What we can learn from the 1918 flu pandemic

1918 spanish flu pandemic
Photo via Armed Forces Institute of Pathology-National Museum of Health and Medicine/Flickr (Public domain)

The numbers are almost unfathomably ominous: about 500 million people infected (which was one-third of the Earth’s population), at least 50 million dead globally, approximately 675,000 who perished in the U.S. It was 1918, and the flu pandemic was felt everywhere.

It was a time of horror and panic. It was a time of lies and underestimation. It was a time of good decisions and bad.

Many of the mistakes that politicians made in 1918 have been made in 2020. Some of the ignorance about a newfound virus that the healthcare system couldn’t treat in the early 20th century has been repeated in the early 21st. Some of the history of that horrid virus has been felt again today.

COVID-19 won’t come close to killing as many people as the H1N1 influenza pandemic of 1918, though some experts believe the coronavirus could be just as deadly. But it could devastate the global economy. It could change our social habits. It could destroy the way the world’s citizens view themselves and the earth on which they live.

The modern world had never seen the kind of mass destruction caused by the 1918 pandemic, but the globe survived and provided lessons to be learned for what (and what not) to do. Here’s what life was like during the pandemic of 1918.

The origins of the 1918 flu pandemic

It’s impossible to nail down exactly where and when this particular virus originated. But there are plenty of theories. Some historians believe it began in Chinese villages along the Great Wall, where dozens of people were dying per day, and then was spread when nearly 100,000 Chinese workers traveled to the Western Front of World War I to work behind the British and French soldiers.

Other historians believe the virus was born in the World War I trenches used by the French—which, according to National Geographic, were “ridden with filth, disease, and death.” As the war was entering its final months in 1918, some think that malnourished soldiers living in such close quarters was one reason the virus became so deadly and so infectious.

Still others theorize that the virus was first found in the heartland of the U.S. In the sparsely populated Haskell County in Kansas, a mysterious flu virus broke out in January 1918, and it was so troublesome at first that a local doctor named Loring Miner alerted the U.S. Public Health Service about it. Even the Santa Fe Monitor, a local Kansas newspaper, noted it, writing, “Most everybody over the country is having lagrippe or pneumonia.”

At one point, a number of men from the county visited Camp Funston, a nearby Army training base. Within two weeks, thousands of soldiers were sick. Smithsonian magazine wrote: “Then, infected soldiers likely carried influenza from Funston to other Army camps in the States—24 of 36 large camps had outbreaks—sickening tens of thousands, before carrying the disease overseas. Meanwhile, the disease spread into U.S. civilian communities.”

Other researchers think the virus actually began in Vietnam in 1917.

Wherever and whenever it began, somebody infected with the H1N1 virus would experience symptoms of a dry cough and a fever. They could begin having stomach problems and excessive sweating. Afterward, pneumonia or respiratory issues could develop, and sometimes, that was what would kill you. Or, as one observer noted, via the National Institutes of Health, “One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred.”

The virus spread relatively quickly and featured at least one big difference from COVID-19: The younger generations were the ones at greatest risk.

Sources: CDC, National Geographic, Live Science, Smithsonian, National Institutes of Health

1918 flu pandemic troops spread
Photo via State Library of South Australia/Flickr (Public Domain)

How the flu spread around the world

The timing for the virus was fortuitous for its long-lasting survival. It first became prevalent in the final months of World War I, and soldiers who caught the virus spread it among themselves and then to their fellow countrymen when they returned to their home lands. Unlike COVID-19, which kills older people at a much higher rate, the flu of 1918 was deadlier for those between the ages of 18 and 45 years old.

It killed so many people in that age range that it lowered the life expectancy in the U.S. by more than a dozen years. As the CDC noted, a “comparable death rate has not been observed during any of the known flu seasons or pandemics that have occurred either prior to or following the 1918 pandemic.”

One theory for the high mortality rate for younger adults is that elderly citizens had already experienced a similar virus when they were younger that made them immune from this particular strain of influenza. That unknown earlier infection for seniors “was close enough to the 1918 virus that they had a lot of protection against it from natural immunity,” John M. Barry, the author of The Great Influenza: The Story of the Deadliest Pandemic in History, told Vox.

Though the H1N1 virus didn’t spread nearly as quickly as the coronavirus of 2020 on a global level, the troops certainly helped move it around the world rather quickly. In the summer of 1918, the flu was discovered in Germany, France, Austria, and Hungary. In July, one London textile factory sent 20% of its 400 workers home one night because they were so sick, and eventually between 25% and 50% of British government workers missed work because of the flu.

By August, Canadian sailors, Swedish soldiers, and South African laborers were infected.

Nobody had effective tools to fight off the virus. Approximately 30% of U.S. physicians who could have helped fight the virus domestically were overseas for military service. There were no flu tests, anyway. There was no vaccine. There were no antiviral drugs that could have helped. There were no intensive care units and no ventilators.

“Without these medical countermeasures and treatment capabilities, doctors were left with few treatment options other than supportive care,” the CDC wrote.

