An outline, era by era

Spanish flu pandemic (1918)

20th Century · 1914 – 2000

The Spanish flu was an influenza pandemic caused by an H1N1 virus that spread around the world in 1918 and 1919. It came in several waves, the deadliest in the autumn of 1918, and reached almost every inhabited region, from Europe and North America to India, Africa, Asia and the Pacific islands. Estimates of the death toll are uncertain and run from about 17 million to 50 million or more, which makes it one of the deadliest disease outbreaks in recorded history.

The pandemic struck in the last year of World War I, when armies, troop ships and railways moved people on a huge scale. It was unusual because many of its victims were young adults, not only the very young and old. It was called Spanish because neutral Spain, with its uncensored newspapers, reported on it openly, not because it began there. Its true origin is still debated. The pandemic shaped later public health systems and the scientific study of viruses.

Things happened, and the rest is history

  1. Influenza and the first alarms in spring 1918

    Event

    What happened

    In March 1918 a sharp rise in influenza cases is recorded at Camp Funston, a US Army training camp in Kansas, and at other camps in the United States. Troops carry the illness to Europe, and by April and May outbreaks are reported among soldiers in France and Britain. The spring illness is highly infectious but mostly not deadly.

    The rest is history

    Historians agree that this milder first wave came before the far deadlier autumn wave. Where the virus began is still debated, with the United States, northern France and China all proposed. The spring outbreaks show how quickly the virus moved along military and shipping routes. By August 1918 a more lethal form was appearing in several ports at nearly the same time.

    Sources

    1. BookBarry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Viking, 2004.
    2. BookSpinney, Laura. Pale Rider: The Spanish Flu of 1918 and How It Changed the World. London: Jonathan Cape, 2017.

  2. The deadly second wave of autumn 1918

    Event

    What happened

    In late August 1918 a far more lethal form of the virus appears at Brest in France, Freetown in Sierra Leone and Boston in the United States. Through September, October and November it spreads through cities, camps and ships. Hospitals fill, and many places record their worst weeks of deaths in October.

    The rest is history

    The second wave caused most of the deaths of the whole pandemic. Many victims died of pneumonia, often a bacterial infection that followed the flu. The wave faded in many countries by December 1918, though a third wave followed in early 1919. Exact totals are unknown because many countries kept poor records.

    Sources

    1. BookCrosby, Alfred W. America's Forgotten Pandemic: The Influenza of 1918. Cambridge: Cambridge University Press, 2003.
    2. ArticleJohnson, Niall P. A. S., and Juergen Mueller. "Updating the Accounts: Global Mortality of the 1918-1920 'Spanish' Influenza Pandemic." Bulletin of the History of Medicine 76, no. 1 (2002): 105-115.

  3. Wartime censorship and the name Spanish flu

    Event

    What happened

    Warring states such as Britain, France, Germany and the United States limit the reporting of bad news in 1918. Spain, which is neutral, has a free press, and its papers report widely on the illness in May and June 1918, including its effect on King Alfonso XIII. Foreign readers come to see the disease as a Spanish one.

    The rest is history

    The name stuck even though there is no evidence the disease began in Spain. Spain suffered heavily, but so did every other country. The episode shows how wartime censorship shaped what the public knew. Many places called it by the name of a rival or distant country, as people often do with new diseases.

    Sources

    1. BookHonigsbaum, Mark. Living with Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918. Basingstoke: Palgrave Macmillan, 2009.
    2. BookSpinney, Laura. Pale Rider: The Spanish Flu of 1918 and How It Changed the World. London: Jonathan Cape, 2017.

  4. Troop movements and the end of the war

    Event

    What happened

    In 1918 millions of soldiers are gathered in crowded camps, trenches and troopships, and many are moved across oceans and borders. Flu outbreaks follow these movements, notably on ships carrying troops to Europe and on ships returning home after the Armistice of 11 November 1918. Returning troops and civilians carry the virus to new places.

