Influenza H1N1 virus
A unseen killer stalks the earth
The 1918–1920 influenza pandemic, commonly referred to as the Great Influenza Epidemic or the Spanish Flu, was an exceptionally deadly global outbreak caused by the H1N1 influenza A virus.
The first case was reported in Kansas, United States, in late spring 1918, where it was initially termed "epidemic influenza" or "the grip." Early reports from Spain appeared on May 21, describing it as a "three-day fever."
By April, cases had also been identified in France, Germany, and the United Kingdom.
...the second wave, which struck in autumn 1918, was the deadliest...
The Spanish flu progressed through three devastating waves. The first wave produced typical flu symptoms with relatively limited fatalities.
However, the second wave, which struck in autumn 1918, was the deadliest. During this period, the virus mutated, leading to severe respiratory issues and a high mortality rate, particularly among young adults.
This wave overwhelmed healthcare systems worldwide. Hospitals were filled to capacity, and many healthcare workers fell ill themselves, exacerbating the crisis.
Patients packed into a flu ward during the Spanish Flu epidemic.
Spanish flu centenary marked by new colourised photos | Daily Mail Online
...contributed significantly to the overall death toll...
The third wave, occurring in winter 1918-1919, was less lethal than the second wave but more severe than the first.
It further strained medical resources and contributed significantly to the overall death toll.
This wave saw the resurgence of the virus in a slightly less virulent form, but it still caused widespread illness and death, particularly in communities already weakened by the previous waves.
Together, these three waves infected over 500 million people globally, approximately one-third of the world’s population at the time.
The pandemic resulted in an estimated death toll of 50 million people worldwide, with some estimates suggesting as many as 100 million.
...Spanish flu ranks among the most lethal in human history...
In the context of historical pandemics, the Spanish flu stands as one of the deadliest.
After the Black Death bubonic plague of 1346–1353, which had an estimated death toll ranging from 17 million to 50 million, and possibly as high as 100 million, the Spanish flu ranks among the most lethal in human history.
Its rapid spread and high mortality rate had profound impacts on societies across the globe, disrupting economies, healthcare systems, and daily life.
Spanish Flu occured in three pandemic waves: This chart shows weekly combined influenza and pneumonia mortality in the United Kingdom, 1918–1919
...widespread morbidity and mortality disrupted societies and economies...
The pandemic's spread and impact were exacerbated by the First World War, which facilitated the virus's global transmission through troop movements and crowded military camps.
Soldiers traveling between continents and countries carried the virus with them, accelerating its spread.
The war also contributed to poor living conditions, malnutrition, and weakened immune systems, making populations more susceptible to the virus.
The widespread morbidity and mortality disrupted societies and economies, leaving lasting impacts on global health and medical practices.
The pandemic underscored the importance of public health measures, such as quarantine, social distancing, and the use of masks, and highlighted the need for international cooperation in managing global health crises.
Spanish influenza : all about it. by Professor Oliver Wade printed by Specialty Press in Melbourne, 1919. The dramatic and ominous presentation aptly reflects the attitude most people had towards Spanish Flu: a deadly and terrifying disease.
Flu Proclamation Timeline - Royal Australian Historical Society (rahs.org.au)
...a reminder of the devastating potential of infectious diseases...
This historical event remains a critical reference point in understanding pandemics, influencing contemporary responses to global outbreaks, including the COVID-19 pandemic.
Lessons learned from the Spanish flu, such as the importance of rapid response, transparent communication, and coordinated public health strategies, continue to inform public health policies and practices today.
The Spanish flu serves as a reminder of the devastating potential of infectious diseases and the ongoing need for vigilance, preparedness, and global collaboration in the face of emerging health threats.
Give it a name
The origins of the Spanish flu are shrouded in uncertainty, partly due to wartime censorship and misinformation.
During the First World War, belligerent countries suppressed unpleasant news to maintain morale, while neutral Spain freely reported on the pandemic.
This transparency gave the misleading impression that Spain was the epicenter of the outbreak, leading to the term "Spanish flu."
As the pandemic spread, the illness quickly acquired the incorrect label of "Spanish influenza" outside Spain.
Newspapers in countries involved in the war rarely reported on the disease due to censorship, but Spanish media, unconstrained by such restrictions, covered the outbreak extensively.
The Oakland Municipal Auditorium in use as a temporary hospital. The photograph depicts volunteer nurses from the American Red Cross tending influenza sufferers in the Oakland Auditorium, Oakland, California, during the influenza pandemic of 1918.
From the Joseph R. Knowland collection at the Oakland History Room, Oakland Public Library.
...entrenching the erroneous belief that Spain was the origin...
This situation is illustrated by a dispatch from The Times of London dated June 2, 1918, titled "The Spanish Epidemic," where a correspondent in Madrid reported 100,000 cases of "…the unexplained disease...clearly of a gripal character."
Three weeks later, The Times published an article that indirectly referenced "Spanish influenza," and advertisements for "Spanish influenza prevention" began to appear, such as the Formamint tablet ad.
In Russia, the pandemic was colloquially referred to as "Ispánka (the Spanish lady) is in town," further entrenching the erroneous belief that Spain was the origin.
Advertisement in The Times, 28 June 1918 for Formamint tablets to prevent "Spanish influenza"
H1N1 1918 influenza virus particles (brown), coloured transmission electron micrograph (TEM). These virus particles (virions) have been recreated from the influenza (flu) virus strain that caused the 1918 Spanish flu pandemic. It was reconstructed by scientists at the Center for Disease Control and Prevention (CDC), Atlanta, USA, in 2005.
H1n1 1918 Influenza Virus, Tem Photograph by Cdc - Fine Art America
...the outbreak did not start in Spain...
This misconception persisted because Spain, being a neutral nation, had no need to maintain an appearance of readiness for battle.
Its newspapers freely reported on the epidemic's effects, including the illness of King Alfonso XIII.
The Spanish reports were so detailed and prominent that they overshadowed the outbreak's presence in other countries, which were equally affected but less forthcoming due to wartime propaganda efforts.
