This was only the largest of what have become commonplace protests around the country. From Sacramento to Sarasota, Boise to Baton Rouge, Americans are defying public health restrictions to voice opposition to stay-at-home orders. But the story of San Francisco’s struggles a century ago—against the 1918-1919 influenza pandemic and against the public health measures designed to combat it—should give such protestors pause. Inadequate protective efforts, or their removal too early, can cost lives.

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When the city of San Francisco recorded its first case of influenza on Sept. 24, 1918, the city’s leadership moved slowly. Though the eastern seaboard offered clear examples of the pandemic’s horrors, they chose only to quarantine the ill and make influenza a reportable disease. Anxious to show off its patriotism with World War I ongoing, the city went ahead with its scheduled Fourth Liberty Loan parade four days later, followed by two weeks of public occasions designed to ensure San Franciscans’ robust participation in the national effort to fund the war effort.

With the situation dramatically worsening, in mid-October the city’s Board of Health finally recommended protective measures such as avoiding crowds and practicing good hygiene. It also closed dance halls and imposed new requirements for ventilation on streetcars, but went no further. Within days it was clear that San Francisco was in serious trouble.

On Oct. 18, the Board of Health finally closed the doors of the city’s schools and public amusements and placed prohibitions on public gatherings. On Oct. 25, the wearing of masks in public was also mandated. With the Bay Area flooded by disease, much of the city’s citizenry greeted the masking order enthusiastically. As the San Francisco Chronicle announced, “It will soon be impolite to acknowledge an introduction without a mask.” The Board of Health reported that even before the ordinance became law, four out of five people were already wearing them.

But such cooperation proved short-lived. From the beginning, there were those who refused to don masks, and many others wore them improperly. Soon San Franciscans abandoned their masks. The police tried enforcing the ordinance, with violators facing a $5 or 10 fine or even a short stay in the county jail. In a single sweep of hotel lobbies, 400 people without masks were arrested. When October ended, almost 20,000 people in the city had been sick with influenza, and over 1,000 had died.

But, after the public health measures had been in place for a few weeks, the situation began to improve. In early November, the Board of Health lifted the closure orders. People rushed from their homes to celebrate the end of their seclusion and crowded together to see movies, shows and boxing matches. Though these audiences were still required to wear masks, many flouted the order. When both the mayor and a public health leader were caught without masks, the masking effort collapsed.

By Dec. 7, the city’s health officer warned that the city was again facing epidemic conditions and asked citizens to put their masks back on. He hoped that alone would be enough to forestall the return of the disease. Yet, left to a voluntary code of conduct, 90% of San Franciscans chose not to wear masks. Hundreds turned out for a public debate on renewed masking on Dec. 16, and on Dec. 19 the Board of Supervisors voted down the proposed order. It would be three more weeks before they acted.

By early January, the costs of this hesitation, and of failing to renew the closure orders, were clear. Physicians reported 600 new cases of influenza on Jan. 10 alone. Finally the supervisors commanded that masks again be worn in public, beginning on Jan. 17, prompting the Anti-Mask League meeting.

This was only the most organized illustration of a broad-based refusal to adhere to the charges of public health leadership in the city. By the time the order was rescinded on Feb. 1, enforcement of the masking order had become impossible. Meanwhile, the city did not even consider a return to the public closures that had been used during the initial wave of disease in the city.

By the time the epidemic came to an end that spring, 45,000 San Franciscans were sickened and 3,000 died over the course of these two waves of the influenza pandemic, resulting in one of the highest death rates in the country.

Research conducted by historians and scientists at the University of Michigan and the Centers for Disease Control and Prevention makes clear that what happened in San Francisco is not an isolated case. Comparative analysis of data from a number of American cities during the 1918-1919 influenza pandemic provide incontrovertible evidence of the effectiveness of the kind of restrictions we are living with today. Cities that imposed expansive closure orders early and maintained them for the duration of pandemic conditions suffered significantly lower death rates than those like San Francisco that did not. While protestors in 1918 fought against the hated mask, their act of gathering, which was at the time entirely legal, was helping to spread the disease.

As we endure our own pandemic today, stay-at-home orders, not mask regulations, are producing the greatest resistance. But those protesting the restrictions do not represent a majority viewpoint in the United States. A recent NBC News/Wall Street Journal poll found that while 58% of those interviewed feared the government would move too quickly in loosening restrictions, just 32% worried the government would move too slowly. Most Americans understand that we owe it to one another to continue to abide by orders to shelter in place. We need our political leadership to listen carefully to the medical and public health experts—and to history. They owe it to us to mandate the responsible measures that have proved, time and again, to save lives.

Historians’ perspectives on how the past informs the present

Nancy Bristow is the author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic. Her new book, Steeped in the Blood of Racism: Black Power, Law and Order, and the 1970 Shootings at Jackson State College, is available May 1.