A Tale of Two Cities: The Catastrophic 1918 Flu Pandemic Can Guide City Policymakers Today

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By Shelley Hearne, DrPH, President of CityHealth

One hundred years ago, in 1918, a novel virus swept the globe, infecting at least 500 million people – one third of the world’s population –and killing an estimated 50 million people worldwide.  Sometimes referred to as the “Spanish Flu,” it was one of the deadliest disease outbreaks in recorded history.  About 675,000 people in the United States died in the pandemic, according to the U.S. Centers for Disease Control and Prevention.

Scientists know that it is simply a matter of time before another new viral threat emerges. As such, in addition to basic medical preparedness, vaccine development, and global surveillance, we must remember to learn from history to ensure not to repeat past missteps. Some of those century old lessons can save lives today. 

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Let’s take a look back at how two cities that acted differently when faced with a health risk can provide insights for today’s leaders.

In Philadelphia, on September 28, 1918, nearly 200,000 people attended a parade for the war effort, even though 10 days earlier, the city’s naval shipyard was infested with the influenza virus. The city’s leadership allowed the parade to go on, despite the health risks, and they experienced the consequences of doing so in lives lost.   Within the two weeks after the parade, more than 600 Philadelphians died from the virus. At the peak of the Philadelphia epidemic, 1,700 citizens died on a single day.

Now, let’s go to St. Louis, which back then was one of the top ten largest U.S. cities. Under the leadership of its Health Commissioner, Dr. Max Starkloff, the city canceled public gatherings, from football games to Halloween parties, closed schools for ten weeks, and even stationed police officers in department stores to keep people from lingering. While businesses bitterly complained, the commissioner was a long-term, well-trusted health expert who had the courage to champion bold actions that other cities resisted.

St. Louis took action within a day of the first cases arriving. Philadelphia waited for over a week before taking infection prevention steps.

Based on a 2007 Journal of the American Medical Association article, researchers found St. Louis experienced one of the lowest excess death rates in the nation: 358 per 100,000 people. In contrast, Philadelphia’s was over twice as high, with 748 excess deaths per 100,000.

Why are we now talking about this tragic event that occurred a century ago?  While the world is different today, lives are still at stake when policies are not put in place from the top down to prevent the spread of disease or create healthy living conditions. Strong health leadership matters in making sure smart policies are put in place.

One policy that can help encourage people to stay home when they are sick – and prevent the spread of disease – is an earned sick leave law.  This law requires employers to allow people to take paid time off for illness or injury for themselves or their family members.  By allowing people to take time off when they are sick, the spread of infectious disease is reduced.  This is an especially important issue for people who work in the food industry or care for children or the elderly. 

 We don’t need a global pandemic to see that policy saves lives. The current hepatitis A outbreak hammers home the importance of earned sick leave policies for all workers. For instance, in 2018, San Diego County experienced a public health crisis, with the nation’s largest hepatitis A outbreak in years. County officials took a range of actions to reduce risks, and now San Diego has one of the best sick leave policies in the country, earning a gold medal from CityHealth. Other cities are now fighting hepatitis A, norovirus, and other outbreaks that could be better limited with widespread earned sick leave policies. Last year, a Detroit resident who worked as a crewmember at McDonald’s was diagnosed with hepatitis A, exposing countless customers to the virus. CityHealth reports no medal for earned sick leave in Detroit.  

Look here to see whether your city has a strong earned leave policy.

So, what are the lessons today of the Spanish Flu of 1918?

  • Policies matter.  Policies such as earned sick leave, affordable housing to avoid unsafe, overcrowded conditions or restaurant grading can create healthier urban environments.

  • Leadership matters. The lead health official should be the city’s chief health strategist - a trusted, respected, knowledgeable professional who is engaged with policymaking at the cabinet level, empowered to be a health champion, and skilled in difficult decision-making situations.

  • Sharing resources and strategies is critical.  Information and resources must be shared between cities, counties, states and the federal government. Strong relationships between health leaders – like those fostered by the Big Cities Health Coalition – allow innovations, successes, and failures to be learned quickly.

At the 100th year anniversary, let’s reflect back on the profound, devastating impact the “Spanish Flu” had on this country’s cities and have it serve as an important reminder for today’s metropolitan leaders. Smart policies and strong leaders will better protect our health and our families, whether it's a moment of medical crisis or for our long-term well being.