In reality, the outbreak did not start in Spain.
Historical evidence suggests the flu may have originated elsewhere, with theories pointing to locations such as Kansas in the United States, where the first recorded case on March 4, 1918, involved Albert Gitchell, an army cook at Camp Funston.
Additionally, earlier cases had been identified in January 1918 in Haskell County, Kansas, where local physician Loring Miner alerted the Public Health Reports journal to the unusual severity of the flu.
Alfonso XIII, the King of Spain became gravely ill from Spanish Flu. His illness and subsequent recovery were reported to the world. This gave the misleading impression that Spain was the most affected area and led to the pandemic being dubbed "the Spanish Flu.
Spanish Flu also reached Ireland. Belfast was the first location where signs of Spanish flu were detected. From there, it spread across the rest of Ireland, thriving in densely populated towns and cities; factories, where workers gathered in close quarters, encouraged the virus to spread. Additionally, the Catholic tradition of holding wakes for the deceased, where family members of the deceased would gather in close proximity, may have contributed to the spread of the virus.
...The true origin remains uncertain...
However, some historians point to the crowded and unsanitary conditions of First World War trenches as breeding grounds for the virus.
The squalor and filth, as well as the constant movement of huge numbers of soldiers makes this a likely culprit.
Another hypothesis suggests that the virus may have originated in China and spread via labourers and soldiers traveling during the war.
The true origin remains uncertain due to conflicting evidence and limited historical data.
...congested living quarters provided ideal environments for the virus...
The pandemic's rapid spread was facilitated by the conditions of the First World War.
Military camps, troop movements, and congested living quarters provided ideal environments for the virus to propagate.
The flu quickly infiltrated Europe, spreading from military camps in the United States to battlefields and civilian populations across France, Great Britain, Italy, and Spain, and reaching Wroclaw and Odessa by May 1918.
Victims of the Spanish flu as they lie in beds at a barracks hospital on the campus of Colorado Agricultural College, Fort Collins, Colorado, in 1918,
American Unofficial Collection of World War I Photographs/PhotoQuest/Getty Images
A mask is worn by a street sweeper in New York in 1918. The admonition of the New York Health Board to wear masks to check the spread of influenza epidemic was: 'Better ridiculous than dead'.
Despite the first wave being relatively mild, with lower mortality rates than the subsequent waves, its impact on global populations and military operations was significant.
Almost 900,000 German soldiers were incapacitated, and approximately 75% of British and French forces were affected, severely hampering war efforts.
Thus, while the term "Spanish flu" suggests a misleading origin, the pandemic's true beginnings are complex, shaped by wartime conditions, censorship, and the interconnectedness of a world at war.
The Spanish flu remains a profound example of how misinformation and global events can shape historical narratives and public perception.
Catching the flu
Spanish flu presented a range of symptoms, from typical flu-like signs to severe and often fatal conditions.
Initial symptoms resembled those of seasonal influenza: high fever, chills, fatigue, headaches, and muscle aches.
However, many sufferers quickly developed more alarming symptoms, such as a deep, wracking cough, severe sore throat, and a pronounced sense of malaise.
Aden Field Force. Indian troops who died of influenza being carried to the burning ghats. A frequent scene at Sheikh Othman during the influenza epidemic of Oct-Nov, 1918.
Spanish Flu: The Unseen Enemy | Imperial War Museums (iwm.org.uk)
...the virus's aggressive attack on the lungs...
One of the most striking and deadly symptoms was acute respiratory distress.
Patients often experienced cyanosis, a bluish discoloration of the skin, especially noticeable on the lips, ears, and extremities, indicating a severe lack of oxygen.
This was caused by the virus's aggressive attack on the lungs, leading to viral pneumonia.
Fluid accumulation in the lungs made breathing increasingly difficult, often resulting in suffocation.
A Spanish Flu headline from the El Paso Times on the 9th October 1918. Catching the Spanish flu carried a high fatality risk due to severe respiratory complications, secondary bacterial infections, and hyperactive immune responses, particularly among young adults, leading to millions of deaths worldwide.
1918 Spanish flu epidemic shut down El Paso (elpasotimes.com)
...blood-tinged sputum...
The Spanish flu also led to secondary bacterial infections, such as bacterial pneumonia, which compounded the suffering and mortality rates.
These infections were difficult to treat effectively, given the limited medical knowledge and lack of antibiotics at the time.
Patients with these secondary infections often experienced high fevers, chest pain, and a productive cough with blood-tinged sputum.
Neurological symptoms were also reported, including delirium and, in some cases, encephalitis (brain inflammation), which could lead to long-term cognitive impairments.
The severe systemic inflammation caused by the flu strained the cardiovascular system, sometimes leading to heart failure.
A conductor checks to see if potential passengers are wearing required masks in Seattle, in 1918.
A quote from Pale Rider by Laura Spinney, which eloquently describes some of the effects of Spanish Flu.
A young couple on the streets in London in 1919. Their masks fail to cover their noses.
The high mortality rate among young adults, rather than the very young or elderly, was a peculiar aspect of this pandemic.
This demographic often suffered from a hyperactive immune response, known as a cytokine storm, which led to severe lung damage and contributed significantly to the high death toll.
Overall, the Spanish flu's symptoms and medical effects were devastating, overwhelming healthcare systems and leaving lasting impacts on global health.
The First Wave
The origins of the Spanish flu pandemic remain a subject of debate among historians and epidemiologists due to conflicting theories and a lack of conclusive historical evidence.
Despite earlier cases, the pandemic is traditionally marked as beginning on March 4, 1918, with the documented case of Albert Gitchell, an army cook at Camp Funston in Kansas, United States.
However, the illness had already been identified in January 1918, about 200 miles away in Haskell County.
A study from Queen Mary University, London, said that doctors, detecting the disease in the early 1900s, dismissed it as a 'minor infection', missing an important window to possibly save countless lives. Written by a medical group in Etaples, northern France, it found evidence of doctors investigating a mystery illness as early as 1915. And they also looked into an 'unusually fatal disease' causing 'complex' breathing problems in 1917. Here, an old gymnasium filled with troops returning home from World War One is re-used as an emergency Spanish Flu hospital.
