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From Spanish Flu to COVID-19

Race, Class and Reopening St. Louis From Spanish Flu to COVID-19

As the novel coronavirus and its associated disease COVID-19 burst onto the global stage, its seemingly indiscriminate rate of infection caused some to label it the “great equalizer.” While the virus has the potential to infect anyone, alarming new demographic data demonstrates that while the virus itself may spread indiscriminately, it exacerbates existing social disparities.

African Americans bear a significant burden of the disease and resulting fatalities. As CNN contributor Van Jones put it, “It’s an epidemic jumping on top of a bunch of other epidemics already in the black community.” St. Louis city illustrates this very conundrum. Like COVID-19 today, the 1918 Spanish flu pandemic occurred at a pivotal moment in St. Louis history, not only in terms of public health policy, but also in terms of municipal race relations. While St. Louis led the nation in implementing “social distancing” policy in 1918, it contributed to a retrenchment of racial policy fueling the implementation of racial segregation. This century-long history, between 1918 and 2020, has contributed to COVID-19 hitting those traditionally marginalized communities extra hard.

The Spanish flu pandemic, of unknown national origin, was similarly seen as a “great equalizer” and remains the prominent comparison point for the contemporary COVID-19 outbreak more than a century later. That early-twentieth-century crisis impacted tens of millions around the world, as the “Great War” came to a close. Among major cities in the United States, St. Louis was the most effective at reducing the flu's fatalities. This was due, in large part, to Health Commissioner Dr. Max Starkloff, who worked with city administrators and special interests to implement a policy of social distancing. Schools and businesses were shuttered. Police enforced distancing. And when cases surged after social distancing was lifted, Starkloff re-implemented the policy, avoiding more fatalities in the pandemic’s second wave.

While this historical case demonstrates that social distancing works, even today’s coverage neglects the impact of that policy on African Americans. Medical historians, like George Washington University Professor Vanessa Gamble, have noted that African Americans did not succumb to the flu at the same rate as other Americans. But the Spanish flu had a long-lasting social impact on African Americans in St. Louis and across the nation. In the years before the Spanish flu hit, African Americans had begun to leave the South in large numbers, making their way to other regions of the country. St. Louis saw its African-American population rise significantly. Between 1910 and 1920, St. Louis’ nonwhite population rose by 59 percent according to U.S. Census data. And in terms of health care access, the city was far from prepared for the influx. Municipal facilities and infrastructure were overwhelmed — including the city’s public hospital. Black St. Louisans obtained hospital care in the colored wards of City Hospital No. 1 or in the private People’s Hospital, if they were hospitalized at all. Frustrated with the lack of access to health care, black elites and health professionals began in 1914 to argue for a negro hospital.

Industries depended on healthy laborers, yet many white St. Louisans feared that germs knew no color line. In 1916, St. Louisans voted to support racial segregation ordinances as backlash against African Americans rose all across the region. (The United States Supreme Court later deemed ordinances like St. Louis’ unenforceable.) The 1917 East St. Louis race “riot” subjected hundreds to racial violence. The pandemic fueled racial segregation policies, the effects of which have led to African Americans’ disproportionate experience of CO- VID-19 more than a century later.

It is no coincidence that the precursor to Homer G . Phillips Hospital, City Hospital No. 2, opened in 1919 — expanding African Americans’ access to segregated hospital facilities at the tail end of the flu's second wave. St. Louis City Hospital No. 1 was later renamed Max C. Starkloff Memorial Hospital in 1942, shortly after the pioneering public health official passed away.

Amid the COVID-19 pandemic, recent studies have shown that African Americans bear a significant burden of the disease and are overly represented among its fatalities. In St. Louis, the city’s first four COVID-19 deaths were African-American women. In the St. Louis American, city Health Director Dr. Fredrick Echols announced that the first twelve COVID-19 deaths in the city were African Americans. Since then, the mortality rates among the black community in both St. Louis and St. Louis County have continued to rise. Considering these data, COVID-19 is in fact not a “great equalizer.”

Although St. Louis is today a mid-sized city, situated far from many coastal virus epicenters, the stakes of its COVID-19 response are exceptionally high. St. Louis’ unfortunate and fraught history of socioeconomic and racial inequities has negatively affected poor and African-American communities. This history, in part, can be traced back to the early twentieth century. Generations of African Americans, particularly in north St. Louis, have and continue to experience undue oppression through social policy. These policies and their ultimate consequences include voter suppression, environmental discrimination, medical racism and experimentation, the racial wealth gap often tied to homeownership, and housing segregation, a consequence of redlining and race-restrictive covenants. How local, state and federal leadership tackle these social inequities will determine how successfully St. Louis flattens the curve.

It was not until April 2 that Affinia Healthcare opened the first COVID-19 testing center in north St. Louis. Suburban and rural metropolitan clinics implemented COVID-19 testing as early as mid-March. A second north St. Louis site opened at Care STL on April 6, just two blocks from the historic Homer G. Phillips Hospital, now Homer G. Phillips Senior Residential Center. But neither clinic has consistently operated due to continuing logistical issues, including lack of personal protective equipment. Such inconsistent operation crucially limits the number of patients served.

Dr. Fredrick Echols is the city’s director of public health. | DOYLE MURPHY

“History doesn’t repeat itself, but it often rhymes,” the saying goes. Histories of previous epidemics frequently suggest that outbreaks expose societies’ greatest vulnerabilities. And in the midst of the current crisis, data and survivor testimonies demonstrate that the most severely impacted in this pandemic will be those who are already the most socially vulnerable — the incarcerated, the unemployed, the unhoused and the uninsured. To generate and maintain a flattened curve, St. Louis municipal leaders must learn from the city’s successful pandemic response more than a century ago. But they must also contend with the persisting negative consequences that marginalized African Americans in particular over the course of the twentieth century. Although President Trump provided guidelines on “Opening America Up Again” on April 16, it is imperative that states do not rush to reopen and return to “business as usual.” A rush to return to normal is not only dangerous for our health but will inevitably produce amnesia, with societies once again forgetting and diminishing the social vulnerabilities that have been exposed.

As French philosopher and Jesuit priest Pierre Teilhard de Chardin once said, “We are one, after all, you and I, together we suffer, together exist, and forever will recreate each other.” Given St. Louis’ pattern up to the present day, it is imperative that we maintain social distancing for much longer than a “downward trajectory of positive tests” and “downward trajectory of documented cases” over a fourteen-day period. Yet Missouri and the St. Louis area are not even waiting for that. Gov. Mike Parson began lifting restrictions on May 4, and the city and county have announced plans for a “soft” opening on May 18.

Under-resourced and socially disadvantaged people do not have the same access to health care or testing opportunities as other Americans. Paradoxically, the most vulnerable among us also serve in “essential” positions, increasing personal risk of exposure. If working-class African Americans (and other communities of color) return to work, church and school too soon, we will again see a resurgence of COVID-19 cases and ultimately COVID-19 deaths. Reopening too quickly threatens to exacerbate an already troubling trend. At this moment, we cannot simply think about "flattening the curve,” but also the broad and long-lasting social consequences of our actions. We must think about how to emerge from this pandemic better than when we entered. Otherwise, rushing to “reopen St. Louis” will have long-lasting deleterious impacts on not only marginalized populations in St. Louis but on us all.