The Spanish flu (also known as the 1918 flu pandemic) was an unusually deadly influenza pandemic. Lasting from January 1918 to December 1920, it infected 500 million people—about a quarter of the world's population at the time. The death toll is estimated to have been anywhere from 17 million to 50 million, and possibly as high as 100 million, making it one of the deadliest pandemics in human history.

Origin of the Spanish Flu:


Emergency hospital set up in Kansas
Emergency hospital set up in Kansas

The origins of this influenza variant is not precisely known. There have been statements that the epidemic originated in the United States. Historian Alfred W. Crosby stated in 2003 that the flu originated in Kansas, and popular author John M. Barry described a January 1918 outbreak in Haskell County, Kansas, as the point of origin in his 2004 article.

This is a picture of an influenza virus. Hemagglutinin (HA) is a surface protein of the virus that plays a role in allowing an influenza virus to enter and infect a healthy cell. Photo Credit: Dan Higgins, CDC.
This is a picture of an influenza virus. Hemagglutinin (HA) is a surface protein of the virus that plays a role in allowing an influenza virus to enter and infect a healthy cell. Photo Credit: Dan Higgins, CDC.

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 situation in New York City in the same time period.

Red Cross workers transport a victim in St. Louis, Missorui
Red Cross workers transport a victim in St. Louis, Missorui

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 was around far prior to 1918 and other studies suggest that the reassortment of the H1N1 virus likely occurred in or around 1915.

The 39th Regiment on its way to France marched through the streets of Seattle, Washington. Everyone provided with a mask made by the Seattle Chapter of the Red Cross. Local Identifier: 165-WW-269B-8
The 39th Regiment on its way to France marched through the streets of Seattle, Washington. Everyone provided with a mask made by the Seattle Chapter of the Red Cross. Local Identifier: 165-WW-269B-8

The name of Spanish Flu came from the early affliction and large mortalities in Spain (BMJ,10/19/1918) where it allegedly killed 8 million in May (BMJ, 7/13/1918). However, a first wave of influenza appeared early in the spring of 1918 in Kansas and in military camps throughout the US.

Red Cross workers making anti-influenza masks for soldiers in camp. Boston, Massachusetts. Local Identifier: 165-WW-269B-26
The 39th Regiment on its way to France marched through the streets of Seattle, Washington. Everyone provided with a mask made by the Seattle Chapter of the Red Cross. Local Identifier: 165-WW-269B-8

Few noticed the epidemic in the midst of the war. Wilson had just given his 14 point address. There was virtually no response or acknowledgment to the epidemics in March and April in the military camps. It was unfortunate that no steps were taken to prepare for the usual recrudescence of the virulent influenza strain in the winter.

Policemen in Seattle, Washington wearing masks made by the Seattle Chapter of the Red Cross during the influenza epidemic. Local Identifier: 165-WW-269B-25
Policemen in Seattle, Washington wearing masks made by the Seattle Chapter of the Red Cross during the influenza epidemic. Local Identifier: 165-WW-269B-25

The lack of action was later criticized when the epidemic could not be ignored in the winter of 1918 (BMJ, 1918). These first epidemics at training camps were a sign of what was coming in greater magnitude in the fall and winter of 1918 to the entire world.

American Red Cross activities in Middletown, Connecticut. Emergency Hospital equipment being inspected by the committee of the Middlesex Chapter. This equipment was sent to Wesleyan University at the outbreak of the Influenza epidemic. Local Identifier: 165-WW-269B-57
American Red Cross activities in Middletown, Connecticut. Emergency Hospital equipment being inspected by the committee of the Middlesex Chapter. This equipment was sent to Wesleyan University at the outbreak of the Influenza epidemic. Local Identifier: 165-WW-269B-57


How did Spanish Flu affect the world?


The pandemic affected everyone. With one-quarter of the US and one-fifth of the world infected with the influenza, it was impossible to escape from the illness. Even President Woodrow Wilson suffered from the flu in early 1919 while negotiating the crucial treaty of Versailles to end the World War (Tice). Those who were lucky enough to avoid infection had to deal with the public health ordinances to restrain the spread of the disease. The public health departments distributed gauze masks to be worn in public.

Emergency hospital at Brookline, Massachusetts to care for influenza cases. Local Identifier: 165-WW-269B-19
Emergency hospital at Brookline, Massachusetts to care for influenza cases. Local Identifier: 165-WW-269B-19

Stores could not hold sales, funerals were limited to 15 minutes. Some towns required a signed certificate to enter and railroads would not accept passengers without them. Those who ignored the flu ordinances had to pay steep fines enforced by extra officers (Deseret News). Bodies pilled up as the massive deaths of the epidemic ensued. Besides the lack of health care workers and medical supplies, there was a shortage of coffins, morticians and gravediggers (Knox). The conditions in 1918 were not so far removed from the Black Death in the era of the bubonic plague of the Middle Ages.