Local physician Loring Miner recognized the unusual severity of the flu and alerted the editors of the Public Health Reports journal of the U.S. Public Health Service, indicating an early awareness of the outbreak's potential gravity.
...its swift transmission capabilities...
Following Gitchell's case, 522 soldiers at Camp Funston reported illness in the subsequent days, showcasing the flu's rapid spread within close quarters.
By March 11, 1918, the virus had reached Queens, New York, evidencing its swift transmission capabilities.
The outbreak was exacerbated by First World War conditions, as Camp Funston was a key training site for American Expeditionary Forces.
The movement of troops and the congested environments of military camps facilitated the virus's dissemination not only across the United States but also to Europe.
Emergency hospital during influenza epidemic, Camp Funston, Kansas, the likely location of the initial outbreak of Spanish Flu in 1918. Pictured here it is being used as an emergency hospital, crowded with patients in beds, in the midst of the influenza epidemic. The flu struck while America was at war and was transported across the Atlantic on troop ships.
National Museum of Health and Medicine
...movement of people played a crucial role in the pandemic's global reach...
The flu quickly infiltrated Europe, spreading to France, Great Britain, Italy, and Spain, reaching Wroclaw and Odessa by May 1918.
The Treaty of Brest-Litovsk in March 1918 further contributed to the spread as Germany released Russian prisoners of war, who then carried the virus back to their home country.
The interconnectedness of the war efforts and the extensive movement of people played a crucial role in the pandemic's global reach.
...highly contagious...
The first wave of the Spanish flu, although highly contagious, was relatively mild in terms of severity and mortality compared to later waves.
In the United States, 75,000 flu-related deaths were reported in the first half of 1918, a slight increase from the 63,000 deaths during the same period in 1915.
This indicates that while the virus was widespread, the death rates were not alarmingly higher than the average for that time.
Similarly, Madrid, Spain, reported fewer than 1,000 influenza-related deaths during May and June 1918.
A scientific graph from the 1918 ‘Spanish’ flu pandemic showing mortality rates in the US and Europe.
Public Domain
...a general underestimation of the potential severity of the outbreak...
The mild nature of the first wave is further evidenced by the lack of major public health responses.
There were no reported quarantines during the first three months of 1918, reflecting a general underestimation of the potential severity of the outbreak.
However, the flu's impact on military operations during World War I was significant. The illness incapacitated almost 900,000 German soldiers, and approximately 75% of the British and French forces were affected, severely hampering military efforts.
Black and white poster of a Red Cross nurse with a gauze mask over her nose and mouth. Text next to the image provides public health information "To prevent influenza!" Photograph by Paul Thompson (1878 - 1940).
Published in New Haven, Conn. : Illustrated Current News, 1918.
To prevent influenza! - Digital Collections - National Library of Medicine (nih.gov)
One notable example of the first wave's reach is its impact on military camps and the subsequent transmission to civilian populations.
In Camp Funston, the close proximity of soldiers and the constant movement of troops created an ideal environment for the virus to spread rapidly.
Soldiers from infected camps carried the virus to other military installations and, eventually, overseas battlefields. This movement facilitated a global spread that was difficult to contain.
The virus quickly exploded and spread out of military bases and to people all over the world. Seen here, teachers tend to children sick with Spanish Flu at Collège La Salle in Thetford Mines, Quebec, Canada.
The second wave strikes
The second wave of the Spanish flu pandemic began in the latter half of August 1918. This wave was notably more deadly and widespread than the first, primarily due to its likely introduction by ships from Brest, France.
Brest was a significant port for American troops and French recruits involved in World War I, and the virus possibly arrived there with these soldiers. From Brest, it spread to Boston and Freetown, Sierra Leone.
At Camp Devens, approximately 30 miles west of Boston, and the Boston Navy Yard, U.S. military installations were quickly affected.
These locations served as crucial points for troops being deployed to Europe, facilitating the flu's rapid dissemination across North America within two months.
Military movements further propelled the virus into Central and South America. Ships carried the flu to Brazil and the Caribbean, with significant outbreaks noted.
A graph showing the percentage of people dying in US cities from the 1918 flu pandemic.
Public Domain
...the flu had arrived in South Africa on ships...
In the Ottoman Empire, the first cases appeared among soldiers in July 1918.
The flu spread from Freetown throughout West Africa via coastal routes, rivers, and colonial railways, reaching remote communities from railheads.
By September, the flu had arrived in South Africa on ships carrying members of the South African Native Labour Corps returning from France.
By November, it had spread to Ethiopia, moving further into southern Africa and beyond the Zambezi River.
St. Louis Red Cross Motor Corps personnel wear masks as they hold stretchers next to ambulances in preparation for victims of the 1918 influenza epidemic.
Library of Congress via AP
...New York City reported its first influenza-related death on the 15th September, 1918...
Spanish Flu in Africa: The Spanish flu had a profound impact on Africa, causing widespread illness and death. It spread rapidly through military and civilian populations, exacerbated by returning soldiers and trade routes. South Africa, in particular, saw high mortality rates, with thousands of deaths reported, significantly disrupting communities and economies across the continent.
Lessons from the 1918-1919 Spanish Flu Pandemic in Africa – Africa Center for Strategic Studies
...leading to approximately 12,000 deaths in Philadelphia alone...
The second wave had a catastrophic impact in the United States. New York City reported its first influenza-related death on the 15th September, 1918.
A severe outbreak followed the Philadelphia Liberty Loans Parade on September 28, 1918, held to support government bonds for the First World War, leading to approximately 12,000 deaths in Philadelphia alone.
This event illustrated how mass gatherings could dramatically accelerate the spread of the virus.
Masks and cloths of all persuasions were worn to help protect the wearer from the killer virus. During the pandemic, face masks were widely used, especially in the United States, to reduce transmission. Their effectiveness was limited due to inconsistent usage and improper fit, but they provided some protection and helped raise public awareness about preventing respiratory infections.
