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As a terrifyingly lethal influenza virus swept across the globe between 1918 and 1920, history’s deadliest pandemic claimed the lives of approximately 50 million people worldwide and 675,000 in the United States. Nearly 200,000 Americans died from the “Spanish Flu” in October 1918 alone, making it the deadliest month in the country’s history.
With cremation an uncommon practice at the time, the sheer number of bodies overwhelmed the capacity of undertakers, gravediggers and casket makers to keep pace with the arduous task of burying the dead. At the same time, a prohibition on public gatherings that included funerals and wakes compounded the pain of many grief-stricken families who could not properly mourn the loss of their loved ones.
America Was Unprepared for the Flu’s Mass Mortality
Nancy K. Bristow, a University of Puget Sound history professor and author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic, says the United States had been caught unprepared for the outbreak partly because advances in bacteriology made many Americans believe they could control infectious diseases.
“This is not what Americans in 1918 expected to occur,” she says. “An enormous number of people died very quickly, particularly on the Eastern Seaboard where the flu struck first, and they didn’t have an opportunity to prepare in any way.”
The mass mortality led to macabre scenes. Red Cross nurses in Baltimore reported instances of visiting flu-ravaged homes to discover sick patients in bed beside dead bodies. In other cases, corpses were covered in ice and shoved into bedroom corners where they festered for days.
Inundated undertakers stacked caskets in funeral home hallways and even in their living quarters. In New Haven, Connecticut, six-year-old John Delano and his friends played outside of a mortuary, scaling a mountain of caskets piled on a sidewalk, unaware of the contents inside. “We thought—boy, this is great. It’s like climbing the pyramids,” he recalled.
Photos: Innovative Ways People Tried to Protect Themselves From the Flu
Cemeteries struggled to handle the soaring death toll. With gravediggers absent from work—either because they had contracted the flu or were afraid that they would—grieving families were sometimes forced to excavate tombs for their loved ones. In New Brunswick, New Jersey, 15 workhouse inmates were handed spades and picks to dig graves under the watchful eyes of guards. In Baltimore, city employees were called into emergency duty as gravediggers while soldiers from Fort Meade were pressed into service to bury a three-week backlog of 175 bodies at Mount Auburn Cemetery.
Casket companies, already busy supplying coffins for the thousands of doughboys killed in World War I, could not keep up with the demand. Facing a desperate shortage in the nation’s capital, District of Columbia Commissioner Louis Brownlow hijacked two train cars filled with 270 coffins bound for Pittsburgh and rerouted them to the city hospital under armed guard. Gravediggers at Boston’s New Calvary Cemetery were spotted dumping corpses out of caskets into graves so that the coffins could be used again. The War Industries Board ordered casket makers to manufacture only plain caskets and immediately cease production of “all fancy trimmed and couch and split panel varieties.” It limited casket sizes for adults to 5 feet, 9 inches and 6 feet, 3 inches.
Philadelphia Resembled the Plague-Infested Middle Ages
The worst horrors were seen in Philadelphia, where the number of deaths approached 1,000 a day at the pandemic’s peak. Entire neighborhoods were draped in crepe that was mounted on front doors to mark deaths inside. Civic leaders recruited the J.G. Brill Company, a streetcar manufacturer, to construct thousands of rudimentary boxes in which to bury the dead, while desperately needed coffins arrived in the city under armed guard.
Five hundred bodies crowded the city morgue, which had a capacity for only 36 corpses. The city scrambled to open six supplementary morgues and placed bodies in cold storage plants. Some Philadelphia residents were unceremoniously tossed into mass graves that had been hollowed out by steam shovels.
“They were primarily poorer and immigrant residents, so there’s a class aspect as the well-to-do were more likely to secure the rites of passage into death in a way that poorer and more recent arrivals were less able to,” Bristow says.
The scenes in Philadelphia appeared to be straight out of the plague-infested Middle Ages. Throughout the day and night, horse-drawn wagons kept a constant parade through the streets of Philadelphia as priests joined the police in collecting corpses draped in sackcloths and blood-stained sheets that were left on porches and sidewalks. The bodies were piled on top of each other in the wagons with limbs protruding from underneath the sheets. The parents of one small boy who succumbed to the flu begged the authorities to allow him the dignity of being buried in a wooden box that had been used to ship macaroni instead of wrapping him a sheet and having him taken away in a patrol wagon.
Restrictions on Public Events Impacted How People Mourned
Public funerals and wakes were banned in cities including Philadelphia and Chicago. Iowa prohibited public funerals and even the opening of caskets. Exceptions were made only for parents or wives identifying soldiers before burial—and even then, they could only open the caskets if family members covered their mouths and noses with masks and refrained from touching the body.
“In many communities, processing the loss of loved ones entails a series of rituals and rites and laying a person to rest in a respectful way,” Bristow says. “In many cities, the restrictions on public events meant that families and communities had those rites interrupted, so grieving didn’t take place in public but became an individual process, which had long-term consequences. Without an opportunity to share it with those around them, that grief was carried around for decades.”
Why the Second Wave of the 1918 Spanish Flu Was So Deadly
Spanish Flu - Symptoms, How It Began & Ended
Why October 1918 Was America's Deadliest Month Ever
How the 1957 Flu Pandemic Was Stopped Early in Its Path
Pandemics That Changed History: Timeline
Sept. 19, 1918
Then assistant secretary of the U.S. Navy , Franklin Delano Roosevelt became ill with pneumonia while aboard a ship en route to New York City.
2020: Navy Capt. Brett Crozier, commander of the USS Theodore Roosevelt, was fired after sending an email pleading for assistance from his superiors in stemming the coronavirus outbreak aboard his ship. Crozier tested positive for the virus and thousands of crew members have been quarantined in Guam. One sailor died.
(Library of Congress photo and Chicago Tribune story, Sept. 20, 1918)
Chicago officials discussed renewing an anti-spitting campaign in light of the influenza epidemic.
The idea was offered up by First Deputy Superintendent Morgan Collins -- who would later become superintendent of the department -- who suggested stenciled signs saying "Don't Spit" on the city's sidewalks.
(Library of Congress photo and Chicago Tribune story, Sept. 20, 1918)
Amid 1918 Flu Pandemic, America Struggled to Bury the Dead - HISTORY
According to a report published Friday by the New York Times, in 2020 the United States suffered the biggest single-year surge in its death rate since the federal government began publishing statistics, significantly surpassing the rise in the death rate during the 1918 Spanish Flu pandemic.
The Times conducted its own analysis of annual US death rates going back a century and found that the rate jump from 2019 to 2020, the first year of the COVID-19 pandemic, was 16 percent, as compared to the 12 percent surge in the US during the global pandemic that occurred over a century ago. The total number of COVID-19 deaths in the US is already approaching 600,000, on track to surpass the 675,000 estimated to have been killed in the US during the 1918 pandemic.
By the Institute for Health Metrics and Evaluations modeling projections, the COVID-19 death toll is expected to surpass 600,000 before June, reaching 620,000 by August under a best-case scenario.
The Times report aligns with an analysis of mortality data conducted by the Centers for Disease Control and Prevention, which found that from March 2020 until February 20, 2021, there were 574,000 more Americans who died than would be expected in a typical year. This places the deaths nationwide at 21 percent higher than what has usually been observed.
A JAMA report published online on April 2, 2021, authored by Dr. Steven H. Wool and colleagues from Virginia Commonwealth University School of Medicine, corroborated these findings in their analysis. They found that between March 1, 2020 and January 2, 2021, there were 522,368 excess deaths, accounting for a 22.9 percent increase in all-cause mortality.
At the time, there had been 378,039 confirmed COVID-19 deaths. As they explained, “Excess deaths not attributed to COVID-19 could reflect either immediate or delayed mortality from undocumented COVID-19 infections, or non-COVID-19 deaths secondary to the pandemic, such as from delayed care or behavioral health crises.”
Adjustments must be made for the differences in population size of the United States in 1918 compared to 2020. Additionally, as health care and public health measures have improved, the population’s lifespan has risen. As a result, the per capita death rates for the two periods are substantially different, which adds complexity to these comparisons. Nevertheless, the 16 percent increase in the death rate in 2020 from preceding year, compared to the 12 percent jump during the 1918 Spanish flu pandemic, is staggering.
Overall, 10 percent of the 3.4 million deaths in the United States were attributed to COVID-19, making it the third leading cause of death in 2020 after heart disease with 21 percent and cancer with 18 percent.
Comparing these two pandemics highlights that the COVID-19 infection is not merely another flu. It is a dangerous pathogen that has repeatedly demonstrated a tremendous ability to wreak havoc on the population’s life, and needs to be treated with the utmost seriousness and caution. Maliciously criminal has been the repeated dismissal of this reality by the political establishment and the ruling elite in their prosecution of the policy of “herd immunity,” which has enriched them in unimagined proportions while allowing the virus to run rampant and mutate into more virulent forms.
In light of advances in our understanding of the biology of these infectious organisms, including the medical advances in the treatment of COVID-19 infections that have saved hundreds of thousands of lives, to have allowed so many to become infected and perish is a historic crime. It is the result of capitalism’s remorseless drive to extract profits and further enrich a layer of oligarchs who number in the tens of thousands on a planet with 7.8 billion people. That the COVID-19 pandemic can even be compared to the Spanish Flu that occurred one hundred years ago speaks to the abject failure of the current political process to govern or protect the population of almost every wealthy nation.
In the US, current infection rates are approximately 64,000 per day, while the average daily death toll has settled in at just over 700. Yet the Biden administration is celebrating these developments as the success story of their vaccination campaign. Meanwhile, one state governor after another is biting at the bit to relax restrictions and fully open their economies.
As of April 23, 135.8 million people had received at least one dose of the COVID-19 vaccine, accounting for 40.9 percent of the population, while 89.2 million people, representing 26.9 percent of the people, have now been fully vaccinated. According to the Washington Post vaccination tracker, a total of 282.2 million COVID-19 vaccines have been distributed to the states.
Despite this achievement, the recent trends in immunization indicate that moving forward, the situation will grow considerably more challenging for the Biden administration. Last week saw an average of only 2.95 million doses per day, a decline of 12 percent. Scientists have estimated that upwards of 70 to 90 percent of the population will need to be inoculated if meaningful herd immunity is to be achieved.
Amid news of the sudden slowdown in vaccination rates, President Biden took to the media on Wednesday to proclaim that the US would reach the milestone of 200 million jabs this week, exceeding the target set for the end of April. He then made his pitch to the nation, stating, “I’m calling on every employer large and small in every state to give employees the time off they need, with pay, to get vaccinated. No working American should lose a single dollar from their paycheck because they chose to fulfill their patriotic duty of getting vaccinated.”
The vaccines are critical to the defeat of the pandemic, but the cynical attempt by the government to use this necessary and life-saving tool to justify the reopening of unsafe factories and offices as well as schools while the pandemic continues to rage only helps the far-right promote vaccine skepticism among sections of the middle class and working class.
A recent report in US News & World Report noted that “states that are having a difficult time disbursing to school districts hundreds of billions of dollars in federal aid from the most recent coronavirus relief package are running up against a Friday deadline to explain to the Education Department why that’s the case.”
Education Secretary Miguel Cardona, seeking to speed up the reopening of the schools, said, “Every child deserves an opportunity to hear their name being spoken in the classroom this year. As our nation heals and recovers from the pandemic, our decisions and actions will impact generations of learners. Our inaction will too.”
Meanwhile, Michigan’s recent surge of COVID-19 cases was preceded by hundreds of school outbreaks throughout the state. Michigan has seen a record-breaking number of children hospitalized with severe infections. Michigan Health & Hospital Association data shows that the number of children hospitalized statewide has reached 70, double the number seen during the worst of the wave that swept through in November.
The push by Democrats no less than Republicans to lift whatever COVID-19-related restrictions remain, especially among the vaccinated, has the potential to fuel more contagious strains of the coronavirus. In 1918, public health officials understood little of the virus that plagued their communities, relying on basic measures to control the death and mayhem it created. The blame for the disaster during the current pandemic lies entirely with the bourgeoisie.
”This is a detective story. Here was a mass murderer that was around 80 years ago and who’s never been brought to justice. And what we’re trying to do is find the murderer.”--Jeffery Taubenberger, molecular pathologist
There are estimates that the 1918 Flu killed anywhere from 20 million to 100 million people dwarfing the number of people killed in World War One. Either number is horrifying, but as modern scientists start putting data together the larger number becomes more realistic. I’ve always ”This is a detective story. Here was a mass murderer that was around 80 years ago and who’s never been brought to justice. And what we’re trying to do is find the murderer.”--Jeffery Taubenberger, molecular pathologist
There are estimates that the 1918 Flu killed anywhere from 20 million to 100 million people dwarfing the number of people killed in World War One. Either number is horrifying, but as modern scientists start putting data together the larger number becomes more realistic. I’ve always been fascinated with the 1918 Flu outbreak for a number of reasons, but the one that really sticks with me is that we never defeated it. We never knocked it to the canvas. It came, it killed, it disappeared.
”Historian Alfred W. Crosby remarks that whatever the exact number felled by the 1918 flu, one thing is indisputable: the virus killed more humans than any other disease in a period of similar duration in the history of the world.”
That is a big statement. It makes the Black Plague look like a featherweight. ”How lethal was it? It was twenty-five times more deadly than ordinary influenzas. This flu killed 2.5 percent of its victims. Normally just one-tenth of 1 percent of people who get the flu die. And since a fifth of the world’s population got the flu that year, including 28 percent of Americans, the number of deaths was stunning. So many died, in fact, that the average life span in the United States fell by twelve years in 1918. If such a plague came today, killing a similar fraction of the U. S. population, 1.5 million Americans would die.”
Interest was reignited in the 1918 influenza outbreak when swine flu/bird flu showed up in the 1970s and again in the 1990s. China is a hot bed for new influenza bugs because of the proximity of birds/swine/humans. Many times you find all three species under the same roof. Birds cannot pass flu to humans, but they can pass it to swine. Swine, being a close genetic relative to humans, (not that surprising) can incubate a bird flu and pass it to humans. The moral of the story is that pigs, birds and humans should not wallow in the same mud hole. The current thought is that the 1918 flu came to humans via pigs via birds.
”In theory, a bird flu could not infect a human because the virus should require cellular enzymes found in bird intestinal cells but not in human lung cells. Yet if, against all odds, a bird flu virus was infecting people, it would have hemagglutinin and neuraminidase proteins that had never been seen before by a human being. No human would be immune to such a virus. The whole world was at risk.”
I know he is cute, but he is a deadly assassin.
