In 1918, one of the deadliest pandemics faced by mankind swept over the globe, killing an estimated 25 to 100 million people and infecting 500 million people, which was ⅓ of the world population. This pandemic, deemed the Spanish Flu, was undoubtedly one of the greatest tragedies faced by mankind with its severe symptoms and death toll among the young and healthy. A year before I had experienced the COVID-19 pandemic for myself, I had conducted a history project on this devastating pandemic, so the Great Influenza Pandemic of 1918 holds a special place in my heart as one of my favorite topics that I’ve come across and researched. With this pandemic from just over a century ago, what caused such a devastating event?
**Note: While the pandemic is referred to as the “Spanish Flu,” it’s important to note that Spain was not responsible for starting the pandemic, nor am I condoning the practice of naming pandemics after countries. The name the “Spanish Flu” is used in this article due to how frequently the name is used!**
The beginning of the pandemic and the first wave
One morning on March 4, 1918 at Camp Funston, the U.S. Army Camp stationed at Fort Riley, Kansas, a camp cook named Albert Gitchell reported to the camp hospital with a sore throat, headache, and a high fever. By noon, there were more than 100 cases of this strange illness. This began the first few cases of the disease, and soon, army camps and prisons around the country reported similar outbreaks. During this time, World War I was going on. As the Americans joined the war in Europe, tens of thousands of American soldiers, nicknamed doughboys, were shipped overseas to France, where the disease began spreading in Europe. Eventually, this disease spread to Spain.
While the news of the flu in other countries was censored due to wartime, Spain was neutral in World War I, which led the new disease to be dubbed “the Spanish Flu” as they reported the news about the flu, even though the flu did not start in Spain. The king of Spain, King Alfonso XIII, became a well-known victim as he quickly became seriously ill with the disease, although he eventually recovered. During this first wave in the spring, the symptoms were relatively mild, with a sore throat, headache, and fever, so some called this disease the “three-day fever.” This wave eventually subsided, but the pandemic was far from over.
“Basically, it gets called the ‘Spanish flu’ because the Spanish media did their job,”Lora Vogt, curator of education at the National WWI Museum and Memorial
The deadly second wave
By August 1918, the “three-day fever” had changed. This time, while most patients reported typical symptoms of the flu, the severe cases were extremely deadly, unlike any other flu that had been seen before. It had turned into a pneumonia-like disease, where victims had trouble breathing and developed mahogany spots on their cheeks. Eventually, the lack of oxygen caused victims to flush red, and as time progressed, their skin turned from red to blue, and from blue to black, starting from the extremities, limbs, and finally the torso and abdomen. With the lack of oxygen, patients were described as “like a fish out of water” as they experienced air hunger. This condition was called heliotrope cyanosis, and often meant that death was imminent for the patient.
In an autopsy, it was found that the lungs of a patient with the Spanish Flu were purple, swollen, and covered with haemorrhage blood and a “watery pink lather” and described to be similar to the effects of chemical warfare. Many victims died drowning in their own fluids as their lungs filled with fluid. For those who were previously healthy, within 24 hours of showing symptoms, the patient would suddenly die. Yet, sudden death may have been the best for the victims, as patients suffered from projectile vomiting, explosive diarrhea, and as the disease dragged on, the lack of oxygen began affecting the nervous system, which caused lifelong problems with the nervous system, heart, lethargy, and depression.
“When the chest was opened and the blue swollen lungs were removed and opened, and Dr. [William Henry] Welch saw the wet, foamy surfaces with real consolidation, he turned and said, ‘This must be some new kind of infection or plague,’ and he was quite excited and obviously very nervous… It was not surprising that the rest of us were disturbed, but it shocked me to find that the situation, momentarily at least, was too much even for Dr. Welch.”Rufus Cole, director of the Rockefeller University Hospital
The Spanish Flu also affected mental health and increased suicide rates
While infectious diseases are often associated with physical symptoms, the Spanish Flu also made an impact on mental health, as there were cases of patients jumping out of buildings or committing suicide. It was suspected that the flu could cause psychosis, delirium, agitation, and temporary insanity. In Seattle, the cases of suicides and suicide attempts increased during the pandemic as people lost family members or became severely ill with the flu.
Philadelphia was hit particularly hard by the flu, as on the peak of the flu, 4,597 people died from influenza or pneumonia in a week. Morgues that were designed to carry 36 bodies were overfilled with nearly 200 bodies crammed into every available space. This meant that in cities hit hardest by the pandemic, bodies were piled up in hospitals, porches, streets, and in homes. As the bodies began decaying and oozing blood, the smell of death was everywhere on the streets, and one nurse described the smell of the Spanish Flu as a “musty straw smell.”
With the Armistice celebration in November of 1918 bringing crowds of people, this led to a resurgence of flu cases, until the second wave of this deadly pandemic began subsiding in December of 1918. This second wave that occurred in the fall of 1918 was the deadliest wave of the pandemic, and many historians attribute this to the mutations that accumulated due to wartime.
