Nearly 100 years ago, in 1918, the world experienced the greatest tidal wave of death since the Black Death, possibly in the whole of human history. We call that tidal wave the Spanish flu, and many things changed in the wake of it. One of the most profound revolutions took place in the domain of public health.
The world was a very different place in the first decades of the 20th century. Notably, there was no real joined-up thinking when it came to healthcare. Throughout the industrialized world, most doctors either worked for themselves or were funded by charities or religious institutions, and many people had no access to them at all.
Public health policies—like immigration policies—were colored by eugenics. It was common for privileged elites to look down on workers and the poor as inferior categories of human being, whose natural degeneracy predisposed them to disease and deformity. It didn’t occur to those elites to look for the causes of illness in the often abject living conditions of the lower classes: crowded tenements, long working hours, poor diet. If they sickened and died from typhus, cholera, and other killer diseases, the eugenicists argued, then it was their own fault, because they lacked the drive to achieve a better quality of life. In the context of an epidemic, public health generally referred to a suite of measures designed to protect those elites from the contaminating influence of the disease-ridden rabble.
The first wave of the Spanish flu struck in the spring of 1918. There was nothing particularly Spanish about it. It attracted that name, unfairly, because the press in neutral Spain tracked its progress in that country, unlike newspapers in warring nations that were censored. But it was flu, and flu as we know is transmitted on the breath—by coughs and sneezes. It is highly contagious and spreads most easily when people are packed together at high densities—in favelas, for example, or trenches. Hence it is sometimes referred to as a “crowd disease.”
Policemen in Seattle wearing masks made by the Red Cross during the influenza epidemic, December 1918. Photo courtesy of the National Archives.
That first wave was relatively mild, not much worse than seasonal flu, but when the second and most deadly phase of the pandemic erupted in the autumn of 1918, people could hardly believe that it was the same disease. An alarmingly high proportion of patients died—25 times as many as in previous flu pandemics. Though initially they reported the classic symptoms of flu—fever, sore throat, headache—soon they were turning blue in the face, having difficulty breathing, even bleeding from their noses and mouths. If blue turned to black, they were unlikely to recover. Their congested lungs were simply too full of fluid to process air, and death usually followed within hours or days. The second wave receded towards the end of the year, but there was a third and final wave—intermediate in virulence between the other two—in early 1919.
Flu is caused by a virus, but virus was a novel concept in 1918, and most of the world’s doctors assumed they were dealing with a bacterial disease. This meant that they were almost completely helpless against the Spanish flu. They had no flu vaccine, no antiviral drugs, not even any antibiotics, which might have been effective against the secondary bacterial infections that killed most of its victims (in the form of pneumonia). Public health measures such as quarantine or the closing of public meeting places could be effective, but even when they were imposed this often happened too late, because influenza was not a reportable disease in 1918. This meant that doctors weren’t obliged to report cases to the authorities, which in turn meant that those authorities failed to see the pandemic coming.
The disease claimed between 50 and 100 million lives, according to current estimates, or between 2.5 and 5 percent of the global population. To put those numbers in perspective, World War I killed about 18 million people, World War II about 60 million. Rates of sickness and death varied dramatically across the globe, for a host of complex reasons that epidemiologists have been studying ever since. In general, the less well-off suffered worst—though not for the reasons eugenicists proposed—but the elites were by no means spared.
The lesson that health authorities took away from the catastrophe was that it was no longer reasonable to blame an individual for catching an infectious disease, nor to treat him or her in isolation. The 1920s saw many governments embracing the concept of socialized medicine—healthcare for all, delivered free at the point of delivery. Russia was the first country to put in place a centralized public healthcare system, which it funded via a state-run insurance scheme, and others in Western Europe followed suit. The United States took a different route, preferring employer-based insurance schemes, but it also took measures to consolidate healthcare in the post-flu years.
Privileged elites looked down on workers and the poor as inferior, … whose natural degeneracy predisposed them to disease. It didn’t occur to those elites to look for the causes of illness in the often abject living conditions of the lower classes: crowded tenements, long working hours, poor diet.
In 1924, the Soviet government laid out its vision of the physician of the future, who would have “the ability to study the occupational and social conditions which give rise to illness and not only to cure the illness but to suggest ways to prevent it.” This vision was gradually adopted across the world: The new medicine would be not only biological and experimental, but also sociological. Public health started to look more like it does today.
The cornerstone of public health is epidemiology—the study of patterns, causes, and effects in disease—and this now received full recognition as a science. Epidemiology requires data, and the gathering of health data became more systematic. By 1925, for example, all U.S. states were participating in a national disease reporting system, and the early warning apparatus that had been so lamentably lacking in 1918 began to take shape. Ten years later, reflecting the authorities’ new interest in the population’s “baseline” health, U.S. citizens were subjected to the first national health survey.
Many countries created or revamped health ministries in the 1920s. This was a direct result of the pandemic, during which public health leaders had been either left out of cabinet meetings entirely, or reduced to pleading for funds and powers from other departments. But there was also recognition of the need to coordinate public health at the international level, since clearly, contagious diseases didn’t respect borders. The year 1919 saw the opening, in Vienna, Austria, of an international bureau for fighting epidemics—a forerunner of today’s World Health Organization.
By the time the WHO came into existence, in 1946, eugenics had been disgraced and the new organization’s constitution enshrined a thoroughly egalitarian approach to health. It stated that, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” That philosophy wouldn’t eliminate the threat of flu pandemics—the WHO has known three in its lifetime, and will surely know more—but it would transform the way human beings confronted them. And it was born of an understanding that pandemics are a social, not an individual problem.
