In February of 1918, the world was embroiled in the bloodiest conflict in the history of civilization. Soldiers from around the globe were mobilized and sent to the front lines of the first world war, fighting battles so terrible that they believed that its conclusion would bring lasting peace and an end to all future wars. This was a mechanized world, more similar to our own than to the world of a century before, and despite the destruction of the Great War, it was a time of optimism for the medical community. Doctors were well on their way to a scientific understanding of disease, and for the first time in the history of humanity they had the power to not only treat but cure infectious disease. One by one, humanity’s greatest killers were coming under the power of man—vaccines, antisera, and new laboratory techniques led some to believe that the microscopic world was on the verge of being conquered. Perhaps it was because of this hubris that few took note of a report of “influenza of severe type” that appeared in the weekly journal Public Health Reports in early 1918 (Barry, 2004, p. 94-95).
Though it is difficult to know with certainty, it is likely that the outbreak that became the “Spanish Flu” originated from a pig farm somewhere in Haskell County, Kansas (Barry, 2004, p. 98). From there it spread to Europe via troop transport and from Europe to the rest of the world. This Spring wave was widespread but not particularly deadly, killing mainly the very young and very old, but sickening enough of the young German military that General Erich von Ludendorff blamed it for the failure of his spring offensive (Barry, 2004, p. 171). The Spring wave also gave the pandemic its name. Because all of the belligerent nations censored their press, it was only neutral Spain that reported openly of the new epidemic and thus it became the “Spanish Flu” (Barry, 2004, p. 171). The death toll fluctuated throughout the spring and summer, provoking sporadic concern and containment efforts across the affected nations but overall, little attention was paid outside of medical circles. Attention to this new virus was intermittent until late summer, in France, when a random mutation resulted in an increase in virulence that prefigured the single deadliest event in all of human history (Barry, 2004, p. 182).
France, the nexus of the allies and central powers war effort and manpower, erupted with influenza and as some of these soldiers were removed to their homes across the world, they carried the new strain of influenza with them. In the United States, some of these soldiers disembarked in Boston and were immediately quarantined by military officials, but despite their best efforts, on September 3, a civilian was admitted to the hospital. Around the same time, the disease reached the nearby and severely overcrowded Camp Devens (Barry, 2004, p. 184-186). Within weeks the Camp was entirely overrun. Barry wrote, “In a single day 1,543 Camp Devens soldiers reported ill with influenza. On September 22, 19.6 percent of the camp was on sick report, and almost 75 percent of those on sick reports had been hospitalized,” (2004, p. 187). Dr. Roy Grist, an army physician at the camp wrote to a colleague:
‘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 vicious type of pneumonia that has ever been seen. Two hours after admission they have the mahogany spots over the cheekbones, 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 colored 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…We have been averaging about 100 deaths per day… pneumonia means in about all cases death…We have lost an outrageous number of Nurses and Drs., and the little town of Ayer is a sight. It takes special trains to carry away the dead. For several days there were no coffins and the bodies piled up something fierce… It beats any sight they ever had in France after a battle. An extra-long barrack has been vacated for the use of the Morgue, and it would make any man sit up and take notice to walk down the long lines of dead soldiers all dressed and laid out in double rows… Good By old Pal, God be with you till we meet again.”(Ross, 2004, p. 187-188)
The hospital at Camp Devens, designed to hold twelve hundred patients, was crammed with more than six thousand, and when medical officers arrived to investigate the cause of the outbreak, they noted that 35% of the nurses were already among the sick (Barry, 2004, p. 187).
Meanwhile, cities across the eastern seaboard were experiencing their first cases of influenza. Some cities, like New York, reacted quickly by imposing social distancing measures early in the outbreak, but others were not so prescient (Strochlic & Champine, 2020). In Philadelphia, city public health director Wilmer Krusen not only did not stockpile supplies at the advice of doctors, but opposed banning public meetings, closing schools, or imposing quarantines on hotspot areas because he feared that this would cause panic or interfere with the war effort (Barry, 2004, p. 203). The newspapers, barred by The Espionage Act under pain of 20 years imprisonment from printing “any disloyal, profane, scurrilous, or abusive language about the government of the United States,” (Barry, 2004, p. 123-124) downplayed the severity of the outbreak. One reported that influenza posed no danger and printed a quote from a public health official that doctors would easily “confine this disease to its present limits” and that “no concern whatever is felt by either the military and naval physicians or by the civil authorities” (Barry, 2004, p. 204). Then, after the deaths began to mount, a paper again quoted, “This disease has about reached its crest. We believe the situation is well in hand. From now on the disease will decrease” (Barry 2004, p. 204).
But the disease did not abate, and in fact, was only just beginning to take root in the city. Just a week later, Krusen went ahead with the scheduled Liberty Loan parade against the now desperate advice of other medical officials, drawing thousands into the streets. Within 3 days of the parade, “every single bed in each of the city’s thirty-one hospitals was filled. And people began dying,” (Barry, 2004, p. 220). Yet despite the panic that was now gripping the city, the papers continued printing Krusen’s reassurances, “the peak of the influenza epidemic has been reached;” when more than 300 people died the next day they reported, “these deaths mark the high watermark in the fatalities;” then, after over 400 had died in one day, “Don’t get frightened or panic-stricken over-exaggerated reports, (Barry, 2004, p. 221-222). Soon the public lost all trust in the papers and in the city government, and even when they started to print logical guidance, few trusted them enough to listen.
