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Spanish Flu

By: History.com Editors

Updated: May 10, 2023 | Original: October 12, 2010

The Spanish flu pandemic of 1918-1919 was the deadliest pandemic in world history, infecting some 500 million people across the globe—roughly one-third of the population—and causing up to 50 million deaths, including some 675,000 deaths in the United States alone. The disease, caused by a new variant of the influenza virus, was spread in part by troop movements during World War I . Though the flu pandemic hit much of Europe during the war, news reports from Spain weren’t subject to wartime censorship, so the misnomer “Spanish flu” entered common usage. With no vaccines or effective treatments, the pandemic caused massive social disruption: Schools, theaters, churches and businesses were forced to close, citizens were ordered to wear masks and bodies piled up in makeshift morgues before the virus ended its deadly worldwide march in early 1920.

What Is the Flu?

Influenza , or flu, is a virus that attacks the respiratory system. The flu virus is highly contagious: When an infected person coughs, sneezes or talks, respiratory droplets are generated and transmitted into the air, and can then can be inhaled by anyone nearby.

Additionally, a person who touches something with the virus on it and then touches his or her mouth, eyes or nose can become infected.

Did you know? During the flu pandemic of 1918, the New York City health commissioner tried to slow the transmission of the flu by ordering businesses to open and close on staggered shifts to avoid overcrowding on the subways.

Flu outbreaks happen every year and vary in severity, depending in part on what type of virus is spreading. (Flu viruses can rapidly mutate.)

In the United States, “flu season” generally runs from late fall into spring. In a typical year, more than 200,000 Americans are hospitalized for flu-related complications, and over the past three decades, there have been some 3,000 to 49,000 flu-related U.S. deaths annually, according to the Centers for Disease Control and Prevention .

Young children, people over age 65, pregnant women and people with certain medical conditions, such as asthma, diabetes or heart disease, face a higher risk of flu-related complications, including pneumonia, ear and sinus infections and bronchitis.

A flu pandemic, such as the one in 1918, occurs when an especially virulent new influenza strain for which there’s little or no immunity appears and spreads quickly from person to person around the globe.

Spanish Flu Symptoms

The first wave of the 1918 pandemic occurred in the spring and was generally mild. The sick, who experienced such typical flu symptoms as chills, fever and fatigue, usually recovered after several days, and the number of reported deaths was low.

However, a second, highly contagious wave of influenza appeared with a vengeance in the fall of that same year. Victims died within hours or days of developing symptoms, their skin turning blue and their lungs filling with fluid that caused them to suffocate. In just one year, 1918, the average life expectancy in America plummeted by a dozen years.

What Caused the Spanish Flu?

It’s unknown exactly where the particular strain of influenza that caused the pandemic came from; however, the 1918 flu was first observed in Europe, America and areas of Asia before spreading to almost every other part of the planet within a matter of months.

Despite the fact that the 1918 flu wasn’t isolated to one place, it became known around the world as the Spanish flu, as Spain was hit hard by the disease and was not subject to the wartime news blackouts that affected other European countries. (Even Spain's king, Alfonso XIII, reportedly contracted the flu.)

One unusual aspect of the 1918 flu was that it struck down many previously healthy, young people—a group normally resistant to this type of infectious illness—including a number of World War I servicemen.

In fact, more U.S. soldiers died from the 1918 flu than were killed in battle during the war. Forty percent of the U.S. Navy was hit with the flu, while 36 percent of the Army became ill, and troops moving around the world in crowded ships and trains helped to spread the killer virus.

Although the death toll attributed to the Spanish flu is often estimated at 20 million to 50 million victims worldwide, other estimates run as high as 100 million victims —around 3 percent of the world’s population.  The exact numbers are impossible to know due to a lack of medical record-keeping in many places.

What is known, however, is that few locations were immune to the 1918 flu—in America, victims ranged from residents of major cities to those of remote Alaskan communities. Even President Woodrow Wilson reportedly contracted the flu in early 1919 while negotiating the Treaty of Versailles , which ended World War I.

Why Was The Spanish Flu Called The Spanish Flu?

The Spanish Flu did not originate in Spain , though news coverage of it did. During World War I, Spain was a neutral country with free media that covered the outbreak from the start, first reporting on it in Madrid in late May of 1918. Meanwhile, Allied countries and the Central Powers had wartime censors who covered up news of the flu to keep morale high. Because Spanish news sources were the only ones reporting on the flu, many believed it originated there (the Spanish, meanwhile, believed the virus came from France and called it the “French Flu.”)

Where Did The Spanish Flu Come From?

Scientists still do not know for sure where the Spanish Flu originated, though theories point to France, China, Britain, or the United States, where the first known case was reported at Camp Funston in Fort Riley, Kansas, on March 11, 1918.

Some believe infected soldiers spread the disease to other military camps across the country, then brought it overseas. In March 1918, 84,000 American soldiers headed across the Atlantic and were followed by 118,000 more the following month.

Fighting the Spanish Flu

When the 1918 flu hit, doctors and scientists were unsure what caused it or how to treat it. Unlike today, there were no effective vaccines or antivirals, drugs that treat the flu. (The first licensed flu vaccine appeared in America in the 1940s. By the following decade, vaccine manufacturers could routinely produce vaccines that would help control and prevent future pandemics.)

Complicating matters was the fact that World War I had left parts of America with a shortage of physicians and other health workers. And of the available medical personnel in the U.S., many came down with the flu themselves.

Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

Officials in some communities imposed quarantines, ordered citizens to wear masks and shut down public places, including schools, churches and theaters. People were advised to avoid shaking hands and to stay indoors, libraries put a halt on lending books and regulations were passed banning spitting.

According to The New York Times , during the pandemic, Boy Scouts in New York City approached people they’d seen spitting on the street and gave them cards that read: “You are in violation of the Sanitary Code.”

Aspirin Poisoning and the Flu

With no cure for the flu, many doctors prescribed medication that they felt would alleviate symptoms… including aspirin , which had been trademarked by Bayer in 1899—a patent that expired in 1917, meaning new companies were able to produce the drug during the Spanish Flu epidemic. 

Before the spike in deaths attributed to the Spanish Flu in 1918, the U.S. Surgeon General, Navy and the Journal of the American Medical Association  had all recommended the use of aspirin. Medical professionals advised patients to take up to 30 grams per day, a dose now known to be toxic. (For comparison’s sake, the medical consensus today is that doses above four grams are unsafe.) Symptoms of aspirin poisoning include hyperventilation and pulmonary edema, or the buildup of fluid in the lungs, and it’s now believed that many of the October deaths were actually caused or hastened by aspirin poisoning.

The Flu Takes Heavy Toll on Society

The flu took a heavy human toll, wiping out entire families and leaving countless widows and orphans in its wake. Funeral parlors were overwhelmed and bodies piled up. Many people had to dig graves for their own family members.

The flu was also detrimental to the economy. In the United States, businesses were forced to shut down because so many employees were sick. Basic services such as mail delivery and garbage collection were hindered due to flu-stricken workers.

In some places there weren’t enough farm workers to harvest crops. Even state and local health departments closed for business, hampering efforts to chronicle the spread of the 1918 flu and provide the public with answers about it.

How U.S. Cities Tried to Stop The 1918 Flu Pandemic

A devastating second wave of the Spanish Flu hit American shores in the summer of 1918, as returning soldiers infected with the disease spread it to the general population—especially in densely-crowded cities. Without a vaccine or approved treatment plan, it fell to local mayors and healthy officials to improvise plans to safeguard the safety of their citizens. With pressure to appear patriotic during wartime and with a censored media downplaying the disease’s spread, many made tragic decisions.

Philadelphia’s response was too little, too late. Dr. Wilmer Krusen, director of Public Health and Charities for the city, insisted mounting fatalities were not the “Spanish flu,” but rather just the normal flu. So on September 28, the city went forward with a Liberty Loan parade attended by tens of thousands of Philadelphians, spreading the disease like wildfire. In just 10 days, over 1,000 Philadelphians were dead, with another 200,000 sick. Only then did the city close saloons and theaters. By March 1919, over 15,000 citizens of Philadelphia had lost their lives.

St. Louis, Missouri, was different: Schools and movie theaters closed and public gatherings were banned. Consequently, the peak mortality rate in St. Louis was just one-eighth of Philadelphia’s death rate during the peak of the pandemic.

Citizens in San Francisco were fined $5—a significant sum at the time—if they were caught in public without masks and charged with disturbing the peace.

Spanish Flu Pandemic Ends

By the summer of 1919, the flu pandemic came to an end, as those that were infected either died or developed immunity.

Almost 90 years later, in 2008, researchers announced they’d discovered what made the 1918 flu so deadly: A group of three genes enabled the virus to weaken a victim’s bronchial tubes and lungs and clear the way for bacterial pneumonia.

Since 1918, there have been several other influenza pandemics, although none as deadly. A flu pandemic from 1957 to 1958 killed around 2 million people worldwide, including some 70,000 people in the United States, and a pandemic from 1968 to 1969 killed approximately 1 million people, including some 34,000 Americans.

More than 12,000 Americans perished during the H1N1 (or “swine flu”) pandemic that occurred from 2009 to 2010. The COVID-19 pandemic , which started in December 2019, spread around the world before an effective COVID-19 vaccine was made available in December 2020. By May of 2023, when the World Health Organization declared an end to the global coronavirus emergency, almost 7 million people had died of COVID-19.

Each of these modern day pandemics brings renewed interest in and attention to the Spanish Flu, or “forgotten pandemic,” so-named because its spread was overshadowed by the deadliness of World War I and covered up by news blackouts and poor record-keeping.

Salicylates and Pandemic Influenza Mortality, 1918–1919 Pharmacology, Pathology, and Historic Evidence. Clinical Infectious Diseases .

In 1918 Pandemic, Another Possible Killer: Aspirin. The New York Times.

How the Horrific 1918 Flu Spread Across America. Smithsonian Magazine.

What the Spanish Flu Debacle Can Teach Us About Coronavirus. Politico .

WHO declares end to Covid global health emergency. NBC News .

COVID-19 Dashboard. WHO .

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The Spanish flu: The global impact of the largest influenza pandemic in history

Parts of the article — mostly the mortality estimates of the various influenza pandemics — were revised in May 2023.

In the last 150 years the world has seen an unprecedented improvement in health. The visualization shows that in many countries life expectancy, which measures the average age of death, doubled from around 40 years or less to more than 80 years. This was not just an achievement across the countries shown here; life expectancy has doubled in all regions of the world.

What also stands out is how abrupt and damning negative health events can be. Most striking is the large, sudden decline of life expectancy in 1918, caused by an unusually deadly influenza pandemic that became known as the ‘Spanish flu’.

To make sense of the fact life expectancy declined so abruptly, one has to keep in mind what it measures. Period life expectancy , which is the precise name for this measure, captures the mortality in one particular year . It summarizes the mortality in a particular year by calculating the average age of death of a hypothetical cohort of people for which that year’s mortality pattern would remain constant throughout their entire lifetimes.

This influenza outbreak wasn’t restricted to Spain and it didn’t even originate there. Recent genetic research suggests that the strain emerged a few years earlier, around 1915, but did not take off until later on. The earliest recorded outbreak was in Kansas in the United States in 1918. 1

But it was named as such because Spain was neutral in the First World War (1914-18), which meant it was free to report on the severity of the pandemic, while countries that were fighting tried to suppress reports on how the influenza impacted their population to maintain morale and not appear weakened in the eyes of the enemies. Since it is very valuable to speak openly about the threat of an infectious disease I think Spain should be proud that it was not like other countries at that time.

The virus spread rapidly and eventually reached all parts of the world: the epidemic became a pandemic. 2 Even in a much less-connected world the virus eventually reached extremely remote places such as the Alaskan wilderness and Samoa in the middle of the Pacific islands. In these remote places the mortality rate was often particularly high. 3

How many people died in the Spanish flu pandemic?

The global death count of the flu today:.

To have a context for the severity of influenza pandemics it might be helpful to know the death count of a typical flu season. Current estimates for the annual number of deaths from influenza are around 400,000 deaths per year. Paget et al (2019) suggest an average of 389,000 with an uncertainty range 294,000 from 518,000. 4 This means that in recent years the flu was responsible for the death of 0.005% of the world population. 5 Even in comparison to the low estimate for the death count of the Spanish flu (17.4 million) this pandemic, more than a century ago, caused a death rate that was 182-times higher than today’s baseline.

Global deaths of the Spanish flu

Several research teams have worked on the difficult problem of reconstructing the global health impact of the Spanish flu.

The visualization here shows the available estimates from the different research publications discussed in the following. The range of published estimates for the Spanish flu is particularly wide.

The widely cited study by Johnson and Mueller (2002) arrives at a very high estimate of at least 50 million global deaths. But the authors suggest that this could be an underestimation and that the true death toll was as high as 100 million. 6

Patterson and Pyle (1991) estimated that between 24.7 and 39.3 million died from the pandemic. 7

The more recent study by Spreeuwenberg et al. (2018) concluded that earlier estimates have been too high. Their own estimate is 17.4 million deaths. 8

The global death rate of the Spanish flu

How do these estimates compare with the size of the world population at the time? How large was the share who died in the pandemic?

Estimates suggest that the world population in 1918 was 1.8 billion.

Based on this, the low estimate of 17.4 million deaths by Spreeuwenberg et al. (2018) implies that the Spanish flu killed almost 1% of the world population. 9

The estimate of 50 million deaths published by Johnson and Mueller implies that the Spanish flu killed 2.7% of the world population. And if it was in fact higher – 100 million as these authors suggest – then the global death rate would have been 5.4%. 10

The world population was growing by around 13 million every year in this period which suggests that the period of the Spanish flu was likely the last time in history when the world population was declining. 11

Other large influenza pandemics

The Spanish flu pandemic was the largest, but not the only large recent influenza pandemic.

Two decades before the Spanish flu the Russian flu pandemic (1889-1894) is believed to have killed 1 million people. 12

Estimates for the death toll of the “Asian Flu” (1957-1958) range from 1.7 to 2.7 million according to Spreeuwenberg et al. (2018). 13

The same authors estimate that the “Hong Kong Flu” (1968-1969) killed between 2 and 3.8 million people. 13

The “Russian Flu” pandemic of 1889-1890 is believed to be caused by an H3 pandemic virus. 14 According to Spreeuwenberg et al. (2018) around 3.7 to 5.1 million people died worldwide. 13

The “Swine flu” pandemic of 2009-2010 was caused by a new H1N1 pandemic virus. Several research groups have made estimates of the global death toll, which ranges from 130,000 to 1.87 million people worldwide. 15

What becomes clear from this overview are two things: influenza pandemics are not rare, but the Spanish flu of 1918 was by far the most devastating influenza pandemic in recorded history.

The impact of the Spanish flu on different age groups

This last visualization here shows the life expectancy in England and Wales by age.

The red line shows the life expectancy for a newborn, with the rainbow-colored lines above showing how long a person could expect to live once they had reached that given, older, age. The light green line, for example, represents the life expectancy for children who have reached age 10.

It shows that life expectancy increased at all ages, which means that the often-heard assertion that life expectancy ‘only’ increased because child mortality declined is not true .

With respect to the impact of the Spanish flu it is striking that the visualization shows that the pandemic had little impact on older people. While the life expectancy at birth and at young ages declined by more than ten years, the life expectancy of 60- and 70-year olds saw no change. This is at odds with what one would reasonably expect: older populations tend to be most vulnerable to influenza outbreaks and respiratory infections. If we look at mortality for both lower respiratory infections (pneumonia) and upper respiratory infections today, death rates are highest for those who are 70 years and older.

This data tells us that young people accounted for a large share of the deaths, this made this pandemic especially devastating.

Why were older people so resilient to the 1918 pandemic? The research literature suggests that this was the case because older people had lived through an earlier flu outbreak – the already discussed ‘Russian flu pandemic’ of 1889–90 – which gave those who lived through it some immunity for the later outbreak of the Spanish flu. 16

The earlier 1889-90 pandemic might have given the older population some immunity, but was a destructive event in itself. According to Smith 132,000 people died in England, Wales, and Ireland alone. 17

How the Spanish flu differs from the Coronavirus outbreak in 2020

Writing in early March 2020 it is an obvious question to ask how the ongoing outbreak of Covid-19 compares. There are a number of important differences that should be considered.