So there is this very unfortunate pig who becomes infected with a human virus and a bird virus at the same time. He becomes a blender for these two viruses and the next time a human scratches him behind the ears, most likely a child (wonderful incubators), he will pass the new concoction on to humanity which is tragic on many levels, but for the pig especially because who will fill his slop trough if his humans are critically sick.
Before HIV appeared on the scene which would shift all infectious disease researchers in that direction there were teams of scientists searching for samples of the 1918 flu. As is the case with a publish or perish society scientists are not very good at sharing informations, so as one team goes to Alaska to look for victims of the 1918 flu, hopefully still frozen in permafrost, another team is planning to go to an island of Norway with the same thought. When the Alaska team finds a perfectly preserved specimen that information of course is not shared with the rivals even though there was a scientist coordinating both teams. Johan Hultin is the man who makes the find.
”She was an obese woman she had fat in her skin and around her organs and that served as a protection from the occasional short-term thawing of permafrost.” Hultin explained. “Those on either side of her were not obese and they had decayed. I sat on the pail and saw this woman in a state of good preservation. And I knew that this was where the virus has got to come from, shedding light on the mysteries of 1918.”
Johan Hultin virus detective.
I would hope, and firmly believe that if the world was on the brink of a major pandemic that scientists would pool their research and share any breakthroughs before publishing (being credited) their findings. During the course of this investigation they also found paraffin preserved lung tissue from victims of the 1918 flu stored at the National Tissue Repository maintained by the Armed Forces Institute of Pathology. Nice to know we have such a handy repository of our disease history.
When a deadly influenza swine flu virus showed up in 1976 President Gerald Ford took the initiative ( I know right who would have thunk it.) that for the first time in human history the government was going to try and immunize the whole country. The press was favorable in the beginning of the program, but papers like the New York Post started to turn the tide towards government conspiracy theories. They wrote on October 14th and article That spoke of a seventy-five-year-old woman who winced at the sting of the hypodermic, then had taken a few feeble steps and dropped dead. Then on October 25th, ”the paper suggested that Carol Gambino, the mobster, had been killed by the Mafia using a swine flu shot as the deadly weapon”.
These misguided, uninformed, paranoid beliefs are laughable, but with politicians like Michelle Bachman and with radio talk show hosts like Rush Limbaugh who are suspicious of any government programs, especially if a Democrat is in the White House, and are very loud about their opposition I’m sure a similar program to try and stop a nasty flu bug before it got started would be met with heavy unwarranted criticism that could ultimately cost a lot of lives. If the 1918 influenza were to appear today we have antibiotics to counter the bacteria that floods the weakened lungs (pneumonia killed as many or more people than the virus) of a virus ridden body so death counts would be reduced from the 1918 level, but due to the efforts of a handful of scientists we do have the ability now to immunize a population if they will let us.
Gina Kolata has taken me on an investigative adventure that not only made science fascinating, but also accessible. I’m scared, but less scared because I have confidence in the ability of our best and brightest to keep the worst nightmares at bay if only we give them the means and we listen to them before the tip over point has been attained. . more
I love a good disease book. And I think the 1918 flu is just about as fascinating as you can get. But this book talks more about theories and old-timey labs than it does about the human side of this epidemic. Which, let&aposs face it, is what&aposs really interesting. Imagine all of a sudden having a common illness sweep through your community and kill young healthy people so fast that you don&apost even have time to bury them right. That&aposs some serious shit. This book just didn&apost do it justice. I would lik I love a good disease book. And I think the 1918 flu is just about as fascinating as you can get. But this book talks more about theories and old-timey labs than it does about the human side of this epidemic. Which, let's face it, is what's really interesting. Imagine all of a sudden having a common illness sweep through your community and kill young healthy people so fast that you don't even have time to bury them right. That's some serious shit. This book just didn't do it justice. I would like to find another that maybe does a better job.
That being said, this lady's name is Gina Kolata. If you like Gina Kolata, and getting caught in the rain. . more
Did not finish.
If you&aposre looking for a book about what it was like to experience the 1918 flu pandemic, this is not the book you want. The title of this book should be The Search for the Virus That Caused the Great Influenza Pandemic of 1918. It starts off with a little bit about the actual pandemic, and the rest of the book is long detailed histories of all the doctors and researchers who tried to figure out how the virus worked, where it came from, and if it had somehow survived for decades i Did not finish.
If you're looking for a book about what it was like to experience the 1918 flu pandemic, this is not the book you want. The title of this book should be The Search for the Virus That Caused the Great Influenza Pandemic of 1918. It starts off with a little bit about the actual pandemic, and the rest of the book is long detailed histories of all the doctors and researchers who tried to figure out how the virus worked, where it came from, and if it had somehow survived for decades in the bodies of those who died from it. There's also quite a lot of discussion of other pandemics of the 20th century, and the efforts to discover if those viruses were somehow "descendants" of that 1918 strain.
This is the third book I have started and abandoned in my quest to find a book that provides a narrative of what it was like to actually live through the 1918 pandemic. Onward! . more
This book was just excellent and that&aposs all that needs to be said.
I recommend it to anyone who has an interest in medical history and likes Germ Theory. Why I didn&apost study science at university instead of the arts is beyond me. This book was just excellent and that's all that needs to be said.
I recommend it to anyone who has an interest in medical history and likes Germ Theory. Why I didn't study science at university instead of the arts is beyond me. . more
I think I chose the wrong book to read about the 1918 pandemic.
Journalist and science writer Gina Kolata takes us on a wild-goose-chase to find the virus behind the mysterious and deadly flu pandemic that killed from 20 million to possibly 100 million people worldwide. It was an interesting perspective from the pre-Covid world but not much in terms of science writing or history or anything much coming from this "investigation." The mysterious nature of the virus itself is never solved. If anyth I think I chose the wrong book to read about the 1918 pandemic.
Journalist and science writer Gina Kolata takes us on a wild-goose-chase to find the virus behind the mysterious and deadly flu pandemic that killed from 20 million to possibly 100 million people worldwide. It was an interesting perspective from the pre-Covid world but not much in terms of science writing or history or anything much coming from this "investigation." The mysterious nature of the virus itself is never solved. If anything, I came away feeling that it didn't even matter if they found it so much as the important thing was how do we deal with the possibility that "a killer virus was lurking." Scientists of the time thought that the virus weakened with the mutations our mainstream scientists are warning us about "variants." Looking at history, all epidemics and pandemics fade away. Survivors come out stronger. They have antibodies that makes them stronger for the next influenza or plague.
Something of interest I want to highlight: early scientists of the pandemic recruited volunteers (prisoners) to expose themselves to the virus by visiting bedside those who had the influenza. They subjected themselves to being coughed on, sneezed on and even injected with it. NOT ONE volunteer became sick with the virus. The scientists were mystified. If it's not directly contagious, how is it spreading?
The most difficult passage of this book was the description of this tragic plague. Gina Kolata, writing in 1999, with a certain bewilderment at their "wearing surgical masks in a vain attempt to ward off the virus" --they attended public, outdoor events wearing masks and much like today, the people of the time became divided on the best course. Some throwing caution to the wind and living their best life now as a way of dealing with this terror. After the pandemic was over, the world became silent about this. It was such a traumatic event that it was largely forgotten in our history books. The Encyclopedia Britannica gave it a mere 3 lines. The novel by Virginia Woolf, "Mrs. Dalloway" is the central character who carries this trauma with her, a silence. That was the legacy of this pandemic- silence.
I did not enjoy this book. I wanted more about the actual pandemic (which had scant info and a brief mention) and I wanted more on virology itself. What there mostly is is so much background--irrelevant to the most interesting threads- the history and the "virus."
It ends not with answers but more questions and empty speculation on how much "better understanding" we would have for the next pandemic. . more
Outstanding. I picked it up a second time because it&aposs in my interests, without recognizing it. It was outstanding the second time through, so I finished it again.
2020Came up today, since the &apos18 flu turned out to be H1N1. Good reading for perspective on science and outbreaks. Outstanding. I picked it up a second time because it's in my interests, without recognizing it. It was outstanding the second time through, so I finished it again.
2020Came up today, since the '18 flu turned out to be H1N1. Good reading for perspective on science and outbreaks. . more
The title is a little bit of a misnomer. It&aposs not so much a history of the pandemic -- just a portion of the first chapter is devoted to that -- as a history of the efforts of scientists subsequent to the actual pandemic to understand where it came from and why it was so lethal. As many as 100 million killed worldwide. The book is also frustrating, because it ends without any resolution to those questions, but with a tease that results are just around the corner. It was published in 1999, so I&aposm The title is a little bit of a misnomer. It's not so much a history of the pandemic -- just a portion of the first chapter is devoted to that -- as a history of the efforts of scientists subsequent to the actual pandemic to understand where it came from and why it was so lethal. As many as 100 million killed worldwide. The book is also frustrating, because it ends without any resolution to those questions, but with a tease that results are just around the corner. It was published in 1999, so I'm hoping there may be something more recent that may provide some answers.
That said, it was a very good read. Well written, compelling, almost like a detective story, with interesting characters throughout. A reasonable amount of technical biological detail about the virus was handled well. Not too heavy for a non-scientist. . more
A good book on the deadly, ill named, spanish flu because today nobody knows where exactly this pandemia begun.
The book is devoted to the history,epidemiology and investigation of this letal virus,that killed over 50 million humans arroun the world in the 1918 pandemia ,the most letal after the black dead,and its final reconstruction by means of frozen inuit lungs,dead by the disease, in the alaskan permafrost
"Flu" is a quick, easy, read that skims over the 1918 Pandemic and introduces the reader to the current science of influenza.
However, the book draws no solid conclusions, and has no real ending. It also leaves threads hanging at the conclusion. (We are never told from what virus strain (H1N1) the recovered RNA indicated the 1918 flu belonged. Finally, the chatty biographies of the books personalities were really annoying to have to wade through. (Does it really matter that Kirsty Duncan does Cel "Flu" is a quick, easy, read that skims over the 1918 Pandemic and introduces the reader to the current science of influenza.
However, the book draws no solid conclusions, and has no real ending. It also leaves threads hanging at the conclusion. (We are never told from what virus strain (H1N1) the recovered RNA indicated the 1918 flu belonged. Finally, the chatty biographies of the books personalities were really annoying to have to wade through. (Does it really matter that Kirsty Duncan does Celtic dancing?)
What I am most grateful for is the book's introducing me to Crosby's America's Forgotten Pandemic: The Influenza of 1918. Pass this book up and go straight to America's Forgotten Pandemic. . more
I really enjoyed this book. The book covers a range of time from the beginning of the 1918-19 flu right up to still lingering questions about what made that particular flu strain so deadly and why it affected the young and healthy as much as the elderly and very young.
I really learned a lot about the Flu and about the fight to determine its origins and genetic composition. Some of the things in this book mirrored [Book:The Great Influenza:The Epic Story of the Deadliest Plague in History], altho I really enjoyed this book. The book covers a range of time from the beginning of the 1918-19 flu right up to still lingering questions about what made that particular flu strain so deadly and why it affected the young and healthy as much as the elderly and very young.
I really learned a lot about the Flu and about the fight to determine its origins and genetic composition. Some of the things in this book mirrored [Book:The Great Influenza:The Epic Story of the Deadliest Plague in History], although I've found that of the three or four books I've read recently, none of them mention one symptom that John M. Barry focused on which is a sometimes altered personality for Flu survivors. (In fact, Barry attributes Woodrow Wilson's treatment of the League of Nations to a personalty change brought on by the Flu).
Flu is so rich I hardly know where to begin. In the course of reading the book I learned about a national repository of tissues samples which was put into place by Abraham Lincoln (the thing is beyond huge and a treasure trove of information), a massive and ultimately failed attempt to vaccinate the American public against a swine flu in the 1970s (which may well be a partial explanation for why some people so mistrust vaccines), and the route another deadly flu is likely to take. I gained an understanding of why some in the medical community were so worried about avian flu. It's thought that the 1918-19 flu may well have started in bird, passed to pigs where it mixed with a human flu, and was then transmitted to humans. I also have a better understanding of why (nearly?) every strain of flu has started in southeast Asia (it has to do with a farming system that encourages birds and pigs raised in close proximity).
One of the most fascinating aspects of the book (for me) was that in the beginning when the first group of people attempted to dig up corpses long buried in permafrost with absolutely no protection whatsoever or even any thought about the fact that they might unleash another wave of the 1918-19 flu and kill millions, it seems horrible. By the end the amazing precautions another group wants to take when trying to do the same thing seem downright silly.
I also think it's very interesting that the people who made the biggest strides in uncovering the origins and genetic structure of the Spanish Flu were not scientists who had made studying the Flu their focus. Indeed, one of the people who helped tremendously was a "lowly" lab technician.
The end of the book is in some ways very frustrating because there is still no answer to why that particular flu was so deadly and there were a good five or six promising investigations that were started or yet to be started and I really wanted to know how they turned out. . more
This book has received mixed reviews, because the title is something of a bait and switch. The great influenza of 1918 is covered in Chapter One. The rest of the book is about how the memory of that worldwide pandemic has affected modern epidemiology. It discusses some of history’s great epidemics, the search for the 1918 virus after it had disappeared from the population, and the way it influenced decision making in later years when virulent strains appeared and a response had to be developed t This book has received mixed reviews, because the title is something of a bait and switch. The great influenza of 1918 is covered in Chapter One. The rest of the book is about how the memory of that worldwide pandemic has affected modern epidemiology. It discusses some of history’s great epidemics, the search for the 1918 virus after it had disappeared from the population, and the way it influenced decision making in later years when virulent strains appeared and a response had to be developed that took into account the possibility of another worldwide pandemic. It is interesting, written for a general audience and published in 2001, but for those who want something more specific to the 1918 pandemic, there are more focused books, such as John Barry’s The Great Influenza: The Story of the Deadliest Pandemic in History, from 2005, and Laura Spinney’s Pale Rider: The Spanish Flu of 1918 and How It Changed the World, published in 2017.
There are two chapters dealing with the Swine Flu panic in 1976 and its litigious aftermath. They are informative and well written, going step by step through the decision making processes of the people involved, each trying to weigh the risk of the tiny chance of a disastrous outbreak against the time, expense, and consequences of large scale vaccinations. Everyone was trying to do the right things, but as the consensus built it became harder and harder for people who disagreed to make their voices known. One of the dissenters posed a question that, in hindsight, was so incisive that his name became a shorthand for how to stop runaway consensus, the “Alexander question.”
Had he pressed his concerns more forcefully he might have changed the outcome of the debate, but he did not, and was ignored. President Ford and Congress were convinced to appropriate $135 million to prepare vast quantities of the vaccine and inoculate the entire population of the United States.
