Although a century apart there are often comparisons made between the Spanish Flu of 1917-18 to today’s Covid 19 pandemic. Often, the experiences of the Spanish Flu have been mentioned/used as justifications or reasons behind Covid 19 policies.
Despite being the epidemic that caused the most American deaths, the details of the Spanish Flu are not well known and the details of how the disease was handled are even less well known. This blog provides a brief summary of the history, effects and management of the Spanish Flu, and the lessons that can or can’t be learned from the experience. This discussion will not compare the technical differences between the two diseases.
The actual number of cases and deaths due to the Spanish Flu are not known because of relatively poor record keeping at the time, it was a global pandemic and it happened in the midst of World War I. However, many estimates indicate over 500 million people worldwide were infected and somewhere between 30 and 100 million died. In the US, it is estimated that 25 million (28% of the population) were infected causing 670,000 deaths. In contrast with Covid 19, the Spanish Flu was most deadly for those ages between 20-40. The mortality rate for 15-34 year olds in 1918 was 20x higher than any other previous year. The mass movement of millions of soldiers and conditions of World War I contributed to the wide spreading of the disease. An estimated 50% of the US soldiers who died in Europe during the war died from the Spanish Flu.
This is a long blog, but if you read on, there are 5 sections. The history section is a bit long but you can skip down to the other discussions as your interests guides you.
- History of the Spanish Flu
- How the Spanish Flu was handled by the Government
- 1917 vs 2020.
- Lessons Learned
History It is important to note that Spanish Flu happened during World War I. At the beginning of World War I in 1914, President Woodrow Wilson declared that the US would remain neutral in the conflict. However, in 1917 there were a series of incidences of involving US lives and ships being destroyed by Germany which led to the US declaration of war on April 2, 1917. However, preparation of US troops was well underway before the declaration was made. The war would play a large part in spreading the disease around the world.
It is not specifically known what the original source of the Spanish Flu was. That is, it is not known where the first case in the world appeared. There are theories that the disease began in France in 1916 or China of Vietnam. Many theories also suggest that the disease could have started in the US (although it is not known how it got to the US). One of the earliest (some say the earliest) report of this disease was January 1917 in Haskell County, Kansas. An outbreak of an unknown disease was so severe that it was reported to the US Public Health Service. This is believed to be one of the first recorded notices anywhere of an unusual respiratory disease. Several men from Haskell went to a military, Camp Funston in central Kansas. On March 4, days after they arrived the first soldier known to have the what we now call the Spanish flu, reported ill. Within 2 weeks, over 1000 soldiers on the base were admitted to the hospital with thousands more sick in the barracks. 38 soldiers died. It is likely that infected soldiers from here infected 24 of 36 large training camps, sickening thousands and killing hundreds. Many of these infected soldiers then brought the disease to Europe. In June 1917, 14,000 US troops landed in France. By May 1918, a million US soldiers had landed in Europe. By the end of the war on November 11,1918 more than 2 million American soldiers had served on the battlefields of Europe.
The ‘first wave’ outbreak at Camp Funston and in Europe through early 1918 did not cause serious concern because although many were infected, there were relatively few deaths. For instance in 1918 the British Grand Fleet reported over 10,000 sailors had fallen ill but only 4 had died. It was not until the King of Spain, Alfonso XII, contracted the disease that the disease became noteworthy. Spain was also neutral in the war and was free to publish information about infections without censorship from other countries. Because most of the early detailed reports were from Spain, it became known as the Spanish Flu (even though it did not begin there.)
In August 1918, the second wave, more deadly than the first, began in areas of Europe. It is speculated that the ‘first wave’ virus had mutated into a more lethal version.
In late August 1918 military ships departed from the English port of Playmouth carrying troops with a virulent form of the Spanish Flu and went to cities like Brest, France, Boston, USA and Freetown Africa. In Boston, shortly after their arrival sailors and civilians marched together through the streets of Boston for a ‘Win the War Rally’. Soon, the surrounding Boston area and New England would feel the full force of the disease. In September 1918, a Navy ship from Boston carried infected sailors to Philadelphia. Although sailors began to die within days of arriving at Philadelphia, city officials did not truthfully report the deadly disease. In fact, they publicly dismissed the seriousness of the disease and on September 28, they famously held a large parade in the middle of the city attended by an estimated 200,000 people. Within 72 hours of the parade, every bed in Phialdelphia’s 32 hospitals were filled and in a week, 2600 Phildadelphians had died of the Spanish flu. A week later another 4500 had died. By March 1919, over 15,000 Philadelphians had died from the disease.
The disease spread all over the country from the Atlantic to the Pacific and from Canadian to Mexican borders. Spain, Britain and France were all particularly hit hard with the disease but the disease also spread to Asia, Africa, South American and the South Pacific.
It is highly likely that the war conditions contributed significantly to the spread of the disease. First, millions of soldiers from the US were transported to Europe. Once in Europe, soldiers and civilians were often in cramped, damp and crowded conditions making the spread of disease easy. The poor sanitation and malnutrition also helped to spread the infection. Further, there were vast movements of people both civilian and military due to fighting. During the summer of 1918, many troops returning home brought the disease back to the countries they came from. All of these factors likely contributed significantly to spread of the disease.
It is interesting to note that is speculated that President Woodrow Wilson was infected during the Versaille Peace Conference at the end of the war. This possibly contributed to Wilson accepting some surprising terms in the treaty.
Overall, the Spanish Flu is likely to be deadliest epidemic in the history of world. Estimates are that 1-3% of the world’s population died from the Spanish Flu. So many younger people died in the US in 1918 that the average US life expectancy was reduced by 10 years.
