Spanish Flu: the Mother of all Pandemics

The coronavirus (Covid-19) has generated a lot of panic recently.  It’s not the first recent pandemic but fears have run rampant both in the US and abroad.  The Spanish Flu (1918-1919) was the worst pandemic in American History and until recently has been largely forgotten and ignored.  I wrote this article on the Spanish Flu at its 100th anniversary.  It’s worth a few minutes to read about then and now and hopefully be comforted.  Covid-19 does not really compare to the Influenza outbreak of 1918.  The Spanish Flu killed over 670,000 Americans and was particularly dangerous because of the high mortality rate among the young and healthy.  Thus far, the mortality rate for Covid is almost exclusively among the elderly over 70 and those with compromised immune systems.  Younger people still get Covid-19 but most are asymptomatic or mildly affected.  Even vulnerable populations today will fare better than their counterparts in 1918. Doctors 100 years ago had no way to test and few treatments or tools like ventilators to moderate the effects of the virus.  What is interesting is that Americans back in 1918 used many of the same strategies we do today including social distancing, quarantine, and masks.  We should come through the current pandemic with far less death even though our population is more than three times greater.  

 

We recently received the quarterly journal from the Virginia Historical Society celebrating the centennial of World War I.  The journal re-published an Honor Roll of the 3,700 Virginian servicemen who died in the Great War (out of 50,000 Americans overall.)  Thumbing through the list, I noticed that as many or more soldiers and sailors died of “disease” as battlefield wounds.  The journal made no mention of an even greater catastrophe than World War I that began in 1918 as the war ended.  Recently, the US Center for Disease Control and Prevention referred to the 1918 outbreak of “Spanish Flu” as “the Mother of all Pandemics.”  This month marks the 102nd anniversary of the first reports of influenza in the US, where the pandemic likely began.   Though often overlooked, the disease took a terrible toll spreading to every part of the world killing more human beings in one year than the Black Plague took in a century.

The first cases of influenza drew little interest.  In early March, 1918, several soldiers at Camp Funston, Kansas reported sick.  Within days, ill soldiers filled the 1,100 beds of the camp’s hospital with thousands more laid up in their barracks.  America declared war in 1917, and 9 months later had amassed a large army crammed into training camps across the US.  Cases soon appeared in the surrounding civilian population and spread nationwide to other camps and towns.  US government officials covered up the problem and took no serious countermeasures.  The first wave of influenza was not especially deadly and the relatively low number of fatalities helped keep a lid on the story.

In neutral Spain, death rates were higher and reporting was not censored.  At the time, the flu seemed to appear first in Spain which is why it is commonly called the “Spanish Flu.”  In reality, it began elsewhere.  Some concluded it started in China or European trenches.  However, the CDC and other authoritative sources report that the influenza epidemic actually began in the US spreading to Europe as US troops deployed and later to Asia.  Though both Allied and Central Power combatants suffered similar effects, both sides covered up the news out of fear of giving the enemy a competitive advantage and to avoid a loss of morale in civilian and military populations.

The second wave arrived in September in a more virulent form.  The first known incident occurred at Fort Devens in Massachusetts.  On September 1, 1918, the 1,200 bed hospital had 84 patients.  One week later, the facility was overwhelmed with thousands of soldiers.  At its peak, the camp hospital admitted 1,543 soldiers in a single day.  This time the death rate was much higher and came quickly.  It’s worth noting here that the Spanish Flu was unique in that it struck the young and healthy with great frequency.  The mortality rate for Covid-19 for individuals under 70 is almost 0% and hospitalization rates are low as well.  

The flu took hold in the lungs, scarring tissue often creating secondary pneumonia infections that were increasingly fatal.  Dr. Roy Grist described the scene at Fort Devens:

“These men start with what appears to be an ordinary attack of . . . Influenza, and . . .  very rapidly develop the most vicious type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis [the term refers to a person turning blue from lack of oxygen] extending from their ears and spreading all over the face….It is only a matter of a few hours then until death comes…It is horrible….We have been averaging about 100 deaths per day…For several days there were no coffins and the bodies piled up…”1

The second wave spread quickly once again beginning in the crowded military camps dotting the US and spreading to surrounding civilian populations.  The death toll skyrocketed.  Government officials denied there was an emergency even as they began quietly cancelling public parades and imposing quarantines.  A compliant press did not cover the story at first.  When that became impossible, newspapers reported the outbreak was subsiding or being effectively contained.

Privately, medical officials were worried.  Dr. Victor Vaughan served as Dean of the University of Michigan’s Medical School and President of the American Medical Association before the war.  In 1918, he was acting as Chief of the US Army Communicable Disease Section.  Dr. Vaughan assessed the threat: “If the epidemic continues its mathematical rate of acceleration, civilization could easily disappear…from the face of the earth within a matter of a few more weeks.”  2

The rate of infection over the fall of 1918 justified Dr. Vaughan’s observation.  The flu hit Camp Travis in September and soon appeared in nearby San Antonio infecting as much as 53% of the populace by October.  San Antonio was notably worse but nearly all US population centers were severely affected.  In Philadelphia, death came so frequently bodies were placed on the porch of homes to be picked up by death carts that roamed the streets, a scene reminiscent of the worst days of the Black Plague.  With coffins in short supply, undertakers had to place them under armed guard to prevent theft.  Steam shovels dug mass graves to keep up.  In October, 1918, 195,000 Americans succumbed to influenza in what remains the deadliest month in American History.