...exacerbated by the Russian Civil War...
In Europe, the second wave originated and spread southwest to northeast, affecting Russia and reaching Iran. It spread through the holy city of Mashhad and moved across Asia, exacerbated by the Russian Civil War and the extensive reach of the Trans-Siberian Railway.
By September 1918, the flu had reached India, with China and Japan reporting cases by October. In conjunction with the Armistice celebrations on November 11, 1918, Lima and Nairobi experienced significant outbreaks.
By December, the intensity of the second wave had diminished.
Seattle policemen wearing cloth face masks handed out by the American Red Cross during the Spanish flu pandemic, December 1918.
...led to more severe respiratory complications...
The second wave proved far deadlier than the first. While the initial wave primarily affected the elderly and those with preexisting health conditions, the second wave caused severe illness and high mortality rates among younger, healthier individuals.
This shift was likely due to a mutation in the virus, which led to more severe respiratory complications. October 1918 marked the peak of the pandemic's fatality rate.
Between September and December 1918, the United States reported 292,000 deaths, a significant increase compared to the 26,000 deaths during the same period in 1915.
The Netherlands recorded over 40,000 deaths from influenza and acute respiratory illnesses, and Bombay, with a population of 1.1 million, saw 15,000 deaths. In India alone, the flu epidemic claimed an estimated 12.5–20 million lives in the last quarter of 1918.
A bar chart showing the relative number of deaths in US cities from the flu pandemic.
Public Domain
Extract of letter from nurse to her friend at the Haskell Indian Nations University, Kansas, 17th October 1918. Bureau of Indian Affairs.
In this letter, a volunteer nurse assigned to various military bases, writes to friend about her experiences. Her initial reaction to death is a window into a personal experience, rather than an official report: "the first one [officer] that died sure unnerved me-I had to go to the nurses' quarters and cry it out."
Overall, the second wave of the Spanish flu pandemic highlighted the virus's capacity for rapid mutation and widespread transmission, exacerbated by global movements during the First World War.
The high mortality rates and extensive spread underscored the severe impact of this global health crisis, which remains one of the deadliest pandemics in history.
Children wearing masks during the Spanish Flu pandemic in 1918, many of which continued to attend school during the outbreak.
Canmore Museum
Third Wave of 1919
The third wave of the Spanish flu pandemic occurred during the winter of 1918-1919 and extended into the spring of 1919.
This phase, while less deadly than the second wave, was still significantly more lethal than the initial outbreak.
The third wave is characterized by its recurrence in populations already weakened by the earlier waves, compounded by the harsh winter conditions, which exacerbated the spread and impact of the virus.
The third wave began to manifest in January 1919. Many cities that had experienced devastation during the second wave saw a resurgence of cases.
The virus continued to spread along well-established routes of human movement and interaction, heavily influenced by the aftermath of the First World War.
Troop demobilizations, the return of soldiers to their home countries, and the movement of laborers and refugees played critical roles in this renewed spread.
During the Spanish flu pandemic, public information posters were crucial in disseminating health guidelines. They promoted hygiene practices, such as hand washing and disinfecting surfaces, urged the use of masks, and advised on social distancing measures to prevent virus spread. These posters helped educate the public and mitigate the outbreak's impact.
N.C. Digital Archives
How the 1918 Flu Pandemic Played a Role in Women’s Suffrage (qcnerve.com)
In Sydney, Australia, nurses leave Blackfriars Depot in Chippenedale during the flu epidemic in April of 1919. Throughout all the outbreaks of Spanish Flu, masks continued to be the main source of protection for most people, regardless of their effectiveness.
NSW State Archives / Tara Majoor
Spanish flu centenary marked by new colourised photos | Daily Mail Online
...the third wave may have caused tens of thousands of additional deaths worldwide...
Department of the US Navy: Precautions Against Influenza. During the Spanish flu pandemic, the US Navy implemented strict quarantines, limited shore leave, and converted ships into floating hospitals. They also enforced hygiene measures, including frequent hand washing and disinfecting living quarters, to control the virus's spread.
In the United States, the third wave struck major cities including San Francisco, New York, and Detroit. San Francisco, which had implemented strict quarantine measures during the second wave, saw a substantial rise in cases once those measures were relaxed.
The city's health officials quickly reinstated mask mandates and public gathering bans in response to the surge in infections.
While the third wave was generally less deadly than the second wave, it still resulted in significant casualties.
Estimates suggest that the third wave may have caused tens of thousands of additional deaths worldwide. In the United States alone, around 100,000 people died during this period.
The high mortality rates continued to disproportionately affect young adults, although the elderly and those with pre-existing health conditions also suffered heavily.
The pattern of deaths indicated that the virus had not lost much of its virulence despite some earlier hopes that it might have attenuated.
An pneumonia porch at the U. S. Army Camp Hospital in Aix-les-Bains, France, during the Spanish Flu epidemic of 1918-19. Most flu deaths were of healthy young adults, who died from bacterial pneumonia, a secondary infection caused by the influenza.
...health measures varied in effectiveness and enforcement...
The third wave had a profound impact on public health systems and societal norms. Hospitals, already stretched thin from the previous waves, struggled to cope with the influx of patients.
Medical staff, many of whom had been infected during earlier waves, were overworked and exhausted, leading to severe shortages in healthcare provision.
Public health measures varied in effectiveness and enforcement.
In some cities, repeated lockdowns and quarantine measures led to public fatigue and resistance, making it difficult for authorities to maintain compliance.
For example, in New York City, compliance with public health measures was inconsistent, leading to fluctuations in case numbers.
People believed back then was that the flu made the air toxic, especially indoors, which led to the creation of indoor breathing contraptions like this one.
...public health measures, including quarantine and isolation, were rigorously enforced...
a San Francisco police officer warning a man to wear a mask. During the height of the Spanish Flu pandemic, many of the larger U.S. cities required citizens to wear masks in public, and most public gatherings were banned.