“The rapid movement of soldiers around the globe was a major spreader of the disease… The entire military industrial complex of moving lots of men and material in crowded conditions was certainly a huge contributing factor in the ways the pandemic spread.”James Harris, a historian at Ohio State University studying infectious disease and World War I
The final wave of the pandemic
By winter of 1919, the flu had come back again, this time called the third wave. Australia, which had largely escaped the two previous waves due to its remote location, was hit hard by this third wave, with an estimated 12,000 deaths. Australia’s indigenous population was severely impacted by this wave, as in some communities, the mortality rate was nearly 50%. In order to combat the pandemic, Australia began implementing a variety of measures including closing schools, pubs, theaters, and other public places, requiring masks in public, spraying streets, and even attempting to make a vaccine by mixing the sputum from victims.
On October 5th, 1918, it was reported by The Times that the Surgeon General of the United States, Rupert Blue, advocated for schools, churches, and theaters, and other public places to be closed, but he was largely powerless as it was up to individual states and municipalities to make decisions regarding the pandemic. By the summer of 1919, the Spanish Flu had largely subsided. Many scientists believe that this was because enough people had either gained immunity against the virus or had died, which meant that the virus was not able to spread. However, in some places such as Japan, the epidemic lasted until 1920. Japan experienced a fourth wave of the pandemic, which was called the “sumo flu.”
Medical research and treatments during the Spanish Flu
Doctors frequently took blood and sputum samples from their patients and inoculated onto Petri dishes with blood agar. During this time, the medical understanding of microorganisms was not very sufficient, and scientists believed that the disease was caused by Pfeiffer’s bacillus, now known as Haemophilus influenzae, a bacteria known for causing infections. However, when Peter Olitsky and Frederick Gates at The Rockefeller Institute took nasal secretions from patients and passed them through Berkefeld filters that were able to filter out bacteria, it showed that the infectious agent was able to pass through the filters, this suggested that it was not a bacteria.
With little information on the infectious agent causing the disease, many people turned to home remedies, such as tying garlic around their necks, putting kerosene on sugar cubes, or putting a deer by their beds. Medical treatments treated symptoms, such as by reducing a fever or pain, so doctors often prescribed aspirin, acetylsalicylic acid,or salicin to reduce pain, discomfort, and fevers. For patients with cyanosis, doctors often injected oxygen under the skin or by mask. Patients were rested and given plenty of fluids and warm drinks, while warm or cool compresses were also used.
While bacterial pneumonia was often the killer behind the flu, the first antibiotic, penicillin, was not discovered until 1928. However, these medical treatments did not have much scientific reasoning behind it, as the science at the time was not sufficient to develop treatments. With the war, the Allied Forces suspected that the flu was a chemical weapon developed by Germany, as the patients of the second wave did show symptoms similar to the effects of mustard gas, with hemorrhaging in the mucous membrane and bleeding from the nose, ears, and mouth. The anti-German sentiment during World War I caused many Americans to believe that German submarines were releasing influenza on the Atlantic coast. Even German pharmaceutical brand, Bayer, was suspected of poisoning its aspirin pills with influenza.
“The daily death toll from influenza alone in Philadelphia would exceed the city’s average weekly death toll from all causes. In a single day, 759 people died from the pandemic alone. In an average week, 485 died from all causes.”Calm, Cool, Courageous, University of Pennsylvania School of Nursing
Wartime censorship was a huge contributor to the spread of the pandemic
One of the major contributors to the severity of the pandemic was wartime censorship, as countries fighting in the war suppressed information and stories about the flu in order to boost wartime morale. In France, the United Kingdom, and the United States, newspapers were prevented from reporting on events that could lower morale and harm the war effort, including news about the flu. For example, in the United States, the Sedition Act passed in 1918 prohibiting any speech that would “belittle the efforts to win the war” likely caused newspapers to downplay the severity of the flu, while British public health expert Arthur Newsholme refused to impose a quarantine even though it was known that this would have been the best strategy to control the infection when he stated, “the relentless needs of warfare justified incurring [the] risk of spreading infection.”
In addition, quarantines were not imposed in many places in order to prevent the lack of workers from harming the war effort. Yet, the Spanish Flu may have also played a significant role in ending World War I, as both sides experienced devastating consequences with soldiers dying due to the flu. In fact, the Spanish Flu directly contributed to the failure of a major German spring offensive on the Western front, known as Kaiserschlact, as it weakened German troops and drained their supplies. This forced General Erich Lundendorff to put off his final offensive, as his troops were sick and dying of the flu. The cramped living conditions within trenches and army camps became the ideal conditions for the flu to spread quickly.
In particular, one ship, the USS Leviathan became a hotbed for the Spanish Flu with its cramped quarters and unsanitary conditions. During its trip in September 1918 from Hokoben, New Jersey to Brest, France, 2,000 men fell sick with the flu, and 90 died. Beds were turned into makeshift sick beds, but there were not enough beds for victims, so the decks blood and vomit that were tracked around due to the narrow spaces. Future President Franklin D. Roosevelt was one of the survivors on this trip.
