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<B><font size=+1 color=green><center>What he knew in 1918 could save millions of lives</font>
By Harry Levins
POST-DISPATCH SENIOR WRITER
07/08/2006
<A href="http://www.stltoday.com/stltoday/news/stories.nsf/nation/story/33344E3A2C8C937C862571A5006A3EAD?OpenDocument">LINK</a></center>
With masks over the faces, members of the American Red Cross remove a victim of the Spanish Flu from a house at Etzel and Page Avenues in St. Louis. In 1918, the flu killed 50 million around the world, 675,000 in America and 3,000 in St. Louis.</b>
As health experts look ahead to the possibility of a bird flu pandemic, they're also looking backward to St. Louis as a model of dealing with the disease.
The last worldwide flu pandemic - also a bird flu, dubbed the Spanish Flu - struck in the fall of 1918. Worldwide, it killed perhaps 50 million people, including 675,000 Americans.
In St. Louis, the toll for 1918 rose to just shy of 3,000. That's a heavy loss, about the same as the fatalities in the terror attacks of Sept. 11, 2001.
But among America's big cities, those 3,000 flu deaths were remarkably low. Although nobody can pinpoint Philadelphia's precise death total, it may have topped 15,000. Advertisement
In 1918, nobody had a flu vaccine that worked. If avian flu strikes now, nobody will have a flu vaccine for the first six to eight months. Until that vaccine gets into doctors' hands, public health workers are going to have to rely on what worked in 1918.
What worked then in St. Louis was stern "social distancing" - the medical bureaucrat's term for quarantining the sick and keeping everybody else as isolated as possible, all to check the spread of the disease through coughing and sneezing.
That "social distancing" of 1918 was the brainchild of the city's health commissioner, Dr. Max C. Starkloff. Working with Mayor Henry Kiel, Starkloff closed schools, barred public gatherings and shut or limited businesses.
As a result, the city's flu death rate for each 1,000 residents was 3.0 - the lowest big-city figure. Philadelphia's rate was 7.3, and that was only third-worst among big cities. San Francisco's rate ran to 7.6. In Pittsburgh, the figure hit 8.0.
Starkloff's approach worked back then, and some experts think it could well work again.
Among them is Dr. Howard Markel, a physician and a medical historian at the University of Michigan's medical school. He's leading a team that has just started a Spanish Flu study for the federal Centers for Disease Control. That agency wants to know just what, short of a vaccine, worked. MORE
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Starkloff recalled as being hard-nosed
Flu wasn't really Spanish
"St. Louis is definitely one of the cities we expect to study," Markel said in a phone interview. And in a salute to Starkloff, Markel said, "That guy in St. Louis was a remarkably adept politician. He got his ducks in a row, and he worked well with the mayor."
The 1918 flu is the subject of "The Great Influenza," an award-winning history written by John M. Barry and published in 1994.
Although the book skips over St. Louis, Barry said in a recent phone interview, "St. Louis was a very interesting place in 1918. Now it's being studied to see what we can learn - whether the city had aggressive leadership or just plain luck."
Luck? William Stanhope of St. Louis University's School of Public Health says St. Louis was lucky, but not in the sense that the Spanish Flu merely brushed against the city in random fashion.
"This city was incredibly lucky," says Stanhope, whose research has delved deeply into the city's flu response. The reason for St. Louis' luck: "It had a hard-nosed health commissioner - and it had a mayor with the guts to back up the health commissioner."
Disaster in Philadelphia
Stanhope thinks the Spanish Flu originated in Asia. Barry thinks it started closer to home, in southwestern Kansas, as a mild flu in the spring of 1918.
In Barry's book, American soldiers bound for the battlefields of World War I carried the flu to France. Most experts agree that in Europe, the virus mutated into its killer form. Then it recrossed the Atlantic on naval ships, hitting the Eastern Seaboard in early September 1918.
The flu came ashore in Boston, New York and, most hurtfully, in Philadelphia. In fact, in dealing with the flu, Philadelphia became a model of ineptitude. "They were tardy in everything they did," says Stanhope.
