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[[File:Plague doctors beak-shaped mask.png|thumb|Figure 2. These bird-like masks helped doctors stay away from people during the Black Death. ]]__NOTOC__ While social distancing is a common phrase used in recent periods, the concept is ancient and as mass pandemics have developed in different periods, it has been the most effective and common form of practicespractice. Some history of this practice is given.

The earliest evidence for social distancing come from the early 2nd millennium BCE, where texts from the ancient Syrian city of Mari indicate individuals with infections, perhaps a form of flu or fever, were placed in isolation and were told to keep away from others. While no evidence indicates this was a widespread practice during a pandemic, it does indicate knowledge of distancing of individuals with infections can be traced to at least the early 2nd millennium BCE and likely earlier. Medical texts from the 3rd millennium BCE discuss treatments that may include isolation, but it is unclear if social distancing was practiced. More commonly, social distancing began to develop as a form of class differentiation. Societies in the Old World, including India, China, the Near East, Greece, and Egypt all developed some forms of social distancing between lower classes, or even slaves, and upper classes. Clothing, how the hair was groomed, beards, or even physical marks were all used as ways to keep people away from each other. There are some connections to health that may have motivated this distancing, as outbreaks were probably more likely to form in the classes who had less access to clean water, but over time this would have developed into purely a class-based action.<ref>For more example of social distancing in ancient periods in the Old World, see: Porter, R. (Ed.), 2001. <i>The Cambridge illustrated history of medicine, 1st pbk. ed. ed, Cambridge illustrated history</i>. Cambridge University Press, Cambridge ; New York.</ref>

Some of the earliest evidence of social distancing in the Medieval Period come from the period of the Black Death in the 14th century. In this time, in parts of Europe, doctors and carers looking after patients wore pointed, bird-like masks (Figure 1). This was intended to keep people who were not sick away, while also enabling doctors to ostensibly have some protection from getting the contact. Doctors also wore long sleeves and usually covered most of their body when dealing with patients. People did seem to make attempts to keep away or isolate themselves to avoid infection during the Black Death, but public coordination is not clear in records. In cases, isolation and distancing were not practiced, particularly as people were often unaware how the disease spread. However, the Black Death did lead to increasing building of country villas in the late 14th and early 15th centuries, as wealthier classes began to realise isolating themselves or having homes ready where they could isolate themselves, and have large stocks of food and provisions, could be a way to counteract future plagues. Clothing in early Modern Europe also increasingly became elaborate for the upper classes and this usually was the most ostensible way social distancing was maintained, once again demonstrating that wealth and class, rather than health, were the main reasons to distance segments of the population from other segments. Lower classes were never expected to approach nobility unless invited to do so. Strict guidelines were particularly enforced when individuals met royal individuals. Women's skirts also developed large hoops, initially in Spain in the 15th and 16th century, which increasingly became popular in the 18th and 19th centuries through different areas of Europe. These hoops, called crinolines, were intended to act as barriers as well as fashion items. The idea was to keep genders segregated, particularly for middle and upper class women who wanted to maintain their reputation. Generally, women who did not do much work wore such dresses, as they were far too cumbersome to be of practical use. This cumbersome aspect warned others to stay away from well-off ladies, while also demonstrating that such a woman did not have to do manual labour, indicating her high status. In fact, in the 19th century Victorian era, even larger skirts were ways for women to indicate that they were of the highest class and even distinguished themselves from other well-off ladies. Men could not come too close to these women, also suggesting their purity. During the 19th century, outbreaks of small-pox occurred and some evidence does suggest these skirts did help in preventing women from catching this infection, mainly because it was hard for anyone to come close. However, historians also point out sometimes women died because these skirts were too large and easily caught fire in emergency situations, inhibiting the person from easily escaping. In the late 1890s, skirts began to narrow, but hairpins and large hats became popular. These also became symbols to others that they should avoid getting too close to upper-class females, replacing the large hoop dresses of earlier periods. <ref>For more on how fashion was used for social distancing, both for medical and class reasons, see: Ross, R., 2008. <i>Clothing: a global history: or, The Imperialists’ new clothes</i>. Polity, Cambridge, pg. 76.</ref>

Perhaps something approaching current practices The most clear case of social distancingbeing needed for a public health emergency developed during the Spanish Flu pandemic of 1918. In September 2018, without implying class-based differencesPhiladelphia held a major parade, is sometime after the first evident in New York's polio outbreak in 1916cases of the pandemic flu were reported. More than 2000 people died in New York from polio and The city government allowed the city took widespread social distancing guidelines parade to limit go through even though they had known about the outbreak, with over 200,000 people gathered to watch the parade. This included closing movie theatresWithin days all of the city's 31 hospitals were filled with flu patients, meetings were either limited causing 4500 or cancelled, various public gatherings were outlawedmore to die.  Similarly, New York began to experience a large intake of sickness and children were told death. Many cities in the United States began to avoid water fountains record outbreaks of the flu and pools, limiting their contact with even parks some did go into a relatively rapid lockdown and playgroundscreated strict social distancing policies. The response No national-level coordination was relatively effectivedeveloped, but mayors and governors began to take action in their own hands, as although by later 1918 most cities began to enforce some social distancing.  One of the death toll was limited relative earliest to react to the threatpandemic in the US was St.<ref>For more on Louis, which was praised for enforcing strict social distancing within three days of the 1916 polio outbreakin October 1918, see: Oshinsky, Dlimiting its overall death 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.MLouis when adjusted for population.Other cities were either too slow in enforcing social distancing or, very often, 2005. <i>Polio: an American story</i>. Oxford University Presswere too quick to loosen social distancing guidelines, Oxford ; New Yorkcausing catastrophic second-wave infections and death.</ref>

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 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 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>

[[FileFor 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:Distancing Crosby, A.png|thumb|Figure 2W. Death rates comparing Philadelphia and St, 2003. Louis in <i>America’s forgotten pandemic: the influenza of 1918 flu pandemic</i>, 2nd ed. ed. Cambridge University Press, Cambridge ; New York.]]</ref>

The concept of distancing from sick or infected individuals is ancient and texts speak of isolating people who had developed some form of infection. This could have influenced or even affected class or social distancing based on class. In fact, clothing and even fashion markings were used to keep people away from each other. Infections were often higher in those in lower classes, mainly due to their exposure to poorer living conditions. However, over time we see in Europe and much of Eurasia the use of clothing as social markers that kept people away from each other. This became extreme by the 19th century, particularly for women using their large skirts as a way to keep unwanted attention away. In the Medieval period, there is evidence some social distancing was practiced during the Black Death. However, public policy was not developed to the point where health officials made this a wide-scale practice. It was only in the 1916 polio outbreak and more widespread in the 1918 flu pandemic do we see the development of mass social distancing, although only after very painful lessons such as from Philadelphia which had among the highest death rates in US cities.