“…pools of blood from severe nasal hemorrhages were scattered throughout the compartments, and the attendants were powerless to escape tracking through the mess, because of the narrow passages between the bunks.”Official Navy report
In total, an estimated 50 million people died in this pandemic and 1/3 of the world population infected
In this devastating pandemic, it was estimated that 50 million people died, although some estimates go anywhere from 25 to 100 million. ⅓ of the world population, or 500 million people, had been infected by the Spanish Flu. If a pandemic that killed a similar proportion of people were to occur today, it would have killed more people today than the number of people that die from heart disease, cancers, strokes, chronic pulmonary disease, AIDS, and Alzheimer’s disease combined. The case fatality rate was particularly high compared to other influenza pandemics, as the Spanish Flu had a case fatality rate of >2.5%, while other flu pandemics had a case fatality rate of less than 0.01%.
While diseases typically show a U-shaped curve with a higher mortality among young children and infants and the elderly, it was observed during the Spanish Flu that healthy adults aged 20-40 were disproportionately affected, resulting in a distinct W-shaped curve that had not been documented before. In fact, in New York City alone, 31,000 children had lost one or both parents. This spike in cases of those who were previously healthy was due to the cytokine storm caused by the virus. Cytokine storms occur when the body releases an uncontrolled amount of inflammatory cytokines, which are proteins that are chemical messengers that allow the immune system to communicate, and this can cause a life-threatening immune response that causes the body to attack its own cells and organs. Therefore, the stronger the immune system, the stronger the cytokine storm. Ironically, people with the strongest immune systems are the most at risk to die from a cytokine storm, which caused the spike in cases in people aged 20-40.
However, this drastically impacted the economy, as most of the workforce was made up of people aged 20-40. On average, countries experienced a 6% drop in GDP per capita, which is comparable to the Great Recession in the United States in 2008. According to the United States Center for Disease Control, the Spanish Flu cost the United States $166 billion.
“These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. 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 cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face….It is only a matter of a few hours then until death comes…It is horrible….We have been averaging about 100 deaths per day…For several days there were no coffins and the bodies piled up something fierce…”Roy Grist, physician at the Camp Devens hospital
What caused this devastating pandemic?
Scientists began studying the influenza virus that had caused the pandemic, and in 1931, a virologist from Iowa named Richard Snopes observed that there had been two outbreaks of swine flu in pigs in 1918 and 1929. To study the infectious agent, he took samples from infected pigs and filtered the samples. He discovered a highly infectious agent that was capable of causing severe disease in pigs when mixed with bacteria, which established the idea of a swine influenza.
Eventually, after years of research, it was proposed that the virus responsible for the Spanish Flu was caused by an avian flu virus and swine flu virus that had recombined in a pig as a “mixing vessel” and infected a human. Haskell County, which reported the first incidence of a strange illness before the first case at Camp Funston, did have farmers that raised hogs, as well as 17 species of birds. It is likely that the flu virus began spreading when men from Haskell County travelled to Camp Funston.
However, the Spanish Flu virus was much more virulent than future flu pandemics because it had not adapted to surviving in the human body. This is because contrary to popular belief, viruses do not exist to kill their host, as that would mean less of a chance of passing it on to others. Over time, viruses evolve to become less virulent, but because of its zoonotic origin, the Spanish Flu virus had not evolved and caused severe disease in humans.
In 1951, microbiologist Johan Hultin traveled to a remote village in Alaska called Brevig Mission to uncover samples of the virus, since most of the inhabitants of the village had died in the pandemic and were buried in a mass grave under the permafrost. While his first attempt failed, his second attempt 46 years later succeeded, and this sample was shared with the Armed Forces Institute of Pathology, where they sequenced the genome and categorized the virus as an influenza A(H1N1) virus.
Eventually, in 2004, Dr. Terrence Tumpey, a microbiologist at the Centers for Disease Control (CDC), and his team reconstructed the H1N1 virus that had caused the Spanish Flu using reverse genetics, which is a method to identify the function of a gene by observing its phenotypes. In their study, they found that this virus had genes that contributed to the high rate of virulence and replication observed with the pandemic.
Throughout the course of this pandemic, 50 million people were killed, making this a disease “more deadly than war.” With wartime censorship and unreliable leadership that further exacerbated the spread of the virus, the Spanish Flu became one of the worst tragedies faced by mankind as it caused a devastating economic and social impact. 31,000 children lost one or both parents in New York City alone, while in cities hit hardest by the pandemic, bodies were stacked in rooms and porches as horse-drawn wagons circled neighborhoods to collect the dead. Yet, further research in the flu sparked a new hope as scientists gained a better understanding of swine and avian flu viruses, and today, we now know what caused the devastating pandemic as scientists at the CDC have reconstructed the H1N1 virus. Nevertheless, it’s important to take the understanding from the 1918 Spanish Flu pandemic to change humankind and public health for the better.
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