A few years back, the Museum of the City Of New York (MCNY) unveiled their Germ City exhibit, to mark the 100th anniversary of the 1918 Spanish flu pandemic which killed tens of thousands of people in NYC. The exhibit traced the protracted battle against contagious-disease carrying microbes since long before we built subways or bowling alleys.

With the number of confirmed cases of COVID-19 in New York and the rest of the country continuing to rise, we spoke to MCNY's Chief Curator Sarah Henry, who curated that Germ exhibition, to take a closer look at the long and complex history of infectious disease and try to get some context for how NYC has dealt with epidemic outbreaks in the past—like how the city used to stagger business hours to try to prevent rush hour from getting too crammed on the subway, or how the NYPD used to hand out tickets for not covering your mouth while coughing.

Can you place the coronavirus into some historical context for our readers? Are there any particularly apt comparisons we can make to previous outbreaks? We did an exhibition in the fall of 2018 to mark the hundredth anniversary of the worldwide Spanish flu pandemic. We looked at a whole series of outbreaks and epidemics that have occurred in New York. Many of them came from other places like this. And of course, we don't know if this is going to turn into a true outbreak here, so it's hard to say.

But we have been thinking about the previous times that New York has dealt with microbes in an outbreak kind of way. And of course, that happened repeatedly in the 19th century. And then I think the comparison most people are making is to the Spanish flu of 1918/1919. But of course, you don't need me to tell you there's also been a lot of conversation of how this might be similar or different from SARS and MERS and the H1N1, etc. So there are outbreaks of new diseases and familiar diseases sprinkled throughout New York City's history.

How did the city deal with Spanish flu when it came? Well, they were already on a state of high alert, but I think it's similar to this moment in a way because they knew that there was a flu that was originating in Europe. And so the health officials were already on alert looking out for it and focused very much at first on the port. Thinking about the way that the germ was likely to arrive in 1918, of course, would be on a boat. And they really sprung into action.

Now, there's been some debates about whether they did or didn't do enough, and you can get historians arguing on each side. New York was proud that it had fewer fatalities, or lower mortality rates, than other American coastal cities, but they really drew upon the infrastructure of public health that had been crafted around the endemic threat of tuberculosis in New York in the previous generation. And they moved into emergency mode.

They controversially did not close schools and did not close movie theaters, but they did create a whole system of temporary hospitals. So there was a big deployment of healthcare professionals. There was a whole system of quarantine. And then they took certain citywide measures like instituting staggered opening times for different businesses. So different sectors were assigned to have different business hours in an effort to tamp down on rush hours on the subways. There was a lot of focus on the threat of people being jammed together on mass transit. That was a big focus.

arrow Young women office workers in NYC with gauze mask carefully tied about their faces to protect against the spread of influenza. Oct. 16th, 1918 Courtesy Everett Collection/Shutterstock

In addition to creating this network of care all across the city—emergency health districts and centers and home care visits—they also worked to empower the police to give out tickets to people if they weren't covering their mouth, for example, when they coughed or sneezed, and they enlisted the Boy Scouts to hand out cards with public health information. So there was a big emphasis on education. I think this is one of the reasons that they didn't close the movie theaters actually, because they saw it as a place where they could educate people about hygiene and not spreading the disease. And they also used the schools themselves as a place for education for students.

Wait...they gave out tickets for coughing? Yes. But it was not for coughing. It was for not covering your mouth when coughing.

And the police enlisted the Boy Scouts in the campaign? It was more that if people were doing things like spitting or coughing, the Boy Scout would come up and give that person a card educating them about how they were endangering their fellow citizens. The police gave out fines. The Boy Scouts did not.

I would hope they would not be deputized to do that. Yeah. So there were 30,000 deaths in the city as a result of this, though as I mentioned before, the mortality rate was lower than in cities like Boston or Philadelphia. And public health officials definitely claimed credit for that, though some historians also argue that there was probably a higher level of herd immunity in the city because there had been a milder form of the flu that had come through some months before. So there was probably also an element of convergence of factors that was at work.

Was there any pattern to the 30,000 people who died? Was it centered in a specific part of the city, was it older people? So the Spanish flu had the worst effect on healthy young adults. It's surprising, compared to what we might expect. And so there was a special attention actually paid to people who were in that age group, and who worked in public facing jobs. People who might work in an office or at a bank or a ticket seller at a movie theater or the subway were often those of that age.

There was a big deployment, for example, of having people wear masks who were in that age group and who worked in those areas. Ironically, the masks didn't really do very much because the virus could live for many hours outside of a human body. So it wasn't just about preventing people from breathing or coughing directly on each other. And that's why the flu could spread so much.

I think the analysis was that the healthy young adults, their immune systems could actually overreact to the flu virus. That's at least one explanation that I've read as to why they were affected more severely and had more higher mortality rates than younger or older people.

Malcolm Gladwell’s 1997 report on the deadly the Spanish-flu epidemic of 1918. https://t.co/TYBKem9qrc — The New Yorker (@NewYorker) March 4, 2020

You mentioned about how officials tried to stagger subway usage during this period—was that successful? Was it ever used again in the 20th century? I'm trying to imagine how or if this could ever be applied today considering how jam packed the subways are now. I know! And the idea that you could reverse-engineer congestion on the subway. So they made staggered opening hours for different types of business—you had to report to work at a different hour depending upon what field you were in.