They are not the same disease and the virus causing these diseases are very different. The virus that causes Covid-19 is a coronavirus, not an influenza virus that caused the Spanish flu and the other influenza pandemics listed above.

The age-specific mortality seems to be very different. As we’ve seen above, the Spanish flu in 1918 was especially dangerous to infants and younger people. The new coronavirus that causes Covid-19 appears to be most lethal to the elderly, based on early evidence in China. 18

We’ve also seen above that during the Spanish flu many countries tried to suppress any information about the influenza outbreak. Today the sharing of data, research, and news is certainly not perfect, but very different and much more open than in the past.

But it is true that the world today is much better connected. In 1918 it was railroads and steamships that connected the world. Today planes can carry people and viruses to many corners of the world in a very short time.

Differences in health systems and infrastructure also matter. The Spanish flu hit the world in the days before antibiotics were invented; and many deaths, perhaps most, were not caused by the influenza virus itself, but by secondary bacterial infections. Morens et al (2008) found that during the Spanish flu “the majority of deaths … likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria.” 19

And not just health systems were different, but also the health and living conditions of the global population. The 1918 flu hit a world population of which a very large share was extremely poor – large shares of the population were undernourished, in most parts of the world the populations lived in very poor health , and overcrowding, poor sanitation and low hygiene standards were common. Additionally the populations in many parts of the world were weakened by a global war. Public resources were small and many countries had just spent large shares of their resources on the war.

While most of the world is much richer and healthier now , the concern today too is that it is the poorest people that are going to be hit hardest by the Covid-19 outbreak. 20

These differences suggest that one should be cautious in drawing lessons from the outbreak a century ago.

But the Spanish flu reminds us just how large the impact of a pandemic can be, even in countries that had already been successful in improving population health. A new pathogen can cause terrible devastation and lead to the death of millions. For this reason the Spanish flu has been cited as a warning and as a motivation to prepare well for large pandemic outbreaks, which have been considered likely by many researchers. 21

Worobey, M., Han, G.-Z., & Rambaut, A. (2014). Genesis and pathogenesis of the 1918 pandemic H1N1 influenza A virus. Proceedings of the National Academy of Sciences, 111(22), 8107–8112. https://doi.org/10.1073/pnas.1324197111

Barry, J. M. (2004). The site of origin of the 1918 influenza pandemic and its public health implications. Journal of Translational Medicine, 2(1), 3. https://doi.org/10.1186/1479-5876-2-3

For the definitions of epidemic and pandemic see the CDC here .

Burnet F. M., Clark E. (1942) – Influenza: A Survey of the Last 50 Years in the Light of Modern Work on the Virus of Epidemic Influenza. London: Macmillan. Partly online on Google books.

The mortality rate in some populations like Alaska and Samoa were said to be 90% and 25% respectively. See the following two publications:

McLane, J. R. (2013). Paradise locked: The 1918 influenza pandemic in American Samoa. Sites: a journal of social anthropology and cultural studies , 10(2), 30-51.  

Mamelund, S. E. (2017). Profiling a Pandemic. Who were the victims of the Spanish flu?{ref} While peak mortality was reached in 1918 the pandemic did not wane until two years later in late 1920.

Paget et al (2019) suggest an “average of 389 000 (uncertainty range 294 000-518 000) respiratory deaths were associated with influenza globally each year”.

John Paget, Peter Spreeuwenberg, Vivek Charu Robert J Taylor, A Danielle Iuliano, Joseph Bresee, Lone Simonsen, Cecile Viboud,3 and for the Global Seasonal Influenza-associated Mortality Collaborator Network and GLaMOR Collaborating Teams (2019) – Global mortality associated with seasonal influenza epidemics: New burden estimates and predictors from the GLaMOR Project. In J Glob Health. 2019 Dec; 9(2): 020421. Published online 2019 Oct 22. doi: 10.7189/jogh.09.020421 PMCID: PMC6815659 PMID: 31673337 Online here .

This is (389,000/7,500,000,000)*100=0.0052%

From the paper: Further research has seen the consistent upward revision of the estimated global mortality of the pandemic, which a 1920s calculation put in the vicinity of 21.5 million. A 1991 paper revised the mortality as being in the range 24.7-39.3 million. This paper suggests that it was of the order of 50 million. However, it must be acknowledged that even this vast figure may be substantially lower than the real toll, perhaps as much as 100 percent understated.

Johnson, N.P. and Mueller, J. (2002) – Updating the accounts: global mortality of the 1918-1920 “Spanish" influenza pandemic. In Bulletin of the History of Medicine, 76(1), pp.105-115. Online here .

The paper includes detailed breakdowns of mortality estimates by world region and country.

Patterson and Pyle (1991) wrote 'we believe that approximately 30 million is the best estimate for the terrible demographic toll of the influenza pandemic of 1918' and published a range from 24.7-39.3 million deaths.

Patterson, K.D. and Pyle, G.F. (1991) – The geography and mortality of the 1918 influenza pandemic. Bulletin of the History of Medicine, 65(1), p.4. Online here .

P. Spreeuwenberg; et al. (1 December 2018). "Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic". American Journal of Epidemiology. 187 (12): 2561–2567. doi:10.1093/aje/kwy191. PMID 30202996. Online here .

The calculation is (17,400,000/1,832,196,157)*100=0.95

50,000,000 deaths / 1,832,196,157 people = 0.02729 And with a death count twice is high: 0.05458.

In available historical reconstructions (like this one ) this decline is not shown. The reason for this is that precise annual counts of the world population are not available for the past.

Instead historians try to reconstruct the population figures for 5-year or 10-year intervals and the annual estimates are interpolations between these estimates.

In other words, if we had precise annual counts they would likely show a decline of the world population in 1918.

Nickol, M.E., Kindrachuk, J. (2019) – A year of terror and a century of reflection: perspectives on the great influenza pandemic of 1918–1919. BMC Infect Dis 19, 117 (2019). https://doi.org/10.1186/s12879-019-3750-8

According to Smith (1995) 132,000 died in England, Wales, and Ireland alone.

Smith F. B. (1995) – The Russian influenza in the United Kingdom, 1889-1894. Soc. Hist. Med. 8 55–73. Online here .

Spreeuwenberg, P., Kroneman, M., & Paget, J. (2018). Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic. American Journal of Epidemiology, 187(12), 2561–2567. https://doi.org/10.1093/aje/kwy191

Dawood, F. S., Iuliano, A. D., Reed, C., Meltzer, M. I., Shay, D. K., Cheng, P.-Y., Bandaranayake, D., Breiman, R. F., Brooks, W. A., Buchy, P., Feikin, D. R., Fowler, K. B., Gordon, A., Hien, N. T., Horby, P., Huang, Q. S., Katz, M. A., Krishnan, A., Lal, R., … Widdowson, M.-A. (2012). Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: A modelling study. The Lancet Infectious Diseases, 12(9), 687–695. https://doi.org/10.1016/S1473-3099(12)70121-4

Simonsen, L., Spreeuwenberg, P., Lustig, R., Taylor, R. J., Fleming, D. M., Kroneman, M., Van Kerkhove, M. D., Mounts, A. W., Paget, W. J., & the GLaMOR Collaborating Teams. (2013). Global Mortality Estimates for the 2009 Influenza Pandemic from the GLaMOR Project: A Modeling Study. PLoS Medicine, 10(11), e1001558. https://doi.org/10.1371/journal.pmed.1001558

Gagnon et al. (2013) – Age-Specific Mortality During the 1918 Influenza Pandemic: Unravelling the Mystery of High Young Adult Mortality.PLoS One. 2013; 8(8): e69586. Published online 2013 Aug 5. doi: 10.1371/journal.pone.0069586. Online here .

The Russian flu pandemic was a devastating event in itself. Smith (1995) estimates that the Russian flu killed 132,000 in England, Wales, and Ireland.

Zhonghua Liu Xing Bing Xue Za Zhi (2020) – The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Feb 17;41(2):145-151. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003. Online here .

Morens D. M., Taubenberger J. K., Fauci A. S. (2008) – Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J. Infect. Dis. 198 962–970. 10.1086/591708. Online here .

Gilbert, Marius, Giulia Pullano, Francesco Pinotti, Eugenio Valdano, Chiara Poletto, Pierre-Yves Boëlle, Eric D’Ortenzio, et al. (2020) – “Preparedness and Vulnerability of African Countries against Importations of COVID-19: A Modelling Study.” The Lancet (February 20, 2020). https://doi.org/10.1016/S0140-6736(20)30411-6 .

Alyssa S. Parpia, Martial L. Ndeffo-Mbah, Natasha S. Wenzel, and Alison P. Galvani (2016) – Effects of Response to 2014–2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa. In Emerg Infect Dis. 2016 Mar; 22(3): 433–441. doi: 10.3201/eid2203.150977 PMCID: PMC4766886 PMID: 26886846 Online here .

See for example: Pandemic influenza preparedness and response – WHO guidance document. Published in 2009 by the WHO. Online here .Roman Duda (2016) – Problem profile: Biorisk reduction. Published by 80,000 hours. Online here .

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The Single Most Important Lesson From the 1918 Influenza

Tell the truth. At its core, society is based on trust.

By John M. Barry

Mr. Barry is the author of “The Great Influenza: The Story of the Deadliest Pandemic in History.”

In 1918, a new respiratory virus invaded the human population and killed between 50 million and 100 million people — adjusted for population, that would equal 220 million to 430 million people today. Late last year another new respiratory virus invaded the human population, and the reality of a pandemic is now upon us. Although clearly a serious threat to human health, it does not appear to be as deadly as the 1918 influenza pandemic. But it is far more lethal than 2009’s H1N1 (swine flu) pandemic, and the coronavirus does not resemble SARS, MERS or Ebola, all of which can be easily contained.

About 15 years ago, after yet another global contagion — the so-called bird flu — emerged in Asia, killing about 60 percent of the people it infected and threatening a catastrophic influenza pandemic, governments worldwide began to prepare for the worst. This effort included analyzing what happened in 1918 to identify public-health strategies to mitigate the impact of an outbreak. Since I had a historian’s knowledge of 1918 events, I was asked to serve on the initial working groups that recommended what became known as non-pharmaceutical interventions, that is, things to do when you don’t have drugs.

They involve only advice constantly reiterated today: social distancing, washing hands, coughing into elbows, staying home when sick. None alone provides great protection, but the hope was that if most people followed most of the advice most of the time, the interventions could significantly reduce the spread of the disease, or “flatten the curve,” a phrase now all too familiar. This may sound simple, but it is not. As with a diet, people know what to eat but often stray; here straying can kill.

As we begin employing these interventions now, we need to recognize what they can and cannot accomplish. Containment — the attempt to limit spread of a virus and even eliminate it — has failed. China has achieved far more than the most optimistic models predicted, but its initial slowness in responding allowed the virus to spread globally. Once that happened, the virus could not be stopped. Right now it is circulating invisibly in developed countries as well as in developing ones with little public-health infrastructure. That means it is here to stay and will constantly threaten to reinfect even countries that initially control it.

The United States is now in a phase of intervention labeled “suppression” by the infectious-disease expert Michael Osterholm: identifying infected people, isolating them, tracing contacts and asking contacts to self-quarantine. Because its incubation period is longer than influenza’s, Covid-19, caused by the coronavirus, allows that time. Whether we use that time well will determine whether a month from now the United States looks like Italy, where the virus seems out of control, or South Korea, which seems to have gained control by testing more than 270,000 of its 51 million people.

Right now virtually every state in America is in suppression mode, but suppression has no chance of succeeding unless cases are identified. With the United States having tested only about 40,000 of its nearly 330 million people — the worst record in the developed world — we are struggling to catch up, which will take weeks, all while the virus spreads, possibly so widely that it becomes entrenched and impossible to suppress. Nonetheless, suppression is worth trying because even partial success will slow the virus, giving us precious time to develop therapeutic drugs and vaccines.

Assuming suppression fails, we must initiate aggressive mitigation, where communities try to lessen the impact of the disease. The crucial statistic from China is that the case fatality rate inside Wuhan is 5.8 percent but only 0.7 percent in other areas in China, an eightfold difference — explained by an overwhelmed health care system. That illustrates why flattening the curve matters; lessening stress on the health care system, especially the availability of intensive care beds, saves lives.

Saying that is easier than doing it. The difficulties lie in timing and compliance. Analysis of when cities in 1918 closed schools, saloons and theaters; banned public events; urged social distancing and the like demonstrated that intervening early, before a virus spreads throughout the community, did flatten the curve. That’s why cities like New York and Los Angeles have closed schools and the Centers for Disease Control and Prevention has recommended that all events of more than 50 people be canceled for the next eight weeks.

But this raises another issue: compliance. The need for early intervention was well known in 1918. The Army surgeon general demanded “influenza be kept out” of the basic-training camps, where new soldiers were being prepared to fight in World War I. “Epidemics of the disease can often be prevented,” he said, “but once established they cannot well be stopped.” He barred civilians from the camps and ordered that soldiers entering them be quarantined, soldiers showing symptoms be isolated and whole units quarantined if several soldiers were ill. Of 120 camps, 99 imposed those measures.

But an Army study found no difference in morbidity and mortality between camps that did and did not follow orders, because over time most became sloppy. Further investigation found that only a tiny number of camps rigidly enforced measures.

For interventions to work, people have to comply and they have to sustain that compliance; most of that depends on voluntary efforts and individual behavior. Army camps in wartime failed to sustain compliance, so it will be an enormous challenge for civilian communities in peacetime to do so. At the height of the H1N1 outbreak, Mexico City urged mask usage on public transit and distributed free masks. Usage peaked at 65 percent; 10 days later it was at 10 percent.

Today we are still trying to stop the disease from becoming deeply entrenched. If that fails, we will need tougher measures. Scott Gottlieb, a former commissioner of the Food and Drug Administration, has talked of states’ shutting down their economies . “That’s what’s going to need to happen,” he said. “Close businesses, close large gatherings, close theaters, cancel events.” All of that happened in 1918 in most cities. On Monday, after initially calling for limiting gatherings to 250 people — a recommendation based on a desire not to disrupt rather than on modeling — the federal government finally recommended that no more than 10 people gather.

But many cities and states have yet to take stringent action. They should, and now.

In 1918 many cities imposed restrictions, lifted them too soon, then reimposed them. Covid-19’s average incubation period is more than double influenza’s, so compliance may have to be sustained for months, and openings and closings may also have to be repeated. Again, if the public is going to comply over time, they will have to be led, inspired or compelled.

That brings us back to the most important lesson of 1918, one that all the working groups on pandemic planning agreed upon: Tell the truth. That instruction is built into the federal pandemic preparedness plans and the plan for every state and territory.

In 1918, pressured to maintain wartime morale, neither national nor local government officials told the truth. The disease was called “Spanish flu,” and one national public-health leader said, “This is ordinary influenza by another name.” Most local health commissioners followed that lead. Newspapers echoed them. After Philadelphia began digging mass graves; closed schools, saloons and theaters; and banned public gatherings, one newspaper even wrote: “This is not a public health measure. There is no cause for alarm.”

Trust in authority disintegrated, and at its core, society is based on trust. Not knowing whom or what to believe, people also lost trust in one another. They became alienated, isolated. Intimacy was destroyed. “You had no school life, you had no church life, you had nothing,” a survivor recalled. “People were afraid to kiss one another, people were afraid to eat with one another.” Some people actually starved to death because no one would deliver food to them.

Society began fraying — so much that the scientist who was in charge of the armed forces’ division of communicable disease worried that if the pandemic continued its accelerating for a few more weeks, “civilization could easily disappear from the face of the earth.”

The few places where leadership told the truth had a different experience. In San Francisco, the mayor and business, labor and medical leaders jointly signed a full-page ad that read in huge all-caps type, “Wear a Mask and Save Your Life.” They didn’t know that masks offered little protection, but they did know they trusted the public. The community feared but came together. When schools closed, teachers volunteered as ambulance drivers, telephone operators, food deliverers.

Compliance today has been made vastly more difficult by the White House, echoed by right-wing media, minimizing the seriousness of this threat. That seemed to change on Monday. But will President Trump stick to his blunt message of Monday? Will his supporters and Rush Limbaugh’s listeners self-quarantine if called upon? Or will they reject it as media hype and go out and infect the community?