Health experts weren’t even aware that influenza viruses existed. Instead, they thought the pandemic was caused by bacteria called “Pfeiffer’s bacillus” and spent millions of dollars trying to test and treat for it. Of course, that wasn’t the cause of the pandemic.

“This was a huge distraction for medical science,” historian James Harris told History.

Doctors and scientists couldn’t fight the disease, because they (unknowingly) didn’t know what it was—much in the same way that today’s researchers and scientists are fighting an enemy in the novel coronavirus that has unknown capabilities and consequences.

In 1918, though, many local politicians in the U.S. only made things worse.

Sources: CDC, Vox, Live Science, History

How the U.S. reacted to the 1918 flu pandemic and tried to stop it

The COVID-19 pandemic has forced politicians and scientists on different paths. Many in the medical field preach the benefits of social distancing and warn of a second wave of the coronavirus. Many politicians, meanwhile, have relaxed restrictions on society and put people back to work to open up their economies.

The response from politicians and healthcare professionals 102 years ago could be a good roadmap to help figure out our way back from COVID-19.

Though doctors didn’t know how to cure the H1N1 flu (or even what it was), they advised patients to avoid crowded places and other people, and they told people to cover their faces in public. They recommended using disinfectants and maintaining good personal hygiene. They asked people to stop shaking hands.

Yes, unscrupulous citizens tried to make money by selling fake cures for the flu, and yes, some physicians recommended eating cinnamon or drinking beef broth to avoid it. Even worse, one researcher said that citizens stopped believing what the government relayed to them because of all the untruths being told.

“The government lied. They lied about everything,” historian John M. Barry told Vox. “We were at war and they lied because they didn’t want to upend the war effort. You had public health leaders telling people this was just the ordinary flu by another name. They simply didn’t tell the people the truth about what was happening.”

It didn’t take long for people to realize it.

“People noticed pretty quickly what was up when their neighbors started dying 24 hours after symptoms first appeared,” Barry said. “People were in the streets bleeding out of their noses, bleeding out of their mouths, bleeding out of their eyes and ears. It was horrific. Everyone understood very quickly that this was not an ordinary flu.

“… The lack of trust made it harder to implement critical public health measures in a timely way, because people just didn’t believe what they were being told. And by the time the government was forced to be transparent about the situation, it was mostly too late. The virus was already widely disseminated. So the lying and the lack of trust cost a lot of lives.”

New York was actually ahead of the game in combating the influenza outbreak. It had built a successful public health infrastructure, according to the National Institutes of Health, because of a previous issue with tuberculosis. For the previous 20 years, the city had railed against spitting, and officials made sure to reemphasize that during the pandemic. Pamphlets that were translated in English, Italian, German, and Yiddish asked citizens not to spit, and according to the New York Tribune, Boy Scouts who caught people disobeying in public handed them a card that read, “You are violating the Sanitary Code.”

Violators who were caught were subject to arrests and fines (usually a punishment of $1).

Though public schools controversially remained open because government officials thought it would keep students safer and in a cleaner environment—you’ll recall a similar controversy erupted in March 2020 when New York City Mayor Bill de Blasio did all he could to keep the school system open—the city’s mortality rate never spiraled out of control.

In fact, New York’s death rate was less than Boston’s or Philadelphia’s. (Compare that to how New York City is an epicenter for COVID-19 in 2020.)

1919 flu pandemic New York face masks
Photo via Archives of Ontario/Flickr (Public Domain)

Philadelphia’s response, meanwhile, was a debacle, and history points to one event in particular that made the City of Brotherly Love a disaster zone.

In an effort to support the soldiers fighting in the Great War and to raise millions in bond dollars, the city organized the Liberty Loan parade in the heart of Philadelphia in September 2018. Although infection rates were beginning to creep up in the city and even though infectious disease experts told local officials that the parade, expected to draw a few hundred thousand citizens, would be “a ready-made inflammable mass for a conflagration,” the parade rolled onward.

A few days later, every bed in the city’s 31 hospitals was filled by infected patients. Soon after, 4,500 Philadelphians had died, and in a six-week period, that number swelled to about 12,000.

To contrast Philadelphia’s disastrous decision, the city of St. Louis shut down schools, libraries, theaters, pool halls, and churches while also limiting streetcar ridership and public gatherings. According to a paper from the National Academy of Sciences, St. Louis forcefully responded to the flu two weeks before Philadelphia did, and as a result, the death rate of the two cities, respectively, were 347 per 100,000 people vs. 719 per 100,000 people.

St. Louis proved in 1918 that social distancing can save a massive number of lives. Philadelphia proved that large gatherings in the early stages of a pandemic is a terrible idea.

More than 100 years later, New York City’s mayor was already planning on ways to celebrate the end of the coronavirus. As WNBC reported on April 21, Bill De Blasio said that healthcare workers and first responders at some point will be celebrated … with a ticker-tape parade down a street in the heart of Manhattan.