Social cohesion broke down.  In scenes that have become familiar to Americans in 2020, people stopped coming to work.  Even in essential war effort industries, 50% or more of the workforce were absent.  Isaac Starr was a 3^rd year medical student and pressing into emergency duties at a hospital in Philadelphia.  He wrote that at the height of the crisis, he drove 12 miles to work without seeing another vehicle: “the life of the city had almost stopped. Public assembly was forbidden, so there were no plays, movies, concerts, or church services.” 3   In Washington, D.C., William Sardo recalled people feared basic interaction: “You had no school life, you had no church life, you had nothing…It completely destroyed all family and community life…The terrifying aspect was when each day dawned you didn’t know whether you would be there when the sun set that day.”4

Terror gripped smaller towns as well.  Dan Tonkel, a resident of Goldsboro, North Carolina, observed: “We were almost afraid to breathe…You were afraid even to go out…The fear was so great people were afraid to leave their homes…afraid to talk to one another.”5   In Perry County, Kentucky, the local Red Cross director begged for volunteers.  He had: “hundreds of cases…[of] people starving to death not from lack of food but because the well were panic stricken and would not go near the sick.”6

 

The national death rate was about 1% which may not seem large, but the high infection rate caused an estimated 670,000 deaths across the US, more than double the rate of servicemen lost in World War I and II combined.  The mortality rate for Covid-19 should be well below 1% for the entire population.  Tabulating a final number will be difficult because so many will contract the virus and never show symptoms, thus the final mortality rate will probably still be inflated.  

Europe and Asia also suffered a severe second wave of influenza in the latter half of 1918.  The death toll was about the same as in the US (1%) but there were likely more unreported cases with millions of men in lines of trenches stretching from Switzerland to the sea.  Modern estimates set the death toll at 2.64 million but may be low considering the number of combatants whose infection may not have been discovered.

The Third World bore the brunt of the misery.  Africa mostly avoided the first wave but the second wave hit hard and African mortality rates were more than double the rate of Europe.  The second wave also struck Asia where death came even more frequently.  India alone lost 17 million or more.  The second outbreak subsided at the end of 1918, but Europe, Africa and Asia endured a third deadly wave in 1919.  90% of the deaths worldwide came from Africa, South America and Asia.

Exact figures are debated but modern researchers believe the influenza pandemic infected half a billion people worldwide resulting in 50-100 million deaths, as much as 5% of the world population.*  Then as suddenly as it began, the pandemic subsided.  Quarantines may have stemmed the spread, but most other countermeasures had done nothing.  Recently, I have read that the flu tends to be seasonal and that changes in temperature can adverely affect a virus’ ability to spread.  March/April is a transitional part of the year like October/November so it is very possible the infection rate for Covid-19 will drop off significantly. 

Just as the origins of the outbreak remain mysterious, so too do the reasons it ended.  Dr. Vaughan later summed up the situation: “Never again allow me to say that medical science is on the verge of conquering disease.  . . . [Modern medicine] knew no more about the flu than 14th century Florentines had known about Black Death.” 7  Even today, researchers are unsure why the influenza took such a devastating toll.  

The American public reacted with panic in the moment but in the years after World War I, memories quickly faded.  The flu was seen as yet another part of the misery of war and Americans wanted to move on.  Many naively believed World War I was the “war to end all wars.”  The Roaring 20s brought a higher standard of living as innovations such as electricity, automobiles, radios and other consumer goods generated optimism.  Americans were looking forward, not back.  The Great Depression swept the globe in 1929 which forced a focus on the present and everyday survival.  The great tragedy of World War II overshadowed events in 1918-1919 as well.  In short, the Great Influenza Pandemic was absorbed into the statistics of worldwide strife and mostly forgotten.

Hopefully today’s modern medicine with better understanding of disease, immunology and other scientific endeavors will prevent a worldwide cataclysm such as the “mother of all pandemics.”  We may not be able to stop a pandemic, but given the lower death rates in 2020, it seems probable these threats can be contained.  The Black Plague killed a higher percentage of the human race, but we should remember those many millions who died 100 years ago.

 

*The inexact figures result from a lack of recordkeeping and systemic medical care in third world nations.

 

Sources:

 

1  John M. Barry, How the Horrific 1918 Flu Spread Across America.  Smithsonian Magazine, Nov., 2017.  https://www.smithsonianmag.com/history/journal-plague-year-180965222/#JbHm5V61i7Q2dWeT.99

2  John M. Berry, The Great Influenza: The Story of the Deadliest Pandemic in History, New York: Penguin Books (2004), 365.

3  Isaac Starr, MD, Influenza in 1918: Recollections of the Epidemic in Philadelphia, Annals of Internal Medicine, 1976.  http://annals.org/aim/fullarticle/726088/influenza-1918-recollections-epidemic-philadelphia

4  Berry, Supra, 346-347.

5  Ibid., 346.

6  Ibid., 347.

7  Ibid., 403

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Thomas Wirth, Influenza (“Spanish Flu” Pandemic, 1918-19), The Encyclopedia of Greater Philadelphia.  http://philadelphiaencyclopedia.org/archive/influenza-spanish-flu-pandemic-1918-19/

European figures: Sevérine Ansart, et al, Mortality burden of the 1918–1919 influenza pandemic in Europe, Influenza and other Respiratory Disorders, National Center for Biotechnology Information, Vol. 3, Issue, 3, (2009) p. 91-106.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634693/

Jeffery K. Taubenberger and David M. Morens, 1918 Influenza: the Mother of All Pandemics, Emerging Infectious Diseases, Vol. 12, No. 1 (Jan., 2006).  https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article

Marion Moser Jones, PhD, The American Red Cross and Local Response to the 1918 Influenza Pandemic: A Four-City Case Study, Public Health Rep. 2010; 125(Suppl 3): 92–104.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862338/

Howard Phillips, Influenza Pandemic (Africa), International Encyclopedia of the First World War, October 8, 2014.  https://encyclopedia.1914-1918-online.net/article/influenza_pandemic_africa

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