This is not a hoax.

John M. Barry is the author of “The Great Influenza: The Story of the Deadliest Pandemic in History” and a professor at the Tulane University School of Public Health and Tropical Medicine.

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The Spanish Flu of 1919

Written by: David Pietrusza, Independent Historian

By the end of this section, you will:.

• Explain the causes and effects of international and internal migration patterns over time

Suggested Sequencing

Use this Narrative at the beginning of Chapter 11 to explore the Spanish flu’s effect on the United States.

Mercifully, many of the diseases that once plagued humanity, such as polio, tuberculosis, and smallpox, have been brought under better control or even eradicated through innovative science. One disease – influenza or “the flu” – still flares periodically, but in 1918 it really was a plague, a raging pandemic called the Spanish flu that killed tens of millions worldwide in just a few months.

The world had plenty of trouble in 1918. World War I had raged since August 1914. Between nine million and 11 million soldiers died in the conflict, millions more were taken captive, and five million to six million civilians perished. Yet those numbers paled in comparison to the toll of the influenza pandemic. Between 50 and 100 million people died worldwide about 5 percent of the world’s population and the equivalent of more than 400 million based on today’s higher population levels. It was the worst pandemic since the Middle Age’s bubonic plague (“the Black Death”) killed 30 to 60 percent of Europe’s population in the 1300s.

The Spanish flu hit some areas such as the Pacific Islands, Iran, and India far harder than others. More than a quarter of the U.S. population became sick, and at least half a million Americans died in a population of fewer than 100 million. Men, women, and children wore surgical masks on the streets to avoid infection, and movie theaters and vaudeville houses closed. In Canada, the Stanley Cup hockey championship playoff was cancelled. Fear stalked every school, factory, and home.

Police officers in Seattle wore face masks provided by the Red Cross to help protect against the flu epidemic of 1918.

In New York, the cities of Rochester and Buffalo closed schools, theaters, pool halls, and saloons. The city of Buffalo went into the coffin business. On October, 10, 1918, Philadelphia was particularly hard hit 528 persons died in a single day. A doctor travelling 12 miles to his home each day reported seeing no people or cars on the road. As author A. A. Hoehling wrote of conditions in that city: “The dead lay sometimes for more than a day besides the gutters, and yet longer in half-abandoned, chill rooming houses. A mixed fear and revulsion had frustrated calls for stretcher-bearers and gravediggers.” An anonymous army doctor at Fort Devens near Boston observed that “it takes special trains to carry away the dead. For several days there were not enough coffins and the bodies piled up something fierce.” Dr. Victor C. Vaughan, former president of the American Medical Association and head of the Army’s Division of Communicable Disease, warned, “If the epidemic continues its mathematical rate of acceleration, civilization could easily have disappeared from the face of the earth within a matter of a few more weeks.”

The strain of flu that raged in 1918 is still known as the Spanish flu for a couple of reasons. First, it infected (but did not kill) the Spanish king, Alfonso XIII – a very high-profile victim. Second, Spain was one of the very few neutral nations in World War I. Wartime censorship was not in force, and developments there, including the spread of flu, could be more freely revealed than where the war raged.

Ordinary flu is painful and weakens people, but it is not usually deadly. The Spanish flu was amazingly harsh. High fevers caused hallucinations. People coughed violently and suffered excruciating pain. They turned black. They bled – not just from the mouth and nose but also from the ears and even, rarely, the eyes. Lungs became so weakened that they crackled when flu victims turned over in their beds. A person could be perfectly healthy in the morning and dead that night.

The worst flu mortality rates usually occur among the very young and the very old, whereas healthy young adults are best able to produce natural antibodies to fight the disease and survive fairly easily. That was not the case in 1918. Very young children did suffer a great deal. In the two years that the Spanish flu raged, the excess deaths for children one to four years of age equaled the normal number of such dead over 20 years. But those 65 years and older suffered an increase of less than 1 percent in excess mortality. Shockingly, more than half the dead were in what was normally the safest group: healthy young adults aged 18 to 45 years. One of the possible reasons is that these flu victims produced far too many antibodies, which overwhelmed not only the flu virus but their own bodies, causing death. If this is true, nature’s “cure” was truly worse than the disease.

Dorothy Deming, a nurse at New York City’s Columbia Presbyterian Hospital, observed that “until the epidemic, death had seemed kindly, coming to the very old, the incurably suffering, or striking suddenly without the knowledge of its victims. Now, we saw death clutch cruelly and ruthlessly at vigorous, well-muscled young women in the prime of Life. Flu dull[s] their resistance, choke[s] their lungs, swamp[s] their hearts. . . . There was nothing but sadness and horror to this senseless waste of human life”.

Nurses at the Red Cross Emergency Ambulance Station in Washington, DC, demonstrated how to help victims of the Spanish flu. Note the face masks they wear.

The Spanish flu pandemic was not entirely understood at the time. Its origin was unclear, as were the reasons it was so hard to treat and so deadly. Some believed the flu began at the U.S. Army’s huge base at Fort Riley, Kansas. Some said it originated abroad. But wherever it came from, it spread like wildfire. The war only worsened matters, given that soldiers from America, Asia, and Europe, all with different immune systems, had fought side by side in Europe. They lived in close quarters in tents, in barracks, on ships, and in the trenches of France’s western front. They were weakened from the stress of living under fire, and some had lung damage from the poison gas enemy forces lobbed at each other. And, of course, the same ships and trains that carried men and women across the country and around the world in record numbers also transported the microbes that transmitted this deadly strain of disease. In France, the U.S. 88th division counted 444 dead from the flu, but just 90 were killed, wounded, or captured in combat.

“The conditions cannot be visualized by anyone who has not actually seen them,” wrote Colonel E. W. Gibson of Vermont’s 57th Pioneer Division, who witnessed the worsening situation on the troopship Leviathan . “Pools of blood from severe nasal hemorrhages of many patients were scattered throughout the compartments, and the attendants were powerless to escape tracking through the mess, because of the narrow passages between the bunks. The decks became wet and slippery, groans and cries of the terrified added to the confusion of the applicants clamoring for treatment, and altogether a true Inferno reign[ed] supreme.”

Wartime censorship complicated the crisis. In 1918, Woodrow Wilson and Congress enacted an amendment to the 1917 Espionage Act (known as the Sedition Act), which decreed that “whoever, when the United States is at war, shall willfully utter, print, write, or publish any disloyal, profane, scurrilous, or abusive language about the form of government of the United States . . . shall be punished by a fine of not more than $10,000 or imprisonment for not more than twenty years, or both.” This Act made fighting the disease even more difficult because it choked off much honest conversation (and even reporting) about the situation.

As Chicago’s Public Health Commissioner John Dill Robertson stated, “It is our duty to keep the people from fear. Worry kills more people than the epidemic.” Actually, people had good reason for fear. At Chicago’s Cook County Hospital, 40 percent of all influenza patients died.

Eventually, the deadly pandemic ran its course and life returned to normal. A similar pandemic may return to wreak havoc on humanity, particularly with the frequency of international travel. And if it does, censorship will not help the situation any more than it did in 1918.

Review Questions

1. The 1918 Spanish flu outbreak was the worst pandemic since

• smallpox in the nineteenth century
• the bubonic plague in the fourteenth century
• polio in the nineteenth century
• tuberculosis in the eighteenth century

2. As the Spanish flu progressed across the United States, a unique characteristic that emerged was that the disease

• seemed to be without symptoms until the end
• killed a disproportionate number of women
• struck a disproportionate number of people in New England
• killed mostly young, healthy adults

3. A major effect of the Spanish flu on U.S. society was

• the collapse of the economy
• an immediate demand that immigration be halted
• a temporary closure of schools and businesses
• a decline in the medical industry

4. The quote “it is our duty to keep the people from fear. Worry kills more people than the epidemic” from Chicago Public Health Commissioner John Dill Robertson is related to what policy of the U.S. government?

• Wartime censorship of news concerning the Spanish flu
• The need for the medical profession to bring an end to the epidemic
• Encouragement of accurate reporting regarding the epidemic
• Temporary halting of migration

5. The passage of the Sedition Act made it even more difficult to fight the flu pandemic because

• it stifled honest discussion and reporting of the disease
• it allowed the arrest of many of the health-care workers fighting the disease
• it increased immigration and thus the flow of disease carriers into the United States
• it reopened schools and businesses that had been closed to control the contagion

Free Response Questions

• Explain the impact of Spanish influenza on commerce in the United States.
• Analyze the role that censorship of free speech played in the nation’s ability to fight the Spanish flu pandemic.
• Compare society’s response to the Spanish flu pandemic in 1919 with the COVID-19 pandemic of 2020. What similarities do you notice?

AP Practice Questions

A 1919 public health broadside provides information on the Spanish flu pandemic.

1. The information presented in the broadside at the provided link could be used to support which of the following conclusions?

• The government developed public policies for fighting the disease.
• Private business banned individuals on the basis of their health status.
• Censorship impeded the spread of information about the disease.
• Widespread panic set in because there was little understanding of the way the disease spread.

2. The publication of this broadside most likely indicates

• an expansion of the role of the federal government
• the widespread health concerns caused by the epidemic
• the national government’s concern about the effects of the epidemic on trade
• the ignorance of most citizens of the time about healthy habits

3. The situation that prompted the broadside can be best described as

• the Red Scare created a fear of socialism in America
• people feared America becoming involved in another European war if the United States joined the League of Nations
• the rebirth of the Ku Klux Klan led a fear that personal freedoms would be lost
• a devastating Spanish flu epidemic spread fear, misery, and death around the world

Primary Sources

Price, George M. “Influenza-Destroyer and Teacher: A General Confession by the Public Health Authorities of a Continent.” The Survey 41, no. 12 (1918): 367-369.

“Quarantine and Isolation in Influenza.” Journal of the American Medical Association 71, no. 15 (1918): 1220.

“Spanish Influenza the Way to Treat It and to Avoid It.” A Vicks VapoRub advertisement. Portland Morning Oregonian . January 8, 1919, p. 6. https://oregonnews.uoregon.edu/lccn/sn83025138/1919-01-08/ed-1/seq-6/

Suggested Resources

Barry, John M. The Great Influenza . New York: Viking, 2004.

Hoehling, A. A. The Great Epidemic . Boston: Little, Brown and Company, 1961.

Iezzoni, Lynette. Influenza 1918: The Worst Epidemic in American History . New York: TV Books, 1999.

Kolata, Gina. Flu: The Story of The Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It . New York: Farrar, Straus and Giroux, 1999.

Tucker, Spencer and Priscilla Mary Roberts (eds.). World War I: A Student Encyclopedia . Santa Barbara, CA: ABC-CLIO, 2006.

Withington, John. Disaster!: A History of Earthquakes, Floods, Plagues, and Other Catastrophes . New York: Skyhorse Publishing, 2010.

Related Content

Life, Liberty, and the Pursuit of Happiness

In our resource history is presented through a series of narratives, primary sources, and point-counterpoint debates that invites students to participate in the ongoing conversation about the American experiment.

Working Paper The Great Influenza Pandemic of 1918–20

An interpretative survey in the time of covid-19.

The Great Influenza Pandemic of 1918-20—commonly known as the Spanish flu—infected over a quarter of the world’s population and killed over 50 million people. It is by far the greatest humanitarian disaster caused by infectious disease in modern history. Epidemiologists and health scientists often draw on this experience to set the plausible upper bound (the ‘worst case scenario’) on future pandemic mortality.

The purpose of this study is to piece together and analyse the scattered multi-disciplinary literature on the pandemic in order to place debates on the evolving course of the current COVID-19 crisis in historical perspective. The analysis focuses on the changing characteristics of pathogens and disease over time, the institutional factors that shaped the global spread, and the demographic and socio-economic consequences.

Prema-chandra Athukorala

Chaturica Athukorala

WIDER Working Paper 124/2020

https://doi.org/10.35188/UNU-WIDER/ 2020/881-8

© UNU-WIDER 2020

Related content

• Spanish flu

The 1918 Flu Pandemic: Why It Matters 100 Years Later

Here are 5 things you should know about the 1918 pandemic and why it matters 100 years later.

1. The 1918 Flu Virus Spread Quickly

In 1918, many people got very sick, very quickly. In March of that year, outbreaks of flu-like illness were first detected in the United States. More than 100 soldiers at Camp Funston in Fort Riley Kansas became ill with flu. Within a week, the number of flu cases quintupled. There were reports of some people dying within 24 hours or less. 1918 flu illness often progressed to organ failure and pneumonia, with pneumonia the cause of death for most of those who died.  Young adults were hit hard. The average age of those who died during the pandemic was 28 years old.

2. No Prevention and No Treatment for the 1918 Pandemic Virus

3. Illness Overburdened the Health Care System

As the numbers of sick rose, the Red Cross put out desperate calls for trained nurses as well as untrained volunteers to help at emergency centers. In October of 1918, Congress approved a $1 million budget for the U. S. Public Health Service to recruit 1,000 medical doctors and more than 700 registered nurses.

At one point in Chicago, physicians were reporting a staggering number of new cases, reaching as high as 1,200 people each day. This in turn intensified the shortage of doctors and nurses.  Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

4. Major Advancements in Flu Prevention and Treatment since 1918

There is still much work to do to improve U.S. and global readiness for the next flu pandemic. More effective vaccines and antiviral drugs are needed in addition to better surveillance of influenza viruses in birds and pigs. CDC also is working to minimize the impact of future flu pandemics by supporting research that can enhance the use of community mitigation measures (i.e., temporarily closing schools, modifying, postponing, or canceling large public events, and creating physical distance between people in settings where they commonly come in contact with one another). These non-pharmaceutical interventions continue to be an integral component of efforts to control the spread of flu, and in the absence of flu vaccine, would be the first line of defense in a pandemic.

5. Risk of a Flu Pandemic is Ever-Present, but CDC is on the Frontlines Preparing to Protect Americans

CDC works tirelessly to protect Americans and the global community from the threat of a future flu pandemic. CDC works with domestic and global public health and animal health partners to monitor human and animal influenza viruses. This helps CDC know what viruses are spreading, where they are spreading, and what kind of illnesses they are causing. CDC also develops and distributes tests and materials to support influenza testing at state, local, territorial, and international laboratories so they can detect and characterize influenza viruses.  In addition, CDC assists global and domestic experts in selecting candidate viruses to include in each year’s seasonal flu vaccine and guides prioritization of pandemic vaccine development. CDC routinely develops vaccine viruses used by manufacturers to make flu vaccines. CDC also supports state and local governments in preparing for the next flu pandemic, including planning and leading pandemic exercises across all levels of government. An effective response will diminish the potential for a repeat of the widespread devastation of the 1918 pandemic.

Visit CDC’s 1918 commemoration website for more information on the 1918 pandemic and CDC’s pandemic flu preparedness work.

63 comments on “The 1918 Flu Pandemic: Why It Matters 100 Years Later”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy » .

Hi, Thank you for this article. Very informative. Maybe the people that do not understand and do not accept the vaccination campaign will change their minds.

Excellent historical perspective on the 1918 incident. We have come a long way in treatment protocols and diagnostic advancements with respect to infectious diseases. The major concern,at this time, is an unknown pathogen which will be quickly spread worldwide my international jet travel. A few sick people on an aircraft entering the US could easy spread the disease from one end of the Country to the other. Depending on the conditions’ incubation period many more people will be affected before public health officials begin to see a problem. I guess the only thing we can be sure of is something similar will occur again , it’s just a matter of the right conditions and time.

This is a wonderful article on the influenza virus. I have extensively read about the pandemic, and its devastating effect on people. I must admit that I am appalled at the refusal to use trained nurses because they were Black Americans. That nonsense was part of the failure to help people in need of care at this crucial time . I must say it was hateful and ignorant of White Americans. White Americans are not reminded enough that they are immigrants to America just like any other race that came to this country from another country. America does not belong to white people. I don’t believe sick people care who is attending to them when they are on the brink of death.

Well done article. However. You could include a list of historical accounts for Further reading materials.

The possibility of another potential outbreak of any kind is a very scary and real test of how very little know. We indeed have come along way but still have a distance to go. .. Thank you for sharing this fascinating story.