It was a debacle. Swine Flu never reappeared, the massive push to prepare enough vaccine meant that not enough vaccine for that year’s normal strain of flu was made, and the floodgates of litigation were open.
There is also a chapter on the Bird Flu incident in Hong Kong in 1997. Memories of Swine Flu constrained the choices of the epidemiologists and researchers, who were once again facing the prospect of a new strain of the virus, one which seemed to have mutated directly from birds into a human-contagious form which mankind had never been exposed to, and thus would have no resistance against. In the end millions of chickens, ducks, and other fowl were killed, which might (or might not) have prevented further outbreaks.
The book has chapters on two different attempts to find the virus in the bodies of people who died from it in 1918 and who were buried in permafrost, which might have preserved it. A lot of detail is given these expeditions, including biographies of the researchers, the obstacles they encountered, the people they met, the weather, and how they exhumed the bodies and took samples. For all of that, one was a complete bust, because frost heave had raised the bodies into the zone of annual melting, destroying any traces of the virus. In the other expedition only fragments of the virus were found, which were painstakingly sequenced to gradually build up a partial view of the killer from 1918. Since the book was published a great deal more has been learned from additional exhumations and better sequencing tools.
Every year new strains of flu emerge, and we must all live with the knowledge that any one of them could start a worldwide pandemic. With a better understanding of virology and advances in healthcare, the odds of a repeat of 1918 are unlikely in the advanced countries, but even there it would take months to create enough vaccine for all who would need it. For the majority of the world’s population, lacking sanitation and access to effective healthcare, it would be a killer on a massive scale, and with international air travel it could spread across the globe in a matter of days. We should not feel too confident that we can avoid pandemics in the future. . more
When I wanted to acknowledge the centennial of the worst pandemic in history (yes, far worse than bubonic plague), I didn&apost know two new books had been released in 2018 by Catharine Arnold and Jeremy Brown, on the 1918 global flu pandemic. It was difficult to find Alfred Crosby&aposs 1989 historical work, so I settled on Kolata&aposs 1999 popular account, since I like her breezy yet scientifically accurate style. Funny thing is, based on synopses of the Arnold and Brown books, our knowledge of the 1918 When I wanted to acknowledge the centennial of the worst pandemic in history (yes, far worse than bubonic plague), I didn't know two new books had been released in 2018 by Catharine Arnold and Jeremy Brown, on the 1918 global flu pandemic. It was difficult to find Alfred Crosby's 1989 historical work, so I settled on Kolata's 1999 popular account, since I like her breezy yet scientifically accurate style. Funny thing is, based on synopses of the Arnold and Brown books, our knowledge of the 1918 flu has not expanded much in the 20 years since Kolata wrote this book.
The author begins her book by mentioning several funny things. She had a lifelong interest in health and infectious diseases, yet knew almost nothing about the pandemic. The more she probed, the more her ignorance made sense. The media in 1918 was strangely silent, and the victims' families and public health officials seemed almost embarrassed to talk about it, a scenario similar to the 1970s-80s early reaction on AIDS. Crosby and Kolata both attribute this to psychological numbing and wartime censorship -- the world had just ended a devastating global war, and no one seemed ready to confront another atrocity.
This book is not a definitive historical guide to what happened in 1918. One could turn to Crosby or Arnold for that. Instead, it operates as numerous detective stories, taking place immediately following the flu's decline, and in the 1950s, 1970s, and 1990s. Kolata does a good job of weaving these stories together, particularly the efforts to find bodies of victims frozen in the permafrost in order to gain virus samples. Along the way, Kolata talks about the swine flu vaccine misfire during the Ford administration in 1976, and the public health crisis over live chickens in Hong Kong in the late 1990s. Sometimes she goes far afield, in describing Johan Hultin's Alaska adventures in the 1950s, but her journeys are usually enjoyable ones. Other times, her character assessments seem a bit harsh, like her easy dismissal of Kirsty Duncan in the Spitzbergen expedition. (Duncan was appointed Minister of Science in Justin Trudeau's government in Canada, so one could say she had the last laugh.)
What emerges from Kolata's hopscotching across the decades is that science uses the tools available at the time, and often has to retrace its steps as new tools make it possible to conduct studies that were impossible decades earlier. But gaining clarity does not always mean gaining deeper understanding. We know that the 1918 flu was an H1N1 bird flu derivative, we know details of its protein coat, but we don't know why it was so astonishingly virulent, killing close to 100 million people worldwide. Kolata ends her book, not with a series of revelations, but with a series of new questions raised as researchers continued their viral studies at the end of 1999. The last possibility she raises turns out to be one that many scientists accept today: the strain of the virus itself was not particularly aggressive, since it arrived in two waves in early and late 1918 (and perhaps even in 1916-17 in France). Rather, most deaths were caused by an overreaction of the body's immune system, creating a cytokine storm that led to total respiratory failure.
We all now that the rapid mutation of the flu virus makes the annual flu vaccine offered by health authorities a crapshoot at best, though the vaccine is certainly better than nothing. But health authorities also must look at antibody histories of those receiving flu shots, to see if maybe a vaccine, or a particular flu strain, could trigger the kind of cytokine storm that led to a pandemic in its own right. A century later, we are still not close to unlocking all the mysteries of the 1918 flu. And our ability to avoid a future pandemic depends on our increasing our understanding fairly quickly. The problems of the 1976 vaccine show we must avoid making costly errors, as well. . more
Right now, I&aposm thoroughly enjoying this read by NYT reporter Gina Kolata - it does seem odd that with the impact of the 1918 flu we haven&apost heard more about it or how it changed American life as we know it.
I had no idea Katherine Anne Porter&aposs Pale Horse, Pale Rider dealt with this topic, nor Thomas Wolfe&aposs Look Homeward, Angel, so I am going to now read these two books after this one with a different context and knowledge base - which I hope will give me a deeper appreciation for both.
I&aposll be Right now, I'm thoroughly enjoying this read by NYT reporter Gina Kolata - it does seem odd that with the impact of the 1918 flu we haven't heard more about it or how it changed American life as we know it.
I had no idea Katherine Anne Porter's Pale Horse, Pale Rider dealt with this topic, nor Thomas Wolfe's Look Homeward, Angel, so I am going to now read these two books after this one with a different context and knowledge base - which I hope will give me a deeper appreciation for both.
I'll be back with my concluding thoughts.
Okay, I'm back. I think this was a good, fast-paced interesting read until the end, when it devolved into scientific political struggles and a muddled message. I found it difficult to keep interest, but finished it because I felt I had invested so much in the story to that point, however the ending left a lot to be desired. It did, however, have a lot of end notes and an extensive bibliography. . more
I thought that this informative book about an interesting topic, the influenza epidemic of 1918, made some complex scientific processes approachable by the lay reader. The book reads almost like a biography of influenza informing readers about previous epidemics/pandemics similarities and differences between known influenzas the attempts, both failed and successful, to identify and isolate the various molecular fragments of the viral genes. The focus, of course, was what differentiated the 19 I thought that this informative book about an interesting topic, the influenza epidemic of 1918, made some complex scientific processes approachable by the lay reader. The book reads almost like a biography of influenza informing readers about previous epidemics/pandemics similarities and differences between known influenzas the attempts, both failed and successful, to identify and isolate the various molecular fragments of the viral genes. The focus, of course, was what differentiated the 1918 pandemic from those previous. Why was it so deadly? How did it spread? How was it able to spread so quickly around the world? Who was vulnerable? Who wasn't? Why? Why? Why?
As of the date of publication, 1999, there were tantalizing bits of the mystery that were being slowly revealed through a myriad of scientific investigative techniques made possible by advances in technologies, but the major questions had still not been answered. I am curious enough to look further into the progress made in the intervening years.
Some interesting facts I gleaned from the book are: most flu strains originate in or around Guangdong (formerly Canton), China the 1918 pandemic killed more than 20 million people in India, alone there is a connection between the 1918 influenza and swine flu in an attempt to find extant virus from 1918 flu victims, two different groups of scientists exhumed the graves of people known to have died of the flu. These graves were in permafrost areas of Alaska and Spitsbergen (a region of Norway just 800 miles from the Arctic Circle). The thought was that bodies buried in the permafrost, even decades ago, would deteriorate very, very slowly allowing for the possibility that soft tissue from the lungs of those corpses would still exist, samples of which could be taken and tested, using new technologies that, hopefully, would reveal the virus that caused the flu.
All in all FLU was a good read and very informative. If you are interested in science, medicine, or history this could be a book for you.
One criticism that I have of the book is that the author repeated herself a number of times, using phrasing that she had used before when writing about the same topic. . more
A lot of people asked me why I was reading this book, right now, with Covid-19 being a thing right now. Wasn&apost I scared? For me, it was to help me create a basis in understanding what we may or may not be dealing with, how it affects the world, and what we&aposve learned from the past. I was also sick of seeing/reading news about Covid-19 that misinterprets facts or blatantly just spews out false information.
For the first few chapters, I honestly felt like I would not get into this book. I realize A lot of people asked me why I was reading this book, right now, with Covid-19 being a thing right now. Wasn't I scared? For me, it was to help me create a basis in understanding what we may or may not be dealing with, how it affects the world, and what we've learned from the past. I was also sick of seeing/reading news about Covid-19 that misinterprets facts or blatantly just spews out false information.
For the first few chapters, I honestly felt like I would not get into this book. I realize how terrible the 1918 flu was, but it seemed like the author was just saying the same thing over and over again, just with different words.
However, starting with the Swedish Adventurer chapter, it turned into a scientific journey in discovering why the virus was so deadly. That is when the book became incredibly interesting and worth that extra star! Gina did an amazing job introducing each scientist, explaining their history and how they became involved with solving the puzzle of the 1918 flu. Which is sadly, still a puzzle. Scientists still shed light on their insightful theories which was definitely intriguing and in the end, I have a fresher perspective on current events today. . more
An interesting look at a part of our history that can get glossed over sometimes. Unfortunately, this was focused more on the science that went into deciphering the flu rather than the history of the flu itself. While it was an enlightening read, and some of the people who worked on this project were extremely driven, fascinating people, mostly it just made me want to read a good old fashioned history book about the influenza pandemic.
My one real issue was the completely unnecessary pages of lis An interesting look at a part of our history that can get glossed over sometimes. Unfortunately, this was focused more on the science that went into deciphering the flu rather than the history of the flu itself. While it was an enlightening read, and some of the people who worked on this project were extremely driven, fascinating people, mostly it just made me want to read a good old fashioned history book about the influenza pandemic.
My one real issue was the completely unnecessary pages of lists that Kolata put in - naming every. single. doctor. who attended a particular conference, for instance. It's a waste of space and it mostly just made me drift, especially when two thirds of those doctors and scientists were never mentioned again. . more
It was on one of my trips to Goodwill that when I was browsing the book section, I stumbled upon Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It by Gina Kolata. Unlike the other books that were visibly used and dog eared, this book seemed almost untouched. I bought the book for $1, still shocked about the condition of the book, this being the reason I picked up the book that and the fact that I was immediately reminded of Rupert Holmes’ song “E It was on one of my trips to Goodwill that when I was browsing the book section, I stumbled upon Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It by Gina Kolata. Unlike the other books that were visibly used and dog eared, this book seemed almost untouched. I bought the book for $1, still shocked about the condition of the book, this being the reason I picked up the book that and the fact that I was immediately reminded of Rupert Holmes’ song “Escape” after seeing the authors name above the blue, almost infectious looking title, “Flu”.
It’s 1918, and thousands of people have perished within the span of a couple of months, thousands more fear that they may be next. What was to blame? World War 1? No. The Great Influenza Pandemic of 1918 was to blame. Gina Kolata tells us the story of the mysterious influenza virus that spread throughout the world in 1918. As well as the story of the influenza outbreak that occurred in several military camps and various other locations, Kolata tells the stories of the numerous scientists who studied the virus in attempts to learn about the origins of the deadly virus and the attempts to find a vaccine to thwart future pandemics that would be similar to that of 1918.
The story of the influenza pandemic is told in two ways: through a collection of facts and data and also through personal accounts of scientists studying the virus, as well as those who witnessed the spreading of the virus. One such example was when Kolata describes how a pastor in a small eskimo village in Alaska witnessed more than half of the village’s population die from the influenza virus. Personally, I found it more interesting to read the parts of the book that were told through personal accounts of the people who were affected by the virus. I feel like I could connect more to their stories about how they watched their whole family and almost entire town perish from the likes of the flu. While reading parts of the books that were focused on facts and data, it was harder to follow with all the facts that were being thrown at you. I also found myself skimming over these parts most of the time. Through this book, Kolata tells the story of the “spanish flu” pandemic and tries to find answers to one of history’s biggest medical mysteries.
Typically when we think of the flu, we think of it as harmless, but the way Kolata describes the Flu, in the case of the pandemic of 1918, she brings truth to what the flu actually was like. When she says, “Then it disappeared, returning in the fall with the power of a juggernaut”(8) we see just how monstrous this flu is. Gina Kolata also doesn’t hesitate to include gruesome details of the effects of this influenza, “. your body feebly cries out ‘no,’ you are moving steadily toward death… you die- by drowning, actually-as your lungs fill with a reddish fluid”(4). With these gruesome details, readers get a glimpse into the suffering and pain that those affected by the influenza virus had to undergo. This also puts emphasis on how Gina Kolata wants us to see the massive impact that this virus had on people.
In writing this book, Gina Kolata also sheds light on this pandemic that is hardly mentioned in the history books to inform us about this major pandemic that occurred. Gina Kolata makes sure to emphasize this is instances such as: “Crosby looked at a recent edition of the Encyclopedia Britannica. The 1918 flu got three sentences. He looked at a recent edition of the Encyclopedia Americana. One sentence was devoted to the flu, and it said that the epidemic killed 21 million people. ‘Which was a gross understatement [since it killed roughly 51 million people]”(52). The fact that many people have such little knowledge on such an important event that has taken place in history is why Gina Kolata has written this book. Because of this, the idea of this being such an important event is highly stressed throughout the book.
Often times, I found that throughout the book, the writing didn’t keep me engaged. The information was very repetitive and I found that there also was a lot of unnecessary information. For example, whenever one of the chapter’s would delve into the life of the scientist that was being focused on in that chapter, there was information included that seemed very unnecessary. For example, “He was born in Stockholm and grew up in a wealthy home in the suburbs of the capital city…” Gina Kolata writes when describing Johan V. Hultin, a scientist who made a significant discovery with the Spanish flu virus. It then continues for several more pages as Kolata writes about Hilton's whole life leading up to his scientific work, which I believe was unnecessary and keeps readers distracted from the main idea of the book.