Through ignorance, wishful thinking and a readiness to cave in to civic and business pressure, Philadelphia's leaders took a business-as-usual approach. The population paid dearly.
For example: That city's movers and shakers had long planned a war-bond parade for Sept. 28. The spectacle was expected to draw a crowd of hundreds of thousands downtown - a ground zero for the flu. Even so, nobody in City Hall could muster the backbone to call it off. The crowds filled downtown Philadelphia.
"And three days later," says Dr. William Kincaid of the St. Louis Health Department, "you couldn't find an empty hospital bed in all of Philadelphia."
Today, Kincaid is what Starkloff was in 1918 - St. Louis' top health official. And back in September 1918, despite wartime censorship that tended to mute bad news, Starkloff sniffed out what was heading across America toward St. Louis that September.
Mostly, the flu rode with soldiers and sailors moving south and west from post to post, base to base. All accounts of the flu note that soldiers and sailors clustered in the age group that was hit hardest - people in their 20s and 30s.
Typically, flu tends to kill the very young and the very old. The typical flu tends to spare young adults, whose immune systems work at peak efficiency. But the Spanish Flu hit the other way.
When this alien species of flu invaded the lungs of a young adult with a strong immune system, that system went berserk in an effort to override the virus. "It set off a chemical cascade," says Stanhope. "People got acute respiratory distress syndrome - 'white lung' - and they died."
(Ominously, The New York Times reported this month that the avian flu now on the horizon targeted the same age group, with the same awful severity.)
In the fateful fall of 1918, Starkloff took pains to keep in touch with the Army doctors at Jefferson Barracks, then a bustling post of 6,000 soldiers. And sure enough, the flu seems to have arrived here on troop trains pulling into Jefferson Barracks.
'A monster in a cage'
On Oct. 1, 1918, the Post-Dispatch reported that nationwide, flu had infected 72,000 soldiers and sailors - no surprise, given the crowded barracks of that era. The same day's paper reported that officials at Jefferson Barracks were tight-lipped about the flu situation here.
But nobody can keep a lid on news that ugly. On Oct. 4, Jefferson Barracks conceded that the flu had struck down 500-plus soldiers - one in every 12 on the post.
Before long, the flu spread beyond the post's gates. A headline for Oct. 5 read, "Family of 7 Here Ill With Influenza."
Starkloff pressed the mayor to take action, but Kiel straddled the issue. Although the aldermen got a bill giving the mayor emergency powers, Kiel said that using those powers would be premature.
Things got worse over the weekend of Oct. 5-6. By Monday, Oct. 7, Jefferson Barracks had 900 sick soldiers, and in the city, 115 civilians were ailing. That same day, Starkloff rounded up the city's elite for a head-banging meeting in his office. Afterward, Kiel issued an emergency declaration that eventually:
Closed all schools.
Shut down theaters.
Barred public gatherings, such as banquets.
Shuttered churches.
Stopped dancing in hotels and cafes.
Suspended hospital visits.
Kept children from their playgrounds and library reading rooms.
Canceled conventions.
Closed streetcars to straphangers.
Put a pox on Halloween.
Before long, judges were suspending trials, Washington and St. Louis universities were canceling football games, and debutantes were putting weddings on hold. But by mid-month, the flu had stricken almost 3,200 St. Louisans, 69 of them fatally.
(Among the dead was U.S. Rep. Jacob E. Meeker, R-St. Louis, a former Protestant minister who just 11 months before had divorced his wife. On his deathbed, he married his secretary.)
Despite the deaths, Starkloff took grim comfort in the fact that the fatality rate was relatively low for St. Louis, then a city of 779,951.
On Oct. 18, he noted that flu had killed just 2.85 St. Louisans out each 1,000 population. In contrast, Starkloff said, Chicago's rate for the previous week was 10.25 - and for the current week, 12.99
Still, a backlash built up. The Women's Christian Temperance Union groused that although schools and churches were closed, bars remained open. Retailers complained that Starkloff's rules were hurting business. Archbishop (later Cardinal) John Glennon leaned on Starkloff to reopen churches, albeit restricting worshippers to every other pew.
Starkloff stood his ground. "The wisdom of this order has been proved by the small percentage of influenza infection in St. Louis," he said on Oct. 24.
