Children and the Influenza Pandemics of 1918-1919 and 2020-2021

June 23, 2021

By Cynthia Connolly, PhD RN, Field Center Faculty Director

Professor of Nursing

Rosemarie B. Greco Endowed Term Chair in Advocacy

Associate Director, Barbara Bates Center for the Study of the History of Nursing

In early December of 1918, physician Harriet L. Hartley, Chief of the Philadelphia Health Department’s Bureau of Child Hygiene, took the stage in Chicago at the American Child Hygiene Association’s annual meeting. She was clearly still somewhat bewildered by the events of the past year that had befallen her city. Her presentation, “The City Nurse as an Agent for the Prevention of Infant Mortality,” led with her only good news. Since 1916, the city had more than doubled the number of public health nurses it employed [1]. Hartley, like other public health experts around the nation, believed that nurses, with their ability to provide health education, screening, care coordination, and health care to indigent pregnant women, mothers, infants, and young children provided an essential public health infrastructure. With the city’s dramatically increased investment in maternal and child well-being, she had likely hoped to report a corresponding reduction in morbidity and mortality to the impoverished families her department served [2].

But if that was the case, Hartley could not have been more wrong. Despite the new nurses, infant mortality had only slightly declined in 1917. The city still had the fourth highest infant mortality of any large city in the United States. Hartley knew that the data for 1918 would likely be even worse. Philadelphia had suffered mightily all year. First, the winter of 1918 had been intensely cold and a coal shortage meant that the most vulnerable families, such as those in the tenement districts, struggled to keep warm. Higher coal prices meant that parents had less money to purchase food and milk for their children. This extreme cold was followed by an unusually hot summer, with recorded temperatures as high as 106 degrees. In an era before most families owned refrigerators this meant that food and milk spoiled readily, heightening children’s risk for life-threatening dehydration and infectious diarrheal diseases.

Two Nurses with Four Babies, c.1918, Alumni Association of the Philadelphia General Hospital School of Nursing Image Collection, Barbara Bates Center for The Study of The History of Nursing, School of Nursing, University of Pennsylvania.

And although World War 1 had ended a month earlier, in November, Philadelphia remained crowded with soldiers stationed at the city’s military bases as they came and went from Europe. During the war, there had also been an influx of extra factory workers who poured into the city to meet the growing industrial production needs. All of these additional people increased crowding and strained the city’s public health and hospital resources, especially since many nurses and doctors had not yet returned from providing health care to wounded soldiers in Europe.

But as Hartley made clear in her talk, none of this compared to the influenza pandemic that still traumatized Philadelphia. Between the last week of September and the end of October thousands had died. Tens of thousands became sick but recovered. It would be months before it became clear that the pandemic had ultimately claimed more than 12,000 Philadelphians in the autumn of 1918, one of the highest mortality rates in the nation [3].

Conventional wisdom stipulated that healthy young adults had been most impacted by the flu in Philadelphia. While young adults certainly were disproportionately affected, Hartley, in a March 1919 report to the health department, noted that the pandemic’s severe consequences to infants and young children had not come into focus until the pandemic was over. Hartley reminded her colleagues that at the beginning of the pandemic experts even believed that infants and young children were “escaping” the flu. Unfortunately, however, of the 12,000 recorded deaths from flu-related causes in Fall, 1918, almost 2,000 of them occurred in children under the age of five years of age. The infant mortality rate for 1918 increased by 16% over 1917 [4].

This is an interesting story, but what, if anything, does this Philadelphia story say about the nation and the nation’s children in 2021 as we emerge from another pandemic? I argue that if we look closely enough there are lessons for today. Sick children with the flu in 1918, who made it to a hospital were, just as today, overwhelmingly likely to survive [5]. This is good news, of course. But the data in 1918, as 2021, reveals something else. While Philadelphia’s health department in 1918 tracked morbidity and mortality, neither it, nor any other group, was charged with developing and overseeing a coordinated policy for children’s health and welfare in the city. Support for families was then, as now, a complicated patchwork of public and private initiatives, leaving many families to fend for themselves [6].

Four Children, September 28, 1918, Alumni Association of the Philadelphia General Hospital School of Nursing Image Collection, Barbara Bates Center for The Study of The History of Nursing, School of Nursing, University of Pennsylvania.