Even though Flu had some flaws, I found it a good book to read if your interested in learning more about the influenza virus. I would also recommend it to those who are interested in microorganisms and bio-medicine. This book is filled with interesting stories of the deadly influenza virus that took place in 1918, along with the decades long journey of finding the vaccine.
If this were a book that were at least $15, I wouldn’t say it was worth it. But, even though it may not have been what I was expecting when first purchasing this book at Goodwill, I would say that it was $1 well spent. . more
Although its geographic origin is unknown (see below), the disease was called Spanish flu as early as the first wave of the pandemic.    Spain was not involved in the war, having remained neutral, and had not imposed wartime censorship.   Newspapers were therefore free to report the epidemic's effects, such as the grave illness of King Alfonso XIII, and these widely-spread stories created a false impression of Spain as especially hard hit. 
Alternative names were also used at the time of the pandemic. Similar to the name of Spanish flu, many of these also alluded to the purported origins of the disease. In Senegal it was named 'the Brazilian flu', and in Brazil 'the German flu', while in Poland it was known as 'the Bolshevik disease'.  In Spain itself, the nickname for the flu, the "Naples Soldier", was adopted from a 1916 operetta, The Song of Forgetting (La canción del olvido) after one of the librettists quipped that the play's most popular musical number, Naples Soldier, was as catchy as the flu.  Today, however, 'Spanish flu' (Gripe Española) is the most widely used name for the pandemic in Spain. 
Other terms for this virus include the "1918 influenza pandemic," the "1918 flu pandemic", or variations of these.   
First wave of early 1918
The pandemic is conventionally marked as having begun on 4 March 1918 with the recording of the case of Albert Gitchell, an army cook at Camp Funston in Kansas, United States, despite there having been cases before him.  The disease had already been observed in Haskell County as early as January 1918, prompting local doctor Loring Miner to warn the editors of the US Public Health Service's academic journal Public Health Reports.  Within days of the March 4 first case at Camp Funston, 522 men at the camp had reported sick.  By 11 March 1918, the virus had reached Queens, New York.  Failure to take preventive measures in March/April was later criticized. 
As the US had entered World War I, the disease quickly spread from Camp Funston, a major training ground for troops of the American Expeditionary Forces, to other US Army camps and Europe, becoming an epidemic in the Midwest, East Coast, and French ports by April 1918, and reaching the Western Front by the middle of the month.  It then quickly spread to the rest of France, Great Britain, Italy, and Spain and in May reached Breslau and Odessa.  After the signing of the Treaty of Brest-Litovsk (March 1918), Germany started releasing Russian prisoners of war, who then brought the disease to their country.  It reached North Africa, India, and Japan in May, and soon after had likely gone around the world as there had been recorded cases in Southeast Asia in April.  In June an outbreak was reported in China.  After reaching Australia in July, the wave started to recede. 
The first wave of the flu lasted from the first quarter of 1918 and was relatively mild.  Mortality rates were not appreciably above normal  in the United States
75,000 flu-related deaths were reported in the first six months of 1918, compared to
63,000 deaths during the same time period in 1915.  In Madrid, Spain, fewer than 1,000 people died from influenza between May and June 1918.  There were no reported quarantines during the first quarter of 1918. However, the first wave caused a significant disruption in the military operations of World War I, with three-quarters of French troops, half the British forces, and over 900,000 German soldiers sick. 
Deadly second wave of late 1918
The second wave began in the second half of August 1918, probably spreading to Boston and Freetown, Sierra Leone, by ships from Brest, where it had likely arrived with American troops or French recruits for naval training.  From the Boston Navy Yard and Camp Devens (later renamed Fort Devens), about 30 miles west of Boston, other U.S. military sites were soon afflicted, as were troops being transported to Europe.  Helped by troop movements, it spread over the next two months to all of North America, and then to Central and South America, also reaching Brazil and the Caribbean on ships.  In July 1918, the Ottoman Empire saw its first cases in some soldiers.  From Freetown, the pandemic continued to spread through West Africa along the coast, rivers, and the colonial railways, and from railheads to more remote communities, while South Africa received it in September on ships bringing back members of the South African Native Labour Corps returning from France.  From there it spread around southern Africa and beyond the Zambezi, reaching Ethiopia in November.  On September 15, New York City saw its first fatality from influenza.  The Philadelphia Liberty Loans Parade, held in Philadelphia, Pennsylvania, on 28 September 1918 to promote government bonds for World War I, resulted in 12,000 deaths after a major outbreak of the illness spread among people who had attended the parade. 
From Europe, the second wave swept through Russia in a southwest–northeast diagonal front, as well as being brought to Arkhangelsk by the North Russia intervention, and then spread throughout Asia following the Russian Civil War and the Trans-Siberian railway, reaching Iran (where it spread through the holy city of Mashhad), and then later India in September, as well as China and Japan in October.  The celebrations of the Armistice of 11 November 1918 also caused outbreaks in Lima and Nairobi, but by December the wave was mostly over. 
The second wave of the 1918 pandemic was much more deadly than the first. The first wave had resembled typical flu epidemics those most at risk were the sick and elderly, while younger, healthier people recovered easily. October 1918 was the month with the highest fatality rate of the whole pandemic.  In the United States,
292,000 deaths were reported between September–December 1918, compared to
26,000 during the same time period in 1915.  The Netherlands reported 40,000+ deaths from influenza and acute respiratory disease. Bombay reported
15,000 deaths in a population of 1.1 million.  The 1918 flu pandemic in India was especially deadly, with an estimated 12.5–20 million deaths in the last quarter of 1918 alone.  [ page needed ]
Third wave of 1919
In January 1919, a third wave of the Spanish Flu hit Australia, where it killed around 12,000 people following the lifting of a maritime quarantine, and then spread quickly through Europe and the United States, where it lingered through the spring and until June 1919.     It primarily affected Spain, Serbia, Mexico and Great Britain, resulting in hundreds of thousands of deaths.  It was less severe than the second wave but still much more deadly than the initial first wave. In the United States, isolated outbreaks occurred in some cities including Los Angeles,  New York City,  Memphis, Nashville, San Francisco and St. Louis.  Overall American mortality rates were in the tens of thousands during the first six months of 1919. 
Fourth wave of 1920
In spring 1920, a fourth wave occurred in isolated areas including New York City,  Switzerland, Scandinavia,  and some South American islands.  New York City alone reported 6,374 deaths between December 1919 and April 1920, almost twice the number of the first wave in spring 1918.  Other US cities including Detroit, Milwaukee, Kansas City, Minneapolis and St. Louis were hit particularly hard, with death rates higher than all of 1918.  Peru experienced a late wave in early 1920, and Japan had one from late 1919 to 1920, with the last cases in March.  In Europe, five countries (Spain, Denmark, Finland, Germany and Switzerland) recorded a late peak between January–April 1920. 
Despite its name, historical and epidemiological data cannot identify the geographic origin of the Spanish flu.  However, several theories have been proposed.
The first confirmed cases originated in the United States. Historian Alfred W. Crosby stated in 2003 that the flu originated in Kansas,  and author John M. Barry described a January 1918 outbreak in Haskell County, Kansas, as the point of origin in his 2004 article. 
A 2018 study of tissue slides and medical reports led by evolutionary biology professor Michael Worobey found evidence against the disease originating from Kansas, as those cases were milder and had fewer deaths compared to the infections in New York City in the same period. The study did find evidence through phylogenetic analyses that the virus likely had a North American origin, though it was not conclusive. In addition, the haemagglutinin glycoproteins of the virus suggest that it originated long before 1918, and other studies suggest that the reassortment of the H1N1 virus likely occurred in or around 1915. 
The major UK troop staging and hospital camp in Étaples in France has been theorized by virologist John Oxford as being at the center of the Spanish flu.  His study found that in late 1916 the Étaples camp was hit by the onset of a new disease with high mortality that caused symptoms similar to the flu.   According to Oxford, a similar outbreak occurred in March 1917 at army barracks in Aldershot,  and military pathologists later recognized these early outbreaks as the same disease as the Spanish flu.   The overcrowded camp and hospital at Etaples was an ideal environment for the spread of a respiratory virus. The hospital treated thousands of victims of poison gas attacks, and other casualties of war, and 100,000 soldiers passed through the camp every day. It also was home to a piggery, and poultry was regularly brought in from surrounding villages to feed the camp. Oxford and his team postulated that a precursor virus, harbored in birds, mutated and then migrated to pigs kept near the front.  
A report published in 2016 in the Journal of the Chinese Medical Association found evidence that the 1918 virus had been circulating in the European armies for months and possibly years before the 1918 pandemic.  Political scientist Andrew Price-Smith published data from the Austrian archives suggesting the influenza began in Austria in early 1917. 
A 2009 study in Influenza and Other Respiratory Viruses found that Spanish flu mortality simultaneously peaked within the two-month period of October and November 1918 in all fourteen European countries analyzed, which is inconsistent with the pattern that researchers would expect if the virus had originated somewhere in Europe and then spread outwards. 
In 1993, Claude Hannoun, the leading expert on the Spanish flu at the Pasteur Institute, asserted the precursor virus was likely to have come from China and then mutated in the United States near Boston and from there spread to Brest, France, Europe's battlefields, the rest of Europe, and the rest of the world, with Allied soldiers and sailors as the main disseminators.  Hannoun considered several alternative hypotheses of origin, such as Spain, Kansas, and Brest, as being possible, but not likely.  In 2014, historian Mark Humphries argued that the mobilization of 96,000 Chinese laborers to work behind the British and French lines might have been the source of the pandemic. Humphries, of the Memorial University of Newfoundland in St. John's, based his conclusions on newly unearthed records. He found archival evidence that a respiratory illness that struck northern China (where the laborers came from) in November 1917 was identified a year later by Chinese health officials as identical to the Spanish flu.   However, no tissue samples have survived for modern comparison.  Nevertheless, there were some reports of respiratory illness on parts of the path the laborers took to get to Europe, which also passed through North America. 
One of the few regions of the world seemingly less affected by the Spanish flu pandemic was China, where several studies have documented a comparatively mild flu season in 1918.    (Although this is disputed due to lack of data during the Warlord Period, see Around the globe.) This has led to speculation that the Spanish flu pandemic originated in China,     as the lower rates of flu mortality may be explained by the Chinese population's previously acquired immunity to the flu virus.   
A report published in 2016 in the Journal of the Chinese Medical Association found no evidence that the 1918 virus was imported to Europe via Chinese and Southeast Asian soldiers and workers and instead found evidence of its circulation in Europe before the pandemic.  The 2016 study suggested that the low flu mortality rate (an estimated one in a thousand) found among the Chinese and Southeast Asian workers in Europe meant that the deadly 1918 influenza pandemic could not have originated from those workers.  Further evidence against the disease being spread by Chinese workers was that workers entered Europe through other routes that did not result in a detectable spread, making them unlikely to have been the original hosts. 
Transmission and mutation
The basic reproduction number of the virus was between 2 and 3.  The close quarters and massive troop movements of World War I hastened the pandemic, and probably both increased transmission and augmented mutation. The war may also have reduced people's resistance to the virus. Some speculate the soldiers' immune systems were weakened by malnourishment, as well as the stresses of combat and chemical attacks, increasing their susceptibility.   A large factor in the worldwide occurrence of the flu was increased travel. Modern transportation systems made it easier for soldiers, sailors, and civilian travelers to spread the disease.  Another was lies and denial by governments, leaving the population ill-prepared to handle the outbreaks. 
The severity of the second wave has been attributed to the circumstances of the First World War.  In civilian life, natural selection favors a mild strain. Those who get very ill stay home, and those mildly ill continue with their lives, preferentially spreading the mild strain. In the trenches, natural selection was reversed. Soldiers with a mild strain stayed where they were, while the severely ill were sent on crowded trains to crowded field hospitals, spreading the deadlier virus. The second wave began, and the flu quickly spread around the world again. Consequently, during modern pandemics, health officials look for deadlier strains of a virus when it reaches places with social upheaval.  The fact that most of those who recovered from first-wave infections had become immune showed that it must have been the same strain of flu. This was most dramatically illustrated in Copenhagen, which escaped with a combined mortality rate of just 0.29% (0.02% in the first wave and 0.27% in the second wave) because of exposure to the less-lethal first wave.  For the rest of the population, the second wave was far more deadly the most vulnerable people were those like the soldiers in the trenches – adults who were young and fit. 
After the lethal second wave struck in late 1918, new cases dropped abruptly. In Philadelphia, for example, 4,597 people died in the week ending 16 October, but by 11 November, influenza had almost disappeared from the city. One explanation for the rapid decline in the lethality of the disease is that doctors became more effective in the prevention and treatment of pneumonia that developed after the victims had contracted the virus. However, John Barry stated in his 2004 book The Great Influenza: The Epic Story of the Deadliest Plague In History that researchers have found no evidence to support this position.  Another theory holds that the 1918 virus mutated extremely rapidly to a less lethal strain. Such evolution of influenza is a common occurrence: there is a tendency for pathogenic viruses to become less lethal with time, as the hosts of more dangerous strains tend to die out.  Some fatal cases did continue into March 1919, killing one player in the 1919 Stanley Cup Finals.
Signs and symptoms
The majority of the infected experienced only the typical flu symptoms of sore throat, headache, and fever, especially during the first wave.  However, during the second wave, the disease was much more serious, often complicated by bacterial pneumonia, which was often the cause of death.  This more serious type would cause heliotrope cyanosis to develop, whereby the skin would first develop two mahogany spots over the cheekbones which would then over a few hours spread to color the entire face blue, followed by black coloration first in the extremities and then further spreading to the limbs and the torso.  After this, death would follow within hours or days due to the lungs being filled with fluids.  Other signs and symptoms reported included spontaneous mouth and nosebleeds, miscarriages for pregnant women, a peculiar smell, teeth, and hair falling, delirium, dizziness, insomnia, loss of hearing or smell, blurred vision, and impaired color vision.  One observer wrote, "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 severity of the symptoms was believed to be caused by cytokine storms. 
The majority of deaths were from bacterial pneumonia,    a common secondary infection associated with influenza. This pneumonia was itself caused by common upper respiratory-tract bacteria, which were able to get into the lungs via the damaged bronchial tubes of the victims.  The virus also killed people directly by causing massive hemorrhages and edema in the lungs.  Modern analysis has shown the virus to be particularly deadly because it triggers a cytokine storm (overreaction of the body's immune system).  One group of researchers recovered the virus from the bodies of frozen victims and transfected animals with it. The animals suffered rapidly progressive respiratory failure and death through a cytokine storm. The strong immune reactions of young adults were postulated to have ravaged the body, whereas the weaker immune reactions of children and middle-aged adults resulted in fewer deaths among those groups.  