Two of my grandparents were killed in their 30s by this epidemic, leaving my 1 year-old mother, my aunt, and my uncle orphaned. This is important stuff; people need to take influenza seriously.

My grandfather was a doctor in the Spokane Wa area and died from the flu in July of 1918 at age 46 . He was from the St Louis Missouri area and had been in the Spokane area for several years but could have visited or was visited by people from the St Louis area which is close to Kansas City to have caught the flu . Spokane was very isolated . This article gives no answer but gives some background to how he caught the flu in the middle of nowhere at the beginning of this pandemic

Would the mortality rate be as bad as the flu pandemic in 1918 where 675,000 people were killed? How would our economy be affected? Any thoughts?

The book “The Great Influenza” by John M. Barry has many historical references on this topic.

Good summary of the 1918 flu pandemic. But the sentence “The average age of those who died during the pandemic was 28 years old” (end of the first section) is inaccurate. Twenty-eight was the age at which mortality peaked among young adults, who were the hardest hit, along the very young and the very old. As for the average, variations in infant or old adult mortality could easily tip the balance away from 28 years.

In researching flu a few years ago, I read that one reason this flu killed people of supposedly optimum age for strength and resistance (~28 years), was for exactly that reason – their immune systems responded so quickly – with fluid in the lungs – that they drowned. People who responded more slowly, with less fluid produced less quickly – were more likely to survive.

By the way, if this thing posts (my first post ever on this site), I’m getting this message:

You are posting comments too quickly. Slow down.

(Please check your software)

I would agree with Tonya and Robert, there is an ever-present threat of a variant flu virus reeking havoc as many go unprepared for each flu season by not vaccinating, but also with a new, unknown pathogen. With the climate changing and the glacier ice melting to new low levels, bacteria, viruses and parasites previously encased in ice soon may be exposed to air, water, and humans. I am thankful for the diligent surveillance that the CDC and the WHO provides.

Thank you for that summary. The pandemic took my grandmother in the Spring of 1919. My father and his two sisters were orphans then. Their father had died in France, November 1918. It is always so sad for me to read about this.

Any plan to slow or stop a pandemic would include quickly identifying those who are contagious and minimizing their contact with others. However we do not have in place policies that would encourage that behavior, particularly in the low income and immigrant populations, including people who: * cannot afford to take time off work without pay * would lose their jobs if they did not show up * have no health insurance and can’t afford medical care * are afraid to seek care because of immigration status (their own or family member’s) And anyone who was quarantined would want to know that their basic needs would be met if they complied. I believe these issues would be best addressed in advance to overcome resistance. Once a potential pandemic starts, it will be difficult to get the necessary public and private buy-in, resources and authority until it is too late.

It’s surprising that to see that the first three items listed would apply to any similar pandemic of unknown origin today. Today’s air travel would spread an illness at previously unheard of rates. Couple that with an unknown origin and our health care systems would be over run just as they were in 1918.

Thank you so much for this article. I appreciate the information included and I pray that it convinces people with reservations to keep their own and their families health in mind for everyone’s sake but especially their own.

My grandmother was 11 years old in 1918. The family was from Philadelphia. I remember her telling me that she had to help load dead bodies into wagons. They would yell in the neighborhoods, “throw out your dead!” She never got the flu, but it must have been horrible! That is why we were always told never to spit on the streets. It can carry diseases, etc. People—Don’t think this cannot happen again. We live in an age where we can prevent the worst from happening when it comes to flu and other diseases. Get your flu shots!

Very educative write-up. A big lesson for us in Africa. The surveillance of influenza viruses must be sustained especially at animal-human interface to monitor possible new mutations. Thank you.

My grandfather was 15 years old. His parents and his two siblings were very ill with the flu so he ran to get help. By the time he got back to the house they were all dead. I am lying in bed with the H1N1 right now. Probably the sickest I’ve ever been. I personally believe facemasks should be mandatory and all public transportation. What a tragedy all the way around.

Great information on the flu pandemic. Very educative and sad.

History has taught us much about various past outbreaks. It’s the future unknown pathogens manmade or natural we need to worry about.

Great article on the flu pandemic. I have done a lot of studying on the issue. John Barry has written many books about the pandemic I find it incredible and riveting to learn about how people would wake up in the morning feeling fine and be dead in the evening. I have spoken to many people who experienced the flu through their families. I have always wondered if this can never happen again. Let’s hope not.

Great informative article thanks I`ve just been watching THE LATEST NEWS ON THE 2020 CORONAVIRUS! making me wonder ?? I also remember COLLAPSING as I was walking down the street with HONG KONG FLU in 1956 Woke up in hospital…..TOOK MANY WEEKS TO RECOVER!!

while air travel will spread the virus faster today than before, the news of such virus is traveling even faster today, as can be seen in the current outbreak of 2019CoV. People around the world are in a state of panic as soon as it is reported. China did a total lock down pretty quickly. Nowadays, we get more information about the characteristics of the virus, like the temperature and humidity condition that is favorable/unfavorable to it, Scientists can produce a vaccine much sooner than before. So yes, we should be vigilant, but we do not need to be too scared to live our life normally.

Reading this in 2020, and it looks like the U.S. has not learned much.

those who do not know history are doomed to repeat it.

Actually, if you read how fast the flu spread, and how many died, some within 24 hours, we have come a long way! It took over 30 years to develop a flu vaccine, and within 3 months of coronavirus hitting, we have already started the clinical trials of a vaccine. Amazing!!

It’s like you saw into the future. The very not so distant future. Thanks for writing this as it reinforces the steps and procedures being followed today. If only they had been implemented sooner.

Here we go all over again

From this article I think WHO and CDC have not learned much to be in preparation. After 100 year another virus is here to take million lives away. Poor nation like Africa is in trouble. America should have known better to be prepare after 100years. God save us all

Apparently, there was no national plan then either. The lack of leadership by politicians on national and local levels is appalling and the realization that many top officials refuse to accept and follow recommendations of the CDC and other experts is terrifying. We are following exactly the same recommendations as were suggested in 1918, and there is inconsistent use of the precautions that we know help. Please support those who are taking the Coronavirus seriously and working to help us all. Bless the CDC and Drs and nurses on the front lines trying to save us all.

Great information

Watching the overrun hospitals, lack of supplies and reliance on local and state authorities because the federal government cannot or will not help. Schools are canceled. All groups more than 10 people. Social distancing rules are in place. The economy is crashing. No possible vaccine. History is repeating itself. I am literally hiding in my home with my family, knowing it’s the only way to avoid it.

Thank you for this article. It certainly puts the current COVID-19 pandemic in perspective, as well as reinforcing the need for social distancing! We are fortunate to live in a time when significant advances have been made in medicine and technology.

The CDC dropped the ball on this one, we need to shut down the country to prevent a worst case scenario. (writing this on 3/30/20) The economy will tank no matter what, but we can prevent millions of deaths yet.

My mother’s cousin was 21 when the 1918 influenza epidemic hit. He had cerebral palsy and was at risk for disease and he died. It’s hard though to comprehend how the influenza reached his tiny town outside of Abilene, Texas. There was very little medicine for colds or pneumonia for anyone in that time period.

100 years later viruses are still a problem.

The history repeats itself, we can see USA as the richest country, powerful country, is so unprepared! Doctors and nurses are lacking of protective gears, yet they have to work with the patients who are infected with the virus! The States have to bid against one another for ventilators etc. So many people are infected and die from this neglected, unguided way ! So sad!

Very informative information and thanks to all those people that put this information together. It seems to be working for this coronavirus we are currently experiencing. Keep up the good work and lets try to do our best to improve what we have learned from this virus and make it better next time around as we can see …. there will be a next time …. just currently unknown as to when.

Sydney Daniels Looking back at the comments in 2018 it is haunting. The accuracy of concerns and predictions! The rapid spread through international travel , the less privileged forced to continue working ,not only to perish but spread it. The fear of an unknown pathogen and it’s economic impact. The parallels of past and present are too hard to ignore. The Spanish flu acting very similar to Coronavirus. There are several stories in the news of patients over 100, who were alive during the 1918 flu, surviving coronavirus. Is it a stretch to think whatever immunity they acquired back in 1918 could have given them an edge or are they just tough as nails!? Is it immunologically impossible being a different virus and the years past? Just a thought? Unfortunately the reassurance, given in this article, that we have multiple guardrails in place to prevent such a huge spread again was wishful thinking. God bless everyone and stay safe.

My grandfather died from the Spanish flu and struck both my father and uncle as children. My father suffered cardiomyopathy and succumbed to it decades later. Financial struggles where perhaps worse since women had less legal rights and job opportunities that had any semblance of equal pay. My grandmother supported her family through a variety of seamstress jobs and cleaning for those that could afford that luxury. History is a good teacher if we can learn from it.

Watching the BOSSA. 45 min documentary on the spanish flu of 1918 so enlightening also. The symptoms of severe cases were bizarre and freakish, fatal in less than 24 hrs. A second wave (fall 2020) of covid must be minimized if world wants to prevent millions of deaths. Unfortunately, so many spoiled americans are selfish and very impatient willing to risk and sacrifice many others lives for a day at the beach or a new tattoo. If only they all could have done a 6 month sentence in county jail they would see that they could stomach months of quarantine in their own homes standing on their head, provided ample food and necessities are avialable.Too bad history will be repeated and this will be a disaster for so many more that shall lose their lives

here we go again!

102 years later and the struggles that our ancestors dealt with daily are being resurfaced again. As an RN working in the frontlines with the current flu pandemic, the level of stress that is experienced among health care workers is almost unbearable. Just as the 1918 flu was fast to spread with no prevention or treatment plan in place, this new outbreak is fast to spread and hard to treat and prevent. Taking a lesson from the 1918 pandemic, our facility took to making the staff and the patients wear mask for all interactions during their stay at our facility in an effort to reduce the risk of spreading patient to nurse or nurse to patient. The most unnerving concern to me personally is the fact that unlike the 1918 flu, an estimated 50% of individuals who have the COVID-19 virus have experienced zero symptoms. This makes the task of identifying the positive patients from simple screening procedures much more difficult due to lack of testing ability to confirm actual positive patients. For example, we had an elderly man in our facility for more than two weeks for an unrelated health care issue, screening upon admission declared he was a zero risk for COVID-19 and he never exhibited a single symptom during his admission, however upon discharge and transfer to a rehab facility, he had a COVID-19 positive test result. He continues to have ZERO symptoms but has exposed multiple health care workers and family members to COVID-19. The risk of infecting health care workers who are already spread thin only increases the workload demand on those still able to work.

We are currently short staffed at our facility with most nurses working four to six 12 hour shifts per week to keep the work demand in our facility at a manageable level. With the re-opening of our surgical units and other outpatient services, the “extra” support we were receiving from their health care staff has diminished but the increased workload demand on the inpatient staff is ever growing as the community continues to open up and social distancing is not adhered to. Our COVID-19 related ER visits more than doubled over one weekend when beaches alone opened up. As with the 1918 pandemic, the call for help in many areas had been made even to the point of allowing current nursing students to perform duties as an RN.

Because health care facilities across our nation are short staffed and limited on PPE, the task of identifying positive flu patients is important to isolate the continued spread of the virus but to also protect the health care workers and reduce the waste of precious PPE. Just as our health care workers in the past, social distancing, hand washing and face covers are the best methods that we have available to help slow the spread of this virus.

A hard lesson learned in the 1918 pandemic was that the early shut down of large social events and gatherings could help slow the spread and decrease the the burden on the local healthcare facilities. The CDCs plans of closing down schools, shopping centers, social gatherings of large numbers, and bars/clubs was the outcome of that hard learned lesson from 1918. Our community seems to have fared well with the early closing as we have not had many local citizens hospitalized with COVID-19, we do have a many COVID-19 patients in our facilities due to hospital transfers however due to our location being near two other States, one of which is a well known hot zone. We are all in this together and just like our 1918 health care teams, we too have answered the call to aid our neighboring States.

Opening up the public with care and caution is going to have to occur as many small business owners have already had to close their doors to our community permanently due to the length of time they went with no income. The economical impact this virus had already had on our community is evident and will only be truly seen in the future as things begin to return to our “New” normal.

COVID19 will also last for years as compared to Spanish flu and we should take the precautionary measures seriously

That was hard to read , here we are again in 2020.

im postin just to post kepp up the good work guys

It was so good but it was only 100 years and we have a sickness that is killing the people.

My father and his younger sister both had the flu in Glasgow in 1919. He survived, his sister died. He never had the flu again, and I have never had it…I’m 81 now. I’ve been told I am immune and have never had the flu shot. There is an area south of Glasgow/northern England that has been studied because there is are a number of people there who are also immune. J. Wilson Saville

To keep this thread (article) in check and updated I’d like to add that there was hope of a slow down. However, the desire for normalcy has in turn resulted in a resurgence of the virus. Hospitals are now getting brunt of the aged ill. Some retirement homes are nearly at 75% plus positive to the virus, whereas; the nurses are infected as well and even though now overtaken by the virus are capable of working. In my opinion, this will continue for another year. I hope the timeframe is less, but the end result will likely be another depression. Our country needs to prepare and seek aid from other countries to prepare for this. The USA are the worlds leading consumers and I dint believe the rest of the world could take a financial hit like a US collapse.

Well, vaccines are on the way. Half of America is still crazy. I guess you could say we started “rounding the corner” on Nov. 3rd. Hopefully things back to normal this time next year.

Very good and informative article. Thank you

The Spanish fly and the COVID -19 are are bit similar

When roll out to massive vaccinate happens worldwide we will heal. It reminds me of the World War 2 armament. Once we got the ball rolling we were successful.

I was always strong never in the hospital because of illness. October 2020 came , and despite all my efforts to avoid COVID-19 I landed in the local hospital, and spent the month of October in the covid unit. The infectious disease specialists went to work with what was available, and saved my life. I was on oxygen until March, or April, and I was doing rehab at home until I could walk again. Thank God my wife and I were able to get our COVID-19 shots. Please get yours, everyone!!!

History have already repeating it self In a bad way and we did not learn anything at all ! .

The covid -19 or coronavirus in 2020

Life expectancy dropped by 12 years during the Spanish flu. The virus continued until 1957. Some believe a lack of nutrition played a part in the mortality rate at the time Life expectancy for COVID 19 is the same as normal life expectancy (around 78). Like the Spanish flu our body should adapt to the coming variations. Like the Spanish flu it may last decades.

Why was there a 37 year absence of flu pandemic between 1920 & 1957; yet subsequent to 1957 they have appeared more frequently?

@Sumeyo, I think you mean “The Spanish Flu” 😉

people did not learn about the requirements for this😑. I mean really!

Good info and everything but could had added more info

The article was worded very well and fairly informative. And that leads me to bring up a part of the Article that most people tend to over look. The flu started in the military and spread rapidly. When i was six years old i had very similar symptoms of the Spanish flue and I compared the symptoms of covid 19 and what I had when it was six was actually worse. Im 55 yrs old now and I haven’t had a flu shot in 36 years now and I have no intentions of getting another one with all the Chemical war fair going on in the world.

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‘It Is Pretty Bad Down Here at Present.’ What We Can Learn From a Letter Written Just After the Height of the 1918 Flu Pandemic

O n Oct. 8, 1918, faced with the reality of that year’s flu pandemic , the chancellor of the University of Kansas ordered a temporary shutdown of the school, expecting it to only last for a week. The front page of the University Daily Kansan announced the decision. “BY AUTHORITY AND DIRECTION OF THE STATE BOARD OF HEALTH there will be NO CLASSES in the University beginning at NOON today, October 8,” read the proclamation. “The University will re-open Tuesday, October 15, unless notice is given to the contrary. Students are FORBIDDEN to leave Lawrence—to do so would help spread infection. They must remain in Lawrence.”

By the time the closure actually ended a month later, almost 1,000 members of the university community, including students and faculty, had fallen ill with the flu.

For some students, though, life went on as normal—or, rather, as normal as could be at the height of a global public-health emergency. The so-called “Spanish flu” spread in three main waves, starting in March 1918 and coming to an end by the summer of 1919. The pandemic’s peak was during the second wave, which began in September 1918 and lasted through the fall. Spread in part by the war, the virus killed almost 200,000 Americans in October 1918 alone.

