Changes

The most clear case of social distancing being needed for a public health emergency developed during the Spanish Flu pandemic of 1918. In September 2018, Philadelphia held a major parade, sometime after the first cases of the pandemic flu were reported. The city government allowed the parade to go through even though they had known about the outbreak, with over 200,000 people gathered to watch the parade. Within days all of the city's 31 hospitals were filled with flu patients, causing 4500 or more to die. Similarly, New York began to experience a large intake of sickness and death. Many cities in the United States began to record outbreaks of the flue flu and some did go into a relatively rapid lockdown and created strict social distancing policies. No national-level coordination was developed, but mayors and governors began to take action in their own hands, although by later 1918 most cities began to enforce some social distancing. One of the earliest to react to the pandemic in the US was St. Louis, which was praised for enforcing strict social distancing within three days of the outbreak in October 1918, limiting its overall death rates rate to levels far lower than other major cities (Figure 2). A close look at the death rates reveals the curve for fatalities being far flatter for St. Louis when adjusted for population. Other cities were either too slow in enforcing social distancing or, very often, were too quick to loosen social distancing guidelines, causing catastrophic second-wave infections and death. Social distancing also extended to forced school closures and, in some cases, it was estimated that forced school closures could have reduced death rates by nearly 90%. During the 1918 outbreak, this was also the first time people began to widely wear medical masks. Later studies have shown that cities with the strictest social distancing guidelines and closures were the most effective in lowering death rates. Using lessons from the 1918 pandemic, public health officials began to use this as guidelines for periodic small-scale outbreaks of flu or other infectious diseases. For instance, in the 1957–1958 flu outbreak, social distancing practiced early on in the UK and other countries, which included school closures and banning of mass gatherings, also brought death rates more than 40% lower than if these practices were not applied.<ref>For more on the 1918 pandemic and social distancing practices that arose from this pandemic, including public coordination of responses, see: Crosby, A.W., 2003. <i>America’s forgotten pandemic: the influenza of 1918</i>, 2nd ed. ed. Cambridge University Press, Cambridge ; New York.</ref>