    The rest is history

    Historians widely agree that wartime crowding and mobility helped the virus spread. Soldiers were also weakened by hunger, stress and gas injuries in some cases. Influenza affected fighting forces on both sides, though how far it changed the course of battles is debated. The pandemic and the war together left many societies grieving.

    Sources

    1. BookByerly, Carol R. Fever of War: The Influenza Epidemic in the U.S. Army during World War I. New York: New York University Press, 2005.
    2. BookBarry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Viking, 2004.

  5. Philadelphia, St. Louis and different city responses

    Event

    What happened

    In September 1918 Philadelphia holds a large Liberty Loan parade on 28 September, and flu cases rise sharply in the following days. Officials close schools, churches and theatres in October. St. Louis acts earlier, closing public places soon after the first cases are found.

    The rest is history

    Later studies found that cities which introduced measures such as closures and bans on gatherings early had lower peak death rates than those which waited. This work is a standard reference in modern discussion of public health measures. Results varied, and measures were often lifted early. The experience informed later pandemic planning.

    Sources

    1. ArticleMarkel, Howard, Harvey B. Lipman, J. Alexander Navarro, Alexandra Sloan, Joseph R. Michalsen, Alexandra Minna Stern, and Martin S. Cetron. "Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic." JAMA 298, no. 6 (2007): 644-654.
    2. ArticleHatchett, Richard J., Carter E. Mecher, and Marc Lipsitch. "Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic." Proceedings of the National Academy of Sciences 104, no. 18 (2007): 7582-7587.

  6. The pandemic in India and the colonial world

    Event

    What happened

    Influenza reaches Bombay by ship in late May and June 1918 and spreads along the railways. A far deadlier wave arrives in September 1918 and moves through the subcontinent over the following months. Colonial territories in Africa, the Pacific and elsewhere are also hit hard, as at Western Samoa in November 1918.

    The rest is history

    India is thought to have suffered some of the highest death totals of any country, with estimates of well over ten million. Weak health services, hunger and crowded living conditions played a part. In Western Samoa about a fifth of the population died after a ship arrived from Auckland and no quarantine was imposed. The pandemic's toll was thus uneven, and these experiences fed later political criticism of colonial administrations.

    Sources

    1. ArticleMills, I. D. "The 1918-1919 Influenza Pandemic: The Indian Experience." Indian Economic and Social History Review 23, no. 1 (1986): 1-40.
    2. BookPhillips, Howard, and David Killingray, eds. The Spanish Influenza Pandemic of 1918-19: New Perspectives. London: Routledge, 2003.

  7. Recovering the virus of 1918

    Event

    What happened

    In 1933 researchers in Britain first isolate a human influenza virus. In the 1990s and 2000s scientists led by Jeffery Taubenberger recover fragments of the 1918 virus from preserved tissue samples of soldiers and from a victim buried in the permafrost at Brevig Mission, Alaska. In 2005 they publish the full genetic sequence.

    The rest is history

    The work showed that the 1918 virus was an H1N1 influenza A virus with genes closely related to those of birds. Its descendants shaped later human flu viruses. The research helped modern studies of how pandemic flu viruses arise. The cause had been unknown to doctors in 1918, who mostly believed a bacterium was responsible.

    Sources

    1. ArticleTaubenberger, Jeffery K., Ann H. Reid, Raina M. Lourens, Ruixue Wang, Guozhong Jin, and Thomas G. Fanning. "Characterization of the 1918 Influenza Virus Polymerase Genes." Nature 437 (2005): 889-893.
    2. BookKolata, Gina. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It. New York: Farrar, Straus and Giroux, 1999.

  8. Health ministries and international cooperation after 1918

    Event

    What happened

    After the pandemic several governments reshape their health services. Russia creates a people's commissariat for health in 1918, and Britain founds a Ministry of Health in 1919. In 1923 the League of Nations Health Organization takes up work on epidemic reporting and in 1947 a surveillance network begins that later becomes the WHO Global Influenza Programme.

