In the waning days of September 1918, Dr. Max C. Starkloff, Health Commissioner for the city of St. Louis, actively monitored the news from Boston – at the center of the nation’s influenza epidemic – and watched the contagion as it spread westward. Not one to dodge grim reality, Starkloff understood that influenza would soon find its way to St. Louis. Quickly, he prepared the city for that inevitability. His first action was to issue a request through the influential St. Louis Medical Society that physicians voluntarily report to his office any and all cases of influenza they discovered. Next, he wrote an article in the St. Louis Post-Dispatch detailing how best to avoid influenza and the deadly pneumonia that often accompanied this new form of the disease. He warned residents to avoid fatigue, alcohol, and crowds, and to get plenty of fresh air and to avoid those who are ill. 1

For the time being, Starkloff did not believe that greater action was necessary, though he kept a sharp eye on developments at Jefferson Barracks, a military training camp approximately ten miles from the city. A few dozen men there had developed influenza by October 1, prompting the commander to discontinue all public entertainment and bar all gatherings, to prohibit visitors from entering buildings occupied by draftees and enlisted men, and revoking passes to travel outside the barracks. A few days later, the initial 40 mild cases had swelled to 500, overwhelming the small staff of nurses on base. Dr. C. E. Freeman, the chief surgeon at the barracks, issued an urgent plea for every nurse and nurse trainee from St. Louis he could get.2 Unfortunately, the ban on visitors to Jefferson Barracks did not apply to two-term Congressman Jacob E. Meeker, who visited the facility on October 9 during his re-election campaign. Seven days later, the 40-year old Meeker died of influenza at Jewish Hospital in St. Louis, believed to have been contracted at Jefferson Barracks. Just hours before his death, Meeker married his secretary of six years. Wedding attendants wore gauze masks.3

Meanwhile, St. Louis physicians began reporting their first cases of influenza. On October 5, a family with seven cases was identified, purportedly the first in the city. By the next day, approximately fifty cases were reported. Realizing the seriousness of the situation, Starkloff requested that the upcoming Liberty Loan drive be cancelled. He also asked the Board of Alderman to pass an emergency bill declaring influenza a contagious disease – thus giving the mayor legal authority to take declare a state of public health emergency – and providing for stiff fines for physicians who failed to report cases of the disease.4 For the time being, Starkloff believed that sick individuals should self-isolate, but that more widespread action was not yet necessary.

Alarmed by the rapidly growing number of influenza cases in the early days of October, however, Starkloff abruptly changed his mind about the need for a sweeping closure order and gathering ban. On October 7, Starkloff called Mayor Henry Kiel, representatives from the United States Public Health Service, the Red Cross, the St. Louis medical community, business interests, city hospitals, and the public school system to his office to discuss the most effective way to fight the city’s nascent epidemic. Several present were against the prospect of mass closures. With over one hundred civilian cases in the city and 900 cases at Jefferson Barracks, however, Starkloff urged them to consider drastic action in order to halt the spread of the disease. After some debate, the group agreed. They conferred Starkloff with legal authority to make public health edicts. They also agreed to a sweeping closure order. Starting on October 8, St. Louis’s theaters, movie houses, pool halls and other public amusement venues would be closed, and all public gatherings banned. Schools would close on October 9, giving them one day to inform and prepare students. Starkloff closed churches after holding a separate meeting with Mayor Kiel on October 8.5

The Spirit of Volunteerism

The closures came none too early. Although St. Louis’s influenza epidemic was not yet severe, physicians, nurses, and medical supplies were in short supply due to the war effort. By October 11, City Hospital was full, mostly the result of private hospitals that refused to accept influenza patients. The local chapter of the Red Cross faced a severe nursing shortage, and was already having difficulty securing volunteer ambulance drivers; the city had to press police patrol cars into service.6 To ameliorate the situation, the Nursing Committee of the Red Cross presented Starkloff with a comprehensive plan for districting the city and for recruiting and assigning nurses, aides and helpers from the Red Cross, the health department, the public school system, and the various visiting nurse groups. Starkfloff gladly accepted the plan and the help.7 The Nursing Committee also appealed to physicians to give wide publicity for this assistance. For the rest of the epidemic, the Red Cross and other agency nurses provided home nursing – often free of charge – and distributed linens and supplied community kitchens with foods and milk for the sick. The Red Cross motor corps recruited volunteer drivers and automobiles to supplement ambulances and chauffeur nurses from one quarantined house to the next. Through this volunteer system, approximately 40 nurses cared for 3,096 patients who otherwise had no access to private nursing, for a total of 14,339 nursing visits.8