It is not clear why the second wave of the virus was so much more lethal than the first. There is some speculation that there may have been a mild and deadly version of the virus, but this has not been definitively confirmed. In the ‘developed’ world, the mortality rate was generally believed to be about 2%. In other counties, the mortality rate has been estimated to have caused up 14% of a population (Fiji islands) to die.
Eventually, toward the end of 1918 the number of deaths caused by the virus began to decrease. This is believed to be because there were so many people that had already been infected and/or the virus may have mutated again to be less invasive to the lungs. It eventually ‘devolved’ to be part of the seasonal flu. There was never a vaccine developed for the Spanish Flu.
How was the Spanish Flu handled by the state and federal government? There was no national policy for dealing with the Spanish Flu. It was left to the states to come up with how and when to deal with the disease. It was common practice for politicians, administrators and those responsible for the public safety to deny, deceive or out right lie about the dangers of Spanish Flu. City and government officials did not disclose the danger to the general public so that public spirits would not be diminished and that support for the war would be encouraged. That’s why the parades in Boston and Philadelphia were held despite the fact that city officials were aware of the potential danger from the Spanish Flu.
There was policy that started with President Woodrow Wilson that authorized, even encouraged lying to the public. When the United States entered the war, Woodrow Wilson created the Committee on Public Information, which was inspired by an adviser who wrote, “Truth and falsehood are arbitrary terms. The force of an idea lies in its inspirational value. It matters very little if it is true or false.”
Official government posters and advertisements urged people to report to the Justice Department anyone “who spreads pessimistic stories…cries for peace, or belittles our effort to win the war.” The real fatalities and illness of the Spanish flu fell into this ‘pessimistic story’ category.
An example of this is that the director of Public Health in Philadelphia, continually reassured the public that the illnesses being reported were ‘contained’ or would be decreased and that it would ‘nipped in the bud’. Under these misdirections, he authorized and put on the large parade that infected thousands of Philadelphians. Across the country, the lie that disease was nothing to worry about was commonly told my officials. This lie was told in large cities like New York and Los Angeles as well as less populated areas like Arkansas. Even the U.S. Surgeon General Rupert Blue said, “There is no cause for alarm if precautions are observed.”
Eventually, the people caught on because the true effect of the Spanish flu could not be hidden. For instance, 53% of San Antonio, Texas got infected and death could come quickly and dramatically. It was also evident how serious the disease was when towns ran out of coffins and people could not be buried fast enough.
It was only when the threat of the flu could not be denied that procedures to try and curb the infection (flatten the curve in today’s terminology) were put into place. Each state and city had their own instructions but they included a mix of the following procedures.
- Wear masks
- Don’t shake hands
- Stay in doors
- Closed schools and theaters and limited public gatherings
There were places that instituted these practices early, such as San Francisco, St. Louis, Milwaukee and Kansas City. These early adopters had 30% to 50% lower disease and mortality rates than cities that enacted fewer restrictions and/or started their restrictions later. It should be noted that other than schools, theaters, churches and bars there were few other businesses that were forced to shutdown. Compliance to these restrictions was highly variable from city to city and enforcement was often a problem.
1917 vs 2020.
The world is a difference place now that it was in 1917. In 1917 the world was at war and millions of people were being moved to fight or flee from the war in Europe. The conditions of the war overcrowding, dampness, malnutrition provided ample opportunity for infections to spread. Millions of people were transported into and out of the US that were infected with the Spanish flu. Especially, after the war infected soldiers returned to their homes all over the US. The movement of millions of people in a short period of time is exactly the opposite of a travel ban.
The political atmosphere was generally not to tell the truth regarding the disease and to downplay it’s seriousness. This lack of candor was accompanied by organizing large gatherings of people despite knowing that there was a serious infectious disease in their presence. It was not easy for the public get accurate information about the effects of the Spanish Flu.
There was a shortage of doctors compared today but the shortage was made even worse in the US as a large number of doctors were in the Army and overseas. There were also fewer hospital beds per capita in 1918.
The 1917 level of medical knowledge and medical technology was very low compared today. The ability to test for the disease was virtually nonexistent in 1917.
Social distancing and masks appear to have been effective in 1917 and appear to be effective now. However, the shutdown of nonessential businesses around the world has never been done before. Given all the other societal and technical differences between 1917 and now, it is not clear how effective a nationwide shutdown of businesses in 1917 would have been with hundreds of thousands of infected people returning home.
Unlike the situation in 1917, there is a lot of information regarding Covid 19 from around the world easily accessible via the internet and television. Unlike 1917, the statistics of Covid 19 are posted often and the public has direct knowledge of the effect of the disease in their city, county and state.
The most effective efforts had simultaneously closed schools, churches, and theaters, and banned public gatherings along with the use of masks. There were no large scale shutdowns of other businesses, although some places staggered business hours. At later stages of the epidemic, they tried to isolate those who had the disease but I can not find many efforts to quarantine (isolate) those who were not infected.
Public officials in charge of public health must be honest with the public and give truthful assessment of the disease.
Disease must be recognized and mitigating policies must be put in place to slow the spread of the virus.
You can slow down and reduce infections if you do social distancing and wear masks.
No gatherings of large numbers of people if you can not also social distance and wear masks.
We should be wary of how decisions are made and be aware if a decision is politically driven or public health driven.
There were many societal differences between 1917 and 2020. The main difference being World War I and the associated movement of people, along with crowded and poor conditions. The 1917 public was not well informed of the number of infections and number of fatalities caused by the Spanish Flu.