On a national level, the response was not much different. While President Wilson extolled the nation to continue the war in Europe, he completely ignored the outbreak of disease. There is no record of Wilson ever making any public statement about influenza, and according to Barry, “From neither the White House nor any other senior administration post would there come to any leadership, any attempt to set priorities, any attempt to coordinate activities, any attempt to deliver resources,” (2004, p. 302).
Across the nation, scenes played out that were reminiscent of pandemics of ages long past. Coffins everywhere were in short supply, and in Philadelphia an undertaker noted that seminary students volunteered to dig graves, recalling, “they brought in a steam shovel to Holy Cross Cemetery and actually excavated… they would begin bringing caskets in and doing the committal prayers right in the trench,” (Barry 2004, p. 327). As in prior pandemics, the poor died at greater rates than the rich (Barry, 2004, p. 408-409), and where there was fear, soon followed conspiracy theories. There was a persistent rumor that the influenza outbreak was the result of a German biowarfare attack. A Mississippi paper printed, “The Hun resorts to unwanted murder of innocent non-combatants… He has been tempted to spread sickness and death thru germs, and has done so in authenticated cases,” (Barry, 2004, p. 341). And though it didn’t result in major atrocities, racism was prevalent throughout the pandemic, particularly against immigrant groups such as Italians and against native people (Spinney, 2017, p. 106).
But in the midst of all this suffering, there was a bright spot—in the years during and surrounding the 1918-19 influenza pandemic, it is not hyperbole to say that the doctors and scientists who cared for the sick did so while inventing modern medicine. For several years prior to the pandemic, new scientific practices had been enshrined in medical and nursing education, among which were an understanding of the germ theory of disease, epidemiology, and the reliance on clinical trials to prove the effectiveness of interventions. These precepts resulted in the testing and adoption of the use of cloth masks to prevent infection, the development of a pneumococcal antiserum and eventual vaccine that would be administered during the pandemic, and an awareness of the potential that a filterable virus was causing the disease. The work that began as a race to save lives during the epidemic would later directly lead to the discovery of penicillin by Alexander Fleming, and the discovery of DNA as heritable material by Oswald Avery (Barry, 2004).
The transition to modernity was not always smooth. In many places, people viewed the massive death toll of the 1918-1919 influenza as a repudiation of science and instead turned to homeopathy and superstition. The New York Times declared “Science has failed to guard us” (Spinney, 2017, p. 235) and in a similar vein, the New York commissioner was removed for political reasons and replaced with homeopath Royal Copeland who would later go on to the senate and ensure that homeopathic remedies were recognized as “drugs” by the FDA (Barry, 2004, p. 267). And while medical journals such as JAMA or The New England Journal of Medicine presented accurate assessments of the death toll and printed negative results of studies of influenza treatments such as quinine or typhoid vaccine as an immune adjuvant (Barry, 2004, p. 353), other magazines were not so beholden to fact. In Philadelphia, a Christian science magazine proclaimed that prayer alone had been more effective than conventional treatment (Spinney, 2017, p. 236), and a national homeopathic journal claimed that the mortality of conventional medical treatment was 28.2% and that the mortality among homeopathic treatment was 1.05% (Barry, 2004, p. 353). Further, there was a backlash against the compulsory wearing of masks, and in San Francisco, an Anti-Mask League was founded (Canales, 2020) though they did not gain much traction.
In all, the 1918-1919 influenza pandemic killed an estimated 50 million people, including 675,000 Americans (History of 1918 Flu Pandemic, 2018), more Americans than have been killed in all the wars of the 20th century combined. There was a trimodal death curve, peaking for those under 5 and over 65, but also uncharacteristically peaking among those 20-40 (History of 1918 Flu Pandemic, 2018) with one autopsy study revealing that almost half of those died of what would today be considered ARDS (Barry, 2004, p. 252). This pandemic strained the global healthcare system to its breaking point and highlighted both the hubris and the promise of medical science at the dawn of the 20th century. In the years since the pandemic, the Spanish Flu has become the case study from which most of our pandemic preparedness has been based, and from its ashes grew the seeds of a rigorous, scientific, medical field with the tools to more effectively cure disease and relieve suffering. Nevertheless, the Spanish Flu has often been called the forgotten pandemic, and given the granularity of recent past along with its confounding proximity to WWI, it is hard to draw more firm societal trends from the chaos of recent history than we could with more ancient events. Thus, beyond its immediate consequences, it remains to be seen what the effects of ‘flu in the 20th century’ will be.
Barry, J. M. (2004). The great influenza: the epic story of the deadliest pandemic in history. New York: Penguin Books.
Canales, K. (2020, May 21). Photos show how San Francisco had to convince its ‘mask slackers’ to wear masks after many defied the law while the 1918 Spanish flu pandemic seized the city. Retrieved from: https://www.businessinsider.com/san-francisco-anti-mask-league-1918-spanish-flu-pandemic-2020-5
History of 1918 Flu Pandemic. (2018, March 21). Retrieved from: https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918- pandemic-history.htm
Spinney, L. (2017). Pale rider: the Spanish flu of 1918 and how it changed the world.
London: Vintage. Strochlic, N., & Champine, R. D. (2020, April 7). How some cities ‘flattened the curve’ during the 1918 flu pandemic. Retrieved from: https://www.nationalgeographic.com/history/2020/03/how-cities-flattened-curve-1918-spanish-flu-pandemic-coronavirus/