    The rest is history

    Historians link the pandemic to a wider push for public health organisation in these years, though other pressures such as the war also mattered. The pandemic is often described as a spur to later influenza surveillance. The World Health Organization was founded in 1948, and its global influenza network started in 1952.

    Sources

    1. BookSpinney, Laura. Pale Rider: The Spanish Flu of 1918 and How It Changed the World. London: Jonathan Cape, 2017.
    2. BookHonigsbaum, Mark. A History of the Great Influenza Pandemics: Death, Panic and Hysteria, 1830-1920. London: I. B. Tauris, 2014.

  9. The pandemic began in Spain

    Popular belief

    The legend

    The name tells the story: the Spanish flu is said to have started in Spain and spread from there to the rest of Europe and the world.

    The rest is history

    There is no evidence that the pandemic began in Spain. The name arose because Spanish newspapers, free of wartime censorship, reported the outbreak openly in spring 1918. Early outbreaks were recorded in the United States and France, and some historians have argued for northern China or a British camp at Étaples, but none of these origins is proven. Spain was hit hard, and King Alfonso XIII himself fell ill in 1918. Today the origin remains debated.

    Sources

    1. BookBarry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Viking, 2004.
    2. ArticleTrilla, Antoni, Guillem Trilla, and Carolyn Daer. "The 1918 'Spanish Flu' in Spain." Clinical Infectious Diseases 47, no. 5 (2008): 668-673.

  10. The flu decided the First World War

    Popular belief

    The legend

    A common claim is that influenza ended the war, striking the German army in 1918 so badly that it could no longer fight and had to seek an armistice.

    The rest is history

    Influenza did hit armies on both sides, and German commanders noted its effects on their troops in 1918. But historians generally hold that the German defeat came mainly from military, economic and political causes, including the Allied offensives of summer and autumn 1918 and the collapse at home. Flu affected the Allies as well. It is fair to say it made the fighting harder, but there is no good evidence it decided the outcome.

    Sources

    1. BookByerly, Carol R. Fever of War: The Influenza Epidemic in the U.S. Army during World War I. New York: New York University Press, 2005.
    2. BookSpinney, Laura. Pale Rider: The Spanish Flu of 1918 and How It Changed the World. London: Jonathan Cape, 2017.

  11. A strong immune system made young adults die

    Popular belief

    The legend

    Many people say young adults died in large numbers because their strong immune systems overreacted to the virus in a so-called cytokine storm, and that the healthy were therefore at most risk.

    The rest is history

    The unusual pattern of deaths among people aged about 20 to 40 is well documented. The cytokine storm idea is an appealing explanation, but it is not settled. Other proposals include earlier exposure to flu viruses that left some age groups less protected, and bacterial pneumonia as the main cause of death. Studies of the reconstructed virus have shown it was very damaging to lung tissue in animals. Scientists still debate the exact reasons.

    Sources

    1. ArticleTaubenberger, Jeffery K., and David M. Morens. "1918 Influenza: The Mother of All Pandemics." Emerging Infectious Diseases 12, no. 1 (2006): 15-22.
    2. ArticleMorens, David M., Jeffery K. Taubenberger, and Anthony S. Fauci. "Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza." Journal of Infectious Diseases 198, no. 7 (2008): 962-970.

  12. The pandemic was soon forgotten

    Popular belief

    The legend

    It is often said that the Spanish flu was forgotten almost at once, leaving little trace in memory, literature or public life.

    The rest is history

    There is some truth in this. Historians such as Alfred Crosby noted in 1976 how little attention it received compared with the war. But the pandemic did appear in diaries, letters, newspapers and some literature, including Katherine Anne Porter's story Pale Horse, Pale Rider of 1939. Private grief was great even where public memorials were rare. Research grew sharply from the 1970s and again after 2000.

    Sources

    1. BookCrosby, Alfred W. America's Forgotten Pandemic: The Influenza of 1918. Cambridge: Cambridge University Press, 2003.
    2. BookPorter, Katherine Anne. Pale Horse, Pale Rider: Three Short Novels. New York: Harcourt, Brace, 1939.

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