Americans Must Learn the Lessons of the Spanish Flu

Makeshift hospital for Spanish Flu victims.
Source: National Archives

Few people were prepared for the worldwide scourge thrust upon us by the sudden advent of the novel corona virus SARS-COV-2, the virus that causes the deadly COVID-19 disease. Yet despite repeated use of adjectives like “unprecedented,” and “extraordinary,” the fact is just 100 years ago the world faced a similar plague, the so-called Spanish Flu, which swept over the globe for the same reason today’s corona virus has—thanks to government secrecy and incompetence, and the inability for some ordinary citizens to look after themselves or care a damn about their friends and neighbors.

Yet the same virus that devastated the world a century ago can also teach us the way we can—and must—fight the current pandemic.

In America’s head-long rush to war in early 1918, few paid much attention to the growing number of soldiers reporting in sick with high fevers, body aches, and chills. It was, after all, flu season, and wartime expediency would not allow common influenza to slow down military training. Within a year, however, that flu would kill would vastly surpass the number of soldiers and sailors who died in combat on all sides during all four years of World War I.

So-Called Spanish Flu Death Toll

From August 1914 to the signing of the armistice in November 1918, about 16 million military personnel and civilians were killed or died of diseases associated with combat. From the spring of 1918 to the spring of 1919, the Spanish Flu claimed the lives of at least 40 million people—far more, too, than were lost in the Black Plague. Some estimates of the number of persons who succumbed to the Spanish Flu reach as high as 100 million.

Just as health experts today are warning of subsequent waves of SARS-COVID-2, the Spanish Flu came in three waves, with infection rates rising and ebbing, then rising again. At its height in the fall of 1918, the Purple Death, as it was also known, could kill a person in mere hours. Unlike most influenza variants, this flu killed more than just the very young and the very old. It was also particularly harsh for victims 20 to 40 years old—the very population that was fighting at the front.

And like today, there was no cure, no vaccine, and little support that medicine could provide other than prayer.

Flu Epidemic: Where Did It Come From?

Even today, no one absolutely is sure where such a virulent avian H1N1 flu virus came from. Some researchers believe it may have started in China. Others theorize the virus had been around for years, with minor outbreaks occurring in France in 1916 and England in 1917.

What we do know is that in January and February 1918, flu swept through rural Haskell County, Kansas. Between late February and early March, three recruits from Haskell County reported for training at Fort Riley, Kansas. Many historians believe one or more of these recruits carried the virus. By the end of March, thousands of Fort Riley soldiers were ill. Soldiers transferring to other military camps carried the virus with them, and soon 24 of the nation’s 36 largest military installations were suffering large outbreaks of influenza.

Though highly contagious, at this point the flu was still relatively mild. Though the death rate from this was somewhat higher than the normal rate of 0.1%, it wasn’t high enough to cause alarm. Infected and uninfected soldiers were packed into cramp troop ships for the voyage to the French port of Brest. By the time the ships arrived, even more of the soldiers were infected. They, in turn, carried the virus into the trenches.

Once brought into the trenches, the virus quickly spread through the British, French, and German forces. In wartime, however, casualty rates, even for illness, are kept secret. Media censorship prevented journalists from reporting on the large numbers of soldiers coming down ill in both the training camps and trenches. The families of soldiers who died of the flu were simply notified that their love one “died on the field of honor. “Whether on the battlefront or the home front, few people knew there was a flu epidemic. And no one realized how quickly it would become a global pandemic—or how deadly it would be.

By spring, the flu reached Spain, probably brought across the border by returning Spanish laborers who had been working in France. Because Spain was neutral in the war, there was no press censorship, and the Spanish media reported freely on what the news service Agencia Fabra called a “strange form of disease of epidemic character. “When the citizens of the belligerent countries finally became aware of the epidemics in their own nations, the flu had a new name. “Under the name of Spanish influenza, an epidemic is sweeping the North American Continent,” reported the Canadian Medical Association Journal. “It is said to have made its appearance first in Spain, hence Spanish influenza.”

The Second Wave Arrives

The flu subsided during the summer months of 1918, so much so that British military authorities declared the end to the Spanish Flu on August 10. But that—just as we’re seeing today—was merely wishful thinking. The influenza virus was only in waiting; changing itself, mutating into a more efficient predator.

Today, scientists understand that viruses can become more virulent as they pass from one human to another, a process called “passage.” The 1960 Nobel recipient Dr. Macfarlane Burnet estimated the relatively mild virus seen in the first wave of Spanish Flu had gone through fifteen to twenty human passages, emerging in the fall of 1918 a much more lethal disease than before. It would be this mutation that would give the Spanish Flu the nickname Purple Death.

As American soldiers continued to arrive in France in late August, French military authorities saw another eruption of influenza among their troops. So many sick French and American soldiers were hospitalized that the hospital had to turn away new victims.