He had an ally in Kiel, who told Starkloff: "I don't want anyone to die. Therefore, I shall support you." (Kiel's counterpart in Kansas City fired his own activist health commissioner. In the end, Kansas City's death rate reached 7.1 - more than double the rate in St. Louis.)
Another ally of Starkloff was Dr. Ellsworth Smith, president of the St. Louis Medical Society. On Nov. 1, Smith said, "We have got a monster in a cage. The question is, should we let him out and see if we can catch him again?"
One last surge
Starting Nov. 9, Starkloff imposed a four-day closure of all establishments except those "supplying sustenance, medical attention or the conduct of the war." Starkloff said the order "will have the effect of making every day appear like Sunday." It all but made downtown a ghost town.
Although the order was to last four days only, St. Louis University's Stanhope theorizes that Starkloff meant it to last four days if it worked. Otherwise, it would last longer. "But the federal government torpedoed Starkloff," Stanhope says. The government said the broad rule was hampering the war effort, even though the war was rapidly ending.
On Nov. 11, the Germans signed an armistice. That day, Starkloff let a downtown dry-goods store sell American flags to clamoring customers - but only if the clerks stood on the sidewalk outside the store.
Within days of the armistice, schools reopened and the ban on dancing disappeared. On Nov. 18, Starkloff lifted the last vestiges of his closing order.
Late in the month, the infection curve nosed upward again. Starkloff again closed schools and banned children from theaters. (Kirkwood took the school-closing notion further, closing Sunday schools as well.) But at month's end, St. Louis registered Case No. 20,000 since the emergency order of Oct. 7.
The spike continued into December. Things hit a gruesome peak on Dec. 11, with 85 deaths from flu and pneumonia, a one-day record here. (The one-day record in Philadelphia: 759, on Oct. 10).
On the plus side that same December day, 950 St. Louisans were reported cured, with only 534 newly infected. The disease seemed to be on the downward slope.
Indeed, at year's end, the Spanish Flu simply petered out. In the week of Dec. 8-14, it killed 502 people, the worst week here. But in the week of Dec. 29-Jan. 4, the death total from flu and pneumonia fell to just 16.
Stanhope says that after infecting more than 31,500 St. Louisans, the flu had finally worked its way through the vulnerable population. "It ran out of steam - out of new victims," he says.
Starkloff: Forgotten?
Nine decades ago, death at a young age was vastly more common than it is today. And the carnage of WWI made early death an everyday fact of life.
Maybe that explains why press accounts of the flu in St. Louis bore such a bloodless tone. On Dec. 10, the Post-Dispatch used three sentences of just-the-facts-please prose to tell about a cluster of heartbreak:
"The bodies of Mrs. Clara Breunig, wife of Anton Breunig, 2585 West Hebert Street, her son, Edward, 5 years old, and her daughter, Dolores, 4 years old, all of whom died of influenza, will be forwarded to Hermann, Mo., for interment.
"The boy died at 4:45 a.m. Friday, the mother at 3:30 p.m. Friday and the daughter at 3:15 p.m. Sunday. An older daughter, Agnes, and a 6-month-old baby are ill with influenza at St. Mary's infirmary."
But Stanhope and Kincaid insist that without Starkloff's stubborn stand, the paper would have had to run page after page of such poignant prose.
After Starkloff died in 1942, St. Louis renamed City Hospital in his honor. But right up until Max C. Starkloff Memorial Hospital closed in 1985, most St. Louisans kept calling the place "City Hospital."
Today, a city health clinic at Lemp and Shenandoah avenues bears Starkloff's name. Stanhope thinks Starkloff deserves more.
"Butch O'Hare was a pilot from St. Louis and got a Medal of Honor in WWII and had a big airport in Chicago named for him," Stanhope says. "I'm not certain that on that scale, having only a small health clinic named for Starkloff is equal."
To Stanhope, Starkloff was a towering hero in the war against the Spanish Flu - and now is winning national recognition as such. Stanhope says that in St. Louis, Starkloff's story "should be every bit as much a part of civic pride as the 1904 World's Fair or the Gashouse Gang."