Because the virus that caused the disease was too small to be seen under a microscope at the time, there were problems with correctly diagnosing it.  The bacterium Haemophilus influenzae was instead mistakenly thought to be the cause, as it was big enough to be seen and was present in many, though not all, patients.  For this reason, a vaccine that was used against that bacillus did not make an infection rarer but did decrease the death rate. 
During the deadly second wave there were also fears that it was in fact plague, dengue fever, or cholera.  Another common misdiagnosis was typhus, which was common in circumstances of social upheaval, and was therefore also affecting Russia in the aftermath of the October Revolution.  In Chile, the view of the country's elite was that the nation was in severe decline, and therefore doctors assumed that the disease was typhus caused by poor hygiene, and not an infectious one, causing a mismanaged response which did not ban mass gatherings. 
The role of climate conditions
Studies have shown that the immune system of Spanish flu victims was weakened by adverse climate conditions which were particularly unseasonably cold and wet for extended periods of time during the duration of the pandemic. This affected especially WWI troops exposed to incessant rains and lower-than-average temperatures for the duration of the conflict, and especially during the second wave of the pandemic. Ultra-high-resolution climate data combined with highly detailed mortality records analyzed at Harvard University and the Climate Change Institute at the University of Maine identified a severe climate anomaly that impacted Europe from 1914 to 1919, with several environmental indicators directly influencing the severity and spread of the Spanish flu pandemic.  Specifically, a significant increase in precipitation affected all of Europe during the second wave of the pandemic, from September to December 1918. Mortality figures follow closely the concurrent increase in precipitation and decrease in temperatures. Several explanations have been proposed for this, including the fact that lower temperatures and increased precipitation provided ideal conditions for virus replication and transmission, while also negatively affecting the immune systems of soldiers and other people exposed to the inclement weather, a factor proven to increase likelihood of infection by both viruses and pneumococcal co-morbid infections documented to have affected a large percentage of pandemic victims (one fifth of them, with a 36% mortality rate).      A six-year climate anomaly (1914–1919) brought cold, marine air to Europe, drastically changing its weather, as documented by eyewitness accounts and instrumental records, reaching as far as the Gallipoli campaign, in Turkey, where ANZAC troops suffered extremely cold temperatures despite the normally Mediterranean climate of the region. The climate anomaly likely influenced the migration of H1N1 avian vectors which contaminate bodies of water with their droppings, reaching 60% infection rates in autumn.    The climate anomaly has been associated with an anthropogenic increase in atmospheric dust, due to the incessant bombardment increased nucleation due to dust particles (cloud condensation nuclei) contributed to increased precipitation.   
Public health management
While systems for alerting public health authorities of infectious spread did exist in 1918, they did not generally include influenza, leading to a delayed response.  Nevertheless, actions were taken. Maritime quarantines were declared on islands such as Iceland, Australia, and American Samoa, saving many lives.  Social distancing measures were introduced, for example closing schools, theatres, and places of worship, limiting public transportation, and banning mass gatherings.  Wearing face masks became common in some places, such as Japan, though there were debates over their efficacy.  There was also some resistance to their use, as exemplified by the Anti-Mask League of San Francisco. Vaccines were also developed, but as these were based on bacteria and not the actual virus, they could only help with secondary infections.  The actual enforcement of various restrictions varied.  To a large extent, the New York City health commissioner ordered businesses to open and close on staggered shifts to avoid overcrowding on the subways. 
A later study found that measures such as banning mass gatherings and requiring the wearing of face masks could cut the death rate up to 50 percent, but this was dependent on their being imposed early in the outbreak and not being lifted prematurely. 
As there were no antiviral drugs to treat the virus, and no antibiotics to treat the secondary bacterial infections, doctors would rely on a random assortment of medicines with varying degrees of effectiveness, such as aspirin, quinine, arsenics, digitalis, strychnine, epsom salts, castor oil, and iodine.  Treatments of traditional medicine, such as bloodletting, ayurveda, and kampo were also applied. 
Due to World War I, many countries engaged in wartime censorship, and suppressed reporting of the pandemic.  For example, the Italian newspaper Corriere della Sera was prohibited from reporting daily death tolls.  The newspapers of the time were also generally paternalistic and worried about mass panic.  Misinformation also spread along with the disease. In Ireland there was a belief that noxious gases were rising from the mass graves of Flanders Fields and being "blown all over the world by winds".  There were also rumors that the Germans were behind it, for example by poisoning the aspirin manufactured by Bayer, or by releasing poison gas from U-boats. 
Around the globe
The Spanish flu infected around 500 million people, about one-third of the world's population.  Estimates as to how many infected people died vary greatly, but the flu is regardless considered to be one of the deadliest pandemics in history.   An early estimate from 1927 put global mortality at 21.6 million.  An estimate from 1991 states that the virus killed between 25 and 39 million people.  A 2005 estimate put the death toll at 50 million (about 3% of the global population), and possibly as high as 100 million (more than 5%).   However, a 2018 reassessment in the American Journal of Epidemiology estimated the total to be about 17 million,  though this has been contested.  With a world population of 1.8 to 1.9 billion,  these estimates correspond to between 1 and 6 percent of the population.
A 2009 study in Influenza and Other Respiratory Viruses based on data from fourteen European countries estimated a total of 2.64 million excess deaths in Europe attributable to the Spanish flu during the major 1918–1919 phase of the pandemic, in line with the three prior studies from 1991, 2002, and 2006 that calculated a European death toll of between 2 million and 2.3 million. This represents a mortality rate of about 1.1% of the European population (c. 250 million in 1918), considerably higher than the mortality rate in the US, which the authors hypothesize is likely due to the severe effects of the war in Europe.  The excess mortality rate in the UK has been estimated at 0.28%–0.4%, far below this European average. 
Some 12–17 million people died in India, about 5% of the population.  The death toll in India's British-ruled districts was 13.88 million.  Another estimate gives at least 12 million dead.  The decade between 1911 and 1921 was the only census period in which India's population fell, mostly due to devastation of the Spanish flu pandemic.   While India is generally described as the country most severely affected by the Spanish flu, at least one study argues that other factors may partially account for the very high excess mortality rates observed in 1918, citing unusually high 1917 mortality and wide regional variation (ranging from 0.47% to 6.66%).  A 2006 study in The Lancet also noted that Indian provinces had excess mortality rates ranging from 2.1% to 7.8%, stating: "Commentators at the time attributed this huge variation to differences in nutritional status and diurnal fluctuations in temperature." 
In Finland, 20,000 died out of 210,000 infected.  In Sweden, 34,000 died. 
In Japan, 23 million people were affected, with at least 390,000 reported deaths.  In the Dutch East Indies (now Indonesia), 1.5 million were assumed to have died among 30 million inhabitants.  In Tahiti, 13% of the population died during one month. Similarly, in Western Samoa 22% of the population of 38,000 died within two months. 
In Istanbul, capital of the Ottoman Empire, 6,403  to 10,000  died, giving the city a mortality rate of at least 0.56%. 
In New Zealand, the flu killed an estimated 6,400 Pakeha and 2,500 indigenous Maori in six weeks, with Māori dying at eight times the rate of Pakeha.  
In the US, about 28% of the population of 105 million became infected, and 500,000 to 850,000 died (0.48 to 0.81 percent of the population).    Native American tribes were particularly hard hit. In the Four Corners area, there were 3,293 registered deaths among Native Americans.  Entire Inuit and Alaskan Native village communities died in Alaska.  In Canada, 50,000 died. 
In Brazil, 300,000 died, including president Rodrigues Alves. 
In Britain, as many as 250,000 died in France, more than 400,000. 
In Ghana, the influenza epidemic killed at least 100,000 people.  Tafari Makonnen (the future Haile Selassie, Emperor of Ethiopia) was one of the first Ethiopians who contracted influenza but survived.   Many of his subjects did not estimates for fatalities in the capital city, Addis Ababa, range from 5,000 to 10,000, or higher. 
The death toll in Russia has been estimated at 450,000, though the epidemiologists who suggested this number called it a "shot in the dark".  If it is correct, Russia lost roughly 0.4% of its population, meaning it suffered the lowest influenza-related mortality in Europe. Another study considers this number unlikely, given that the country was in the grip of a civil war, and the infrastructure of daily life had broken down the study suggests that Russia's death toll was closer to 2%, or 2.7 million people. 
Even in areas where mortality was low, so many adults were incapacitated that much of everyday life was hampered. Some communities closed all stores or required customers to leave orders outside. There were reports that healthcare workers could not tend the sick nor the gravediggers bury the dead because they too were ill. Mass graves were dug by steam shovel and bodies buried without coffins in many places. 
Bristol Bay, a region of Alaska populated by indigenous people, suffered a death rate of 40 percent of the total population, with some villages entirely disappearing. 
Several Pacific island territories were hit particularly hard. The pandemic reached them from New Zealand, which was too slow to implement measures to prevent ships, such as Talune, carrying the flu from leaving its ports. From New Zealand, the flu reached Tonga (killing 8% of the population), Nauru (16%), and Fiji (5%, 9,000 people).  Worst affected was Western Samoa, formerly German Samoa, which had been occupied by New Zealand in 1914. 90% of the population was infected 30% of adult men, 22% of adult women, and 10% of children died. By contrast, Governor John Martin Poyer prevented the flu from reaching neighboring American Samoa by imposing a blockade.  The disease spread fastest through the higher social classes among the indigenous peoples, because of the custom of gathering oral tradition from chiefs on their deathbeds many community elders were infected through this process. 
In Iran, the mortality was very high: according to an estimate, between 902,400 and 2,431,000, or 8% to 22% of the total population died.  The country was going through the Persian famine of 1917–1919 concurrently.
In Ireland, during the worst 12 months, the Spanish flu accounted for one-third of all deaths.  
In South Africa it is estimated that about 300,000 people amounting to 6% of the population died within six weeks. Government actions in the early stages of the virus' arrival in the country in September 1918 are believed to have unintentionally accelerated its spread throughout the country.  Almost a quarter of the working population of Kimberley, consisting of workers in the diamond mines, died.  In British Somaliland, one official estimated that 7% of the native population died.  This huge death toll resulted from an extremely high infection rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms. 
In the Pacific, American Samoa  and the French colony of New Caledonia  succeeded in preventing even a single death from influenza through effective quarantines. Australia also managed to avoid the first two waves with a quarantine.  Iceland protected a third of its population from exposure by blocking the main road of the island.  By the end of the pandemic, the isolated island of Marajó, in Brazil's Amazon River Delta had not reported an outbreak.  Saint Helena also reported no deaths. 
Estimates for the death toll in China have varied widely,   a range which reflects the lack of centralized collection of health data at the time due to the Warlord period. China may have experienced a relatively mild flu season in 1918 compared to other areas of the world.     However, some reports from its interior suggest that mortality rates from influenza were perhaps higher in at least a few locations in China in 1918.  At the very least, there is little evidence that China as a whole was seriously affected by the flu compared to other countries in the world. 
The first estimate of the Chinese death toll was made in 1991 by Patterson and Pyle, which estimated a toll of between 5 and 9 million. However, this 1991 study was criticized by later studies due to flawed methodology, and newer studies have published estimates of a far lower mortality rate in China.    For instance, Iijima in 1998 estimates the death toll in China to be between 1 and 1.28 million based on data available from Chinese port cities.  The lower estimates of the Chinese death toll are based on the low mortality rates that were found in Chinese port cities (for example, Hong Kong) and on the assumption that poor communications prevented the flu from penetrating the interior of China.  However, some contemporary newspaper and post office reports, as well as reports from missionary doctors, suggest that the flu did penetrate the Chinese interior and that influenza was severe in at least some locations in the countryside of China. 
Although medical records from China's interior are lacking, extensive medical data were recorded in Chinese port cities, such as then British-controlled Hong Kong, Canton, Peking, Harbin and Shanghai. These data were collected by the Chinese Maritime Customs Service, which was largely staffed by non-Chinese foreigners, such as the British, French, and other European colonial officials in China.  As a whole, accurate data from China's port cities show astonishingly low mortality rates compared to other cities in Asia.  For example, the British authorities at Hong Kong and Canton reported a mortality rate from influenza at a rate of 0.25% and 0.32%, much lower than the reported mortality rate of other cities in Asia, such as Calcutta or Bombay, where influenza was much more devastating.   Similarly, in the city of Shanghai – which had a population of over 2 million in 1918 – there were only 266 recorded deaths from influenza among the Chinese population in 1918.  If extrapolated from the extensive data recorded from Chinese cities, the suggested mortality rate from influenza in China as a whole in 1918 was likely lower than 1% – much lower than the world average (which was around 3–5%).  In contrast, Japan and Taiwan had reported a mortality rate from influenza around 0.45% and 0.69% respectively, higher than the mortality rate collected from data in Chinese port cities, such as Hong Kong (0.25%), Canton (0.32%), and Shanghai. 
Patterns of fatality
The pandemic mostly killed young adults. In 1918–1919, 99% of pandemic influenza deaths in the U.S. occurred in people under 65, and nearly half of deaths were in young adults 20 to 40 years old. In 1920, the mortality rate among people under 65 had decreased sixfold to half the mortality rate of people over 65, but 92% of deaths still occurred in people under 65.  This is unusual since influenza is typically most deadly to weak individuals, such as infants under age two, adults over age 70, and the immunocompromised. In 1918, older adults may have had partial protection caused by exposure to the 1889–1890 flu pandemic, known as the "Russian flu".  According to historian John M. Barry, the most vulnerable of all – "those most likely, of the most likely", to die – were pregnant women. He reported that in thirteen studies of hospitalized women in the pandemic, the death rate ranged from 23% to 71%.  Of the pregnant women who survived childbirth, over one-quarter (26%) lost the child.  Another oddity was that the outbreak was widespread in the summer and autumn (in the Northern Hemisphere) influenza is usually worse in winter. 
There were also geographic patterns to the disease's fatality. Some parts of Asia had 30 times higher death rates than some parts of Europe, and generally, Africa and Asia had higher rates, while Europe and North America had lower ones.  There was also great variation within continents, with three times higher mortality in Hungary and Spain compared to Denmark, two to three times higher chance of death in Sub-Saharan Africa compared to North Africa, and possibly up to ten times higher rates between the extremes of Asia.  Cities were affected worse than rural areas.  There were also differences between cities, which might have reflected exposure to the milder first wave giving immunity, as well as the introduction of social distancing measures. 
Another major pattern was the differences between social classes. In Oslo, death rates were inversely correlated with apartment size, as the poorer people living in smaller apartments died at a higher rate.  Social status was also reflected in the higher mortality among immigrant communities, with Italian Americans, a recently arrived group at the time, were nearly twice as likely to die compared to the average Americans.  These disparities reflected worse diets, crowded living conditions, and problems accessing healthcare.  Paradoxically, however, African Americans were relatively spared by the pandemic. 