It's interesting because this is happening at the tail end of World War I, and the country had been in emergency mode as it were for some time. There was a lot of top-down mobilization of industry and citizens during World War I, but there was also propaganda. WWI was famously the crucible of 20th century advertising and propaganda. The Four Minute Men [volunteers who were authorized to give speeches on the war effort at public places] were the ones who would go into the movie theaters and give a pitch for buying Liberty Bonds. The idea that the government would actively use public space to change people's behavior or require them to change their behavior was something that was very much of the moment as part of the war effort. So the idea that industry would have to take orders in some way from government as to what their opening hours could be, would not be as alien an idea in 1918 as it might've been, say, in 1898 when we had the Spanish-American War.

arrow A traffic policeman in NYC wearing a gauze mask for protection against influenza. Oct. 16th, 1918 Courtesy Everett Collection/Shutterstock

What were quarantine procedures like back then, and what were the quarantine islands? During the 1918/1919 flu epidemic, people quarantined in their homes. The quarantine islands were different—they come from Italian maritime history, where when ships came into port, there would be a period of waiting before people could disembark. New York has historically dealt with people arriving in the port with an illness in different ways. Because sometimes the border control aspect has created problems. For example, in the early 19th century, there was a quarantine hospital on Staten Island that was the target of mob violence because people feared that it was spreading disease there. There were people who had arrived and were being held there, and then it was attacked by mob and burned to the ground in 1858.

After the burning of the quarantine hospital in 1858, that's when New York turned to using islands in the harbor to be the temporary places for people who were arriving in New York—who either had diseases or were suspected of having diseases—to be held until they could be cleared. The two places were Swinburne and Hoffman islands, two little tiny islands, and in the exhibition we had some great photographs that photographer Alice Austin took on both islands documenting the conditions, which were very cutting edge at the time. They had these huge sterilizers that they put the mattresses in, for example. So the practice of quarantine improved as people understood what caused disease, that communicable disease is spread by microbes, which wasn't understood in the earlier part of the city's history.

There there are cases like Mary Malone, a.k.a. Typhoid Mary, with is a parallel but complicated story, because Mary Malone was never ill from typhoid, she was a silent carrier of it. And she was sent twice to North Brother Island and ended up living out the remainder of her life there after the second time. She was somebody who never believed herself to be sick. I guess what I would say is that throughout the whole history of disease in New York and elsewhere, there's always this complex line between public safety and personal rights that has to be navigated. And it often gets inflicted by social attitudes, xenophobia, racism, homophobia, all different kinds of perspectives that people bring to the story of disease. That they complicate that fine relationship between people's freedom and the safety of those around them, that's just a repeating theme.

arrow Immigrants held on one of the quarantine islands, Hoffman or Swinburne, located off the coast of Staten Island Library Of Congress

The census count is coming up this year. Could an outbreak like this affect it in any way? Well, this is also our first all-online census, so there isn't any reason, in practical terms, that people's participation should be affected by this, since you can do it from anywhere. I did see that there was an article published this week that said that it could complicate the process of sending people door-to-door for the followups or in the hard to count areas. So I think there's a concern out there and we're going to have to wait and see what direction all of this takes.

Is there anything else you want to add about historical context, or anything that can help give some perspective to what we may be facing in the coming weeks? Throughout history, there's been a question of balancing what is prudent and effective and necessary on the one hand, with people's fears on the other. And there definitely is a history of people, as is human nature when they feel afraid, of overreacting in various ways, of stigmatizing others or stereotyping people or taking actions that just aren't necessary or effective. In 1916, there was a polio outbreak, and it was believed that it was being spread by household pets, and so there was a big euthanizing of dogs and cats, thousands and thousands of them.

In the exhibition that we did here last year, we thought of the responses that a city makes to stop an outbreak as four big categories. One is containment: trying to wall it off in some way, whether it's walling it out at the borders, walling people in physically, confining them on islands, or more metaphoric ways of walling people off, like the ban on blood donations by gay men, which is a social and medical isolation.

Then there's the construction of knowledge, the investigation that is at the heart of epidemiology, of just trying to figure out what's going on, getting the best possible information so that you know what to do. The third area is direct care, so how do you treat people who get sick or prevent them from getting sick in the first place? And there's rich histories there. And then the fourth one is really about creating a safer environment, which is our collective health—how do we diminish the risks in the first place? And those have to do with sanitation and vaccination and control of vectors like insects and so on.

So the thing that we learned from doing the exhibition is that collectively as a city, even though these responses are sort of universal across time, as medical sciences advance, knowledge is created, and [the responses] evolve. But every new situation needs to sort of reenact those steps, hopefully with more experience and knowledge, but also with novel problems. Overall, throughout New York's history, a lot of our city has been shaped by our fight against disease. So the water system was a direct response to the outbreaks of diseases like cholera in the 19th century as people began to understand that you got sick from bad water. They didn't know why at first, but they knew it was connected to water. Or there's the development of the sanitation departments, as people began to understand that horse manure and other things we're spreading disease.

Because when we're at risk from communicable diseases, you can't consider these things as just someone else's problem the way, maybe, some other social challenges are. Because diseases don't respect neighborhoods or boundaries or social classes, they get a collective response. So it's really interesting to see how that has played out over time.