s the world sees armed protesters in the United States demanding an end to “shelter-in-place” orders, reads stories of shopping malls in Brazil reopening as their president joins anti-lockdown protests, and hears laissez-faire voices call for their governments to “ease” restrictions as soon as possible, we might do well to look back at parallel moments in history. In recent days, striking images of scientific charts and graphs from the 1918 influenza pandemic have been making the rounds on social media. Though these hand-drawn diagrams may look archaic to our eyes, they offer a clear rebuke to those moving too quickly to step away from the public health restrictions so many around the world are currently enduring. In 1918, influenza swept the globe in a series of waves. Probably emerging in the spring of 1918 in the American midwest, this new virus moved through the US largely unnoticed by a nation at war. Soon, though, it travelled to Europe through American troops, infecting first combatants, then the entire continent and beyond. But this pandemic was only getting started. In late August a second, more deadly wave crashed on to the shores of the US, France and Sierra Leone almost simultaneously and rushed from there to sicken the entire world. This was, in many communities, soon followed by a third wave. When the virus finally slowed in 1920, an estimated 500 million people had been stricken worldwide, and 50 million to 100 million people had perished. Of those, 675,000 deaths were in the US. As they faced this scourge in 1918, scientists lacked technology that would allow them to see the virus that caused it. The bacteriological revolution of the 19th century gave American medical and public health authorities confidence, though, that this was a contagious disease. Nationally, the United States Public Health Service (USPHS) encouraged education and, if needed, a range of controls on Americans’ behaviour. It would be up to state, county and local leadership to make the decisions about how to manage the pandemic. Their choices proved critical. Public health leaders had a range of tools at hand. They began by training the population in basic hygienic practices – washing their hands and covering coughs and sneezes. The USPHS printed millions of pamphlets providing information on the disease and recommending precautions for avoiding and treating the illness. The American Red Cross published its own circular in eight different languages. Many communities passed laws against public spitting, and banned the common drinking cup still shared in public spaces such as schoolrooms and train stations. These were the easy steps. Soon, better ventilation was called for on streetcars, and some cities staggered work times and store hours to prevent crowding. The flu kept coming, and more comprehensive controls often followed. Bans on public gatherings, the closure of all but the most essential businesses, even prohibitions on weddings and funerals frequently followed. Some cities tried requiring the wearing of masks. Others turned to quarantining the sick. There were even cities that employed new and untested vaccines. But what’s most useful to us today is the comparative experience of Philadelphia and Seattle. Philadelphia, despite having some warning that the pandemic was coming, did little to prepare. Though Boston was under siege by late September, Philadelphia continued to conduct business as usual. On 28 September it hosted a massive kickoff parade for the Fourth Liberty Loan, the bond drive used to support the American war effort. Three days later the city reported 635 new influenza cases, and the situation soon worsened. Though the city now moved to protect itself, Philadelphia was overwhelmed by the epidemic. Available healthcare resources, already compromised by the war effort, were quickly stretched past their limits. Morgues overflowing with the dead, a desperate shortage of coffins and a resort to mass graves resulted from the city’s failure to move early to prepare. Philadelphia suffered one of the nation’s highest death rates. Seattle offers a very different story. On 20 September, the city’s commissioner of health, Dr JS McBride, acknowledged that “it was not unlikely” that influenza would reach the city and warned the citizenry that, if it did, isolating cases would be necessary. When soldiers at nearby Camp Lewis came down with the flu, the camp was quarantined. On 4 October, the story broke that large numbers of students at the naval training station at the University of Washington had contracted influenza. Within two days the city had, despite significant opposition, closed schools, prohibited church services and shuttered many public entertainments. Crowding was prohibited in those businesses still operating. In the days to come, other measures followed. A local hotel was requisitioned for use as an emergency hospital. Spitting in public could mean a jail cell and public shaming, the wearing of masks was required in public, business hours were shortened and further limitations were placed on those allowed to remain open. Though he had initially hoped the pandemic would pass in less than a week, the health commissioner maintained the restrictions, even as the number of cases began to decrease. Finally, on 11 November, both the city and state announced an end to closures and masking. Not uncommonly, the city soon faced a return of the disease. Again the city acted, this time quarantining the sick. As a result of these actions, Seattle suffered one of the lower death rates on the West Coast, substantially lower than Philadelphia’s. There was certainly opposition to the kinds of restrictions Americans faced during the 1918 pandemic. Church leaders routinely protested that, in the midst of a pandemic, their congregants’ needs were best met by access to religious gatherings. Business owners fought hard to stay open. Theatre owners pursued legal challenges, while opposition was voiced to school closures. In San Francisco, an “Anti-Mask League” organised against face-coverings. But the authorities that resisted this opposition fared the best. Research conducted by scholars at the Center for the History of Medicine at the University of Michigan and the Centers for Disease Control and Prevention makes clear that the “early, sustained, and layered” imposition of non-pharmaceutical interventions such as social distancing worked in 1918, slowing the pandemic’s pace and lowering death rates. And Seattle and Philadelphia offer a stark lesson – imposing “shelter-in-place” orders, as well as other measures such as public masking and the quarantining of the sick and infected, saves lives. They can do so again, if we can find the courage and the resources to maintain them. • Nancy K Bristow is a professor of history at the University of Puget Sound and is the author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic and Steeped in the Blood of Racism (published in July 2020)