Sources: CDC, Live Science, National Institutes of Health, New York Times, History, Quartz, National Academy of Sciences, Smithsonian magazine, National Institutes of Health, WNBC, Vox

The second wave of the pandemic was even worse

It seems almost certain that the COVID-19 pandemic will experience a second wave of devastation. It could happen in the fall of 2020. It could happen in 2021. Now that states are reopening in May and people are protesting the killing of George Floyd, it could happen in June. 

In 1918, the second wave of the flu caused even more deaths than the first.

Though the virus spread quickly in April and May of 1918, the symptoms were relatively mild and quick to leave the body. Then, the infection rates slowed that summer, and some believed the virus was heading toward extinction.

But researchers now believe the virus mutated, and it had a devastating effect—Smithsonian magazine compared the incoming second wave to “a great tsunami that initially pulls water away from the shore, only to return in a towering, overwhelming surge.”

1918 flu pandemic British Red Cross
Photo via British Red Cross/Flickr (CC BY 2.0)

According to the History Channel, 195,000 Americans died in the month of October 1918 alone, and many of them were healthy people in their mid-20s and mid-30s who were found to have high spiking fevers and “nasal hemorrhaging and pneumonia.” Much like the coronavirus, some suffered from a cytokine storm, where the immune system overwhelms everything in the body to snuff out the virus—and then ends up snuffing out that person’s life as a result.

“That really freaked out the medical establishment,” historian James Harris said.

A third wave of the virus appeared in January 1919, and though it wasn’t as deadly as the second, it still killed millions of people.

It even severely affected President Woodrow Wilson, who is believed to have been struck by the virus as he negotiated the terms to end World War I that April. At the Paris Peace Conference in France, Wilson grew weak and confused and eventually collapsed. Wilson reportedly never publicly mentioned the flu pandemic, but some believe that the virus affected him neurologically and caused him to yield his demands on the treaty. Those decisions by a compromised Wilson were called “disastrous” by Smithsonian, which wrote that the president’s actions (or inactions) later contributed to the start of World War II a few decades later.

While San Francisco had successfully stymied the worst of the consequences of the flu through the first two waves—thanks to effective quarantines and the early decision to close schools and ban public gatherings—it was struck hard by the third. Residents were bound by law to wear face masks, and because people believed that protection was what shielded them from the virus in the first two waves, they weren’t quite as keen to practice social distancing and stay away from public gatherings by 1919.

In November 1918, the city officially lifted the mask mandate, and the San Francisco Chronicle wrote: “After four weeks of muzzled misery, San Francisco unmasked at noon yesterday and ventured to draw its breath. Despite the published prayers of the Health Department for conservation of gauze, the sidewalks and runnels were strewn with the relics of a torturous month.”

A few weeks later, more and more cases began to pile up, and thousands of San Franciscans died. According to Smithsonian, an analysis completed in 2017 theorized that if the city had retained its anti-flu protections into the spring of 1919, deaths would have been reduced by 90%.

In mid-April 2020, medical experts claimed that if social distancing measures had been put in place in the U.S. on March 2 instead of March 16, 90% of the deaths experienced in the country could have been avoided.

Sources: History, Smithsonian, Washington Post, Business Insider, San Francisco Chronicle, The Hill

Can a pandemic on that scale happen again?

Technology is infinitely better in 2020 than it was in 1918. So is the information about preventing and treating diseases. Yes, some of the same mistakes that were made in the 20th century are being made in the 21st. But it’s unlikely that the death and global destruction caused by the H1N1 virus in 1918 will ever be seen again.

But as we’ve seen since January 2020, no matter how much we know and how savvy the technology is, viruses can still grow recklessly into pandemics. And they’ll still infect millions and kill hundreds of thousands (if not more) as hospitals become overwhelmed and people eschew social distancing measures.

As the CDC noted: “As human populations have risen, so have swine and poultry populations as a means to feed them. This expanded number of hosts provides increased opportunities for novel influenza viruses from birds and pigs to spread, evolve and infect people. Global movement of people and goods also has increased, allowing the latest disease threat to be an international plane flight away. Due to the mobility and expansion of human populations, even once exotic pathogens, like Ebola, which previously affected only people living in remote villages of the African jungle, now have managed to find their way into urban areas, causing large outbreaks.”

There have been other pandemics, including the swine flu of 2009 that killed about 12,500 Americans, but in the past several decades, they haven’t been nearly as deadly. (The 1957 and 1968 pandemics killed about 100,000 Americans apiece).

In 1918, experts didn’t even know about the existence of viruses. They didn’t know what they didn’t know. In 2020, COVID-19 is such a new disease that sometimes it feels the same. But the 1918 pandemic can teach those who live in 2020 plenty of lessons.

“The questions they asked then are the questions being asked now,” Oregon State University history professor Christopher Nichols told WebMD. “And while it’s very rare that history provides a simple straightforward lesson for the present, this is one of those instances.”

It’s unclear if we’re actually listening.

Sources: CDC, WebMD

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