See How Your City Scores: Celebrating Child Health Everyday with High Quality, Accessible Pre-K

By Shelley Hearne, DrPH, President of CityHealth

Welcome to the CityHealth blog!

CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, provides leaders with a package of evidence-based policy solutions that will help millions of people live longer, better lives in vibrant, prosperous communities. CityHealth regularly evaluates cities on the number and strength of their policies.

We awarded each of the cities either a gold, silver, bronze or no medal designation based on that assessment.  Our goal is that all city leaders use our assessment as a tool to work together and move toward the gold standard in each policy area by adapting evidence-based policies shown to improve the well-being and quality of life for their residents.  This is also about accountability - so our nation’s citizens have the data they need to hold their elected officials accountable for taking the steps necessary to make their city thrive.

Visit us here to find out more about policymaking at the city level that supports healthy communities, and meet local leaders and experts who are finding innovative ways to help cities thrive. To receive new blog entries in your inbox, sign up here.


Today, to celebrate Child Health Day, CityHealth recognizes a great way city leaders can enhance every child’s opportunity to be healthy and thrive: by creating high-quality, accessible early education programs for kids.  Pre-Kindergarten (Pre-K)’s educational benefits to three- and four-year-olds are well established, but here’s the significant added benefit: done right, Pre-K can provide an important, life-lasting health boost for our youngest citizens.  Because of these health benefits, CityHealth targets and assesses Pre-K as one of its nine top recommended policies for city leaders to improve quality of life for urban residents (see scores below.) 

There is no question that there are numerous health benefits associated with attending high quality Pre-K programs – both in the short-term and long-term.  Ninety percent of children’s adult brain volume is developed by age six, and we know that experiences during early childhood fundamentally affect the structural development and neurobiological pathways in the brain.  On a more practical level, when children are in high quality Pre-K programs, the odds improve that children who need treatment for vision, hearing, or chronic issues, like asthma, get the help they need.  Preschool participants are more likely to go to a doctor, receive appropriate immunizations and screenings, and get dental care.

In fact, the U.S. Centers for Disease Control and Prevention (CDC) recognizes Early Childhood Education programs, such as Pre-K, as one of the most important and effective policies available to improve population health.   The nation’s leading health agency cited the strong evidence demonstrating that early childhood education fosters socio-emotional, cognitive, and motor skill development, in addition to academic achievement.  Early Childhood Education also leads to longer-term benefits such as reductions in obesity, child abuse and neglect, youth violence, teen birth rates and emergency room visits.

CityHealth recognizes that in order for cities and their children to fully reap the benefits, Pre-K programs must be of high quality and widely accessible. To help catalyze widespread adoption of this important health intervention, CityHealth awards medals – gold, silver, bronze, or no medal--based on the National Institute for Early Education Research’s 10 research-based quality standards benchmarks and an assessment of the level of enrollment in the city’s largest Pre-K program. Thirty-three out of 40 cities received a medal for offering, accessible, high-quality Pre-K, including five gold, eight silver, and 20 bronze. Incredible progress was made in recent years to open access and increase quality of Pre-K programs around the country. However, our goal is for every child to live in a gold medal city, and clearly in order to meet this standard, there is much more work for us to do.

We invite you to see how your city performs when it comes to Pre-K policy and learn more about how our medals were awarded and what they mean for children and families.

            As we celebrate Child Health Day, it is also a great time to recognize cities that are going beyond traditional Pre-K programs to ensure that the children being served get the health services they need.  For example, Seattle built on an already strong system by coordinating health and mental health services on-site at Pre-K provider locations in consultation with teachers.  Another highlight is the Cincinnati Preschool Promise public school sites, which provide access to school-based health centers, school nurses and other school-based support groups.  Recognizing the importance of wrap-around services for children and families is crucial to keep a city’s residents healthy and provide them the tools they need to succeed.

CityHealth is working with urban leaders who want to increase access and quality of Pre-K programs in their cities.  If you are interested in how cities are making high Pre-K available to kids, and want to know more about how city leaders are leveraging policy to create stronger communities that support healthy families and kids,  sign up here to keep in touch with CityHealth.