More men than women were killed by the flu, as they were more likely to go out and be exposed, while women would tend to stay at home.  For the same reason men also were more likely to have pre-existing tuberculosis, which severely worsened the chances of recovery.  However, in India the opposite was true, potentially because Indian women were neglected with poorer nutrition, and were expected to care for the sick. 
A study conducted by He et al. (2011) used a mechanistic modeling approach to study the three waves of the 1918 influenza pandemic. They examined the factors that underlie variability in temporal patterns and their correlation to patterns of mortality and morbidity. Their analysis suggests that temporal variations in transmission rate provide the best explanation, and the variation in transmission required to generate these three waves is within biologically plausible values.  Another study by He et al. (2013) used a simple epidemic model incorporating three factors to infer the cause of the three waves of the 1918 influenza pandemic. These factors were school opening and closing, temperature changes throughout the outbreak, and human behavioral changes in response to the outbreak. Their modeling results showed that all three factors are important, but human behavioral responses showed the most significant effects. 
World War I
Academic Andrew Price-Smith has made the argument that the virus helped tip the balance of power in the latter days of the war towards the Allied cause. He provides data that the viral waves hit the Central Powers before the Allied powers and that both morbidity and mortality in Germany and Austria were considerably higher than in Britain and France.  A 2006 Lancet study corroborates higher excess mortality rates in Germany (0.76%) and Austria (1.61%) compared to Britain (0.34%) and France (0.75%). 
Kenneth Kahn at Oxford University Computing Services writes that "Many researchers have suggested that the conditions of the war significantly aided the spread of the disease. And others have argued that the course of the war (and subsequent peace treaty) was influenced by the pandemic." Kahn has developed a model that can be used on home computers to test these theories. 
Many businesses in the entertainment and service industries suffered losses in revenue, while the healthcare industry reported profit gains.  Historian Nancy Bristow has argued that the pandemic, when combined with the increasing number of women attending college, contributed to the success of women in the field of nursing. This was due in part to the failure of medical doctors, who were predominantly men, to contain and prevent the illness. Nursing staff, who were mainly women, celebrated the success of their patient care and did not associate the spread of the disease with their work. 
A 2020 study found that US cities that implemented early and extensive non-medical measures (quarantine, etc.) suffered no additional adverse economic effects due to implementing those measures,  when compared with cities that implemented measures late or not at all. 
A 2006 study in the Journal of Political Economy found that "cohorts in utero during the pandemic displayed reduced educational attainment, increased rates of physical disability, lower income, lower socioeconomic status, and higher transfer payments received compared with other birth cohorts."  A 2018 study found that the pandemic reduced educational attainment in populations.  The flu has also been linked to the outbreak of encephalitis lethargica in the 1920s. 
Survivors faced an elevated mortality risk. Some survivors did not fully recover from physiological condition(s). 
Despite the high morbidity and mortality rates that resulted from the epidemic, the Spanish flu began to fade from public awareness over the decades until the arrival of news about bird flu and other pandemics in the 1990s and 2000s.  This has led some historians to label the Spanish flu a "forgotten pandemic". 
There are various theories of why the Spanish flu was "forgotten". The rapid pace of the pandemic, which killed most of its victims in the United States within less than nine months, resulted in limited media coverage. The general population was familiar with patterns of pandemic disease in the late 19th and early 20th centuries: typhoid, yellow fever, diphtheria, and cholera all occurred near the same time. These outbreaks probably lessened the significance of the influenza pandemic for the public.  In some areas, the flu was not reported on, the only mention being that of advertisements for medicines claiming to cure it. 
Additionally, the outbreak coincided with the deaths and media focus on the First World War.  Another explanation involves the age group affected by the disease. The majority of fatalities, from both the war and the epidemic, were among young adults. The high number of war-related deaths of young adults may have overshadowed the deaths caused by flu. 
When people read the obituaries, they saw the war or postwar deaths and the deaths from the influenza side by side. Particularly in Europe, where the war's toll was high, the flu may not have had a tremendous psychological impact or may have seemed an extension of the war's tragedies.  The duration of the pandemic and the war could have also played a role. The disease would usually only affect a particular area for a month before leaving. [ citation needed ] The war, however, had initially been expected to end quickly but lasted for four years by the time the pandemic struck.
In fiction and other literature
The Spanish flu has been represented in numerous works of fiction:
- 's novella Pale Horse, Pale Rider, published under the same title in a 1930 collection of three works , a 1985 American drama film.
- The Last Town on Earth, a 2006 novel.
- Spanish Flu: The Forgotten Fallen, a 2009 British television series.
- Downton Abbey, a 2010 British historical drama television series. 
- Vampyr, a 2018 video game.
- Resident Evil Village, a 2021 video game.
In addition, Mary McCarthy referred to it in her memoir Memories of a Catholic Girlhood (1957), as she and her three brothers were orphaned by their parents' deaths from the flu.
Comparison with other pandemics
The Spanish flu killed a much lower percentage of the world's population than the Black Death, which lasted for many more years. 
In the ongoing COVID-19 pandemic, as of 26 June 2021, more than 180 million cases have been identified and more than 3.91 million deaths recorded worldwide. 
The origin of the Spanish flu pandemic, and the relationship between the near-simultaneous outbreaks in humans and swine, have been controversial. One hypothesis is that the virus strain originated at Fort Riley, Kansas, in viruses in poultry and swine which the fort bred for food the soldiers were then sent from Fort Riley around the world, where they spread the disease.  Similarities between a reconstruction of the virus and avian viruses, combined with the human pandemic preceding the first reports of influenza in swine, led researchers to conclude the influenza virus jumped directly from birds to humans, and swine caught the disease from humans.  
Others have disagreed,  and more recent research has suggested the strain may have originated in a nonhuman, mammalian species.  An estimated date for its appearance in mammalian hosts has been put at the period 1882–1913.  This ancestor virus diverged about 1913–1915 into two clades (or biological groups), which gave rise to the classical swine and human H1N1 influenza lineages. The last common ancestor of human strains dates between February 1917 and April 1918. Because pigs are more readily infected with avian influenza viruses than are humans, they were suggested as the original recipients of the virus, passing the virus to humans sometime between 1913 and 1918.
An effort to recreate the Spanish flu strain (a subtype of avian strain H1N1) was a collaboration among the Armed Forces Institute of Pathology, the USDA ARS Southeast Poultry Research Laboratory, and Mount Sinai School of Medicine in New York City. The effort resulted in the announcement (on 5 October 2005) that the group had successfully determined the virus's genetic sequence, using historic tissue samples recovered by pathologist Johan Hultin from an Inuit female flu victim buried in the Alaskan permafrost and samples preserved from American soldiers  Roscoe Vaughan and James Downs.  
On 18 January 2007, Kobasa et al. (2007) reported that monkeys (Macaca fascicularis) infected with the recreated flu strain exhibited classic symptoms of the 1918 pandemic, and died from cytokine storms  – an overreaction of the immune system. This may explain why the Spanish flu had its surprising effect on younger, healthier people, as a person with a stronger immune system would potentially have a stronger overreaction. 
On 16 September 2008, the body of British politician and diplomat Sir Mark Sykes was exhumed to study the RNA of the flu virus in efforts to understand the genetic structure of modern H5N1 bird flu. Sykes had been buried in 1919 in a lead coffin which scientists hoped had helped preserve the virus.  The coffin was found to be split and the cadaver badly decomposed nonetheless, samples of lung and brain tissue were taken. 
In December 2008, research by Yoshihiro Kawaoka of the University of Wisconsin linked the presence of three specific genes (termed PA, PB1, and PB2) and a nucleoprotein derived from Spanish flu samples to the ability of the flu virus to invade the lungs and cause pneumonia. The combination triggered similar symptoms in animal testing. 
In June 2010, a team at the Mount Sinai School of Medicine reported the 2009 flu pandemic vaccine provided some cross-protection against the Spanish flu pandemic strain. 
One of the few things known for certain about influenza in 1918 and for some years after was that it was, except in the laboratory, exclusively a disease of human beings. 
In 2013, the AIR Worldwide Research and Modeling Group "characterized the historic 1918 pandemic and estimated the effects of a similar pandemic occurring today using the AIR Pandemic Flu Model". In the model, "a modern-day 'Spanish flu' event would result in additional life insurance losses of between US$15.3–27.8 billion in the United States alone", with 188,000–337,000 deaths in the United States. 
In 2018, Michael Worobey, an evolutionary biology professor at the University of Arizona who is examining the history of the 1918 pandemic, revealed that he obtained tissue slides created by William Rolland, a physician who reported on a respiratory illness likely to be the virus while a pathologist in the British military during World War One.  Rolland had authored an article in the Lancet during 1917 about a respiratory illness outbreak beginning in 1916 in Étaples, France.   Worobey traced recent references to that article to family members who had retained slides that Rolland had prepared during that time. Worobey extracted tissue from the slides to potentially reveal more about the origin of the pathogen. [ citation needed ]
The high mortality rate of the influenza pandemic is one aspect that sets the pandemic apart from other disease outbreaks. Another factor is the higher mortality rate of men compared with women. Men with an underlying condition were at significantly more risk. Tuberculosis was one of the deadliest diseases in the 1900s, and killed more men than women. But with the spread of influenza disease, the cases of tuberculosis cases in men decreased. Many scholars have noted that tuberculosis increased the mortality rate of influenza in males, decreasing their life expectancy. During the 1900s tuberculosis was more common in males than females, but studies show that when influenza spread the tuberculosis mortality rate among females changed. The death rate of tuberculosis in females increased significantly and would continue to decline until post-pandemic. 
Death rates were particularly high in those aged 20–35. The only comparable disease to this was the black death, bubonic plague in the 1300s. As other studies have shown, tuberculosis and influenza had comorbidities and one affected the other. The ages of males dying of the flu show that tuberculosis was a factor, and as males primarily had this disease at the time of the pandemic, they had a higher mortality rate. Life expectancy dropped in males during the pandemic but then increased two years after the pandemic 
Island of Newfoundland
One major cause of the spread of influenza was social behavior. Men had more social variation and were mobile more than women due to their work. Even though there was a higher mortality rate in males, each region showed different results, due to such factors as nutritional deficiency. In Newfoundland the pandemic spread was highly variable. Influenza did not discriminate who was infected, indeed it attacked the socioeconomic status of people. Although social variability allowed the disease to move quickly geographically, it tended to spread faster and affect men more than women due to labor and social contact. Newfoundland's leading cause of death before the pandemic was tuberculosis and this is known to be a severe underlying condition for people and increases the |mortality rate when infected by the influenza disease. There was diverse labor in Newfoundland, men and women had various occupations that involved day-to-day interaction. But, fishing had a major role in the economy and so males were more mobile than females and had more contact with other parts of the world. The spread of the pandemic is known to have begun in the spring of 1918, but Newfoundland didn't see the deadly wave until June or July, which aligns with the high demand for employment in the fishery. The majority of men were working along the coast during the summer and it was typical for entire families to move to Newfoundland and work. Studies show a much higher mortality rate in males compared with females. But, during the first, second, and third waves of the pandemic, the mortality shifted. During the first wave, men had a higher mortality rate, but the mortality rate of females increased and was higher during the second and third waves. The female population was larger in certain regions of Newfoundland and therefore had a bigger impact on the death rate. 
Influenza pandemic among Canadian soldiers
Records indicate the most deaths during the first wave of the pandemic were among young men in their 20s, which reflects the age of enlistment in the war. The mobility of young men during 1918 was linked to the spread of influenza and the biggest wave of the epidemic. In late 1917 and throughout 1918, thousands of male troops gathered at the Halifax port before heading to Europe. Any soldier that was ill and could not depart was added to the population of Halifax, which increased the case rate of influenza among men during the war. To determine the cause of the death during the pandemic, war scientists used the Commonwealth War Graves Commission (CWGC), which reported under 2 million men and women died during the wars, with a record of those who died from 1917 to 1918. The movement of soldiers during this time and the transportation from United States between Canada likely had a significant effect on the spread of the pandemic. 
1918 pandemic: Amid tales of woe, story of a woman who wanted a child so bad she stole one may be the saddest
The Spanish Influenza Epidemic of 1918 was one of the most devastating events in human history, killing an estimated 20 to 50 million people worldwide.
Like everywhere else, Syracuse felt the pain, with 900 deaths reported in the city.
One of the saddest stories to emerge locally involved a young woman named Daisy Lovine, who was so desperate for a child of her own she kidnapped a baby. But the story doesn’t end as you might think. In fact, it’s a story of compassion and forgiveness that, as one newspaper writer at the time said was so compelling, “only a master novelist could do it justice.”
That story begins on a sidewalk outside Woolworth’s five and ten store on Salina Street on March 7, 1918.
Syracuse was shocked with news that a bay was taken from in front of the city's Woolworth store in broad daylight on March 7, 1918. These headlines are from the front page of the Syracuse Herald the next day. Heritage Microfilm Heritage Microfilm
Besides murder, kidnapping was the most serious crime that a person could commit in Syracuse in 1918. In the history of Onondaga County, up to that point, there had not been a single kidnapping trial.
So that could explain the shocked reaction to what occurred outside of Syracuse’s Woolworths on South Salina Street on March 7, 1918.
In broad daylight, a cream-colored baby carriage holding ten-month-old Dorothy Martin was taken, with the child inside, while her mother shopped inside the store.
(This, apparently, was what done with babies while people shopped. “More than once women remained with her while I shopped and sometimes men would stop and cast admiring eyes at the baby,” the child’s mother told the police.)
The police were summoned, and officers were posted outside of railroad and trolley stations.
Meanwhile, the abducted child’s parents, Cora and James of 517 Lodi Street, walked the streets of the city, “wild with grief,” all night and into the next morning, searching for their baby.
In desperation, Cora even turned to a clairvoyant for help, the medium telling her that the child was taken by “a woman who had admired the baby.”
After almost 26 hours of terror, the Martins worst fears were over when there was a knock on their door.
On the front porch was a young couple, John and Daisy Lovine of Shonnard Street, holding the unharmed, and very happy, Dorothy Martin.
This snapshot of the Martins, Cora and James, with baby Dorothy, was taken shortly before the baby was kidnapped by Daisy Lovine. Taken from the March 9, 1918 Syracuse Herald. Heritage Microfilm Heritage Microfilm
“My baby! My baby,” Cora shouted. “Oh, Jim, they brought her back safe!”
“Then baby was in mother’s arms, fairly smothered by the embraces and kisses,” a Post-Standard reporter who was in the home wrote. “There was no happier woman in Syracuse last night than Mrs. Martin.”