It was after witnessing the worst of the virus that one student at the University of Kansas, Lawrence, wrote a letter to her aunt. More than a century later, as the world confronts another pandemic, the letter provides a look at what life was like at that moment—and how even the deadliest pandemic of modern history was the new normal for those who lived through it.

In the letter, the student, Myrtle, mentions that the flu—which she spells “flue,” a not-uncommon spelling at the time—“is awful bad” where her parents are and that schools near her university have shut down because it’s “pretty bad” there too. The note, pictured above and transcribed below, is part of a larger collection of letters donated by the descendants of Jacob Myer to the National World War I Museum and Memorial; Myer, whose mother was the recipient of the letter, eventually died of the flu.

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Myrtle’s experience is one with which many students today would empathize. In response to the spread of the novel coronavirus, more than 1,000 colleges and universities in the U.S. have shut down, affecting an estimated 14 million students. The 1918 flu also held a parallel to today’s instances of pandemic-related xenophobia, as the front page of the student newspaper announcing the school’s closure also had an article seizing on wartime anti-German sentiment to argue that the flu, which is believed to have caused its first known case right there in Kansas , “should be called Hun influenza, because it is a slick, sly, tricky and heartless ailment.”

Similar to today, volunteers in the community had stepped up to try to fight the pandemic. Myrtle mentions someone who sounds like a love interest, Ralph, being in “the barracks”; he was likely part of the Student Army Training Corps, which played an active role in helping the university deal with the pandemic. When the manager of the Lawrence movie houses refused to shut down the theaters, the commander of the Training Corps stationed members at entrances to ensure they didn’t open to students. And as demand for medical facilities and doctors outweighed the supply, the Student Army’s barracks were turned into makeshift hospitals, where the university’s medical students came to help.

But what is perhaps most notable about the letter is how little of it is dedicated to the flu. She writes about typical student things: class, schoolwork, her relationship, and how life for her is generally fine.

Stacie Petersen, exhibitions manager and registrar at the World War I Museum, says that Myrtle’s blasé tone shows “an acceptance of what is happening. At this point in time with it being December 1918, the second wave of the flu had been going on now for a couple of months. It’s just what is happening in life.”

By the end, the flu had infected nearly 500 million people, or a third of the world’s population, and caused an estimated 675,000 deaths in the U.S. It is inevitable that those who lived through it experienced waves of fear and grief. And yet, as Mrytle’s letter shows, amid such a long-lasting pandemic, there were moments when life simply went on.

Dec. 10, 1918.

Dear Aunt and Family:-

I have thought of you many times but to day [sic] is the first time that I succeeded in finding time to write you a few lines.

Ralph and I are fine, and have not gotten the “flue” [sic] yet altho [sic] it is pretty bad down here at present. It seems to be among the older folks and children. The graded schools and High School is closed here but only a few students of K.U. have it, they thought it was not necessary to close college until they see that it must be done. Heard you folks had it this fall but hope you are all over it and feeling fine. This is beautiful weather for December and to think of such a heavy snow we already had at Thanksgiving seems almost impossible.

Ralph is still in the barracks, he is looking to be discharged most any day altho [sic] they have been waiting for discharging blanks to come, as each must fill out a blank and have a physical examination before he can get out of the army. And the boys here will be pleased to get out too. The boys who do not intend to go to school after being discharged have to drill all day long and the others only have to drill 1 hr. each morning and then they are free the rest of the day until 5:30 for retreat. The barracks here are built in town but they are on K.U. Campus. Dwelling houses on one side of the street and barracks on the other.

I try to see Ralph once each day. If we do not happen to see each other at school, he comes down in the afternoon after class and if he hasn’t time to come, I go to the barracks and he comes out. We rec’d a letter from the folks at home this morn. and the flue [sic] is awful bad around there now. I like it fine down here altho [sic] it is a different life in town than in the country.

I certainly like my school work and time goes so fast, have all my classes in the forenoon but the lessons are so long it takes all P.M. and until 10 P.M. to prepare lessons for next day.

I am as ever your niece, Myrtle

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What Can We Learn from the Spanish Flu Pandemic of 1918-19 for COVID-19?

This post first appeared May 18 as an Economic Synopses essay .

The COVID-19 pandemic has spurred intense efforts among researchers to estimate the likely course of the pandemic and its economic effects. Several studies have sought insights from global pandemics of the past, including the Spanish flu pandemic of 1918-19, which is thought to have infected some 500 million persons, or about one-third of the world's population, and killed anywhere from 50 to 100 million people. Johnson and Mueller (2002) estimate 50 million deaths worldwide and provide estimates for several countries. Jorda et al. (2020) report an estimate of 100 million deaths, as well as mortality estimates for other pandemics since the fourteenth century with at least 100,000 deaths. Lessons from the Spanish flu pandemic are relevant and informative. Like COVID-19, the Spanish flu was highly contagious; it was also unusually lethal compared with a typical seasonal flu. As the flu became more widespread and its dangers apparent, many cities sought to contain the virus by imposing restrictions on social and economic interactions. These efforts can provide insights about the economic and public health impacts of government efforts to limit the spread of pandemic diseases. This essay discusses some recent research findings on the effects of the Spanish flu pandemic and measures that cities took to control it.

The Spanish flu pandemic came in three waves beginning in the spring of 1918. The second wave, in the fall of 1918, was the largest by far in terms of total infections and deaths. A third wave occurred in the spring of 1919. Overall, the pandemic is estimated to have infected about 25 percent of the U.S. population, or about 25 million people, and killed 675,000 for roughly a 3 percent mortality rate.  Taubenberger and Morens (2006). See also Garrett (2008) and references therein for data and other information about the origins and spread of the pandemic in the United States. The pandemic began during World War I, and the virus is thought to have been introduced and spread throughout the United States by soldiers returning from Europe. By the end of 1918, some 45,000 U.S. soldiers had contracted and died from the disease, a number only modestly smaller than the 53,000 American combat deaths.  Eric Durr, " Worldwide Flu Outbreak Killed 45,000 American Soldiers During World War I ." As with typical seasonal flu, young children and the elderly were particularly susceptible to the Spanish flu. However, the Spanish flu was especially lethal for young, "prime-age" adults, especially men. In 1918, the mortality rate from the flu and pneumonia among men 15 to 34 years of age was more than 20 times higher than in previous years, and throughout the pandemic, half of all flu deaths were among adults between 20 and 40 years of age. Furthermore, the absolute risk of death from the flu was higher among those younger than 65 years of age than those 65 or older, with those younger than 65 accounting for 99 percent of excess flu deaths in 1918-19. Taubenberger and Morens (2006). The high fatality rate among young adults, especially young adult men, is striking in comparison with both typical seasonal flu and COVID-19, where the case fatality rate has been far higher among the elderly than among the young. These differences in age-related fatality rates are one reason the economic impacts of the COVID-19 and Spanish flu pandemics might differ. The high fatality rate among prime-age males during the Spanish flu pandemic reduced labor supply and boosted real wage rates in locations where the incidence of the disease was high (Garret, 2009, and Correia et al., 2020). Such an effect seems unlikely from the COVID-19 pandemic.  In a study of 15 major pandemics since the fourteenth century, Jorda, Singh, and Taylor (2020) find that real wages are typically elevated for several years after pandemics, while the returns to capital are low, likely because of widespread deaths among the working-age population.

As the COVID-19 pandemic spread across the United States, most state and local governments imposed restrictions on economic activity, such as requiring certain non-essential businesses to close or reduce their in-store services. Many firms have voluntarily reduced their operations to protect the health of their employees or because of weaker demand for their products. At the same time, many households have refrained from non-essential purchases and travel in an effort to protect themselves and to help limit the spread of the virus. To date these measures appear to have helped slow the pandemic and avoid overwhelming the health care system in most locations. However, aggregate economic activity and employment have declined sharply, leading many states and cities to ease restrictions even as COVID-19 cases and fatalities continue to rise.

A similar pattern played out during the Spanish flu pandemic. In an effort to stem the pandemic, many cities adopted measures such as closing schools and churches, prohibiting large gatherings of people, shutting down theaters and other entertainment venues, and temporarily closing non-essential businesses.  Detailed information about the use of NPIs by 50 cities during the pandemic is available from the University of Michigan Center for the History of Medicine . Several studies examine the effects of such non-pharmaceutical interventions (NPIs) on flu incidence and mortality rates. A general finding is that cities that put NPIs in place earlier or took more aggressive action had lower excess mortality rates, later peaks in caseloads and mortality, and, to a lesser extent, fewer total fatalities than cities that moved slowly or adopted fewer measures.  See Barro (2020), Correia et al. (2020), Bootsma and Ferguson (2007), Hatchett et al. (2007), and Markel et al. (2007). Barro (2020) notes that the mean duration of NPIs across 43 cities was 4-6 weeks and suggests that a duration of 12 weeks would have produced a substantially lower total death rate. The experiences of Philadelphia and St. Louis are often compared. Philadelphia was slow to implement measures to stem the pandemic and experienced a surge in cases following a large parade in support of a Liberty Loan drive. St. Louis, by contrast, canceled a similar parade and took other measures soon after the first cases were reported. Philadelphia had among the highest mortality rates of any of the U.S. cities, with a peak weekly excess mortality rate of 250 deaths per 100,000 persons and a total pandemic mortality rate of 748 deaths per 100,000 persons. St. Louis had among the lowest rates of all major cities, with a peak weekly excess mortality rate of just 30 deaths per 100,000 persons and a total mortality rate of 358 deaths per 100,000 persons (Markel et al., 2007).

Most cities relaxed their measures after just a few weeks when flu deaths began to recede. However, many cities faced a surge in cases when measures were eased, which resulted in a second peak—often higher than the first—that led to reactivation of some NPIs (Bootsma and Ferguson, 2007, and Markel et al., 2007). The experience of St. Louis is a case in point. St. Louis's authorities moved quickly to close schools, churches, saloons, theaters, and other entertainment venues when the city's first cases appeared in early October. Businesses and factories were permitted to remain open, but business hours were reduced and police were dispatched to keep shoppers from lingering in stores. On November 9, the health commissioner ordered all non-­essential stores and factories closed for four days, and cases peaked within days. Businesses were permitted to reopen on November 13 and schools opened on November 14. Flu cases continued to decline for the next two weeks but then began to climb sharply. The city closed schools again and reinstated a ban on all public gatherings. The second peak in cases—with a higher excess mortality rate than the first peak—was reached in December. Cases then began to decline and the city lifted all restrictions on businesses on December 28 and reopened schools on January 2. University of Michigan Center for the History of Medicine .

The economic impacts of the flu pandemic and NPIs implemented to contain it are somewhat less clear than the epidemiological effects. Perhaps surprisingly, given the widespread incidence of illness and many deaths, the pandemic did not trigger a major contraction in aggregate economic activity. A mild recession began in September 1918 and continued to March 1919. Federal spending on the war effort might explain why the aggregate economy did not slow appreciably: "[T]he never-ending demand for coal, steel, machinery, textiles, and other products needed for the war effort largely offset the effects of such a severe pandemic on aggregate economic activity" (Benmelech and Frydman, 2020). Industrial production did fall sharply but recovered quickly. Retail sales appear to have been little affected by the pandemic, perhaps because of a surge in consumer purchases after Armistice on November 11, and neither business failures nor other forms of financial distress increased significantly.  Velde (2020) examines a variety of high-frequency economic time series data during the pandemic and concludes that the pandemic had only modest impact on economic activity. Barro et al. (2020) examine the impact of the pandemic across countries and attempt to control for differences in war intensity using data on combat deaths. The study finds that the flu pandemic caused a 6.2 percent decline in GDP in a typical country and a decline of about 1.5 percent in the United States. The pandemic did have a large impact on some sectors, however—notably manufacturing. Correia et al. (2020) estimate that the pandemic caused an 18 percent decline in manufacturing output and a 23 percent decline in manufacturing employment, in part because several cities with large manufacturing industries were among those with the highest flu fatality rates.

Some NPIs, such as temporary closures of non-essential businesses, clearly impose direct economic costs on affected firms and households. However, widespread illness or deaths can also be economically costly, suggesting that, conceivably, the economic benefits of containing a pandemic might outweigh the direct costs imposed on owners and employees of firms that are required to close. During the Spanish flu pandemic, cities with lower excess flu mortality rates had smaller declines in some measures of economic activity, suggesting that the direct cost of NPIs might have been offset at least to some extent by stronger economies. Moreover, there is evidence that cities that imposed NPIs earlier and more rigorously during the pandemic had higher growth in manufacturing output and employment for up to four years after the pandemic. Correia et al. (2020) use a dynamic difference-in-difference regression approach to examine the impact of NPIs on manufacturing across cities. Their model controls for various pre-crisis state and local characteristics, such as total population, urbanization, manufacturing share of employment, and growth of manufacturing output and employment from 1909 to 1914. The study finds that implementing NPIs earlier in the pandemic and using them more intensely produced significantly higher rates of growth in manufacturing output and employment from 1919 to 1923 than did slower activation or less intense use of NPIs. Estimates from the study's base model indicate that a one standard deviation increase in the speed of adopting NPIs (8 days) is associated with 4 percent higher growth of employment after the pandemic, while a one standard deviation increase in NPI intensity leads to 6 percent higher employment growth. The authors estimate several models with different sets of controls, and though not all show a statistically significant impact of NPIs on growth or employment, none indicate that NPIs reduced economic activity. The base specification controls include measures of urbanization, pre-crisis population, manufacturing employment share, and flu mortality in 1917, as well as state-level agricultural employment share. Additional control variables in other specifications include the growth in manufacturing output and employment from 1909 to 1914, census region fixed effects, longitude, WWI servicemen mortality rate, and health and total public spending per capita in 1917.

Clearly, there are limits to the applicability of the Spanish flu episode to the COVID-19 pandemic. In particular, the unusually high fatality rate among young, working-age men suggests that the flu pandemic might have had a larger economic impact, particularly on labor-intensive industries, than will COVID-19. The structure of the U.S. economy and distribution of the population are also very different today than in 1918, which could affect how either a pandemic or the NPIs imposed to contain it affect public health or the economy. For example, because pandemic mortality is strongly associated with population density, increased urbanization suggests that NPIs might have more public health benefit today than in 1918. On the other hand, the substantial increase over time in employment in the service sector suggests that the direct costs of mandatory business closures, which tend to fall more heavily on retail establishments and other service industries, could be higher today than in 1918. In 1918, the U.S. population was split evenly between urban and rural areas in 1918, whereas today the urban population is five times the rural population. Moreover, in 1918, 33 percent of the labor force was employed in agriculture and 28 percent was employed in manufacturing, compared with 2 percent and 8 percent, respectively, today (Velde 2020). As of 2018, some 80 percent of the U.S. labor force was employed in service industries. See Bureau of Labor Statistics Employment Projections data . Still, insights from the Spanish flu and other pandemics should not be dismissed entirely. So long as we remain cognizant of the environmental features in which they occurred, the pandemics of the past can provide useful data points for helping to forecast how the COVID-19 and future pandemics are likely to play out, and in particular for addressing such questions as whether NPIs are likely to be the sole source of economic disruptions in a pandemic, or whether a pandemic would cause an economic downturn in the absence of interventions to slow its spread.

1 Johnson and Mueller (2002) estimate 50 million deaths worldwide and provide estimates for several countries. Jorda et al. (2020) report an estimate of 100 million deaths, as well as mortality estimates for other pandemics since the fourteenth century with at least 100,000 deaths.

2 Taubenberger and Morens (2006). See also Garrett (2008) and references therein for data and other information about the origins and spread of the pandemic in the United States.

3 Eric Durr, " Worldwide Flu Outbreak Killed 45,000 American Soldiers During World War I ."

4 Taubenberger and Morens (2006).

5 In a study of 15 major pandemics since the fourteenth century, Jorda, Singh, and Taylor (2020) find that real wages are typically elevated for several years after pandemics, while the returns to capital are low, likely because of widespread deaths among the working-age population.

6 Detailed information about the use of NPIs by 50 cities during the pandemic is available from the University of Michigan Center for the History of Medicine .