And then, victims were dying in large numbers—20 times higher than normal flu—and many only hours after first showing symptoms. It was not unusual for a victim to wake up feeling fine, then collapse a few hours later. By dinner they would be dead. In between, bloody fluid filled the lungs, preventing the exchange of CO2 for oxygen. Cyanosis turned the skin blue, then purple, and sometimes nearly black, as the victim literally drowned in their own bodily fluids.

The current belief regarding today’s SARS-COVID-2 virus is it damages the capillaries (small blood vessel) that line the lung and the alveoli sacs, preventing proper gas exchange. Similarly, some victims of COVID-19 die only a few hours after falling ill.

 The Flu Comes Full Circle

In September the virus came full circle, returning to the U.S. with a vengeance aboard troop ships and warships returning from France. Once again, wartime expediency help spread the disease. On September 25, 3,108 soldiers boarded a troop train at Camp Grant, Illinois. By the time they reached their destination at Camp Hancock, Georgia, a 950-mile trek, 2,000 of the soldiers had to be hospitalized with the flu. Dozens died.

On September 28 Philadelphia held a patriotic parade featuring thousands of soldiers, sailors, Boy Scouts, and civic group members. Within three days, every hospital room in the city was filled with flu victims. As many as a quarter of the victims died every day, only to be replaced with new victims.

Similar results were seen in every large city in the nation. Like today, public health officials ordered stores and theaters closed. Businesses shut down. Public coughing and hand shaking were prohibited. Outside their homes, people had to wear cloth masks over their faces. Field hospitals like those normally seen on battlefields began popping up across the country to take in the overflow of flu patients from brick and mortar hospitals.

Mandatory face masks helped prevent the spread
of Spanish Flu. Source: National Archives

Many today think social distancing orders are excessive, but the extreme means Gunnison, Colorado took to save its citizens demonstrated its effectiveness. The city literally sealed itself off from the rest of the world. Armed guards prevented any outsider from entering the city limits; the also prevented any resident from leave. Extreme, yes, but it worked Gunnison was probably the only town in the U.S. to avoid the Spanish Flu. 

Eventually, the country’s leaders realized the best way to stop the flu was to stop feeding it. The military draft imposed to build up America’s small peacetime army was halted, and by October almost all military training was halted. The pipeline of fresh troops headed for the trenches of France began to dry up. Fortunately, the war ended on November 11.

Historians estimate about 700,000 Americans died from the Spanish Flu—more than all the American skilled in combat in WWI, WWII, the Korean War, and the Vietnam War together.

A Pandemic of Global Devastation

But America was not alone in its suffering. This second wave of influenza spread throughout Europe, Africa, and Asia. In Spain, which gave the pandemic its name, Catholic Masses held to pray for deliverance only helped spread the virus faster. Twelve hundred flu victims died daily in Barcelona alone; eventually more than 260,000 Spaniards would perish. Churches and funeral homes could not keep up with the dead.

When the killing stopped on the battlefields, the dying from influenza and secondary infections continued. A week after the November 11 armistice, the number of flu-related deaths in England soared to 19,000; eventually some 200,000 would die in the United Kingdom. India lost 5 million to the flu. Between 30,000 and 50,000 Canadians died. Many more perished in Africa, Latin America, Asia, and the Middle East. Then, by the end of November, it was gone. The virus that arrived in the third wave in December was a mere shadow of its former self. The virus had undergone an antigenic shift, creating a less virulent mutation. The third wave swept over New York City and San Francisco, California. It lingered throughout much of 1919, causing outbreaks here and there, but never the devastation the second wave wrought.

Spanish Flu: Aftermath

Despite its devastation, the Spanish Flu was largely forgotten until recently. Even the deadly outbreaks of the severe acute respiratory syndrome (SARS) virus in 2003 and the Novel H1N1 “swine flu” virus in 2009 did little to prepare us for the novel corona virus that plagues us today. (I survived the 2009 virus. Ironically, I contracted it while attending, as a U.S. Navy analyst in military medical operations, a class on responding to pandemics held aboard the hospital ship Mercy.)

Many factors tribute to the world’s slow response to the current virus, but they weren’t new or unprecedented factors. First was China’s secrecy about the virulence of the disease. That was exasperated by the leadership of too many nations failing to recognize the health disaster looming before them—including Donald Trump’s ongoing inability to deal with reality or to care about anyone or anything except himself and his re-election.

But by understanding what worked and didn’t work to combat the 1918 flu, we can understand better what’s working—and not working— today. Today’s politically-motivated demonstrations against stay-at-home orders forcing an early reopening harkens back actions that help spur the virus in 1918. The success of Gunnison to avoid any flu victims at all demonstrates isolation works. In the end, public health should always trump politics.