The Martins and the Lovines went to police headquarters to tell detectives what had happened.
Daisy Lovine told a fantastic story of how little Dorothy had fallen into her care.
A cousin from Chittenango, Sadie Kimble from Chittenango, whom the Lovines had not seen for years, had come for a visit and asked Daisy to watch her child for a couple of days while she sought work in Syracuse. Kimble also brought a baby carriage that she asked to be repainted by Daisy’s husband. Kimble gave Daisy a can of blue enamel and a small brush to do the job.
To police, this Sadie Kimble sounded like just person who would commit such an act as kidnapping.
As a young girl she had been confined at the Shelter for Unprotected Girls and her most of her male family members were currently incarcerated, including her father, uncle and brother.
In addition, a child born to Kimble in 1915 had died shortly after birth.
Maybe she was overcome by grief by the loss of a child? Maybe she wanted to use the Martin baby as ransom?
A frantic search was begun for Kimble but after three days there were no signs of her.
But Syracuse Deputy Police Chief O’Brien was not satisfied with Daisy Lovine’s story and put two detectives on her trail.
In some clever police work, Detectives Edward Smith and Edward Bamrick secretly photographed Daisy and went to a bunch of Syracuse stores which sold paint and paintbrushes.
At Kresge’s on South Salina Street, a clerk, remembered selling blue paint and a small brush to the woman in the photo.
The detectives went to the Lovine home and, after originally sticking to her story, Daisy broke down and confessed to the kidnapping.
After her confession on March 11, 1918, 22-year-old Daisy Lovine was taken directly to the Onondaga County Jail. She faced between 10 and 50 years for the serious crime of kidnapping.
After one day, Daisy Lovine's story fell apart and she confessed to Syracuse police that she was responsible for the kidnapping of Dorothy Martin. New York State Digital Library New York State Digital Library
The Syracuse Herald got a glimpse of the young woman and called her a “pitiful sight.”
“Her face was chalky pale. Her eyes were dim and faded from weeping and she was trembling like an aspen.”
To the reporter, looking at her in her cell, Lovine resembled a “little creature, looking in her strange surroundings like some little animal caught in a trap.”
Her arrest was just the latest chapter in her sad life.
She was born in Vernon, to a family that the Herald said, “counted more in police and justice court annals than among good citizens.”
Her mother died when she was two, her father, the “usual village ne’er-do-well,” a few years later.
She spent a few years with an abusive grandmother before being sent to the Rome Orphan Asylum. She married a soldier when she was 16, John Jayne, who was deployed to the Philippines forcing her to look for a job.
She worked as a housekeeper for a family in Oneida and soon began a relationship with the family’s adult son.
When her husband returned after being wounded in China and found out what she was up to, he filed for divorce.
Her life turned around after she met John Lovine. She was working as a waitress at the Preston lunchroom at Fayette Street in Syracuse and the young machinist was a frequent customer. They married and began a happy life together.
(John, who knew nothing of the plan to kidnap the baby, would stand by his wife throughout.)
But there was still something missing the couple could not conceive a child, which is what Daisy had always wanted.
“I can’t remember the time when I didn’t want a baby,” she told a Herald reporter, after her confession. “I never cared for dolls as other children do. I would go to the homes of the neighbors and ask permission to hold their babies or to take them out in their carriages or rock them in their cradles.”
Once, she went to the Onondaga Orphans’ Home and picked up an application to adopt a child but never filled it out, fearing rejection.
Something in her snapped on that March afternoon in front of the Woolworths’ store.
“It used to make my blood boil to look at them,” she said of the line of unattended baby carriages. “I’d think to myself, ‘If you were mine, I’d never want to go downtown. I’d just want to stay home and take care of you and make things for you to wear.’”
She began feeling guilty about what she had put the Martins through and came up with the cousin story.
Despite facing a lengthy sentence at Auburn State Prison, Lovine said she would “always remember” the night she was a mother.
There were a couple of interested spectators at Daisy Lovine’s arraignment on March 13, 1918 inside Judge Cobb’s courtroom at the Onondaga Courthouse.
James and Cora Martin, with little Dorothy, “crowing and gurgling” in the front row, watched intently as Daisy Lovine plead ‘not guilty.”
“They won’t do anything to her, will they,” Mrs. Martin asked the person next to her.
“If she is convicted, she will have to go to prison for at least ten years,” was the response.
The young mother jumped to her feet and exclaimed:
“She won’t do anything of the kind. I’ll just go to the judge and withdraw my warrant this minute. It’s my baby and my case and my warrant and I won’t have her sent to prison, so there!”
When told that the decision was out of her control, the Herald said Mrs. Martin became “very wrathful indeed.”
Soon, almost all of Syracuse’s female community was joining Martin and supporting Lovine.
“I am heartily sorry for the girl,” said Florence Grannis, Onondaga County’s agent for dependent children, “and I would do anything that I could do to help her.”
In an informal Herald survey, nearly every woman polled expressed “pity and sympathy” for Lovine and almost all pleaded for leniency.
“I believe that the girl should go free,” said Mrs. John Dunfee, president of St. Joseph’s Hospital’s Women’s Auxiliary. “I should hate to see her punished and would do anything in my power to prevent such a consummation.”
Unfortunately, the person in charge for bringing Lovine’s case forward felt differently.
Assistant District Attorney Henry Wilson, the Herald said, was “deeply interested” in prosecuting the case.
The short, two-day trial began on May 2, 1918 and was argued before an all-male jury.
In his closing statement, Wilson attacked any notion that Lovine deserved any sympathy:
“This woman lied, Not once, repeatedly. She lied to her husband and shifted the blame for her sin on her cousin, putting her under a cloud of suspicion. She lied to the Martins, she lied to the police.
You men must not be swayed by sympathy. The other mother, who wrung her hands, walked the streets searching for the baby and who suffered the torments of a broken heart is the one who deserves your sympathy and not this woman who deliberately walked away with the choicest and God-given possession of another.”
But none of Wilson’s words could overcome the powerful visual of what had happened after Daisy Lovine stepped down from the witness stand.
While heading back to her seat, she walked past where Mrs. Martin was standing, holding Dorothy.
The young mother reached out a hand and grabbed Lovine’s.
“I hope everything will be all right,” Martin said, as Dorothy stooped to bury her lips in the back of the child’s neck.
The child giggled and Mr. Lovine and Mr. Martin smiled at each other.
The acquittal of Daisy Lovine on May 3, 1918 brought about one of the biggest celebrations inside a Syracuse courtroom the city had ever seen. Heritage Microfilm Heritage Microfilm
It was to no one’s surprise that the jury took just 13 minutes to acquit Daisy Lovine, who fainted as soon as the verdict was read.
While the room exploded in applause, Lovine was carried to the judge’s anteroom. Deputy Sheriff Mary Tomney splashed water on her face and administered smelling salts.
When she came to, Lovine saw Cora Martin’s face, applying a wet compress to her forehead.
“Brace up, honey, you have lots of good friends and everyone is just as happy as they can be about what the jury did,” Martin told her, tears filling both women’s eyes.
The verdict kicked off one of the most joyous scenes ever seen in a Syracuse courtroom
Women flocked to the judge’s chambers to share in the moment, reminding a rather sexist Syracuse Journal reporter to remark that the scene reminded him of a “bargain sale rush a minute before a sale closes and there are only a few choice items left to fight for.”
During the Influenza Epidemic of 1918, death was common in Syracuse. But the loss of five-month-old of Marjorie Helen Lovine was particularly painful. Headlines from the Oct. 11, 1918. Heritage Microfilm Heritage Microfilm
Shortly after the trial, the story of Daisy Lovine took another incredible turn. And then, later, a heartbreaking one.
In June of 1918, just three months after being accused of kidnapping, a newborn baby girl was put up for adoption. Daisy and John Lovine were chosen to be her new parents.
Marjorie Helen Lovine, with big blue eyes and golden hair, and her new mother was seen all over Syracuse, being pushed in a new baby carriage.
“Never was a baby neater or sweeter,” the Herald said, “never did a baby receive more tender care.”
In September 1918, the newspaper said that Daisy had spoken with one of the countless women who had supported her during the trial.
“The mother of the little foster mother, as she showed off her darling, was glorified.”
Then the Influenza Epidemic struck in October and the illness, which had devastated so many families, took little Marjorie on the morning of the 11th.
The adopted daughter of Daisy Lovine, five-month-old Marjorie Helen Lovine, appears in the Syracuse Journal's influenza death list on Oct. 12, 1918. She was one of 42 people from Onondaga County who died that day from the epidemic. New York State Digital Library New York State Digital Library
“In a time like this there are so many sorrowful stories that one more or less fails to make the impression that it might under normal conditions,” the Herald reported. “But even today it is safe to guess that there is not a mother in Syracuse whose heart will not be sadder by the news that Marjorie Helen Lovine died this morning.”
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.
September 24, 1918, diary entry (Collection of the Massachusetts Historical Society)
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.”
History suggests we may forget the pandemic sooner than we think
O ne day this will all be over. That’s hard to believe now, when even this month seems interminable, the January that refused to end. But one day, not soon perhaps, we will speak of the pandemic in the past tense. When that time comes, how will we remember the plague that visited death upon us?
So far, the act of remembering has been deferred or even forbidden. Second only to the deaths themselves, perhaps the greatest pain the coronavirus has inflicted has been its denial of the right to say goodbye. Quarantine rules have kept people from the bedsides of loved ones in their final hours, their parting words exchanged by phone or left unsaid. I’m still haunted by the story of an early victim of the virus, a 13-year-old boy whose family had to stay away from their child’s funeral. For many, that most intimate of rituals has come via a livestream: better than nothing, but remote in every sense. Even those able to bury their dead in person have had to keep their distance from one another, denied the consolation of touch.
I lost my much-loved cousin Ruth to Covid in April. A memorial service for her was scheduled for spring 2021, on the assumption that the crisis would surely have passed by then. Now it has been postponed indefinitely.
It’s a bit like that for society as a whole, delaying the moment of collective mourning until we can be certain it’s all over. This week the UK death toll passed 100,000, with the week’s per capita death rate the highest in the world. That offered an opening for contemplation – with plenty of graphics to make sense of such an unimaginably large number – but it was not quite mourning. The signals from the top are that commemoration, like the learning of lessons, will have to wait.
In the US, public expressions of grief were suppressed until last week because Donald Trump could not bring himself to utter so much as a word of recognition of the dead, let alone consolation for the bereaved. Joe Biden sought to make amends with a modest ceremony – 400 lights and Leonard Cohen’s Hallelujah – on the eve of his inauguration, but it released only a trickle of the sorrow that is pent up, waiting for the dam to break.
But even when the mortal danger has passed, will there be a process of collective remembering? Instinctively, you assume the answer has to be yes. After all, this has been an upending event on a global scale, one that has touched us all. Given that we still cherish ceremonies and monuments that recall the horrors of long-distant wars, including one fought a century ago, surely we will soon devise fresh rituals to channel this new collective sorrow.
History suggests we may not. Look around almost any British town or village and you will see a war memorial, usually first built to honour the fallen of 1914 to 1918. But scour this country and the rest of the world, and you will struggle to find more than a couple of markers for the event that, globally and at the time of the war’s end, took many more lives. The first world war killed some 17 million people, but the “Spanish” flu that struck in 1918 infected one in three people on the planet – a total of 500 million – leaving between 50 million and 100 million dead. The number of dead was so much greater and yet, as the leading historian of that pandemic, Laura Spinney, writes, “there is no cenotaph, no monument in London, Moscow or Washington DC” for any of them. The great writers of the age, the Hemingways and Fitzgeralds, all but ignored the plague that had descended.
Why is that? An explanation begins in the novelist Graham Swift’s conception of man as “the storytelling animal”. Wars offer a compelling, linear story. There are causes and consequences, battles, surrenders and treaties, all taking place in a defined space and time. Pandemics are not like that. They sprawl the entire globe. And the facts can take decades to emerge. For many years, the 1918-20 pandemic was thought to have cost 20 million lives. Only relatively recently has the truer, more deadly picture emerged.
Crucially, a pandemic lacks the essential ingredients of a story: clear heroes and villains with intent and motive. The Covid enemy is, despite our best efforts to anthropomorphise it, an invisible and faceless virus. That matters because commemoration is necessarily a moral exercise. Think of the way we marked Holocaust Memorial Day this week, lighting candles and telling the stories of those who survived or resisted the Nazi menace. We cast the past as a moral test, judging who passed and who failed. Wars can be remembered proudly by those who won, and even by those who lost: witness the Confederate statues put up in the early 20th century to honour what white racist southerners believed was a noble if lost cause.
A mass illness does not invite that kind of remembering. The bereaved cannot console themselves that the dead made a sacrifice for some higher cause, or even that they were victims in an epic moral event, because they did not and were not. To die of the Spanish flu or Covid-19 is to have suffered the most terrible bad luck.
That’s especially true when the virus is as indiscriminate as the 1918 disease was, affecting everyone, everywhere. The global number killed by illnesses related to HIV-Aids since 1981 is a staggering 35 million, most of them in Africa. That epidemic, too, has scarcely had the commemoration such a toll should command. But, as the absorbing Channel 4 drama It’s a Sin demonstrates, just as Angels in America did before it, HIV/Aids lends itself to storytelling precisely because that disease initially seemed to single out one group in particular. There is a moral story to be told about that first phase of the disease, a story of prejudice, bigotry and shame.
In this sense Covid is rather more like Spanish flu, which, as the medical historian Mark Honigsbaum writes, cut “across social, sexual and ethnic lines” and so “did not become a vehicle for stigma or a motor for outrage”. Lacking those elements, the current pandemic could eventually be enveloped in the same cultural amnesia that surrounded the one that struck a century earlier.
There’s one last piece of common ground between these two events, one that might further encourage forgetting. Scholars of the Spanish flu speak of “contagion guilt”, as the living asked themselves whether they might have inadvertently infected and killed a mother, a daughter, a son. Relatives of those who die in battle might also be cursed by guilt, but it will rarely be so direct.
We are practised in the collective memory of war, but with pandemics we do something different. “We remember them individually, not collectively,” says Spinney. “Not as a historical disaster, but as millions of discrete, private tragedies.”
That’s what the precedent of 1918 suggests we’ll do this time, and yet I can’t help but hope that’s wrong. When this is over, I hope we take each other’s hands and remember this strange, dark period together – even if we spent so much of it apart, so much of it alone.
This article was amended on 8 February 2021 to clarify that a mention of the UK having the highest death rate in the world was referring to weekly, rather than cumulative, figures.
Spanish flu killed millions, but few remember
The Allied Forces were gaining hard-earned ground in the late summer of 1918, carving a path that would shortly lead to an armistice for the First World War.
