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Perhaps something approaching current practices of social distancing, without implying class-based differences, is first evident in New York's polio outbreak in 1916. More than 2000 people died in New York from polio and the city took widespread social distancing guidelines to limit the outbreak. This included closing movie theatres, meetings were either limited or cancelled, various public gatherings were outlawed, and children were told to avoid water fountains and pools, limiting their contact with even parks and playgrounds. The response was relatively effective, as the death toll was limited relative to the threat.
The most clear case of social distancing being needed for a public health emergency developed during the Spanish Flu pandemic of 1918. In September 2018, Philadelphia held a major parade, sometime after the first cases of the pandemic flu were reported. The city government allowed the parade to go through even though they had known about the outbreak, with over 20200,000 people gathered to watch the parade. Within days all of the city's 31 hospitals were filled with flu patients, causing 4500 or more to die. Similarly, New York began to experience a large intake of sickness and death. Many cities in the United States began to record outbreaks of the flue and some did go into a relatively rapid lockdown and created strict social distancing policies. One of the earliest to react was St. Louis, which was praised for enforcing social distancing within three days of the outbreak in October 1918, limiting its overall death rates. Other cities were either too slow in enforcing social distancing or, very often, were too quick to loosen social distancing guidelines, causing catastrophic second-wave infections and death. Social distancing also extended to forced school closures and, in some cases, it was estimated that forced school closures could have reduced death rates by nearly 90%. During the 1918 outbreak, this was also the first time people began to widely wear medical masks. Later studies have shown that cities with the strictest social distancing guidelines and closures were the most effective in lowering death rates.
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