Mark Landis
https://www.sbsun.com/2020/04/13/how-the-1918-spanish-flu-ravaged-southern-california/
In Europe, the third wave compounded the challenges faced by war-torn countries.
In the United Kingdom, the third wave hit just as the country was beginning to recover from the second wave, leading to further disruptions in daily life and economic activity.
Schools and workplaces faced closures, and public gatherings were again restricted in an effort to curb the spread.
Even Australia was not spared from the third wave. The flu spread rapidly through major cities such as Sydney and Melbourne, where public health measures, including quarantine and isolation, were rigorously enforced.
In comparison to other nations at the time, Australia's death rate of 2.7 per 1000 people was among the lowest, despite up to 40& of the population being infected.
However, the virus still managed to infiltrate rural and remote areas, reaching vulnerable populations, including Aboriginal communities.
Red Cross nurses in Washington demonstrate patient care during the outbreak by carrying an ill person on a stretcher into a car. During the third wave of the Spanish flu pandemic, patient care was severely strained, with hospitals overwhelmed, medical staff exhausted, and shortages of essential supplies. Efforts focused on basic nursing, hydration, and managing respiratory distress.
...certain Aboriginal communities saw a mortality rate of 50%...
The impact on Aboriginal Australians was particularly severe. Many Aboriginal communities lacked access to adequate healthcare and were already suffering from poor living conditions, malnutrition, and other diseases. Certain Aboriginal communities saw a mortality rate of 50%.
The Spanish flu exacerbated these issues, leading to high mortality rates. The lack of immunity and limited medical resources in these communities meant that the flu spread quickly and lethally, with entire communities being decimated.
The third wave of the Spanish flu left a lasting legacy on global health policies and pandemic preparedness.
It highlighted the need for sustained public health measures and the dangers of premature relaxation of these measures.
The recurrence of the virus demonstrated the importance of vigilance and adaptability in public health responses.
Moreover, the third wave contributed to a broader understanding of the influenza virus's behavior and its potential for causing widespread illness and death.
This knowledge paved the way for future research into vaccines and treatments, ultimately leading to the development of more effective influenza vaccines in the subsequent decades.
Walter Reed Hospital, Washington, D.C., during the great Influenza Pandemic of 1918 - 1919, also known as the "Spanish Flu". Patients are set up in rows of beds on an open gallery, seperated by hung sheets. A nurse wears a cloth mask over her nose and mouth.
Harris & Ewing photographers - Photo by Harris & Ewing via Library of Congress website
1920: Further outbreaks
Throughout the spring and summer, there were a spate of isolated or solitary instances of flu being reported across the United States.
Even though there had been an increase in isolated cases since September, Chicago began to see one of the first significant flu outbreaks in the middle of January.
Days after Chicago's rapid increase in cases, it was clear that the flu was spreading there even more quickly than it had in winter 1919, though there were fewer fatalities.
The number of new cases in the city surpassed the peak of the 1919 wave within a week. New York City started to experience a dramatic rise of cases around the same time, and other cities throughout the nation quickly followed.
Poster advising what precaution to take to prevent spreading catching and spreading Spanish Flu, 1920.
At a free community clinic, patients wait for a doctor’s attention. Palestine, 1920.
JDC during the Time of the Spanish Flu (1918–1920) | JDC Archives
...New York City alone reported 6,374 deaths...
In cities like Chicago, Memphis, and New York City, certain pandemic restrictions—including the closure of schools and theatres and staggered business hours to reduce congestion—were reinstated in the hope they would help restrict the spread of the flu.
The fourth outbreak in the United States peaked in early February before dissipating as quickly as it had risen.
Data at the time showed that the outbreak caused one-third as many deaths as the events of 1918–1919.
Between December 1919 and April 1920, New York City alone reported 6,374 deaths, about twice as many as the initial wave in spring 1918.
...by May 1920, the town had been overrun by an outbreak...
Other US cities were particularly heavily struck, with death rates exceeding those of the entire year 1918. These cities included Detroit, Milwaukee, Kansas City, Minneapolis, and St. Louis.
Early in 1920, when the pandemic reached its height in the Territory of Hawaii, 1,489 people there died from flu-related causes, compared to 615 in 1918 and 796 in 1919.
Similarly, Nenana, Alaska, missed the worst of the epidemic for the first two years, but by May 1920, the town had been overrun by an outbreak.
According to reports, the majority of the town's residents contracted the disease within the first two weeks of the month; 10% of the population is thought to have perished.
A Philadelphia streetcar is shown during the pandemic adorned with the 'Spit spreads death' sign, reminding people of the dangers of infection.
Shawshots/Alamy
American Red Cross volunteers at an emergency medical station at Washington.
Royston Leonard – Mediadrumworld.com
...the 1920 pandemic vanished in a matter of weeks...
"Coughs and Sneezes Spread Diseases - As Dangerous as Poison Gas Shells". U.S. Public Health ad on dangers of Spanish Flu epidemic during the First World War.
A fourth outbreak also occurred in a number of locations in the winter and spring of 1920, including Switzerland, Scandinavia, Mexico, and some South American islands.
In contrast to the peak of 92 deaths in December 1918, Poland saw a devastating outbreak over the winter months.
However, the 1920 pandemic vanished in a matter of weeks, whereas the 1918-1919 wave had evolved during the entire second half of 1918.
The origins of the deadly virus are unclear and it is unknown exactly how many people died but it killing anywhere between 20 and 70 million across the space of two years. Pictured is a typist wearing a mask while she works in New York City during the epidemic.
Royston Leonard – Mediadrumworld.com
...the pandemic virus had developed into a far less dangerous strain...
Western Europe, in contrast, experienced a "benign" outbreak, with the age distribution of fatalities beginning to resemble that of a seasonal flu.
Between January and April 1920, five European nations—Spain, Denmark, Finland, Germany, and Switzerland—recorded a late high.
Early 1920 saw a late wave in Peru, and late 1919 to early 1920 saw one in Japan, with the last cases occurring in March.