Other groups helped as well. The St. Louis Tuberculosis Society transformed its clinics into influenza information centers, and eight of its members visited factories to give short talks on preventive influenza care. The Society also printed thousands of educational flyers and enlisted the library and department stores to distribute the information.9 Police patrolmen made sickness surveys of their districts and took measures to assure that patients received medical care.1 Public school personnel chipped in as well. Initially, school system officials opposed the idea of closing schools. Once Starkloff ordered the closure, however, its leaders rallied.11 In addition to loaning school nurses and physicians to the war on influenza, school officials moved quickly to encourage all 2,500 teachers to volunteer at the health department. Many of them did. Ironically, the school system’s first move was to call a large meeting of teachers and principals to coordinate volunteer activities, with special dispensation for the gathering from Starkloff.12 Theater owners and other business owners were not so fortunate. They, too, intended to meet to discuss ways to join the fight against influenza, but Starkloff prohibited that meeting.13

Not everything worked smoothly. Due to miscommunication between the health department, schools, and police about the best way to close schools, many parents mistakenly sent their children to their classes as usual on he morning after the proclamation. School authorities believed the order would go into effect after pupils were assembled and notified. The police had a different understanding, and some officers prevented children from entering their school buildings.14

To rectify the communication and coordination problems, Starkloff created a Bureau of Information and put his trusted Assistant Health Commissioner, Dr. G. A. Jordan, in charge. In normal times, Jordan managed the health department’s sanitary section. Now, he and every other physician at the health department worked to stem the influenza crisis, some by supplying free care at police stations.15 Jordan shouldered much of the department’s influenza communications with the press and rendered decisions about the many day-to-day policy and enforcement questions.16 He also issued warnings to any establishment not complying with the closure orders.

Starkloff’s Leadership

On October 15, as the total number of influenza cases reached over 3,000, the city’s Isolation Hospital began accepting influenza patients in order to relieve congestion at City Hospital.17 With the mounting case tallies, Starkloff revised his plan. Meeting with downtown retailers, the Health Commissioner asked store owners and managers to stop advertising Saturday sales in order to reduce weekend crowding.18 Several days later, on October 20, Starkloff issued a new order restricting downtown business hours to 9:30 am to 4:30 pm in the busy downtown section of St. Louis bounded by Olive Street, Washington Avenue, and Fourth and Twelfth Streets. Saloons in this zone likewise had to follow the new hours. The energetic Health Commissioner announced to the city that the closure orders and gathering bans would not be lifted until the epidemic was completely stamped out, whether that be in a week or a month.19

The business community immediately vocalized its opposition to the restricted business hours. Only two days later, Starkloff bowed to the pressure and rescinded the business hour restriction, citing the hardship he felt it caused for small business owners.20 Mayor Kiel, however, under pressure from not only the business community but religious leaders as well, advocated lifting the gathering bans entirely, starting with a two-day trial. Starkloff broached this idea to his advisory committee on October 24, but the physicians on the panel did not agree; they argued against lifting the ban until new cases dropped below 150 a day. Kiel, understanding that that medical advice took precedent over financial concerns, gave way.21 Displeased clergy and business owners – theater owners especially – continued pressing for a change.

As October drew to a close, the number of new influenza cases diminished, though nowhere near the 150 per day mark Starkloff desired. Mayor Kiel, insistent that the restrictions be lifted as soon as possible, pressured his health commissioner into calling another advisory board meeting.22 Starkloff’s direct supervisor, Director of Public Welfare John Schmoll, looked for a compromise and proposed gradually easing the restrictions. In particular, Schmoll wanted to see churches reopened soon.23 After some debate and the weighing in of medical experts, the group decided that the bans would continue.24

In fact, Starkloff enacted even stricter measures. Starting on November 2, he placed policemen in department stores and five-and-ten shops to keep crowds moving.25 A week later, on November 9, he issued a sweeping proclamation immediately closing all non-essential stores, businesses, and factories for four days in a drastic attempt to stamp out the epidemic once and for all.26 As Starkloff explained later in his annual report, the November 10 was a Sunday and November 11 was Armistice Day; in reality, his ban only affected the city’s economy for one-and-a-half days. That fact did not placate business owners. The Retailer’s Association and the Chamber of Commerce complained loudly, and even the Federal government, concerned about war production, bore down on Starkloff. Someone even checked with the City Attorney to see if Starkloff’s had legal authority to issue the proclamation.27 He did. In spite of the furor, people and businesses generally complied, though the beleaguered health commissioner did amend the proclamation to allow work on war contracts to continue.28