7 See Barro (2020), Correia et al. (2020), Bootsma and Ferguson (2007), Hatchett et al. (2007), and Markel et al. (2007). Barro (2020) notes that the mean duration of NPIs across 43 cities was 4-6 weeks and suggests that a duration of 12 weeks would have produced a substantially lower total death rate.

8 University of Michigan Center for the History of Medicine .

9 Velde (2020) examines a variety of high-frequency economic time series data during the pandemic and concludes that the pandemic had only modest impact on economic activity. Barro et al. (2020) examine the impact of the pandemic across countries and attempt to control for differences in war intensity using data on combat deaths. The study finds that the flu pandemic caused a 6.2 percent decline in GDP in a typical country and a decline of about 1.5 percent in the United States.

10 The base specification controls include measures of urbanization, pre-crisis population, manufacturing employment share, and flu mortality in 1917, as well as state-level agricultural employment share. Additional control variables in other specifications include the growth in manufacturing output and employment from 1909 to 1914, census region fixed effects, longitude, WWI servicemen mortality rate, and health and total public spending per capita in 1917.

11 In 1918, the U.S. population was split evenly between urban and rural areas in 1918, whereas today the urban population is five times the rural population. Moreover, in 1918, 33 percent of the labor force was employed in agriculture and 28 percent was employed in manufacturing, compared with 2 percent and 8 percent, respectively, today (Velde 2020). As of 2018, some 80 percent of the U.S. labor force was employed in service industries. See Bureau of Labor Statistics Employment Projections data .

Barro, Robert J. "Non-Pharmaceutical Interventions and Mortality in U.S. Cities During the Great Influenza Pandemic, 1918-1919." NBER Working Paper 27049, April 2020.

Barro, Robert J.; Ursua, Jose F. and Weng, Joanna. "The Coronavirus and the Great Influenza Pandemic—Lessons from the 'Spanish Flu' for the Coronavirus's Potential Effects on Mortality and Economic Activity." NBER Working Paper 26866, March 2020.

Benmelech, Efraim and Frydman, Carola. "The 1918 Influenza Did Not Kill the US Economy." VOX CEPR Policy Portal, April 29, 2020.

Bootsma, Martin C.J. and Ferguson, Neil M. "The Effect of Public Health Measures on the 1918 Influenza Pandemic in U.S. Cities." Proceedings of the National Academy of Sciences, May 2007, 104(18), pp. 7588-93.

Correia, Sergio; Luck, Stephan and Verner, Emil. "Pandemics Depress the Economy, Public Heath Interventions Do Not: Evidence from the 1918 Flu." SSRN Working Paper No. 3561560, April 10, 2020.

Garrett, Thomas A. "Pandemic Economics: The 1918 Influenza and Its Modern-­Day Implications." Federal Reserve Bank of St. Louis Review, March/April 2008, pp. 75-93.

Garrett, Thomas A. "War and Pestilence as Labor Market Shocks: U.S. Manufacturing Wage Growth 1914-1919." Economic Inquiry, October 2009, 47(4), pp. 711-25.

Hatchett, Richard J.; Mecher, Carter E. and Lipsitch, Marc. "Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic." Proceedings of the National Academy of Sciences, May 2007, 104(18), pp. 7582-87.

Johnson, Niall P.A.S. and Mueller, Juergen. "Updating the Accounts: Global Mortality of the 1918-1920 'Spanish' Influenza Pandemic." Bulletin of the History of Medicine, Spring 2002, 76(1), pp. 105-15.

Jorda, Oscar; Singh, Sanjay R. and Taylor, Alan M. "Longer-Run Economic Consequences of Pandemics." Federal Reserve Bank of San Francisco Working Paper 2020-09, March 2020.

Markel, Howard; Lipman, Harvey B.; Navarro, J. Alexander; Sloan, Alexandra; Michalsen, Joseph R.; Stern, Alexandra Minna and Cetron, Martin S. "Nonpharmaceutical Interventions Implemented by U.S. Cities During the 1918-1919 Influenza Pandemic." Journal of the American Medical Association, 2007, 298(6), pp. 644-54.

Taubenberger, Jeffery K. and Morens, David M. "1918 Influenza: the Mother of All Pandemics." Emerging Infectious Diseases, January 2006, 12(1), pp. 15-22.

Velde, Francois R. "What Happened to the U.S. Economy During the 1918 Influenza Pandemic? A View Through High-Frequency Data." Federal Reserve Bank of Chicago Working Paper 2020-11, April 2020.

© 2020, Federal Reserve Bank of St. Louis. The views expressed are those of the author(s) and do not necessarily reflect official positions of the Federal Reserve Bank of St. Louis or the Federal Reserve System.

David Wheelock is senior vice president and special policy advisor to the Bank president. Read more about his work .

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History | April 13, 2020

What We Can Learn From 1918 Influenza Diaries

These letters and journals offer insights on how to record one’s thoughts amid a pandemic

Meilan Solly

Associate Editor, History

When Dorman B.E. Kent , a historian and businessman from Montpelier, Vermont, contracted influenza in fall 1918, he chronicled his symptoms in vivid detail. Writing in his journal , the 42-year-old described waking up with a “high fever,” “an awful headache” and a stomach bug.

“Tried to get Dr. Watson in the morning but he couldn’t come,” Kent added. Instead, the physician advised his patient to place greased cloths and a hot water bottle around his throat and chest.

“Took a seidlitz powder”—similar to Alka-Seltzer—“about 10:00 and threw it up soon so then took two tablespoons of castor oil,” Kent wrote. “Then the movements began and I spent a good part of the time at the seat.”

The Vermont historian’s account, housed at the state’s historical society, is one of countless diaries and letters penned during the 1918 influenza pandemic , which killed an estimated 50 to 100 million people in just 15 months. With historians and organizations urging members of the public to keep journals of their own amid the COVID-19 pandemic, these century-old musings represent not only invaluable historical resources, but sources of inspiration or even diversion.

“History may often appear to our students as something that happens to other people,” writes Civil War historian and high school educator Kevin M. Levin on his blog , “but the present moment offers a unique opportunity for them to create their own historical record.”

The work of a historian often involves poring through pages upon pages of primary source documents like diaries—a fact that puts these researchers in a position to offer helpful advice on how prospective pandemic journalers might want to get started.

First and foremost, suggests Lora Vogt of the National WWI Museum and Memorial , “Just write,” giving yourself the freedom to describe “what you’re actually interested in, whether that’s your emotions, [the] media or whatever it is that you’re watching on Netflix.”

Nancy Bristow , author of American Pandemic: The Lost Worlds Of The 1918 Influenza Epidemic , advises writers to include specific details that demonstrate how “they fit into the world and … the pandemic itself,” from demographic information to assessment of the virus’ impact in both the public and personal spheres. Examples of relevant topics include the economy; political messaging; level of trust in the government and media; and discussion of “what’s happening in terms of relationships with family and friends, neighbors and colleagues.”

Other considerations include choosing a medium that will ensure the journal’s longevity (try printing out entries written via an electronic journaling app like Day One , Penzu or Journey rather than counting on Facebook, Twitter and other social media platforms’ staying power, says Vogt) and defying the sense of pressure associated with the need to document life during a “historic moment” by simply writing what comes naturally.

Journaling “shouldn’t be forced,” says Levin. “There are no rules. It’s really a matter of what you take to be important.”

If all else fails, look to the past: specifically, the nine century-old missives featured below. Though much has changed since 1918, the sentiments shared in writings from this earlier pandemic are likely to resonate with modern readers—and, in doing so, perhaps offer a jumping-off point for those navigating similar situations today.

Many of these journalers opted to dedicate space to seemingly mundane musings: descriptions of the weather, for instance, or gossip shared by friends. That these quotidian topics still manage to hold our attention 100 years later is a testament to the value of writing organically.

State historical societies are among the most prominent record-keepers of everyday people’s journals and correspondence, often undertaking the painstaking tasks of transcribing and digitizing handwritten documents. The quotes featured here—drawn in large part from local organizations’ collections—are reproduced faithfully, with no adjustments for misspelling or modern usage.

Edith Coffin (Colby) Mahoney

From the massachusetts historical society.

Between 1906 and 1920, Edith Coffin (Colby) Mahoney of Salem, Massachusetts, kept “ three line-a-day diaries ” featuring snippets from her busy schedule of socializing, shopping and managing the household. Most entries are fairly repetitive, offering a simple record of what Mahoney did and when, but, on September 22, 1918, she shifted focus to reflect the pandemic sweeping across the United States.

Fair & cold. Pa and Frank here to dinner just back from Jefferson Highlands. Rob played golf with Dr. Ferguson and Mr. Warren. Eugene F. went to the hospital Fri. with Spanish influenza. 1500 cases in Salem. Bradstreet Parker died of it yesterday. 21 yrs old.

Four days later, Mahoney reported that Eugene had succumbed to influenza. “Several thousand cases in the city with a great shortage of nurses and doctors,” she added. “Theatres, churches, gatherings of everykind stopped.”

Mahoney’s husband, Rob, was scheduled to serve as a pallbearer at Eugene’s September 28 funeral, but came down with the flu himself and landed “in bed all day with high fever, bound up head and aching eye balls.”

By September 29—a “beautiful, mild day,” according to Mahoney—Rob was “very much better,” complaining only of a “husky throat.” The broader picture, however, remained bleak. Another acquaintance, 37-year-old James Tierney, had also died of the flu, and as the journal’s author noted, “Dr says there is no sign of epidemic abating.”

Franklin Martin

From the national library of medicine, via research by nancy bristow.

In January 1919, physician Franklin Martin fell ill while traveling home from a postwar tour of Europe. His record of this experience, written in a journal he kept for his wife , Isabelle, offers a colorful portrait of influenza’s physical toll.

Soon after feeling “chilly all day,” Martin developed a 105-degree fever.

About 12 o'clock I began to feel hot. I was so feverish I was afraid I would ignite the clothing. I had a cough that tore my very innards out when I could not suppress it. It was dark; I surely had pneumonia and I never was so forlorn and uncomfortable in my life. … Then I found that I was breaking into a deluge of perspiration and while I should have been more comfortable I was more miserable than ever.

Added the doctor, “When the light did finally come I was some specimen of misery—couldn't breathe without an excruciating cough and there was no hope in me.”

Martin’s writing differs from that of many men, says Bristow, in its expression of vulnerability. Typically, the historian explains, men exchanging correspondence with each other are “really making this effort to be very brave, … always apologizing for being sick and finding out how quickly they’ll be back at work, or [saying] that they’re never going to get sick, that they’re not going to be a victim of this.”

The physician’s journal, with its “blow-by-blow [treatment] of what it was like to actually get sick,” represents a “really unusually profound” and “visceral” point of view, according to Bristow.

Violet Harris

Violet Harris was 15 years old when the influenza epidemic struck her hometown of Seattle. Her high school diaries, recounted by grandniece Elizabeth Weise in a recent USA Today article, initially reflect a childlike naivete. On October 15, 1918, for example, Harris gleefully reported:

It was announced in the papers tonight that all churches, shows and schools would be closed until further notice, to prevent Spanish influenza from spreading. Good idea? I’ll say it is! So will every other school kid, I calculate. … The only cloud in my sky is that the [School] Board will add the missed days on to the end of the term.

Before long, however, the enormity of the situation sank in. The teenager’s best friend, Rena, became so sick she “could hardly walk.” When Rena recovered, Harris asked her “what it felt like to have the influenza, and she said, ‘Don’t get it.’”

Six weeks after Seattle banned all public gatherings, authorities lifted restrictions, and life returned to a semblance of normal. So, too, did Harris’ tone of witty irreverence. Writing on November 12, she said:

The ban was lifted to-day. No more .... masks. Everything open too. 'The Romance of Tarzan' is on at the Coliseum [movie theater] as it was about 6 weeks ago. I’d like to see it awfully. .... School opens this week—Thursday! Did you ever? As if they couldn’t have waited till Monday!

N. Roy Grist

Fort Devens , a military camp about 40 miles from Boston, was among the sites hardest hit by the 1918 influenza epidemic. On September 1, some 45,000 soldiers waiting to be deployed to France were stationed at the fort; by September 23, according to the New England Historical Society , 10,500 cases of the flu had broken out among this group of military men.

Physician N. Roy Grist described the devastation to his friend Burt in a graphic September 29 letter sent from Devens’ “Surgical Ward No. 16.”

These men start with what appears to be an attack of la grippe or influenza, and when brought to the hospital they very rapidly develop the most viscous 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 extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves.

On average, wrote the doctor, around 100 patients died each day.

Grist’s letter is “a remarkably distinct and accurate description of what it was like to be in the midst of this,” says Bristow. “And then it goes on to talk about how difficult it is to be a doctor, … this sense of not being able to do as much as one might like and how exhausting it all is.”

Toward the end of the letter, Grist notes how much he wishes Burt, a fellow physician, was stationed at Fort Devens with him.

It’s more comfortable when one has a friend about. ... I want to find some fellow who will not ‘talk shop’ but there ain’t none, no how. We eat it, sleep it, and dream it, to say nothing of breathing it 16 hours a day. I would be very grateful indeed if you would drop me a line or two once in a while, and I promise you that if you ever get into a fix like this, I will do the same for you.

Clara Wrasse

From the national wwi museum and memorial.

In September 1918, 18-year-old Clara Wrasse wrote a letter to her future husband , Reid Fields, an American soldier stationed in France. Though her home city of Chicago was in the midst of battling an epidemic, influenza was, at best, a secondary concern for the teenager, who reported:

About four hundred [people] died of it at the Great Lakes … quite a number of people in Chi are suffering with it too. Mother thought that I had it when I wasn’t feeling good, but I am feeling fine now.

Quickly moving on from this mention of disease, Wrasse went on to regale her beau with stories of life in Chicago, which she deemed “to be the same old city, altho there are lots of queer things happening.”

Signing off with the lines “hoping you feel as happy as you did when we played Bunco together,” Wrasse added one last postscript: “Any time you haven’t got anything to do, drop me a few lines, as I watch for a letter from you like a cat watches a mouse.”

Vogt of the National World War I Museum cites Wrasse’s letters as some of her favorites in the Kansas City museum’s collections.

“It's so clear how similar across the ages teenagers are and what interests them,” she says, “and that … they’re kind of wooing each other in these letters in a way that a teenager would.”

Leo Baekeland

From the smithsonian’s national museum of american history.

Inventor Leo Baekeland , creator of the world’s first commercialized plastic, “documented his life prolifically” in diaries, laboratory notebooks, photographs and correspondence, according to the museum’s archives center , which houses 49 boxes of the inventor’s papers.

Baekeland’s fall 1918 journal offers succinct summaries of how the epidemic affected his loved ones. On October 24, he reported that a friend named Albert was sick with influenza; by November 3, Albert and his children were “better and out of bed, but now [his] wife is sick with pneumonia.” On November 10, the inventor simply stated, “Albert’s wife is dead”—a to-the-point message he echoed one week later, when he wrote that his maid, Katie, was “buried this morning.”

Perhaps the most expressive sentiment found among Baekeland’s entries: “From five who had influenza, two deaths!”

Dorman B.E. Kent

From the vermont historical society.

From the age of 11 to his death at 75 in 1951, Dorman B.E. Kent recorded his life in diaries and letters. These papers—now held by the Vermont Historical Society , where Kent served as a librarian for 11 years—document everything from his childhood chores to his views on Franklin Delano Roosevelt’s New Deal and his sons’ career progress.

Of particular interest is Kent’s fall 1918 diary , which contains vivid descriptions of his own bout with influenza. On September 24, he wrote (as mentioned above):

Awoke at 7:00 [a.m.] sick, sick, sick. Didn’t get up or try to. Had a high fever an awful headache every minute all day and was sick to my stomach also. Tried to get Dr. Watson in the morning but he couldn’t come. Told us instead what to do. Greased cloths with inflamacene all day and put around throat and chest and held a bottle of hot water at throat most of the time. Took a seidlitz powder about 10.00 and threw it up soon so then took two tablespoons of castor oil. Then the movements began and I spent a good part of the time at the seat … There is a tremendous lot of influenza in town.

Kent recovered within a few days, but by the time he was able to resume normal activities, his two sons had come down with the flu. Luckily, all three survived the illness.