By 1920, the pandemic virus had developed into a far less dangerous strain that only caused seasonal flu going forward. Deaths had reached pre-pandemic levels by 1921.
A group of people standing outside are shown wearing masks during the pandemic. One woman wears a sign saying, 'wear a mask or go to jail.'
Niday Picture Library/Alamy
Treatment
The Spanish flu pandemic featured unusually high mortality rates among young adults, a deviation from the typical pattern of influenza epidemics, which generally affect the very young and the elderly more severely. Scientists have proposed several explanations for this anomaly.
One theory suggests that a six-year climate anomaly prior to the pandemic influenced disease vector migration, potentially increasing the spread of pathogens through water bodies.
...bacterial superinfection, which often led to death...
Another significant factor was the cytokine storm triggered by the virus, which overwhelmed the robust immune systems of young adults, leading to severe respiratory complications and high mortality rates.
Malnutrition, overcrowded medical facilities, and poor hygiene, exacerbated by the conditions of the First World War, also played critical roles.
These factors promoted bacterial superinfection, which often led to death following prolonged illness.
Hospitals and medical camps were ill-equipped to handle the influx of patients, further worsening outcomes.
This room at Wilson High School in Pasadena was converted into a flu isolation ward during the 1918 Spanish Flu pandemic. The sheer scale of the Spanish flu pandemic overwhelmed hospitals, forcing the conversion of schools, churches, and other public buildings into makeshift facilities to accommodate the influx of patients, straining medical resources and staff to their limits.
Mark Landis
How the 1918 Spanish flu ravaged Southern California – San Bernardino Sun (sbsun.com)
...in dangerously high doses...
During the pandemic, the absence of antiviral drugs and antibiotics posed severe challenges for medical practitioners. Doctors resorted to a diverse array of treatments with varying degrees of effectiveness.
Commonly used medications included aspirin, quinine, arsenics, digitalis, strychnine, Epsom salts, castor oil, and iodine.
Aspirin, for example, was widely recommended, sometimes in dangerously high doses, leading to aspirin toxicity in many patients.
Comparison of the different waves of Spanish Flu across the globe.
Lessons from the 1918-1919 Spanish Flu Pandemic in Africa – Africa Center for Strategic Studies
Traditional medical practices were also employed. Bloodletting, an ancient method, was used despite its questionable efficacy. Ayurvedic treatments, rooted in traditional Indian medicine, and Kampo, traditional Japanese medicine, were also tried.
These methods were often based on the principles of balancing bodily humors or energies and included herbal remedies, dietary changes, and physical treatments like massages and baths.
...exploiting the fear and uncertainty of the public...
The desperation of the time led to the proliferation of numerous failed or fake treatments.
Some of these were based on superstition or incorrect medical theories.
For instance, the use of camphor and mercury in various forms was common, despite their lack of effectiveness and potential harm.
Patent medicines, often containing alcohol, opium, or other narcotics, were marketed aggressively as cures, exploiting the fear and uncertainty of the public.
Doctors and nurses treat soldiers returning home from the front lines of World War One, where the virus began to spread. Some 60,000 soldiers were being admitted to British and French army hospitals in 1915 and 1916 with flu-like symptoms – and around half of them were dying.
...a fertile ground for these fraudulent treatments...
Quack remedies flourished as well. Snake oil salesmen peddled concoctions that promised miraculous recoveries but delivered little more than false hope.
The lack of regulation and the urgent demand for cures created a fertile ground for these fraudulent treatments.
Despite the prevalence of ineffective and dangerous treatments, the Spanish flu pandemic did spur some significant medical advancements.
The experience highlighted the need for better understanding and treatment of viral infections and secondary bacterial infections.
This period underscored the importance of scientific research and evidence-based medicine.
Advertisement, Scotland’s People,
National Newspaper Archive
Not another global pandemic! - Scottish Dental magazine : Scottish Dental magazine (sdmag.co.uk)
Children in a school in New York City in the late 1940s line up for their flu vaccination. The development of the Spanish flu vaccine was not achieved during the 1918 pandemic due to limited scientific knowledge and technology. Research intensified afterward, leading to significant advancements in virology and the eventual creation of effective influenza vaccines in the 1940s.
Library of Congress.
...accelerated the push for the development of vaccines...
One notable advancement was in the field of public health and epidemiology.
The pandemic led to the development of more sophisticated methods for tracking disease spread and understanding transmission dynamics.
This laid the groundwork for modern epidemiological practices and public health responses.
The crisis also accelerated the push for the development of vaccines.
While an effective influenza vaccine would not be developed until the 1940s, the Spanish flu pandemic demonstrated the critical need for vaccines and other preventative measures.
Research into the influenza virus intensified, eventually leading to the identification of the virus itself and the development of targeted vaccines.
...demonstrated the importance of vigilance and adaptability...
Spanish Influenza in army hospitals. Masks and cubicles used in United States of America General Hospital Number 4, Fort Porter, New York, 1918. Patients' beds are reversed, alternately so breath of one patient will not be directed toward the face of another.
National Archives and Records Administration/Wikimedia Commons
The Spanish Flu of 1918: Remembering a Forgotten Pandemic and its Victims | Beyond the Dash
The Spanish flu pandemic left a lasting legacy on global health policies and pandemic preparedness.
It underscored the need for sustained public health measures, such as quarantine and social distancing, and the dangers of prematurely relaxing these measures.
The recurrence of the virus in multiple waves demonstrated the importance of vigilance and adaptability in public health responses.
Moreover, the pandemic's impact on young adults provided crucial insights into the body's immune response to infections.
The concept of the cytokine storm, where an overactive immune response can be as deadly as the pathogen itself, became a significant area of study.
This understanding has influenced treatments for various diseases, including COVID-19.
A ravaged lung (at the National Museum of Health and Medicine) from a U.S. soldier killed by flu in 1918.