The Influenza Pandemic and The War
Frederick Holmes, MD
Professor of Medicine Emeritus and of The History of Medicine
University of Kansas School of Medicine
War and epidemic disease have been partners from time immemorial; and so it was with The War which spanned the years 1914 to 1918 and the influenza pandemic which spanned the years 1918 and 1919. Contrary to popular belief the 1918 virus - now known to be of the H1N1 strain - did not originate in Spain but rather in Kansas in the United States. In January and February of 1918 Dr. Loring Miner of Haskell County, in the very southwestern corner of Kansas, reported and described the year’s first influenza cases of unusual severity. It is virtually certain that young men leaving Haskell County for military service at Camp Funston in eastern Kansas carried the virus with them. By early March there were hundreds of cases and many deaths at this very large - over 50,000 soldiers - induction and training camp. From Camp Funston soldiers departed by the thousands for assignment to military camps across the United States and eventually on to Europe, quite obviously carrying the flu virus with them. Influenza reached the port of Brest, France, with American soldiers in April. In retrospect a more efficient incubator and disseminator of an infectious disease to pandemic proportions could not be imagined, young non-immune persons concentrated in close quarters for weeks and then dispersed throughout the world. In contrast to epidemic typhus, which was never a problem on the Western Front but which sickened and killed millions on the Eastern Front, influenza started its sweep through the Western Front in France in May and quickly spread across the trenches, through Germany, and on to Austria and the Slavic nations to the east.
America Was Paralyzed By the Epidemic
Military transport ships were the likely vector of influenza which was well-established around the world by August of 1918. As the pandemic grew and matured its virulence apparently increased. Mortality rates on the eastern coast of America climbed in newspaper reports, the epidemic seeming to emanate from military bases there. Thus, what had been called the “three day flu” at Camp Funston in March, with a mortality rate of perhaps two-percent, evolved into a much more severe illness in India where mortality rates in some places may have reached ten-percent. However, on the Western Front, with an estimated attack rate of about forty-percent of soldiers, the mortality rate of influenza hovered at about two percent in all military personnel and the pandemic started to wane in October and then diminished further by year’s end only to spike once again early in 1919 before the pandemic ran its course. It must be recognized that attack rates and mortality rates in major epidemics are always exaggerated, fueled by panic in the populace and the press and other media. The best benchmark statistics for American soldiers come from U S Army official statistics, thus: of 791,907 admissions for influenza to army hospitals there were 24,664 deaths, interestingly, about half the total number of battle deaths. That is just over a three-percent death rate for influenza serious enough to merit hospital admission. And, the actual cause of most of these deaths was complicating bacterial pneumonia.
Classic Photo of a Temporary Military Influenza Hospital
The fact that attack and mortality rates were highest in young adults made the pandemic all the more obvious and important in armies largely composed of young men. Death from influenza, especially in young adults, occurs in four circumstances. Thus, first, acute viral pneumonia; second, hyper-reaction of the patient’s immune mechanisms leading to extensive lung tissue damage; third, superimposed pneumonia from the pneumococcus bacillus; and fourth, pneumonia from other bacterial species. The first two of these can lead to death in just hours, while the latter caused death days to weeks after the initial acute illness.
Microscopic View of the Lung in Fatal Influenza
No one can doubt that the influenza pandemic shortened The War. After four years of fighting Germany was running out of men, food, and money and was becoming politically unstable. American troops were flooding France; in all there were about two million fighting men in the American Expeditionary Force - the AEF in parlance of the time - under the command of General John “Black Jack” Pershing. The first large engagement of American troops was at Belleau Wood in June 1918 and it was there that the Germans, in awe of their fighting prowess, christened the United States Marines teufel hunden, devil dogs. It was by the end of that summer, with the terrible toll of morbidity and mortality exacted by the influenza virus, that the Allied forces attacked the dispirited German army in the Meuse-Argonne offensive and in the period of six weeks leading to the 11 November 1918 Armistice, overran the Germans, forcing them to sue for peace.
Tin Pan Alley Celebrates The Red Cross Nurse
Sick soldiers can’t fight. While influenza is a self-limited viral disease with a relatively low mortality rate and uncommon aftereffects, the American army did a better job of keeping healthy troops in the frontlines than the Germans. The Base Hospitals of the American Army, far from the front but reached swiftly by special ambulance trains, had special wards for influenza patients and, with excellent nursing care, were able to return the majority of them to the front after brief periods of convalescence. Most influenza deaths were caused by complicating pneumonia which, as there were no antibiotics in 1918, could only be managed expectantly. It was not until the early 1930s that the viral cause of influenza was discovered, so treatment in the large Base Hospitals was largely supportive. It is not possible to over-estimate the altruism, value, and importance of the thousands of American nurses who cared for sick soldiers and who stemmed the tide of the influenza pandemic.
The War's Only Icon of Caring and Mercy - The Red Cross Nurse
Looking back to 1918, now nearly one-hundred years in the past, one must marvel that America armed itself and its allies and sent two million soldiers across the Atlantic Ocean to France and Belgium to end “The War to End All Wars”. This was done in spite of the facts that the influenza epidemic brought almost every aspect of life in America to a halt and America’s military power had to be projected three thousand miles across the Atlantic Ocean.
Images are from the Wellcome Library in London, the National World War I Museum at Liberty Memorial in Kansas City, and several other sources. The statistics are from the volumes of The Medical Department of the United States Army in The World War.
Last modified: Dec 31, 2014