In early October, Kent participated in a door-to-door census count of the disease’s toll. Surveying two wards in Montpelier on October 2, he and his fellow volunteers recorded 1,237 sick in bed, 1,876 “either ill or recovered,” and 8 dead in one night. The following day, Kent reported that “25 have died in Barre today & the conditions are getting worse all the while. … Terrible times.”

Donald McKinney Wallace

From the wright state university special collections and archives, partially transcribed by lisa powell of dayton daily news.

Donald McKinney Wallace , a farmer from New Carlisle, Ohio, was serving in the U.S. Army when the 1918 pandemic broke out. The soldier’s wartime diary detailed conditions in his unit’s sick bay—and the Army’s response to the crisis. On September 30, Wallace wrote:

Layed in our sick ward all day but am no better, had a fever all day. This evening the Doctor had some beef broth brought down to us which was the first I had eaten since last Fri. Our ward was fenced off from rest of the barrack by hanging blankets over a wire which they stretched clear across the ceiling.

On October 4, the still-ailing farmer added, “Not a bit well yet but anything is better than going over to the hospital. 2 men over there have Spanish Influenza bad and are not expected to live. We washed all windows and floors with creoline solution tonight.”

Wallace survived his illness (and the war), dying in 1975 at age 78.

Though Wallace’s writings don’t reference the situation in his hometown, Bristow notes that many soldiers expressed concern for their families in correspondence sent from the front.

“You get these letters from soldiers who are so worried about their families at home,” she says, “and it’s not what anyone had expected. Their job was to go off soldiering, and the family would worry about them. And now, suddenly, the tables are turned, and it’s really unsettling.”

Helen Viola Jackson Kent

From utah state university’s digital history collections.

When Helen Viola Jackson Kent’ s children donated her journals to Utah State University, they offered an apt description of the purpose these papers served. Like many diary writers, Kent used her journal to “reflect her daily life, her comings and goings, her thoughts, her wishes, her joys, and her disappointments.”

On November 1, 1918 , the lifelong Utah resident wrote that she “[h]ad a bad head ache all day and did not accomplish much. Felt very uneasy as I found out I was exposed to the ‘flu’ Wed. at the store.”

Kent escaped the flu, but her husband, Melvin—called “Mell” in her diary—was not so lucky. Still, Melvin managed to make a full recovery, and on November 18 , his wife reported:

Mell much better and dressed today. Almost worn out with worry and loss of sleep. So much sickness and death this week, but one great ray of light and hope on the outcome of the war as peace came this past [11th].

Interestingly, Kent also noted that the celebrations held to mark the end of World War I had sparked an inadvertent uptick in illness.

“On account of the rejoicing and celebrating,” she wrote, “this disease of influenza increased everywhere.”

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Meilan Solly is Smithsonian magazine's associate digital editor, history.

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Spanish Flu: How America Fought a Pandemic a Century Ago

Science and medicine have come a long way since the 1918 outbreak.

by Aaron Kassraie, AARP , Updated September 21, 2021

National Archives

Nurses carry a patient in St. Louis, Missouri, during the Spanish Flu pandemic in 1918.

En español | Before scientists identified the influenza virus in 1933, the medical community had far less knowledge of how the flu passed from person to person and how to treat those infected. In 1918, as the world was nearing the end of the first world war, what became known as the Spanish flu was spreading rapidly among the soldiers who lived in close quarters. Some erroneously attributed the deadly pandemic that ultimately claimed an estimated 50 million to 100 million lives around the globe to everything from volcanic eruptions to bad Russian oats, according to Jeremy Brown, author of  Influenza: The 100-Year Hunt to Cure the Deadliest Disease in History .

Many countries censored news reports during World War I, especially information about the pandemic. Since Spain remained a neutral country, its press was free to report on the outbreak's relentless spread, leading to the name Spanish flu. Scientists are split over where the virus originated, with three possibilities being Kansas, France and China.

The Spanish flu killed about 675,000 people in the U.S. In September 2021, 18 months after the start of the coronavirus pandemic, American deaths attributed to COVID-19 hit 676,000, surpassing the toll of the influenza pandemic of 1918. Here are historical photos from the National Archives that show just how hard the Spanish flu hit America — and how Americans tried to avoid it, treat it and live with it.

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PHOTO BY: National Archives

Parades and other large public gatherings were common, contributing to the spread of the flu. Here munitions workers in Washington, D.C., line up for hot chocolate.

Convalescing soldiers were placed within arm's reach of each other in sick wards, separated by little more than a sheet, aiding the Spanish flu's spread. These patients were being housed at Eberts Field in Lonoke, Arkansas, because there was no room in the hospital.

Public health officials gathered in Chicago to address the epidemic, which at that point had already killed 400,000 people in three months. Experts agreed that whatever transmitted the disease could be found in mucus from the throat, nose and mouth. Gargling with salt water was recommended to military personnel as a preventive measure.

Hospitals were crowded and offered limited treatment options. Antibiotics to treat secondary bacterial infections that often accompany the flu had yet to be discovered. At Fort Porter in New York, beds were reversed so patients wouldn't breath in each other's faces.

Face masks made of gauze were widely used but offered little real protection. Nonetheless, these Red Cross workers in Boston assembled masks. “It is our duty to keep people from fear,” said Chicago's health commissioner. “Worry kills more people than the epidemic."

As disease spread, medical officers (above, at Love Field in Dallas) sprayed the mouths and throats of 800 healthy men daily with a solution of dichloramine-T, a disinfectant. But when they compared their influenza rates with 800 untreated men, they were disappointed to find that “over a period of twenty days the incidence in the two groups was the same,” according to a public health report.

It was thought that keeping windows open would deter the spread of the Spanish flu. This flyer in a trolley car in Cincinnati encouraged the practice, which was utilized nationwide.

Court officials in San Francisco held proceedings outside in hope that the open air would prevent infections.

It was a truly global epidemic; 100 American soldiers were buried in Devon, England, where they succumbed to the disease.

Editor's note: This story was updated with the latest numbers on COVID-19.

More on Politics & Society

• More states moving their primaries because of coronavirus
• Governors order coronavirus-related restrictions across America
• Will coronavirus impact the 2020 census?

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A science journalist explains how the Spanish flu changed the world

It's estimated that the Spanish Flu killed around 50 million people in between 1918 and 1919. Image:  via REUTERS

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Stay up to date:.

• Over three waves of infections, the Spanish flu killed around 50 million people between 1918 and 1919.
• Science journalist Laura Spinney studied the pandemic for her 2018 book Pale Rider: The Spanish Flu of 1918 and How It Changed the World.
• Here, she explains the impact the disease had on 20th-Century society – and talks about the lessons for the COVID-19 pandemic today.

A couple of years ago, journalist Laura Spinney could hardly believe how little people thought about the Spanish flu pandemic, which swept the globe in three deadly waves between 1918 and 1919.

So she wrote a book – Pale Rider: The Spanish Flu of 1918 and How It Changed the World – to bring the tragedy that claimed 50 million lives back into our consciousness,

Have you read?

Coronavirus and flu: why covid-19 poses more of a threat , how can we save lives and the economy lessons from the spanish flu pandemic, coronavirus and the lessons we can learn from the 1918-1920 great influenza pandemic.

“It seemed to me there was this huge hole in our collective memory about the worst disaster of the 20th Century. It’s definitely not remembered in the same way as the two world wars – there is some different way we remember pandemics.

“One of the ways I tried to explain it in my book was that, to me, that pandemic is remembered individually as millions of discrete tragedies, not in a history book sense of something that happened collectively to humanity.”

Here she explains what the world was like a century ago and how society changed as a result of the Spanish flu.

What was the Spanish flu?

It was a pandemic of influenza that struck in three waves. The first, mild wave in the Northern hemisphere's spring of 1918 receded in the summer or late spring. A much more lethal second wave erupted in the latter part of August and receded towards the end of that year, and the third wave emerged in the early months of 1919.

We think it infected about 500 million people – so one in three people in the world alive at that time, and it killed 50 million of them. The death toll could have been even higher because there was a big problem with under-reporting at the time. They didn't have a reliable diagnostic test.

Why was it so deadly?

Pandemic flu is much worse than seasonal flu, and we think there have been 15 flu pandemics in the past 500 years. Every seasonal flu started out as a pandemic flu, which was much more virulent because it was new in the human population. Gradually over time, it evolved to become more benign and to live in a more harmonious relationship with humanity.

There are lots of theories for why the Spanish flu was so virulent and they're not mutually exclusive. Some of them have to do with the inherent biology of that virus, and some of them with the state of the world at the time. That pandemic obviously emerged when the world was at war; there were extraordinary circumstances. Lots of people were on the move, not only troops, but also civilians: refugees and displaced persons. And there was a lot of hunger.

All of these factors may have fed into the virulence of the virus. There was definitely something very abnormal about 1918. If you think about the five flu pandemics we've had since the 1890s, none of them has killed more than about 4 million people maximum, whereas we think Spanish flu killed 50 million.

How different was the world in 1918?

There are a lot of similarities, but also a lot of really fundamental differences.

The population was about a quarter the size of what it is today and infectious diseases were still the main killer of people. It was a world that didn't know viruses very well. The first virus had been identified at the end of the 19th Century. So we had germ theory and people understood that microbes caused infectious diseases, but almost every doctor in the world thought they were dealing with a bacterial disease – and that shapes the whole story.

It means they had no reliable diagnostic test and no really good treatments. It was called many different things, which meant we had a problem counting the dead as well.

There were no commercial aeroplanes, so the fastest way you could get around was by ship or by train. Henry Ford had invented his Model T motor car, but they were still the preserve of the rich, as were telephones. And illiteracy was much higher than it is now, which had an impact because the main way that news was transmitted was by newspapers. In illiterate populations news travelled much more slowly and was often distorted.

Why is it called the Spanish flu?

It's a historical accident and unjust because we know for sure that it didn't start in Spain. We don't know where it did start, but there were cases in at least the US, Britain, France and probably some other European countries before it was in Spain.

But Spain was neutral in the war so it didn’t censor its press. And when the first cases broke out there in the spring of 1918, the newspapers reported on them, whereas in these other countries, it was kept out of the news. Those first Spanish cases included Alfonso XIII, the King of Spain, which made it very visible.

So that name kind of stuck, unfortunately, with the encouragement of the other warring nations who were quite happy to point the blame at somebody else. There is a parallel with today because pandemics have always gone hand-in-hand with xenophobia. There's always this human instinct, unfortunately, to point the finger at another country and say it came from there.

How did the Spanish flu change society 100 years ago?

In the short term, there was a jump in life expectancy, because a lot of people who were very ill with, for example, TB, which was a massive killer at that time, were purged from the population. They were probably the first to die of the Spanish flu because they were already in a weakened state. The people who were ill died and the people who were left behind were healthier.

There was also a baby boom in the 1920s, which has always been put down to the war and the men returning from the front. But there is an argument that the flu could have contributed because it left behind a smaller, healthier population that was able to reproduce in higher numbers. Norway, for example, had a baby boom even though it was neutral in the war.

Among those very vulnerable to the Spanish flu were the 20 to 40-year-olds. Normally flu is most dangerous to young children and to the very old, but in 1918, bizarrely, it was this middle age group. There wasn't much of a social welfare net, even in wealthy countries, so lots of dependents were left without any means of support because the breadwinners were taken out by the flu.

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Since its launch on 11 March, the Forum’s COVID Action Platform has brought together 1,667 stakeholders from 1,106 businesses and organizations to mitigate the risk and impact of the unprecedented global health emergency that is COVID-19.

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One of the great tragedies of 1918 is that those dependents just vanish into the cracks of history. We don't really know what happened to them but we get the occasional glimpse, for example, from a study in Sweden we know that a lot of old people moved into workhouses and a lot of the children became vagrants.

Men were more vulnerable than women overall globally, though there were regional variations. Pregnant women were particularly vulnerable and had miscarriages at frighteningly high numbers because, to fight the virus, the body took resources away from the womb and the growing foetus. Some of those babies survived and we know now there's a lifelong effect called foetal programming. That generation was physically and cognitively slightly reduced. They were more likely to suffer from heart attacks and to go to prison – and came of age just in time to go and fight in the Second World War.

How did healthcare change after the Spanish flu?

In many Western countries, there was a turning away from science after the pandemic because people were disillusioned with it. From the 1920s, for example, in America, alternative medicine took off in a big way and spread around the world.

But at the same time, in countries that had not really embraced the scientific method, you see the opposite effect. So China becomes a little bit more scientific after the pandemic. There's a move to better disease surveillance, better public health, more organized collection of healthcare data, because they saw that to prevent future pandemics they needed to turn towards science.

It gave a big boost to the concept of socialized medicine and healthcare, which no country had really got around to organizing yet. The pandemic is what gave the stimulus to do that because there was a realization that a pandemic was a global health crisis you had to treat at the population level. You couldn't treat individuals and there was no point in blaming individuals for catching an illness or treating them in isolation.

Russia was the first, followed by Western European nations, to put in place socialized healthcare systems. Along with that comes epidemiology, the search for patterns and causes and effects of patterns in healthcare. The baseline health of populations started to become much more transparent, and much more visible.

What parallels are there with today’s coronavirus?

The Spanish flu was democratic on one level. It could infect anyone: British Prime Minister David Lloyd George came down with the flu and Boris Johnson has had COVID-19 today. Nobody is, in theory, spared.

If you look at the population level though, there's a very clear disparity and basically the poorest, the most vulnerable, the ones with the least good access to healthcare, the ones who work the longest hours, who live in the most crowded accommodation, and so on, are more at risk.

But in 1918, it was a time of eugenics-type thinking and it was perceived that those people who were more prone to the flu were constitutionally somehow inferior, that it was somehow their fault. Of course eugenics was completely discredited after the Second World War.

Today, we understand that the reason those poorer groups in society are more vulnerable is because of the environment they inhabit and the fact that they don't have access to better healthcare. That effect is strong in every pandemic and, unfortunately, it's likely that developing countries are the ones that are going to bear the burden of this pandemic.

What protective measures were put in place in 1918?

We've always understood that in order to contain contagion you have to separate sick and healthy people. Concepts like isolation and quarantine are very old and they predate germ theory. So we didn't have to understand that diseases are spread by microbes to understand how to rein them in.

Public health measures were put in place in some parts of the world. America did very well, Europe didn't do too badly, but there was a war on and it wasn't possible to keep those things in place very effectively, or for long enough.

The dates of the waves were dependent on where you were in the world. They came later in the Southern hemisphere, which meant Australia had the luxury of seeing this thing approach in space and time from the north, and took advantage of that to put in place maritime quarantine.

It managed to keep out the lethal second wave in October 1918, which is one of the rare exceptions of public health measures really working that year. But they lifted it too soon and the third wave of infection of early 1919 came into the country and killed 12,000 Australians. But it would have been much, much worse if they had not put the quarantine in place when they did.

Will COVID-19 be remembered in history?

It's too early to know if we’ll remember this one, but the precedents suggest we won’t. There were two other flu pandemics in the 20th Century: the 1957 Asian flu and the 1968 Hong Kong flu. They killed about 2 million and 4 million people, respectively. We are nowhere near those numbers yet and yet we don't compare this pandemic to them. We immediately head for the enormous one in 1918, which is strange in itself. But they were much worse than this one to date, and we don't remember them.

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Comparison of public health measures taken during Spanish flu and COVID-19 pandemics: A Narrative Review

Sampada tambolkar.