St. Louis Reopens

The closure order and gathering ban was kept in place on Armistice Day, November 11. Starkloff lauded the fact that the stores were all closed, thus forcing downtown celebrants to remain outdoors where, he believed, it was decidedly more difficult to contract influenza. Mayor Kiel announced that a more formal celebration of peace would be announced after the epidemic was over and the closure orders removed.29 The next day, Starkloff and his medical advisory board agreed to lift the ban gradually over the course of the coming week. Commercial businesses were allowed to open beginning November 13, with St. Louis’s 100,000 schoolchildren returning to their classrooms the day after that. The ban on public meetings would remain in place until Monday, November 17. Starkloff was quick to point out to businesses and the public that the state of public health emergency was still in effect, allowing him to reinstate the measures if necessary.30

For the next two weeks, the infection rate gradually declined, lulling residents into what proved to be a false sense of security. Keeping a vigilant eye on new case tallies, Starkloff spotted a spike on November 27, when more than 700 cases were reported for the previous 24-hour period, half of them children.31 After a hurried conference with other health department personnel, city officers, and public school authorities, Starkloff announced that he was closing schools once again. Because so many of the recent influenza victims were children, Starkloff banned children under 16 years of age from places of amusement, stores, or any other locations where people congregate. For the city’s adults, all public gatherings, conventions, and banquets were barred. Stores were barred from advertising special sales.32 As before, retailers, theater owners, unions, and mass transportation companies rushed to protest the economic hardship this second round of orders would cause. Sick with a bad cold, and with the epidemic on the rise again, Starkloff was in no mood for protest. Exhausted, the health commissioner took to his bed for rest, leaving Assistant Health Commissioner Jordan in charge.33 Jordan quickly set to work enforcing his boss’s orders, including the closure of five theaters caught admitting children.34

By December 5, it became clear that the percentage of influenza cases in children under 16 years of age was decreasing, prompting Superintendent of Schools Dr. J. W. Withers to seek permission to reopen St. Louis’s high schools. Examining the data, Starkloff agreed to allow junior and senior high school students to report for class on Monday, December 9.35 Two weeks later, the number of new cases fell below 125 per day – Starkloff’s criteria for lifting the ban. On December 20, the health commissioner lifted the remaining bans, with two exceptions. First, kindergarten through 10th grade classes remained closed, and children under 12 years of age were barred from places of amusement and allowed in downtown stores only before noon and only if accompanied by a parent or guardian. Second, large and unusual public gatherings were still prohibited. The Globe-Democrat reported, possibly with some glee, that the health department cited the Christmas party of its archrival, the Post Dispatch, as the type of gathering now banned.36

By the end of the year, the daily tally of new cases was consistently under 50. Starkloff lifted all restrictions on December 28 and announced schools would reopen on January 2.37 For the rest of the winter, St. Louis continued to experience low numbers of influenza cases, but the tallies – now compiled as weekly data – remained quite low. Perhaps the real sign of recovery was the resumption of the city’s traditional economic rivalry with the Windy City. When Chicago Health Commissioner John Dill Robertson, citing the recent influenza epidemic, announced in early-February that his city was the safest in the United States, St. Louis businesses jumped at the opportunity to prove him wrong. Launching an advertising campaign, the St. Louis Chamber of Commerce created circulars for its members to send to out-of-town customers showing that St. Louis had a lower epidemic death rate than did Chicago, and that it was therefore the healthier city.38

Conclusion

Led by a strong-willed and capable health commissioner who had the foresight to act quickly and decisively, and supported through home nursing by an organized local Red Cross, St. Louis fared well in its battle against influenza. Despite persistent pressures from various constituents, Health Commissioner Max C. Starkloff and Mayor Kiel moved beyond their differences to execute an open-minded, flexible approach to social distancing measures. Among their innovations was a health officer (Jordan) dedicated almost exclusively to stakeholder communications, an advisory committee, and age-appropriate restrictions for children.

When discussing the history of the tragic 1918 influenza epidemic, St. Louis is often held up as a model city. Because of the quick and sustained action by its leaders, St. Louis experienced one of the lowest excess death rates in the nation, just 358 per 100,000 people. Only five cities – Grand Rapids, Minneapolis, Indianapolis, Milwaukee, Toledo, and Columbus – had better outcomes.