Cade Martin
How the Horrific 1918 Flu Spread Across America | Smithsonian (smithsonianmag.com)
Impact on the First World War
The Spanish flu pandemic of 1918-1920, concurrent with the closing stages of the FirstWorld War, significantly impacted both the warring sides and the post-war recovery efforts.
The overlap of a devastating pandemic with a global conflict exacerbated the challenges faced by military and civilian populations, influencing the outcomes of military engagements and the subsequent peace process.
The spread of the Spanish flu among soldiers had a direct impact on the capacity of military forces.
An increase in soldiers unable to fight due to flu infection reduced the number of active combatants, weakening military operations.
Reports from military camps in Europe and the United States documented high rates of infection, with some units experiencing up to a 40% reduction in fighting capability.
This loss of manpower was critical during the final offensives of the war, affecting the strategic planning and execution of military operations.
Report on staffing crisis at military depot in Philadelphia, October 8, 1918. Office of the Quartermaster General. The flu was highly contagious and spread rapidly, as documented in a military report notifying the Office Quartermaster General in Washington D.C., of a staffing crisis. The report notes 11 officers and 1,489 employees "absent today," with the situation not improving.
An American Red Cross nurse aids wounded soldiers at Montmirail, France, May 31, 1918. The Spanish flu significantly reduced manpower during the First World War, incapacitating and killing thousands of soldiers. High infection rates weakened military units, disrupted operations, and strained medical resources, impacting the overall war effort and strategic capabilities.
Troops already exhausted and weakened by the harsh conditions of trench warfare were particularly susceptible to the flu.
The close quarters, poor nutrition, and constant stress undermined their immune systems, making them more vulnerable to severe illness.
The crowded and unsanitary living conditions in the trenches facilitated the rapid spread of the virus, leading to high infection rates among soldiers.
Hospital beds crammed head to toe at the San Francisco Naval Training Station. They are occupied by soldiers. Crowded conditions in military establishments during the First World War significantly increased the spread of the Spanish flu. Close quarters, poor sanitation, and constant troop movements facilitated rapid virus transmission, leading to widespread infections and high mortality rates among soldiers.
This exacerbated the overall morbidity and mortality, contributing to the staggering death toll of the pandemic.
The influx of flu patients placed an enormous strain on medical units, which were already overwhelmed by battlefield injuries.
Military hospitals and medical staff were stretched to their limits, trying to manage both combat casualties and flu victims.
The lack of effective treatments for the flu compounded the problem, as medical personnel struggled to provide adequate care with limited resources.
This dual burden on the medical system highlighted the dire need for better healthcare infrastructure and emergency preparedness.
The unsanitary conditions in military camps and civilian areas further facilitated the spread of the flu. In the trenches, soldiers lived in close proximity to each other, often in damp and muddy environments with little access to clean water and proper sanitation.
These conditions were ideal for the transmission of the virus, leading to widespread outbreaks that decimated entire units. Similarly, civilian populations living in overcrowded and unsanitary urban areas experienced high infection rates, contributing to the overall death toll.
The movement of refugees during and after the war played a significant role in spreading the flu. Displaced by the conflict, refugees moved from area to area seeking shelter, often carrying the virus with them.
This constant movement facilitated the transmission of the flu across borders and into new populations, making containment efforts exceedingly difficult. The lack of coordinated international response to the refugee crisis further exacerbated the spread of the disease.
During the early stages of the pandemic, there was a notable absence of effective precautions or preventative measures to curb the spread of the flu.
The germ theory of disease was still relatively new, and many public health officials did not fully understand how to combat the virus. Quarantine measures, where implemented, were often too late or poorly enforced.
The use of masks and social distancing was not widespread, and public gatherings continued in many areas, facilitating the spread of the virus. This lack of effective public health strategies allowed the flu to spread unchecked through both military and civilian populations.
Effect on the economy
The Spanish Flu pandemic of 1918-1919 had profound and immediate effects on national and global economies.
As the deadly influenza outbreak claimed an estimated 50 million lives worldwide, it severely disrupted economic activities and exacerbated the social and economic turmoil already caused by the First World War.
In the immediate aftermath, significant labour shortages arose due to high mortality rates, which drastically impacted industrial and agricultural production.
The loss of a substantial portion of the working-age population strained economies, leading to decreased productivity and increased financial instability. Governments, already overburdened by war debts, struggled to manage the additional economic downturn, which contributed to widespread unemployment and poverty.
Life goes on: A baseball player wearing a mask during the Flu epidemic of 1918. The pandemic severely disrupted sports, causing cancellations of major events, including the 1919 Stanley Cup, and affecting athlete health and team operations.
George Rinhart/Corbis via Getty Images
Flu notice in the Oct. 9, 1918 edition of the Bloomington Daily Telephone. Restrictions on public gatherings during the Spanish flu severely impacted the economy by shutting down businesses, reducing consumer spending, and causing widespread unemployment, leading to significant financial losses and economic instability across affected regions.
Dan Combs
How Did Monroe County Deal With The Spanish Flu Pandemic Of 1918? | News - Indiana Public Media
Many companies in the leisure and service sectors reported revenue declines as the pandemic forced closures and reduced consumer spending.
Businesses such as theatres, restaurants, and hotels suffered significant financial losses as people avoided public spaces to curb the spread of the virus.
This downturn led to bankruptcies and the collapse of many small businesses, further aggravating the economic crisis.
Conversely, the healthcare sector experienced profit increases.
The pandemic underscored the critical importance of healthcare services, leading to substantial growth in the nursing profession.
Historian Nancy Bristow notes that the pandemic, along with the rise in female college enrolment, played a significant role in the success of women in nursing.
The majority-male medical professionals' failure to control and stop the disease highlighted the effective care provided by majority-female nursing staff, who took pride in their successful patient care efforts.
As the a 4th outbreak of the disease had struck London in 1920, masked cleaners sprayed public transportation with an anti-bacterial spray like this man disinfecting the top of a bus.
The Spanish Flu also exposed the inadequacies of public health systems and the lack of international cooperation in addressing global health crises.