Site of the mass grave in Brevig Mission, Alaska, where 72 of the small village’s 80 adult inhabitants were buried after succumbing to the deadly 1918 pandemic virus. Photo credit: Angie Busch Alston.
Site of the mass grave in Brevig Mission, Alaska, where 72 of the small village’s 80 adult inhabitants were buried after succumbing to the deadly 1918 pandemic virus. Photo credit: Angie Busch Alston.

The major UK troop staging and hospital camp in Étaples in France has been theorized by researchers as being at the center of the Spanish flu. The research was published in 1999 by a British team, led by virologist John Oxford.

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.

1918 flu pandemic

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 bad in some locations in the countryside of China.


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 Samoa 22% of the population of 38,000 died within two months.

1919 Tokyo, Japan
1919 Tokyo, Japan

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.

1918 influenza epidemic burial site in Auckland, New Zealand
1918 influenza epidemic burial site in Auckland, New Zealand

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.

In the U.S., about 28% of the population of 105 million became infected, and 500,000 to 675,000 died (0.48 to 0.64 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.

Things to learn from the 1918 flu pandemic in the face of COVID-19?

In Brazil, 300,000 died, including president Rodrigues Alves. In Britain, as many as 250,000 died; in France, more than 400,000.

spanish flu 1918 death in Brazil

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. In British Somaliland, one official estimated that 7% of the native population died.

How did the Flu Spread?


When an infected person sneezes or coughs, more than half a million virus particles can spread to those nearby. 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 increased the lethality of 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.

1918 flu
The 1918 virus was extremely virulent. Image a) shows mouse lung tissue infected with a human seasonal H1N1 flu virus. Image c) shows the impact of the 1918 virus in mouse lung tissue. The 1918 virus replicates quickly and causes severe disease in the lung tissues of mice. In 1918, the virus caused severe disease in the lungs of people infected, as well. Photo credit: CDC, Science.

A large factor in the worldwide occurrence of this 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.

Crowded conditions and the movement of troops during World War I
Crowded conditions and the movement of troops during World War I likely contributed to the spread of the 1918 virus around the world. (Photo credit: www.museumsyndicate.com/item.php?item=56784#)


Spanish Flu Symptoms:


The first wave of the 1918 pandemic occurred in the spring and was generally mild. The sick, who experienced such typical flu symptoms as chills, fever and fatigue, usually recovered after several days, and the number of reported deaths was low.

However, a second, highly contagious wave of influenza appeared with a vengeance in the fall of that same year. Victims died within hours or days of developing symptoms, their skin turning blue and their lungs filling with fluid that caused them to suffocate. In just one year, 1918, the average life expectancy in America plummeted by a dozen years.

Aspirin Poisoning and the Flu


With no cure for the flu, many doctors prescribed medication that they felt would alleviate symptoms… including aspirin, which had been trademarked by Bayer in 1899—a patent that expired in 1917, meaning new companies were able to produce the drug during the Spanish Flu epidemic. 

Before the spike in deaths attributed to the Spanish Flu in 1918, the U.S. Surgeon General, Navy and the Journal of the American Medical Association had all recommended the use of aspirin. Medical professionals advised patients to take up to 30 grams per day, a dose now known to be toxic. (For comparison’s sake, the medical consensus today is that doses above four grams are unsafe.) Symptoms of aspirin poisoning include hyperventilation and pulmonary edema, or the buildup of fluid in the lungs, and it’s now believed that many of the October deaths were actually caused or hastened by aspirin poisoning.

Modern analysis has shown the virus to be particularly deadly because it triggers a cytokine storm (overreaction of the body's immune system), which ravages the stronger immune system of young adults. 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.

End of the pandemic


After the lethal second wave struck in late 1918, new cases dropped abruptly – almost to nothing after the peak in the second wave. 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 prevention and treatment of the 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. Some fatal cases did continue into March 1919, killing one player in the 1919 Stanley Cup Finals.

Since 1918, there have been several other influenza pandemics, although none as deadly. A flu pandemic from 1957 to 1958 killed around 2 million people worldwide, including some 70,000 people in the United States, and a pandemic from 1968 to 1969 killed approximately 1 million people, including some 34,000 Americans.

More than 12,000 Americans perished during the H1N1 (or “swine flu”) pandemic that occurred from 2009 to 2010. The novel coronavirus pandemic of 2020 is spreading around the world as countries race to find a cure for COVID 19 and citizens shelter in place in an attempt to avoid spreading the disease, which is particularly deadly because many carriers are asymptomatic for days before realizing they are infected.

COVID 19

Each of these modern day pandemics brings renewed interest in and attention to the Spanish Flu, or “forgotten pandemic,” so-named because its spread was overshadowed by the deadliness of WWI and covered up by news blackouts and poor record-keeping.

Sources: History | CDC | Stanford | Wikipedia

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