As those armies battled over the blood-soaked fields of Europe 90 years ago, another enemy was on the move. This adversary didn't choose sides. It didn't restrict itself to Europe. It didn't spare civilians.
By the time it was through rampaging around the globe, this assailant – the Spanish flu – had killed between 50 million and 100 million people, several times more than had lost their lives in the soon-to-be-concluded War to End All Wars.
Yet despite the scope of the death and illness, the fear and social disruption, amazingly – inexplicably – the history books made little mention of what is now viewed as the deadliest outbreak of infectious disease in recorded history.
"If I hadn't researched and written a book myself, I'd want to go look it up in the Encyclopedia Britannica to find out whether it really happened or not," historian Alfred Crosby said in a recent interview from his home on Nantucket Island.
Crosby's 1976 account of the event – "America's Forgotten Pandemic: The Influenza of 1918" – sank the first spade in what has turned into a historical and scientific excavation of the Spanish flu.
"For me, that's the most mysterious thing about it," Crosby says. "The vagaries of the virus, we'll understand them eventually. And we'll understand how flu epidemics work."
"But we're never going to understand: How the hell did we have something that killed millions and millions of people and then we said 'Oh, well' and went on to the World Series or something?"
"It's impossible. And yet it's true."
Most of us would have had a relative – an aunt, a grandfather, a great-grandmother – who was sick with the Spanish flu. If we'd asked or if they'd offered, they could have told stories of a taxing time, when gymnasiums morphed into crowded makeshift hospitals, when undertakers ran out of coffins, when the Stanley Cup playoffs were shelved – the only time that happened until the NHL lockout of 2004-05.
In fact, there are still some among us who can recall those dreadful months in the fall of 1918 and the spring of 1919. Rev. Francis Stevens of Coquitlam, B.C., is one.
Now nearly 102 and a retired United Church minister, Stevens remembers vividly that it felt like the world was spinning out of control when the Spanish flu coursed through his Vancouver neighbourhood.
His entire family was sick. Stevens, then 12, caught the flu first and recovered, only to find school closed and chums either bedridden or forbidden by frightened parents from playing with others who might infect them.
"You were kept in. Kept in at home, kept out at school," Stevens recalls. "Your school and your home were your two places of security. And both were collapsing."
Recounting the details now, the story seems like bad science fiction – 50 million to 100 million dead globally, 30,000 to 50,000 dead in Canada. If a similarly virulent outbreak occurred now, between 186 million and 372 million people around the world would die, and between 112,000 and 186,000 Canadians would succumb.
Today such a catastrophe would be non-stop news. Consider the SARS outbreak of 2003: the disease infected just over 8,000 people and killed fewer than 800, but rivalled the start of the war in Iraq for top-of-the-newscast status.
Not so in 1918. Accounts of the war in Europe crowded news about the flu bug out of the front pages of newspapers. "Usually it was on Page 12," Crosby notes.
Heather MacDougall, a historian at the University of Waterloo, has studied Canadian newspaper coverage of the time.
"The press was heavily self-censored because the war was still on. And when you look at the news stories, the rhetoric of the stories is that this is just another battle that we have to fight. Except it's against disease, not against the Germans."
"And given that we are now finally winning the war against the Germans, we will win this war against disease."
It has been suggested the curious under-reporting of the event in countries that were combatants in the First World War contributed to the evolution of the outbreak's moniker, which implies the virus arose in Spain. (Influenza viruses are named after the place where they are first found.)
The thinking is that because Spain was a non-combatant, its newspapers were more openly reporting on the alarming new twist on an old illness.
Influenza viruses circulate all the time, sending victims to their beds with bone-aching fatigue. They can even kill. In Canada, between 4,000 and 8,000 people a year – often the elderly – die from influenza or the pneumonia that can follow. But occasionally a new influenza virus for which humans have little or no immunity will emerge from nature, causing a global outbreak of disease known as a pandemic.
There appears to be no cycle or pattern involved. Nine years separated two pandemics in the mid-1800s, but it's now been 40 years since the most recent pandemic, the 1968-69 Hong Kong flu.
American historian John Barry, author of the 2004 book "The Great Influenza," believes the virus responsible for the 1918 pandemic emerged in the spring in the U.S. heartland, probably Kansas. Unusually virulent outbreaks of influenza were reported in some military camps there. Later, Barry and others believe, troop ships took the virus to the battlefields of Europe, where massive numbers of soldiers on both sides fell ill.
The virus went quiet in the northern hemisphere's summer, but reports started to crop up of renewed sickness in Europe in late August. In September, the illness erupted at Camp Devens, a military base near Boston.
In Canada, the first report of an outbreak among civilians occurred at Victoriaville College in Quebec on Sept. 8. School officials elected to send home students who were well enough to travel, undoubtedly sending flu along with some of them.
It was during this second wave of the pandemic that the new influenza virus turned preternaturally deadly.
It's thought that roughly 2.5 per cent of people who caught the flu died from it – an extraordinarily high rate for influenza. But the toll was substantially worse among certain groups – pregnant women, aboriginals and young, previously healthy adults.
When influenza kills, it normally claims the very young or the very old. But for reasons scientists are still trying to puzzle out, young adults were the hardest hit age group.
In remote communities in the U.S. and Canadian North, the devastation reached apocalyptic levels.
According to Eileen Pettigrew's "The Silent Enemy: Canada and the Deadly Flu of 1918," only 70 people of 220 survived in the Labrador town of Hebron. At Okak, also on the Labrador coast, 207 of 266 people died. The survivors, who later abandoned the site, fought to keep starving sled dogs from devouring corpses.
In the Western Arctic and northern British Columbia, First Nations and Inuit communities were also ravaged.
"It struck with the same kind of ferociousness or ferocity in aboriginal communities as it did in non-aboriginal communities," says Mary-Ellen Kelm, a social historian who has studied the Spanish flu's impact on native communities in British Columbia.
"But the death rates (in aboriginal communities) were. I think about seven times the rates for non-aboriginal for British Columbia as a whole."
Kelm, a professor at Simon Fraser University in Burnaby, says high rates of tuberculosis may have made aboriginal people more vulnerable to the viral assault. And there is evidence that some of the young children who died didn't succumb to flu, but to neglect. There were no adults to care for them.
Everywhere communities struggled to cope with the sick and the dead.
"The undertaking parlours couldn't handle the bodies as people died," says Louise Brooks, 99, of Vancouver, who battled the flu herself. "I have this vague memory that they were having to use school auditoriums and places like that to store bodies temporarily."
With hospitals overwhelmed, most people struggled through the illness at home. Most pulled through, even without the help of antiviral drugs or vaccine. (Vaccines were made, but against the wrong germ. Science hadn't yet discovered viruses and doctors thought the bacterium Bacillus influenzae was to blame.)
The lucky folks had neighbours or relatives who stepped in to help.
There were cases of heroism. Pettigrew's book noted the hamlet of Beaubier, in southeastern Saskatchewan, was named after Eleanor Beaubier, a teacher who tirelessly nursed the sick before perishing herself.
Anna Shillinglaw, 97, remembers neighbours who helped her family pull through when both parents and all seven children were struck down with flu. A boy, Henry Kindopp, would come to tend to her father's animals on their homestead near Bitter Lake, Sask.
"And his mother cooked soup and they put it in a big lard pail and he brought it to the house for us so we had something to eat," recalls Shillinglaw, who lives in Langley, B.C.
As Kelm notes, in other places the lack of such aid contributed to the death toll. Ottawa's mayor, Harold Fisher, issued an appeal for the well to help the sick.
"I want to make it absolutely clear that people are dying in our midst because they are not provided with proper care," Pettigrew's book quotes Fisher as saying.
"They are not dying because we don't know about them. We know where they are, but we have nobody to send. Knitting socks for soldiers is very useful work but we are now asking the women of Ottawa to get in the trenches themselves."
Today, scientists are still trying to figure out why the virus was so deadly. Back then, doctors were trying and failing to cope with a flu bug that caused regular influenza in some people and a rapidly progressing and devastating disease in others.
"There was terror," says Barry, who notes doctors, who felt medicine was on the verge of conquering infectious diseases because of scientific advances, were helpless in the face of the onslaught.
"It kicked them right in the face and destroyed their confidence," he notes. "And of course society itself was just overwhelmed."
"People could die in less than 24 hours after the first symptoms. And they could die with horrific symptoms. People could bleed not only from their nose and mouth, but from their eyes and ears. People were turning so dark blue from lack of oxygen that physicians were saying it was difficult to tell whites from blacks."
The virus swept round the world like a firestorm in the fall of 1918. After a brief respite, a third wave hit in the spring of 1919 in some places the third wave occurred in 1920.
And then the virus seems to have weakened and flu seasons resumed their normal pattern.
The bug, an H1N1 flu virus, continued to circulate for decades. In fact, descendants of the virus still circulate, though they are now the milder of two influenza A viruses that cause disease each winter.
The ‘Very Proteus of Diseases’
Influenza has long defied medical categorisation. Writing in 1891, for instance, the Victorian throat expert Morell MacKenzie called it ‘the very Proteus of diseases, a malady which assumes so many different forms that it seems to be not one, but all diseases epitome’, while in 1907 Clifford Albutt, Regius Professor of Physic at Cambridge, described flu as ‘the most protean’ disease of all, ‘more diversified even than syphilis’. Footnote 41 Flu’s protean qualities are nowhere better symbolised than by its diverse nervous symptomatology, hence its association in the fin-de-siècle period with depression, neurasthenia and psychosis. Footnote 42 For all that it was common for Victorians to confuse influenza with other familiar nervous and febrile conditions, however, medics tended to regard it as ‘comparatively harmless’, the chief dangers being relapse and the way that cases of ‘simple’ flu might combine with bronchitis and pneumonia to spark fatal respiratory infections. Footnote 43 However, during epidemics and pandemics, such as had occurred in 1847–8 and 1889–93, it was recognised that the respiratory complications of flu could greatly elevate the death rate, fuelling flu’s comparison with ‘plague’. Footnote 44 At the same time, unfamiliarity with the novel symptoms triggered public alarm, greatly complicating the medical management of the disease. As an editorial writer in The Lancet observed at the height of the first wave of Russian flu, some sections of the public were guilty of a ‘morbid dread’ of the disease and were ‘so fully alive to the prospects of the spread of this ailment that they have almost passed into a state of panic’. At the same time the journal lamented a ‘growing tendency among the better educated classes to regard the epidemic as something almost too trivial for serious consideration’. Footnote 45
By the turn of the century it was recognised that flu epidemics presented the greatest risk to infants, the elderly and patients with pre-existing lung conditions. Footnote 46 The problem was that the line between what one might term ‘appropriate’ and ‘inappropriate’ dread of the disease was continually shifting. Thus during pandemic periods, when influenza presented as a ‘new’ disease with unfamiliar symptoms, it made sense to err on the side of caution, but once the pandemic form had been described and the health risks were understood, dread became pathologically suspect. Footnote 47
Retrospective accounts of the 1918–19 pandemic tend to treat the successive waves of Spanish flu as a single epistemic event. However, as Ramussen has argued, at the time it was experienced more as ‘a succession of crises and moments of respite’. Footnote 48 Similarly, Bresalier points out that, initially, the relationship between the mild summer wave and lethal follow-on waves in the autumn of 1918 and winter of 1919 baffled the Edwardian medical community. It was only later that epidemiological and military bacteriological experts agreed on the essential identity of the three waves and the pandemic came to be seen as a ‘single cataclysmic event’. Footnote 49 Consequently, in the summer of 1918, when Owen wrote to his mother, there was little reason for Britons to fear flu. As in other countries, flu epidemics were seasonal occurrences. Flu visited Britain every autumn and winter, elevating the death rate of infants and the over sixty-fives but leaving the adult mortality rate unchanged. The result was that, in most years, flu rarely accounted for as many as 1,000 annual deaths in London. Footnote 50
The first Britons knew of the flu was in late May when the Daily Express and the Daily Mail ran brief reports about a ‘mysterious epidemic’ in Spain. Footnote 51 Wary of frightening the public, the British Medical Journal (BMJ) dismissed the reports as ‘alarmist’ while The Lancet ignored them entirely. Footnote 52 In contrast to the Russian flu pandemic, when the Local Government Board (LGB) for England & Wales had instructed its Medical Department to initiate a nationwide investigation, in 1918 the LGB made no effort to investigate the epidemiology or bacteriology of the Spanish flu or to canvass doctors as to the symptoms or the incubation period of the disease. Indeed, at a ‘discussion on influenza’ with other experts at the Royal Society of Medicine (RSM) on 13 November 1918, Arthur Newsholme, the Chief Medical Officer of the LGB, said that in the summer he had considered issuing a memorandum on flu only to shelve it on the grounds of expediency, reasoning that there were ‘national circumstances in which the major duty is to “carry on”’. Footnote 53 This was perhaps understandable given that, as Eyler points out, in 1918 the LGB’s authority was much diminished and Newsholme lacked manpower due to the war effort. Footnote 54 According to Bresalier, confusion over the identity of influenza also meant Newsholme had little confidence in preventive measures, hence his willingness to defer to the Medical Department of the War Office and the Medical Research Committee (MRC), who he reasoned were in a better position to conduct detailed bacteriological and pathological investigations into the cause of the epidemic. Footnote 55
This ‘silence’ on the part of British medical authorities contrasts with the more proactive measures taken in other Allied countries, such as Australia and the United States (US), and has prompted the claim that British medical professionals suffered a ‘failure of expertise’ in 1918. Footnote 56 However, to seek to compare the British response with the more vigorous measures taken elsewhere is to overlook the very different conditions prevailing on the home front in Britain in 1918 and the extent to which the LGB and the medical press were active participants in the propaganda effort. Like the Northcliffe press, the British medical profession’s priority in 1918 was to avoid panicking the civilian population, especially as more than half of all medical personnel were occupied with military duties. Footnote 57 However, as the epidemic spread and chemists reported a rush on quinine and other medications, sparking fears of panic-buying, it became clear that this silence could not be sustained. Footnote 58 Instead, Newsholme turned to the Northcliffe press, briefing the Daily Mail and, it seems The Times’s medical correspondent, about the board’s knowledge of the epidemic and using its columns to issue practical and upbeat medical advice to readers. In so doing, Newsholme’s actions can be seen as form of biopolitics. However, I will argue that, in the process Newsholme, like other medical commentators, soon found himself caught between opposing discourses – discourses that, on the one hand, required him to counsel civilians to take the threat of influenza seriously and which at the same time valorised the maintenance of a ‘cheerful’ disposition lest fear itself become the ‘mother’ of infection. Footnote 59