The failure to effectively manage the pandemic fostered public distrust in governments and institutions, contributing to political instability.
In the long term, the compounded crises from the pandemic and post-war challenges set the stage for the Great Depression in the 1930s, further destabilizing economies and societies. The resultant economic hardships and political instability were crucial factors in the rise of fascist regimes in Europe.
The inability of weakened democracies to effectively address these issues ultimately led to the aggressive expansionism and conflicts that sparked the Second World War.
Thus, while not a direct cause, the Spanish Flu pandemic played a significant role in shaping the volatile global environment that contributed to the outbreak of the war.
Mass gatherings, schools, theaters, and nonessential businesses were closed off during the Spanish Flu pandemic in New York City.
A couple wearing facemasks at the height of the Spanish Flu pandemic.
Aftermath and Global Impact
Eventually, the Spanish Flu began to fade from the public consciousness, overshadowed by the First World War and its aftermath.
As terrible as the flu was, its horror was overshadowed by the four years of death and destruction which dominated the media and remained firmly in the public eye.
When people read the obituaries, they saw the influenza deaths next to the war or postwar dead. The virus may not have had a significant psychological effect or may have appeared to be a continuation of the war's horrors, especially in Europe where the war's toll was great.
The length of the pandemic and the conflict may have also had an impact. Normally, the sickness would only stay in one place for a month before moving on.
But even though it was initially anticipated that the conflict would end quickly, it had already been going on for four years when the epidemic began.
This has led some historians to refer to the Spanish flu as the “forgotten pandemic".
The pandemic had profound and far-reaching effects on the global stage, particularly in the 1920s and 1930s, indirectly contributing to the conditions that led to the outbreak of the Second World War.
This deadly influenza outbreak killed an estimated 50 million people worldwide, exacerbating the already severe social and economic disruptions caused by the First World War.
In the immediate aftermath of the pandemic, many countries faced significant labour shortages due to the high mortality rates, impacting industrial and agricultural production.
The loss of a substantial portion of the working-age population strained economies further, leading to decreased productivity and increased financial instability.
Governments, already burdened by war debts, struggled to manage the additional economic downturn, which contributed to widespread unemployment and poverty.
One of the most vulnerable groups were poorer children, as they couldn't even afford masks. Here, you can see a group of American kids wearing small bags with Camphor oil around their necks - "a good way" to protect yourself against the virus.
The Spanish Flu pandemic also highlighted the inadequacies of public health systems and the lack of international cooperation in addressing global health crises.
This failure to effectively manage the pandemic fostered public distrust in governments and institutions, contributing to political instability.
As societies grappled with these challenges, extremist political movements found fertile ground for growth.
In Germany, for instance, the economic and social turmoil created a breeding ground for radical ideologies, including the rise of the Nazi Party.
The Pandemic had a profound impact on world politics, significantly influencing both immediate and long-term geopolitical landscapes.
The pandemic struck during the final stages of the First World War, severely affecting soldiers and civilians alike, which complicated military operations and hastened the war's end.
US President Woodrow Wilson. Wilson contracted the Spanish flu during the Paris Peace Conference, impairing his cognitive abilities and decision-making. This illness affected his contributions to the Treaty of Versailles, ultimately influencing the conference's outcomes.
Leaders like U.S. President Woodrow Wilson and British Prime Minister David Lloyd George were personally affected by the flu, which impaired their capacities during crucial peace negotiations at the Paris Peace Conference in 1919.
...devastated urban populations...
Additionally, the pandemic exacerbated economic instability and social unrest, contributing to political upheavals.
For instance, in Russia, the flu, combined with famine, devastated urban populations, pushing Lenin to implement one of the first modern public healthcare systems to stabilize the country.
Similarly, the pandemic's aftermath influenced the 1920 U.S. presidential election, with Warren G. Harding's call for a "return to normalcy" resonating with a population exhausted by war and disease.
...left lasting scars on the collective psyche...
Moreover, the Spanish Flu's psychological impact cannot be underestimated. The immense loss of life and the pervasive fear of disease left lasting scars on the collective psyche, fostering a sense of disillusionment and despair.
This widespread trauma weakened social cohesion and contributed to the appeal of authoritarian leaders who promised order and stability.
A vaccine for the Spanish Flu became widely available only in the 1940s. Here, a patient receives the vaccine.
As the world moved into the 1930s, these compounded crises set the stage for the Great Depression, further destabilizing economies and societies.
The resultant economic hardships and political instability were crucial factors in the rise of fascist regimes in Europe.
The inability of weakened democracies to effectively address these issues ultimately led to the aggressive expansionism and conflicts that sparked the Second World War.
Thus, the Spanish Flu pandemic, while not a direct cause, played a significant role in shaping the volatile global environment that led to the war.
This comparison chart aptly demonstrates how lethal Spanish Flu could be compared to other pandemics.
The Spanish flu: The global impact of the largest influenza pandemic in history - Our World in Data
Further reading
The Spanish flu of 1918–1920, with a death toll between 50 and 100 million, was a monumental disaster, overshadowed by the First World War. In "Pale Rider," Laura Spinney traces the pandemic's global impact, highlighting how it reshaped politics, race relations, family structures, and thought across medicine, religion, and the arts. Spinney shows the flu's significance in testing human ingenuity and vulnerability, demonstrating its profound effect on modern history.
This publication details the devastating 1918-1920 influenza pandemic, examining its origins, rapid spread, and catastrophic impact on global populations. The book delves into the scientific, social, and political consequences of the outbreak, highlighting the challenges faced by healthcare systems and the lasting changes in public health policies. It provides a comprehensive overview of one of history's deadliest pandemics, emphasizing its significant legacy on modern medicine and society.
Parker explores the origins, spread, and devastating effects of the 1918 influenza pandemic. The book delves into the medical, social, and economic impacts of the outbreak, which killed millions worldwide. Parker examines the responses of governments and healthcare systems, highlighting lessons learned and the pandemic's lasting legacy on global health practices. This comprehensive account provides a detailed narrative of one of the deadliest health crises in human history.
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