1 Department of Pediatrics, Dr D.Y. Patil Medical College, Hospital and Research Center and Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Manas Pustake

2 Department of Internal Medicine, Grant Government Medical College and Sir J. J Group of Hospitals, Mumbai, Maharashtra, India

Purushottam Giri

3 Department of Community Medicine, IIMSR Medical College, Badnapur Dist. Jalna, Maharashtra, India

Isha Tambolkar

4 Department of Community Medicine, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India

The similarity of the consequences of COVID-19 reminded us of the destruction caused by the Spanish flu over a century ago and led us to find similarities in the way the two pandemics were handled. PRISMA Guideline was followed for a systematic search to identify eligible published articles. Information about the public health measures adopted during both the pandemics was taken from literature. It was found that there are parallels between the two pandemics in terms of general unpreparedness, attitudes of the community and government, and various policy issues. All the measures implemented in 2020 were the same as those implemented in 1918–1919, with the same trend, uncertainty, early relaxing, and rapid reversals. Even from a scientific standpoint, all the elements were already known. All the issues such as social isolation, intra-family spread, personal protective equipment, medicine types (quinine, aspirin, anti-inflammatories, etc.), immunization requirements, and so on had already been addressed. No doubt, we do have technology today at our disposal for managing the spread of the disease and even spread awareness among people much easily. We also have taken many steps forward in the world of globalization, which make the progression and spread of the pandemic very fast as well. Both factors tend to counter each other and hence make timely public health intervention as important (if not more) today as it was yesterday. When possible, approaches and goals should be found on scientific facts and include ethical input. Finally, we must take careful notice of past local and national lessons to avoid repeating the mistakes done in the past. The development of a strategy ahead of time that includes all levels of government health infrastructure and outlines clear lines of duties and functions is critical. The main objective of this article was to compare the public health measures undertaken during the pandemic of Spanish Flu and the pandemic of COVID-19, and assess the similarities and differences in the public health measures taken during these pandemics. The correlation of the public health measures and the outcomes was assessed and the implication of this article was to be pandemic-ready in the future.

Introduction

The world Health Organization (WHO) declared the COVID-19 outbreak as a public health emergency of worldwide concern on January 30, 2020, and began classifying it as a pandemic in March 2020 to highlight the seriousness of the situation and to urge all governments to take action in detecting illness and preventing spread. The announcement made by WHO on March 7, 2020, “Responding to community spread of COVID-19,” states that preventing COVID-19 from spreading is through the development of coordination mechanisms not only in health, but also in areas such as transportation, travel, commerce, finance, security, and other sectors that encompasses the entirety of society.[ 1 ] The consequences of the disease reminded us of the destruction caused by the Spanish flu over a century ago and led us to find similarities in the way the two pandemics were handled. The Spanish Flu of 1918–19 was the deadliest pandemic in history, killing more than 50 million people. Even as we deal with the current pandemic of COVID-19, the public health implications of the Spanish flu pandemic remain unclear.[ 2 ]

In the absence of a vaccine, public health interventions are the first line of protection against an outbreak. This can be attributed to the fact that globalization, urbanization, and the increase in the density of population have made controlling a pandemic difficult.[ 3 ] Every variant of the virus will not have a vaccine and public health interventions assume paramount importance in such conditions. Implementation of these interventions need to be done at grassroot levels. The role of primary health care centers, family physicians, and general practitioners is significant in these situations. This review article focuses on and compares the public health measures undertaken during the pandemics of Spanish Flu and COVID-19, and also discusses relevant updates in the pandemic preparedness strategy to attenuate the effects of pandemics in the future.

The following measures are currently being used to handle pandemics:

Social distancing

The goal of social distancing is to decrease interactions between people in a larger population where individuals may be contagious but haven’t been detected and hence not isolated, particularly important when the disease spreads due to close contact.[ 4 ] This is not limited to maintaining a safe distance while in public. It includes closing schools, colleges, offices, avoiding public gatherings, and measures like encouraging online shopping instead of physically going to the market.[ 5 ] Traffic restrictions, the cancellation of social events, and home quarantine have all been linked to a decrease in the degree of transmission.[ 6 ]

Quarantine is the restriction of activities or separation of persons who are not unwell, but may have been exposed to an infectious agent or disease, with the goal of monitoring their symptoms and guaranteeing early diagnosis of cases. Quarantine itself comes from the Italian word ‘Quaranta,’ which means forty. This is because, ships coming at the Venice port in fourteenth-century Italy from other plague-infected ports had to anchor and wait for 40 days before disembarking their surviving passengers, which was a common public health norm.[ 5 ] Prior research states that quarantine is the most efficient approach for reducing both the number of infected and the number of deceased.[ 6 , 7 ] To ensure success, quarantine should be implemented as soon as possible and combined with other public health initiatives.[ 8 ]

Isolation is the exclusion of sick people with infectious diseases from non-infected people to protect the latter group. It is most commonly seen in hospitals.[ 4 ] Isolation of the infected people helps in slowing down the transmission of the disease.

Use of face masks

The purpose of the face mask is to prevent transmission of the virus by containing the secretions of the people.[ 5 ] Face masks should be used in the community in addition to, not instead of, other prevention measures including physical separation, staying home while sick, respiratory etiquette, meticulous hand hygiene, and avoiding touching the face, nose, eyes, and mouth.[ 9 ]

If these steps are deemed inadequate, ‘community-wide containment’ might be necessary. Community-wide containment is a strategy for reducing personal interactions in a community, area, or country, except allowing limited contacts to ensure essential supplies.[ 4 ] This community-wide containment took place in India as the Janata Curfew and the Lockdown in India in the initial days of the spread of the disease. Mass quarantining of disease “hot spots” could be implemented to prevent the disease from spreading to other areas in future waves.[ 10 ] This was also implemented in India in the form of micro-containment zones and containment areas. Mass communication and community education through various media was promoted, which supplemented the aforementioned measures.[ 11 ]

Public Health Measures taken during Spanish Flu Pandemic

The 1918 influenza epidemic was a major social and health event that resulted in a high rate of morbidity and mortality in the general population. The fast onset of symptoms, the spread to large groups of people, and the lack of information about the causal agent were all factors that combined to make the flu a serious public health problem.[ 12 ] The importance of quarantine as a public health measure was strongly proven during the influenza pandemic of 1918.[ 13 ] The most prominent example comes from the United States, in Philadelphia, where the first case was discovered on September 17, but societal measures to limit the spread, such as restricting crowds in public locations, were implemented on October 3, when there were 40 deaths per 100,000 people. Unfortunately, the subsequent steps were ineffective, and by the middle of October, the number had risen to 250/100,000 persons. In St. Louis, Missouri, the first case was discovered on October 5, and social restrictions were imposed on October 7, and both the number of patients and the rate of mortality were kept low.[ 5 ] Another interesting example comes from Milan where the then Head Physician of the Municipality proposed some public health measures to prevent the spread of disease. In Milan, murmurs of Spanish influenza prompted Guido Bordoni Uffreduzzi (1859–1943), the Municipality’s chief physician, to intervene. On a collective basis, it was suggested to isolate the sick, to avoid overcrowding, especially in communities and the surroundings. Individually, it was suggested that people avoid unnecessary contact with the sick and convalescents, as well as unnecessary travel while attempting to maintain daily routines as much as possible. It was suggested that people wash their hands multiple times a day and use a moderately acting disinfectant mouthwash to safeguard their oropharynx.[ 14 ]

The simplest of treatments, such as the abundance of air in the environment where the sufferers are located, were thought to have a positive outcome and were implemented.[ 15 ] The study submitted by the Committee formed by the Paris Medical Academy for the prophylaxis of influenza was mentioned in the BMJ of November 2, 1918. They include personal hygiene measures such as mouth washing and gargling twice a day with a glass of warm water containing a solution of chlorine soda, as well as population-related measures such as overcrowding prevention, tramway and railway carriage washing and disinfection, and school closure.[ 16 ] Another unique measure was put in place at St Paul: Elevators were no longer authorized in buildings with fewer than six floors. Due to the close confines and lack of fresh air, elevators were deemed as areas where influenza may quickly spread.[ 17 ] Sanitation laws were enacted, which required restaurants and bars to sterilize their plates and cups, as well as prohibit roller towels and common drinking glasses in public restrooms. A health teaching campaign involving school teachers (who were out of work), postal workers, and Boy Scouts was also held.[ 18 ] Nurses too played a central role in the management of the pandemic. Retired nurses were called back to lend their help in the handling of the pandemic. New spaces were opened up for the sufferers of the disease.[ 19 ]

Finally, summing up the major public health measures, as analyzed by newspapers back in the day, we can say that measures such as the closure of schools and postponement of the start of the academic year, disinfection of facilities, quarantines, isolation, suspension of public celebrations, disinfection and hygiene, border control, suspension of railway communications, and the development and use of various vaccinations and serums to immunize the people were adopted; plasma was also termed to be an effective measure for the treatment of Spanish Flu-caused-pneumonia.[ 20 ] The spread of Spanish flu was slowed by identifying suspicious cases through surveillance and voluntary and/or enforced quarantine or isolation. Because no vaccinations or antivirals were available at the time, these public health initiatives were the only effective weapons against the disease.[ 21 ] Local health departments implemented public health interventions such as providing free soap and clean water to the poor; services for the removal of human waste, the inspection of milk and other food products; prohibiting spitting in the street, which slowed the spread of pocket spittoons; and newspaper and leaflet advertisements touting the therapeutic benefits of water.

Public Health Measures taken during COVID-19 Pandemic

In general, preventive measures in terms of community medicine consumed are voluntary or self-quarantine, mandatory quarantine, hand hygiene, isolation, personal protective equipment, school measures/closures, social distancing, workplace measures/closures.[ 5 ] After the implementation of multifaceted public health measures (including but not limited to intensive intracity and intercity traffic restriction, social distancing measures, home confinement and centralized quarantine, and improvement of medical care) in Wuhan, the number of incident COVID-19 cases were reduced, and the situation was under better control.[ 6 ] India also has put stringent measures such as a lockdown in place to manage the pandemic. India took a technological, social, and legislative approach, which was instrumental in flattening the curve of the disease in the early stages.[ 22 ] However, Sweden has adopted a surprising approach to the pandemic. It looks to be a significant outlier in its public health policy by imposing only very minimal mandates—closure of high schools and colleges alone and prescribing isolation for symptomatic persons and those over 70 years old.[ 23 ] Singapore adopted a resource-intensive containment effort based on the symptoms and travel history of suspicious patients. Despite this cost-containment effort, it was recognized that some COVID-19 individuals with little symptoms might be admitted to the general ward at first. As a result, our hospital prioritized social distancing initiatives across the board.[ 24 ] Some countries have had the best success because they adopted early restrictions and robust testing measures. For instance, New Zealand adopted a “go hard, go early” approach, in which the government responded quickly to signals of community spread.[ 25 ] Despite an early epidemic, South Korea was able to flatten the curve by thorough testing, contact tracing, and widespread mask use. Even in a single country, state policies have varied, which ultimately led to a variation in the number of cases. For instance, different states in the United States of America have responded differently to the pandemic. Outbreaks have been comparatively less in states like New York that have made greater attempts to contain the virus as compared to states like North Dakota, which did little to control the spread of the disease initially.[ 25 ] Although convalescent plasma has been shown to be effective in the treatment of several viral infections in the past, its application in the context of COVID-19 is still controversial.[ 20 ] In fact, the Indian Council of Medical Research has dropped plasma therapy from COVID-19 Management Guidelines.

What Changed and What did not Change: A Comparison of Approaches

There are parallels between the two pandemics in terms of general unpreparedness, attitudes of the community and government, and various methods. All the measures to be implemented in 2020 are the same as those implemented in 1918–1919, with the same trend, uncertainty, early relaxing, and rapid reversals. Even from a scientific standpoint, all the elements (such as social isolation, intra-family spread, personal protective equipment, etc) were already known.[ 14 ] No doubt, we do have the technology today at our disposal for managing the spread of the disease and even spread awareness among people much easier. We also have taken many steps forward in the world of globalization, which makes the progression and spread of the pandemic very fast as well. Both factors tend to counter each other and hence make timely public health intervention as important (if not more) today as it was yesterday. A difference in the testing facilities is also present between the two pandemics. Testing was not available during the deadly Spanish Flu pandemic because we didn’t know what caused it at the time.[ 26 ] The major difference between the two pandemics has been the development of vaccines. Researchers attempted to produce a vaccine during the 1918–1919 pandemic. A number of vaccinations were investigated against Bacillus influenzae (now known as Hemophilus influenzae), as well as pneumococcus, streptococcus, staphylococcus, and Moraxella catarrhalis bacteria. These bacterial vaccinations had little chance of preventing the pandemic, which was caused by a novel strain of the influenza A virus, as we now know.[ 27 ]

On the contrary, the development of a vaccine for the COVID-19 pandemic was in fact a race against time. Within a year and a half of the commencement of the pandemic, India fast-tracked the approval of three COVID-19 vaccinations: Covishield from the Serum Institute in Pune, Covaxin from Bharat Biotech, and Sputnik V, a Russian vaccine. Countries all over the world have started full-fledged vaccination drives. Israel was the first country to demonstrate that vaccines had a widespread impact. The U.S. has administered 89.3 doses for every 100 people.[ 28 ] Another major difference between the two pandemics was that the health education and awareness platforms have been enormous during the recent pandemic, considering that it is the age of social media. Press was the only source of widespread information dissemination during the Spanish flu pandemic. Today, the public health and hygiene measures can reach far and relatively inaccessible areas very easily; but the downside was, it also spread rumors and panic very fast. Another aspect of technology during this pandemic was that the development of Apps like the Arogya Setu App made contact tracing efficient and fast, greatly reducing disease transmission. Also, the App showed the availability of hospital beds and oxygen beds for patients to be admitted. In addition, this pandemic of 2020 had the boon of technology, when home-based care and treatment were possible without physical consultation due to telephonic and video consultation. Concepts of telemedicine and e-consultation have flourished and have had numerous benefits during these tough times. All of this technological assistance was certainly not in place during the Spanish-flu outbreak. Figure 1 compares the availability of health related resources during the COVID-19 pandemic and the Spanish Flu pandemic.

Comparison of availability of resources during the COVID-19 pandemic and the Spanish Flu pandemic.

Conclusions

The choice of strategy should be region-specific and factors like compliance of the population and awareness among the public are some factors that will influence the strategy chosen for a region. Periodic assessment and revision of the strategy will prove beneficial over a longer duration. Public health should be put above social and economic concerns. Finally, ‘such measures can be reduced’ is an issue that demands more research. Patterns in the timing and severity of second waves in 1918, however, appear to have significant implications. This means that till we have an effective vaccine in hand, we need to deploy efficient pharmaceutical interventions to keep the pandemic under control. Finally, every country and government should be ready for any medical emergency and be able to handle it efficiently by getting their priorities right. This is especially applicable to primary healthcare providers who are the first point of contact for many patients. Their role becomes even more significant and important when we aim to spread awareness and ensure the interventions reach the grassroot level. The general physicians are the link between the public health policy and the public. They should be made aware of the intricacies of pandemic management and interventions so that they can effectively disseminate the information. This will only strengthen our healthcare system as community medicine forms the core of any healthcare system.

Recommendations

When possible, approaches and goals should be founded on scientific facts and include ethical input. Finally, we must take careful notice of past local and national lessons in order to avoid repeating the mistakes done in the past. The development of a strategy ahead of time that includes all levels of government health infrastructure is critical. Stakeholders must be consulted on surge capacity and community containment plans, and an agreement must be reached. The healthcare systems are generally overwhelmed at the peak of a pandemic. Therefore, it is important to analyze as to what extent we would require a particular healthcare intervention and enhance its production in the nascent stages of the pandemic. It is also important to have an additional buffer of healthcare staff that could potentially reduce the burden on the frontline medical staff at the height of the pandemic. Family physicians having adequate medical knowledge can be trained in pandemic management per se , and they will be the best additional buffers. They could be trained to work in the hospitals or in special departments like the Emergency Department, Intensive Care Unit, and so on and will be a formidable buffer during pandemics. Thus, it will reduce the chances of having overburdened healthcare workers.

• There are parallels between the two pandemics in terms of general unpreparedness, attitudes of the community and government, and various methods.
• The major differences between the two pandemics has been the development of vaccines and availability of technology (apps like Arogya Setu app, e-consultation, etc).
• We do have the technology today at our disposal for managing the spread of the disease and spreading awareness among people much easier, but we also have taken many steps forward in the world of globalization, which makes the progression of the pandemic very fast as well. Both factors tend to counter each other and hence make timely public health intervention very important.
• The general physicians are the link between the public health policy and the public. They should be made aware of the intricacies of pandemic management and interventions so that they can effectively disseminate the information.
• It is also important to have an additional buffer of healthcare staff (trained family physicians) who could potentially reduce the burden on the frontline medical staff at the height of the pandemic.

Ethical considerations

No human or animal participants were involved in the study. Ethical approval was not required for this study.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.