Hartley and others would document that many children who did not contract the flu themselves suffered because of its impact on their family. In Philadelphia in 1918, with schools closed for weeks, thousands of city youngsters played in the streets, often alongside bodies the overwhelmed city morgue had not yet retrieved. They were at heightened risk for accidents and delinquency. Thousands of orphaned Philadelphia children, or those whose parents were in the hospital or sick at home, languished, becoming malnourished, dehydrated or ill from a lack of monitoring [7].

All of these risk factors disproportionately impacted the city’s poorest and most vulnerable families. Voluntary agencies struggled to coordinate services with the few resources provided by the city [8]. And, unfortunately, the trauma to children from social disruption and loss caused by the pandemic lingered after it ended. Children born during the 1918 flu were more likely to struggle with health-related issues and poverty throughout their lifetime than those born just before or after. Non-white children faced even greater adversity.

No transformative child and family policies emerged from the 1918 flu pandemic. The negative impact of structural inequity, heightened risks to indigent children, and siloed and fragmented supports for the most vulnerable families, were largely forgotten as Americans celebrated the end of World War 1 and a booming economy. Will the historians writing about our response to COVID-19 one hundred years from now in 2121 say the same about us?


  1. Harriet L. Hartley, “The City Nurse as an Agent for the Prevention of Infant Mortality,” Transactions of the Nineth Annual Meeting of the American Child Hygiene Association (Baltimore: Franklin Printing Company, 1919), 122-126.
  2. Beatrix Hoffman, “Health Care Reform and Social Movements in the United States,” American Journal of Public Health 93 (January 2003): 75-85.
  3. Ibid., 122; Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918, 2nd ed. (Cambridge: Cambridge University Press, 2003); John W. Barry, The Great Influenza (New York: Penguin, 2005); Nancy W. Bristow, American Pandemic: The Lost Worlds of the 1918 Influenza Pandemic, 2nd ed. (Oxford: Oxford University Press, 2017); James E. Higgins, “A Lost History: Writing the Influenza Epidemic in Pennsylvania, 1918-1922,” Pennsylvania History 85, no. 3 (2018): 394-405; “Philadelphia: How the Social Agencies Organized to Serve the Sick and the Dead,” The Survey (October 19 1918): 74-76; Emergency Service of the Pennsylvania Council of National Defense in the Influenza Crisis: Report of The Vice-Director, Department of Medicine, Sanitation and Hospitals (Harrisburg, PA: Pennsylvania Council of National Defense, 1918): 5.
  4. Harriet L. Hartley, “The Baby in the Epidemic,” Monthly Bulletin of the Department of Public Health and Charities of the City of Philadelphia 4 (March 1919): 44-45; “Epidemic Statistics,” Monthly Bulletin of the Department of Public Health and Charities of the City of Philadelphia 4 (March 1919): 46-47.
  5. Hartley, “The Baby in the Epidemic,” 45; Jennifer E. Schuster & Annabelle de St. Maurice, “COVID-19 in Children: Not Just Little Adults,”JAMA Network Open, June 7, 2021;4(6): e2111441. doi:10.1001/jamanetworkopen.2021.11441
  6. Jeffrey P. Brosco, “Policy and Poverty: Child and Community Health in Philadelphia, 1900-1930,” Archives of Pediatric and Adolescent Medicine 149 (December 1995): 1381-1387; Cynthia A. Connollyand Janet Golden. (2018). “Save 100,000 Babies:” The 1918 Children’s Year and its legacy, American Journal of Public Health 108(7), 902-907.
  7. Hartley, “The Baby in the Clinic,” Emergency Service of the Pennsylvania Council; “What the Health Department Has Done To Curb the Epidemic of Influenza,” Monthly Bulletin of the Department of Public Health and Charities of the City of Philadelphia 3, no. 10-11 (October-November 1918): 1-27.
  8. Hartley, “The Baby in the Epidemic,” and “The City Nurse”; Jeffrey S. Anderson,” ‘When We Have a Few More Epidemics the City Officials Will Awake’: Philadelphia and the Influenza Epidemic of 1918-1919,” The Maryland Historian 27 (1/2 1996):) 1-27 1996; Edgar Sydenstricker, “The Incidence of Influenza Among Persons of Different Economic Status During the Epidemic of 1918,” Public Health Reports 46 (4 January 21 1931): 154-170.
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